SUFU TAKE HOME MESSAGES FOR GURS
Doreen E. Chung MD, FRCSC and Jessica DeLong MD
The Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) 14th annual winter meeting was held in the desert city of Scottsdale Arizona at the Hyatt Regency Scottsdale at Gainey Ranch. Kathleen Kobashi, MD, and Jennnifer Anger, MD, the program chairs, put together an outstanding comprehensive dynamic program complemented by a vibrant basic science program chaired by Adam Klausner, MD, and Lori Birder, PhD. One recurrent theme was the the utility of urodynamics (UDS) in guiding treatment decisions and for predicting outcomes of surgery. Other difficult topics tackled included the management of refractory neurogenic detrusor overactivity, female sexual dysfunction, and the pre-operative urologic evaluation of the renal transplant recipient. Another meeting highlight was the unveiling of the SUFU’s best practice policy statement on urodynamics antibiotic prophylaxis in the non-index patient.
Tuesday February 28th was the kickoff of the basic and translational science meeting. In the first panel moderated by Vivian Cristofaro, PhD, we learned about novel methods of urodynamic diagnosis. John Speich, PhD, explained how detrusor overactivity may be related to dynamic elasticity and how the frequency of low amplitude rhythmic contractions (LARC) may regulate dynamic elasticity. He also described a novel objective method to identify LARC during urodynamics. Mostafa Fatemi, PhD, described to us methods of ultrasound vibrometry to measure bladder compliance. Lynn Stothers, MD, highlighted new paradigms to augment standard UDS assessment in the neurogenic bladder from the International Collaboration on Repair Discovery (ICORD). Although new less invasive technologies are being developed to query bladder function, urodynamics remains the gold standard.
Wednesday March 1st began with SUFU president Dr. Gary Lemack’s welcoming remarks. Next we heard talks from the basic science top podium selections. There were a wide range of topics including quantification and 3D microvessel architecture of the vagina and bladder, ultrasound quantification of bladder wall biomechanics during urodynamics, alterations of brain functional connectivity in stress induced bladder hyperalgesia, and evidence of P2X4 receptor in detrusor smooth muscle. Dr. Stefan De Wachter gave an informative talk on the science behind urinary urgency. The basic science prize essay award and top podium selection was awarded to Ming Lu who gave an excellent presentation on the acute host response during UTI where big potassium channel (BK) activity in female mouse bladder umbrella cells is enhanced by bacterial lipopolysaccharide.
Thursday March 2nd opened with three debates centered on the whether or not urodynamics should be performed before treatment of mixed urinary incontinence, refractory overactive bladder (OAB), and TURP. The utility of urodynamics in the workup of voiding dysfunction is still a controversial topic and its usefulness in dictating treatment decisions and outcomes has still not been clearly proven in many scenarios. At the same time, the majority of SUFU members perform many urodynamics studies (UDS) and do feel that this part of the workup is useful and necessary. Regarding the workup of mixed urinary incontinence, Dr. Benjamin Brucker argued that urodynamics are very useful before treating mixed urinary incontinence. Multiple studies have shown that UDS findings can predict treatment outcomes, which can help set expectations. Patient satisfaction scores are higher when patients have realistic treatment goals. Ultimately guiding treatment by UDS findings may be cost-effective. Dr. Sandip Vasavada made the point that while UDS increases physician confidence in diagnoses, it has not been show to improve surgical outcomes. Dr. Angelo Gousse made arguments for performing UDS before treatment of refractory OAB. He states that the diagnosis of OAB should be confirmed before proceeding with further potentially invasive third-line treatments. Dr. Jason Kim, on the other hand, contended that detrusor overactivity is only seen in approximately 30-35% of females with OAB and that multiple studies have shown that UDS findings do not predict response to OAB therapies. In addition there is evidence that UDS is associated with patient anxiety, pain, and embarrassment.
The next contentious topic was the utility of UDS before TURP. Dr. Richard Lee was in favor of UDS prior to TURP in certain patients. There is evidence that patients who are not obstructed on UDS are less likely to have good outcomes following TURP. Again, the argument was made that UDS helps to set patient expectations increasing the chances of patient satisfaction following surgery. Dr. Kurt McCammon argued that UDS rarely changes management. Overall, for a mixed urinary incontinence and refractory OAB, there is evidence that UDS may not always change treatment decisions but does help to set patient expectations and increase patient satisfaction following treatment.
Dr. Ann Cameron unveiled the SUFU’s best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient. Whether or not to give antibiotics prior to urodynamics has been a very grey area for most urologists. A single dose of trimethoprim-sulfamethoxazole is the first choice for antibiotic prophylaxis prior to UDS. Antibiotic prophylaxis is no longer recommended in some patients previously thought to be at risk of UTI following UDS. These patients include individuals with uncomplicated diabetes, previous GU surgery, history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, and patients with nutritional deficiencies or obesity. The new recommendations do, however, recommend peri-procedure antibiotics in patients with known relevant neurogenic lower urinary tract dysfunction, elevated post-void residual, asymptomatic bacteriuria, immunosuppression, age > 70 and patients with any form of indwelling catheter, external device, or performing intermittent catheterization. The guidelines also recommend that clinical judgment of the provider always be considered in each case as well.
Dr. Gamal Ghoneim was the recipient of the Blaivas lectureship: lifetime achievement award. Dr. Ghoneim is Professor and Vice-Chair at the UC Irvine ‘s, Department of Urology and the Chief of the Division of Female Urology and Voiding Dysfunction. Dr. Ghoneim gave a talk about the journey of his career including mentors who inspired him, hurdles along the way, and his how his interests in neurourology and female urology evolved. He gave some sage advice on physician burnout – stating that the key is to “identify what is important to you, what you believe in and what you will fight for.”
Drs. Jennifer Anger, Una Lee, and Howard Goldman discussed the surgical management of uterine prolapse. There are many patients that hysteropexy is the best option for such as patients who are planning pregnancy after repair, patients who do not want hysterectomy. Hysterectomy in the setting of uterine prolapse has excellent long-term outcomes, and avoids mesh, but may lead to earlier menopause. For the elderly non-sexually active patient, colpocleisis is a very good option.
The meeting continued on Friday with a video session showcasing several novel techniques. Of note, Dr. Dougher presented the use of a lead extracting device to completely remove a sacral neuromodulation lead – a technique that could prove very useful to simplify a somewhat arduous procedure. The concurrent morning poster/podium sessions focused on both male and female reconstruction. An emphasis was placed on defining and following patient-centered outcome measures, in combination with cost efficiency for representative surgeries.
In a series of point-counterpoint panels throughout the meeting, several key areas of controversy were addressed, including the management of refractory neurogenic detrusor overactivity (OAB) and how to manage OAB following sling placement. As to the management of mixed incontinence post-prostatectomy Dr. MacDiarmid made a compelling argument to first address the outlet, underlining the utility of urodynamics in this situation.
Another focus across urology is incorporating allied health professionals (APP’s), and utilizing proper billing and coding. During the panel both the perspective of the physician and the APP were given: how to best integrate, utilize and retain APP’s, and how to determine the needs of your practice. The SUFU OAB clinical care pathway was another hot topic and was presented at the meeting. The breakout session on Male Reconstruction utilized complex cases in a panel format to discuss varying management strategies for neurogenic bladder and male incontinence.
Dr. Clemens then discussed the findings of the LURN network (Lower Urinary Tract Dysfunction Research Network), which since 2012 has collected data on men and women with LUTS to better define subtypes of symptoms and develop a comprehensive bladder tool for evaluation. Following these updates, Dr. Lucioni gave a case overview of important points when evaluating patients prior to renal transplant. Recommended studies, both functional and anatomic, were discussed.
SER 120, a desmopressin nasal spray developed for the treatment of nocturia, was recently approved by the FDA and data was presented by Dr. Roger Dmochowski’s group showing efficacy in multiple patient groups including those with overactive bladder, BPH, and nocturnal polyuria.
The main take home points from the SUFU 2017 Winter Meeting were the following:
1. Urodynamics may not change management decisions but likely increases patient satisfaction following TURP and for the treatment of mixed urinary incontinence and refractory OAB.
2. There are new guidelines to help direct antibiotic prophylaxis prior to UDS.
3. There are multiple options for the management of refractory neurogenic detrusor overactivity. Finally
4. SER 120 is a desmopressin nasal spray that was recently approved by the FDA with efficacy in multiple patient subtypes.