BERKELEY, CA (UroToday.com) - Our report includes 47 patients, evaluated retrospectively, fulfilling the NIH/NIDDK criteria and assigned to subtype: classic versus non-ulcer BPS/IC. The average median follow-up period was 89 months and the most common procedure was supratrigonal cystectomy and ileocystoplasty, performed in 23 patients. A very remarkable difference in outcome was seen between patients with classic/Hunner type and patients with non-ulcer disease. In 32 out of 34 patients with classic disease there was a favorable outcome, with 28 patients helped by the initial surgery whereas a successful outcome in a further 4 patients required additional surgery (a supplementary diversion procedure, cystectomy or transurethral resection in the trigonal remnant, respectively). In glaring contrast to this, symptom resolution was achieved in only three of the 13 patients with non-ulcer disease and in two of those not until reoperation and supravesical diversion. Thus, we again have to stress the importance of a thorough preoperative evaluation, with emphasis on assessment to identify the relevant subtype, i.e. classic or non-ulcer disease.

Due to the fact that previous reports on major reconstructive surgery almost consistently have failed to recognize the importance of subclassification, our results^1-2 are somewhat difficult to directly compare to others. However, findings that agree with those in the present series are that poor results have often been reported in patients with large preoperative anaesthetic bladder capacity, typically found in patients with non-ulcer disease ³. There are further examples of opposite results in the literature: patients with a supratrigonal bladder resection at the time of augmentation having an excellent outcome ⁴ as well as persisting symptoms even when the entire bladder and urethra have been removed ⁵.

The prevalence of the classic Hunner entity versus non-ulcer disease varies considerably between different series, with the classic form generally being reported as being quite uncommon, prevalences ranging from 3,5%-56% in different studies ^{3, 6-10}. If this is due to real demographic differences or difficulties to adequately perform subclassification remains to be determined. In this context, cystoscopy, hydrodistension and biopsies are important. Some maintain that cystoscopic examination provides little useful information11, identifying “only” features typical for the classic subtype of IC and thereby entailing the risk to falsely exclude more than 90% of patients from the diagnosis. Firstly, the crucial importance of identification of Hunner lesions can not be emphasized enough, since this entity is well-defined with special features as to age, endoscopic and histologic presentation, neurobiologic findings, mast cell expression and treatment options, compared to other presentations of BPS/IC ^{3, 7, 13, 14}. Subtyping allows a better chance to tailor an effective treatment at an earlier point of time. Secondly, Hunner’s lesions are not the only observation of interest. Apart from glomerulations, the significance of that finding with good reasons being debated, multiple, superficial fissures are additional typical findings of the so-called nonulcer form 14 and should have something to say about the disease. We need objective criteria for the progress of research as well as in clinical practice.

Our study lends further support to the notion that the Hunner type of disease is a quite well defined entity with predictable treatment outcome while the non-ulcer subtype seems to be a generic term for apparently similar but possibly still quite varying conditions.

There is every reason to acknowledge heterogeneity and to find means to more deeply explore this complex.

References:
1. Peeker, R., Aldenborg, F., Fall, M.: The treatment of interstitial cystitis with supratrigonal cystectomy and ileocystoplasty: difference in outcome between classic and nonulcer disease. J Urol, 159: 1479, 1998
2. Rossberger, J., Fall, M., Jonsson, O. et al.: Long-term results of reconstructive surgery in patients with bladder pain syndrome/interstitial cystitis: subtyping is imperative. Urology, 70: 638, 2007
3. Peeker, R., Fall, M.: Toward a precise definition of interstitial cystitis: further evidence of differences in classic and nonulcer disease. J Urol, 167: 2470, 2002
4. Flood, H. D., Malhotra, S. J., O'Connell, H. E. et al.: Long-term results and complications using augmentation cystoplasty in reconstructive urology. Neurourol Urodyn, 14: 297, 1995
5. Baskin, L. S., Tanagho, E. A.: Pelvic pain without pelvic organs. J Urol, 147: 683, 1992
6. Hand, J. R.: Interstitial cystitis: Report of 223 cases (204 women and 19 men). J Urol, 61: 291, 1949
7. Holm-Bentzen, M., Jacobsen, F., Nerstrom, B. et al.: Painful bladder disease: clinical and pathoanatomical differences in 115 patients. J Urol, 138: 500, 1987
8. Koziol, J. A., Clark, D. C., Gittes, R. F. et al.: The natural history of interstitial cystitis: a survey of 374 patients. J Urol, 149: 465, 1993
9. Messing, E. M., Stamey, T. A.: Interstitial cystitis: early diagnosis, pathology and treatment. Urology, 12: 381, 1978
10. Parsons, C. L., Mulholland, S. G.: Successful therapy of interstitial cystitis with pentosanpolysulfate. J Urol, 138: 513, 1987
11. Ottem, D. P., Teichman, J. M.: What is the value of cystoscopy with hydrodistension for interstitial cystitis? Urology, 66: 494, 2005
12. Aldenborg, F., Fall, M., Enerbäck, L.: Proliferation and transepithelial migration of mucosal mast cells in interstitial cystitis. Immunology, 58: 411, 1986
13. Fall, M., Johansson, S. L., Aldenborg, F.: Chronic interstitial cystitis: a heterogeneous syndrome. J Urol, 137: 35, 1987
14. Johansson, S. L., Fall, M.: Clinical features and spectrum of light microscopic changes in interstitial cystitis. J Urol, 143: 1118, 1990

Written by
Magnus Fall, MD, as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Long-Term Results of Reconstructive Surgery in Patients with Bladder Pain Syndrome/Interstitial Cystitis: Subtyping is Imperative - Abstract

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