Publications by authors named "Benjamin M Brucker"

71 Publications

Intravesical Instillation of OnabotulinumtoxinA in the Treatment of Refractory Overactive Bladder in Participants with Urinary Incontinence.

J Urol 2022 Jul 5:101097JU0000000000002800. Epub 2022 Jul 5.

NYU Langone Health, New York, New York.

Purpose: Intradetrusor injections of onabotulinumtoxinA are efficacious for the treatment of overactive bladder with urgency urinary incontinence in adults refractory to or intolerant of anticholinergics. Delivery of onabotulinumtoxinA via instillation would reduce the need for intradetrusor injections. The objective of this trial was to assess the efficacy and safety of intravesical instillation of an onabotulinumtoxinA + hydrogel admixture.

Materials And Methods: After review of a stage 1 safety phase by an independent committee, participants were recruited into stage 2 and randomized to either onabotulinumtoxinA 100, 300, 400, or 500 U, or placebo, all with hydrogel admixture. End points included change from baseline to week 12 in the number of urinary incontinence episodes (primary); micturition, urgency urinary, and nocturia episodes/day; volume voided per micturition; proportion of participants with a ≥50% decrease from baseline in urinary incontinence episodes/day; and Overactive Bladder Questionnaire total score. Adverse events were reported.

Results: Change from baseline to week 12 in number of urinary incontinence episodes was -2.72 with placebo and ranged from -0.89 to -1.85 in the onabotulinumtoxinA + hydrogel treatment groups. No difference from placebo was observed for any efficacy end point. The proportions of participants with treatment-emergent adverse events were similar among all groups, with asymptomatic bacteriuria the highest reported (6.7%-15.5%). There were no reports of urinary retention or elevated post-void residual volume.

Conclusions: Intravesical instillation of an onabotulinumtoxinA + hydrogel admixture for the treatment of refractory overactive bladder was well tolerated, but it showed no improvement over placebo.
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http://dx.doi.org/10.1097/JU.0000000000002800DOI Listing
July 2022

Chapter 4: Treatment of overactive bladder in men: Is it really different?

Neurourol Urodyn 2022 Jul 3. Epub 2022 Jul 3.

Department of Urology, New York University, New York, New York, USA.

Introduction: Overactive bladder (OAB) in men is a topic that is gaining increasing attention as there is a wider understanding that OAB is not a female condition. There are several treatments; however, data in male populations are lacking compared to female cohorts. The high likelihood of concomitant benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO) adds to the complexity of the treatment algorithm. The overlap in urinary storage symptoms also makes the interpretation of the literature challenging.

Methods: Articles that evaluated men with OAB and men with OAB and BPH/BPO were evaluated and assessed.

Results: Behavioral interventions can offer a significant benefit to male patients with OAB. Medical therapies that have been studied in men with OAB include anticholinergics, beta-3 agonists, and phosphodiesterase-5 inhibits. These agents can be offered in addition to alpha-blockers for men with coexisting BPH/BPO. The literature on Onabotulinumtoxin-A and neuromodulation modulation in the male population is growing and shows promising results.

Conclusion: Male OAB is complex; however, there is a growing body of literature to help guide treatments. Many treatments are available and they have shown considerable success.
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http://dx.doi.org/10.1002/nau.25000DOI Listing
July 2022

Thirty-six-month Prospective Study of Transvaginal Bovine Graft vs Native Tissue Repair for the Treatment of Pelvic Organ Prolapse.

Urology 2022 Jun 15. Epub 2022 Jun 15.

Mount Auburn Hospital, Harvard Medical School, Cambridge, MA.

Objective(s): To compare the safety and effectiveness of dermal bovine transvaginal graft, Xenform, to native tissue in the surgical treatment of anterior and/or apical pelvic organ prolapse. This study was designed in conjunction with Food and Drug Administration requirements.

Methods: This was a prospective, non-randomized, parallel cohort, multi-center trial. The primary objective was to demonstrate noninferiority between transvaginal graft and native tissue repair at 36 months compared to baseline. Treatment success was based on a composite of objective and subjective measures. The co-primary outcome was the rate of serious device- or procedure-related adverse events. A total of 228 patients at 25 sites were included in the study arm and 485 patients underwent native tissue repair. Propensity score stratification was applied to achieve balance between treatment groups. Study outcomes were compared in per protocol and intent-to-treat analysis.

Results: The primary outcome, treatment success at 36 months, was 83.6% (191/228) for transvaginal graft and 80.5% (390/485) native tissue repair (0.2%, 90% confidence interval [-5.6% to 5.9%]), demonstrating noninferiority at a preset margin of -12%. The overall rate of severe adverse events was 5.3% (12/228) in transvaginal graft vs 2.7% (13/485) in native tissue repair groups. The study group demonstrated noninferiority in serious adverse events at the preset margin of 11.6% (2.0%, 90% confidence interval [-0.8% to 4.7%]). There were no reports of graft erosion, and graft exposure rates were low (0.9% [2/228]).

Conclusions: Transvaginal repair of anterior and/or apical prolapse with a biological graft is noninferior to traditional native tissue repair in effectiveness and safety at 36 months.
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http://dx.doi.org/10.1016/j.urology.2022.06.003DOI Listing
June 2022

Selectivity and Maximum Response of Vibegron and Mirabegron for β-Adrenergic Receptors.

Curr Ther Res Clin Exp 2022 14;96:100674. Epub 2022 May 14.

Dermavant Sciences, Morrisville, North Carolina.

Background: The β-adrenergic agonists vibegron and mirabegron have shown favorable safety profiles and efficacy for the treatment of overactive bladder. However, β-adrenergic receptors are also found outside the bladder, which could lead to off-target activity.

Objective: This study assessed the selectivity of vibegron and mirabegron for β-adrenergic receptors and the maximal effect and potency for β-adrenergic receptors.

Methods: Functional cellular assays were performed using Chinese hamster ovary-K1 cells expressing β-, Chinese hamster ovary cells expressing β-, and human embryonic kidney 293 cells expressing β-adrenergic receptors. Cells were incubated with vibegron, mirabegron, or control (β and β, isoproterenol; β, procaterol). Responses were quantified using homogeneous time-resolved fluorescence of cyclic adenosine monophosphate and were normalized to the respective control. Half-maximal effective concentration and maximum response values were determined by nonlinear least-squares regression analysis.

Results: Activation of β-adrenergic receptors with vibegron or mirabegron resulted in concentration-dependent β-adrenergic receptor responses. Mean (SEM) half-maximal effective concentration values at β-adrenergic receptors were 2.13 (0.25) nM for vibegron and 10.0 (0.56) nM for mirabegron. At a concentration of 10 µM, β-adrenergic activity relative to isoproterenol was 104% for vibegron and 88% for mirabegron. Maximum response at β-adrenergic receptors was 99.2% for vibegron and 80.4% for mirabegron. β-adrenergic activity was 0% and 3% for vibegron and mirabegron, respectively; β-adrenergic activity was 2% and 15%, respectively.

Conclusions: Vibegron showed no measurable β and low β activity compared with mirabegron, which showed low β and some β activity. Both showed considerable selectivity at β-adrenergic receptors; however, vibegron demonstrated near-exclusive β activity and a higher maximum β response.
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http://dx.doi.org/10.1016/j.curtheres.2022.100674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9184556PMC
May 2022

Incomplete bladder emptying and urinary tract infections after botulinum toxin injection for overactive bladder: Multi-institutional collaboration from the SUFU research network.

Neurourol Urodyn 2022 02 12;41(2):662-671. Epub 2022 Jan 12.

Virginia Mason Medical Center, Seattle, Washington, USA.

Introduction: Onabotulinumtoxin A (BTX-A) is an effective therapy for overactive bladder (OAB), however, adverse events may prevent patients from initiating therapy. The study objective was to report real-world rates of incomplete emptying and urinary tract infection (UTI) in men and women undergoing BTX-A for OAB.

Methods: Eleven clinical sites performed a retrospective study of adults undergoing first-time BTX-A injection (100 units) for idiopathic OAB in 2016. Exclusions included: postvoid residual (PVR) > 150 ml, prior BTX-A, pelvic radiation, or need for preprocedure catheterization. Primary outcomes at 6 months were incomplete emptying (clean intermittent catheterization [CIC] or PVR ≥ 300 ml without the need for CIC); and UTI (symptoms with either positive culture or urinalysis or empiric treatment). We compared rates of incomplete emptying and UTI within and between sexes, using univariate and multivariable models.

Results: 278 patients (48 men and 230 women) met inclusion criteria. Mean age was 65.5 years (range: 24-95). 35% of men and 17% of women had incomplete emptying. Men had 2.4 (95% CI: 1.04-5.49) higher odds of incomplete emptying than women. 17% of men and 23.5% of women had ≥1 UTI, the majority of which occurred within the first month following injection. The strongest predictor of UTI was a history of prior UTI (OR: 4.2 [95% CI: 1.7-10.3]).

Conclusions: In this multicenter retrospective study, rates of incomplete emptying and UTI were higher than many previously published studies. Men were at particular risk for incomplete emptying. Prior UTI was the primary risk factor for postprocedure UTI.
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http://dx.doi.org/10.1002/nau.24871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8891079PMC
February 2022

Evidence for the Appropriate Use of Telemedicine in Female Pelvic Medicine and Reconstructive Surgery.

Curr Bladder Dysfunct Rep 2021 3;16(4):97-104. Epub 2021 Nov 3.

Departments of Urology and Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, NYU Langone Health/NYU Grossman School of Medicine, New York, NY USA.

Purpose Of Review: To summarize the available literature regarding telehealth interventions in the management of pelvic floor disorders.

Recent Findings: Most Female Pelvic Medicine and Reconstructive Surgery (FPMRS) patients own and feel comfortable operating the technology required to participate in telehealth interventions and would be willing to interact remotely with their providers. Telehealth may be an appropriate and effective tool for patient education about bladder and pelvic physiology and pathophysiology, remote pelvic floor muscle strengthening when in-person physical therapy is not accessible, overactive bladder follow-up and medication management, and for postoperative care following uncomplicated incontinence and prolapse surgery.

Summary: There is a growing body of literature specific to FPMRS supporting various telehealth interventions that could reasonably be expected to improve access to sub-specialty care while maintaining or improving healthcare quality and reducing costs to the patient and the healthcare system.
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http://dx.doi.org/10.1007/s11884-021-00635-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8563823PMC
November 2021

Racial and ethnic representation in primary research contributing to pelvic organ prolapse treatment guidelines.

Int Urogynecol J 2021 Nov 27;32(11):2959-2967. Epub 2021 Sep 27.

Department of Obstetrics & Gynecology, New York University Langone Health, 550 first avenue, NBV 9E2, New York, NY, 10016, USA.

Introduction And Hypothesis: To evaluate whether the studies contributing to the national treatment guidelines on pelvic organ prolapse adequately represent the racial and/or ethnic makeup of the American population.

Methods: This analysis examines the racial and ethnic makeup of all primary study cohorts contributing to the American College of Obstetricians and Gynecologists/American Urogynecologic Society Practice Bulletin No. 214 on pelvic organ prolapse. References were excluded if they lacked a primary patient population or were from outside the US. Mean proportional representation of racial/ethnic groups was compared to the 2018 United States Census data on race/ethnicity. The representation quotient was also calculated to evaluate for relative representation of each group. Descriptive statistics were used.

Results: Of the 110 references, 53 primary studies were included in the final analysis with 30 studies reporting on race/ethnicity. On average, 82% (SD = 15%) of study populations were White, while Blacks, Hispanics, and Asians represented 67% (SD = 7%), 4% (SD = 8%), and < 1% (SD = 1%), respectively, differing significantly from the 2018 US Census (p < 0.01.) The representation quotients for White women was 1.36, demonstrating a 36% overrepresentation, while Black, Hispanic, and Asian women were underrepresented among studies of all evidence levels, with representative quotients of 0.50, 0.23, and 0.09, respectively.

Conclusions: Our study demonstrates a significant underrepresentation of non-White populations in primary cohorts of studies contributing to the ACOG/AUGS Practice Bulletin No. 214 on POP. This analysis reinforces that more efforts are required to include and report on racial and ethnically diverse cohorts to better serve all patients.
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http://dx.doi.org/10.1007/s00192-021-04983-9DOI Listing
November 2021

Dorsal Onlay Oral Mucosa Graft Urethroplasty for Female Urethral Stricture.

Urology 2021 12 16;158:215-221. Epub 2021 Sep 16.

Department of Urology, New York University Langone Health, New York, NY.

Objective: To describe and assess the outcomes of dorsal onlay oral mucosa graft urethroplasty for female urethral stricture.

Methods: We retrospectively reviewed the charts of all female patients who underwent dorsal onlay oral (buccal or lingual) mucosa urethroplasty for urethral stricture between 2011 and 2020 at two academic institutions. The primary endpoint was clinical success defined as any subjective improvement in LUTS self-assessed by the patients 1-3 months after catheter removal. Four surgeons performed the urethroplasties using a standardized technique: suprameatal incision, dissection and longitudinal opening of the dorsal aspect of the urethra, harvest of the oral mucosa graft, graft onlay sutured into the urethral opening.

Results: Nineteen patients were included. The clinical success rate was 94.7% at 1-3 months and 90.9% at 1 year. After a median follow-up of 12 months (range 1-49) there was one recurrence (5.3%), clinical success was achieved in 17 patients (89.5%) and both the maximum urinary flow rate and post void residual were significantly improved (15.2 vs 7.4 ml/s preoperatively; P = .008 and 71.5 vs 161.1 ml preoperatively; P = .001 respectively). The de novo stress urinary incontinence rate was 15.7% at 1-3 months and 9.1% at 1 year.

Conclusion: Dorsal onlay oral mucosa graft urethroplasty for female urethral stricture appears feasible across multiple surgeons and is associated with a low perioperative morbidity, satisfactory functional outcomes and a low recurrence rate. Other series with larger sample size and longer follow-up are needed to confirm these findings.
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http://dx.doi.org/10.1016/j.urology.2021.09.001DOI Listing
December 2021

The Effect of Symptomatic Stress Urinary Incontinence on Catheterization Rates After Intradetrusor OnabotulinumtoxinA Injections.

Female Pelvic Med Reconstr Surg 2021 11;27(11):676-680

Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Chicago, Chicago, IL.

Objectives: To determine whether catheterization rates after intradetrusor onabotulinumtoxinA injection for nonneurogenic overactive bladder and urgency incontinence differ between women with urgency urinary incontinence only and women with urgency-predominant mixed urinary incontinence.

Methods: This was a retrospective cohort study of patients that underwent intradetrusor onabotulinumtoxinA injection of 100 U for nonneurogenic urgency urinary incontinence. The primary outcome was the difference in catheterization rates between women with urgency urinary incontinence alone compared with women with urgency-predominant mixed urinary incontinence. Descriptive statistics and multivariate logistic regression analysis were performed.

Results: Of the 177 women included in the final analysis, 105 had urgency urinary incontinence and 72 had urgency-predominant mixed urinary incontinence. The overall catheterization rate after onabotulinumtoxinA injection was 11.3%, with significantly fewer women with mixed urinary incontinence requiring catheterization when compared with women with urgency urinary incontinence alone (4.2% vs 16.2%; P = 0.03), despite an older population (P = 0.02). Patient-reported improvement (P = 0.37) and decision to continue onabotulinumtoxinA treatments (P = 0.89) were similar between groups. Multivariate logistic regression analysis revealed that women with mixed urinary incontinence had significantly lower odds of requiring catheterization after onabotulinumtoxinA injections than women with urgency urinary incontinence alone (odds ratio, 0.16; 95% confidence interval, 0.04-0.67; P = 0.01).

Conclusions: Findings suggest that the presence of symptomatic stress urinary incontinence is associated with lower rates of catheterization after intradetrusor onabotulinumtoxinA, but does not compromise efficacy of treatment for urgency-predominant mixed urinary incontinence.
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http://dx.doi.org/10.1097/SPV.0000000000001040DOI Listing
November 2021

Estimation of Urinary Frequency: Does Question Phrasing Matter?

Urology 2021 10 24;156:90-95. Epub 2021 Apr 24.

Department of Urology, New York University Medical Center, New York, NY.

Purpose: To evaluate if question phrasing and patient numeracy impact estimation of urinary frequency.

Materials And Methods: We conducted a prospective study looking at reliability of a patient interview in assessing urinary frequency. Prior to completing a voiding diary, patients estimated daytime, and nighttime frequency in 3 ways: (1) how many times they urinated (2) how many hours they waited in between urinations (3) how many times they urinated over the course of 4 hours. Numeracy was assessed using the Lipkus Numeracy Scale.

Results: Seventy-one patients completed the study. Correlation of estimates from questions 1, 2, and 3 to the diary were not statistically different. Prediction of nighttime frequency was better than daytime for all questions (correlation coefficients 0.751, 0.754, and 0.670 vs 0.596, 0.575, and 0.460). When compared to the diary, Question 1 underestimated (8.5 vs 9.7, P = .014) while Question 2 overestimated (11.8 vs 9.7, P = .027) recorded voids on a diary. All questions overpredicted nighttime frequency with 2.6, 2.9, and 3.9 predicted versus 1.6 recorded voids (P < .001). Although not statistically significant, for each question, the predicted frequency of numerate patients was more correlated to the diary than those of innumerate patients.

Conclusion: When compared to a voiding diary for daytime urinary frequency, asking patients how many times they urinated underestimated, and asking patients how many hours they waited between urinations overestimated the number recorded voids. Regardless of phrasing, patients overestimated nighttime urination. Patients in our functional urology population have limited numeracy, which may impact accuracy of urinary frequency estimation.
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http://dx.doi.org/10.1016/j.urology.2021.04.013DOI Listing
October 2021

Persistence in Percutaneous Tibial Nerve Stimulation Treatment for Overactive Bladder Syndrome is Best Predicted by Patient Global Impression of Improvement Rather Than Symptom-Specific Improvement.

Urology 2021 02 21;148:93-99. Epub 2020 Dec 21.

New York University Langone Health, Department of Urology and Obstetrics & Gynecology, New York, NY. Electronic address:

Objectives: To evaluate whether progression to maintenance percutaneous tibial nerve stimulation (PTNS) was related to perceived global impression of improvement (PGII) rather than symptom-specific improvement in patient with overactive bladder (OAB). We hypothesize that PGII will predict continuation of PTNS long-term.

Methods: This prospective observational study included 90 patients with OAB that initiated PTNS. The PGII and OAB short-form questionnaires (OABq-SF) were used to assess bladder symptom severity and improvement. Those that completed the 12-week induction phase were offered to continue PTNS monthly maintenance or pursue other options. The primary outcome was difference in PGII score between those pursuing maintenance therapy versus other options. Descriptive statistics and mixed effect modeling analysis were employed.

Results: Seventy patients (78%) completed 12 weeks of PTNS. The majority of completers pursued monthly maintenance (P< .01) and had significantly lower median PGII scores compared with those who sought alternatives (P < .01), while OABq-SF scores did not differ significantly (P = .65). Patients that pursued monthly PTNS maintenance had lower body mass index than those who chose alternative therapies (P < .01). Only 19% continued PTNS therapy for at least 1 year.

Conclusion: More patients pursued PTNS monthly maintenance over any other therapy, and this was significantly associated with lower PGII scores. Global improvement, and not symptom-specific response, predicts long-term PTNS maintenance. No symptom-specific predictors were identified in those who pursued maintenance over other options. One-year continuation rates are low.
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http://dx.doi.org/10.1016/j.urology.2020.12.009DOI Listing
February 2021

Venous thromboembolism prophylaxis in vaginal surgery for pelvic organ prolapse: Predictors of high risk in a low-risk population.

Neurourol Urodyn 2021 01 14;40(1):176-182. Epub 2020 Oct 14.

New York University Langone Health, New York, New York, USA.

Aim: Venous thromboembolism (VTE) rates in vaginal pelvic organ prolapse (POP) repair are low. Our aim is to evaluate specific risk factors for VTE in patients undergoing vaginal POP repair.

Methods: This is a cross-sectional study using the American College of Surgeons NSQIP database. Using CPT codes, cases of vaginal POP repair between 2014 and 2017 were identified. Patient and operative characteristics were collected. VTE was defined as pulmonary embolism (PE) or deep vein thrombosis (DVT) within 30 days from surgery. Univariate analyses were performed using the Student t test for continuous and χ  tests for categorical variables. Multivariate logistic regression was performed to identify factors independently associated with VTE.

Results: Of 44 207 women who underwent vaginal POP repair, there were 69 cases of VTE (0.16%). VTE rates for obliterative (0.15%) and functional (0.16%) vaginal POP repair, as well as for repairs with hysterectomy (0.17%) and without hysterectomy (0.12%) were not significantly different (p = .616 and .216, respectively). Multivariate analysis demonstrated predictors for postoperative VTE to be ASA physical status classification ≥ 3 (aOR, 1.99; p = .014), length of stay >75th percentile (aOR, 2.01; p = .007), operative time >3 h (aOR, 2.24; p = .007), and dyspnea (aOR, 3.26, p = .004).

Conclusion: Despite the low incidence of VTE after vaginal POP repair, patients with ASA physical status classification ≥ 3, length of stay >75th percentile, operative time >3 h, and dyspnea were at higher risk for VTE. Vaginal POP repair may have independent VTE risk factors not captured in standard risk assessment tools.
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http://dx.doi.org/10.1002/nau.24529DOI Listing
January 2021

Mirabegron Versus Solifenacin in Multiple Sclerosis Patients With Overactive Bladder Symptoms: A Prospective Comparative Nonrandomized Study.

Urology 2020 11 19;145:94-99. Epub 2020 Aug 19.

New York University Langone Health, New York, NY.

Objective: To determine the patient-perceived effectiveness and tolerability of mirabegron compared to solifenacin in a multiple sclerosis (MS) population with overactive bladder (OAB) symptoms.

Materials And Methods: MS patients with OAB symptoms who were not on medication for their urinary symptoms at enrollment were prospectively recruited. Patients enrolled in years 1-2 were prescribed mirabegron, whereas patients enrolled in years 3-4 were prescribed solifenacin. At enrollment and 6-week follow-up, patients completed several patient reported outcome measures. The primary outcome was change in OAB Questionnaire Short Form (OAB-q SF) symptom severity and minimal clinically important difference (MCID) achievement. The Patient Assessment of Constipation Symptoms (PAC-SYM) was used to assess bowel function over the treatment period.

Results: Sixty-one patients were enrolled. The majority of the mirabegron (70%) and the solifenacin (69%) group achieved the OAB-q SF symptom severity MCID. The solifenacin group had a statistically significant greater decrease in its end of study OAB-q SF score (Δ = -37.87 vs -20.43, P = .02). Constipation improved in the mirabegron group and worsened in the solifenacin group (ΔPAC-SYM = -0.38 vs +0.22; P = .02), with 30% of patients prescribed solifenacin experiencing worsening above the MCID threshold.

Conclusion: Among MS patients, we demonstrated similar response rates to mirabegron and solifenacin, with approximately 50%-70% achieving each patient reported outcome measure's MCID. Though this small study showed some short-term evidence that improvement in urinary symptom severity was greater with solifenacin, this potential benefit must be weighed against the observed risk of worsening constipation. Further studies are needed to confirm these findings.
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http://dx.doi.org/10.1016/j.urology.2020.08.008DOI Listing
November 2020

Optimizing Nonsurgical Treatments of Overactive Bladder in the United States.

Urology 2020 11 26;145:52-59. Epub 2020 Jun 26.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Overactive bladder syndrome is a prevalent condition impacting quality of life, activities of daily living, work productivity, physical and psychological health, sleep, and sexuality. Published guideline recommendations and effective behavioral, pharmacologic, and neuromodulatory therapies exist; however, adherence can be poor. Clinicians have important roles educating patients, setting treatment expectations, and providing follow-up. Determining patient goals, routinely assessing and adjusting therapy, and combining treatment strategies may improve outcomes. We review the benefits and challenges of overactive bladder treatments and propose approaches to improve patient management, with the goals of initiating therapy earlier and achieving better patient satisfaction, functioning, and quality of life.
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http://dx.doi.org/10.1016/j.urology.2020.06.017DOI Listing
November 2020

Radiation exposure during videourodynamic testing: Is dose reduction possible using a standardized protocol?

Neurourol Urodyn 2020 02 17;39(2):715-720. Epub 2019 Dec 17.

Department of Urology, New York University Medical Center, New York, New York.

Aims: To evaluate the impact of a protocol for standardized image capture during video urodynamics (VUD) on radiation exposure. Secondly, to categorize radiation exposure by condition warranting VUD and to identify clinical variables that correlate with increased radiation exposure.

Methods: One hundred fifty patients underwent VUD using our standardized protocol. All images were taken using low dose and pulsed settings. Four images are captured: one scout image, one filling image, one voiding image, and one post-void image. If the patient is unable to void with the catheter in place, the catheter is removed and a second image is taken during an attempt at unintubated flow. If vesicoureteral reflux (VUR) is identified, an alternate protocol is entered to document parameters. The mean radiation exposure measured in dose area product (DAP), fluoroscopy time, and number of images were noted and compared with previously published fluoroscopy data collected at our institution before protocol implementation.

Results: The mean fluoroscopy exposure after the implementation of our protocol was 273.5 mGy/cm taking 5.2 images in 4.5 seconds. Protocol implementation leads to a 51.2% reduction in radiation exposure calculated by mean DAP (P < .0001) and a 96.5% reduction in fluoroscopy time (P < .0001). The presence of VUR, fluoroscopy time, and body mass index (BMI) > 25 were associated with higher radiation exposure (P < .0001).

Conclusion: Implementation and adherence to a standardized protocol for fluoroscopy led to a reduction in radiation exposure fluoroscopy time. The presence of VUR, fluoroscopy time, and BMI > 25 were associated with higher radiation exposure.
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http://dx.doi.org/10.1002/nau.24258DOI Listing
February 2020

Nocturia in Patients With Multiple Sclerosis.

Rev Urol 2019 ;21(2-3):63-73

Department of Urology, New York University New York, NY.

The prevalence of nocturia in patients with multiple sclerosis (MS) is high, ranging from 20.9% to 48.8% in this population. Its underlying pathophysiology is complex and different from the non-neurogenic population. In the MS population, the pathophysiology may involve neurogenic lower urinary tract dysfunction (NLUTD) such as detrusor overactivity (NDO), detrusor-sphincter dyssynergia, or detrusor underactivity resulting in reduced bladder capacity. Nocturnal polyuria is also a significant contributor to the pathogenesis of nocturia in MS patients and may be the result of specific mechanisms such as nocturnal hypertension through autonomic cardiovascular dysfunction or lack of diurnal variation of antidiuretic hormone production (ADH) due to demyelinating lesions of the spinal cord. Nocturia might be particularly burdensome in MS patients by contributing to fatigue, a common and highly debilitating symptom in this population. There is likely a complex and multidirectional relationship between nocturia, other sleep disorders, and fatigue in the MS population that has yet to be explored. The assessment of nocturia in MS should rely upon a thorough history and physical examination. Urinalysis should be done to rule out urinary tract infection, a frequency-volume chart might help elucidating the underlying mechanisms, and post-void residual volume may be of interest to screen for urinary retention that could be asymptomatic in MS patients. Other tests such as urodynamics or polysomnography are indicated in selected patients. The treatment should be tailored to the underlying cause. The first steps involve behavioral interventions and treatment of cofactors. When possible, the predominant mechanism should be addressed first. In case of predominant NDO, antimuscarinics and beta-3 agonists should be offered as a first-line treatment and intradetrusor injections of botulinum toxin as a second-line treatment. In cases of incomplete bladder emptying, clean-intermittent self-catheterization is often used as part of multiple other interventions. In cases of nocturnal polyuria, desmopressin may be offered, inclusive of use of newer formulations (desmopressin acetate nasal spray, desmopressin orally disintegrated tablet) in countries where they are approved.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864911PMC
January 2019

Primary Bladder Neck Obstruction.

Rev Urol 2019 ;21(2-3):53-62

New York University Langone Medical Center New York, NY.

Primary bladder neck obstruction (PBNO) is a functional obstruction caused by abnormal opening of the bladder neck during the voiding phase of micturition. PBNO may present with a variety of symptoms including voiding symptoms (slow urinary stream, intermittent stream, incomplete emptying), storage symptoms (frequency, urgency, urgency incontinence, nocturia), and/or pelvic pain and discomfort. The diagnosis of PBNO can be made with videourodynamic testing, which demonstrates elevated voiding pressures with low flow, and fluoroscopic imaging demonstrating obstruction at the level of the bladder neck. Treatment options include conservative management with watchful waiting, pharmacologic management, and surgical intervention. In this article, we review the etiology, presentation, diagnosis, and treatment of PBNO in men, women, and children.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864907PMC
January 2019

Guideline of guidelines: urinary incontinence in women.

BJU Int 2020 05 8;125(5):638-655. Epub 2020 Mar 8.

Department of Urology, New York University Medical Center, New York, NY, USA.

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http://dx.doi.org/10.1111/bju.14927DOI Listing
May 2020

Urodynamic Mechanisms Underlying Overactive Bladder Symptoms in Patients With Parkinson Disease.

Int Neurourol J 2019 Sep 30;23(3):211-218. Epub 2019 Sep 30.

Department of Urology, New York University School of Medicine, New York, NY, USA.

Purpose: To assess the urodynamic findings in patients with Parkinson disease (PD) with overactive bladder symptoms.

Methods: We performed a retrospective chart review of all PD patients who were seen in an outpatient clinic for lower urinary tract symptoms (LUTS) between 2010 and 2017 in a single-institution. Only patients who complained of overactive bladder (OAB) symptoms and underwent a video-urodynamic study for these symptoms were included. We excluded patients with neurological disorders other than PD and patients with voiding LUTS but without OAB symptoms.

Results: We included 42 patients (29 men, 13 women, 74.5±8.1 years old). Seven patients (16.7%) had a postvoid residual (PVR) bladder volume >100 mL and only one reported incomplete bladder emptying. Detrusor overactivity (DO) was found in all 42 patients (100%) and was terminal in 19 (45.2%) and phasic in 22 patients (52.4%). Eighteen patients had detrusor underactivity (DU) (42.3%). Later age of PD diagnosis was the only parameter associated with DU (P=0.02). Patients with bladder outlet obstruction (BOO) were younger than patients without BOO (70.1 years vs. 76.5 years, P=0.004), had later first sensation of bladder filling (173.5 mL vs. 120.3 mL, P=0.02) and first involuntary detrusor contraction (226.4 mL vs. 130.4 mL, P=0.009).

Conclusion: DO is almost universal in all patients with PD complaining of OAB symptoms (97.1%). However, a significant percentage of patients also had BOO (36.8%), DU (47%), and increased PVR (16.7%) indicating that neurogenic DO may not be the only cause of OAB symptoms in PD patients.
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http://dx.doi.org/10.5213/inj.1938086.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790817PMC
September 2019

The current state and the future of robotic surgery in female pelvic medicine and reconstructive surgery.

Turk J Urol 2019 09 1;45(5):331-339. Epub 2019 Sep 1.

Department of Urology, New York University, New York, USA.

In this article, we review the current uses and future directions of robotic surgery in the field of female pelvic medicine and reconstructive surgery. Pelvic surgery is ideal for the use of surgical robots, which provide improved visualization and ease of suturing deep within the pelvis. Robots have been successfully used for the treatment of pelvic organ prolapse, in procedures such as sacrocolpopexy, sacrohysteropexy, and uterosacral ligament plication. Surgeons have used the robotic successfully to treat various etiologies of female pelvic pain including fibroids, endometriosis, and nerve entrapment. Robotic repair of iatrogenic injury has been described with excellent outcomes and avoidance of conversion to open surgery in the event of an injury caused using the robotic platform. While more data is needed on this topic, there has been increasing interest in using the robot for urologic reconstruction including repair of vesico-vaginal fistula, cystectomy, augmentation cystoplasty, and continent and non-continent diversions. Recently the use of the robot has been described in the treatment of stress urinary incontinence in females, with robotic placement of an artificial urinary sphincter. While robotic surgery is associated with increased cost, the outcomes of robotic surgery in female urology are promising. More studies that properly evaluate the benefits of robotic surgery as compared to open and laparoscopic approaches are needed.
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http://dx.doi.org/10.5152/tud.2019.19068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739090PMC
September 2019

Impact of preoperative urodynamics on women undergoing pelvic organ prolapse surgery.

Int Urogynecol J 2020 08 27;31(8):1663-1668. Epub 2019 Aug 27.

Department of Urology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California Los Angeles, Los Angeles, CA, USA.

Introduction And Hypothesis: Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling.

Methods: We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery.

Results: Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement.

Conclusions: UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.
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http://dx.doi.org/10.1007/s00192-019-04084-8DOI Listing
August 2020

Diagnosis and treatment of urinary and sexual dysfunction in hereditary TTR amyloidosis.

Clin Auton Res 2019 09 26;29(Suppl 1):65-74. Epub 2019 Aug 26.

Department of Urology, University of Rennes, Service d'Urologie, 2 Rue Henri Le Guilloux, 35000, Rennes, France.

Purpose: We aimed to review the current knowledge on the epidemiology, diagnosis, and management of urinary and sexual dysfunction in patients with TTR amyloidosis (ATTR).

Methods: We performed a review of the literature, screening for randomized controlled trials, prospective and retrospective series, position papers, and guidelines on urinary and sexual dysfunction in ATTR patients published in PubMed and Embase.

Results: Lower urinary tract dysfunction is present in up to 83% of patients with ATTR. Voiding symptoms are the most common, reported in 34.8-87.5% of patients, while urinary tract infections are reported in up to 50%. Urinary incontinence is observed in 16.7-37.5% of the ATTR population, mostly due to decreased urethral resistance. Sexual dysfunction affects over 40% of ATTR patients, with erectile dysfunction and sexual arousal disorder being the most common symptoms in male and female patients, respectively. In addition to a thorough clinical examination, invasive pressure-flow urodynamic testing is a cornerstone in the assessment of ATTR lower urinary tract dysfunction. The most common finding is detrusor underactivity and intrinsic sphincter deficiency. Poor bladder compliance can also be observed in patients, due to amyloid deposits on the bladder wall. Urinary tract imaging may be of interest to rule out upper urinary tract deterioration. Given the paucity of data in the ATTR population, treatment should be tailored to the individual patient.

Conclusion: Urinary and sexual dysfunction are highly prevalent in ATTR patients. Comprehensive assessment and multidisciplinary management are keys to avoiding upper urinary tract damage and improving patients' quality of life.
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http://dx.doi.org/10.1007/s10286-019-00627-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6763525PMC
September 2019

Rectus Fascia Versus Fascia Lata for Autologous Fascial Pubovaginal Sling: A Single-Center Comparison of Perioperative and Functional Outcomes.

Female Pelvic Med Reconstr Surg 2020 08;26(8):493-497

Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Objective: To compare perioperative and functional outcomes of autologous fascia lata versus rectus fascia pubovaginal sling in female patients with stress urinary incontinence (SUI).

Methods: The charts of all patients undergoing pubovaginal sling for SUI from 2012 to 2017 at a single center were retrospectively reviewed. Patients were divided into 2 groups: those with the sling harvested from the fascia lata (FL group) and those with the sling harvested from the rectus fascia (RF group).

Results: Between 2012 and 2017, 105 women underwent pubovaginal slings: 21 using FL and 84 using RF. Operative time did not differ significantly between the FL and RF groups (84 vs 81.9 minutes; P=0.68). Estimated blood loss was lower in the FL group (91.7 vs 141.6 mL; P=0.04). There were more wound complications in the RF group, although this was not statistically significant (0% vs 14.3%; P=0.12). Overall complications were comparable between FL and RF groups (52.4% vs 48.9%; P=0.81), but the proportion of Clavien grade 2 or greater were higher in the RF group (4.8% vs 20.2%; P=0.11). Overall, wound complications accounted for 29.3% of postoperative complications in the RF group (12/41). Functional outcomes were comparable between FL and RF groups, with similar rates of patients without SUI symptoms after 1 month (82.4% vs 76.4%; P=0.74), 1 year (55.6% vs 63.8%; P=0.76), and at the latest follow-up (66.7% vs 65.8%; P=0.87).

Conclusions: When compared with rectus fascia for pubovaginal sling, fascia lata may decrease perioperative morbidity, especially wound complications, without compromising functional outcomes.
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http://dx.doi.org/10.1097/SPV.0000000000000761DOI Listing
August 2020

Nocturia in female patients: Current clinical features, treatment patterns and outcomes at a tertiary referral centre.

Arab J Urol 2019 Mar 18;17(1):82-86. Epub 2019 Apr 18.

Department of Urology, New York University, New York, NY, USA.

: To report the current clinical features, treatment patterns and outcomes of female patients who were seen at a tertiary referral centre with a primary diagnosis of nocturia, and to assess the predictive factors of therapeutic management failure. : A retrospective chart review of all new female patients seen in a single-centre functional urology practice with the diagnosis of nocturia was performed. Up to three visits within a 12-month period from the time of presenting were reviewed. The primary endpoint was patient-reported improvement assessed at each follow-up visit and the change in the number of nocturia episodes. : In all, 239 female patients were included for analysis. The prevalence of nocturnal polyuria, reduced bladder capacity, and global polyuria were 75%, 40.2%, and 18.1%, respectively. Within the first two visits, 72.7% of patients had started a treatment beyond behavioural therapies. Anticholinergics were the most commonly initiated treatment (47.2% of patients). At the latest considered visit, 80 patients reported improvement in nocturia (45.5%) and there was a mean - 0.8 decrease in the number of nocturia episodes from 4 to 3.2, which was statistically significant ( < 0.001). There was no statistically significant association between any of the bladder diary findings and treatment outcomes. A smaller number of nocturia episodes was the only predictive factor of therapeutic management failure in multivariate analysis (odds ratio 0.10; = 0.01). : Whilst the prevalence of nocturnal polyuria in women with nocturia is high, the therapeutic management until 2016 seemed to rely mostly upon overactive bladder medications with a relatively low success rate. : BD: bladder diary; BPS: bladder pain syndrome; ICD(-9)-(10): International Classifications of Disease (ninth revision) (10th revision); NPI: Nocturnal Polyuria Index; OAB: overactive bladder; OR: odd ratio; POP: pelvic organ prolapse.
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http://dx.doi.org/10.1080/2090598X.2019.1589792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583713PMC
March 2019

Pharmacokinetic and Pharmacodynamic Properties of a Micro-Dose Nasal Spray Formulation of Desmopressin (AV002) in Healthy Water-Loaded Subjects.

Pharm Res 2019 Apr 29;36(6):92. Epub 2019 Apr 29.

Serenity Pharmaceuticals LLC, Milford, Pennsylvania, USA.

Purpose: Antidiuretic therapy with desmopressin for nocturia has been hampered by formulations with high doses, low bioavailability and variable pharmacokinetics. AV002 (SER120), a novel, emulsified, microdose desmopressin nasal spray, with a permeation enhancer (cylcopentadecanolide), was developed to have pharmacokinetic characteristics suitable for nocturia treatment.

Methods: Twelve healthy subjects participated in an open-label, dose-escalating study. Water-loaded subjects were sequentially dosed every 48 h with AV002 0.5, 1.0, 2.0 μg and 0.12 μg desmopressin subcutaneous (SC) bolus injection.

Results: AV002 intranasal administration produced a time-to-maximum concentration (T) between 15 and 30 min and a maximum concentration (C) <10 pg/mL. C and area under the curve showed dose proportionality. Coefficient of variation for AV002 was similar to that observed for the SC dose. Bioavailability of AV002 was approximately 8% compared to SC injection. AV002 demonstrated pharmacodynamic effects within 20 min of dosing and showed increasing magnitude and duration with escalating doses. AV002 2.0 μg had maximum median urine osmolality of 629 mOsm/kg and median urine output ≤2 mL/min for 5-6 h.

Conclusions: AV002 demonstrated rapid absorption, high bioavailability, limited duration of action, and low coefficient of variation, suggesting it may be a suitable formulation for nocturia treatment. Trial registration not required (single-center, phase 1).
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http://dx.doi.org/10.1007/s11095-019-2628-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488552PMC
April 2019

Exploring stress urinary incontinence outcomes after sling excision for perforation or exposure.

Low Urin Tract Symptoms 2019 Sep 22;11(4):206-210. Epub 2019 Mar 22.

Department of Urology, New York University Langone Health, New York, New York.

Objective: This study assessed stress urinary incontinence (SUI) outcomes after sling excision for urinary tract perforation or vaginal exposure, and compared the outcomes of concomitant versus staged autologous fascia pubovaginal sling (AFPVS).

Methods: A retrospective chart review of all patients who underwent midurethral sling (MUS) excision for urinary tract perforation or vaginal exposure at a tertiary referral center between 2010 and 2015 was performed. Therapeutic strategies were categorized as concomitant AFPVS, staged AFPVS, and no anti-incontinence procedure.

Results: In all, 32 patients were included for analysis: 13 with vaginal tape exposure (40.6%) and 19 with urinary tract tape exposure (59.4%). In patients who had SUI prior to sling excision (43.8%), the rate of resolved or improved SUI postoperatively was higher in the concomitant AFPVS group than in those who underwent sling excision alone (83.3% vs 12.5%, respectively; P = 0.03). Of 18 patients with no SUI prior to sling excision, 12 experienced recurrent SUI after sling removal (66.7%). The rate of recurrent SUI was lower in patients with vaginal MUS exposure than urinary tract MUS perforation, but this did not reach statistical significance (57.1% vs 72.7%, respectively; P = 0.63). The rates of resolved SUI after AFPVS were comparable in patients with concomitant and staged AFPVS (66.7% vs 71.4%, respectively; P = 0.99).

Conclusions: Many patients with MUS perforations or exposures will have SUI at initial presentation or develop SUI after removal of the synthetic sling. The decision to perform a concomitant AFPVS or to stage the surgical management of SUI can be individualized.
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http://dx.doi.org/10.1111/luts.12263DOI Listing
September 2019

Magnetic Resonance and Intraoperative Imaging of a Periurethral Leiomyoma.

J Minim Invasive Gynecol 2019 Sep - Oct;26(6):1004-1005. Epub 2019 Feb 28.

Departments of Urology (Drs. Sussman Tano, and Brucker).

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http://dx.doi.org/10.1016/j.jmig.2019.02.013DOI Listing
February 2019

Nocturia: Finding an Identity.

Rev Urol 2018 ;20(4):170-173

NYU Langone Health New York, NY.

Nocturia is a condition that has a tremendous impact on a patient's health and wellbeing. Getting up 2 or more times a night to urinate fragments sleep, preventing deep, restorative stages of the sleep cycle. With safer and more effective therapies, nocturia is a treatable condition that no longer should be overlooked. The simplicity of directly targeting the cause of nocturia, the overproduction of urine (ie, nocturnal polyuria) should be considered. Noctiva™ (desmopressin acetate) nasal spray (Avadel Pharmaceuticals plc, Chesterfield, MO), a novel FDA-approved microdose desmopressin nasal spray, can reduce nighttime urine production and potentially mitigate the potential harm of nocturia.
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http://dx.doi.org/10.3909/riu0822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375005PMC
January 2018
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