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Plotti F, Cundari GB, Ficarola F, Terranova C, De Cicco Nardone C, Montera R, Luvero D, Guzzo F, Silvagni A, Ferrari A, Caserta D, Angioli R. Intravesical Instillations of Hyaluronic Acid as First-Line Treatment in Patients with Interstitial Cystitis/Bladder Pain Syndrome: Use, Efficacy and Effects on Quality of Life. Healthcare (Basel) 2024; 12:1190. [PMID: 38921303 PMCID: PMC11203325 DOI: 10.3390/healthcare12121190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/02/2024] [Accepted: 06/11/2024] [Indexed: 06/27/2024] Open
Abstract
The efficacy of hyaluronic acid instillations as therapy for patients with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) has been demonstrated in some clinical studies, with response rates up to 70%. The aim of the study is to investigate the change in symptoms and quality of life in female patients with IC/BPS after intravesical instillations of hyaluronic acid used as first-line treatment. A retrospective single-center cohort study was conducted. Female patients, whose symptoms were compatible with the diagnosis of IC/BPS as defined by the International Continence Society, were treated with a variable number of intravesical instillations of a hyaluronic acid-based drug. Three validated questionnaires were administered by telephone to all patients, before the beginning of the treatment and 6 months after the last administration of the drug. A total of 50 patients with symptoms compatible with the diagnosis of IC/BPS were included in the study. The median number of instillations performed is 4. For all questionnaires, the median value was significantly reduced following treatment with intravesical instillations (p = 0.000). The present study has shown that intravesical hyaluronic acid treatment results in both statistically and clinically significant symptomatic improvement, thereby improving the quality of life of patients with IC/BPS.
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Affiliation(s)
- Francesco Plotti
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Gianna Barbara Cundari
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Fernando Ficarola
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Corrado Terranova
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Carlo De Cicco Nardone
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Roberto Montera
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Daniela Luvero
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Federica Guzzo
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Adele Silvagni
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Amerigo Ferrari
- Division of Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Donatella Caserta
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant’Andrea Hospital, Via di Grottarossa, n. 1035/1039, 00189 Rome, Italy;
| | - Roberto Angioli
- Research Unit of Gynaecology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (F.P.); (F.F.); (C.T.); (C.D.C.N.); (R.M.); (D.L.); (F.G.); (A.S.); (R.A.)
- Research Unit of Gynaecology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
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Li J, Yi X, Ai J. Broaden Horizons: The Advancement of Interstitial Cystitis/Bladder Pain Syndrome. Int J Mol Sci 2022; 23:ijms232314594. [PMID: 36498919 PMCID: PMC9736130 DOI: 10.3390/ijms232314594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022] Open
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating disease that induces mental stress, lower urinary symptoms, and pelvic pain, therefore resulting in a decline in quality of life. The present diagnoses and treatments still lead to unsatisfactory outcomes, and novel diagnostic and therapeutic modalities are needed. Although our understanding of the etiology and pathophysiology of IC/BPS is growing, the altered permeability of the impaired urothelium, the sensitized nerves on the bladder wall, and the chronic or intermittent sensory pain with inaccurate location, as well as pathologic angiogenesis, fibrosis, and Hunner lesions, all act as barriers to better diagnoses and treatments. This study aimed to summarize the comprehensive information on IC/BPS research, thereby promoting the progress of IC/BPS in the aspects of diagnosis, treatment, and prognosis. According to diverse international guidelines, the etiology of IC/BPS is associated with multiple factors, while the presence of Hunner lesions could largely distinguish the pathology, diagnosis, and treatment of non-Hunner lesions in IC/BPS patients. On the basis of the diagnosis of exclusion, the diverse present diagnostic and therapeutic procedures are undergoing a transition from a single approach to multimodal strategies targeting different potential phenotypes recommended by different guidelines. Investigations into the mechanisms involved in urinary symptoms, pain sensation, and bladder fibrosis indicate the pathophysiology of IC/BPS for further potential strategies, both in diagnosis and treatment. An overview of IC/BPS in terms of epidemiology, etiology, pathology, diagnosis, treatment, and fundamental research is provided with the latest evidence. On the basis of shared decision-making, a multimodal strategy of diagnosis and treatment targeting potential phenotypes for individual patients with IC/BPS would be of great benefit for the entire process of management. The complexity and emerging evidence on IC/BPS elicit more relevant studies and research and could optimize the management of IC/BPS patients.
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Affiliation(s)
- Jin Li
- West China School of Medicine, Sichuan University, Chengdu 610041, China
- Department of Urology, Institute of Urology, Sichuan University, Chengdu 610041, China
| | - Xianyanling Yi
- West China School of Medicine, Sichuan University, Chengdu 610041, China
- Department of Urology, Institute of Urology, Sichuan University, Chengdu 610041, China
| | - Jianzhong Ai
- Department of Urology, Institute of Urology, Sichuan University, Chengdu 610041, China
- Correspondence:
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Madurga Patuel B, González-López R, Resel Folkersma L, Machado Fernández G, Adot Zurbano JM, Bonillo MÁ, Vozmediano Chicharro R, Zubiaur Líbano C. Recommendations on the use of intravesical hyaluronic acid instillations in bladder pain syndrome. Actas Urol Esp 2022; 46:131-137. [PMID: 35256323 DOI: 10.1016/j.acuroe.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/25/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Bladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet. OBJECTIVE To synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA. The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations. RESULTS There is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment). CONCLUSIONS Intravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles). Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up).
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Affiliation(s)
- B Madurga Patuel
- Servicio de Urología, Hospital Universitario Puerta del Mar, Cádiz, Spain.
| | - R González-López
- Servicio de Urología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - L Resel Folkersma
- Servicio de Urología, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - J M Adot Zurbano
- Servicio de Urología, Hospital Universitario de Burgos, Burgos, Spain
| | - M Á Bonillo
- Servicio de Urología, Hospital Universitario La Fe, Valencia, Spain
| | | | - C Zubiaur Líbano
- Servicio de Urología, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain
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Madurga Patuel B, González-López R, Resel Folkersma L, Machado Fernández G, Adot Zurbano J, Bonillo M, Vozmediano Chicharro R, Zubiaur Líbano C. Recomendaciones sobre el uso de las instilaciones endovesicales de ácido hialurónico en el síndrome de dolor vesical. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bschleipfer T, Kaftan B. [Interstitial cystitis: interventions and surgery - more than a last resort?]. Aktuelle Urol 2021; 52:561-568. [PMID: 34847608 DOI: 10.1055/a-1668-2975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Interstitial cystitis is an underdiagnosed chronic-relapsing to chronic-progressive urinary bladder disease, whose pathogenesis and aetiology has not been fully elucidated. The disease itself cannot be cured and treatment is symptomatic. Treatment options comprise conservative and medicinal approaches as well as a large number of interventional/surgical procedures. These include intravesical instillation, transurethral procedures such as injections of botulinum toxin A, corticosteroids and local anaesthetics, hydrodistension and neuromodulation as well as (laser) fulguration, resection and cystectomy. Although surgical procedures are considered a late option and are often referred to as last-resort therapy, these interventional options often show good to very good response rates, manageable complications and a favourable risk-benefit evaluation. An overall generalisation of surgery as a last-resort treatment option should therefore be avoided and its use should be discussed based on the individual needs of each patient.
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Affiliation(s)
- Thomas Bschleipfer
- Klinik für Urologie, Andrologie und Kinderurologie, Interdisziplinäres Kontinenz- und Beckenbodenzentrum, Zentrum für Interstitielle Zystitis (IC) und Beckenschmerz, Klinikum Weiden/Klinken Nordoberpfalz AG, Weiden, Germany
| | - Björn Kaftan
- Klinik für Urologe, Interdisziplinäres Kontinenz- und Beckenbodenzentrum, Zentrum für Interstitielle Zystitis (IC) und Beckenschmerz, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
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Digesu GA, Tailor V, Bhide AA, Khullar V. The role of bladder instillation in the treatment of bladder pain syndrome: Is intravesical treatment an effective option for patients with bladder pain as well as LUTS? Int Urogynecol J 2020; 31:1387-1392. [PMID: 32358624 PMCID: PMC7306012 DOI: 10.1007/s00192-020-04303-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/01/2020] [Indexed: 11/26/2022]
Abstract
The aetiology of bladder pain syndrome/interstitial cystitis is still unknown. Numerous mechanisms have been proposed and treatments targeting various aspects of these are used. This review looks at the existing evidence on bladder instillations and whether they could be used in the treatment of lower urinary tract symptoms as well.
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Affiliation(s)
| | - Visha Tailor
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Alka A Bhide
- St Mary's Hospital, Imperial College NHS Trust, London, UK.
| | - Vik Khullar
- St Mary's Hospital, Imperial College NHS Trust, London, UK
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Han E, Nguyen L, Sirls L, Peters K. Current best practice management of interstitial cystitis/bladder pain syndrome. Ther Adv Urol 2018; 10:197-211. [PMID: 30034539 DOI: 10.1177/1756287218761574] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/02/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Over the last 100 years, the terminology and diagnosis criteria for interstitial cystitis have evolved. Many therapeutic options have changed, but others have endured. This article will review the idea of separating 'classic' Hunner lesion interstitial cystitis (HL IC) from non-Hunner lesion interstitial cystitis and bladder pain syndrome (N-HL IC/BPS) and their respective treatment algorithms. Methods/Results A literature search was performed to identify articles and research on HL IC and N-HL IC/BPS including definitions, etiological theories, and treatments. This article is an overview of the existing literature. We also offer insight into how HL IC and N-HL IC/BPS are approached at our tertiary referral center. Additionally, American Urological Association guidelines have been integrated and newer treatment modalities and research will be introduced at the conclusion. Conclusion The AUA guidelines have mapped out a stepwise fashion to treat IC/BPS; at our institution we separate patients with HL IC from those with N-HL IC/BPS prior to them entering a treatment pathway. We identify the rarer patient with HL as having classic 'IC'; this cystoscopic finding is critical in guiding treatment. We believe HL IC is a distinct disease from N-HL IC/BPS and therapy should focus on the bladder. The vast majority of patients with N-HL IC/BPS need management of their pelvic floor muscles as the primary therapy, complemented by bladder-directed therapies as needed as well as a multidisciplinary team to manage a variety of other regional/systemic symptoms. Ongoing research into IC/BPS will help us better understand the pathophysiology and phenotypes of this complex disease while exciting and novel research studies are developing promising treatments.
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Affiliation(s)
- Esther Han
- Beaumont Health, 3535 W. Thirteen Mild Road, Ste 438, Royal Oak, MI 48073, USA
| | | | - Larry Sirls
- Beaumont Health, Royal Oak, MI, USA Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Kenneth Peters
- Beaumont Health, Royal Oak, MI, USA Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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Orally Administered Combination of Hyaluronic Acid, Chondroitin Sulfate, Curcumin, and Quercetin in the Prevention of Postcoital Recurrent Urinary Tract Infections: Analysis of 98 Women in Reproductive Age After 6 Months of Treatment. Female Pelvic Med Reconstr Surg 2018; 25:309-312. [DOI: 10.1097/spv.0000000000000560] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Meng E, Hsu YC, Chuang YC. Advances in intravesical therapy for bladder pain syndrome (BPS)/interstitial cystitis (IC). Low Urin Tract Symptoms 2018; 10:3-11. [DOI: 10.1111/luts.12214] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/19/2017] [Accepted: 12/01/2017] [Indexed: 12/22/2022]
Affiliation(s)
- En Meng
- Department of Urology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Yu-Chao Hsu
- Department of Urology; Linko Chang Gung Memorial Hospital; Taipei Taiwan
- College of Medicine; Chang Gung University; Taipei Taiwan
| | - Yao-Chi Chuang
- Department of Urology; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine; Kaohsiung Taiwan
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Lv YS, Gao R, Lin QM, Jiang T, Chen Q, Tang SX, Mao HP, Zhou HL, Cao LS. The role of TSG-6 and uroplakin III in bladder pain syndrome/ interstitial cystitis in rats and humans. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2018; 20:1242-1249. [PMID: 29299202 PMCID: PMC5749359 DOI: 10.22038/ijbms.2017.9540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives We investigated the relationship between the expression of tumor necrosis factor-inducible gene 6 (TSG-6) with inflammation and integrity of the bladder epithelium in the bladder tissues of patients with bladder pain syndrome/interstitial cystitis (BPS/IC) and the mechanism of action using a rat model of BPS/IC. Materials and Methods Expression of TSG-6 and uroplakin III was determined by immuno- histochemistry of bladder biopsy samples from control human subjects and patients with verified BPS/IC. Our rat model of BPS/IC was employed to measure the perfusion of bladders with hyaluronidase, and assessment of the effect of TSG-6 administration on disease progression. Treatment effects were assessed by measurement of metabolic characteristics, RT-PCR of TGR-6 and interleukin-6, bladder histomorphology, and immunohistochemistry of TGR-6 and uroplakin III. Results The bladders of patients with BPS/IC had lower expression of uroplakin III and higher expression of TSG-6 than controls. Rats treated with hyaluronidase for 1 week developed the typical signs and symptoms of BPS/IC, and rats treated with hyaluronidase for 4 weeks had more serious disease. Administration of TSG-6 reversed the effects of hyaluronidase and protected against disease progression. Conclusion Our results indicate that TSG-6 plays an important role in maintaining the integrity of the bladder epithelial barrier.
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Affiliation(s)
- Yi-Song Lv
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Rui Gao
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Qing-Ming Lin
- Department of Emergency Medicine, Fujian Provincial Hospital, Fuzhou 350005, China
| | - Tao Jiang
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Qin Chen
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Song-Xi Tang
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Hou-Ping Mao
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Hui-Liang Zhou
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Lin-Sheng Cao
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
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Reviewing Interstitial Cystitis Models and Treatments: A Focus on the Urothelium. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2017. [DOI: 10.5812/rijm.64551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Interstitial cystitis (IC) is a progressive bladder disorder that presents with symptoms of bladder urgency, frequency and pain. The aetiology of the disease remains uncertain, but it is postulated that there is an initial infective insult which damages the glycosaminoglycan (GAG) layer of the bladder urothelium. This defect allows an influx of ions, particularly potassium, which initiates an inflammatory reaction in the bladder wall, which incites the symptoms described above. Treatment initially involves behavioural and oral medication, with second line being intravesical instillation therapy. Treatment strategies focus on restoring lower urinary tract epithelial function, inhibiting neural activation, controlling allergies and relieving symptoms. In this review, current intravesical therapy will be discussed, as well as what lies on the horizon for intravesical therapy in IC.
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Affiliation(s)
- Tanya Ha
- Urology Department, Royal Perth Hospital, Perth, Australia
| | - Jie Hua Xu
- Urology Department, Royal Perth Hospital, Perth, Australia
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Zhang W, Deng X, Liu C, Wang X. Intravesical treatment for interstitial cystitis/painful bladder syndrome: a network meta-analysis. Int Urogynecol J 2016; 28:515-525. [PMID: 27614759 DOI: 10.1007/s00192-016-3079-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 06/14/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic inflammatory condition of the submucosal and muscular layers of the bladder. So far, there is no effective and targeted treatment strategy for IC/PBS. This study aimed to assess the efficacy and safety of intravesical instillation treatment in IC/PBS patients. METHODS We searched various databases up to October 2015. A network meta-analysis was performed to compare global response assessment (GRA) for different treatment strategies, including botulinum toxin A (BoNTA), bacillus Calmette-Guerin (BCG), resiniferatoxin (RTX), lidocaine, chondroitin sulfate (CS), oxybutynin, and pentosan polysulfate (PPS). A traditional meta-analysis was also performed. RESULTS Sixteen trials evaluating 905 patients were included. Network meta-analysis indicated that BoNTA had the highest probability of being the best treatment course according to GRA assessment results (probability 81.7 %). BCG or BoNTA therapy yielded significant improvement in GRA incidence according to traditional meta-analysis. Patients who received PPS showed higher urinary frequency results compared with the placebo groups. BCG- and PPS-treated patients had elevated urinary urgency treatment effects compared with placebo groups. Bladder capacity restoration results also showed significant improvements in patients who received BoNTA compared with placebo-treated individuals. CONCLUSIONS These findings indicate that BoNTA therapy has the highest probability of being the best therapy according to GRA, and significantly improves bladder capacity in IC/PBS patients. BCG treatment also significantly increases the incidence of GRA and improves the symptoms of urinary urgency. PPS can significantly improve urinary frequency and urgency symptoms in IC/PBS patients.
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Affiliation(s)
- Wei Zhang
- Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin Medical University, 23 Pingjiang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Xiaojing Deng
- Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin Medical University, 23 Pingjiang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Chunyu Liu
- Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin Medical University, 23 Pingjiang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Xu Wang
- Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin Medical University, 23 Pingjiang Road, Hexi District, Tianjin, 300211, People's Republic of China.
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Barua JM, Arance I, Angulo JC, Riedl CR. A systematic review and meta-analysis on the efficacy of intravesical therapy for bladder pain syndrome/interstitial cystitis. Int Urogynecol J 2016; 27:1137-47. [PMID: 26590137 PMCID: PMC4947101 DOI: 10.1007/s00192-015-2890-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 11/02/2015] [Indexed: 11/26/2022]
Abstract
Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease characterised by persistent irritating micturition symptoms and pain. The objective was to compare the clinical efficacy of currently available products for intravesical therapy of BPS/IC and to assess their pharmacoeconomic impact. A Pubmed/Medline database search was performed for articles on intravesical therapy for BPS/IC. A total of 345 publications were identified, from which 326 were excluded. Statistical evaluation was performed with effect size (ES) assessment of symptom reduction and response rates. The final set of 19 articles on intravesical BPS/IC therapy included 5 prospective controlled trials (CTs), the remaining were classified as uncontrolled clinical studies. The total number of patients included was 801, 228 of whom had been evaluated in a CT. For CTs, the largest ES for symptom reduction as well as response rate was observed for high molecular weight hyaluronic acid (HMW-HA), with similar findings in two uncontrolled studies with HMW-HA. The number needed to treat to achieve a response to intravesical therapy was 2.67 for intravesical pentosan polysulphate and 1.31 for HMW-HA which were superior to all other instillates. HMW-HA was significantly superior in cost effectiveness and cost efficacy to all other instillation regimes. The present meta-analysis combined medical and pharmacoeconomic aspects and demonstrated an advantage of HMW-HA over other instillation agents; however, direct comparisons between the different products have not been performed to date in properly designed controlled studies.
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Affiliation(s)
- Jayanta M Barua
- King George Hospital (BHRUT), Ilford, UK
- Barts and the London School of Medicine & Dentistry, QMUL, London, UK
| | - Ignacio Arance
- Servicio de Urología, Hospital Universitario de Getafe, Universidad Europea de Madrid, Madrid, Spain
| | - Javier C Angulo
- Servicio de Urología, Hospital Universitario de Getafe, Universidad Europea de Madrid, Madrid, Spain
| | - Claus R Riedl
- Department of Urology, Landesklinikum Thermenregion, Wimmergasse 19, 2500, Baden, Austria.
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The effects of intravesical therapy with hyaluronic acid for painful bladder syndrome: Preliminary Chinese experience and systematic review. Taiwan J Obstet Gynecol 2016; 54:240-7. [PMID: 26166334 DOI: 10.1016/j.tjog.2014.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To present the preliminary results of treating a series of Chinese patients with painful bladder syndrome/interstitial cystitis (PBS/IC) using intravesical hyaluronic acid (HA). MATERIALS AND METHODS A series of 13 patients with PBS/IC received first-line therapy followed by HA once-a-week for 4 weeks and then once monthly for 4 months. Outcomes measured included O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ISPI) scores, voiding frequency, and bladder capacity. RESULTS ISPI and ICSI scores were significantly (p < 0.001) decreased after treatment [median change (interquartile range): ISPI = 2 (2-3); ICSI = 3 (2-3)]. Voiding frequency and functional bladder capacity were significantly (p < 0.001) decreased [median change: 7 (6-8) times/d] and increased [median change: 190 (116-233) mL], respectively after treatment. CONCLUSION Our case series supports the efficacy of intravesical HA in the treatment of PBS/IC.
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Chuang YC, Chermansky C, Kashyap M, Tyagi P. Investigational drugs for bladder pain syndrome (BPS) / interstitial cystitis (IC). Expert Opin Investig Drugs 2016; 25:521-9. [PMID: 26940379 DOI: 10.1517/13543784.2016.1162290] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Bladder pain syndrome (BPS)/interstitial cystitis (IC) is associated with sensory lower urinary tract symptoms. Unfortunately, many of the existing oral treatments are ineffective in most patients of BPS/IC, which is the motivation for developing new drugs and therapeutic approaches. This review covers the latest drugs that have been investigated in BPS/IC patients. Intravesical treatments offer the opportunity to directly target the painful bladder with less systemic side effects. AREAS COVERED In this review, the authors analyze the existing literature supporting the treatment of BPS/IC with conventional drugs including heparin, hyaluronic acid, chondroitin sulfate, and dimethylsulfoxide (DMSO). Furthermore, investigational drugs such as tanezumab and adalimumab, capable of sequestering nerve growth factor (NGF), and Tumor necrosis factor-α (TNF- α) are discussed. Investigational treatments such as liposomes, botulinum toxin (BTX), liposomal BTX, PD-0299685 (a Ca(2+) channel ɑ2δ ligand), continuous intravesical lidocaine, and AQX-1125 (a novel SHIP1 activating compound) are also covered. EXPERT OPINION New investigational drugs offer promising improvements in clinical outcomes for BPS/IC patients; however, BPS/IC is a chronic pain disorder that is very vulnerable to a strong placebo effect. In addition, BPS/IC is a heterogeneous disorder that can be classified into several phenotypes. Since different phenotypes of BPS/IC respond differently to systemic and intravesical treatments, the authors believe that new drugs developed for BPS/IC are more likely to meet their predetermined clinical endpoints if the inclusion/exclusion criterion is tailored to specific phenotype of BPS/IC patients.
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Affiliation(s)
- Yao-Chi Chuang
- a Department of Urology, Kaohsiung Chang Gung Memorial Hospital , Chang Gung University College of Medicine , Kaohsiung , Taiwan.,b Institute of Medicine , Chung Shan Medical University , Taichung , Taiwan
| | - Christopher Chermansky
- c Department of Urology , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Mahendra Kashyap
- c Department of Urology , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
| | - Pradeep Tyagi
- c Department of Urology , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
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Cervigni M. Interstitial cystitis/bladder pain syndrome and glycosaminoglycans replacement therapy. Transl Androl Urol 2016; 4:638-42. [PMID: 26816865 PMCID: PMC4708541 DOI: 10.3978/j.issn.2223-4683.2015.11.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating chronic disease characterized by discomfort or recurrent abdominal and pelvic pains in the absence of urinary tract infections. Its symptomatology includes discomfort, increased bladder pressure, sensitivity and intense pain in the bladder and pelvic areas, increased voiding frequency and urgency, or a combination of these symptoms. For these reasons, this pathology has a very negative impact on quality of life. The etiology of IC/BPS is still not well understood and different hypotheses have been formulated, including autoimmune processes, allergic reactions, chronic bacterial infections, exposure to toxins or dietary elements, and psychosomatic factors. The finding of an effective and specific therapy for IC/BPS remains a challenge for the scientific community because of the lack of a consensus regarding the causes and the inherent difficulties in the diagnosis. The last recent hypothesis is that IC/BPS could be pathophysiologically related to a disruption of the bladder mucosa surface layer with consequent loss of glycosaminoglycans (GAGs). This class of mucopolysaccharides has hydrorepellent properties and their alteration expose the urothelium to many urinary toxic agents. It has been hypothesized that when these substances penetrate the bladder wall a chain is triggered in the submucosa. In order to improve the integrity and function of the bladder lining, GAG layer replenishment therapy is widely accepted as therapy for patients with IC/BPS who have poor or inadequate response to conventional therapy. Currently, Chondroitin sulfate (CS), heparin, hyaluronic acid (HA), and pentosan polysulphate (PPS), and combinations of two GAGs (CS and HA) are the available substances with different effectiveness rates in patients with IC/BPS. There are four different commercially available products for GAG replenishment including CS, heparin, HA and PPS. Each product has different concentrations and dosage formulations. Recently, a combination of CS and HA is the latest commercially available product with promising results.
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Affiliation(s)
- Mauro Cervigni
- Interstitial Cystitis Referral Center, Catholic University, Rome, Italy
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Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common and frequently misdiagnosed disorder in men. Hallmark symptoms are the presence of chronic discomfort attributed to the urinary bladder associated with bladder filling and relieved with bladder emptying, often associated with irritative voiding symptoms, in the absence of any other identifiable cause. It is often grouped with another common clinical entity, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Men with IC/BPS often suffer from a delay in diagnosis and subsequent treatment, often being categorized as having prostatitis, benign prostatic hyperplasia, or epididymitis before the correct diagnosis is reached. The etiology of IC/BPS is poorly understood, and its pathogenesis may involve multiple pathways leading to a common clinical entity. Diagnostic criteria continue to evolve over time as the understanding of IC/BPS improves, and a clinical diagnosis with properly performed history and physical exam is suitable for diagnosis after other processes such as infection, radiation, or pharmaceutical exposure are appropriately excluded. No set pathological findings, biomarkers, or phenotypic descriptions have been universally accepted as a result of conflicting studies. Guidelines for diagnostic and treatment options are limited by available data, and few studies incorporate substantial numbers of male patients. Reported outcomes for common therapies are mixed or have not yet been subjected to study in rigorous placebo-controlled clinical trials in men. Lessons learned from the treatment of CP/CPPS can be applied to IC/BPS, by favoring a phenotypically directed, multimodal approach rather than a stepwise algorithm as advocated by current practice guidelines.
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Affiliation(s)
- Hans C Arora
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Daniel A Shoskes
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Pazin C, de Souza Mitidieri AM, Silva APM, Gurian MBF, Poli-Neto OB, Rosa-e-Silva JC. Treatment of bladder pain syndrome and interstitial cystitis: a systematic review. Int Urogynecol J 2015; 27:697-708. [DOI: 10.1007/s00192-015-2815-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 07/24/2015] [Indexed: 11/28/2022]
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Henry RA, Morales A, Cahill CM. Beyond a Simple Anesthetic Effect: Lidocaine in the Diagnosis and Treatment of Interstitial Cystitis/bladder Pain Syndrome. Urology 2015; 85:1025-1033. [PMID: 25917728 DOI: 10.1016/j.urology.2015.01.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 12/29/2014] [Accepted: 01/17/2015] [Indexed: 11/19/2022]
Abstract
Intravesical local anesthetics, in a wide variety of combinations, are increasingly used to treat patients with interstitial cystitis-bladder pain syndrome (IC/BPS). Lidocaine has demonstrated properties that block the neuroinflammatory cycle associated with IC/BPS at many of the interactive points in this cycle. Intravesical lidocaine has been shown to assist in identifying the bladder as the source of pain in patients with pelvic pain. An appreciation of these anti-inflammatory effects and of the pharmacokinetics of intravesical lidocaine in patients with IC/BPS could lead to a safe and effective diagnosis and treatment for an as yet unidentified subset of patients in the IC/BPS spectrum.
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Affiliation(s)
- Richard A Henry
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alvaro Morales
- Department of Urology, Queen's University, Kingston, Ontario, Canada.
| | - Catherine M Cahill
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
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Lee CL, Peng CH, Kuo HC. Therapeutic effects and predictive factors for successful intravesical hyaluronic acid instillation in patients with interstitial cystitis/bladder pain syndrome. UROLOGICAL SCIENCE 2015. [DOI: 10.1016/j.urols.2014.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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23
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Chennamsetty A, Ehlert MJ, Peters KM, Killinger KA. Advances in Diagnosis and Treatment of Interstitial Cystitis/Painful Bladder Syndrome. Curr Infect Dis Rep 2014; 17:454. [DOI: 10.1007/s11908-014-0454-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hung M, Su T, Lin Y, Huang W, Lin T, Hsu C, Chuang F, Tsai C, Shen P, Chen G. Changes in Sexual Function of Women with Refractory Interstitial Cystitis/Bladder Pain Syndrome after Intravesical Therapy with a Hyaluronic Acid Solution. J Sex Med 2014; 11:2256-63. [DOI: 10.1111/jsm.12507] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Lv YS, Yao YS, Rong L, Lin ME, Deng BH, Xie Y, Huang H, Lin TX, Xu KW, Huang J. Intravesical hyaluronidase causes chronic cystitis in a rat model: a potential model of bladder pain syndrome/interstitial cystitis. Int J Urol 2013; 21:601-7. [PMID: 24286489 DOI: 10.1111/iju.12358] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 10/29/2013] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine whether a potential rat model of bladder pain syndrome could be developed through long-term intermittent intravesical hyaluronidase. METHODS A total of 64 female Sprague-Dawley rats were divided into a control group, a low-dose hyaluronidase (1 mg/mL) group, a high-dose hyaluronidase (4 mg/mL) group and a hyaluronic acid-treated group. Hyaluronidase was given intravesically three times a week for 1 month. Hyaluronic acid (0.5 mL, 0.8 mg/mL) was introduced intravesically to hyaluronidase-treated rats' bladders. Histological changes, cystometry, nociceptive behaviors, and messenger ribonucleic acid levels of inflammatory factors were evaluated and compared between groups. RESULTS All hyaluronidase-treated rats showed chronic inflammation and fibrosis, increased and activated mast cells, thinned bladder epithelium with abnormal expressions of uroplakin III and zonula occluden-1, and increased levels of interleukin-6 and intercellular adhesion molecule-1 messenger ribonucleic acid. However, the inflammatory score and levels of interleukin-6 and intercellular adhesion molecule-1 were more significant in the high-dose hyaluronidase group than in the low-dose hyaluronidase group (P < 0.01). Furthermore, hyaluronidase-treated rats showed markedly decreased intercontraction intervals, bladder capacity and increased sensitivity to pain compared with controls (P < 0.01). Hyaluronic acid treatment significantly decreased the inflammatory level, number of mast cells, sensitivity to pain, levels of interleukin-6 and intercellular adhesion molecule-1, and increased intercontraction intervals and bladder capacity (P < 0.01). CONCLUSIONS Long-term intermittent intravesical hyaluronidase could develop a severe chronic cystitis with diffused fibrosis accompanied by altered histology and bladder function. This chronic cystitis rat model can resemble the clinical and histopathological features of human bladder pain syndrome, and might be a potential valuable model for investigation of this troublesome disease.
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Affiliation(s)
- Yi Song Lv
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Department of Urology, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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GAGs and GAGs diseases: when pathophysiology supports the clinic. Urologia 2013; 80:173-8. [PMID: 24526593 DOI: 10.5301/ru.2013.11500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 11/20/2022]
Abstract
The urinary epithelium has been the subject of considerable interest and much research in recent years. What has radically changed in the last decade is the concept of what the bladder epithelium really is. It is currently no longer considered just a simple barrier and a non-specific defence against infections, and it has been recognized as a specialized tissue regulating complex bladder functions and playing a fundamental and active role in the pathogenesis of cystitis. Researchers have been focussing on the receptors and mediators that are active in the sub-epithelial layer, with the hope that understanding the role of the urothelium defect will offer the opportunity for new therapeutic strategies. On the surface of the urothelial umbrella-cells there is a thick layer of glycoproteins and proteoglycans, which together are called Glycosaminoglycans (GAGs). They constitute a hydrophilic mucosal coating and act as a barrier against solutes found in urine. In recent years they have received special attention because injury to Gags, due to different noxae, has been identified as the first step in the genesis of chronic inflammatory bladder diseases, such as recurrent urinary tract infections, chemical or radiation cystitis, interstitial cystitis and/or Bladder Pain Syndrome. Aim of this study is to define the importance of the urothelium starting from the anatomy and physiology of the bladder wall. Furthermore, we will underline the role of glycosaminoglycans, focusing both on their pathophysiological role in the principal bladder diseases and on the therapeutic aspects from the clinical point of view.
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Chrysanthopoulou EL, Doumouchtsis SK. Challenges and current evidence on the management of bladder pain syndrome. Neurourol Urodyn 2013; 33:1193-201. [DOI: 10.1002/nau.22475] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 07/09/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Eleftheria L. Chrysanthopoulou
- Department of Obstetrics and Gynaecology; St George's Healthcare NHS Trust/St George's University of London; London United Kingdom
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Lv YS, Yao YS, Lin ME, Rong L, Deng BH, Huang J, Hao WP. Interleukin-6 levels in female rats with protamine sulfate-induced chronic cystitis treated with hyaluronic acid. Int J Urol 2013; 20:1017-22. [PMID: 23379983 DOI: 10.1111/iju.12090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 12/26/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | - You-Sheng Yao
- Department of Urology; Sun Yat-sen Memorial Hospital; Sun Yat-sen University; Guangzhou; China
| | | | - Lu Rong
- Department of Urology; Sun Yat-sen Memorial Hospital; Sun Yat-sen University; Guangzhou; China
| | - Bi-Hua Deng
- Department of Urology; Sun Yat-sen Memorial Hospital; Sun Yat-sen University; Guangzhou; China
| | - Jian Huang
- Department of Urology; Sun Yat-sen Memorial Hospital; Sun Yat-sen University; Guangzhou; China
| | - Wei-Ping Hao
- Department of Urology; Sun Yat-sen Memorial Hospital; Sun Yat-sen University; Guangzhou; China
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