Yoshiyuki Akiyama: Okay. Hi, I'm Yoshiyuki Akiyama from Japan. And first, I thank Dr. Wein for giving me this opportunity and my presentation is about the clinical outcomes of the transurethral resection of the Hunner lesions in Japanese patients. Okay. So the transurethral resection of the Hunner lesions combined with the bladder hydrodistension is still the gold-standard endoscopic treatment option for patients with Hunner lesions, especially the electrocautery of Hunner lesion. It's the most important procedures for the surgeries. And in Japan, we perform this surgery as a first choice for treatment-naive patients because the broader histology helps the further treatment selection. Whether it manifests the severe chronic inflammation or little chronic inflammation, which lead to the potential application of the further immunosuppressive agents or not.
And we need to perform the bladder hydrodistension simultaneously with the electrocautery of the Hunner lesions. With some previous papers, it's just presented here, the Son et al and Lee et al, demonstrated better post-operative outcomes in performing the concomitant bladder hydrodistension compared to the electrocautery of Hunner lesions alone. So the previous papers, including these two papers, demonstrated the favorable treatment results of the transurethral resection Hunner lesions combined with the bladder hydrodistensions. This paper from South Korea reported longer year treatment duration and also the white paper from the United States demonstrated its 14.5 months on average of the treatment duration. However, more than 19% of patients needed the re-sessions, re-surgery after the first session. And also the 3.98 sessions is nearly the three times of surgery are needed in patients in subject of this paper. However, the frequent elimination of Hunner lesions may decrease the bladder capacity.
So we reported in 2021, the changes in bladder capacity over the course of multiple surgery of the transurethral resection Hunner lesions. And we included the time to surgery, not only the frequency of surgery, into the explanatory variables and using the mixed-effect linear regression models. The patients underwent mean times of the 2.7 times surgeries during the mean survey 8.5 months. And yes, the results demonstrated the 50 ml decrease per single surgery of the transurethral resection of the Hunner lesions, but it could be offset by 10 ml per single year. So the results indicate that the excessive implementation and fulguration of the Hunner lesions should be refrained. So how extendedly and deeply do we treat Hunner lesion in the endoscopic surgeries? We usually do the circumferential marking of the Hunner lesion before hydrodistension.
After the hydrodistension, overall bladder mucosa changed to the red and manifest mucosal bleeding after distension, so the Hunner lesions could be big after the bladder distention. So it is very important to mark the circumferential Hunner lesion before hydrodistension. And the results over the study demonstrated, yes, available is the 30 months of the response duration. So we investigated the 104 patients who underwent their initial sessions of the surgeries, only the initial sessions and the duration of response, it's about the 39 months. And at the 12 months after surgery, it's more than half patients were still responded like this. So summary and take-home message, the transurethral elimination of the Hunner lesion with bladder distention provides still a promising treatment outcomes, including over a year symptom relief more than 50% of patients. However, the repeating endoscopic surgery for Hunner lesions may reduce the bladder capacity, and so the circumferential marking of Hunner lesions before hydrodistension may have excessive fulgurations. And also, the subsequent intravesical therapies, including the DMSO or triamcinolone after surgery may help prolong the duration of responses. Thank you for your attention.
Alan Wein: Thank you so much. That was really, really interesting. So when a typical patient comes in, typical story that suggests interstitial cystitis, do you immediately cystoscope them under anesthesia? In other words, is that basically your first step to see if they do have a Hunner's lesion?
Yoshiyuki Akiyama: Thank you. Thank you for your question. I usually perform a cystoscopy at the outpatient clinic without anesthesia. And if at the outpatient cystoscopy, if the Hunner lesions could be found, then we proceed with the anesthetic hydrodistension and elimination of the Hunner lesions.
Alan Wein: Okay. Can you just go back to the second slide that showed the cystoscopic images? So the top left labeled A, that patch of redness, obviously it's not an ulcer and I think that's why you call it a Hunner's lesion instead of an ulcer. Is that right?
Yoshiyuki Akiyama: That's right. Yes.
Alan Wein: Yeah, so it's really a patch of redness. And the B picture is what?
Yoshiyuki Akiyama: Yeah, it's a Narrow Band Imaging, some kind of there.
Alan Wein: Okay. And that basically shows the same area, but a little more distinct. Now, when you do the hydrodistension, what pressure do you do it at?
Yoshiyuki Akiyama: Mark it.
Alan Wein: How much?
Yoshiyuki Akiyama: Yeah, thank you. It's usually we perform the hydrodistension at 80 centimeters H2O.
Alan Wein: 80 centimeters of water?
Yoshiyuki Akiyama: Yeah, 80. And for three minutes.
Alan Wein: Just for three minutes?
Yoshiyuki Akiyama: Yeah, just for three minutes. And then all saline were drained all the way. Yeah.
Alan Wein: And then the lesions show up in a more pronounced fashion after that?
Yoshiyuki Akiyama: Exactly.
Alan Wein: And able for you to mark them?
Yoshiyuki Akiyama: Yeah. The Hunner lesion could be big or ambiguous after the bladder distension.
Alan Wein: Right. Does fulguration work as well as resection or not?
Yoshiyuki Akiyama: It works.
Alan Wein: So fulguration works as well?
Yoshiyuki Akiyama: Yeah, works as well.
Alan Wein: So let's say in a woman who has what appears to be a thin bladder, do you use fulguration instead of resection?
Yoshiyuki Akiyama: No, we prioritize the resections of the Hunner lesions, rather than the fulguration because it's fulgurations could lead to the bladder tension or... Yeah.
Alan Wein: Now, do you use a lower cutting current than you would use, let's say, for a bladder tumor? In other words, what do you have the machine set at when you do this?
Yoshiyuki Akiyama: Yeah, it's just simple, the loop electric forcep or loop optic, and we only use a cutting loop.
Alan Wein: Right. And no fulguration. And so you use it on a relatively low setting, just high enough to cut?
Yoshiyuki Akiyama: Yeah. Yes.
Alan Wein: And it looks like the treatment lasts the patients for an average of, I think it was 34 months. Is that right?
Yoshiyuki Akiyama: Yeah, 30 months on average.
Alan Wein: Right. And then after that, if their symptoms return, you go back and do it again?
Yoshiyuki Akiyama: No, I never. I rarely do it again. And I usually apply the intravesical therapy after the recurrence of disease. Only one time.
Alan Wein: Only one time. And then the-
Yoshiyuki Akiyama: Only one.
Alan Wein: Yeah, the intravesical therapy that you use then is DMSO plus a steroid?
Yoshiyuki Akiyama: A DMSO alone. Yeah, it's only approved in Japan for patients with interstitial cystitis.
Alan Wein: Yep. Yeah. It's approved in the US as well. So you would suggest that the hydrodistension, then the resection, the patients, I'm assuming, will be pretty symptomatic for a day or two afterwards, and then their discomfort will start to go down?
Yoshiyuki Akiyama: Yes, exactly. Yeah.
Alan Wein: Yeah. How many days does it usually take after the treatment before they feel markedly better?
Yoshiyuki Akiyama: Okay. It depends on patients, individuals. So yes, some patients immediately. Some patients immediately it get better after surgery or others need one month or two months after surgeries.
Alan Wein: Right. And during that time, do you give them intravesical therapy or not?
Yoshiyuki Akiyama: No, only the analgesia, maybe the acetaminophen only.
Alan Wein: Right. So only if they get better and then they get worse again?
Yoshiyuki Akiyama: Yeah, it's only the analgesia. And so during the follow-up after the surgery, I never add the intravesical therapy during the follow-up period. Only see using some analgesia, acetaminophen or NSAIDs.
Alan Wein: Right. And if you see a real ulcer, in other words, not just what I normally call a patch, which is like upper left. If you see an ulcer, a true ulcer, do you do the same thing? In other words, you resect the area of the ulcer?
Yoshiyuki Akiyama: No, I am doing the same thing for all the patients.
Alan Wein: So you do the same thing?
Yoshiyuki Akiyama: Yeah, regardless of the Hunner lesions or had ulcers.
Alan Wein: Right. So you mark it and then you resect it and you stay only in that area to keep from decreasing the bladder capacity too much.
Yoshiyuki Akiyama: Yeah. Yeah, exactly. So for some patients, this way of eliminating the Hunner lesions by circumferential marking, maybe insufficient for some patients. Yeah, so those patients relapse earlier than the other patients, but I will add the intravesical DMSO treatment immediately after the symptom relapse.
Alan Wein: The results in a patient with a true ulcer, do they last longer or do they last a shorter time than the patients that, let's say, have a patch like this?
Yoshiyuki Akiyama: Yeah, based on my experience, there are no differences.
Alan Wein: There's no differences.
Yoshiyuki Akiyama: Yeah, no differences based on my experience.
Alan Wein: Right. And do you do all your cystoscopies with Narrow Band Imaging and regular white light?
Yoshiyuki Akiyama: Yes. If the cystoscopy is equipped with the Narrow Band Imaging option.
Alan Wein: Well, I think that's really very interesting. And the results that you get are pretty remarkable considering the failure of so many other treatments that we've tried for interstitial cystitis. So I hope that based on your experience, based on the experience, it looks like Ken Peters has had in his paper that he was the senior author in, I hope more people will try this therapy. So thank you so much, Professor, and thank you so much for taking your time. I know that's quite a time difference in Japan than here, and we very much appreciate your putting aside this time to talk to us. So thank you, and I hope to see you at one of the international meetings.
Yoshiyuki Akiyama: Yeah, thank you so much, Professor Wein, and I even really, really thank you for giving me such an opportunity and also look forward to seeing you in international society. Maybe the next ICS?
Alan Wein: Yes, next ICS. Yes.
Yoshiyuki Akiyama: Yeah. I look forward to see you in person.
Alan Wein: Exactly. Thank you so much.
Yoshiyuki Akiyama: Yeah, thank you so much. I'm very happy to meet you today.
Alan Wein: Likewise.
Yoshiyuki Akiyama: Thank you. Thank you.