Bladder neck stenosis surgery in interstitial cystitis / bladder pain syndrome treatment

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Abstract


Introduction. Current methods of interstitial cystitis / bladder pain syndrome (IC/BPS) treatment don’t allow to achieve long-term clinical remission.

Aim of the study was to investigate the clinical efficacy of bladder neck transurethral incision (TUI) in women with IC/BPS, who had bladder outlet obstruction signs.

Materials and methods. TUI was performed to patients with IC/BPS and proven bladder neck stenosis (n = 29). Assessment of the results of this operation was provided after 1, 3 and 6 months after surgical treatment. Treatment efficacy was evaluated by using Global Response Assessment (GRA) Scale, Pelvic Pain and Urgency / Frequency (PUF) Patient Symptom Scale, urination diaries, analysis of which allowed to determine functional bladder capacity, urinary frequency and nocturia. Pain assessment was made with 10-point Visual Analogue Pain Scale (VAS). Functional efficacy was evaluated with urodynamic examination, which included cystometric bladder capacity, maximal urinary flow rate and residual volume rate. Treatment results were compared with such in 39 patients with IC/BPS without signs of bladder neck stenosis.

Results. GRA score ≥2 had 96.5% and 72.4% in 1 and 3 months after bladder neck TUI, respectively. VAS, PUF Scale parameters, cystometric bladder capacity, maximal urinary flow rate, residual volume rate, urinary frequency and nocturia values also significantly improved after surgery.

Conclusions. This prospective clinical study is the first, in which IC/BPS course in women with bladder neck stenosis was investigated. It was noticed, that in 1 month after bladder TUI in 96.5% of patients decreased severity of IC/BPS symptoms, there were no urinary tract infection and local complications. In addition, this effect lasted for 3 months after surgery in 72.4% of patients and for 6 months in 68.9% of patients.


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INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition characterized by bladder pain and frequent urination. Although this pathology has been studied for many years, none of the treatment methods can currently provide a completely acceptable result for patients [1]. Hydrodistension, intravesical injections of hyaluronic acid, chondroitin sulfate, botulinum toxin A, and oral medications such as amitriptyline, sodium pentosan polysulfate, cyclosporine A have a low and short-term efficacy [2–8] due to the absence of the pathogenic management of this disease.

Clinical experience in the diagnosis and treatment of IC/BPS reveals that the nature of its pain may be different; it is assumed that the pain is not only caused by the localization of the zones of Hunner lesions, but also by the anatomical and functional state of the bladder [9–12].

Therefore, the aim of this study was to investigate the clinical efficacy of bladder neck transurethral incision (TUI) in women with IC/BPS, who had bladder outlet obstruction signs.

MATERIALS AND METHODS

The study involved 68 women with a typical IC/BPS, who had Hunner lesions, detected by cystoscopy. The disease duration for these patients was at least 2 years. According to urine culture analysis, all patients had no clinically significant bacteriuria. The mean age was 60.1 ± 10.5 years. All patients underwent check-up and were included into the study according to the NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) criteria [13].

All the patients had recieved previous treatments, including lifestyle changes; bladder hydrodistension; non-steroidal anti-inflammatory drugs; tricyclic antidepressants; intravesical instillations of lidocaine, dimethyl sulfoxide, heparin; and transurethral coagulation of Hunner lesions.

Before treatment, all the participants were asked to keep a voiding diary in order to determine the functional bladder capacity, urinary frequency (urgency) and nocturia. Severity of IC/BPS symptoms was evaluated using a questionnaire “Pelvic Pain, Urgency, and Frequency Patient Symptom Scale” (PUF Scale). Pain was assessed with the 10-point Visual Analogue Pain Scale (VAS). A questionnaire survey was also conducted with the Global Response Assessment (GRA) Scale [14, 15]. Urodynamic evaluation and cystometry were performed, with assessment of the sensitivity, detrusor overactivity, and cystometric bladder capacity. Bladder neck obstruction was identified during cystoscopy, followed 2 weeks later by uroflowmetry and urodynamic studies.

After hydrodistension; which leads to an increase in the bladder capacity, 29 (42.6%) patients noticed an increase in pain during urination and a change in the location. During endoscopic examinations, these same 29 patients were diagnosed with bladder neck stenosis, which was also confirmed by urodynamic studies.

The patients with bladder neck stenosis (n = 29); the study group, underwent bladder neck TUI. The incision of the bladder neck was performed at the 12 o’clock position using a hook-type electrode along a length of 5–7 mm through the mucosa, submucosa, and part of the muscular layer of the bladder. A resectoscope (22 Ch, Karl Storz, Germany) was used. Afterwards, repeated bladder hydrodistension was performed. The surgery was completed with bladder catheterization using a 14 Ch Foley catheter which was removed on postoperative day 2.

Patients without bladder neck stenosis (n = 39); the control group, underwent a standard therapy for IC/BPS including transurethral coagulation of Hunner lesions, bladder hydrodistension, tricyclic antidepressants, and intravesical instillations of lidocaine, dimethyl sulfoxide, and heparin. Control evaluations were performed 1, 3, and 6 months after treatment.

Wilcoxon rank sum test was used to evaluate the difference between two dependent groups (repeated measurements in the same group of patients). The level of significance was defined as p < 0.05.

RESULTS

In the bladder neck stenosis group a GRA ≥2 was found in 96.5%, 72.4%, and 68.9% of patients 1, 3, and 6 months after the bladder neck TUI, respectively. Thus, most of the women had a satisfactory outcome for 6 months after treatment.

In the bladder neck stenosis group, parameters of the PUF Scale and VAS, cystometric bladder capacity, maximal urinary flow rate, postvoid residual urine volume, urinary frequency per day, and nocturia values improved after surgery (Table 1). All the patients had no signs of bladder outlet obstruction or urinary tract infection. Of note, only one (3.5%) of the 29 patients experienced no clinical effect from the surgical treatment.

 

Table 1 / Таблица 1

Dynamics of symptoms and functional urination parameters after bladder neck TUI in patients of the main group (n = 29)

Динамика симптомов и функциональных показателей мочеиспускания после трансуретральной инцизии шейки мочевого пузыря у пациенток основной группы (n = 29)

Parameter

Before treatment

1 month after treatment

3 months after treatment

6 months after treatment

PUF Scale, scores

24.6 ± 6.0

15.8 ± 6.1

15.9 ± 6.1

14.1 ± 6.1

VAS, scores

7.6 ± 1.5

3.2 ± 1.8

3.3 ± 2.1

3.2 ± 1.1

Cystometric bladder capacity, ml

178.2 ± 51.6

338.5 ± 133.6

351.8 ± 149.1

343.6 ± 108.6

Qmax, ml/sec

10.6 ± 7.8

23.0 ± 10.2

21.7 ± 10.4

21.2 ± 9.8

Postvoid residual urine volume, ml

66.4 ± 139

21.7 ± 27.6

23.9 ± 31.8

22.5 ± 33.7

Urinary frequency per day

17.9 ± 3.8

11.5 ± 4.9

11.4 ± 4.9

11.6 ± 5.7

Nocturia

3.7 ± 0.7

3.0 ± 1.0

3.0 ± 1.1

2.9 ± 1.1

GRA scale, scores

0

2.0 ± 1.1

2.0 ± 1.0

1.8 ± 1.0

Note. PUF Scale – Pelvic Pain, Urgency, and Frequency Patient Symptom Scale, VAS – 10-point Visual Analogue Pain Scale, Qmax – maximum flow rate, GRA scale – Global Response Assessment scale.

 

In the control group GRA ≥ 2 was found in 76.8% and 69.3% of patients 3 and 6 months after the standard therapy, respectively. There was an improvement in the symptoms of IC/BPS according to the PUF Scale and VAS, an increase in functional and cystometric bladder capacities, a decrease in urinary frequency per day, and nocturia values in these patients. However, the degree of clinical improvement in the control group was lower than that in the bladder neck stenosis group (Table 2).

 

Table 2 / Таблица 2

Dynamics of symptoms and functional urination parameters before and 3 and 6 months after treatment of patients of the main and comparison groups (n = 68)

Динамика симптомов и функциональных показателей мочеиспускания до и через 3 и 6 месяцев после лечения у пациенток основной группы и группы сравнения (n = 68)

Parameter

Study group (n = 29)

Control group (n = 39)

Before treatment

3 months after treatment

6 months after treatment

Before treatment

3 months after treatment

6 months after treatment

PUF Scale, scores

24.6 ± 6.0

15.9 ± 6.1*

14.1 ± 6.1*

27.4 ± 5.7

20.3 ± 8.0*

21.2 ± 8.1*

VAS, scores

7.6 ± 1.5

3.3 ± 2.1*

3.2 ± 1.1*

7.5 ± 2.2

4.0 ± 2.3

5.1 ± 2.3

Cystometric bladder capacity, ml

178.2 ± 51.6

351.8 ± 149.1*

343.6 ± 108.6*

201.7 ± 80.7

325.3 ± 144.5

319.0 ± 147.3

Qmax, ml/sec

10.6 ± 7.8

21.7 ± 10.2*

21.2 ± 9.8*

21.6 ± 5.3

23.9 ± 12.4

22.6 ± 11.5

Postvoid residual urine volume, ml

66.4 ± 139

23.9 ± 31.8*

22.5 ± 33.7*

22.4 ± 21

15.4 ± 17.2

15.7 ± 12.4

Urinary frequency per day

17.9 ± 3.8

11.4 ± 4.9

11.6 ± 5.7*

16.9 ± 4.5

12.7 ± 5.3

13.2 ± 4.7*

Nocturia

3.7 ± 0.7

3.0 ± 1.1*

2.9 ± 1.1*

3.6 ± 1.0

2.5 ± 1.4*

1.8 ± 0.9*

Note. PUF Scale – Pelvic Pain, Urgency, and Frequency Patient Symptom Scale, VAS – 10-point Visual Analogue Pain Scale, Qmax – maximum flow rate. * р < 0.05 comparing with parameters before treatment.

 

Due to the unstable course of the disease and regular recurrences requiring repeated therapy, the follow-up period did not exceed 6 months.

Urodynamic parameters before TUI in the bladder neck stenosis group differed significantly from those in the control group. However, even after surgical treatment during the follow-up period of 6 months, the two groups did not differ significantly in terms of the urodynamic parameters.

The study showed that 42.6% of women with IC/BPS had endoscopic and urodynamic features of the bladder neck stenosis. Of them, a clinical improvement after bladder neck TUI was registered in 28 (96.5%) one month after surgery, in 21 (72.4%) 3 months after surgery, and in 20 (68.9%) of the 29 operated patients 6 months after surgery. Accordingly, there were no urinary tract recurrences and no surgical complications. In this group of patients, pain intensity, urinary frequency, and urodynamic parameters improved significantly after the bladder neck TUI.

CONCLUSION

Additional examinations for signs of a bladder neck stenosis is important in patients with IC/BPS who failed from standard therapy because surgical correction may be an important step for treatment and may promote more long-lasting remission in these patients.

About the authors

Vladimir L. Medvedev

Kuban State Medical University; Regional Clinical Hospital No. 1 named after prof. S.V. Ochapovsky; Rostov State Medical University

Email: medvedev_vl@mail.ru
ORCID iD: 0000-0001-8335-2578

Russian Federation, Krasnodar; Krasnodar; Rostov-on-Don

Doctor of Medical Science, Professor, Chairman of the Department of Urology; Deputy Chief Physician for Urology, Head of the Urological Center of Scientific Research Institute; Professor of the Department of Urology and Human Reproductive Health (with a Course in Pediatric Urology-Andrology)

Igor V. Mihailov

Kuban State Medical University; Regional Clinical Hospital No. 1 named after prof. S.V. Ochapovsky

Email: miv67@yandex.ru
ORCID iD: 0000-0003-3724-2794

Russian Federation, Krasnodar

Doctor of Medical Sciences, Professor, Department of Urology; Doctor of the Oncourology Department 

Sergey N. Lepetunov

Kuban State Medical University; Regional Clinical Hospital No. 1 named after prof. S.V. Ochapovsky; Rostov State Medical University

Author for correspondence.
Email: Lepetunov@gmail.com
ORCID iD: 0000-0001-6657-1496

Russian Federation, Krasnodar; Krasnodar; Rostov-on-Don

Assistant of the Department of Urology; Urologist; Postgraduate, Department of Urology and Human Reproductive Health (with a Course in Pediatric Urology-Andrology)

Yuriy N. Medoev

Regional Clinical Hospital No. 1 named after prof. S.V. Ochapovsky; Rostov State Medical University

Email: dadoev@list.ru
ORCID iD: 0000-0002-3726-0186

Russian Federation, Krasnodar; Rostov-on-Don

Urologist; Postgraduate, Department of Urology and Human Reproductive Health (with a Course in Pediatric Urology-Andrology)

Mikhail I. Kogan

Rostov State Medical University

Email: dept_kogan@mail.ru
ORCID iD: 0000-0002-1710-0169

Russian Federation, Rostov-on-Don

Doctor of Medical Science, Professor, Chairman of the Department of Urology and Human Reproductive Health (with a Course in Pediatric Urology-Andrology)

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Copyright (c) 2020 Medvedev V.L., Mihailov I.V., Lepetunov S.N., Medoev Y.N., Kogan M.I.

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