Recommendations on the use of intravesical hyaluronic acid instillations in bladder pain syndrome

INTRODUCTION

Bladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet.

OBJECTIVE

To synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA. The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations.

RESULTS

There is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment).

CONCLUSIONS

Intravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles). Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up).

[Comparative study between patients undergoing laparoscopic colposacropexy with and without prior surgery for the treatment of apical prolapse]

INTRODUCTION

Colposacropexy is the treatment of choice for apical prolapse. Studies comparing this technique as primary surgery for pelvic organprolapse (POP), with its success in recurrent POPs after surgery, are scarce.

MATERIALS AND METHODS

Retrospective analysis of a series of patients diagnosed with POP who underwent laparoscopic colposacropexy, comparing a group without previous prolapse surgery with another group that has recurred after previous surgery (with or without mesh). Our objective was to analyze the differences regarding surgical time (skin to skin), intraoperative complications, mean stay, resolution of symptoms and recurrence. As preoperative data, we compared: age, body mass index (BMI), parity, previous hysterectomy, physical examination, symptoms, and flowmetry; and as peri/postoperative data: follow-up, intervention duration, intra and postoperative complications, mean stay, physical examination (Baden-Walker classification), symptom resolution and flowmetry.

RESULTS

Twenty-three patients have been operated on in 12 months. Nine (39.1%) were recurrent POPs after previous surgery, 6 (66.7%) of them with some type of mesh. Follow-up (mean months): 6.44 ± 4.19 (previous cx) vs. 4.79 ± 4.00. Both groups were comparable with respect to preoperative variables. Previously operated patients had greater dyspareunia (p<0.05). We did not find differences in the rest of symptoms between both groups. There were no differences in the duration of the intervention, mean stay, or regarding intraoperative complications (p>0.05) between both groups. Sensation of vaginal lump, urge incontinence and dyspareunia resolved in all patients. Flowmetry improved in both groups (p>0.05).

CONCLUSIONS

Laparoscopic colposacropexy is an effective and safe technique to correct POP after previous surgery, with or without mesh.

[Cystoscopy in the assessment of patients with bladder pain syndrome: Results of a national multicenter observational study.]

OBJECTIVES

To study the use and results of cystoscopy and bladder hydrodistension in the objective assessment of patients with Bladder Pain Syndrome (BPS), in routine clinical practice.

MATERIAL AND METHODS

Observational, non-interventional, national, multicenter study carried out in Functional Urology and Urodynamic Units of Spain belonging to the IFU Group. 273 women with BPS who underwent cystoscopy at baseline as a diagnostic tool according to clinical criteria and following the routine clinical practice of each center, were studied. The pre and post hydrodistension findings and the scores of the symptom and Health-Related Quality of Life (HRQoL) questionnaires were described: BPIC-SS, PPBC, PGI-S and EQ-5D-5L.

RESULTS

The mean age (SD) was 59 (14) years with a high presence of bladder symptoms: increased voiding frequency (81.7%), nocturia (74%) and urgency (60.4%). 40.7% of cystoscopies were performed under anesthesia and 73.7% uses a standard rigid cystoscope. Hunner lesions were observed in 9.9% of the patients, hypervascularizations (46.2%), glomerulations (23.4%), mild bleeding (6.6%) and scars (2.2%). After hydrodistension, a greater number of grade 1 and 2 lesions were observed. In 51.6% of the patients there were no changes, but in 27.5% slight changes were observed and in 11.4% moderate or severe changes. Symptom and HRQoL questionnaire scores showed no association with cystoscopy findings before and after hydrodistension.

CONCLUSIONS

The value of the cystoscopic findings in the SDV has yet to be defined, although it plays a fundamental role in the differential diagnosis. In this observational study, we did not find a correlation of the cystoscopic findings with the symptoms of the patients, measured by validated questionnaires, nor with the HRQoL.

Prospective Observational Cohort Study of the Efficacy of Bacterial Immune Prophylaxis in the Prevention of Uncomplicated, Recurrent Urinary Tract Infections

OBJECTIVE

To investigate the long-term prophylactic effect of a vaccine on lower urinary tract infections (UTI) of bacterial and the impact of the intensity of the symptoms on the quality of life (QoL).

METHODS

Adult female could be enrolled in this study if they had acute UTI at the enrolment visit and bacterial microbiological count of ≥103 CFU/mL of Escherichia coli.

RESULTS

A total of 21 patients were included. Fifteen days after the administration of a vaccine for 3 months, the number of infections dropped almost to zero. Significant differences were observed in the QoL score (p < 0.05). The safety profile was good.

CONCLUSIONS

In patients diagnosed with recurrent UTI and treated for 3 months with the vaccine the number of UTI episodes fell very quickly (15 days), and patients remained free of episodes and improved their QoL significantly for 1 year. These results suggest that bacterial vaccines are a possible effective alternative in the prevention of recurrent UTI.

[Current status of laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse.]

OBJECTIVES

Surgical restoration of pelvic floor anatomy in pelvic organ prolapse (POP) should avoid extensive areas that may injure healthy tissues and lead to scar fibrosis producing dysfunctional rigidity. Laparoscopic sacrocolpopexy corrects POP by lifting pelvic elements with a minimally invasive procedure.Various current strategies and approaches make it a diverse procedure.

METHODS

We performed a bibliographic review on the published experience about abdominal sacrocolpopexy over the last 20 years. We analyze the philosophy of each technique, advantages, disadvantages, and results.

RESULTS

Among current theories that explain how is the anatomy and function of the pelvic floor, the comprehensive theory of the pelvic floor announces that anatomical deviation produces pelvic dysfunction (diagnostic algorithm)(1). Surgical invasion with reconstructive purposes may hide results if the true physiopathology of the defects found is not known. Although current diagnostic tools cannot solve the problem as a whole, results of different techniques are much better than those of previous times.

CONCLUSIONS

Laparoscopic sacrocolpopexy is an adequate strategy that restores anatomy in POP, mainly apical, and function with minimal invasion. Technical development and better knowledge of the female pelvis functional anatomy is enabling today a more precise understanding of its physiopathology, so it facilitates the design of site-specific operations. Various surgical approaches and techniques are offered depending on the defect, where combined procedures give good solutions. It is necessary to have an appropriate surgical training to obtain the better competence, and a safe and correct repair.

[Conservative treatment of renal cell carcinoma in kidney transplantation]

PURPOSE

To evaluate the new treatment strategies in renal cell carcinoma (RCC) that affects the graft in renal recipients.

ACQUISITION OF EVIDENCE

A literature review is made, analyzing all the published cases of conservative surgery in renal graft RCC.

SYNTHESIS OF EVIDENCE

A total of 51 partial nephrectomies in renal graft patients have been described, with a graft survival rate of 88% and a recurrence rate of 6%. Most of the patients (75%) were asymptomatic at the time of diagnosis, and the mean lesion size was 2.8 cm. Enucleation was the most frequent technique employed. 77% of all immunosuppressor regimens included cyclosporine A. Six patients with graft RCC were subjected to radiofrequency ablation and two patients underwent percutaneous cryoablation, with a single case of relapse and a graft survival rate of 100%.

CONCLUSIONS

Nephron-sparing surgery is a good management option in renal graft RCC, affording good oncological control and graft survival. Modification of immunosuppression with the withdrawal of cyclosporine A and the introduction of mTOR inhibitors is an adequate measure in such patients.