NEWS & VIEWS DECADE IN REVIEW—URINARY INCONTINENCE
Advances in female urology and voiding dysfunction Marisa M. Clifton and Howard B. Goldman
Over the past decade, management of common urological problems has metamorphosed in the field of female urology and voiding dysfunction; from treatment of routine stress urinary incontinence (SUI) with synthetic sling placement, to management of refractory overactive bladder (OAB) with neuromodulation. Clifton, M. M. & Goldman, H. B. Nat. Rev. Urol. 11, 613–614 (2014); published online 14 October 2014; doi:10.1038/nrurol.2014.279
For most of the past decade, urodynamic studies (UDS) were a routine part of the evaluation for a patient with stress urinary incontinence (SUI). UDS is an invasive and relatively expensive procedure that can cause anxiety in patients and, until recently, its value in improving treatment outcomes was unknown. However, in 2012, Nager et al.1 published a multicentre, random ized noninferiority trial evaluating the need for UDS in patients undergoing mid urethral sling surgery. In this study, women with uncomplicated SUI were randomized to undergo office evaluation and UDS or office evaluation only. Patients had a history of SUI symptoms for 3 months or more, a score on the Medical, Epidemiological and Social Aspects of Aging (MESA) inventory for SUI that was greater than their score for urinary urgency incontinence (UUI), evi dence of urethral mobility on examination and a posit ive stress test during physical examination. Patients with previous anti- incontinence surgery, a history of pelvic radiation, pelvic surgery within the past 3 months and women with pelvic organ pro lapse of stage III or greater were excluded from the study. The primary outcome of treatment success at 12 months was deter mined by a Urogenital Distress Inventory (UDI) reduction of 70% and a Patient Global Impression of Improvement (PGII) of ‘much better’. A total of 630 women were randomized equally into the two study arms. Successful treatment was observed in 76.9% of patients who underwent UDS and office evaluation, compared with 77.2% of patients who only received office evaluation, showing
that UDS has no real effect on patient out comes. Eliminating the need to put patients with straightforward SUI through this medical examination should expedite patient care, decrease morbidity, reduce costs and improve the patient experience.
‘‘
…the past decade has been an exciting one for the field of female urology and voiding dysfunction
’’
Throughout the previous decade, the gold standard for the treatment of SUI involved a retropubic suspension or autologous pubovaginal sling—both of which are rela tively invasive, typically involve general or regional anaesthesia and often require overnight hospitalization. Tension-free vaginal tape (TVT)—a synthetic retropubic midurethral sling—was introduced in the late 1990s, and was widely adopted by uro logists over the decade between 2004–2014, owing to excellent 5‑year outcome results and minimal invasiveness compared with retropubic suspensions or autologous pubovaginal slings.2 Nilsson et al.3 recently published the 17 year follow-up period results of a multicentre prospective TVT study. A total of 78% of women initially included in the study were evaluated, with over 90% of these patients objectively conti nent on follow-up after 17 years, and 87% of patients subjectively cured or significantly improved according to PGII, Incontinence Impact Questionnaire-short form (IIQ‑7), the UDI-short form (UDI‑6), and Urinary
NATURE REVIEWS | UROLOGY
Incontinence Severity Score (UISS). This prospective study provides evidence for the durability of the TVT sling as well as excellent patient outcomes with minimal complications. The synthetic retropubic midurethral sling is now considered a gold standard in the management of female SUI.4 Overall, with the advent of the syn thetic retropubic midurethral sling and the transobturator midurethral sling (which has accrued data demonstrating excellent results for most patients)5 the treatment of SUI has become less invasive, more predict able and more acceptable to patients and physicians alike. One of the most important advances to have garnered attention over the past few years has been in the treatment of over active bladder (OAB). Previously, OAB has been difficult to treat, and limited thera peutic options have been available; but now onabotulinumtoxinA is considered the standard treatment for patients with either refractory idiopathic OAB or neurogenic detrusor overactivity (NDO). 6 Recently, Nitti et al.7 performed a multicentre, ran domized, placebo-controlled trial to evalu ate onabotulinumtoxinA for the treatment of patients with idiopathic OAB and UUI. Patients were ≥18 years old and experienced ≥3 UUI episodes over a 3‑day period. They were randomized to receive either 100 U of intravesical onabotulinumtoxinA or placebo. Primary end points were a change in the mean number of UUI episodes per day and the proportion of patients with a positive treatment response on the treat ment benefit scale. Secondary end points were improvement in OAB symptoms, such as a decrease in the average frequency of micturition and urgency episodes as well as scores on health-related quality of life (QOL) questionnaires. This study demon strated that onabotulinumtoxinA therapy decreased the mean daily frequency of UUI episodes experienced by patients by 2.65 compared with a decrease in patients receiv ing placebo of only 0.87, which was statis tically significant (P
Advances in female urology and voiding dysfunction Marisa M. Clifton and Howard B. Goldman
Over the past decade, management of common urological problems has metamorphosed in the field of female urology and voiding dysfunction; from treatment of routine stress urinary incontinence (SUI) with synthetic sling placement, to management of refractory overactive bladder (OAB) with neuromodulation. Clifton, M. M. & Goldman, H. B. Nat. Rev. Urol. 11, 613–614 (2014); published online 14 October 2014; doi:10.1038/nrurol.2014.279
For most of the past decade, urodynamic studies (UDS) were a routine part of the evaluation for a patient with stress urinary incontinence (SUI). UDS is an invasive and relatively expensive procedure that can cause anxiety in patients and, until recently, its value in improving treatment outcomes was unknown. However, in 2012, Nager et al.1 published a multicentre, random ized noninferiority trial evaluating the need for UDS in patients undergoing mid urethral sling surgery. In this study, women with uncomplicated SUI were randomized to undergo office evaluation and UDS or office evaluation only. Patients had a history of SUI symptoms for 3 months or more, a score on the Medical, Epidemiological and Social Aspects of Aging (MESA) inventory for SUI that was greater than their score for urinary urgency incontinence (UUI), evi dence of urethral mobility on examination and a posit ive stress test during physical examination. Patients with previous anti- incontinence surgery, a history of pelvic radiation, pelvic surgery within the past 3 months and women with pelvic organ pro lapse of stage III or greater were excluded from the study. The primary outcome of treatment success at 12 months was deter mined by a Urogenital Distress Inventory (UDI) reduction of 70% and a Patient Global Impression of Improvement (PGII) of ‘much better’. A total of 630 women were randomized equally into the two study arms. Successful treatment was observed in 76.9% of patients who underwent UDS and office evaluation, compared with 77.2% of patients who only received office evaluation, showing
that UDS has no real effect on patient out comes. Eliminating the need to put patients with straightforward SUI through this medical examination should expedite patient care, decrease morbidity, reduce costs and improve the patient experience.
‘‘
…the past decade has been an exciting one for the field of female urology and voiding dysfunction
’’
Throughout the previous decade, the gold standard for the treatment of SUI involved a retropubic suspension or autologous pubovaginal sling—both of which are rela tively invasive, typically involve general or regional anaesthesia and often require overnight hospitalization. Tension-free vaginal tape (TVT)—a synthetic retropubic midurethral sling—was introduced in the late 1990s, and was widely adopted by uro logists over the decade between 2004–2014, owing to excellent 5‑year outcome results and minimal invasiveness compared with retropubic suspensions or autologous pubovaginal slings.2 Nilsson et al.3 recently published the 17 year follow-up period results of a multicentre prospective TVT study. A total of 78% of women initially included in the study were evaluated, with over 90% of these patients objectively conti nent on follow-up after 17 years, and 87% of patients subjectively cured or significantly improved according to PGII, Incontinence Impact Questionnaire-short form (IIQ‑7), the UDI-short form (UDI‑6), and Urinary
NATURE REVIEWS | UROLOGY
Incontinence Severity Score (UISS). This prospective study provides evidence for the durability of the TVT sling as well as excellent patient outcomes with minimal complications. The synthetic retropubic midurethral sling is now considered a gold standard in the management of female SUI.4 Overall, with the advent of the syn thetic retropubic midurethral sling and the transobturator midurethral sling (which has accrued data demonstrating excellent results for most patients)5 the treatment of SUI has become less invasive, more predict able and more acceptable to patients and physicians alike. One of the most important advances to have garnered attention over the past few years has been in the treatment of over active bladder (OAB). Previously, OAB has been difficult to treat, and limited thera peutic options have been available; but now onabotulinumtoxinA is considered the standard treatment for patients with either refractory idiopathic OAB or neurogenic detrusor overactivity (NDO). 6 Recently, Nitti et al.7 performed a multicentre, ran domized, placebo-controlled trial to evalu ate onabotulinumtoxinA for the treatment of patients with idiopathic OAB and UUI. Patients were ≥18 years old and experienced ≥3 UUI episodes over a 3‑day period. They were randomized to receive either 100 U of intravesical onabotulinumtoxinA or placebo. Primary end points were a change in the mean number of UUI episodes per day and the proportion of patients with a positive treatment response on the treat ment benefit scale. Secondary end points were improvement in OAB symptoms, such as a decrease in the average frequency of micturition and urgency episodes as well as scores on health-related quality of life (QOL) questionnaires. This study demon strated that onabotulinumtoxinA therapy decreased the mean daily frequency of UUI episodes experienced by patients by 2.65 compared with a decrease in patients receiv ing placebo of only 0.87, which was statis tically significant (P
