And I have the great pleasure of talking to Rachel Sussman, who's an associate professor of urology and gynecology, urogynecology at Georgetown University.
And yesterday she gave a really spectacular talk about something that always comes up and that is if a man has both bladder outlet obstruction and some symptoms and also has typical overactive bladder symptoms, urgency frequency, maybe urgency incontinence, what do you do? What do you treat first?
Do you treat them both at the same time, you resect the outlet, you give trying to make medication or whatever you have to do for overactive bladder? So her talk was spectacular and I've asked her to summarize it and then perhaps we'll have time for a few questions about it.
So Rachel, take it away. It's your show.
Rachael Sussman: Sure. Yeah. So I was definitely taking this side yesterday of the importance of really treating what patients are complaining of. So I think it's really common that we see men and they come in and they're bothered by urgency frequency. They say, "Doc, I just want to be dry."
And I think oftentimes as urologists, we are very hyper focused on the prostate. We look at the flow rate, we look at the PVR and we have a tendency to focus on the things that we can see on the page. And I think the highlight of the talk yesterday was really just trying to listen to what bothers our patients and trying to treat them the best we can to improve their symptoms.
So in someone whose primary bother is urgency, even if they are obstructed, but particularly if they're not having infections, they don't have any upper tract deterioration from retention, things like that, I think we should treat their urgency. And I reviewed some of the data on both anticholinergics and beta-3 agonists, which AUA and SUFU guidelines both support the use of OAB medications in combination with alpha blockers. Beta-3 agonists I think are really a game-changer. They're very well-tolerated. They have very few side effects.
The data shows there's pretty low risk, no meaningful change with both Vibegron and Mirabegron of PVR or retention when compared to alpha blockers alone. So I think that's a no-brainer. And men who are complaining of urgency to at least try putting them on combination therapy. I think it gets a little more interesting when we think then about minimally invasive therapies and in the talk yesterday, just trying to weigh the pros and cons of focusing on the bladder or the organ that's causing the bothersome symptom versus going straight to outlet reduction, which does have its own risk of side effects.
So when you're thinking about going onto an outlet reduction procedure that has anesthetic risks, the risks of bladder neck contracture, stress incontinence, persistent or bothersome urgency. I went through some of the data at what predicts poor outcomes of having persistent urgency or worsening leakage after outlet reduction. And those factors that we know predict poor outcomes are advanced age, low bladder capacity, terminal detrusor overactivity on urodynamics, impaired compliance and preoperative leakage. So in patients with those characteristics, you may want to consider really focusing on the bladder.
And so we have very good minimally invasive therapies, whether that's PTNS, implantable tibial nerve stimulation, sacral neuromodulation, or Botox. And in this patient population where we know there may be an obstruction, I think neuromodulation's a really great option because there's no risk of retention, there's no risk of de novo worsening urgency or leakage, and it's very successful at treating bothersome symptoms of urgency.
OnabotulinumtoxinA is something we have to use a little more cautiously in this population, but definitely an option as long as patients are well counseled.
And then one thing I brought up a little bit that I tend to do a lot of in my practice is in men with the primary bother of urgency, the idea of perhaps if you're going to go on to outlet reduction, consider doing OnabotulinumtoxinA injection at the same time.
Alan Wein: At the time. Yeah.
Rachael Sussman: Which we definitely need more data on, but single-arm studies do show there is no increased risk of retention when combining OnabotulinumtoxinA injection with outlet reduction, no increased risk of retention or bleeding. I think the traditional thinking or what I've learned in training is treat the outlet, counsel the patient that their urgency may or may not get better and if it persists, you treat it later.
But I think it's a really interesting space to potentially consider treating both upfront so that you don't have these frustrated patients and their first three months post-op just waiting, "Oh, are my symptoms going to get better, are they not?"
Alan Wein: Or even longer. Yeah.
Rachael Sussman: Yeah.
Alan Wein: So basically if someone's untreated, they come in on nothing, you would put them on both an alpha blocker and some medication for overactive bladder. And what's your go to? Is your go to a beta-3? It sounds like it is.
Rachael Sussman: Yeah, it is.
Alan Wein: I agree.
Rachael Sussman: I mean, because they're just so much better tolerated, fewer side effects, better safety profile long-term. And the biggest issue with those is just insurance coverage, but usually particularly in a lot of these patients that are over 65 years old, there's better coverage out there for at least one of the beta-3 agonists.
Alan Wein: And if that combination doesn't work, what's your go to first neuromodulation choice?
Rachael Sussman: So I think it depends on the patient, right? If you have someone who's older, they're retired, they got time to come into the office every week, they want to do that. I think PTNS is a good option. Sacral neuromodulation's a better, more long-term solution, but I think sometimes depending on the patient, they may be a little less excited to put a permanent implant in. But I think the nice thing about sacral neuromodulation is they get to try it out first, right?
You say it's an easy thing to try, come in for an office-based PNE, and if they see a symptom improvement, then they're going to be motivated.
Alan Wein: What do you think about the implantable tibial neuromodulation systems?
Rachael Sussman: Yeah. So I think we definitely need a little more time to tell how these devices are going to work in this landscape, but I do think a lot of patients, the idea of having an implantable stimulator in the ankle is less scary than putting something near their spine. So I think-
Alan Wein: No question.
Rachael Sussman: ... it's an easier sell for someone who's a little more hesitant for an implantable.
Alan Wein: That makes common sense. I mean, I'm pretty conservative and like you, I don't believe that a reflex should be someone comes in, "Oh, we'll just do a little TURP, or we'll do a resume, or we'll do an aqua ablation and then we'll see what happens and we can always treat you later."
I'm always amazed by the disparate results between the procedure doers and the non-procedure doers about how many people actually are on medications after those procedures.
Because the non-procedure doers say, "Oh, it's a lot. It's 60 or 70%." The procedures doers say, "No, no, no, no. It's only 10 or 20%," so it's interesting.
Rachael Sussman: And I think it really depends on the pre-op complaint, right? I mean, a lot of times someone may have a slow flow rate or they may have a slightly elevated PVR, but if that's not what bothers them-
Alan Wein: Right.
Rachael Sussman: ... I think we need to focus on what the patient's goals are and how we can best help them to achieve those goals.
Alan Wein: Yep. I think the shared decision-making with accurate information like you give is really the key to having a happier patient.
Rachael Sussman: Yeah.
Alan Wein: Well, listen, thank you so much.
Rachael Sussman: Well, thank you so much.
Alan Wein: Because I think everybody will profit from listening to you.
Rachael Sussman: Wonderful. Thank you for having me.