LUTS/BPH Medical and Surgical Management. Sung Tae Cho, MD, Ph.D Department of Urology Hallym University Kangnam Sacred Heart Hospital

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1 LUTS/BPH Medical and Surgical Management Sung Tae Cho, MD, Ph.D Department of Urology Hallym University Kangnam Sacred Heart Hospital

2 AUA Annual Meeting, 2013 Plenary : 8 Poster and Podium : 6 sessions BPH Medical therapy (12) BPH Surgical therapy and New technology (22) Female pelvic medicine and Reconstructive surgery (13) Incontinence therapy (40) Live surgery : 2 Vaginal repair for prolapse and Sling procedure Robotic sacrocolpopexy

3 Plenary : Controversies in Urology Synthetic Sling is the Correct Choice for Index Patients with SUI Moderator : Victor Nitti Pro : Eric Rovner, Michael Kennelly Con : Helen O Connell, Jerry Blaivas

4 Crossfire : Controversies in Urology Pro About 3 million such surgeries have been performed worldwide since the procedure was introduced in the 1990s. And while sling complications occur, they are not unique to mesh surgeries. Con Pubovaginal sling that uses the patient s own fascia

5 Science of Female Pelvic Health The Underactive Bladder Moderator : William Steers Michael Chancellor, Naoki Yoshimura Roger Dmochowski, Gommert Van Koeveringe Aging population, lack of good treatment α blocker to reduce outlet resistance Catheterization, UTI Safety, quality of life, cost of care

6 Plenary : Critical Discussion UAB and Chronic Urinary Retention in Older Adults Critical Discussant: Jerry Blaivas Presenter: Michael Chancellor, Christopher Smith While OAB is well defined and has effective treatments, there is no consensus definition for UAB and effective treatments

7 Underactive bladder (UAB) Increase with age, highest in women > 55 yrs, in institutionalized patients

8 Factors contribute to UAB Functional and/or anatomical changes result from BOO or reduced detrusor contractility Abnormalities of sensory and motor neural pathways and cognitive function

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12 1 st international congress CURE-UAB

13 Plenary : Named Lecture New Developments in the Pharmacological Treatment of the OAB Karl-Erik Andersson

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16 Live Surgery : Vaginal repair for POP and Sling procedure Kurt McCammon 82-yr-old female with Gr 4 cystocele SUI when reduced cystocele Good apical support vaginal approach If not robotically Bleeding control before placing mesh Hold pressure, bipolar, monopolar, suture Mesh exposure : litigation over complication Vaginal dissection much deeper Close the incision in two layer Separate incision for sling to be midurethra Significant dyspareunia d/t mesh moving out Pull out mesh, put porcine dermis, put another mesh in

17 Live Surgery : Robotic sacrocolpopexy Wesley White 62-yr-old female with stage 3 POP, nurse Mixed incontinence with low stage prolapse (2011) : anticholinergics Next 3yrs, worsen prolapse symptoms, stage 3, ant. prolapse with significant apical discent Supracervical hysterectomy, sacrocolpopaxy with MUS Polypropylene mesh to anchor the cervix to the sacral promontory to lift the vagina and bladder Advanced prolapse hysterectomy first Ix : advanced ant. prolapse, failed a previous vaginal repair Cx : mesh extrusion, injury to tissues or organs, bleeding, infection, internal scarring can cause dysfunction or pain Some studies : longer op time, higher postop pain and costs vs. laparo-, but no significant difference in outcomes

18 Late-Breaking Abstract: Urinary Continence after Robotic Prostatectomy A randomized, double-blind multi-center phase 4 Clinical Trial evaluating Solifenacin vs. Placebo (Vanguard Trial) smartphone device by Fernando Bianco MD N=1,125 patients RALP

19 Objective efficacy and safety of 12 wks Tx. Primary Outcome Measures Time (first dose continence) Urinary continence : 1 st of 3 days, no pads or a dry pad for security Secondary Outcome Measures Proportion of subjects (continence at each visit) Average daily pad usage (base - each month) QoL (AUASS, ICIQ-SF) Work productivity (WPAI) Time (base 1 st day of returning to work)

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23 Best Abstract: 5-yr outcomes after Retropubic vs Transobturator MUS Kimberly Kenton Primary outcome = Treatment success No retreatment for SUI (behavior,pharmacological, pessary or surgery) AND no self-reported SUI Sx There was no difference in success rates between RMUS and TMUS p=0.09

24 Conclusion Treatment success for RMUS is 7.9% higher than TMUS (51.3% vs 43.4%, 95% CI -1.4, 17.2) and did not meet criteria for equivalence Satisfaction remains high in both groups (78.9%, RMUS vs 84.7%, TMUS, p=0.15) Urinary symptoms increased and QoL declined (UDI and IIQ) significantly over time (p<0.001) with TMUS having better urinary QoL scores than RMUS (p=0.02) Mesh erosion remains low at 1.7%

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26 12 week changes, behavioral therapy, alone or with ɑ blockers Behavioral therapy, while not statistically superior to α-blocker therapy in this small trial, provides a meaningful treatment option for nocturia in men.

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29 180W XPS PVP vs TURP Functional results when assessed by prostate size between XPS and TURP are comparable after 1 year follow-up The complication free rate continues to be better in the XPS arm compared to the TURP arm 80.0% XPS and 87.5% TURP (small) 87.1% XPS and 72.6% TURP (medium) p= % in both XPS and TURP (large)

30 180W XPS PVP vs HoLEP Compared to HOLEP, 180-W PVEP/XPS is safe, non-inferior and effective in treatment of BPH regardless prostate size.

31 180W XPS PVP large, multicenter (n=1,053) High conversion rate with prostate > 80 g (11.2% vs. 1.2 %, p < 0.001)

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35 Rezūm System - NexThera Transurethral water vapor therapy Controlled, phase-change, convective thermal heat transfer using sterile water (steam) to ablate tissue : compartmentalization

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38 The role of transperineal US in evaluation of the failed AdVance sling AdVance male sling at rest Dynamic compression of urethra by sling Malposition and lack of compression

39 Malposition with early sling failure (7) Paradoxical distraction/opening of urethra : 3 Partial detachment : 2 Distal location in perineum : 2 Satisfactory position (10) Early failure: 2 True failure : 4 (significant ISD) Voiding dysfunction : 4 Malposition and absence of dynamic compression technical failure : suitable for re-do sling

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42 The Outcome of Replacement Surgery for Suspected AUS Malfunction N = 50 Recurring incontinence in these patients is not due to urethral atrophy but most likely caused by a change in the mechanical properties of the reservoir with time Result in loss of tensile strength, preventing it from transmitting an adequate occlusive pressure to the urethra

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44 Prostate Urethral Lift UroLift -Neotract

45 Multi-center, prospective, nonrandomized study

46 Conclusions Medical management Botulinum toxin, β3 agonists, PDE5 inhibitors Surgical management Laser for BPH (180W XPS, HoLEP) Advance XP, Argus and AUS for male SUI Alternative surgery & New technology Prostatic arterial embolization, Rezum, UroLift Hot topic LUTS in geriatric patients (UAB, Nocturia, UI)

47 Thank you