Patient treatment preferences for symptomatic refractory urodynamic idiopathic detrusor overactivity

Introduction: There is a multiplicity of treatments currently available for patients with symptomatic refractory urodynamic idiopathic detrusor overactivity (SRU IDO). We have assessed patient treatment preferences and their outcomes over a 12-month period from January 1 2009 to December 31 2009. Patients and Methods: A retrospective database of all patients with SRU IDO was reviewed for patient demographics, treatment preference, and outcome. All patients attending for treatment in the time period were offered: no further treatment, repeat bladder training ± antimuscarinic (BT ± AM), acupuncture, intravesical botulinum toxin injection, sacral neuromodulation (SNM), clam cystoplasty ± Mitrofanoff channel formation, and ileal conduit. Statistical Analysis Used: Statistical analysis of outcomes was done by Chi–square test, and statistical significance was determined as P< 0.05. Results: A total of 217 patients with SRU IDO underwent primary treatment in this time period, with a median age of 56 years and follow-up for a minimum of 12 months' posttreatment to determine outcome. No patients opted for any further treatment or an ileal conduit. The majority of patients opted for intravesical botulinum toxin injections and SNM with similar success rates (approximately 70%). A small number of patients decided to have nonsurgical interventions (BT ± AM or acupuncture) and had a broadly similar success rate (50%). A minority opted for clam cystoplasty ± Mitrofanoff channel formation – this group reported the highest success rate at 86%. Conclusions: Treatment options in SRU IDO are diverse, with the majority of patients opting for minimally invasive surgery. Clinicians should be familiar with all treatment options for management of SRU IDO

Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision

Context: Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%. Aims: We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum. Patients and Methods: All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram. Statistical Analysis Used: Statistical analysis was performed by Chi-squared and Fisher's exact. Results: Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential. Conclusions: New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI – rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision

Overnight Ambulatory Urodynamics Change Patient Management Strategies and Improve Symptomatic Outcomes

ObjectivesTo determine the diagnostic value of overnight ambulatory urodynamics (aUDS) and to assess if a urodynamic diagnosis of detrusor overactivity (DO) or nocturnal enuresis resulted in a change in patient management and an improvement in their urinary symptoms. MethodsA retrospective review of 25 consecutive patients (28% male) with a median age of 38 years (range 18 to 86) having overnight aUDS for bothersome urinary symptoms of primarily nocturia and/or nocturnal enuresis following non-diagnostic conventional urodynamics between November 1998 and August 2018. Urinary symptoms were assessed before overnight aUDS and again after urological treatment following any changes in urodynamics diagnosis and treatment. Six patients were excluded as follow-up data were not available. ResultsTwenty-four patients (96%) presented with nocturia and 20 (80%) presented with nocturnal enuresis. DO was demonstrated in 19 (76%) patients (mean pressure 69.1±53.3 cmH2O). UUI was demonstrated in 16 (80%) out of the 20 patients who complained of nocturnal enuresis. Of the 19 patients with follow-up data, following overnight aUDS a change in urodynamic diagnosis was made in 15 patients (79%); 16 patients (84%) also had their clinical diagnosis and subsequent management changed; and 15 patients (79%) reported an improvement in their urinary symptoms following these changes in diagnosis and treatment. There was a significant improvement in ICIQ-OAB (120±44 versus 32±53, P < 0.0001) scores following the changes to clinical management post-overnight aUDS. ConclusionIn our study cohort, change in primary diagnosis following overnight aUDS led to a significant change in treatment care pathway and resulted in significant improvement in urinary symptoms at follow-up

The importance of overcoming the challenges in delivering the Proper Understanding of Recurrent Stress Urinary Incontinence Treatment (PURSUIT) study

There is insufficient data to assess the effects of any of the different management strategies for recurrent or persistent stress urinary incontinence in women after failed interventional treatment. The evidence base lacks well-designed randomised trials with sufficient power to answer this hugely important issue. PURSUIT is the Proper Understanding of Recurrent Stress Urinary Incontinence Treatment study, assessing through randomisation whether endoscopic or surgical interventions achieve better cure and/or quality of life outcomes at 1 year, and will follow up to 3 years to see if responses are sustained. The manuscript provides an outline of the study, describes the challenges it has faced, and advocates the importance of ensuring its successful delivery

On-going mechanical damage from mastication drives homeostatic Th17 responses at the oral barrier

Immuno-surveillance networks operating at barrier sites are tuned by local tissue cues to ensure effective immunity. Site-specific commensal bacteria provide key signals ensuring host defense in the skin and gut. However, how the oral microbiome and tissue-specific signals balance immunity and regulation at the gingiva, a key oral barrier, remains minimally explored. In contrast to the skin and gut, we demonstrate that gingiva-resident T helper 17 (Th17) cells developed via a commensal colonization- independent mechanism. Accumulation of Th17 cells at the gingiva was driven in response to the physiological barrier damage that occurs during mastication. Physiological mechanical damage, via induction of interleukin 6 (IL-6) from epithelial cells, tailored effector T cell function, promoting increases in gingival Th17 cell numbers. These data highlight that diverse tissue-specific mechanisms govern education of Th17 cell responses and demonstrate that mechanical damage helps define the immune tone of this important oral barrier