6. Ar-Razi
• "If a stone is impacted in the tip of the urethra be
aware not to force it out by pushing as this causes
laceration and subsequent severe pains and infections,
but incise the end of the penis and remove the stone"
8. Metallic syringe for
injecting solutions into
the bladder. Top, from
original Arabic
manuscript (Bes. 503),
courtesy Süleymaniye
Umumi Kütüphanesi
Müdürlüğü. Bottom,
from Argellata 1531,
courtesy National Library
of Medicine
9.
10.
11.
12.
13.
14. النفيس ابن
• Uro-physiology.
• Contrary to Galen who
described the bladder
wall as formed of only
one layer, Ibn al-Nafis,
in his book Sharh
Tashrih al-
Qanun described the
bladder wall as
consisting of two layers
• description of the anti-
reflux and micturition
mechanisms
16. Content overview
• Management of male LUTS
– Evaluation
– Medical treatment LUTS
– Surgical treatment LUTS
– Post-prostate treatment LUTS
URO/2016/0002/MEAa; Prepared: April 2016
• Management of UI
Bladder neck closure
Artificial urinary sphincter
• Management of female SUI
Surgical treatment
• Management of OAB
Evaluation
• Neurogenic DO
Medical treatment
• Ageing and the lower urinary tract
Medical treatment
Surgical treatment
20. Desmopressin add-on therapy for persistent nocturia
in pts with LUTS treated with α-blockers
• Multi-centre RCT in N=86 men with LUTS and persistent nocturia (≥2
voids/night, nocturia index score ≥1) under α-blocker treatment for ≥8 wks
treated with add-on placebo or desmopressin 0.2 mg
• Incidence of adverse events: desmopressin: 16%, placebo: 21%
Desmopressin add-on therapy seems effective and safe in men with
LUTS and persistent nocturia while on α-blocker treatment
Cho K. Eur Urol Suppl 2016;15(3):e543
Change from baseline Desmopressin
(N=47)
Placebo
(N=39)
P
No of nocturia episodes -1.13 -0.68 0.034
Nocturnal urine volume (ml) -283.6 -112.6 <0.001
Total IPSS -5.2 -2.5 0.042
Nocturnal polyuria index -13.9 -5.1 0.001
ICIQ-N -3.3 -1.6 0.001
Willingness to continue (% pts) 83% 62% 0.025
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
21. Long-term outcomes of antimuscarinic plus α-blocker
therapy vs α-blocker alone for men with BPH and OAB
• Single-centre RCT in 120 men with BPH (IPSS ≥8, prostate volume ≥25 ml)
and OAB (≥1 urgency episode/week, OABSS ≥3) randomised to silodosin
8 mg/d or silodosin 8 mg/d + propiverine 20 mg; FU: 1 yr
Long-term combination therapy of an antimuscarinic + α-blocker seems
more effective than α-blocker alone for treatment of BPH and OAB
Matsukawa Y. Eur Urol Suppl 2016;15(3):e867
Mean change from baseline Silodosin +
propiverine (N=51)
Silodosin
(N=53)
P
IPSS -7.4 -5.3 0.09
IPSS QoL -1.9 -1.2 0.01
OABSS -3.4 -2.5 0.04
Maximum cystometric capacity (ml) 61 33 0.02
Qmax (ml/s) 1.7 2.3 0.27
BOOI -18.5 -20.6 0.45
Adverse events (% pts) 24% 19% -
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
22. Combination therapy of tamsulosin plus dutasteride
plus imidafenacin for men with BPH and OAB
• Multi-centre RCT in N=163 BPH pts (prostate volume ≥30 ml) with persistent
OAB (OABSS ≥3, OABSS urgency ≥2) after tamsulosin treatment for ≥8 wk,
randomised to dutasteride or dutasteride + imidafenacin; FU: 24 wk
In BPH pts with a large prostate and persistent OAB symptoms with
tamsulosin, addition of dutasteride + imidafenacin seems more
effective than addition of dutasteride alone
Yamanishi T. Eur Urol Suppl 2016;15(3):e868
Change from baseline Tam + Dut + Imi (N=82) Tam + Dut (N=79) P
OABSS -3.1 -2.0 0.006
BII -2.7 -1.5 0.01
Qmax (ml/s) 1.5 -0.3 0.047
No of voids -1.4 -0.4 0.01
Volume voided/micturition (ml) 25.0 2.1 0.01
Urgency episodes -1.7 -1.6 0.86
PVR (ml) 19.3 1.4 0.01
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
23. Botulinum neurotoxin type A (BoNT-A) vs medical
therapy for BPH-related LUTS: PROTOX study
• Multi-centre, RCT in N=127 pts treated with 200 UI BoNT-A prostatic
injection (N=64) vs medical therapy (N=63); 18 mo FU
– 30 d after randomisation BoNT-A pts were asked to stop any LUTS-related
medical Tx
• At 18 mo: 37 pts (58%) in the BoNT-A group did not receive additional Tx
and were included in final analysis
• Efficacy:
• Safety:
– Serious AEs: prostatitis (N=2 in BoNT-A), haematuria (N=3 in BoNT-
A) and AUR (N=2 in each group)
BoNT-A injection seems to be associated with a sustained improvement
in IPSS in pts with BPH-related LUTS
Delongchamps NB. Eur Urol Suppl 2016;15(3):e1079
16.9
12.3
0
10
20
Baseline 18 mo
MeanIPSS
Time
P=0.001
• No differences between groups in
IPSS, Qmax, IIEF5 and prostate
volume during FU
URO/2016/0002/MEAa; Prepared: April 2016
25. *HoLEP vs TURP for symptomatic BPH
• Single-centre RCT in N=118 men with BOO due to BPH randomised to HoLEP
(N=59) or TURP (N=59)
• At 2 yr FU: HoLEP improved IPSS (P<0.001), QoL (P<0.001), Qmax (P=0.012),
prostate volume and urodynamically proven obstruction (P<0.001) vs baseline
HoLEP seems effective and safe for treatment of BOO due to BPH,
also in the long term
Yuan Y. Eur Urol Suppl 2016;15(3):e964
HoLEP vs TURP P
Haemoglobin drop <0.001
Intra-operative irrigation volume <0.001
Post-operative irrigation volume and time <0.001
Recovery room stay <0.001
Catherisation time <0.001
Hospital stay <0.001
Resected tissue <0.001
URO/2016/0002/MEAa; Prepared: April 2016
26. *HoLEP as a day case surgery
• Single-centre, single-surgeon, prospective observational
study in N=95 men with LUTS/BPH suitable for day case HoLEP (no ongoing
anti-coagulant therapy, fit medical condition, distance to hospital <50 km,
accompagnied by adult at home night after surgery)
HoLEP seems feasible as a day case surgery with acceptable
conversion and complication rates
Comat V. Eur Urol Suppl 2016;15(3):e965
% pts N=95
Conversion to conventional hospitalisation
• Due to gross haematuria requiring bladder irrigation
18.9%
15.8%
Readmission (at 3 mo)
• Due to AUR at day after surgery
14.7%
11.6%
Re-operation (at 3 mo) 2.1%
Complications
• AUR
• UTI
• Haematuria
36.8%
11.6%
10.5%
6.3%
Complications Clavien grade >2 2.1%
URO/2016/0002/MEAa; Prepared: April 2016
27. *Prostatic urethral lift (PUL) vs TURP in the
treatment of BPH-related LUTS: 2-yr results of BPH6
study
• Multi-centre RCT in N=80 men treated with PUL (N=45) or TURP (N=35)
• BPH6 endpoint* and sub-item responders at 2 yr (*responder if all 6 thresholds
are met)
PUL seems to be superior over TURP in reaching the BPH6 endpoint
at 2 yr
Gratzke C. Eur Urol Suppl 2016;15(3):e1076
46
62
82
97 100
83
92
22
91
53
94
64
75 79
0
20
40
60
80
100
BPH6
endpoint
LUTS (≥30%
IPSS ↓)
Recovery
(≥70% VAS at
1 mo)
Erectile
function (<6
SHIM ↓)
Ejaculatory
function
(MSHQ-EjD
#3 ≠ 0)
Continence
(ISI<5)
Safety (no
Clavien-Dindo
II+)
%ofresponders
PUL (N=45) TURP (N=35)
P=0.05
P=0.01 P<0.01
P<0.01
URO/2016/0002/MEAa; Prepared: April 2016
28. *Efficacy and safety of the prostatic urethral lift (PUL)
in men with LUTS due to BPH
• Multi-centre, randomised, blinded study; 4-yr FU
• N=206 men with LUTS due to BPH
– 2:1 randomised to either PUL (N=140) or a sham procedure (N=66)
– At 4 yr: 19 pts had repeat PUL or other procedure
• Improvements were significant and sustained at 4 yr (all P<0.0001)
• Adverse events were mild and transient
• Sexual function was preserved
PUL seems to provide a sustained (until 4 yr) improvement of BPH-
related LUTS, with a low morbidity and a preserved sexual function
Roehrborn C. Eur Urol Suppl 2016;15(3):e1077
44 42
33
47 51
57 59
46
57 61
69
0
20
40
60
80
IPSS reduction QoL reduction BPH II reduction Qmax increase
%change
1 mo (N=135)
1 yr (N=123)
4 yr (N=48)
URO/2016/0002/MEAa; Prepared: April 2016
29. *Efficacy of combined urethral lift and resection of
the prostate (CURP) in men with LUTS due to BPH
• Two-centre, prospective study, N=24 (mean age 65 yr, mean prostate volume 41
ml); 9-mo FU
• CURP: combination of transurethral prostatic urethral lift (PUL) and a limited
resection of the posterior bladder neck and/or prostatic middle lobe
• Significant improvements in IPSS, QoL, Qmax and PVR (all P<0.01)
• Minor post-operative complications (except 2 pts with blood clot retention)
• Antegrade ejaculation and sexual function were preserved
CURP seems to be a promising minimally invasive technique to
alleviate BPH-related LUTS with a low morbidity and preserved
sexual function
Schoenthaler M. Eur Urol Suppl 2016;15(3):e1078
62
49
91
79
0
20
40
60
80
100
IPSS reduction QoL increase Qmax increase
(ml/s)
PVR reduction
(ml)
%changefrom
baseline
URO/2016/0002/MEAa; Prepared: April 2016
30. *Efficacy of prostatic artery embolisation (PAE) vs
TURP in the treatment of BPH
• Single-centre, prospective, randomised, non-inferiority trial; preliminary
results
• 46 men included, 34 reached primary endpoint (IPSS at 3 mo)
• Efficacy:
• Safety:
– 2 pts with moderate pain and 1 with erectile dysfunction in PAE group
PAE seems to be a promising, minimally invasive technique for the
treatment of BPH with comparable efficacy to TURP
Abt D. Eur Urol Suppl 2016;15(3):e1080
Data from poster
Median
values
PAE TURP
Baseline 3 mo Baseline 3 mo
IPSS 19.5 9.0 16.0 7.5
QoL 4.0 1.0 4.0 2.0
Qmax (ml/s) 7.4 13.8 8.4 21.3
PVR (ml) 100 81.5 194 20
URO/2016/0002/MEAa; Prepared: April 2016
31. *Efficacy of Aquablation for BPH
• Multi-centre trial in N=21 BPH pts treated with Aquablation (high-velocity
saline stream under electromechanical control and live ultrasound guidance
for the ablation of prostatic tissue); mean prostate volume 57 g
• All procedures were technically successful:
– Mean total operative time: 38 min
– Mean Aquablation treatment time: 5 min
– Median catheterisation time: 1 d (all pts were catheterised)
• Significant improvements in:
• No reports of retrograde ejaculation, UI or erectile dysfunction
Aquablation seems a promising technique for ablation of enlarged
prostates
Anderson P. Eur Urol Suppl 2016;15(3):e1083
Baseline (N=21) 1-yr FU (N=20)
Qmax (ml/s) 8.6 18.3
IPSS 23.0 6.8
QoL 5.0 1.7
PVR (ml) 143 54
URO/2016/0002/MEAa; Prepared: April 2016
32. *Impact of thulium vapoenucleation with an ejaculation
sparing technique (TES) on sexual outcomes
• Single-centre study in N=167 men with BPH-related LUTS (mean age 69 yr,
mean prostate volume 79 ml) treated with thulium vapoenucleation/vaporisation
using an ejaculation sparing technique
– Preservation of 1 cm of tissue proximal to the verum montanum, performing an
inverted U-shaped incision using low power settings (40 watt)
– Questionnaires at 3- and 6-mo FU: ICIQ-MLUTSsex, MSHQ-EjD, IIEF5, IPSS
and QoL
• Efficacy:
TES appears a promising technique to relieve LUTS, while preserving
ejaculation and erectile function
Carmignani L. Eur Urol Suppl 2016;15(3):e1085
• Significant improvements on IPSSLUTS
• No differences observed
• 94 pts (56.3%) maintained ejaculation
Erectile function
URO/2016/0002/MEAa; Prepared: April 2016
33. *Comparison between thulium laser enucleation (ThuLEP)
and transurethral resection in saline (TURis) of the prostate
• Prospective study in N=208 men randomised to ThuLEP (N=102) or TURis
(N=106); 3 mo FU
• Perioperative parameters:
• AT 3 mo FU: no differences in Qmax, IPSS, PVR and QoL
ThuLEP and TURis seem to be equally efficient to relieve LUTS, but
ThuLEP seems to be associated with a shorter catheterisation time
and hospital stay compared with TURis
Bozzini G. Eur Urol Suppl 2016;15(3):e1086
Mean values ThuLEP (N=102) TURis (N=106) P
Operative time (min) 54 62 0.123
Enucleated/resected
prostate volume (g)
51 49 0.321
Catheterisation time (d) 1.3 4.8 0.011
Haemoglobin ↓ (g/dl) 0.5 2.8 0.005
Irrigation volume (l) 29 69 0.002
Hospital stay (d) 1.7 5.2 0.016
URO/2016/0002/MEAa; Prepared: April 2016
34. Impact of 5α-reductase inhibition (5-ARI) on efficacy of
photoselective vaporisation of the prostate (PVP) in Goliath study
• Retrospective evaluation of 1-yr data from the multi-centre Goliath study
• N=136 BPH pts treated with 180W GreenLight-XPS PVP, 36 on 5-ARI Tx
5-ARI Tx does not seem to impact on lasing efficiency and efficacy
outcomes of the GreenLight-XPS laser system
Brassetti A. Eur Urol Suppl 2016;15(3):e1088
Data from poster
Perioperative parameters 5-ARI (N=36) No 5-ARI (N=100) P
Lasing time 51 42 0.03
Delivered energy (kJ) 269 219 0.04
Lasing density (kJ/g) 5.5 4.8 0.19
Postoperative parameters
Change from baseline 5-ARI (N=36) No 5-ARI (N=100) P
IPSS -15 -14 0.78
Prostate volume (ml) -28 -26 0.82
Qmax (ml/s) 12 13 0.56
PVR (ml) -69 -73 0.78
URO/2016/0002/MEAa; Prepared: April 2016
37. Urinary complications after prostate cancer (PCa)
surgery: what is the incidence and how to manage?
• Incidence:
– 15-yr follow-up of pts undergoing prostatectomy or RT for prostate
cancer: no significant differences in functional outcomes1
– ~1 in 5 men have no control or frequent urinary leakage after
prostatectomy1
– The chance to have UI rises with increasing PCa survivorship duration2
– The chance to become incontinent, due to the ageing process, is 11%,
despite being continent after surgery3
– Unclear if the surgical approach contributes to UI development4,5
– Adjuvant RT associated with a higher chance of urinary complications
(than no adjuvant RT in post-RP pts)6
• Diagnostic workup:
1Resnick MJ et al. N Engl J Med 2013;368:436-45; 2Kopp RP et al. Eur Urol 2013;64:672-9; 3Naselli A et al. Int J Urol
2011;18:76-9;4Ficarra V et al. Eur Urol 2009;55:1037-63; 5Robertson C et al. BJU Int 2013;112:798-812; 6Suardi N
et al. Eur Urol 2014;65:546-51
1 of 2
URO/2016/0002/MEAa; Prepared: April 2016
39. Urinary complications after prostate cancer surgery:
what is the incidence and how to manage?
• Decision-making process taking into account:
• Treatment options:
Post-prostatectomy incontinence is a growing challenge for the urologist
who will face more cases as the life expectancy increases
1Crivellaro S et al. Neurourol Urodyn 2015;doi:10.1002/nau.22873
2 of 2
UI severityCo-morbidities
Pt’s expectations:
• Willingness to accept
2nd procedure
• Adversity to a
mechanical device
• Treatment preference
AUS
• Gold standard
• Highest success rate: 20-89%1
• Replacement needed in long
term
Slings
• Different types with different
outcomes available
• Success rate: 30-79%1
URO/2016/0002/MEAa; Prepared: April 2016
40. Slings or AUS: which is the best to treat incontinence
after radical prostatectomy (RP)?
AUS is the most effective and slings are the most convenient treatment
option. So patient’s preference is key in the decision making
1EAU guidelines 2016, available at http://uroweb.org/guideline/urinary-incontinence/; 2James MH et al. Int J Urol 2014;21:536-43
Slings AUS
Evidence level1 3 2
Recommendation grade1 B B
Incontinence level Mild-moderate All
Average success rate ~70-75% (50% ↓ in SUI) ~83% (0-1 pad/d)2
Average explant/revision rate 0.7% (explant rate with Advance®) 20-23%
Life span Unknown 10 yr
After radiotherapy or stricture Less efficacy Only option
Efficacy
Convenience
Patient’s choice
URO/2016/0002/MEAa; Prepared: April 2016
41.
42. Long-term outcomes of transobturator male sling for
post-prostatectomy incontinence
• Multi-centre, prospective cohort study (2007-2012)
• N=100 men with post-prostatectomy incontinence (24-h pad test < 400 g)
and no pelvic radiotherapy, implanted with transobturator sling (ISTOP-
TOMSTM)
• Median FU: 60 mo
The transobturator male sling for post-prostatectomy incontinence
seems effective in the long term
Malval B. Eur Urol Suppl 2016;15(3):e197
38
50 51
44
38
77
90 88 84
71
0
20
40
60
80
100
1 yr 2 yrs 3 yrs 4 yrs 5 yrs
%ofpts
Follow-up
Dry
0 or 1 pad
URO/2016/0002/MEAa; Prepared: April 2016
43. Six-arm vs 2-arm retropubic suburethral autologous
sling placed during robotic radical prostatectomy (RP)
• Single-centre, prospective, randomised study in N=120 men with localised
prostate cancer undergoing robotic RP having placed a 6-arm or 2-arm
autologous sling during RP
• The mean ICIQ-UI-SF score at 1 mo was lower for pts having 6-arm sling
(1.8) vs pts having 2-arm sling (2.4; P=0.07)
Preliminary data suggest that a 6-arm retropubic suburethral autologous
sling placed during radical prostatectomy may improve early urinary
incontinence recovery vs a 2-arm sling
Cestari A. Eur Urol Suppl 2016;15(3):e344
60
70
87
35
46
70
0
20
40
60
80
100
At catheter
removal
10 days 30 days
%ofcontinentpts
6-arm sling (N=60)
2-arm sling (N=60)
P=0.02
P=0.03
P=0.04
URO/2016/0002/MEAa; Prepared: April 2016
44. How to treat incontinence after radiation therapy
(RT)?
• 30-80% of pts suffer from incontinence after pelvic RT1,2
• Different underlying causes:
– Often both surgery and RT are responsible for damages
• Treatment options exist, but lack evidence in irradiated pts:
– Studies are scarce
– Follow-up is short
– Cohorts have low numbers
– Subgroup analysis is sometimes missing
1Erekson EA et al. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:159-63; 2Pisarska M et al. Eur J Gynaecol Oncol 2003;24:490-4
Bladder damage
• Compliance ↓
• Capacity ↓
• Change in contractility
• Change in bladder
sensation
• Long-term: fistula
Sphincter damage
• Bladder neck stricture
• Change in striated
sphincter
Local vascular or
neurological damage
1 of 2
URO/2016/0002/MEAa; Prepared: April 2016
45. How to treat incontinence after radiation therapy
(RT)?
Different treatment options exist, but evidence in this population is lacking. So
individual management is needed in this challenging condition
1Chartier-Kastler E et al. BJU Int 2011;107:1618-26; 2EAU guidelines 2016, available at http://uroweb.org/guideline/urinary-
incontinence/; 3Son CH et al. Pract Radiat Oncol 2015; doi: 10.1016/j.prro.2015.12.004
2 of 2
Bladder damage Sphincter damage
♀ ♂
Conservative management
mostly fails
Mid-urethral slings
• Erosion or complications emerge on
short to mid term
AUS
• Grade B recommendation in
EAU guidelines for men with
moderate-to-severe post-
prostatectomy incontinence2
• Bladder has to be controlled
Bladder enlargement in end-
staged pts
Aponevrotic slings
• Usually not most effective
Urinary diversion as last
solution
AUS1
• Pelvic RT= absolute contraindication
ACT balloons
• Associated with many local
problems
Pro-ACT balloons and slings
• Not prohibited, but high
complication and low
continence rates
Bulking agents
• Not the most effective treatment
• Obtain prospective data on urodynamic changes after RT
• Better understand individual tissue alterations3
URO/2016/0002/MEAa; Prepared: April 2016
• Treatment options:
Better collaboration with radiation oncologist needed to:
46. Transobturator sling for incontinence after radical prostatectomy
(RP) combined with radiotherapy (RT) for prostate cancer
• Systematic review and meta-analysis
• N=8 studies, N=126 pts treated with transobturator sling for incontinence
after RP+RT
• FU range 12-24 mo
Transobturator sling for incontinence after RP+RT seems to have a
poor success rate and only about half of pts are satisfied
Ajay D. Eur Urol Suppl 2016;15(3):e198
Post-operative success rate* 0-55%
% of pts that were satisfied post-operatively ± 50%
Most common AEs AUR, urethral injury
*Studies used different definitions of post-operative success
URO/2016/0002/MEAa; Prepared: April 2016
48. Is bladder neck closure a treatment option for
incontinence?
• Indications include refractory incontinence in neurogenic pts, previously
treated (surgical or RT) pts, trauma or congenital malformation
• The preoperative workup includes:
– Clinical examination (incontinence observation, tissue quality, sensation/motor
innervation)
– Cystoscopy
– Video-urodynamics
• Evidence in literature is scarce (≠ populations and ≠ techniques)1-5:
– ~150 pts
• No outcome data for previously irradiated pts: probably worse
Bladder neck closure is an effective solution to restore continence. But
pts should be informed about the high complication and revision rate
1Kavanagh A et al. J Urol 2012;188:1561-5; 2Kranz J et al. Cent European J Urol 2014;66:481-6; 3O’Connor RC et al. Urology
2005;66:311-5;4Shpall AI et al. J Urol 2004;172:2296-9; 5Spahn M et al. Urology 2010;75:1185-92
Success rate for closure Any revision Any complication
83-100% 13-41% 27-53%
Many patients require additional surgeries to achieve a functionally acceptable outcome
URO/2016/0002/MEAa; Prepared: April 2016
50. Long-term outcomes and durability of artificial
urinary sphincter (AUS) for male SUI
• Single-centre, retrospective study; N=137 pts having AUS implantation (AMS 800TM)
from 2003-2015; mean FU: 43.7 mo
• Current or prior smoker was a risk factor for re-operation (P=0.011)
AUS for male SUI may offer a high rate of continence although it is
associated with a relatively high rate of re-operation
Suh YS. Eur Urol Suppl 2016;15(3):e190
Outcome
Treatment success
• Dry (no pads)
• ≤1 pad/day
77%
84%
Re-operation (revision or explantation)
• Explantation
25%
4%
Mean duration from AUS implantation to re-operation 27.6 mo
5-yr survival rate without re-operation 66.8%
Aetiology of re-operation
• Mechanical failure
• Non-mechanical failure
• Subcuff urethral atrophy
26%
74%
53%
URO/2016/0002/MEAa; Prepared: April 2016
51. Management of tissue atrophy after artificial urinary
sphincter (AUS) placement for SUI
• Single-centre retrospective study in N=26 pts who underwent AUS revision due to
recurrent SUI caused by tissue atrophy (25 men, 1 woman)
• Mean time to tissue atrophy: 22 mo
• 88.6% of pts had satisfactory continence (decrease in security pads from 5.6 to 0.7)
Tissue atrophy at cuff site can be managed by different techniques which
should be individualised to tissue state, location and no. of primary cuffs
Comat V. Eur Urol Suppl 2016;15(3):e1157
Placement of cuff in primary AUS % pts (N=26)
Bladder neck 7.7%
Membraneous urethra 65.4%
Bulbar urethra 26.9%
Management of tissue atrophy % pts (N=26)
Cuff downsizing in same position 57.7%
New cuff position 15.4%
Double cuff in new position 19.2%
Adding cuff besides old cuff 26.9%
URO/2016/0002/MEAa; Prepared: April 2016
52. Complications and explantation rates of single-cuff vs
double-cuff artificial urinary sphincter (AUS) for male SUI
• Multi-centre, retrospective cohort study; N=477 men with SUI who
underwent AUS implantation (2010-2012)
– N=159 perineal single-cuff (PERSC)
– N=101 penoscrotal single-cuff (PENSC)
– N=217 primary double-cuff (DC)
• Multivariate analysis for explantation witin 6 mo: PENSC (P=0.02),
intra-operative complications (P=0.006), bleeding (P=0.02), infection
(P<0.001) were independent risk factors
Short-term explantation rates seem higher for penoscrotal single-cuff
AUS than for perineal single-cuff AUS or double-cuff AUS
Kretschmer A. Eur Urol Suppl 2016;15(3):e191
% of pts PERSC
(N=159)
PENSC
(N=101)
DC
(N=217)
P
Post-operative infection 5.7% 7.9% 14.3% 0.02
Explantation within 6 mo 8.2% 19.8% 6.0% 0.004
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
53. Artificial urinary sphincter (AUS) mechanical failure:
replacement of entire device or malfunctioning part
• Single-centre cohort study (1983-2011); N=125 men with SUI with a primary
AUS having mechanical device malfunction; median FU: 4.2 yr
– Urethral cuff failure: 46.1%
– Abdominal reservoir failure: 22.6%
– Tubing failure: 21.7%
– Pump failure: 9.6%
It remains unclear if replacing the entire device or
malfunctioning part of AUS impacts on AUS survival
Linder B. Eur Urol Suppl 2016;15(3):e195
Data from poster
Risk of AUS failure HR 95% CI P
Time to AUS failure 0.89 0.71-1.12 0.33
Replace entire device vs single part 0.47 0.16-1.33 0.15
Interaction 1.12 0.87-1.44 0.39
Entire device replaced Single part replaced P
AUS survival at 3 yr 76% 60% 0.11
URO/2016/0002/MEAa; Prepared: April 2016
55. The impact of ageing on the lower urinary tract
• The prevalence of LUTS increases by age in men and women1:
– At age ≥60 yr: 62.9% of men and 58.7% of women reported any
LUTS1
• In the elderly:
1Irwin DE et al. Eur Urol 2006;50:1306-14
1 of 2
Predisposing
factors
Age-related
changes
LUT
dysfunctioning
URO/2016/0002/MEAa; Prepared: April 2016
56. The impact of ageing on the lower urinary tract
• What to expect with ageing1,2:
Age-related changes have a major impact on functioning of the lower
urinary tract
1Resnick MJ et al. Campbell-Walsh Urology 2012:2204-22; 2Griebling TL. Campbell-Walsh Urology 2016:2083-102
2 of 2
Increase in
• DO
• PVR (≤50-100 ml)
• Nocturia
• Prostate size (♂)
• Obstruction (♂)
• Atrophic vaginitis (♀)
• POP (♀)
• Depression
Decrease in
• Bladder sensation
• Ability to postpone
• Contractility (not at
myocyte level)
• Mobility
• Maximal urethral
closure pressure (♀)
URO/2016/0002/MEAa; Prepared: April 2016
57. AGEING AND THE
LOWER URINARY TRACT
Surgical treatment
URO/2016/0002/MEAa; Prepared: April 2016
58. Treatment of the elderly: which surgical options can
be used?
• Level 1 evidence is available for different surgical techniques, but
only limited information for elderly patients1:
• TAKE INTO ACCOUNT: age, life expectancy, anticoagulation,
hospital stay and comorbidities
Patient characteristics and hospital stay are key in the decision
1Cornu JN et al. Eur Urol 2015;67:1066-96; 2EAU guidelines 2016, available at http://uroweb.org/guideline/treatment-of-non-
neurogenic-male-luts/; 3Drake MJ et al. Eur Urol 2016;doi:10.1016/j.eururo.2016.01.035
PV <30 ml
• TURP
• Laser vaporisation
PV 30-80 ml
• TURP
• Laser vaporisation
• Laser enucleation
PV >80 ml
• Laser enucleation
• B-TURP
• Laser vaporisation?
• Open prostatectomy
BPO surgery in elderly Urodynamics2,3Minimally invasive
techniques
URO/2016/0002/MEAa; Prepared: April 2016
59. Surgical treatment of BPO in the elderly: what are
the key factors to decide on treatment?
Safety
• Comorbidities
• Treatment-related
adverse events
• Post-operative
incontinence
• Need of re-
operation
Efficacy
• LUTS improvement
• Cost-effectiveness
evaluation1
Clinical
Progression
• Life expectancy
• QoL expectancy
• AUR risk
Age is not the limit for safe and efficient surgery
1DiSantostefano RL et al. BJU Int 2006;97:1007-16; 2Balslev Jørgensen J et al. Eur Urol 1997;31:281-5; 3Lourenco T et al. World J
Urol 2010;28:23-32; 4Mmeje CO et al. BJU Int 2013;112:982-9; 5Sønksen J et al. Eur Urol 2015;68:643-52; 6Gratzke C. Eur Urol
Suppl 2016;15(3):e1076; 7Porpiglia F et al. BJU Int 2015;116:278-87
• Minimally-invasive procedures are the treatment of choice:
– TURP2, TUIP3, laser vaporisation/enucleation (greenlight, holmium4, thulium)
– Evidence is growing for prostatic urethral lift5,6, TIND7
URO/2016/0002/MEAa; Prepared: April 2016
60. Photovaporisation of the prostate (PVP) with
Greenlight laser in octogerians with BPH
• Multi-centre retrospective cohort study in N=396 pts with BPH treated with
PVP (2005-2014); FU: 1 yr
• Complications were Clavien ≤2 in 92.5% of pts; no differences between
groups
• Pts ≥80 yr reported more erectile dysfunction and retrograde ejaculation
PVP seems effective and safe also in BPH patients ≥80 yr
Pradere B. Eur Urol Suppl 2016;15(3):e962
Change from baseline at 1 yr <80 yr old
(N=249)
≥80 yr old
(N=147)
P
IPSS -13.7 -11.5 0.3
IPSS QoL -3.5 -3.8 0.45
Qmax (ml/s) 10.5 7.5 0.24
PVR (ml) -142 -162 0.71
≥1 complication (% pts) 39.4% 40.5% 0.83
URO/2016/0002/MEAa; Prepared: April 2016
62. *Intravesical pressure-attenuation balloon system for
female SUI
• Free-floating, non-occlusive intravesical balloon filled with compressible gas to reduce
transient spikes in intravesical pressure in pts with SUI
• Multi-centre RCT in N=63 women with SUI; N=41 balloon, N=22 sham control
• Composite endpoint: ≥10 point increase in I-QOL and ≥50% decrease in provocative
pad weight
• Results were maintained at 6 mo FU
• AEs in first 3 mo: dysuria (15%), gross haematuria (10%), UTI (7%)
The intravesical pressure-attenuation balloon seems effective and safe
for the treatment of female SUI
De Wachter S. Eur Urol Suppl 2016;15(3):e2
63
80
59
32
45
27
0
10
20
30
40
50
60
70
80
90
Composite endpoint ≥ 50% decrease in pad
weight
Improvement on PGI-I
%ofpts
Balloon (N=41)
Control (N=22)
at 3 mo FU:
P<0.02
P<0.05
Data from poster
P<0.05
URO/2016/0002/MEAa; Prepared: April 2016
63. *Differences in complications after sling procedures for
female SUI performed by gynaecologists or urologists
• Multi-centre database study of 10,508 female sling procedures:
– N=4,538 (43%) performed by urologists
– N=5,970 (57%) performed by gynaecologists
• Most common complication: UTI (84% of all complications)
• No differences in 30-day cardiovascular, pulmonary, thrombotic, septic,
renal, wound, and bleeding complications
• No differences in re-operation and re-admission rates
Gynaecologists seem to have a slightly higher complication rate for
sling procedures in women than urologists
Löppenberg B. Eur Urol Suppl 2016;15(3):e7
Gynaecologist Urologist P
Additional procedures after sling surgery 22.2% 10.5% <0.0001
UTI 3.6% 2.3% <0.0001
Overall complications 4.1% 2.9% 0.001
URO/2016/0002/MEAa; Prepared: April 2016
64. *TVT-O vs single incision sling (SIS) for female SUI;
effects on sexual function and quality of life
• Multi-centre RCT; N=48 women with pure SUI randomised to TVT-O or SIS;
FU at 12 mo
Both TVT-O and SIS showed a high rate of
continence and improved sexual function
in women with pure SUI
Al Salhi Y. Eur Urol Suppl 2016;15(3):e907
24 23.528.1 27.4
0
50
TVT-O (N=21) SIS (N=21)
Mean
FSFI
score
Baseline
12 mo FU
% pts reporting TVT-O (N=21) SIS (N=21)
Complete SUI resolution 85.7% 80.9%
Improvement SUI symptoms 4.7% 9.5%
P<0.001 P<0.001
URO/2016/0002/MEAa; Prepared: April 2016
MiniArc™ Single-Incision Sling System
65. *Early vs delayed removal of suburethral mid-
urethral sling (MUS) for voiding dysfunction in
women
• Single-centre, retrospective database study; N=116 non-neurogenic women who
underwent suburethral sling removal (SSR) for MUS complications (2005-2015)
– N=73 early sling removal (<5 yr from placement of sling), median FU: 20 mo
– N=43 delayed sling removal (≥5 yr from placement of sling), median FU: 13 mo
Delayed removal of MUS may still lead to improvements in symptoms
related to MUS complications
Aggarwal H. Eur Urol Suppl 2016;15(3):e902
Patient self-reported
complication
Early sling removal (N=73) Delayed sling removal (N=43)
Pre-SSR Post-SSR P Pre-SSR Post-SSR P
Voiding dysfunction 55 7 <0.001 36 3 <0.001
Dyspareunia 42 16 <0.001 27 9 <0.001
Pelvic pain 52 21 <0.001 34 11 <0.001
Pure SUI 7 5 NS 8 2 NS
UUI and urge predominant MUI 45 13 0.0001 24 11 NS
Recurrent UTI 44 14 <0.001 27 10 <0.0002
Pts with multiple complaints 71 32 <0.001 42 17 <0.001
URO/2016/0002/MEAa; Prepared: April 2016
66. *Pulsed magnetic stimulation (PMS) for female SUI
• Multi-centre, randomised, double-blind, sham-controlled trial in N=115
women with SUI treated with PMS or sham for 8 wks
• No significant differences between PMS and sham arm in treatment
experience (comfort, pain, convenience) and adverse events (PMS: 5% vs
sham: 9%)
PMS seems an effective and well-tolerated treatment for female SUI
Lim R. Eur Urol Suppl 2016;15(3):e4
79 83
68
22
47
19
0
20
40
60
80
100
Treatment
responder*
(Completely)
satisfied with
treatment
PGI-I (very) much
better
%otpts
PMS (N=57)
Sham (N=58)
*Treatment responder: 5 point reduction in ICIQ-UI SF
P<0.001
P<0.001
P<0.001
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
67. *Cost benefit of omitting urodynamics (UDS) before
surgery in female SUI
• The role of UDS before surgery in pts with uncomplicated SUI has been
questioned; in the US 13-33 million $ can be saved when omitting UDS in
uncomplicated female SUI pts
• Single-centre study investigating the costs of UDS before surgery for female
SUI in Italy and possible savings if UDS are omitted in pts with
uncomplicated SUI
• Possible reasons for differences between countries: a lower reimbursement
and lower number of procedures in ItalyThe costs of UDS before female SUI surgery in
Italy seem modest and lower than in the USA;
omitting UDS before female SUI surgery seems
not relevant in Italy
Patruno G. Eur Urol Suppl 2016;15(3):e5
Italy US
Costs saved by omitting UDS before female
SUI surgery per 1,000 inhabitants
13 Euro
(14 $)
38-97 Euro
(42-106 $)
URO/2016/0002/MEAa; Prepared: April 2016
68. *Safety of vaginal mesh for POP repair or SUI
surgery
• Multi-centre, retrospective, US database study (2008-2013) in N=48,389 pts
having vaginal mesh for POP repair or SUI surgery (mean age 56.2 yr)
• Outcomes at 1 yr after initial surgery
Combined incontinence and POP repair
using mesh seems associated with the
highest risks of erosion and repeat surgery
Forde JC. Eur Urol Suppl 2016;15(3):e901
% pts POP repair (mesh) +
sling (N=5,785)
POP repair (mesh), no
sling (N=4,380)
POP repair (no mesh)
+ sling (N=12,813)
Synthetic sling only
(N=25,411)
Repeat surgery 5.3% 3.9% 3.7% 2.4%
Median time to repeat
surgery (d)
141 180 138 116
Erosion 2.6% 1.8% 1.8% 1.5%
Median time to erosion (d) 114 136 122 107
Urinary retention 8.5% 9.4% 7.2% 4.2%
URO/2016/0002/MEAa; Prepared: April 2016
70. Role of filling rate in the 3d bladder diary in
idiopathic OAB
• Single-centre, retrospective study; N=103 women with OAB (mean age 55 yr)
• 5,041 voids included (mean volume 182 ml, mean interval 2.6h, mean filling rate 98
ml/h)
• PPIUS scale 3-4: 37.7%; urgency incontinence: 19.6%
• Influence of median day filling rate (categorised by voided volume [VV]) on
PPIUS scale and urgency incontinence (UI) during the day:
• Median filling rate and micturition frequency can be predicted by the amount
of liquid ingested (P<0.0001)
For voided volumes >150 ml, urgency and UI seem to be triggered by
greater filling rates
Gomez de Vicente JM. Eur Urol Suppl 2016;15(3):e1114
Data from poster
Filling rate
(ml/h)
PPIUS scale UI
0-2 3-4 P No Yes P
VV <150 ml 50 50 NS 50 50 NS
VV 150-250 ml 78 96 <0.001 80 100 <0.001
VV >250 ml 100 123 0.002 102 125 0.028
URO/2016/0002/MEAa; Prepared: April 2016
72. *Botox failure: what, why and how to prevent?
• Rate of poor efficacy or secondary failure: generally low1,2
• Possible reasons for variation in treatment response:
– Procedure-related factors Possible, but probably rare
• Correct storage and reconstitution is very important
– Antibody production Really uncommon
• Meta-analysis among 2240 pts: 0.2% had neutralising Ab at final visit3
• DIGNITY extension study in neurogenic detrusor overactivity pts: 1 (out of
387) pts had neutralising Ab4
– Technical issues during the injection Possible
• How to prevent failure: personal experience regarding optimal
injection
– Wait long (≥5 s) before removing the needle
– Perform every injection deeper and perpendicular into the bladder wall
– Solutions spread about 2 cm from the injection site
A careful and precise injection technique is key to prevent Botox failure
1Dowson C et al. Eur Urol 2012;61:834-9;2Mohee A et al. BJU Int 2013;111:106-13; 3Naumann M et al. Mov Disord 2010;25:2211-8;
4Kennelly M et al. Neurourol Urodyn 2015; doi:10.1002/nau.22934
URO/2016/0002/MEAa; Prepared: April 2016
73. *Onabotulinumtoxin A (onabotA) for urinary incontinence (UI) due to
neurogenic detrusor overactivity (NDO) in non-catheterising multiple
sclerosis (MS) patients
• RCT in N=144 non-catheterising MS pts with UI due to NDO inadequately
managed by ≥1 anticholinergic treated with onabotA 100U or placebo
• Most common AEs with onabotA vs placebo: UTI (26% vs 6%), residual urine
volume (17% vs 1%), urinary retention (15% vs 1%)
• Clean intermittent catheterisation: onabotA: 15.2% vs placebo: 2.6%
OnabotA 100U seems effective and well-tolerated
in non-catheterising MS pts with UI due to NDO
inadequately managed by anticholinergics
Chartier-Kastler E. Eur Urol Suppl 2016;15(3):e647
Change from baseline OnabotA 100U
(N=66)
Placebo
(N=78)
P
UI episodes/day -2.8 -1.1 <0.001
100% reduction in UI (% pts) 53% 10% <0.001
Maximum cystometric capacity (ml) 127.2 -1.8 <0.001
Maximum detrusor pressure (cm H2O) -19.6 3.7 <0.01
I-QOL 38.8 7.6 <0.001
Duration of effect (months) 11.9 2.9 <0.001
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
74. Bacteriuria in pts having onabotulinumtoxin A (onabotA)
for refractory neurogenic detrusor overactivity (NDO)
• Multi-centre, prospective cohort study (2012-2014) in N=154 pts with
refractory NDO having onabotA treatment (N=273 treatments) without
antibiotic prophylaxis; urine sample collected before treatment
Bacteriuria in pts having onabotA injections for refactory NDO does not
seem to affect the safety and efficacy of onabotA.
Antibiotic prophylaxis may need to be critically considered
Leitner L. Eur Urol Suppl 2016;15(3):e649
Bacteriuria
(N=200 samples)
No bacteriuria
(N=73 samples)
OR
(95% CI)
P
Adverse events (%) 5% 7% 0.64
(0.23-1.81)
0.4
UTI (%) 4% 7% - -
Therapy failure (%) 31% 26% 0.78
(0.43-1.43)
0.4
Treatment effect (mo) 12 10 - 0.56
Data from posterURO/2016/0002/MEAa; Prepared: April 2016
75. Role of urodynamics (UDS) in the assessment of efficacy of
onabotulinumtoxinA (onabotA) for neurogenic detrusor
overactivity (NDO) incontinence
• Prospective, single-centre study in N=148 pts with refractory NDO
incontinence treated with onabotA intradetrusor injections
• UDS prior and 6 wk after onabotA
• Continence rates at 6 wk: 98 (66%) pts were completely dry
• Among continent pts:
– No significant differences for other urodynamic parameters (bladder volume at 1st
DO, max cystometric capacity, compliance)
UDS seem useful for the outcome assessment of onabotA treatment in
pts with NDO incontinence
Tornic J. Eur Urol Suppl 2016;15(3):e1113
Data from poster
Max detrusor pressure during
storage phase
>40 cmH2O ≤40 cmH2O P
N (%)
• DO after treatment, N (%)
18 (18%)
18 (100%)
80 (82%)
50 (63%) <0.01
URO/2016/0002/MEAa; Prepared: April 2016
76. Spingosine-1-phosphate (S1P) as biomarker of detrusor
overactivity (DO) in pts with multiple sclerose (MS)
• Open-label prospective study in N=51 pts with LUTS: N=16 MS pts and
N=35 pts without neurological disease
• Measurement of urinary levels of S1P via ELISA; DO assessed via
urodynamics
Urinary S1P levels seem to be increased in MS pts with DO and
decreased with treatment. S1P may be a biomarker of DO in MS pts
Sanson S. Eur Urol Suppl 2016;15(3):e271
70.1
2.5
0
10
20
30
40
50
60
70
80
MS with
DO
MS without
DO
S1P(ng/ml)
P=0.0006
4.3
17.3
0
5
10
15
20
MS pts with
treatment*
MS pts without
treatment*
S1P(ng/ml)
*Anticholinergic or botulinum toxin A injection
P=0.07
URO/2016/0002/MEAa; Prepared: April 2016
