After a two-year hiatus due to the pandemic, it was wonderful for SUFU (Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction) to be able to host an in-person program at the AUA Annual Meeting. The theme was how the various AUA guidelines, applicable to the practice of female pelvic medicine and reconstructive urology, should be optimally interpreted and used. Drs. Jaspreet Sandhu and Blayne Welk did an outstanding job putting the program together, which was kicked off by Dr. Peter Clark, who recently rotated off as Chair of the AUA Practice Guideline Committee, who discussed the guidelines process. There were five main topics that were covered during the afternoon session.

The first few sessions, moderated by Dr. Sandip Vasavada, focused on overactive bladder with debates on the optimal use of oral therapies and third line therapies once oral therapies have failed. The potential concerns related to impact on cognition with anticholinergics (as well as other side effects such as dry mouth and constipation) versus the potential extra cost associated with beta-3 agonist use was discussed. Drs. Doreen Chung and CR Powell debated the optimal third line therapy for a 60-year-old woman with OAB. The primary take home was there is not one option for each patient with a variety of factors impacting the decision such as associated other symptoms (eg SNS would be a preferable option in patients who also have fecal incontinence or issues of incomplete emptying), avoiding botulinum toxin if a patient is unable to catheterize and avoiding PTNS if the patient cannot attend weekly sessions for the first 12 weeks of therapy (though that may be evolving with the ability to use an implantable tibial nerve stimulator).

Drs. Kathleen Kobashi and Rena Malik moderated the sessions focused on stress urinary incontinence (SUI). The first debate focused on repeat midurethral (MUS) vs nonmesh sling for a woman with recurrent UTI and the second debate of this session focused on whether to reassure or encourage an alternative for a woman who is unsure about the safety of a synthetic MUS. For recurrent SUI, both MUS and autologous fascial slings (AFS) are viable options and patient counseling is an important part of the process towards making a decision. For the patient unsure about synthetic slings, counseling regarding the pros and cons of all options–pelvic floor therapy, MUS, AFS and urethral bulking–allows for patients to be optimally educated and allow for a choice to be made in a shared decision making process. In fact, with many of the above mentioned alternatives being viable options for each scenario, the process of shared decision making was a vital and common theme and take home message from both debates.

Dr. Alan Wein moderated the sessions focused on urodynamics, which went through a variety of case scenarios evaluating how these studies should be optimally used. There is general agreement that urodynamics are unnecessary in straightforward patients with SUI or overactive bladder. Clinical scenarios that were presented in this session highlighted when urodynamics can be helpful and included several examples of patients with neurogenic lower urinary tract dysfunction (NLUTD) and a woman with incomplete bladder emptying, a large bladder diverticulum and bladder neck obstruction. All patients with NLUTD do not require urodynamics; patients that volitionally void with a low PVR can be managed without urodynamics unless needed to guide therapy. However, patients on CIC, or those that void with elevated residuals, should undergo UDS to complete risk stratification and evaluate bladder storage pressures as well as to help guide treatment,

The sessions on incontinence after prostate treatment, moderated by Dr. Kurt McCammon, focused on the effect of radiation therapy (XRT) on post-prostatectomy incontinence (PPI) and the role of urinary diversion in patients with intractable bladder neck contracture (BNC) and/or multiple artificial urinary sphincter (AUS) failures. While both male slings and the use of an AUS are options for select men with PPI, the consensus from the panel was that most men with prior XRT do better after AUS for PPI. Men with multiple prior AUS failures and/or intractable BNC continue to be challenges for the clinicians caring these patients. The consensus of this panel was that not only is there a role for urinary diversion, but this is an option that may be considered earlier than when it is often discussed with the patient. This is one of those challenging clinical scenarios where we often trial many less invasive options that are not always successful. The option of urinary diversion, which resolves the issue, may be considered sooner in the treatment paradigm for select patients rather than continuing to try and resolve the recurrent BNC or placing multiple sphincters in patients without success.

Dr. Jennifer Anger moderated the recurrent UTI sessions, which focused on the role of cranberry and nonantibiotic solutions as well as long-term antibiotic prophylaxis. Cranberry continues to have a role for women with recurrent UTI and has a conditional recommendation in the Recurrent UTI Guidelines. Other options such as methenamine, D-mannose and increasing water intake were mentioned and are clinically used; however, there was not enough evidence to include them as guideline recommendations. One of the take home messages from this session was that further evidence is needed to better understand the potential role of these nonantibiotic options. In addition, the role of next generation sequencing of the urinary microbiome was discussed; it was agreed that this diagnostic test is not ready for prime time and would likely only lead to overtreatment of bacteria that may not require therapy. Lastly, Drs. Chai and Abraham debated on the use of long-term antibiotic prophylaxis with the consensus being that this should be discussed in a shared decision making manner, with a through discussion of the risks and benefits, for women with recurrent UTI.