Incontinence

Reviewing the Literature

RIU0368_12-12.qxd 12/12/07 8:29 PM Page 241 Incontinence no evidence of invasive disease in the prostatic urethra. Patients with T1 tumors should be considered for cystectomy if they have: 1. multifocal or extensive tumors that cannot be completely and reliably resected, either during the first resection or soon thereafter 2. deep penetration of the lamina propria approaching muscularis propria 3. involvement of the prostatic mucosa or ducts 4. recurrent T1 within 3 months after intravesical therapy 5. residual T1 disease on repeat TUR 6. concurrent CIS or onset while receiving therapy 7. micropapillary variant 8. extensive invasion of the lymphatic space 9. poor patient compliance The presence of 1 or more of these risk factors should prompt the clinician to consider the pitfalls of proceeding with conservative treatment compared with the trade-offs of radical cystectomy. Whereas a single risk factor may not be sufficient to warrant early cystectomy, the aggregate risk of multiple factors supports the need for immediate cystectomy. 14. 15. 16. 17. 18. 19. 20. 21. 22. tumors: a combined analysis of 5 European Organization for Research and Treatment of Cancer Trials. J Urol. 2000;164:1533-1537. Shariat SF, Palapattu GS, Karakiewicz PI, et al. Discrepancy between clinical and pathologic stage: impact on prognosis after radical cystectomy. Eur Urol. 2007;51:137-149. Wiesner C, Pfitzenmaier J, Faldum A, et al. Lymph node metastases in nonmuscle invasive bladder cancer are correlated with the number of transurethral resections and tumour upstaging at radical cystectomy. BJU Int. 2005;95: 301-305. Bianco FJ Jr, Justa D, Grignon DJ, et al. Management of clinical T1 bladder transitional cell carcinoma by radical cystectomy. Urol Oncol. 2004;22: 290-294. Nieder AM, Simon MA, Kim SS, et al. Radical cystectomy after bacillus Calmette-Guérin for high-risk Ta, T1, and carcinoma in situ: defining the risk of initial bladder preservation. Urology. 2006;67:737-741. Shariat SF, Karakiewicz PI, Palapattu GS, et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the bladder cancer research consortium. J Urol. 2006;176:2414-2422. Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001;19:666-675. Stockle M, Alken P, Engelmann U, et al. Radical cystectomy—often too late? Eur Urol. 1987;13:361-367. Schrier BP, Hollander MP, van Rhijn BW, et al. Prognosis of muscle-invasive bladder cancer: difference between primary and progressive tumours and implications for therapy. Eur Urol. 2004;45:292-296. Herr HW, Sogani PC. Does early cystectomy improve the survival of patients with high risk superficial bladder tumors? J Urol. 2001;166:1296-1299. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Heney NM. Natural history of superficial bladder cancer. Prognostic features and long-term disease course. Urol Clin North Am. 1992;19:429-433. Heney NM, Ahmed S, Flanagan MJ, et al. Superficial bladder cancer: progression and recurrence. J Urol. 1983;130:1083-1086. Shelley MD, Court JB, Kynaston H, et al. Intravesical bacillus Calmette-Guérin versus mitomycin C for Ta and T1 bladder cancer. Cochrane Database Syst Rev: CD003231. 2003. Huncharek M, Kupelnick B. The influence of intravesical therapy on progression of superficial transitional cell carcinoma of the bladder: a metaanalytic comparison of chemotherapy versus bacilli Calmette-Guérin immunotherapy. Am J Clin Oncol. 2004;27:522-528. Cookson MS, Herr HW, Zhang ZF, et al. The treated natural history of high risk superficial bladder cancer: 15-year outcome. J Urol. 1997;158:62-67. Shariat SF, Weizer AZ, Green A, et al. Prognostic value of P53 nuclear accumulation and histopathologic features in T1 transitional cell carcinoma of the urinary bladder. Urology. 2000;56:735-740. Shariat SF, Kim JH, Ayala GE, et al. Cyclooxygenase-2 is highly expressed in carcinoma in situ and T1 transitional cell carcinoma of the bladder. J Urol. 2003;169:938-942. Shariat SF, Ashfaq R, Sagalowsky AI, Lotan Y. Predictive value of cell cycle biomarkers in nonmuscle invasive bladder transitional cell carcinoma. J Urol. 2007;177:481-487. Sylvester RJ, Oosterlinck W, van der Meijden AP. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer: a meta-analysis of published results of randomized clinical trials. J Urol. 2004;171:2186-2190. Herr HW, Donat SM. A re-staging transurethral resection predicts early progression of superficial bladder cancer. BJU Int. 2006;97:1194-1198. Herr HW. Restaging transurethral resection of high risk superficial bladder cancer improves the initial response to bacillus Calmette-Guérin therapy. J Urol. 2005;174:2134-2137. Chang BS, Kim HL, Yang XJ, Steinberg GD. Correlation between biopsy and radical cystectomy in assessing grade and depth of invasion in bladder urothelial carcinoma. Urology. 2001;57:1063-1066. Van Der Meijden A, Sylvester R, Collette L, et al. The role and impact of pathology review on stage and grade assessment of stages Ta and T1 bladder Incontinence Curing Stress Urinary Incontinence, or Shades of Dryness Reviewed by Frank Costa, MD, Michael Chancellor, MD Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA. [Rev Urol. 2007;9(4):241-242] © 2007 MedReviews, LLC istorically the gold standard in treatment of stress urinary incontinence (SUI) in urologists' hands is the pubovaginal sling, whereas gynecologists have often preferred the Burch and MMK procedure. The ageadjusted rate of inpatient surgical procedures for SUI in women in the United States increased from 0.32 per 1000 women in 1979 to 0.60 per 1000 women in 1997. Given the aging of the US population, the total number of procedures for treatment of SUI is expected to continue to rise. Yet there are few data from randomized trials to inform surgical decision making. We would like to review an important recent paper and companion editorial on this topic in the New England Journal of Medicine. H VOL. 9 NO. 4 2007 REVIEWS IN UROLOGY 241 RIU0368_12-12.qxd 12/12/07 8:29 PM Page 242 Incontinence continued Burch Colposuspension Versus Fascial Sling to Reduce Urinary Stress Incontinence Albo ME, Richter HE, Brubaker L, and the Urinary Incontinence Treatment Network. N Engl J Med. 2007;356:2143-2155. Shades of Dry—Curing Urinary Stress Incontinence Strohbehn, K. N Engl J Med. 2007;356:2198-2200. From February 2002 to June 2004, the Urinary Incontinence Treatment Network (UITN) funded by the National Institutes of Health screened 2405 women for trial eligibility, randomizing women with SUI to either the sling or Burch operation. Of these women, 556 were ineligible, 1193 declined to participate or withdrew consent, and 1 died before randomization. The remaining 655 women were randomly assigned to a study procedure: 326 to undergo the sling procedure and 329 to undergo the Burch procedure. A total of 520 women (79%)—265 in the sling group (81%) and 255 in the Burch group (78%)—were either assessed for treatment success at the 24-month visit or deemed to have had a treatment failure before that visit. Women in the 2 surgical groups were similar in demographic, anthropometric, clinical, and urodynamic-study characteristics. The frequency of previous surgery for urinary incontinence was similar in the 2 groups (13% in the sling group and 15% in the Burch group). The rates of concomitant surgery for pelvic prolapse (including anterior and posterior vaginal repairs, apical suspension procedures, and hysterectomy) were also similar in the 2 groups (55% in the sling group and 48% in the Burch group). The sling and Burch groups had similar estimated blood loss during the procedures (229 mL and 238 mL, respectively) and similar operative times (136 minutes and 138 minutes, respectively). Women in the sling group had 24-month cumulative rates of success that were significantly higher than those in the Burch group, with overall success rates of 47% versus 38% (P  .01). Treatment-satisfaction rates for the 480 subjects who answered the satisfaction question at 24 months were significantly higher in the sling group than in the Burch group (86% vs 78%; P  .02). Adverse events were more common in the sling group than in the Burch group (63% vs 47%; P
.001), with 415 events among 206 women in the sling group as compared with 305 events among 156 women in the Burch group. This difference was 242 VOL. 9 NO. 4 2007 REVIEWS IN UROLOGY due primarily to urinary tract infections, of which there were 305 among 157 women in the sling group (48%) and 203 among 105 women in the Burch group (32%). When urinary tract infections were excluded, the rates of adverse events were similar in the two groups. Surgical procedures to reduce voiding symptoms or improve urinary retention were performed exclusively in the sling group, in which 19 patients underwent 20 such procedures. Voiding dysfunction was more common in the sling group than in the Burch group (14% vs 2%; P
.001). More patients were treated for postoperative urge incontinence in the sling group than in the Burch group (87 patients [27%] vs 65 patients [20%]; P  .04). The difference in urge incontinence was due to differences in the proportion of patients treated for persistent urge incontinence rather than to differences in the proportion with new-onset urge incontinence. The bottom line of this study was that at 24 months, the pubovaginal fascial sling had significantly higher rates of success. But does this study matter? Although this study provides important information for patients and clinicians in deciding between the Burch procedure and the pubovaginal sling, new techniques are rapidly expanding the available options. A new generation of mesh synthetic slings has been introduced in the past decade, with cited advantages of lower rates of urinary retention, smaller incisions, less pain, quicker recovery, and lower cost and complications. Such slings are placed with needles through the retropubic or transobturator space, guiding the sling to the midurethral area through a small vaginal incision. Risks include possible vaginal, urethral, or bladder erosion of the synthetic materials. Injuries to adjacent structures (bowel, bladder, urethra, and large blood vessels) have also been reported owing to the blind nature of needle passage. Randomized trials such as this one greatly advance our ability to counsel patients and effectively compare surgical options for treatment of SUI. Objective and subjective outcome data are often discordant, and there is no consensus on which “shade” of dry is most important. The cure rates in both groups were lower than those commonly reported, an observation that is probably explained by the use of strict criteria to define cure and the variable criteria for cure used in previous studies. At present, there is no single outcome that adequately measures success after treatment of SUI. There are as many “shades of dry.” We would like to congratulate the members of the UITN for a job well done on a difficult but important study.