Abstract
The idea of removing Hunner lesions to improve symptoms is not new. Guy Hunner himself found that resection of lesions was one means to obtain symptom remission, although mostly short-lived so he gave up this kind of treatment. TUR was on trial more recently [1, 2] but this kind of surgery was not accepted when we started our first series. Initially, when applying TUR our goals were twofold: to obtain sufficient tissue to permit a reliable and sufficiently detailed histopathological diagnosis, and also to establish whether careful resection of lesions actually could help patients. At this stage there was some skepticism, with questions like: if you have an ulcer and by an operation create an even bigger ulcer, how is it possible that such a measure would make any improvement? There are reasonable explanations, though [3, 4]: peripheral denervation with removal of inflamed nerve endings, reduction of aggregates of potent inflammatory mediators and elimination of epithelial mast cell recruiting factors as well as epithelial and subepithelial mast cells might cause disease remission. In this context it is worth noting that perineural localization of inflammatory cells is a very typical feature in classic interstitial cystitis [5]. At the initial stage there was also much uncertainty about what Hunner lesions really look like [6] and certainly about their prevalence. Prevalence was thought to be in the range of 5–10% of subjects with bladder pain while in our series it is around 50% [7, 8]. Recent reports indicate that the use of cystoscopy and bladder distension as a routine in BPS/IC—or lack of such routine—is decisive for the number of patients with Hunner lesion you detect or miss. In centers where the traditional way of diagnostics was not abandoned prevalence similar to ours has been reported. Fortunately, the role of cystoscopy is now increasingly appreciated worldwide [9, 10].
Access provided by CONRICYT-eBooks. Download chapter PDF
Similar content being viewed by others
The idea of removing Hunner lesions to improve symptoms is not new. Guy Hunner himself found that resection of lesions was one means to obtain symptom remission, although mostly short-lived so he gave up this kind of treatment. TUR was on trial more recently [1, 2] but this kind of surgery was not accepted when we started our first series. Initially, when applying TUR our goals were twofold: to obtain sufficient tissue to permit a reliable and sufficiently detailed histopathological diagnosis, and also to establish whether careful resection of lesions actually could help patients. At this stage there was some skepticism, with questions like: if you have an ulcer and by an operation create an even bigger ulcer, how is it possible that such a measure would make any improvement? There are reasonable explanations, though [3, 4]: peripheral denervation with removal of inflamed nerve endings, reduction of aggregates of potent inflammatory mediators and elimination of epithelial mast cell recruiting factors as well as epithelial and subepithelial mast cells might cause disease remission. In this context it is worth noting that perineural localization of inflammatory cells is a very typical feature in classic interstitial cystitis [5]. At the initial stage there was also much uncertainty about what Hunner lesions really look like [6] and certainly about their prevalence. Prevalence was thought to be in the range of 5–10% of subjects with bladder pain while in our series it is around 50% [7, 8]. Recent reports indicate that the use of cystoscopy and bladder distension as a routine in BPS/IC—or lack of such routine—is decisive for the number of patients with Hunner lesion you detect or miss. In centers where the traditional way of diagnostics was not abandoned prevalence similar to ours has been reported. Fortunately, the role of cystoscopy is now increasingly appreciated worldwide [9, 10].
The electrical settings were on the lowest intensity possible, still effective for resection, and there was only pin-point coagulation of bleeding vessels with no coagulation over large surfaces, with the intention to minimize development of scar tissue that could promote bladder contracture [3]. That makes the operation technically challenging and now and then also time-consuming since, based on experience, it is important to identify all lesions and remove all involved areas including the peripheral edema zone; completeness is crucial for the result. That is a limitation of this technique since it takes a very experienced surgeon to perform mostly multiple, wide resections over the entire bladder area, typically including the dome, on thin-walled bladders. Simple coagulation of lesions is much easier but carries its own downside, since radical wide coagulation in an organ prone to contraction seems risky. It is reasonable to believe that the result of TUR would be better and more durable, with less risk of inducing bladder contracture, although admittedly a reasoning of probability since at this stage there are no comparative studies. It is also worth noting that in a recent large series coagulation did not result in bladder volume decrease [11]. When comparing various reports duration of symptom relief seems to be longer following TUR.
The hitherto largest series [4] confirm the remarkable efficacy of this treatment, 92 of 103 patients having remission of symptoms after TUR, and long-term relief. Ablative treatment has stood the test of time and is today standard treatment with no need of justification as first line treatment of classic interstitial cystitis (ESSIC type 3C) [12].
29.1 What Did We Get Right?
The pioneering initiative by the NIH/NIDDK to establish scientific criteria for IC, presented in the book of 1990, drew attention to IC and in the following years a large number of articles were published. It was gradually realized, however, that chronic pelvic pain encompasses not only a large group of individuals but also a number of conditions lacking consensus definition criteria; very important notions. At this stage there was a conflict between the expansion of the target group and the lack of scientific clarity and transparency when grouping together a variety of conditions and syndromes with similar symptoms as their principal common feature. We began to realize that IC, for example, does not only represent one disease, but rather various subtypes or even various diseases. All treatments cannot be expected to work in all subjects. Adequate phenotyping is the key to success.
29.2 What Seminal Publications Changed Our Thinking?
Our contribution was to point out and further illustrate the multiple characteristics that differentiate classic Hunner IC from other phenotypes of BPS/IC, in terms of age at first appearance of symptoms, endoscopic presentation, histologic features including mast cell expression, response to various treatments, and neurobiological findings [5, 7, 13,14,15,16]. That also includes notions on prevalence [7, 8].
A real turning point came in 2003 when Tomohiro Ueda organized a world meeting on IC in Kyoto. The amazing differences between centers, countries and continents were exposed. The first meeting of ESSIC took place in Copenhagen somewhat later that year and resulted in epoch-making publications [12, 17]. Initiatives by large organizations to establish guidelines followed and has had a great impact, including the AUA and EAU guidelines, among many other things including the notion that chronic pain might be a disease process in its own right [18,19,20,21].
29.3 Where Were We Off Base?
29.4 Where Do We Go from Here?
There are arguments for and against all available methods as to possible risks/advantages, like possible induction of bladder wall scarring, duration of remission after treatment and the prevalence of side effects. Comparable studies with long-range observation would be of interest. Recent interest in steroid injection of Hunner lesions can be traced to Schulte and Reynolds in 1956. Risk/benefit ratios of resection, fulguration, and steroid injection to treat Hunner disease remain to be determined [22, 23].
In the scientific community, treatment methods require high scoring in level of evidence to earn high grades of recommendation. Such grading depends on the outcome of RCTs. No such studies on local ablation in BPS/IC have as yet been accomplished but are eagerly awaited.
References
Kerr WJ. Interstitial cystitis: treatment by transurethral resection. J Urol. 1971;105(5):664–6.
Greenberg E, Barnes R, Stewart S, Furnish T. Transurethral resection of Hunner’s ulcers. J Urol. 1974;111:764–6.
Fall M. Conservative management of chronic interstitial cystitis: transcutaneous electrical nerve stimulation and transurethral resection. J Urol. 1985;133:774–8.
Peeker R, Aldenborg F, Fall M. Complete transurethral resection of ulcers in classic interstitial cystitis. Int Urogynecol J. 2000;11:290–5.
Fall M, Johansson SL, Vahlne A. A clinicopathological and virological study of interstitial cystitis. J Urol. 1985;133(5):771–3.
Gillenwater JY, Wein AJ. Summary of the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland, August 28-29, 1987. J Urol. 1988;140(1):203–6.
Peeker R, Fall M. Towards a precise definition of interstitial cystitis: further evidence of differences in classic and nonulcer disease. J Urol. 2002;167:2470–2.
Logadottir Y, Fall M, Kåbjörn-Gustafsson C, Peeker R. Clinical characteristics differ considerably between phenotypes of bladder pain syndrome/interstitial cystitis. Scand J Urol Nephrol. 2012;46(5):365–70.
Homma Y, Ueda T, Tomoe H, Lin A, Kuo H, Lee M, et al. Clinical guidelines for interstitial cystitis and hypersensitive bladder updated in 2015. Int J Urol. 2016;23(7):542–9. Epub 2016 May 24
Doiron R, Tolls V, Irvine-Bird K, Kelly K, Nickel J. Clinical phenotyping does not differentiate hunner lesion subtype of interstitial cystitis/bladder pain syndrome: a relook at the role of cystoscopy. J Urol. 2016;196(4):1136–40.
Chennamsetty A, Khourdaji I, Goike J, Killinger K, Girdler B, Peters K. Electrosurgical management of Hunner ulcers in a referral center’s interstitial cystitis population. Urology. 2015;85(1):74–8. Epub 2014 Nov 5.
van de Merwe JP, Nordling J, Bouchelouche P, Bouchelouche K, Cervigni M, Daha LK, et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol. 2008;53(1):60–7.
Fall M, Johansson SL, Aldenborg F. Chronic interstitial cystitis: a heterogeneous syndrome. J Urol. 1987;137:35–8.
Logadottir Y, Ehren I, Fall M, Wiklund NP, Peeker R. Intravesical nitric oxide production discriminates between classic and nonulcer interstitial cystitis. J Urol. 2004;171:1148–51.
Peeker R, Aldenborg F, Dahlström A, Johansson SL, Li J-Y, Fall M. Increased tyrosine hydroxylase immunoreactivity in bladder tissue from patients with classic and nonulcer interstitial cystitis. J Urol. 2000;163:112–5.
Peeker R, Fall M, Enerbäck L, Aldenborg F. Recruitment, distribution and phenotypes of mast cells in interstitial cystitis. J Urol. 2000;163:1009–15.
Nordling J, Anjum F, Bade J, Bouchelouche K, Bouchelouche P, Cervigni M, et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol. 2004;45(5):662–9.
Engeler D, Baranowski A, Dinis-Oliveira P, Elneil S, Hughes J, Messelink E, et al. The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol. 2013;64(3):431–9.
Fall M, Baranowski A, Elneil S, Engeler D, Hughes J, Messelink E, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2010;57(1):35–48.
Fall M, Baranowski AP, Fowler CJ, Lepinard V, Malone-Lee JG, Messelink EJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2004;46(6):681–9.
Hanno P, Burks D, Clemens J, Dmochowski R, Erickson D, Fitzgerald M, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185(6):2162–70.
Schulte TL, Reynolds LR. Transurethral intramural injection of hydrocotone hyaluronidase for interstitial cystitis (hunner's ulcers). J Urol. 1956;75:63–5.
Cox M, Klutke JJ, Klutke GC. Assessment of patient outcomes following submucosal injection of triamcinolone for treatment of Hunners ulcer subtype interstitial cystitis. Can J Urol. 2009;16:4536–40.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG
About this chapter
Cite this chapter
Fall, M. (2018). Reappraisal of Transurethral Resection in Classic Interstitial Cystitis. In: Hanno, P., Nordling, J., Staskin, D., Wein, A., Wyndaele, J. (eds) Bladder Pain Syndrome – An Evolution. Springer, Cham. https://doi.org/10.1007/978-3-319-61449-6_29
Download citation
DOI: https://doi.org/10.1007/978-3-319-61449-6_29
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-61448-9
Online ISBN: 978-3-319-61449-6
eBook Packages: MedicineMedicine (R0)