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MacDiarmid S, Glazier DB, McCrery RJ, Kennelly MJ, Nelson M, Ifantides KB, McCammon KA. Efficacy and safety of an alternative onabotulinumtoxinA injection paradigm for refractory overactive bladder. Neurourol Urodyn 2024; 43:31-43. [PMID: 37746881 DOI: 10.1002/nau.25290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 09/26/2023]
Abstract
AIMS In studies utilizing a 20-injection-site paradigm of onabotulinumtoxinA treatment for overactive bladder (OAB), some patients performed clean intermittent catheterization (CIC). An alternative injection paradigm of fewer injections targeting the lower bladder may reduce the need for CIC by maintaining upper bladder function. This study evaluated the efficacy and safety of an unapproved alternative 10-injection-site paradigm targeting the lower bladder. METHODS In this phase 4, double-blind, parallel-group study, patients with OAB and urinary incontinence (UI) for ≥6 months with ≥3 episodes of urinary urgency incontinence (no more than 1 UI-free day) and ≥8 micturitions per day over 3 days during screening were randomized 2:1 to onabotulinumtoxinA 100 U or placebo injected at 10 sites in the lower bladder. RESULTS Of 120 patients, 78 in the onabotulinumtoxinA group and 39 in the placebo group had efficacy assessments. In the double-blind phase, mean change from baseline at week 12 in daily frequency of UI episodes was greater with onabotulinumtoxinA (-2.9) versus placebo (-0.3) (least squares mean difference [LSMD]: -2.99, p < 0.0001). Achievement of 100% (odds ratio [OR]: 6.15 [95% confidence interval, CI: 0.75-50.37]), ≥75% (OR: 7.25 [2.00-26.29]), and ≥50% improvement (OR: 4.79 [1.87-12.28]) from baseline in UI episodes was greater with onabotulinumtoxinA versus placebo. Reductions from baseline in the daily average number of micturitions (LSMD: -2.24, p < 0.0001), nocturia (LSMD: -0.71, p = 0.0004), and urgency (LSMD: -2.56, p < 0.0001) were greater with onabotulinumtoxinA than with placebo. Treatment benefit was improved or greatly improved in the onabotulinumtoxinA group (74.0% of patients) versus placebo (17.6%) (OR: 13.03 [95% CI: 3.23-52.57]). Mean change from baseline in Incontinence Quality of Life score was greater with onabotulinumtoxinA versus placebo (LSMD: 24.2, p = 0.0012). Two of 78 (2.6%) patients in the onabotulinumtoxinA group used CIC during the double-blind period; no females used CIC during the double-blind period. Commonly reported adverse events (≥5%) were urinary tract infection (UTI), dysuria, and productive cough for both groups; rate of UTI was higher with onabotulinumtoxinA versus placebo. CONCLUSION In patients treated with onabotulinumtoxinA for OAB with UI, an unapproved alternative injection paradigm targeting the lower bladder demonstrated efficacy over placebo, with a low incidence of CIC.
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Affiliation(s)
| | | | - Rebecca J McCrery
- Adult and Pediatric Urology and Urogynecology, Omaha, Nebraska, USA
- Virginia Urology, Richmond, Virginia, USA
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Dmochowski RR, Rovner ES, Kennelly MJ, Newman DK, Abedinzadeh L, Snyder D, Thomas E, Haag-Molkenteller C, Rosenberg MT. Study design of a phase 4, real-world study (COMPOSUR) to evaluate vibegron in patients with overactive bladder. BMC Urol 2023; 23:64. [PMID: 37095473 PMCID: PMC10124676 DOI: 10.1186/s12894-023-01240-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 04/06/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Overactive bladder (OAB) is defined as urinary urgency accompanied by frequency and nocturia, with or without urge urinary incontinence (UUI). Vibegron, a selective β3-adrenergic receptor agonist approved in the US in December 2020, demonstrated efficacy in reducing symptoms of OAB and was safe and well tolerated in the 12-week EMPOWUR trial and its 40-week, double-blind extension trial. The goal of the COMPOSUR study is to evaluate vibegron in a real-world setting to assess patient treatment satisfaction, tolerability, safety, duration of treatment, and persistence. METHODS This is a 12-month, prospective, observational, real-world study, with an optional 12-month extension to 24 months, in the US assessing adults ≥ 18 years old starting a new course of vibegron. Patients must be previously diagnosed with OAB with or without UUI, symptomatic for ≥ 3 months before enrollment, and receive prior treatment with an anticholinergic, with mirabegron, or with a combination of an anticholinergic and mirabegron. Enrollment is performed by the investigator following exclusion and inclusion criteria guided by US product labeling, reinforcing a real-world approach. Patients complete the OAB Satisfaction with Treatment Questionnaire (OAB-SAT-q) monthly and the OAB Questionnaire short form (OAB-q-SF) and Work Productivity and Activity Impairment Questionnaire (WPAI:US) at baseline and monthly for 12 months. Patients are followed up via phone call, in-person visits, or telehealth (ie, virtual) visits. The primary endpoint is patient treatment satisfaction as determined by the OAB-SAT-q satisfaction domain score. Secondary endpoints include percent positive responses to individual OAB-SAT-q questions, additional OAB-SAT-q domain scores, and safety. Exploratory endpoints include adherence and persistence. DISCUSSION OAB leads to a significant decrease in quality of life, as well as impairment of work activities and productivity. Persistence with OAB treatments can be challenging, often due to lack of efficacy and adverse effects. COMPOSUR is the first study to provide long-term, prospective, pragmatic treatment data for vibegron in the US and the resultant effect on quality of life among patients with OAB in a real-world clinical setting. Trial registration ClinicalTrials.gov identifier: NCT05067478; registered: October 5, 2021.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA.
| | - Eric S Rovner
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Diane K Newman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Werneburg GT, Welk B, Averbeck MA, Blok BFM, Hamid R, Kennelly MJ, Liao L, Musco S, Vasudeva P, Kessler TM. Neuro-Urology: Call for Universal, Resource-Independent Guidance. Biomedicines 2023; 11:biomedicines11020397. [PMID: 36830934 PMCID: PMC9953088 DOI: 10.3390/biomedicines11020397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/01/2023] Open
Abstract
Neurogenic lower urinary tract dysfunction (NLUTD), the abnormal function of the lower urinary tract in the context of neurological pathology, has been the subject of multiple efforts worldwide for the development of clinical practice guidelines. These guidelines are based on the same body of evidence, and are therefore subject to the same gaps. For example, sexual and bowel dysfunction in the context of NLUTD, optimal renal function assessment in those who are non-ambulatory or with low muscle mass, optimal upper tract surveillance timing, and modification of diagnostic and treatment modalities for low-resource nations and communities are inadequately addressed. In addition, many aspects of the conclusions and final recommendations of the guidelines are similar. This duplicative work represents a large expenditure of time and effort, which we believe could be focused instead on evidence gaps. Here, we call for a global unified approach to create a single, resource-independent, comprehensive guidance on NLUTD, neurogenic sexual, and neurogenic bowel dysfunction. Targeted research addressing the evidence gaps should be called for and pursued. This will allow for focus to shift to filling the gaps in the evidence for future guidelines.
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Affiliation(s)
- Glenn T. Werneburg
- Department of Urology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Blayne Welk
- Department of Surgery and Epidemiology & Biostatistics, Western University, London, ON N6A 3K7, Canada
| | - Marcio A. Averbeck
- Department of Urology, Moinhos de Vento Hospital, Porto Alegre 90035-000, Brazil
| | - Bertil F. M. Blok
- Department of Urology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Rizwan Hamid
- Department of Neuro-Urology, London Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
| | - Michael J. Kennelly
- Department of Urology, Atrium Health, Carolinas Rehabilitation, Charlotte, NC 28203, USA
| | - Limin Liao
- Department of Urology, China Rehabilitation Research Centre and Capital Medical University, Beijing 100068, China
| | - Stefania Musco
- Department of Neuro-Urology, Azienda Ospedaliera Careggi, 50134 Florence, Italy
| | - Pawan Vasudeva
- Department of Urology & Renal Transplant, V.M. Medical College and Safdarjang Hospital, New Delhi 110029, India
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Correspondence:
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Frankel J, Staskin D, Varano S, Kennelly MJ, Jankowich RA, Haag-Molkenteller C. An Evaluation of the Efficacy and Safety of Vibegron in the Treatment of Overactive Bladder. Ther Clin Risk Manag 2022; 18:171-182. [PMID: 35264853 PMCID: PMC8901416 DOI: 10.2147/tcrm.s310371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/13/2022] [Indexed: 11/23/2022] Open
Abstract
Pharmacologic treatment for overactive bladder (OAB), which is characterized by bothersome symptoms such as urgency and urge urinary incontinence (UUI), includes anticholinergics and β3-adrenergic receptor agonists. Anticholinergics are associated with adverse effects including dry mouth, constipation, cognitive impairment, and increased risk of dementia. Therefore, the drug class of β3-adrenergic receptor agonists may represent an effective, safe treatment option. Vibegron, a β3-adrenergic receptor agonist, was approved for use in Japan (2018) and the United States (2020). Over the past 3 years, 2 phase 3 trials (EMPOWUR, EMPOWUR extension) have been conducted with once-daily vibegron 75 mg for the treatment of OAB, and additional secondary and subgroup analyses have detailed the efficacy and safety of vibegron. In the international phase 3 EMPOWUR trial, treatment with vibegron was associated with significant improvements compared with placebo in efficacy outcomes of micturition frequency, UUI episodes, urgency episodes, and volume voided as early as week 2 that were sustained throughout the 12-week trial. The 40-week EMPOWUR extension study, following the 12-week treatment period, demonstrated sustained efficacy in patients receiving vibegron for 52 weeks. Treatment with vibegron was also associated with improvements in patient-reported measures of quality of life. Across studies, vibegron was generally safe and well tolerated. A separate, dedicated ambulatory blood pressure monitoring study showed that treatment with vibegron was not associated with clinically meaningful effects on blood pressure or heart rate. Across all studies, vibegron was efficacious, safe, and well tolerated and thus represents a valuable treatment option for patients with OAB. Here, nearly 1 year after US approval, we review the published data on efficacy and safety of vibegron 75 mg for the treatment of OAB.
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Affiliation(s)
- Jeffrey Frankel
- Seattle Urology Research Center, Seattle, WA, USA
- Correspondence: Jeffrey Frankel, PO Box 1192, Mercer Island, WA 98040, USA, Tel +1 206 972 2775, Email
| | - David Staskin
- Tufts University School of Medicine, Boston, MA, USA
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Kennelly MJ, Rhodes T, Girman CJ, Thomas E, Shortino D, Mudd PN. Efficacy of Vibegron and Mirabegron for Overactive Bladder: A Systematic Literature Review and Indirect Treatment Comparison. Adv Ther 2021; 38:5452-5464. [PMID: 34537953 PMCID: PMC8520873 DOI: 10.1007/s12325-021-01902-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/24/2021] [Indexed: 01/05/2023]
Abstract
Background In the absence of head-to-head trials, we performed an indirect treatment comparison of the β3-adrenergic agonists vibegron and mirabegron in the treatment of overactive bladder (OAB). Methods PubMed, Embase, and Cochrane Library were searched for articles related to phase 3, double-blind, controlled trials of vibegron 75 mg and mirabegron 25/50 mg in patients with OAB. Efficacy outcomes included change from baseline at weeks 4, 12, and 52 in mean daily number of total urinary incontinence episodes and micturitions and mean volume voided/micturition. Effect size was computed as placebo-subtracted change from baseline (weeks 4, 12) or active control (tolterodine)-subtracted change from baseline (week 52) for each treatment group. Adverse events (AEs) are presented descriptively. Results After removal of duplicates, 49 records were identified, and after screening 9 met inclusion criteria for analysis. Vibegron showed significantly greater reduction in mean daily number of total incontinence episodes than mirabegron 25 mg at week 4, mirabegron 50 mg (weeks 4, 52), and tolterodine (weeks 4, 12) (P < 0.05, each) and significantly greater improvement in volume voided versus mirabegron 25 mg (week 12), mirabegron 50 mg (weeks 12, 52), and tolterodine (week 4) (P < 0.05, each). Confidence intervals of point estimates overlapped zero for all other comparisons of vibegron and mirabegron (25 or 50 mg) or tolterodine, indicating no significant differences between treatments for these time/endpoints. Urinary tract infection, hypertension, and dry mouth were the most commonly occurring AEs for vibegron, mirabegron, and tolterodine, respectively, in the short-term trials; hypertension was the most commonly occurring AE with all three treatments in the long-term trials. Conclusions Vibegron was associated with significant improvement in total incontinence episodes versus mirabegron at 4 and 52 weeks and volume voided at 12 and 52 weeks. Improvement in micturitions was similar between vibegron and mirabegron or tolterodine. Incidence of AEs was generally comparable between vibegron and mirabegron. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01902-8.
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Affiliation(s)
- Michael J Kennelly
- Department of Urology, Obstetrics and Gynecology, Carolinas Medical Center, 2001 Vail Ave, Suite 360, Charlotte, NC, 28207, USA.
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Miller CA, Kennelly MJ. Pulse article: survey of neurogenic bladder management in spinal cord injury patients around the world. Spinal Cord Ser Cases 2021; 7:16. [PMID: 33674552 DOI: 10.1038/s41394-021-00388-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 11/09/2022] Open
Abstract
STUDY DESIGN Online survey distributed to healthcare professionals (HCPs) involved in care of spinal cord injury (SCI) patients with neurogenic lower urinary tract dysfunction (NLUTD). OBJECTIVES Identify and bring awareness to the variation of neurogenic bladder management in around the world. SETTING International online questionnaire. METHODS A 32-question survey was drafted and circulated among a global network of SCI experts for review. The survey was disseminated to healthcare professionals involved in the care of NLUTD in SCI patients via social media, grassroots methods, and international societies. The survey was available for 6 weeks and respondents answered questions regarding SCI population demographics, access to care, common neurogenic bladder management, diagnostic and imaging methods, complications, and follow up. RESULTS A total of 296 healthcare professionals, 132 from North America, 87 from Europe, 27 from Asia, 24 from Australia, 14 from South America, and 6 from Africa, responded to the survey. Global concurrence was noted among management method for patients without adequate hand function, first-line treatment for neurogenic detrusor overactivity, and common complications. Continents highly differed in responses regarding management method for patients with adequate hand function, frequency of patients reusing catheters, timing of urodynamics, and duration of antibiotic therapy for urinary tract infections. CONCLUSIONS The results of this international survey demonstrate the variability and uniqueness in neurogenic bladder management in SCI patients around the world. Increased international discourse and education will improve global communication and transparency with the efforts of reducing discrepancies in care.
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Affiliation(s)
| | - Michael J Kennelly
- Department of Urology, Atrium Health, Charlotte, NC, USA.,Carolinas Rehabilitation Center, Atrium Health, Charlotte, NC, USA
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Milligan J, Goetz LL, Kennelly MJ. A Primary Care Provider's Guide to Management of Neurogenic Lower Urinary Tract Dysfunction and Urinary Tract Infection After Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2020; 26:108-115. [PMID: 32760189 DOI: 10.46292/sci2602-108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neurogenic lower urinary tract dysfunction (NLUTD), previously termed neurogenic bladder dysfunction, is a common secondary complication of spinal cord injury (SCI). It is associated with significant morbidity, reduced quality of life, increased health care costs, and mortality. Primary care providers (PCPs) play an important role in optimizing urohealth over the life span. This article will review NLUTD in SCI, its complication, surveillance, and management. PCPs should be aware of SCI-related NLUTD, its complications, management, and surveillance recommendations, and when to refer to a specialist.
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Affiliation(s)
- James Milligan
- The Centre for Family Medicine, Kitchener, Ontario, Canada.,McMaster University Department of Family Medicine, Hamilton, Ontario, Canada
| | - Lance L Goetz
- Department of Veterans Affairs, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Michael J Kennelly
- Carolinas Rehabilitation, Charlotte, North Carolina.,Atrium Health, Charlotte, North Carolina
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Abstract
PURPOSE OF REVIEW Pelvic organ prolapse (POP) is a common condition and there is a plethora of surgical techniques available to address this problem. We present a review of biologic grafts, including the latest literature to help guide a surgeon's choice on the type of biologic materials to augment repairs. RECENT FINDINGS Since the 2019 Food and Drug Administration (FDA) ban on mesh, including xenograft, there is a sparsity of biologic graft products available for POP repairs. This has led to a significant decrease in surgical application. Surgeons must be familiar with the biochemical properties, processing, and clinical application of biologic grafts prior to use. They should also be familiar with alternative operative techniques that utilize autografts, although there is limited outcome data on these techniques. With heightened awareness of mesh and its complications, biologic grafts have made a resurgence. Surgeons must be well versed on their available options. Current literature is limited, and studies have not demonstrated superiority of biologic graft over native tissue repairs for prolapse. Nevertheless, there is a role for these types of biologic graft material in specific patient populations. Future studies are warranted.
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Affiliation(s)
- Amanda L Merriman
- Atrium Health, Division of Urogynecology and Pelvic Surgery, 2001 Vail Avenue, Charlotte, NC, 28207, USA.
| | - Michael J Kennelly
- Atrium Health, Division of Urogynecology and Pelvic Surgery, 2001 Vail Avenue, Charlotte, NC, 28207, USA
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Affiliation(s)
- Michael J. Kennelly
- Academy of Spinal Cord Injury Professionals, Atrium Health, Charlotte, North Carolina, USA,Correspondence to: Michael J. Kennelly, President, Academy of Spinal Cord Injury Professionals, Atrium Health, Charlotte, NC, USA.
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Cheng PJ, Keihani S, Roth JD, Pariser JJ, Elliott SP, Bose S, Khavari R, Crescenze I, Stoffel JT, Velaer KN, Elliott CS, Raffee SM, Atiemo HO, Kennelly MJ, Lenherr SM, Myers JB. Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10‐year period: A Neurogenic Bladder Research Group study. Neurourol Urodyn 2020; 39:1771-1780. [DOI: 10.1002/nau.24420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 12/25/2022]
Affiliation(s)
| | - Sorena Keihani
- Division of UrologyUniversity of Utah Salt Lake City Utah
| | - Joshua D. Roth
- Department of UrologyIndiana University School of Medicine Indianapolis Indiana
| | | | - Sean P. Elliott
- Department of UrologyUniversity of Minnesota Minneapolis Minnesota
| | - Sanchita Bose
- Department of UrologyHouston Methodist Hospital Houston Texas
| | - Rose Khavari
- Department of UrologyHouston Methodist Hospital Houston Texas
| | - Iryna Crescenze
- Department of UrologyUniversity of Michigan Ann Arbor Michigan
| | - John T. Stoffel
- Department of UrologyUniversity of Michigan Ann Arbor Michigan
| | - Kyla N. Velaer
- Department of UrologyStanford University Stanford California
| | - Christopher S. Elliott
- Department of UrologyStanford University Stanford California
- Division of UrologySanta Clara Valley Medical Center San Jose California
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Tate DG, Wheeler T, Lane GI, Forchheimer M, Anderson KD, Biering-Sorensen F, Cameron AP, Santacruz BG, Jakeman LB, Kennelly MJ, Kirshblum S, Krassioukov A, Krogh K, Mulcahey MJ, Noonan VK, Rodriguez GM, Spungen AM, Tulsky D, Post MW. Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease. J Spinal Cord Med 2020; 43:141-164. [PMID: 32105586 PMCID: PMC7054930 DOI: 10.1080/10790268.2019.1706033] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.
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Affiliation(s)
- Denise G. Tate
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Giulia I. Lane
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Martin Forchheimer
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Kim D. Anderson
- Department of Physical Medicine and Rehabilitation, Metro Health Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Fin Biering-Sorensen
- Clinic for Spinal Cord Injuries, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Lyn B. Jakeman
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael J. Kennelly
- Department of Urology, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Steve Kirshblum
- Rutgers New Jersey Medical School, Kessler Foundation, Kessler Institution for Rehabilitation, West Orange, New Jersey, USA
| | - Andrei Krassioukov
- International collaboration On Repair Discoveries (ICORD), Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Klaus Krogh
- Department of Clinical Medicine, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - M. J. Mulcahey
- Jefferson College of Rehabilitation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vanessa K. Noonan
- The Praxis Spinal Institute, The Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Gianna M. Rodriguez
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Ann M. Spungen
- VA RR&D National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | - David Tulsky
- Department of Physical Therapy and Psychological & Brain Sciences, University of Delaware, Newark, Delaware, USA
| | - Marcel W. Post
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Brain Center, University Medical Center Utrecht, University of Utrecht and De Hoogstraat, Utrecht, the Netherlands
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De Wachter S, Knowles CH, Elterman DS, Kennelly MJ, Lehur PA, Matzel KE, Engelberg S, Van Kerrebroeck PEV. New Technologies and Applications in Sacral Neuromodulation: An Update. Adv Ther 2020; 37:637-643. [PMID: 31875299 PMCID: PMC7004424 DOI: 10.1007/s12325-019-01205-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 11/26/2022]
Abstract
Recently rechargeable devices have been introduced for sacral neuromodulation (SNM) with conditional safety for full-body magnetic resonance imaging (MRI). Currently a recharge-free SNM device represents the standard implant; however, it is only approved for MRI head scans. As further new technologies with broader MRI capabilities are emerging, the advantages as well as disadvantages of both rechargeable versus recharge-free devices will be briefly discussed in this commentary from the perspective of patients, healthcare professionals, and providers.
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Affiliation(s)
- Stefan De Wachter
- Department of Urology, University Hospital Antwerpen, Antwerp, Belgium.
- Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wlrijk, Belgium.
| | - Charles H Knowles
- Blizard Institute, Barts and the London SMD, Queen Mary University of London, London, UK
| | - Dean S Elterman
- Division of Urology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - Michael J Kennelly
- Department of Urology, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Paul A Lehur
- Coloproctology Unit, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Klaus E Matzel
- Chirurgische Klinik, Universität Erlangen, Erlangen, Germany
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Bastawros D, Hendley N, Zhao J, Myers EM, Taylor GB, Kennelly MJ, Stepp KJ, Tarr ME. 1463 Postvoid Residual Measurements by Bladder Ultrasound in Obese Women: Are They Accurate? J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wheeler TL, de Groat W, Eisner K, Emmanuel A, French J, Grill W, Kennelly MJ, Krassioukov A, Gallo Santacruz B, Biering-Sørensen F, Kleitman N. Translating promising strategies for bowel and bladder management in spinal cord injury. Exp Neurol 2018; 306:169-176. [PMID: 29753647 PMCID: PMC8117184 DOI: 10.1016/j.expneurol.2018.05.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/23/2018] [Accepted: 05/01/2018] [Indexed: 12/18/2022]
Abstract
Loss of control over voiding following spinal cord injury (SCI) impacts autonomy, participation and dignity, and can cause life-threatening complications. The importance of SCI bowel and bladder dysfunction warrants significantly more attention from researchers in the field. To address this gap, key SCI clinicians, researchers, government and private funding organizations met to share knowledge and examine emerging approaches. This report reviews recommendations from this effort to identify and prioritize near-term treatment, investigational and translational approaches to addressing the pressing needs of people with SCI.
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Affiliation(s)
- Tracey L Wheeler
- Craig H. Neilsen Foundation, 16830 Ventura Blvd, Suite 352, Encino, CA 91436, United States.
| | - William de Groat
- University of Pittsburgh, Department of Pharmacology and Chemical Biology, W-1352 Starzl Biomedical Science Tower, University of Pittsburgh Medical School, 200 Lothrop Street, Pittsburgh, PA 15261, United States.
| | - Kymberly Eisner
- Craig H. Neilsen Foundation, 16830 Ventura Blvd, Suite 352, Encino, CA 91436, United States
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, London NW1 2BU, UK.
| | - Jennifer French
- Neurotech Network, PO Box 16776, Saint Petersburg, FL 33733, United States.
| | - Warren Grill
- Duke University, Department of Biomedical Engineering, Fitzpatrick CIEMAS, Room 1427, Box 90281, Durham, NC 27708-0281, United States.
| | - Michael J Kennelly
- Carolinas HealthCare System, McKay Urology, 1023 Edgehill Road South, Charlotte, NC 28207, United States.
| | - Andrei Krassioukov
- ICORD, University of British Columbia, GF Strong Rehabilitation Centre, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
| | | | - Fin Biering-Sørensen
- Rigshospitalet (2081), Blegdamsvej 9, DK-2100 Copenhagen, Denmark; University of Copenhagen, Clinic for Spinal Cord Injuries, NeuroScience Centre Havnevej 25, DK-3100 Hornbæk, Denmark
| | - Naomi Kleitman
- Craig H. Neilsen Foundation, 16830 Ventura Blvd, Suite 352, Encino, CA 91436, United States
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Chang CH, Hardy LA, Peters MG, Bastawros DA, Myers EM, Kennelly MJ, Fried NM. Optical Clearing of Vaginal Tissues in Cadavers. Proc SPIE Int Soc Opt Eng 2018; 10468:104680K. [PMID: 30774176 PMCID: PMC6377076 DOI: 10.1117/12.2285079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A nonsurgical laser procedure is being developed for treatment of female stress urinary incontinence (SUI). Previous studies in porcine vaginal tissues, ex vivo, as well as computer simulations, showed the feasibility of using near-infrared laser energy delivered through a transvaginal contact cooling probe to thermally remodel endopelvic fascia, while preserving the vaginal wall from thermal damage. This study explores optical properties of vaginal tissue in cadavers as an intermediate step towards future pre-clinical and clinical studies. Optical clearing of tissue using glycerol resulted in a 15-17% increase in optical transmission after 11 min at room temperature (and a calculated 32.5% increase at body temperature). Subsurface thermal lesions were created using power of 4.6 - 6.4 W, 5.2-mm spot, and 30 s irradiation time, resulting in partial preservation of vaginal wall to 0.8 - 1.1 mm depth.
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Affiliation(s)
- Chun-Hung Chang
- Department of Physics and Optical Science, University of North Carolina at Charlotte, NC
| | - Luke A. Hardy
- Department of Physics and Optical Science, University of North Carolina at Charlotte, NC
| | - Michael G. Peters
- Women’s Center for Pelvic Health, Carolinas Medical Center, Charlotte, NC
| | - Dina A. Bastawros
- Women’s Center for Pelvic Health, Carolinas Medical Center, Charlotte, NC
| | - Erinn M. Myers
- Women’s Center for Pelvic Health, Carolinas Medical Center, Charlotte, NC
| | - Michael J. Kennelly
- Women’s Center for Pelvic Health, Carolinas Medical Center, Charlotte, NC
- McKay Department of Urology, Carolinas Medical Center, Charlotte, NC
| | - Nathaniel M. Fried
- Department of Physics and Optical Science, University of North Carolina at Charlotte, NC
- McKay Department of Urology, Carolinas Medical Center, Charlotte, NC
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Cameron AP, Campeau L, Brucker BM, Clemens JQ, Bales GT, Albo ME, Kennelly MJ. Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient. Neurourol Urodyn 2017; 36:915-926. [PMID: 28345769 DOI: 10.1002/nau.23253] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 11/12/2022]
Abstract
AIMS Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient. METHODS Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system. RESULTS All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification. CONCLUSIONS These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.
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Affiliation(s)
- Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Benjamin M Brucker
- New York Langone Medical Center, NYU Urology Associates, New York, New York
| | | | - Gregory T Bales
- Section of Urology, The University of Chicago, Chicago, Illinois
| | - Michael E Albo
- Division of Urology, UCSD Medical Center, San Diego, California
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Hardy LA, Chang CH, Myers EM, Kennelly MJ, Fried NM. Computer simulations of thermal tissue remodeling during transvaginal and transurethral laser treatment of female stress urinary incontinence. Lasers Surg Med 2017; 49:198-205. [PMID: 26900038 PMCID: PMC6095190 DOI: 10.1002/lsm.22491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES A non-surgical method is being developed for treating female stress urinary incontinence by laser thermal remodeling of subsurface tissues with applied surface tissue cooling. Computer simulations of light transport, heat transfer, and thermal damage in tissue were performed, comparing transvaginal and transurethral approaches. STUDY DESIGN/MATERIALS AND METHODS Monte Carlo (MC) simulations provided spatial distributions of absorbed photons in the tissue layers (vaginal wall, endopelvic fascia, and urethral wall). Optical properties (n,μa ,μs ,g) were assigned to each tissue at λ = 1064 nm. A 5-mm-diameter laser beam and incident power of 5 W for 15 seconds was used, based on previous experiments. MC output was converted into absorbed energy, serving as input for finite element heat transfer simulations of tissue temperatures over time. Convective heat transfer was simulated with contact probe cooling temperature set at 0°C. Variables used for thermal simulations (κ,c,ρ) were assigned to each tissue layer. MATLAB code was used for Arrhenius integral thermal damage calculations. A temperature matrix was constructed from ANSYS output, and finite sum was incorporated to approximate Arrhenius integral calculations. Tissue damage properties (Ea ,A) were used to compute Arrhenius sums. RESULTS For the transvaginal approach, 37% of energy was absorbed in the endopelvic fascia target layer with 0.8% deposited beyond it. Peak temperature was 71°C, the treatment zone was 0.8-mm-diameter, and 2.4 mm of the 2.7-mm-thick vaginal wall was preserved. For transurethral approach, 18% energy was absorbed in endopelvic fascia with 0.3% deposited beyond the layer. Peak temperature was 80°C, treatment zone was 2.0-mm-diameter, and 0.6 mm of 2.4-mm-thick urethral wall was preserved. CONCLUSIONS Computer simulations suggest that transvaginal approach is more feasible than transurethral approach. Lasers Surg. Med. 49:198-205, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Luke A. Hardy
- Department of Physics and Optical Science, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Chun-Hung Chang
- Department of Physics and Optical Science, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Erinn M. Myers
- McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J. Kennelly
- McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina
| | - Nathaniel M. Fried
- Department of Physics and Optical Science, University of North Carolina at Charlotte, Charlotte, North Carolina
- McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina
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Chang CH, Myers EM, Kennelly MJ, Fried NM. Optical clearing of vaginal tissues, ex vivo, for minimally invasive laser treatment of female stress urinary incontinence. J Biomed Opt 2017; 22:18002. [PMID: 28301637 PMCID: PMC5228554 DOI: 10.1117/1.jbo.22.1.018002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/22/2016] [Indexed: 05/12/2023]
Abstract
Near-infrared laser energy in conjunction with applied tissue cooling is being investigated for thermal remodeling of the endopelvic fascia during minimally invasive treatment of female stress urinary incontinence. Previous computer simulations of light transport, heat transfer, and tissue thermal damage have shown that a transvaginal approach is more feasible than a transurethral approach. However, results were suboptimal, and some undesirable thermal insult to the vaginal wall was still predicted. This study uses experiments and computer simulations to explore whether application of an optical clearing agent (OCA) can further improve optical penetration depth and completely preserve the vaginal wall during subsurface treatment of the endopelvic fascia. Several different mixtures of OCA’s were tested, and 100% glycerol was found to be the optimal agent. Optical transmission studies, optical coherence tomography, reflection spectroscopy, and computer simulations [including Monte Carlo (MC) light transport, heat transfer, and Arrhenius integral model of thermal damage] using glycerol were performed. The OCA produced a 61% increase in optical transmission through porcine vaginal wall at 37°C after 30 min. The MC model showed improved energy deposition in endopelvic fascia using glycerol. Without OCA, 62%, 37%, and 1% of energy was deposited in vaginal wall, endopelvic fascia, and urethral wall, respectively, compared with 50%, 49%, and 1% using OCA. Use of OCA also resulted in 0.5-mm increase in treatment depth, allowing potential thermal tissue remodeling at a depth of 3 mm with complete preservation of the vaginal wall.
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Affiliation(s)
- Chun-Hung Chang
- University of North Carolina at Charlotte, Department of Physics and Optical Science, 9201 University City Boulevard, Charlotte, North Carolina 28223, United States
| | - Erinn M. Myers
- Carolinas Medical Center, Women's Center for Pelvic Health, 2001 Vail Avenue, Suite 360, Charlotte, North Carolina 28207, United States
| | - Michael J. Kennelly
- Carolinas Medical Center, Women's Center for Pelvic Health, 2001 Vail Avenue, Suite 360, Charlotte, North Carolina 28207, United States
| | - Nathaniel M. Fried
- University of North Carolina at Charlotte, Department of Physics and Optical Science, 9201 University City Boulevard, Charlotte, North Carolina 28223, United States
- Carolinas Medical Center, Women's Center for Pelvic Health, 2001 Vail Avenue, Suite 360, Charlotte, North Carolina 28207, United States
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20
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Abstract
Overactive bladder (OAB) symptoms of urgency, frequency, and urge incontinence currently affect a substantial portion of the population, especially as age increases. Sacral neuromodulation has become a popular option for refractory OAB symptoms over the past 2 decades. Studies have demonstrated that it is an effective treatment for OAB and urge incontinence as indicated by decreased number of voids, increased bladder capacity, and fewer leakage events. In addition, the effects have proved to be durable to multiple years following implantation. These benefits come at the expense of a high rate of adverse events, although with comparable long-term cost-effectiveness to botulinum toxin A. We aimed to review the literature that demonstrates that sacral neuromodulation continues to be an efficacious treatment for refractory OAB wet and dry patients, with continuously expanding indications.
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Affiliation(s)
- Troy Sukhu
- Department of Urology, University of North Carolina, Chapel Hill
| | | | - Raj Kurpad
- Department of Urology, University of North Carolina, Chapel Hill
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21
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Hardy LA, Chang CH, Myers EM, Kennelly MJ, Fried NM. Laser Treatment of Female Stress Urinary Incontinence: Optical, Thermal, and Tissue Damage Simulations. Proc SPIE Int Soc Opt Eng 2016; 9689. [PMID: 30774178 DOI: 10.1117/12.2208126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Treatment of female stress urinary incontinence (SUI) by laser thermal remodeling of subsurface tissues is studied. Light transport, heat transfer, and thermal damage simulations were performed for transvaginal and transurethral methods. Monte Carlo (MC) provided absorbed photon distributions in tissue layers (vaginal wall, endopelvic fascia, urethral wall). Optical properties (n,μa,μs,g) were assigned to each tissue at λ=1064 nm. A 5-mm-diameter laser beam and power of 5 W for 15 s was used, based on previous experiments. MC output was converted into absorbed energy, serving as input for ANSYS finite element heat transfer simulations of tissue temperatures over time. Convective heat transfer was simulated with contact cooling probe set at 0 °C. Thermal properties (κ,c,ρ) were assigned to each tissue layer. MATLAB code was used for Arrhenius integral thermal damage calculations. A temperature matrix was constructed from ANSYS output, and finite sum was incorporated to approximate Arrhenius integral calculations. Tissue damage properties (Ea,A) were used to compute Arrhenius sums. For the transvaginal approach, 37% of energy was absorbed in endopelvic fascia layer with 0.8% deposited beyond it. Peak temperature was 71°C, treatment zone was 0.8-mm-diameter, and almost all of 2.7-mm-thick vaginal wall was preserved. For transurethral approach, 18% energy was absorbed in endopelvic fascia with 0.3% deposited beyond it. Peak temperature was 80°C, treatment zone was 2.0-mm-diameter, and only 0.6 mm of 2.4-mm-thick urethral wall was preserved. A transvaginal approach is more feasible than transurethral approach for laser treatment of SUI.
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Affiliation(s)
- Luke A Hardy
- Department of Physics and Optical Science, University of North Carolina at Charlotte
| | - Chun-Hung Chang
- Department of Physics and Optical Science, University of North Carolina at Charlotte
| | - Erinn M Myers
- McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J Kennelly
- McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina
| | - Nathaniel M Fried
- Department of Physics and Optical Science, University of North Carolina at Charlotte.,McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina
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Beusterien K, Kennelly MJ, Bridges JFP, Amos K, Williams MJ, Vasavada S. Use of best-worst scaling to assess patient perceptions of treatments for refractory overactive bladder. Neurourol Urodyn 2015; 35:1028-1033. [PMID: 26370222 DOI: 10.1002/nau.22876] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/19/2015] [Indexed: 11/07/2022]
Abstract
AIMS Refractory overactive bladder (OAB) treatments, including sacral neuromodulation (SNM), onabotulinumtoxin A (OnabotA), and percutaneous tibial nerve stimulation (PTNS), differ considerably. Best-Worst Scaling (BWS) was used to assess patient preferences for these treatments. METHODS A cross-sectional Web survey, based on findings from qualitative interviews with 23 OAB patients and 7 clinical experts, was conducted with idiopathic OAB patients in the US and UK. The BWS exercise involved prioritizing subsets of 13 attributes across 13 choice tasks, where patients identified the attribute they considered as best and as worst in each task. Attribute BWS scores, ranging from -1.0 (worst) to 1.0 (best) were calculated based on the rates that each attribute was chosen. Attitudes toward the attributes also were assessed via like/dislike Likert scales, and questions regarding the percentage likelihood (0-100%) of trying each treatment, based on standardized treatment descriptions. RESULTS The sample included 245 patients (118 US, 127 UK); 79% female, mean age 50 ± 7.8 years. All 13 attribute BWS scores were significantly positive or negative. "Lasting improvement" (0.82), "minimal side effects" (0.67), and "sends signals between bladder and brain" (0.35)' were rated most favorably, and "complications with implant" (-0.65), and "be willing to self-catheterize" (-0.53) were rated worst. All but one of the attribute BWS scores were significantly correlated with the respective like/dislike scores and the percentage likelihood estimates for trying one of the three treatments. CONCLUSION BWS was successful in assessing the magnitude of patient preferences for key attributes associated with substantially different refractory OAB therapies. Neurourol. Urodynam. 35:1028-1033, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Michael J Kennelly
- Women's Center for Pelvic Health, Carolinas Heathcare System, Charlotte, North Carolina
| | - John F P Bridges
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Sandip Vasavada
- Center for Female Pelvic Medicine and Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
Patients with neurologic disease commonly develop overactive bladder (OAB) symptoms of urgency, frequency, and/or urge incontinence that remain bothersome despite oral pharmacologic therapy. Management of refractory OAB in the neurogenic population is a complex issue with no uniform treatment strategy. When treatment fails or patients generally are dissatisfied with the adverse effects of oral therapy, available options include sacral neuromodulation, percutaneous tibial nerve stimulation (PTNS), botulinum toxin injections, and lower urinary tract reconstruction such as augmentation cystoplasty. A thorough knowledge and understanding of available and emerging treatment options for neurogenic detrusor overactivity is paramount to assisting clinicians in choosing an appropriate treatment. This article reviews the non-pharmacologic treatment options for neurogenic OAB, mainly botulinum toxin, neuromodulation, and lower urinary tract reconstruction, and discusses important relevant studies.
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Affiliation(s)
- Raj Kurpad
- Department of Urology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA,
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Kennelly MJ. Synthetic Sling for Index Patients with Stress Urinary Incontinence: The Correct Choice. J Urol 2015; 194:18-9. [PMID: 25892140 DOI: 10.1016/j.juro.2015.04.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Indexed: 11/29/2022]
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Moore RD, De Ridder D, Kennelly MJ. Two-year evaluation of the MiniArc in obese versus non-obese patients for treatment of stress urinary incontinence. Int J Urol 2012; 20:434-40. [PMID: 22989174 DOI: 10.1111/j.1442-2042.2012.03147.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 08/12/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Obesity is a well-established risk factor of stress urinary incontinence, which affects up to 35% of adult women worldwide. We evaluated whether there is a difference in outcomes with MiniArc sling for treatment of stress incontinence in obese women versus non-obese women at 24 months. METHODS A 2-year subanalysis of obese (body mass index >30 kg/m(2) ) versus non-obese patients enrolled into a multicenter, prospective study evaluating the effectiveness of MiniArc sling was carried out. Qualitative (Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7) and quantitative measurements, including the cough stress test, were carried out. Secondary outcome measures included procedure time, estimated blood loss, length of stay, perioperative complications, Wong-Baker Faces Pain Scale and adverse events. RESULTS Of 188 patients, 62 were obese. The mean procedure time, blood loss and length of stay were no different between groups. Obese patients reported significantly more pain immediately postoperatively (2 vs 1, Wong-Baker, P = 0.042), but there was no difference at postoperative day 7. There was no difference in objective cure using the cough stress test (81% obese vs 86% non-obese; P = 0.449). Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7 median scores showed no difference between groups in improvement (P = 0.126 and P = 0.087, respectively). No serious device-related complications were reported in either group. CONCLUSIONS The MiniArc sling represents a safe and effective treatment option for both obese and non-obese patients with stress incontinence. Comparable outcomes at 2 years can be obtained in terms of cure rates using the cough stress test or questionnaires, as well as complication rates.
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Affiliation(s)
- Robert D Moore
- Atlanta Urogynecology Associates, Atlanta, GA 30005, USA.
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Kennelly MJ, Moore R, Nguyen JN, Lukban J, Siegel S. Miniarc single-incision sling for treatment of stress urinary incontinence: 2-year clinical outcomes. Int Urogynecol J 2012; 23:1285-91. [PMID: 22527540 DOI: 10.1007/s00192-012-1734-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 03/04/2012] [Indexed: 01/11/2023]
Abstract
INTRODUCTION AND HYPOTHESIS We report 2-year data on the effectiveness and safety of the MiniArc single-incision sling in women with stress urinary incontinence. METHODS This multi-center, prospective, single-arm, industry-sponsored study measured the effectiveness of the MiniArc sling via quantitative (cough stress test and 1-h pad weight test) and qualitative (Urogenital Distress Inventory-Short Form and Incontinence Impact Questionnaire-Short Form) measurements. The objective efficacy rate was defined as the number of patients with a negative cough stress test or 1-h pad weight test ≤ 1 g at 2 years. The subjective efficacy rate was determined by patient responses to the UDI-6 question # 3, "Do you experience, and if so, how much are you bothered by urine leakage related to physical activity, coughing, or sneezing?" Secondary objectives were to evaluate procedural variables of implantation and long-term safety. RESULTS One hundred and eighty women with a mean age of 51.1 years were implanted in the study. Mean procedure time, blood loss, and length of stay were 11.0 min, 41.7 mL and 9.5 h respectively. At 2 years, 142 patients were available for analysis. The objective efficacy rates for the cough stress test (CST) and pad weight test (PWT) were 84.5 % and 80.1 % respectively and the subjective efficacy rate was 92.9 %. Median Urogenital Distress Inventory-Short Form and Incontinence Impact Questionnaire-Short Form scores showed statistically significant improvement (p < .001). The most common adverse events included UTI (4.8 %), constipation (3.7 %), and temporary urinary retention (3.2 %). CONCLUSION MiniArc is a safe and effective surgical procedure for the treatment of SUI in women with follow-up through 2 years.
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Affiliation(s)
- Michael J Kennelly
- Department of Urology, Carolinas Medical Center, Charlotte, NC 28207, USA.
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Burks D, Rosenbury SB, Kennelly MJ, Fried NM. Selective laser vaporization of polypropylene mesh used in treatment of female stress urinary incontinence and pelvic organ prolapse: Preliminary studies using a red diode laser. Lasers Surg Med 2012; 44:325-9. [DOI: 10.1002/lsm.22020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2012] [Indexed: 11/09/2022]
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Abstract
Traditional retropubic and transobturator midurethral slings are reliable, safe, and effective treatments for stress urinary incontinence. Unfortunately, they also are associated with rare but severe complications, such as bladder or bowel perforation, vascular injury, nerve damage, and/or groin muscle pain that can occur with the blind passage of trocars. To maintain efficacy and patient satisfaction while avoiding such complications, minimally invasive mini-slings have been developed. These smaller mini-slings can be placed through a single vaginal incision at the level of the midurethra without trocars. Mini-slings often are performed as an outpatient surgery, with minimal morbidity, pain, and quick patient recovery. With continued refinement and surgeon experience, mini-slings potentially may be performed safely in the office setting under local anesthesia while maintaining the efficacy of traditional slings.
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Affiliation(s)
- Michael J Kennelly
- Charlotte Continence Center, McKay Department of Urology, 1023 Edgehill Road South, Charlotte, NC 28207, USA.
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Kennelly MJ, Bennett ME, Grill WM, Grill JH, Boggs JW. Electrical stimulation of the urethra evokes bladder contractions and emptying in spinal cord injury men: case studies. J Spinal Cord Med 2011; 34:315-21. [PMID: 21756572 PMCID: PMC3127369 DOI: 10.1179/2045772311y.0000000012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE Electrical stimulation of the urethra can evoke bladder contractions in persons with spinal cord injury (SCI). The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions that empty the bladder. METHODS The first patient was a 45-year-old man with a T6 ASIA A SCI secondary to a gunshot wound 15 years prior. The second patient was a 51-year-old man with a T2 ASIA A SCI secondary to a fall from scaffolding 2 years prior. Both patients demonstrated neurogenic detrusor overactivity on urodynamics and managed their bladder with clean intermittent catheterization and oxybutynin medication. Following informed consent, each patient discontinued oxybutynin 2 days prior to urodynamic testing. Urodynamics were performed with a custom 12 French balloon catheter mounted with ring-shaped electrodes (3 mm) positioned in the prostatic urethra. After filling the bladder to approximately three-fourth of capacity at a rate of 25 ml/minute, the urethra was stimulated with a range of parameters to determine whether electrical stimulation could evoke a bladder contraction and empty the bladder. RESULTS Electrical stimulation of the prostatic urethra evoked bladder contractions (peak detrusor pressures of 60-80 cm H(2)O) that emptied the bladder in both subjects. In the first subject, stimulation (9-12 mA, 20 Hz) emptied 64-75%, leaving post-void residual volumes (PVRs) of 41-20 ml. In the second subject, stimulation (20 mA, 20 Hz) emptied 68-77%, leaving PVRs of 56-45 ml. CONCLUSION Urethral stimulation evoked bladder emptying in persons with SCI.
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Affiliation(s)
- Michael J. Kennelly
- Carolinas Rehabilitation, Urology Department, Charlotte, NC, USA,Correspondence to: Michael Kennelly, Carolinas Rehabilitation, Urology Department, Charlotte, NC, USA.
| | | | - Warren M. Grill
- Department of Biomedical Engineering, Duke University, NC, USA
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Defade BP, Carson CC, Kennelly MJ. Postprostatectomy erectile dysfunction: the role of penile rehabilitation. Rev Urol 2011; 13:6-13. [PMID: 21826123 PMCID: PMC3151582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Radical prostatectomy has become the gold standard for the treatment of prostate cancer in patients who have a longer than 10-year life expectancy. Surgical treatment has led to severe quality-of-life issues in these patients, especially urinary incontinence and erectile dysfunction (ED). This article reviews the etiology and pathophysiology of postprostatectomy ED, and current management strategies for these patients.
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Kennelly MJ, Moore R, Nguyen JN, Lukban JC, Siegel S. Prospective evaluation of a single incision sling for stress urinary incontinence. J Urol 2010; 184:604-9. [PMID: 20639024 DOI: 10.1016/j.juro.2010.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Indexed: 12/18/2022]
Abstract
PURPOSE We report 12-month outcomes of the MiniArc single incision sling for stress urinary incontinence in women. MATERIALS AND METHODS We performed a multicenter, prospective, single arm institutional review board/ethics committee approved study evaluating the effectiveness of the MiniArc sling after implantation via qualitative (Urogenital Distress Inventory-Short Form and Incontinence Impact Questionnaire-Short Form) and quantitative (1-hour pad weight test and cough stress test) measurements. Secondary outcome measures included procedural variables (procedure time and estimated blood loss), length of stay, perioperative complications, Wong-Baker Faces Pain Scale and adverse events. RESULTS A total of 188 women with a mean age of 51.1 +/- 10.6 years (median 50.4, range 25.9 to 79.6) were enrolled in the study. At 1 year 157 patients were available for analysis. Mean procedure time, estimated blood loss and length of hospital stay were 11.0 +/- 6.7 minutes (median 10, range 2 to 55), 41.7 +/- 47.0 ml (median 25, range 0 to 250) and 9.5 +/- 14.1 hours (median 3.2, range 0.5 to 77.2), respectively. At discharge from hospital the mean Wong-Baker pain score was 1.3 +/- 2.0 (range 0.0 to 10.0). Of the patients 90.6% had a negative cough stress test and 84.5% had a 1-hour pad weight test less than 1 gm at 12 months. Median Urogenital Distress Inventory-Short Form and Incontinence Impact Questionnaire-Short Form scores showed a statistically significant decrease (p <0.001). Adverse events included urinary tract infection (4.3%), constipation (3.7%), temporary urinary retention (3.2%), dyspareunia (2.1%) and vaginal extrusion (1.6%). CONCLUSIONS The MiniArc single incision sling is a safe and effective first line surgical procedure for the treatment of female stress urinary incontinence. It demonstrated excellent patient tolerability with minimal pain, early return to normal activity and low morbidity. In addition to sustained efficacy outcomes at 12 months patients treated with the MiniArc experienced a significant improvement in quality of life.
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Kennelly MJ, Arena KC, Shaffer N, Bennett ME, Grill WM, Grill JH, Boggs JW. Electrical stimulation of the urethra evokes bladder contractions in a woman with spinal cord injury. J Spinal Cord Med 2010; 33:261-5. [PMID: 20737800 PMCID: PMC2920120 DOI: 10.1080/10790268.2010.11689704] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Electrical stimulation of pudendal urethral afferents generates coordinated micturition in animals and bladder contractions in men after spinal cord injury (SCI), but there is no evidence of an analogous excitatory urethra-spinal-bladder reflex in women. The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions in a woman with SCI. CASE REPORT A 38-year-old woman with a C6 ASIA A SCI who managed her bladder with clean intermittent catheterization and oxybutynin demonstrated neurogenic detrusor overactivity on urodynamics. Oxybutynin was discontinued 2 days prior to urodynamic testing with a custom 12F balloon catheter mounted with ring-shaped electrodes located in the bladder neck, mid urethra, and distal urethra. The inflated balloon was placed against the bladder neck to stabilize the catheter electrodes in place along the urethra. However, the balloon limited emptying during contractions. Urodynamics were performed at a filling rate of 25 mL/minute until a distention-evoked bladder contraction was observed. The urethra was stimulated over a range of bladder volumes and stimulus parameters to determine whether electrical stimulation could evoke a bladder contraction. FINDINGS Electrical stimulation via urethral electrodes evoked bladder contractions that were dependent on bladder volume (>70% capacity) and the intensity of stimulation. CONCLUSIONS This is the first report of an excitatory urethra-spinal-bladder reflex in a woman with SCI. Future studies will determine whether this reflex can produce bladder emptying.
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Affiliation(s)
- Michael J Kennelly
- Urology Department, Charlotte Institute of Rehabilitation, Charlotte, North Carolina 28203, USA.
| | - Kimberly C Arena
- Department of Urology, Carolinas Rehabilitation, Charlotte, North Carolina
| | - Nell Shaffer
- Department of Urology, Carolinas Rehabilitation, Charlotte, North Carolina
| | | | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
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Kennelly MJ. A comparative review of oxybutynin chloride formulations: pharmacokinetics and therapeutic efficacy in overactive bladder. Rev Urol 2010; 12:12-19. [PMID: 20428289 PMCID: PMC2859137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Antimuscarinic agents remain the mainstay of treatment of overactive bladder. However, the utility of some of these agents is limited due to tolerability concerns, multiple daily dosage regimens, lack of formulary coverage, and high cost. This can lead to problems with long-term compliance and may preclude optimal management. Oxybutynin has been the most widely prescribed antimuscarinic agent for more than 30 years. To meet the needs of tolerability and compliance, oxybutynin has evolved from an immediate-release pill to a once-daily oral dose and is now available as a topical gel. This review compares the various oxybutynin formulations in terms of pharmacokinetics, efficacy, and tolerability issues.
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Kennelly MJ, Lemack GE, Foote JE, Trop CS. Efficacy and Safety of Oxybutynin Transdermal System in Spinal Cord Injury Patients With Neurogenic Detrusor Overactivity and Incontinence: An Open-label, Dose-titration Study. Urology 2009; 74:741-5. [DOI: 10.1016/j.urology.2009.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 04/30/2009] [Accepted: 05/05/2009] [Indexed: 11/25/2022]
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Kennelly MJ, Devoe WB. Overactive bladder: pharmacologic treatments in the neurogenic population. Rev Urol 2008; 10:182-191. [PMID: 18836537 PMCID: PMC2556485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Patients with neurologic disease commonly develop overactive bladder (OAB) symptoms of urgency, frequency, and/or urge incontinence. Although treatment for idiopathic OAB has been extensively studied, therapy for those individuals with neurogenic-mediated OAB has not been thoroughly evaluated. Included in the present article is a description of micturition neurophysiology and a neurourologic evaluation scheme. The pharmacologic treatment options for neurogenic OAB, mainly antimuscarinics and chemical denervation, are reviewed and important studies are discussed. Management of OAB in the neurogenic population is a complex issue with no uniform treatment strategy, and individualized treatment with first-line pharmacologic therapy is often recommended.
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Chen TYH, Ponsot Y, Carmel M, Bouffard N, Kennelly MJ, Tu LM. Multi-Centre Study of Intraurethral Valve-Pump Catheter in Women with a Hypocontractile or Acontractile Bladder. Eur Urol 2005; 48:628-33. [PMID: 15964124 DOI: 10.1016/j.eururo.2005.04.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2005] [Accepted: 04/22/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To compare the safety, effectiveness and patient satisfaction of an intraurethral valve-pump catheter (In-Flow) versus the current standard of care, clean intermittent catheterization (CIC), for females with hypocontractile or acontractile bladder. MATERIALS AND METHODS The study was a multi-centre, prospective, single-arm crossover study. Eligible patients underwent a 1-week In-Flow tolerability trial. Successful patients then continued through an 8-week baseline phase using CIC, followed by a 16-week In-Flow treatment phase, and a final 4-week treatment withdrawal phase. Outcome measures included post-void residual (PVR), Wagner incontinence-specific quality of life (I-QOL), rate of urinary tract infection and adverse events. At study completion, open enrollment was offered. RESULTS A total of 273 women with a mean age of 48.9 years using CIC entered the study in 18 centres under either the original (n=88) or revised protocols (n=185). The revised protocol included the addition of a 1-week tolerability trial. The reasons for the large early withdrawal of subjects (169/273) were mainly related to initial discomfort and leakage. A total of 77 patients completed the In-Flow treatment phase. PVR was comparable during baseline CIC phase and In-Flow treatment phase (20.3 ml vs. 16.1 ml), with significantly improved quality of life (QOL; mean improvement of I-QOL score +25.9; p<0.001). CONCLUSION The In-Flow catheter appears to be a viable alternative to CIC. A subgroup of patients, mainly those unsatisfied with the currently available treatments, was more likely to tolerate In-Flow catheters, and they may achieve enhanced independence and QOL.
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Affiliation(s)
- T Y-H Chen
- Department of Urology, Sherbrooke University Hospital Centre, 3001 12th Avenue Nord, Fleurimont, PQ J1H 5N4, Canada.
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Abstract
Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3-19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty-two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality-of-life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12-month pad weight test over 2.2 g. Quality-of-life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty-six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12-month visit.
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Affiliation(s)
- A E Bent
- Greater Baltimore Medical Center, Baltimore, MD 21204-6881, USA.
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Bent AE, Tutrone RT, McLennan MT, Lloyd LK, Kennelly MJ, Badlani G. Treatment of intrinsic sphincter deficiency using autologous ear chondrocytes as a bulking agent. Neurourol Urodyn 2001. [PMID: 11170190 DOI: 10.1002/1520-6777(2001)20:2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3-19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty-two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality-of-life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12-month pad weight test over 2.2 g. Quality-of-life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty-six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12-month visit.
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Affiliation(s)
- A E Bent
- Greater Baltimore Medical Center, Baltimore, MD 21204-6881, USA.
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Ganem JP, Kennelly MJ. Ruptured Mondor's disease of the penis mimicking penile fracture. J Urol 1998; 159:1302. [PMID: 9507863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- J P Ganem
- McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina, USA
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Abstract
RATIONALE AND OBJECTIVES We tested whether testicular torsion could completely damp distal arterial pulsatility, resulting in venous-appearing arterial waveforms. METHODS Progressively increasing testicular torsion was unilaterally produced in five rats. Doppler waveforms of the testicular artery distal to the torsion were obtained as soon as possible after each level of torsion until a complete absence of pulsatility was noted. RESULTS One animal was not studied further after the first 180 degrees of torsion occluded flow. In three of the remaining four animals, the testicular artery resistive index (RI) at baseline (0.51, 0.58, 0.64) was within the range of the normal human intratesticular RI and decreased with increasing torsion, culminating in nonpulsatile, venous-appearing waveforms at high degrees of torsion. CONCLUSIONS Testicular torsion can completely damp arterial pulsatility, resulting in nonpulsatile, venous-appearing arterial Doppler waveforms.
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Affiliation(s)
- R O Bude
- Department of Radiology, University of Michigan Medical School, Ann Arbor, USA
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Abstract
OBJECTIVES The perioperative and long-term outcomes of children with vesicoureteral reflux (VUR) treated by cross-trigonal ureteroneocystostomy were ascertained. METHODS One hundred ten consecutive children with VUR who underwent bilateral cross-trigonal ureteroneocystostomy were studied retrospectively. Nineteen children with neurovesical dysfunction or megaureters requiring tapered reimplants were excluded. Outcome parameters of the remaining 91 children consisted of operative time, length of hospitalization, days of Foley catheter drainage perioperative complications, correction of reflux, subsequent morbidity, and parental satisfaction. RESULTS Of 182 renal units, 11 (6%) had grade 0 VUR, 18 (10%) had grade I, 43 (24%) had grade II, 59 (32%) had grade III, 36 (20%) had grade IV, and 15 (8%) had grade V reflux. The mean operative and hospitalization times were 180 minutes and 5.6 days, respectively. No postoperative complications occurred. Three children were lost to follow-up, and the remaining 88 children had an extended mean follow-up in excess of 3 years. Voiding cystourethrogram documented a 98.3% (173 of 176 renal units) success rate. Sixteen children (18%) experienced nonfebrile clinically symptomatic cystitis episodes and 3 children (3%) experienced one febrile episode each. Telephone parental survey of overall surgical experience revealed a 94% very satisfied, 2% satisfied, and 3% dissatisified rate. CONCLUSIONS Cross-trigonal ureteroneocystostomy is a safe and effective technique that is virtually complication free and has high parental satisfaction. The results of this study provide a baseline for comparison of non-operative treatment of reflux as well as laparoscopic and endoscopic techniques.
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Affiliation(s)
- M J Kennelly
- University of Michigan Medical Center, Section of Urology, Ann Arbor, USA
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Richardson TD, Kennelly MJ, Faerber GJ. Endoscopic injection of glutaraldehyde cross-linked collagen for the treatment of intrinsic sphincter deficiency in women. Urology 1995; 46:378-81. [PMID: 7660513 DOI: 10.1016/s0090-4295(99)80223-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine the clinical efficacy, safety, and durability of endoscopically injected glutaraldehyde cross-linked (GAX) collagen for the treatment of intrinsic sphincter deficiency (ISD) in women. METHODS Forty-two women with a mean age of 64 years (range, 28 to 88) underwent injection of GAX collagen for ISD. Collagen was injected via a transurethral or periurethral approach. Treatment outcome was based on the change in stress leak point pressures (SLPP) and individual incontinence grades before and after collagen injection. RESULTS With a mean follow-up of 46 months (range, 10 to 66), 83% were cured (n = 17), greatly improved (n = 5), or improved (n = 13), and 17% were unchanged (n = 3) or worse (n = 4). The median number of treatments was 2 (range, 1 to 8). The 22 women greatly improved or cured required a mean of 2.4 collagen injection treatments, whereas the 20 women who were improved, unchanged, or worse had a mean of 4.1 treatments (P = 0.009). The mean amount of collagen injected per patient was 28.3 cc (range, 2.5 to 85). The group of women who were greatly improved or cured had a mean of 17.5 cc of collagen injected, whereas those who were improved, unchanged, or worse had a mean of 39.5 cc injected (P = 0.002). Mean pretreatment SLPPs of women improved, greatly improved, or cured versus the women unchanged or worse were not significantly different (P = 0.015). The 35 women who were improved or cured had a significant increase in mean SLPP of 65.4 cm H2O (P = 0.001) compared to a mean change in SLPP of 14.7 cm H2O in those women who were unchanged or worse (P = 0.038). CONCLUSIONS GAX collagen injection for the treatment of stress urinary incontinence secondary to ISD appears to be safe, effective, and durable; hence, it should be considered the treatment of choice in appropriately selected female patients.
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Affiliation(s)
- T D Richardson
- University of Michigan Medical Center, Department of Surgery, Ann Arbor, USA
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Abstract
We report on a girl with infected perinephric urinoma and myelodysplasia who presented with a febrile urinary tract infection. A complex perinephric fluid collection with internal echoes was found on renal ultrasound, necessitating placement of a percutaneous drainage tube. Initial urodynamic testing after treatment of the infection revealed a noncompliant bladder with an elevated detrusor leak point pressure. Neurovesical dysfunction with elevated leak point pressure is believed to be the cause of urinoma. Clinical presentation, treatment and pathophysiology of this entity are discussed.
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Affiliation(s)
- M J Kennelly
- Department of Surgery, University of Michigan Hospitals, Ann Arbor
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Abstract
Angiomyolipomas were found in 42 kidneys in 23 female and 8 male patients at our medical center. Angiomyolipoma was diagnosed by computerized tomography (CT) alone in 55% of the cases, and by a combination of ultrasound and CT in 36%. Nine of 11 patients with bilateral angiomyolipoma had associated tuberous sclerosis. Treatment consisted of observation in 22 patients, selective arterial embolization in 6, partial nephrectomy in 6 and nephrectomy in 8. A total of 17 patients who were observed had tumors smaller than 4 cm. and 4 h had angiomyolipoma of 4 to 10 cm. With a mean followup of 3.8 years, no observation patient had subsequent renal hemorrhage and only 1 (tumor larger than 10 cm.) had radiographic progression. Despite progression, the latter patient remained asymptomatic for 18 years. Selective arterial embolization (3 tumors 4 to 10 cm. and 3 larger than 10 cm.) resulted in preservation of renal function at a mean of 1 year. All patients treated with partial nephrectomy (6 tumors 4 to 10 cm.) maintained stable renal function without recurrence during a mean 4.7-year followup. Similarly, all individuals who underwent nephrectomy (4 tumors smaller than 4 cm., 3 tumors 4 to 10 cm. and 1 tumor larger than 10 cm.) have stable renal function. We recommend renal conservation for patients with renal angiomyolipoma using a strategy of observation for small asymptomatic tumors, partial nephrectomy for moderate size tumors and selective arterial embolization of large tumors not amenable to partial nephrectomy.
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Affiliation(s)
- M J Kennelly
- Department of Surgery, University of Michigan Medical Center, Ann Arbor
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Abstract
Five patients 18 to 73 years old underwent auto-augmentation for a small capacity, poorly compliant bladder. The mean operative time and hospital stay were 106 minutes and 6 days, respectively. No postoperative complications occurred. Followup ranged from 12 to 82 weeks. Bladder capacity increased from 75 to 310 cc or 40 to 310%. Compliance also improved in all patients. Three patients had reflux preoperatively, which resolved in 1 and improved in 2. Of 4 patients who were incontinent preoperatively 3 became continent postoperatively and extended the interval between catheterizations. Upper tract function has remained stable. No patient required enterocystoplasty to control bladder pressures.
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Affiliation(s)
- M J Kennelly
- Department of Surgery, University of Michigan Medical Center, Ann Arbor
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Abstract
The combination of high spinal cord injury and neurovesical dysfunction can present formidable problems in urological management. The lack of upper extremity function often prevents intermittent catheterization and leads to alternative methods. A total of 23 patients underwent incontinent ileo-vesicostomy in an effort to gain a low pressure bladder and control of urinary soiling: 17 had been previously treated by catheter drainage, 9 had bladder and/or renal calculi, 9 experienced recurrent sepsis, and 7 had urethrocutaneous fistula and total urinary incontinence. Most patients had poorly compliant bladder dysfunction associated in 9 cases with poor urethral continence function. At a mean followup of 45 months (range 3 to 240 months) 22 of 23 patients had a low pressure reservoir with low pressure degrees of urine into a collection device. Complications included stomal stenosis in 3 patients and poor drainage across the ileovesical junction requiring revision in 2. One of these patients ultimately underwent ileal loop diversion. Upper tract function improved or remained stable in all patients.
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Affiliation(s)
- S L Schwartz
- Department of Surgery, University of Michigan Hospital, Ann Arbor
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Abstract
Loss of a ureter in a renal transplant patient often results in transplant nephrectomy. In 1973 we used vesicopyelostomy with the bladder directly sutured to the renal pelvis as a method of reconstruction in 2 renal transplant patients following ureteral loss. These patients have been followed for more than 20 years and both renal allografts have functioned well. The status of these patients and a review of the literature on vesicopyelostomy are presented.
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Affiliation(s)
- M J Kennelly
- Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109
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Abstract
A pure seminal vesicle abscess is a rare condition. We report case 7 in the literature and to our knowledge the first patient who has been managed successfully by noninvasive, conservative antibiotic treatment alone. All previously reported cases of seminal vesicle abscesses have been managed with invasive therapy. In 5 cases the seminal vesicle abscess was incised and drained surgically, while in 1 the abscess was drained percutaneously. We describe a patient with a seminal vesicle abscess, review the literature and recommend a more conservative method of management.
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Affiliation(s)
- M J Kennelly
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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