Reappraisal of Transurethral Resection in Classic Interstitial Cystitis

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].