join us down under © photo mcec - urology...large series reported no epsiodes of sepsis after 3000...

SIU Newsletter June 2015 - 1

JUNE 2015 VOL. 11 NO. 2

Stemming the Tide: Infectious Complications After Prostate Biopsy

The ProblemReports are accumulating from around the world: in-fectious complications after transrectal ultrasound guid-ed prostate biopsy (TRUSBx) have increased to the point of being a serious concern for all patients requiring this intervention. A selection of

This issue

2 Message from the Publications Chair 6What's New at SIU Academy7Tips and Tricks in Intra-Detrusor BoNTA Injections10BPH Management: Simple Prostatectomy vs. Laser Transurethral Surgery

12Featured New SIU Members What it Means To Be a Member

Corporate Sponsors

Continued on page 4

Continued on page 3

A scientifi c programme unlike any other! This year, Scientifi c Co-Chairs Inderbir S. Gill and Margit Fisch, along with their Programme Committee, have taken the develop-ment of the scientifi c agenda to new levels of excellence. The quality of the science is the SIU’s number one priority, and this year’s congress will be no exception.

Sessions will feature the latest research and a wealth of practical tips and tricks that truly add value to your

Peter Black

recent reports is summarized in Table 1. Infectious compli-cations can include fever, urinary tract infection, urosepsis, and even death.

Antibiotic ResistanceInfectious complications appear to be on the rise due to increasing antibiotic resistances, especially to fl uoro-quinolones (FQ), but on the horizon likely also to extend-ed spectrum beta-lacatamase (ESBL)–producing bacteria.1,2

attendance. Plus, our condensed Thursday-to-Sunday pro-gramme allows you to maximize the education time away from practice.

What can you expect from this year’s programme? A diversifi ed and dynamic scientifi c agenda that tackles im-portant topics in fresh and exciting formats.

SIU 2015: Join Us Down Under

© P

hoto

MCE

C

5066_SIU_Newsletter02_June-ƒ.indd 1 2015-04-30 1:59 PM

Shin Egawa

The role and impact of the Société Internationale d’Urologie (SIU) in the global developing urological community cannot be overem-phasized. It has been built up by numerous great urologists and associates, with their zeal, eff orts,

and selfl ess contributions. Dr. Bunzo Asakura, who is the founder of the Japanese

Urological Association, attended the second SIU Congress held in London in 1911. He is also known as the urologist who fi rst introduced the cystoscope to Japan. Can you imagine how deeply he was inspired by the Congress? He bought a cystoscope at his own expense and brought oth-er various tools to Japan, all of which had practical uses. Since then, his activities have been linked to and greatly infl uenced by the SIU. With the cutting-edge knowledge he

obtained from the Congress, he organized the fi rst nation-wide urological meeting in Japan in 1912—which gave birth to the Japanese Urological Association. (We celebrated our 103rd meeting in Kanazawa this year!) Dr. Asakura was the founding president of the meeting; and the SIU has always been associated with the development of the JUA.

This is just a short note to illustrate how the SIU and JUA are deeply connected. I believe every country/region has a similar story to share that speaks to the SIU's great infl uence on their urological development. One of the prime goals of the SIU is to establish a network among our col-leagues across the globe. We must take a cue from the great seniors and predecessors in our fi eld, and develop seamless bridges for future generations.

Sincerely, Shin Egawa, MDSIU Publications Chair

Message from the Publications Chair

SIU Publications Committee ChairmanDr. Shin EgawaJikei University School of MedicineDept. of Urology3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, Japan [email protected]

Layout and DesignSAM Design [email protected]

Editor-in-ChiefNicole S. [email protected]

In this issue, you will fi nd information about the upcoming 35th Congress of the SIU, which will be held in Melbourne, Australia, from Thursday, October 15, 2015, through Sunday, October 18, 2015. We've included a preview of what you can expect from this year's rich scientifi c programme.

Be sure to register by June 15, 2015, to save over 10% off regular registration. Please visit our website for addition-al details: www.siu-urology.org

Don’t Miss!

• Dr. Black’s article on infectious complications• Upcoming events at SIU Academy• New SIU member profi les

Please get in touch if you have an article or news you would like included in our upcoming edition, or if you'd like to give feedback on anything you have read in this issue. –Best Regards

Nicole S. PalmerEditor-in-Chief [email protected]

Editor’s Note

Submission deadline for next issue:5 PM EST, July 1, 2015

2 - SIU Newsletter June 2015



SIU 2015: Join Us DOWN UNDER continued from page 1

Parallel Plenaries highlight the latest information on topics that matter to urologists from around the world. • Diet and Metabolic Aspects• ICUD: Image-Guided Therapy in Urology • RIRS • Urological Trauma: Guidelines Meet Reality • Leadership and Mentoring Workshop • LUTS/BPH and Sex• Management of Multifocal, Recurrent,

and Locally Advanced Kidney Cancers • ESWL • Practical Medical Oncology for Urologists

Shifting Sands address how important themes and topics in urology have changed and continue to evolve with ongoing surgical and medical research. • Testosterone Defi ciency and Sexual Health • Salvage Surgery • Infertility and Men’s Health • Testicular Cancer • Bladder Cancer • Testosterone and Prostate Cancer • Prostate Cancer

Master Classes are advanced sessions led by world experts, and give attendees a large amount of practical information in a condensed timeframe. • Complex Penile and Urethral Reconstruction Surgery • Management of the Azoospermic Male • Troubleshooting in PCNL • Prevention and Management of Complications in

Laparoscopic/Robotic Surgery • Management of Peyronie’s Disease • Finding Prostate Cancer

Global Perspectives provide a thorough discussion of important issues and case presentations describing patient management in various regions of the world. • Common Pediatric Urology Problems • Management of Renal Mass • Management of Female Urinary Incontinence • Management of Bladder Cancer

Debates cover the latest controversies and ask provocative questions that will shape the future of urology. • Testosterone and Cardiac Death: Fact or Fiction? • Is Open Oncological Surgery in Urology Dead? • Transurethral vs. Simple Prostatectomy in Large Glands

Continued on page 4

© P

hoto

MCE

C



The most rational approach to the problem is to identify resistance patterns in patients prior to TRUSBx based on cultures of the rectal flora, and provide individualized pro-phylaxis dependent on those results. This has the potential of minimizing overuse of antibiotics, while also minimizing the risk for infection. This concept of targeted prophylaxis has been demonstrated in retrospective series, but not yet in a prospective trial.8,9

A simpler approach is to identify patients at risk for an infectious complication and provide them with broader antibi-otic coverage (e.g. addition of parenteral dose of gentamicin), while maintaining the usual oral antibiotic for normal risk cases.10 This is frequently done for patients with a history of significant infection after prior TRUSBx. Unfortunately, most infections are not predictable and it is therefore not clear that this strategy is feasible.

It deserves emphasis that the administration of antibi-otics with the intent of lowering the prostate-specific antigen is not only of little utility, it is potentially hazardous as the risk of post-TRUSBx infection is higher in patients with recent exposure to antibiotics.6,11

The prostate biopsy is one of few surgical interventions for which we ignore general principles of antisepsis and do not cleanse the field prior to the intervention. Rectal cleansing with an iodine solution prior to TRUSBx has been tested in various forms with the intent of reducing infectious risk.11,12 Although rectal cleansing is without relevant side effects, its success in reducing infection has been mixed and it has not been widely adopted. Another approach related to bacte-rial decontamination is to dip the biopsy needle in formalin between each biopsy core. This was reported to reduce the risk of infection in one study.13

The most drastic measure to reduce the risk of post- biopsy infection is to avoid needle entry through the rectum entirely and instead perform the biopsies transperineally. Some reports fail to detect a significantly reduced risk of infection in perineal versus transrectal biopsies, yet one large series reported no epsiodes of sepsis after 3000 per-ineal biopsies, and it would seem that a carefully conduct-ed trial would almost certainly demonstrate a benefit.14–17

Several centres around the globe have reported rates of FQ resistance in the rectal flora of men undergoing TRUSBx (approximately 20%).3–5 One multicentre international study revealed that the presence of these bacteria in the rectum predicted subsequent infection and hospitalization after TRUSBx.4 More than 80% of FQ-resistant bacteria iso-lates are Escherichia coli.3–5

Bacterial Virulence vs. Host FactorsBacterial resistance and infectious complications appear to be on the rise, but it is also clear that only a subset of patients harbouring FQ-resistant bacteria in their fecal carriage will develop an infection, implying that there are other potential host and bacterial virulence factors that determine the risk of infection. Relevant host factors vary between studies, but there are suggestions that diabetes could contribute to infectious risk.6

One study determined by strain and plasmid typing that FQ-resistant E. coli isolates from patients undergoing TRUSBx were phenotypically heterogeneous and did not share a common origin.5 This study, however, did not attempt to correlate subtypes with subsequent infectious complications. In another study, sequence type 131 (ST131) E. coli was iso-lated as the causative strain in 41% of patients experiencing bacteremia after TRUSBx.7 This is a specific lineage of FQ-resistant E.coli that is remarkable for not only its virulence, but also its resistance to multiple antibiotics and its ability to acquire new resistance plasmids.

Strategies to Address Increased Infectious ComplicationsA common response to the rising rate of infectious compli-cations is to change the antibiotic prophylaxis. However, this needs to be done with caution. A simple switch to an-other antibiotic such as trimethoprim/sulfamethoxazole only makes sense if the regional resistance patterns to that antibiotic are more favourable than to an FQ, which is unlikely in most regions. The simple addition of a second antibiotic may broaden the spectrum of coverage, but car-ries the risk of inducing new resistances.

Stemming the Tide: Infectious Complications after Prostate Biopsy

SIU 2015:Join Us Down Under

continued from page 1


Surgical Tips arm attendees with valuable tips and tricks to improve surgical outcomes. • Nuances of Radical Prostatectomy • Transplant Surgery • Urinary Diversion • Troubleshooting in Laparoscopy • PCNL

Surgical Demonstrations offer interactive learning experiences that are the next best thing to actually being in the operating room alongside an expert. • Penile Cancer and Phalloplasty • IVC Thrombectomy • Radical Cystectomy for Cancer • Urethral Stricture Surgery

SIU Inaugural Nurses’ Education Symposium This year, the SIU partners with the Australian and New Zealand Urological Nurses Society to offer an afternoon symposium tailored especially to urological nurses. • Urinary Catheter Management: A Global Perspective • Castration-Resistant–Metastatic Prostate Cancer • Management of BCG Failure • Teaching in Developing Countries/Career Opportunities • Surgical Management of Female Urinary Incontinence • The Future of Urological Nursing: The Need for a

Common Framework—Time Is Running Out • Nursing Solutions in Challenging Cases



Table 1. Infectious complications after TRUSBx.

COUNTRY YEAR N OUTCOME MEASURE TREND REF

U.S. (Medicare) 1991– 2007

17,47230-day hospitalization

6.9% after biopsy compared to 2.7% in no biopsy population

increasing over time

[18]

Netherlands (ERSPC–Rotterdam)

1993– 2010 10,474

fever 4.2% increasing over time

[6]hospitalization 0.8% (81% infection)

Canada (Ontario) 1996– 2005

75,19030-day hospitalization

4.1% (72% infection) in 2005increase from 1.0% in 1996

[19]

Global (84 centers) 2010–2011

521

symptomatic UTI

5.2%

– [20]febrile UTI 3.5%

hospitalization for UTI

3.1%

Canada (Quebec) 2002–2011 5,798 infections 2.15% in 2010–2011

increase from 0.52% in 2002–2009

[21]

UTI = urinary tract infection

The overlying question, however, is whether it is worth the increased cost and the anesthetic risk to do all biopsies transperineally, or whether other less resource-rich solutions would not be preferable.

While there is no question that we need to do what we can to minimize the risk of infection, it must also be

emphasized that the absolute frequency of serious infec-tion related to TRUSBx is low and should not dissuade men from having a TRUSBx when clinically indicated. On the other hand, avoiding unnecessary biopsies with more efficient prostate cancer screening and enhanced prostate imaging should mitigate the harm of infectious complications in the near future.

References1. Aly M, Dyrdak R, Nordström T, et al. Rapid increase in multidrug-resistant

enteric bacilli blood stream infection after prostate biopsy—A 10-year population-based cohort study [published online ahead of print March 23, 2015]. Prostate. doi:10.1002/pros.22979.

2. Tsu JH, Ma WK, Chan WK, et al. Prevalence and predictive factors of harboring fluoroquinolone-resistant and extended-spectrum β-lactamase-producing rectal flora in Hong Kong Chinese men undergoing transrectal ultrasound-guided prostate biopsy. Urology. 2015;85:15–21.

3. Taylor S, Margolick J, Abughosh Z, et al. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int. 2013;111:946–953.

4. Liss MA, Taylor SA, Batura D, et al. Fluoroquinolone resistant rectal colonization predicts risk of infectious complications after transrectal prostate biopsy. J Urol. 2014;192:1673–1678.

5. Qi C, Malczynski M, Schaeffer AJ, et al. Characterization of ciprofloxacin resistant Escherichia coli isolates among men undergoing evaluation for transrectal ultrasound guided prostate biopsy. J Urol. 2013;190:2026–2032.

6. Loeb S, van den Heuvel S, Zhu X, et al. Infectious complications and hospital admissions after prostate biopsy in a European randomized trial. Eur Urol. 2012;61:1110–1114.

7. Williamson DA, Roberts SA, Paterson DL, et al. Escherichia coli bloodstream infection after transrectal ultrasound-guided prostate biopsy: implications of fluoroquinolone-resistant sequence type 131 as a major causative pathogen. Clin Infect Dis. 2012;54:1406–1412.

8. Taylor AK, Zembower TR, Nadler RB, et al. Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care. J Urol. 2012;187:1275–1279.

9. Dai J, Leone A, Mermel L, Hwang K, et al. Rectal swab culture-directed antimicrobial prophylaxis for prostate biopsy and risk of postprocedure infection: a cohort study. Urology. 2015;85:8–14.

10. Balakrishnan I, Smith G. Comment on: the national burden of infections after prostate biopsy in England and Wales: a wake-up call for better prevention. J Antimicrob Chemother. 2013;68:2418–2419.

11. Abughosh Z, Margolick J, Goldenberg SL, et al. A prospective randomized trial of povidone-iodine prophylactic cleansing of the rectum before transrectal ultrasound guided prostate biopsy. J Urol. 2013;189:1326–1331.

12. Jeon SS, Woo SH, Hyun JH, et al. Bisacodyl rectal preparation can decrease infectious complications of transrectal ultrasound-guided prostate biopsy. Urology. 2003;62:461–466.

13. Issa MM, Al-Qassab UA, Hall J, et al. Formalin disinfection of biopsy needle minimizes the risk of sepsis following prostate biopsy. J Urol. 2013;190:1769–1775.

14. Pepe P, Aragona F. Morbidity after transperineal prostate biopsy in 3000 patients undergoing 12 vs 18 vs more than 24 needle cores. Urology. 2013;81:1142–1146.

15. Hara R, Jo Y, Fujii T, et al. Optimal approach for prostate cancer detection as initial biopsy: prospective randomized study comparing transperineal versus transrectal systematic 12-core biopsy. Urology. 2008;71:191–195.

16. Miller J, Perumalla C, Heap G. Complications of transrectal versus transperineal prostate biopsy. ANZ J Surg. 2005;75:48–50.

17. Grummet JP, Weerakoon M, Huang S, et al. Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy? BJU Int. 2014;114:384–388.

18. Loeb S, Carter HB, Berndt SI, et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011;186:1830–1834.

19. Nam RK, Saskin R, Lee Y, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol. 2013;189:S12–S17; discussion, S17–S18.

20. Wagenlehner FM, van Oostrum E, Tenke P, et al. Infective complications after prostate biopsy: outcome of the Global Prevalence Study of Infections in Urology (GPIU) 2010 and 2011, a prospective multinational multicentre prostate biopsy study. Eur Urol. 2013;63:521–527.

21. Carignan A, Roussy JF, Lapointe V, et al. Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: time to reassess antimicrobial prophylaxis? Eur Urol. 2012;62:453–459.



What’s New at SIU Academyat SIU Academyat SIU Academyat SIU AcademyA Few Tips to Navigate the Portal We are committed to enhancing your user experience at SIU Academy. In March 2015, we updated several features of the portal’s navigation bar. To learn how to use these en-hanced features, go to: http://siu-urology.org/academy/navigation-tips

Registration Changes for SIU Academy: Continued Access for Non-SIU Members

SIU Academy is a benefi t for all SIU members. If you do not plan on becoming an SIU member, you may continue having access to SIU Academy by paying an annual fee of $100 US(January to December).

Exclusive content is available for SIU members only. Privileged content is available for paying SIU Academy members (Privileged members).

To register for SIU Academy, go to: http://siu-urology.org/academy/register-to-siu-academy

Join the SIU and take advantage of all the benefi ts included in an SIU membership, such as:

• Full access to the SIU Academy• Access to ICUD publications• Annual online subscription to the World Journal of Urology

(WJU), the offi cial monthly journal of the SIU• Signifi cant discount off registration fees at SIU Congresses

Your dues contribute toward various SIU philanthropic activ-ities. Visit our website for more information: http://siu-urolo-gy.org/society/join-siu

Upcoming SIU-Endorsed EventsIn collaboration with other urological societies, the SIU hosts live streaming of meetings or workshops focusing on specifi c urological topics via SIU Academy. In addition, videos from specifi c SIU-endorsed events become available at SIU Academy following the event. Go to the SIU Academy section of www.siu-urology.org for regular updates on upcoming events.

9th MASTERCLASS OF GENITO-URETHRAL RECONSTRUCTIVE SURGERYNOVEMBER 3–6, 2015 LONDON UK

ENDORSED EVENTS



The use of Botulinum toxin in urology has changed since the initial report by Schurch et al.1 on BoNTA injections for neurogenic voiding dysfunction in spinal cord injury (SCI) patients. Its efficacy and safety had been proven in multiple reports, both in neurogenic detrusor overactivity (NDO)2,3 and, more recently, in non-neurogenic voiding dysfunction.4–6 Recent international guidelines, for both neurogenic and non-neurogenic voiding dysfunction,7–9 now consider BoNTA injections as a second-line treatment before applying more invasive treatments as augmenta-tion cystoplasty.

Here, we aim to provide tips and tricks for performing BoNTA injections by describing the different stages of the procedure. We focus on BoNTA because currently, it is the most used and studied type of botulinum toxin worldwide.

Indications and Contraindications for BoNTA Injection

IndicationsNeurogenic voiding dysfunction: Patients with refractory symptoms to first-line treatments or non-resolving upper urinary tract (UUT) risk factors (high detrusor pressure, DLPP >40 cm H2O, vesico-ureteral reflux, hydronephrosis, recurrent urinary tract infections, or cystolithiasis).9

Non-neurogenic voiding dysfunction (idiopathic detru-sor overactivity, IDO): Refractory overactive bladder (OAB) patients, wet and dry.7,8

ContraindicationsBoNTA contraindications include patients with suspected or confirmed myasthenia gravis, known botulinum toxin aller-gy, neuromuscular junction disease, or severe coagulation

disorders. Additional contraindications include pregnant and breastfeeding women.10,11

It is recommended not to exceed a total dose of 360 BoNTA units administrated every 12 to 16 weeks or at lon-ger intervals.12 The urologist should be aware that BoNTA is used for treatment of multiple diseases; for example, it is quite a common treatment for limb spasticity in SCI patients. Ideally, BoNTA injections for different indications should be performed very close to each other, but there are no exten-sive immunological studies supporting this practice.

Preoperative Assessment Before BoNTA InjectionsThere are no universally agreed upon pre-procedure steps for BoNTA injections. Our experience has led to the following suggested practice:

Clinical evaluationDetailed history focusing on prior medical treatment and its efficacy, comorbidities, medications, and prior surgery should be obtained. Physical examination should be tailored according to patient-specific sex and age, focusing on pos-sible differential diagnosis such as bladder outlet obstruc-tion or mixed urinary incontinence. In patients with NDO, a neurological exam is part of the evaluation. Quality of life (QoL) should be assessed before and after each interven-tion. The following are also recommended in this evaluation: 1) disease-specific (Qualiveen in multiple sclerosis [MS] patients or clean intermittent self-catheterization [CIC]13) or by non-specific questionnaires (Overactive bladder symptoms scale [OABSS]14); 2) post-void residual (PVR)

Xavier Biardeau Shachar AharonyJacques Corcos

Tips and Tricks in Intra-DetrusorBotulinum Toxin A (BoNTA) Injections

Continued on page 8



evaluation (either by catheterization or bladder scan); 3) a 3-day voiding/catheterization diary; and 4) a urine culture and analysis.

Advanced evaluating examinationWe strongly advocate a multichannel urodynamic study (UDS) for all patients, NDO and IDO, before BoNTA injections. We feel that this test is important in the evaluation process in patients refractory to medications by providing data on bladder/outlet function. In NDO patients, we also suggest imaging of the UUT (US, CT or renal scan), which may pro-vide additional information regarding specific risk factors before injections and allow assessing improvement after the procedure.

Post-injection retention risk assessmentThe urinary retention risk should be systematically as-sessed before the first procedure. See section entitled

“Denovo retention.”

Perioperative Assessment and Management of BoNTA Injections

UrinalysisA urinalysis and culture should be performed a few days prior to injection. Patients should be treated according to results. In our practice, we have shown (unpublished data) that injecting patients with asymptomatic bactiuria has no effect on efficacy or safety. Based on these data, we per-form a dipstick and culture right before the injection. If the dipstick tests positive, a full course of antibiotics is initiat-ed. Treatment adjustment may be needed after reviewing the bacterial sensitivity. If the dipstick tests negative, no antibiotics are used.

AnesthesiaMost patients will tolerate injections under local anesthesia in an office-based setting. Patients who are prone to auto-nomic dysreflexia require continuous vital sign monitoring and a special setting for controlling dysreflexia crisis.

BoNTA injections dosageThe recommended initial BoNTA dose for NDO patients is 200 U.2,9 A minority of the patients, mostly with SCI etiology, may not exhibit a sufficient effect at 200 U and would bene-fit from an increased dose of 300 U.12 However, most of this patient population is CIC dependent2; therefore, the risk of denovo retention is irrelevant. On the other hand, in MS pa-tients who can void spontaneously, an attempt to preserve their ability to empty the bladder is crucial. Therefore, we ad-opted the results of Mehnert et al.,15 and our starting dose in this specific patient population was 100 U. This dose can be modified according to post-injection patient symptoms.

In order to prevent preparation mistakes, our practice used the same BoNTA dilution (10 U/mL) for every case.

Surgical techniqueBoNTA injections are performed under direct vision visual-ization, preferably with a rigid scope (30° lens, 17 FR) for both men and women. This method allows rapid and bet-ter visualization, with more consistency in the injection template. Flexible scopes will be used only in males with preserved urethral sensation (i.e. MS, Parkinson and OAB etiologies). Patients are given local anesthesia (40 mL of 2% xylocaine) 30 minutes prior to injection via a 14-FR catheter. The procedure commences with an urethrocys-toscopy, allowing full assessment of the urethra and blad-der. There is no strong scientific basis regarding the chosen injection site’s template.16 In our practice, the number of detrusor injections is derived from the overall BoNTA dos-age. The injection template is composed of both lateral and posterior walls; each injection (10 U/mL) is at least 1 cm apart, sparing the trigone. We use the BoNee® needle (flex-ible, 5-FR body, 22 G/4-mm tip, Coloplast, Ltd., Humlebaek Denmark) based on prior cadaveric studies, showing that 4-mm length allows systematic intra-detrusor injections regardless of bladder thickness (unpublished data).

Postoperative Management of BoNTA InjectionsPostoperative symptom assessment and follow-up: Clinical effects are not immediate and may take up to 2 to 3 weeks to become apparent,12 with a maximal effect expected 3 months after treatment. However, all patients should be as-sessed 3 to 7 days post-injection for evaluation of immedi-ate complications. The effect is estimated to last 42 weeks in NDO patients.2 Therefore, our patients are advised to stop taking their anti-cholinergic/β3 agonist medications approx-imately 3 weeks after the injection and only resume taking them according to their symptoms.

BoNTA injections have been shown to decrease lower urinary tract symptoms and urinary incontinence rates, and to significantly improve QoL in both NDO and IDO patients. Post-injection UDS studies have shown increased bladder capacity and decreased maximal detrusor pressure.17,18

Patient symptoms should be evaluated 3 to 4 months post-injection.12 We performed a complete UDS evaluation 3 months after the first BoNTA injection. This approach allows us to assess UUT risk factor reduction (especially decreas-ing detrusor pressure) and to compare urodynamic chang-es in patients who do not report symptomatic improvement. In addition, patients are evaluated with PVR measurements when pertinent, as well as 3-day voiding (or CIC) diaries and specific QoL questionnaires (OABSS for IDO and Qualiveen for NDO). When there is symptomatic improvement or evi-dence of UUT risk factors improvement, the patient is sched-uled for another BoNTA injection procedure 8 months after the prior injection.


Tips and Tricks in Intra-detrusorBotulinum Toxin A (BoNTA) Injections



Denovo retentionRetention is a dose-related known effect of BoNTA injec-tions.2 While it is the expected and hoped for effect in most patients with neurogenic bladder already performing CIC, it becomes a major complication in patients voiding by them-selves. Therefore, every patient who is considered a can-didate for such treatment should be aware of this specific risk. In addition, patients’ manual dexterity and cognition should carefully be evaluated in order to assess their abili-ty to perform CIC. Patients who are unable or unwilling to do CIC should not be injected.

Risk factors for denovo retention include advanced age, male sex, baseline PVR ≥100 mL, BoNTA dosage ≥100 U, and signs of detrusor underactivity on UDS.19,20 Patients with increased risk for denovo retention should be monitored closely in the first few weeks post-injection. Measurements of PVR should be performed 3 weeks after BoNTA injection or earlier if there is a specific concern. Indirect presentation of denovo retention could include new onset or worsening of incontinence, abdominal discomfort, or recurrent urinary tract infections. The decision regarding initiating CIC should not be based only on PVR values, but should take into ac-count patient symptoms, UUT risk factors, bladder capacity, and PVR as measured in the pre-BoNTA UDS.

Management of BoNTA Injection FailuresThe rate of primary nonresponders for BoNTA injection is estimated at 4.5%. In our practice, these patients may ben-efit from a second BoNTA injection trial 3 months after the first. When failure is confirmed, the patient should be dis-cussed in a multidisciplinary meeting in order to consider additional therapeutic approaches.21 The rate of secondary nonresponders (patients who initially responded to BoNTA injections) is approximated to be 32%. The number of prior injections before this phenomenon is still not described.22 Recently, a small pilot study showed the positive effect of switching from abobotulinum (Dysport) to BoNTA in prima-ry nonresponders (57.7% success rate). These interesting results should be confirmed in larger-scale studies includ-ing BoNTA nonresponders (both primary and secondary).23

ConclusionsThe introduction of intra-detrusor botulinum toxin injection as a second-line therapy for refractory IDO and NDO result-ed in a major change in our clinical practice. Profuse data from the last 10 years have proven BoNTA to be both safe and effective in this specific population. There has been an uptick in recent worldwide usage as a result of its minimal invasiveness, office-based setup, and injection technique simplicity. However, its mechanism of action, ideal dosing regimen, and injection technique still require further eval-uation.

References1. Schurch B, Stöhrer M, Kramer G, et al. Botulinum-A toxin for treating

detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol. 2000;164:692–697.

2. Cruz F, Herschorn S, Aliotta P, et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2011;60:742–750.

3. Schurch B, Denys P, Chartier-Kastler E, et al. Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study. J Urol. 2005;174:196–200.

4. Chapple C, Sievert K-D, MacDiarmid S, et al. OnabotulinumtoxinA 100 U significantly improves all idiopathic overactive bladder symptoms and quality of life in patients with overactive bladder and urinary incontinence: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2013;64:249–256.

5. Dmochowski R, Chapple C, Nitti VW, et al. Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: a double-blind, placebo controlled, randomized, dose ranging trial. J Urol. 2010;184:2416–2422.

6. Nitti VW, Dmochowski R, Herschorn S, et al. OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: results of a phase 3, randomized, placebo controlled trial. J Urol. 2013;189:2186–2193.

7. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188:2455–2463

8. Lucas M, Bosch J, Cruz F, et al. EAU guidelines on urinary incontinence. In: Proceedings of the 27th EAU Annual Congress; February 24–28, 2012; Paris, France.

9. Stöhrer M, Blok B, Castro-Diaz D, et al. EAU guidelines on neurogenic lower urinary tract dysfunction. Eur Urol 2009;56:81–88.

10. Emmerson J. Botulinum toxin for spasmodic torticollis in a patient with myasthenia gravis. Mov Dis. 1994;9:367–367.

11. Smith CP, Chancellor MB. Emerging role of botulinum toxin in the management of voiding dysfunction. J Urol. 2004;171:2128–2137.

12. Rovner E. Practical aspects of administration of onabotulinumtoxinA. Neurourol Urodyn. 2014;33:S32–S37.

13. Bonniaud V, Bryant D, Parratte B, et al. Qualiveen: a urinary disorder− specific instrument for use in clinical trials in multiple sclerosis. Arch Physical Med Rehabil. 2006;87:1661–1663

14. Homma Y, Yoshida M, Seki N, et al. Symptom assessment tool for overactive bladder syndrome—overactive bladder symptom score. Urology. 2006;68:318–323.

15. Mehnert U, Birzele J, Reuter K, Schurch B. The effect of botulinum toxin type a on overactive bladder symptoms in patients with multiple sclerosis: a pilot study. J Urol. 2010;184:1011–1016.

16. Nitti VW. Botulinum toxin for the treatment of idiopathic and neurogenic overactive bladder: state of the art. Rev Urol. 2006;8:198–208.

17. Gamé X, Karsenty G, Ruffion A, et al. Idiopathic overactive bladder and BOTOX®: Literature review [in French; published online ahead of print February 3, 2015]. Prog Urol. doi:10.1016/j.purol.2015.01.006.

18. Karsenty G, Corcos J, Schurch B, et al. Pharmacological treatment of neurogenic detrusor hyperactivity: intradetrusor botulinum toxin A injections [in French]. Prog Urol. 2007;17:568–575.

19. Kuo H-C, Liao C-H, Chung S-D. Adverse events of intravesical botulinum toxin a injections for idiopathic detrusor overactivity: risk factors and influence on treatment outcome. Eur Urol. 2010;58:919–926.

20. Liao C-H, Kuo H-C. Increased risk of large post-void residual urine and decreased long-term success rate after intravesical onabotulinumtoxinA injection for refractory idiopathic detrusor overactivity. J Urology. 2013;189:1804–1810.

21. Reitz A, Stöhrer M, Kramer G, et al. European experience of 200 cases treated with botulinum-A toxin injections into the detrusor muscle for urinary incontinence due to neurogenic detrusor overactivity. Eur Urol. 2004;45:510–515.

22. Mangera A, Andersson K-E, Apostolidis A, et al. Contemporary management of lower urinary tract disease with botulinum toxin A: a systematic review of botox (onabotulinumtoxinA) and dysport (abobotulinumtoxinA). Eur Urol. 2011;60:784–795.

23. Peyronnet B, Roumiguié M, Castel–Lacanal E, et al. Preliminary results of botulinum toxin A switch after first detrusor injection failure as a treatment of neurogenic detrusor overactivity [published online ahead of print December 18, 2014]. Neurourol Urodyn. doi:10.1002/nau.22712



Open simple prostatec-tomy (OP) has been one of the oldest procedures practiced for management of large benign prostatic obstruction (BPO). It is still currently practiced, espe-cially in countries where the newly developed com-petitors are unavailable. It has been described as the

most eff ective and durable treatment option for BPO1 and considered the gold standard for the surgical treatment of prostates larger than 100 mL in men with severe lower uri-nary tract symptoms (LUTS). Most current guidelines still recommend OP for large prostates, when the prostate size limits a conventional transurethral resection of the prostate (TURP). However, OP can be associated with relevant mor-bidity; blood transfusion rates of up to 24.7% and periopera-tive morbidity of up to 42.6% have been reported. Therefore, several minimally invasive techniques have been developed to overcome the limitations of OP.

Diff erent types of lasers have evolved during the past two decades for BPO management and proved themselves to be less invasive, less morbid and cost eff ective, and re-quiring shorter hospital stays (day surgery) and catheter-ization time, even in coagulopathic patients. A variety of transurethral laser technologies have been described, in-cluding Holmium:YAG, Green Light 532 nm, Thulium:YAG, and Diode lasers. Laser eff ect on tissue is variable, depending on the wavelength and type of tissue chromophore that absorb radiation of a given laser type. Furthermore, prostate vapor-ization, vaporesection, vapo-enucleation, and enucleation can be performed by all these four types of laser. However, Holmium laser enucleation of the prostate (HoLEP) and pho-toselective vaporization of the prostate (PVP) are the most frequently studied alternatives to TURP and OP and both were recommended in recent guidelines.

There are high levels of evidence which support the comparable safety and effi cacy of laser prostatectomy with TURP. Unfortunately, vaporization alone has not solved the issue of managing large prostates, to date. HoLEP has the highest level of evidence of being comparable to both TURP and OP for glands of any size. Long-term data of randomized studies are available to document its equivalence to OP with less morbidity. It showed comparable effi cacy and improved safety over OP in a randomized controlled study, after 5 years follow-up.2 We have reported long-term reoperation

free rates after HoLEP of 96.9% at 5 years and 95.1% at 10 years for a mean prostate size of 96 mL.3 The reopera-tion rate includes 2% for urethral stricture, 1.2% for bladder neck contracture, and 0.9% to 1.1% for recurrent adenoma compared with 2.2% to 9.8%, 2% to 4.3%, and 4.8% to 6.4% after TURP; and 1.9%, 2% to 3%, and 1.9% after OP (Figure 1). Therefore, HoLEP was recommended as a treatment alterna-tive for OP by the European Association of Urology guidelines on the treatment of non-neurogenic male LUTS.4 It became widely accepted and practicioners using other techniques realized that to safely and eff ectively tackle large glands, they needed to use similar techniques of enucleating large chunks of tissue and delivering them in the bladder, albeit by using diff erent types of energy. Subsequently, the tissue is removed.

Figure 1: Long-term reoperation after HoLEP, OP, and TURP

The question now is: Which of the enucleation tech-niques is superior? All transurethral enucleation tech-niques are based on either blunt or sharp dissection of the prostate off the prostatic capsule, followed by mechanical morcellation of the adenoma in the bladder. The actual sur-gical plane is more diffi cult to achieve and follow with either electro-surgery or continuous laser wavelengths. Therefore, from a technical standpoint, the pulsed nature of the holmi-um laser makes the plane of enucleation easier to develop and follow, gives superior visibility than electro-cautery, and is associated with less charring of tissue. Therefore, it achieved prostatic cavities similar to OP and proved itself as the endoscopic size–independent promising competitor to OP for treating BPO in men with large glands, with signifi -cantly lower perioperative morbidity.2

Based on the HoLEP technique, a vast variety of laser enucleation techniques have been described using diff erent

Mostafa M. Elhilali

Management of BPHLarger Than 100 mL: Simple Prostatectomy Versus Laser Transurethral Surgery



energy sources such as transurethral enucleation of the prostate with GreenLightTM laser (PVEP; American Medical Systems, Minnetonka, MN, USA), thulium (ThuLEP and ThuVEP), diode (DiLEP) and eraser lasers (ELAP). However, long-term data as well as the randomized, controlled tri-als (RCTs) for these enucleation techniques—other than HoLEP—are rather limited. In 2010, the green light XPS-180W was introduced with high expectations, especial-ly with the introduction of the MoXy® (American Medical Systems, Inc.) fi bres. Adoption of the enucleation principle in accomplishing the vaporization process with signifi cant enhancements in the new machine make it a real contender to HoLEP in treating large prostates and control of LUTS. We previously reported comparable effi cacy of HoLEP and PVEP after 12 months in a randomized controlled study. However, HoLEP seems to be more cost eff ective than PVEP, exclud-ing the cost of the laser capital.5 Currently, the literature is striving for trials comparing diff erent new enucleation laser techniques with each other and versus the main competitor, simple OP for large prostates.

ThuVEP has been also shown to be a size-independent, safe, and effi cacious procedure for management of large prostates. Excellent immediate and long-term improve-ment in functional outcome parameters, up to 69 months’ follow-up, have been reported using ThuVEP technique, with low perioperative morbidity and complications, in addition to an effi cient tissue reduction.6–8 The only available study that compared the outcome of ThuLEP versus HoLEP found that both procedures were comparable in low perioperative morbidity, effi cient tissue reduction, and improvement of functional outcomes, which remained stable during the 18-month follow-up period.9 However, a multicentre con-trolled trial is still needed to investigate the outcome of ThuVEP/ThuLEP in comparison with HoLEP or OP for man-agement of BPO due to prostates larger than 100 mL. DiLEP with a 980-nm diode-pulsed laser has been described with comparable functional improvement and transfusion rates with TURP, plasmakinetic enucleation, and resection of the prostate after 12 months. Of interest, the prostate size did not aff ect the improvement of voiding parameters in a sub-group analysis for patients undergoing DiLEP.10

The term “gold standard” is frequently mentioned when a new technology is introduced. However, affi xing the term to

a given technique is a very tall order. We have to make sure that level-1 evidence exists from diff erent sources and for a suffi cient length of time. Additionally, we have to ensure that the technique can be learned and is readily available global-ly, not just limited to certain parts of the world that can af-ford it. In view of the sparse RCTs published for most of these procedures, apart from HoLEP—including only the short-term to intermediate-term follow-up—HoLEP is the standard enucleation technique, with satisfactory long-term results and low complication and reoperation rates. Unfortunately, it has a steep learning curve and requires signifi cant outlay of resources. Supplemental evidence is needed to compare these modern laser enucleation techniques with the stan-dard enucleation competitors: HoLEP and OP. Nevertheless, with so many choices available, there may no longer be a gold standard for management of severe LUTS and large prostates but instead, a good set of alternatives.

References1. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment

and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013;64:118–140.

2. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008;53:160–166.

3. Elshal AM, Elkoushy MA, Elhilali MM. Reoperation after holmium laser enucleation of the prostate for management of benign prostate hyperplasia: assessment of risk factors with time to event analysis [published online ahead of print April 2, 2015]. J Endourol.

4. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013;64:118–140.

5. Elshal AM, Elkoushy MA, El-Nahas AR, et al. GreenLight™ laser (XPS) photoselective vapo-enucleation versus holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic hyperplasia: a randomized controlled study. J Urol. 2015;193:927–934.

6. Netsch C, Bach T, Herrmann TRW, et al. Update on the current evidence for Tm:YAG vapoenucleation of the prostate. World J Urol. 2015;33:517–524.

7. Gross AJ, Netsch C, Knipper S, et al. Complications and early postoperative outcome in 1080 patients after thulium vapoenucleation of the prostate: results at a single institution. Eur Urol. 2013;63:859–867.

8. Netsch C, Engbert A, Bach T, et al. Long-term outcome following thulium vapoenucleation of the prostate. World J Urol. 2014;32:1551–1558.

9. Zhang F, Shao Q, Herrmann TR, et al. Thulium laser versus holmium laser transurethral enucleation of the prostate: 18-month follow-up data of a single center. Urology. 2012;79:869–874.

10. Yang SS, Hsieh CH, Chiang IN, et al. Prostate volume did not aff ect voiding function improvements in diode laser enucleation of the prostate. J Urol. 2013;189:993–998.

www.siu-urology.orgFeaturing theSIU-ICUD Joint Consultation on Image-Guided Therapy in Urologyand theSIU Inaugural Nurses’ Education Symposium

Join the SIU in the land down under



Rayan El HassanUnited States

Joyce BaardThe Netherlands

Name: Rayan El HassanLocation: United StatesPosition: Urology Core Trainee in North East Deanery,

United Kingdom

The culmination of any undertaking is inevitably linked to its beginnings. Mine started at an early age where I spent my early life emulating my father, a practicing plastic sur-geon. During medical school, I was exposed to urology through my away rotations I spent in the United States. I quickly fell in love with this specialty given that it requires a comprehensive foundation of medical knowledge along with exceptional surgical dexterity. I had the honor last year

Name: Joyce BaardLocation: Amsterdam, The NetherlandsPosition: Urologist, Academic Medical Center

I recently finished my urology training in the Academic Medical Center in Amsterdam. During my training, I quickly discovered my interest in the field of endourology and was supported and encouraged to further develop this area of interest by my tutors Dr. de Reijke, Prof. Laguna, and our Prof. de la Rosette—among others—by visiting our colleagues in Addenbrooke’s Hospital in Cambridge and the Tenôn Hopital in Paris to partake in their knowledge of stone management. After completing my training, I was fortunate to be offered a position as a urologist in the hospital where I was educated.

Featured New SIU Membersof presenting at the annual Société Internationale d'Urolo-gie (SIU) Congress. I realize the importance of participating in a meeting like this and staying up-to-date with current research in the field of urology. It provides a great setting to learn cutting-edge surgical techniques and novel approach-es to manage different urological conditions. The Society offers an essential platform that maximizes your talents and connects you with prominent international figures in urology, all of which help you grow and achieve your full potential. I firmly believe that being a member of the SIU will prepare me for my ultimate goal of being an academic urol-ogy surgeon that is actively engaged in clinical research and education.

My first acquaintance with the SIU was during my training, when I was offered full access to the SIU Academy. Furthermore, I attended the annual SIU Congress in Glasgow. One of the striking features of the SIU is that it is really an in-ternational society. During the SIU meetings, urologists from all over the world have the chance to meet and share their knowledge and experiences. The Society actively encourag-es cooperation and education worldwide among others by providing scholarships and an excellent e-learning platform. For urologists and residents alike, the SIU academy is a great and easily accessible portal to keep your knowledge cur-rent. The annual meetings provide an opportunity to meet your colleagues and leading experts in urology, enabling fu-ture collaboration and friendships.

ACCESS TO BASIC UROLOGICAL CARE CAN BE THE DIFFERENCE BETWEEN LIFE AND DEATHIn many countries, lack of adequate care means that many treatable conditions can lead to life-threatening complications or death.

The SIU Foundation puts 100% of all donations toward surgical training—no exceptions.

Donate today at: www.fsiu.org


join us down under © photo mcec - urology...large series reported no epsiodes of sepsis after 3000...

Documents