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Re: Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review
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VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
urgency drop. For the mixture the percentages were 38% and 42%, greater than just the alkalinized lidocaine alone, at 13% and 8%. What I have learned from this article that I did not know is that if lidocaine is employed, it has to be properly alkalinized and not precipitated to effectively absorb into the bladder wall. The authors make the point that instilling a medication into the bladder does not necessarily result in absorption. In the case of lidocaine it must be alkalinized and not precipitated to effectively absorb into the bladder wall. The authors add that if other components like steroids are added to a “cocktail,” the effectiveness of the solution could be seriously reduced if the pH is not correspondingly adjusted and the lidocaine stability is not known. The concept that alkalinizing lidocaine yields a higher serum lidocaine level was supported by the finding that the heparin-lidocaine combination resulted in higher serum lidocaine levels compared to USP lidocaine alone. Nevertheless, the highest lidocaine level achieved was 0.84 mg/ml, well below the 6.0 mg/ml level associated with symptoms of toxicity. Alan J. Wein, MD, PhD (hon)
Re: Prospective Randomized Crossover Trial Comparing Continuous and Cyclic Stimulation in InterStim Therapy D. M. Price and K. Noblett Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics/Gynecology, University of California, Irvine, Orange, California Female Pelvic Med Reconstr Surg 2015; 21: 355e358. doi: 10.1097/SPV.0000000000000188
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26506165 Editorial Comment: This is a small randomized crossover study comparing continuous vs cyclic stimulation in female patients who have undergone successful sacral neuromodulation after a successful test stimulation. No significant differences were noted in voiding diaries or subjective responses between cyclic and continuous stimulation. The authors suggest that patients can be started on the cyclic stimulation used in this study as an initial setting (parameters listed in the article) and further suggest that this along with using the minimum amplitude needed for the optimal clinical response will help to prolong battery life. An additional note was that patients initially programmed for cyclic stimulation tended to favor it more than patients initially started on continuous stimulation. Alan J. Wein, MD, PhD (hon)
Re: Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review M. P. Schneider, T. Gross, L. M. Bachmann, B. F. Blok, D. Castro-Diaz, G. Del Popolo, J. Groen, R. Hamid, G. Karsenty, J. Pannek, L. Hoen and T. M. Kessler Neuro-Urology, Spinal Cord Injury Center/Research and Brain Research Institute, University of Zu¨rich, Balgrist University Hospital, Department of Health Sciences and Technology, Swiss Federal Institute of Technology Zu¨rich and Medignition, Inc., Research Consultants, Zu¨rich, Department of Urology, University of Bern, Inselspital, Bern and Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland, Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands, Department of Urology, University Hospital of the Canary Islands, Tenerife, Spain, Department of Neuro-Urology, Careggi University Hospital, Florence, Italy, Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, United Kingdom, and Department of Urology, Aix Marseille University, Marseille, France Eur Urol 2015; 68: 859e867. doi: 10.1016/j.eururo.2015.07.001
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26194043 Editorial Comment: The authors begin by stating, “Tibial nerve stimulation (TNS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option for patients with an underlying neurological disorder.” They conclude by saying, “Although preliminary data of [randomized controlled trials] and non-[randomized controlled trials] suggest TNS might be effective and safe for treating [neurogenic lower urinary tract dysfunction], the evidence base is poor, derived from small, mostly noncomparative studies with a high risk of bias and confounding.” The authors felt that only 16 studies were suitable for inclusion, having begun with 1,542. Of these only 4 Dochead: Urological Survey
LIT 5.4.0 DTD JURO14083_proof 13 October 2016 1:37 pm EO:
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VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
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were randomized controlled trials. One study compared 4 mg tolterodine plus percutaneous TNS to drug alone, 1 compared percutaneous to stretching sessions to the lower limbs, 1 compared transcutaneous stimulation to sham and 1 compared transcutaneous to pelvic floor muscle training. In 1 study both transcutaneous and pelvic floor muscle training produced a significant reduction in urgency/frequency episodes and 1 study comparing percutaneous therapy to stretching sessions of the lower limbs produced a significant reduction in patients with incontinence and patients with urgency (stroke patients), while the “controlled” study produced none. One study using transcutaneous compared to sham produced a significant result in the stimulation group, none in the sham and no significant difference in the number of patients with incontinence or in maximum cystometric capacity. The authors have stated the case fairly: the data are very poor and no clear consensus is possible. Alan J. Wein, MD, PhD (hon)
Suggested Reading Zecca C, Digesu GA, Robshaw P et al: Maintenance percutaneous posterior nerve stimulation for refractory lower urinary tract symptoms in patients with multiple sclerosis: an open label, multicenter, prospective study. J Urol 2014; 191: 697. Andrews BJ and Reynard JM: Transcutaneous posterior tibial nerve stimulation for treatment of detrusor hyperreflexia in spinal cord injury. J Urol 2003; 170: 926.
Re: Does Defective Volume Sensation Contribute to Detrusor Underactivity? P. P. Smith, D. J. Chalmers and R. S. Feinn Department of Surgery, University of Connecticut Health Center, Farmington and Quinnipiac University School of Medicine, North Haven, Connecticut, and Department of Urology, Children’s Hospital Colorado, Aurora, Colorado Neurourol Urodyn 2015; 34: 752e756. doi: 10.1002/nau.22653
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25220925 Editorial Comment: Smith has long been a proponent of the view that defective volume sensation is a major contributor to detrusor underactivity in neurologically intact unobstructed patients. The data in this article provide limited statistical significance that diminished sensitivity to bladder volumes may be mediated by dysfunctional central processing of afferent information provided during bladder filling rather than impaired afferent generation. Furthermore, premature termination of the micturition reflex due to impaired afferent receptivity may be etiological in the factor to empty efficiently, characterizing detrusor overactivity during filling/storage and impaired contractility during emptying. The authors conclude, “The identification of peripheral and central targets aimed at normalizing perceptions of changing bladder volume may provide new therapeutic opportunity for these difficult clinical problems.” Alan J. Wein, MD, PhD (hon)
Re: Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the Management of Adult Non-Neurogenic Overactive Bladder V. Tse, J. King, C. Dowling, S. English, K. Gray, R. Millard, H. O’Connell, S. Pillay and J. Thavaseelan; Urological Society of Australia and New Zealand; Urogynaecological Society of Australasia Concord Hospital and Pelvic Floor Unit, Westmead Hospital, University of Sydney and Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Calvary Hospital, North Adelaide, South Australia, Fiona Stanley Hospital, Perth, Western Australia and Brisbane Urology Clinic, Brisbane, Queensland, Australia, and Christchurch Public Hospital, Christchurch, New Zealand BJU Int 2016; 117: 34e47. doi: 10.1111/bju.13246
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26456313
Dochead: Urological Survey
LIT 5.4.0 DTD JURO14083_proof 13 October 2016 1:37 pm EO:
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VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
urgency drop. For the mixture the percentages were 38% and 42%, greater than just the alkalinized lidocaine alone, at 13% and 8%. What I have learned from this article that I did not know is that if lidocaine is employed, it has to be properly alkalinized and not precipitated to effectively absorb into the bladder wall. The authors make the point that instilling a medication into the bladder does not necessarily result in absorption. In the case of lidocaine it must be alkalinized and not precipitated to effectively absorb into the bladder wall. The authors add that if other components like steroids are added to a “cocktail,” the effectiveness of the solution could be seriously reduced if the pH is not correspondingly adjusted and the lidocaine stability is not known. The concept that alkalinizing lidocaine yields a higher serum lidocaine level was supported by the finding that the heparin-lidocaine combination resulted in higher serum lidocaine levels compared to USP lidocaine alone. Nevertheless, the highest lidocaine level achieved was 0.84 mg/ml, well below the 6.0 mg/ml level associated with symptoms of toxicity. Alan J. Wein, MD, PhD (hon)
Re: Prospective Randomized Crossover Trial Comparing Continuous and Cyclic Stimulation in InterStim Therapy D. M. Price and K. Noblett Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics/Gynecology, University of California, Irvine, Orange, California Female Pelvic Med Reconstr Surg 2015; 21: 355e358. doi: 10.1097/SPV.0000000000000188
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26506165 Editorial Comment: This is a small randomized crossover study comparing continuous vs cyclic stimulation in female patients who have undergone successful sacral neuromodulation after a successful test stimulation. No significant differences were noted in voiding diaries or subjective responses between cyclic and continuous stimulation. The authors suggest that patients can be started on the cyclic stimulation used in this study as an initial setting (parameters listed in the article) and further suggest that this along with using the minimum amplitude needed for the optimal clinical response will help to prolong battery life. An additional note was that patients initially programmed for cyclic stimulation tended to favor it more than patients initially started on continuous stimulation. Alan J. Wein, MD, PhD (hon)
Re: Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review M. P. Schneider, T. Gross, L. M. Bachmann, B. F. Blok, D. Castro-Diaz, G. Del Popolo, J. Groen, R. Hamid, G. Karsenty, J. Pannek, L. Hoen and T. M. Kessler Neuro-Urology, Spinal Cord Injury Center/Research and Brain Research Institute, University of Zu¨rich, Balgrist University Hospital, Department of Health Sciences and Technology, Swiss Federal Institute of Technology Zu¨rich and Medignition, Inc., Research Consultants, Zu¨rich, Department of Urology, University of Bern, Inselspital, Bern and Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland, Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands, Department of Urology, University Hospital of the Canary Islands, Tenerife, Spain, Department of Neuro-Urology, Careggi University Hospital, Florence, Italy, Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, United Kingdom, and Department of Urology, Aix Marseille University, Marseille, France Eur Urol 2015; 68: 859e867. doi: 10.1016/j.eururo.2015.07.001
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26194043 Editorial Comment: The authors begin by stating, “Tibial nerve stimulation (TNS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option for patients with an underlying neurological disorder.” They conclude by saying, “Although preliminary data of [randomized controlled trials] and non-[randomized controlled trials] suggest TNS might be effective and safe for treating [neurogenic lower urinary tract dysfunction], the evidence base is poor, derived from small, mostly noncomparative studies with a high risk of bias and confounding.” The authors felt that only 16 studies were suitable for inclusion, having begun with 1,542. Of these only 4 Dochead: Urological Survey
LIT 5.4.0 DTD JURO14083_proof 13 October 2016 1:37 pm EO:
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VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285
were randomized controlled trials. One study compared 4 mg tolterodine plus percutaneous TNS to drug alone, 1 compared percutaneous to stretching sessions to the lower limbs, 1 compared transcutaneous stimulation to sham and 1 compared transcutaneous to pelvic floor muscle training. In 1 study both transcutaneous and pelvic floor muscle training produced a significant reduction in urgency/frequency episodes and 1 study comparing percutaneous therapy to stretching sessions of the lower limbs produced a significant reduction in patients with incontinence and patients with urgency (stroke patients), while the “controlled” study produced none. One study using transcutaneous compared to sham produced a significant result in the stimulation group, none in the sham and no significant difference in the number of patients with incontinence or in maximum cystometric capacity. The authors have stated the case fairly: the data are very poor and no clear consensus is possible. Alan J. Wein, MD, PhD (hon)
Suggested Reading Zecca C, Digesu GA, Robshaw P et al: Maintenance percutaneous posterior nerve stimulation for refractory lower urinary tract symptoms in patients with multiple sclerosis: an open label, multicenter, prospective study. J Urol 2014; 191: 697. Andrews BJ and Reynard JM: Transcutaneous posterior tibial nerve stimulation for treatment of detrusor hyperreflexia in spinal cord injury. J Urol 2003; 170: 926.
Re: Does Defective Volume Sensation Contribute to Detrusor Underactivity? P. P. Smith, D. J. Chalmers and R. S. Feinn Department of Surgery, University of Connecticut Health Center, Farmington and Quinnipiac University School of Medicine, North Haven, Connecticut, and Department of Urology, Children’s Hospital Colorado, Aurora, Colorado Neurourol Urodyn 2015; 34: 752e756. doi: 10.1002/nau.22653
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25220925 Editorial Comment: Smith has long been a proponent of the view that defective volume sensation is a major contributor to detrusor underactivity in neurologically intact unobstructed patients. The data in this article provide limited statistical significance that diminished sensitivity to bladder volumes may be mediated by dysfunctional central processing of afferent information provided during bladder filling rather than impaired afferent generation. Furthermore, premature termination of the micturition reflex due to impaired afferent receptivity may be etiological in the factor to empty efficiently, characterizing detrusor overactivity during filling/storage and impaired contractility during emptying. The authors conclude, “The identification of peripheral and central targets aimed at normalizing perceptions of changing bladder volume may provide new therapeutic opportunity for these difficult clinical problems.” Alan J. Wein, MD, PhD (hon)
Re: Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the Management of Adult Non-Neurogenic Overactive Bladder V. Tse, J. King, C. Dowling, S. English, K. Gray, R. Millard, H. O’Connell, S. Pillay and J. Thavaseelan; Urological Society of Australia and New Zealand; Urogynaecological Society of Australasia Concord Hospital and Pelvic Floor Unit, Westmead Hospital, University of Sydney and Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Calvary Hospital, North Adelaide, South Australia, Fiona Stanley Hospital, Perth, Western Australia and Brisbane Urology Clinic, Brisbane, Queensland, Australia, and Christchurch Public Hospital, Christchurch, New Zealand BJU Int 2016; 117: 34e47. doi: 10.1111/bju.13246
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26456313
Dochead: Urological Survey
LIT 5.4.0 DTD JURO14083_proof 13 October 2016 1:37 pm EO:
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