ICS 2018: Contemporary Outcomes of Surgery for Bladder Pain Syndrome/Interstital Cystitis

Philadelphia, PA (UroToday.com) Dr. Chapple from Royal Hallamshire Hospital, Sheffield, and his colleagues presented their experience and outcome of surgical intervention in the management of bladder pain syndrome in a tertiary center.  Management of BPS is multi-modal with a variety of treatments available, however good quality evidence for many is lacking and there is no global consensus for optimum management. The role of surgery is uncertain and currently reserved for patients who are considered refractory to treatment. European Association of Urology guidelines for BPS suggests patients should only undergo surgery as a “last resort” and should be managed in a specialist center. No particular surgical technique is recommended however total cystectomy with ileal conduit is the most common. Other described techniques are supratrigonal or subtrigonal cystectomy with augmentation or total cystectomy and orthotopic neobladder formation. 

This was a retrospective review was performed on all patients who underwent cystectomy or subtotal cystectomy between 2007 and 2017. Data was collected from physical and electronic case notes as well as radiology and pathology computer systems. Primary outcome measures were pain and frequency. Secondary outcome measures were complication and mortality rates. 34 patients were identified, 5 male (14.7%) and 29 females (85.3%). The median age was 49.5 years (range 30-79). The mean duration of symptoms between diagnosis and procedure was 6.4 years. All 34 patients had documented chronic pain perceived to be related to the bladder. The median episodes of nocturia were 6 and median daytime frequency was 1 hourly. 19 patients had a previous history of pelvic surgery and 4 had a history of fibromyalgia. All patients were considered refractory to treatment and had undergone a wide range of previous management modalities. Median bladder capacity under general anesthetic was 500ml with a mean maximum cystometric capacity of 275ml.

The median follow-up was 32 months. 27 patients underwent total cystectomy (79.4%) – 23 had an ileal conduit diversion and 4 had a neobladder constructed with mitrofanoff formation. 7 patients underwent subtotal cystectomy and augmentation cystoplasty with ileum (20.6%). There were no intraoperative complications. The median length of stay overall was 13.5 days (Subtotal cystectomy and augmentation 14 days, total cystectomy and ileal conduit 13 days, total cystectomy and neobladder and mitrofanoff formation 16 (days). Clavien-Dindo grade 3 or above complications occurred in 4 patients (11.8%).  Persistent pain occurred in 8 patients overall (23.5%). 50% (2) of those who underwent total cystectomy and neobladder and mitrofanoff formation continued to have pain; one of whom proceed to excision of neobladder and formation of the ileal conduit, they were pain-free following excision. 28.6% (2) of patients who underwent subtotal cystectomy with augmentation compared to 17.3% of patients who had undergone total cystectomy and ileal conduit formation.

 They have demonstrated that 76.5% of patients in our unit undergoing surgery for BPS had a resolution of their pain with a complication rate of 11.8%. However, it should be emphasized that all patients undergo extensive counseling with the surgical team, specialist nurse, and stoma nurse before embarking on surgery.

At the end, they concluded that surgery for patients with BPS is reserved for patients with severe symptoms who are considered refractory to other treatment options. In our experience, patients have lower rates of persistent pain following total cystectomy and ileal conduit formation compared to subtotal cystectomy and augmentation and total cystectomy with neobladder formation. It is important that all patients with refractory BPS are fully counseled pre-operatively to manage expectations and consider the risks of any procedure fully before embarking on surgical intervention.

Presented by: Alison P Downey, MD, Royal Hallamshire Hospital, Sheffield
Co-Authors: Osman N I, Park J J, Mangera A, Inman R I, Reid S V R, Chapple C, Royal Hallamshire Hospital, Sheffield

Written by: Bilal Farhan, MD; Clinical Instructor, Female Pelvic Medicine and Reconstructive Surgery, University of California, Irvine Medical Center, Twitter: @Bilalfarhan79 at the 2018 ICS International Continence Society Meeting - August 28 - 31, 2018 – Philadelphia, PA USA
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