Impact of Lifetime Obesity on Urinary Incontinence in the Women's Health Initiative.

PURPOSE: We assessed the impact of lifetime obesity on the development of urinary incontinence (UI). MATERIALS AND METHODS: Using data from the Women's Health Initiative, we evaluated the cumulative impact of obesity over a postmenopausal woman's lifetime on the development of UI. Analyses using logistic models assessed the relationship between overweight/obesity duration and the development of UI during the Women's Health Initiative study at year 3. RESULTS: Of the 15,420 women aged 50-79 years, 4,568 (30.0%) developed UI by year 3. When controlling for covariates, the duration of overweight years (OWY) and obese years (OBY) was significantly associated with overall UI. The number of OWY was associated with an increased risk of developing UI postmenopausally (OR 1.17, 95% CI 1.13-1.22) compared to those with 0 OWY. The number of OBY was associated with a higher risk of developing UI postmenopausally (OR 1.28, 95% CI 1.18-1.39). Severity of UI was also associated with higher OWY/OBY. Compared to participants who maintained normal weight, those who gained weight from age 18 to 50 years were more likely to report increased UI (OR 1.26, 95% CI 1.16-1.37), as did those who remained overweight/obese (OR 1.27, 95% CI 1.04-1.55). Those who lost weight reported no difference in rates of any UI. CONCLUSIONS: Chronic, increased body mass index status is associated with an elevated risk of UI later in life. Symptom severity also appears to be worsened with duration of increased body mass index status. Weight management should be supported throughout one's lifetime, as it may impact UI in later stages of life.

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis.

BACKGROUND: The 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy. AIM: To use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement. METHODS: The study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula. OUTCOMES: Relevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements. RESULTS: A total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16). CLINICAL IMPLICATIONS: The use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool. STRENGTHS & LIMITATIONS: This is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention. CONCLUSION: We demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons. Punjani N, Monteiro L, Sullivan J F et al. The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis. J Sex Med 2021;18:1830-1834.

Climacturia After Radical Prostatectomy: MRI-Based Predictors.

BACKGROUND: After radical prostatectomy (RP), climacturia is a prevalent and distressing problem. To date, no specific predictors have been identified. AIM: In this analysis, we sought to find associated pelvic magnetic resonance imaging (MRI) parameters. METHODS: We identified all men in our departmental database who (i) had climacturia post-RP, ≥3 episodes; (ii) underwent a pre-RP endorectal MRI; (iii) had no radiation or androgen deprivation therapy (ADT). Soft tissue and bony dimensions were measured by 2 raters blinded to clinical and pathological data. OUTCOMES: MRI parameters included the following: maximum height, width, and depth of prostate, prostate volume, urethral width and length, lower conjugate of pelvis, bony femoral width, outer and inner levator distances and thickness. Point-biserial correlations were run on univariate associations. Logistic regression was used for the multivariable model. RESULTS: 194 consecutive pre-RP MRI studies were reviewed (56 men with and 138 without climacturia). Mean age was 60 ± 7 years, average time post-RP at assessment, 7 ± 7 months. Of MRI parameters, urethral width (r = 0.13, P = .03) and lower conjugate (r = 0.12, P = .05) were associated with presence of persistent climacturia. 2 others met criteria for multivariable analysis, prostate depth and outer levator distance. Of the non-MRI parameters, none were significantly related to climacturia and only body mass index (BMI) met criteria for multivariable analysis. On multivariable analysis, only urethral width was associated with climacturia (OR = 1.23, 95% CI: 1.01-1.49, P = .04); the wider the urethra, greater the chance of climacturia. CLINICAL IMPLICATIONS: Improved ability to predict the occurrence of orgasm-associated incontinence in the preoperative setting. STRENGTHS AND LIMITATIONS: Limitations include the fact that the MRI endorectal probe may have distorted pelvic tissues during imaging and that our study population size was small. However, prospective data collection, blinded measurements by 2 trained readers, and rigorous statistical analysis should be considered strengths. CONCLUSION: By identifying preoperative risk factors, such as urethral width on MRI, we may be able to better understand the pathophysiology of this condition and furthermore may permit us to better counsel men regarding this postoperative outcome. Sullivan JF, Ortega Y, Matsushita K, et al. Climacturia After Radical Prostatectomy: MRI-Based Predictors. J Sex Med 2020;17:1723-1728.

The Role of Chronic Mesh Infection in Delayed-Onset Vaginal Mesh Complications or Recurrent Urinary Tract Infections: Results From Explanted Mesh Cultures.

OBJECTIVES: Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). METHODS: Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. RESULTS: One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. CONCLUSIONS: In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS-DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS-DN showed that there was a significant decrease in intra-operative blood loss and allograft warm ischaemia time in the LESS-DN group, but also a significant increase in operating time. Other peri-operative outcomes were similar between the two approaches. Evaluation of the LESS-DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS-DN. OBJECTIVE: To present a comparative analysis of peri-operative outcomes for >200 cases of conventional laparoscopic donor nephrectomy (LDN) and laparoendoscopic single site donor nephrectomy (LESS-DN). PATIENTS AND METHODS: From 2006 to 2011, 213 donor nephrectomies were performed by two surgeons (R.E.L and W.A.M.) at a tertiary transplant centre. The approach changed from conventional LDN to LESS-DN over the course of the series. The two approaches were compared retrospectively and evaluated for differences in peri-operative outcomes. Statistical significance was assessed using Student's t-test and chi-squared analysis. RESULTS: A total of 111 patients underwent LDN and 102 patients underwent LESS-DN. Total operating time was significantly longer in the LESS-DN group (206.1 vs 181.9 min, P < 0.001), but LESS-DN resulted in less intra-operative blood loss (61.5 mL vs 85.9 mL, P < 0.001) and shorter warm ischaemia times (4.4 vs 5.0 min, P = 0.01). There were no significant differences in analgesic requirements, subjective pain scores, length of hospital stay, postoperative graft function, or donor's postoperative glomerular filtration rate between the two approaches. Complication rates were low regardless of the approach, and there were no major complications (>grade II) in the LESS-DN group. CONCLUSIONS: In experienced hands, LESS-DN results in peri-operative outcomes similar to those of conventional LDN without compromising donor safety, while providing a desirable cosmetic result. For surgeons familiar with LDN, transitioning to the LESS approach using this technique appears to have a relatively short learning curve.

Complex rectovaginal fistulas after pelvic organ prolapse repair with synthetic mesh: a multidisciplinary approach to evaluation and management.

OBJECTIVES: The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management. METHODS: Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution. RESULTS: Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain. CONCLUSIONS: This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

Higher RENAL Nephrometry Score is predictive of longer warm ischemia time and collecting system entry during laparoscopic and robotic-assisted partial nephrectomy.

OBJECTIVE: To investigate the predictive value of the RENAL Nephrometry Score (RNS) on operative outcomes during both laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN). METHODS: We reviewed 67 consecutive patients with suspicious renal lesions and available radiographic data who underwent LPN or RPN by a single surgeon. Data included operative type, body mass index (BMI), gender, age, and side of tumor. RNSs were recorded using either magnetic resonance imaging or computed tomography scans. Warm ischemia time (WIT), estimated blood loss (EBL), and collecting system entry (CSE) were the endpoints for the analyses. RESULTS: Total RNS entered as a continuous or dichotomous variable (<7 or ≥ 7), R-score, and N-score were independent predictors of WIT on multivariable analyses (P <.001, P = .001, P = .026, and P <.01, respectively). The total RNS and N-score were predictive of CSE in univariate analysis (P <.001). Neither total RNS nor its individual components were predictive of EBL. CONCLUSION: Total RNS, as well as the N- and R-scores, can help predict both longer WIT and CSE during LPN and RPN. The RNS and its individual components may be useful in the preoperative planning and counseling of patients undergoing LPN or RPN.

A single-center experience with prone retroperitoneoscopic versus open renal surgery in children: an age- and procedure-matched comparison.

PURPOSE: We determined how surgical outcomes differ among children undergoing prone retroperitoneoscopic (RP) and open total and partial nephrectomies for benign renal disease. PATIENTS AND METHODS: A retrospective analysis was performed, using medical records of children who were undergoing benign renal surgery at a single institution from 2001 to 2010. Patients were divided into open or RP cohorts, then subdivided into those who were undergoing total or partial nephrectomies. A further breakdown by age (<3 years and ≥3 years) was performed. Bilateral nephrectomies were separately evaluated. Surgical outcomes were compared across groups. RESULTS: There were 308 (333 renal units) children who underwent RP (n=154) or open (n=154) total or partial nephrectomies, 25 of which were bilateral (20 RP, 5 open); 199 patients underwent total nephrectomies (RP n=118, open n=81), and 109 underwent partial nephrectomies (RP n=36, open n=73). After controlling for age and concomitant procedures, operative times were similar for the RP total and bilateral nephrectomy groups, but longer for the RP partial nephrectomy group, compared with their open counterparts. In both total and partial nephrectomies, the RP group had a shorter hospital stay. There were no open conversions in any of the RP groups and no differences in complications in the total, partial, and bilateral analyses. There were 13 patients who previously received peritoneal dialysis (8 bilateral RP, 3 unilateral RP, and 2 unilateral open), all of whom resumed dialysis in a mean of 1.11 days. CONCLUSIONS: This is the largest series to date that compares RP and open renal surgeries in children. The RP and open approaches were comparably safe and efficacious. Hospital stays were significantly shorter in the RP total and partial groups, although operative times were significantly longer in the RP partial nephrectomy group. Prone retroperitoneoscopic surgery should be considered a viable option for renal surgery at any age.

Defining predictors of response to intralesional verapamil injection therapy for Peyronie's disease.

OBJECTIVE: • To assess factors that predict penile curvature responses to intralesional verapamil (ILV) injection therapy for men with Peyronie's disease (PD). PATIENTS AND METHODS: • Men with PD for <1 year were assessed at baseline and after 3 months of bi-monthly ILV-injection therapy. Curvature was assessed at the time of maximum penile rigidity. • Univariate relationships were tested with correlation or chi-square analyses. • Multivariate analyses included logistic and linear regression. • We analysed curvature improvement, defined as a decrease of ≥10 ° from baseline. Additionally, the relationship between curvature outcomes and patient age and degree of baseline penile curvature were assessed. RESULTS: • Data from 131 men were included and the rates of penile curvature change were:26% improved, 12% worsened, and 62% stable. • Age (r=-0.24, P < 0.01) and larger baseline penile curvature (r= 0.33, P < 0.01) were associated with improved curvature on univariate analysis. • On multivariate analysis (logistic regression), both age [odds ratio (OR) 0.93, P < 0.01, 95%CI 0.89-0.97] and larger baseline penile curvature (OR 1.07, P < 0.01, 95%CI 1.04-1.11) were associated with improvements in curvature after ILV-injection therapy. • Improvements in curvature were associated with age (≤40 years vs >40 years; OR 0.27, P < 0.05, 95%CI 0.10-0.75) and degree of penile curvature at baseline (≤30 ° vs >30 °; OR 9.12, P < 0.01, 95%CI 1.94-42.84) when dichotomized as indicated. CONCLUSION: • Younger age and larger baseline penile curvature were predictive of favourable curvature outcomes. • Analysis of dichotomized variables suggests that age and baseline curvature thresholds may be important to consider when deciding on ILV as a therapeutic strategy for PD.

Predicting delay in presentation in men with Peyronie's disease.

INTRODUCTION: Many men with Peyronie's disease (PD) delay presentation to a urologist. The reasons for this are unclear. AIM: To define the differences in men who present early compared to those presenting in a delayed fashion and to determine predictors of delayed presentation. METHODS: A retrospective analysis of all patients presenting for the first medical evaluation of PD. All patients underwent a standard history and physical examination and had a standardized deformity assessment. Demographic and PD parameters were recorded. MAIN OUTCOME MEASURES: Statistical comparison was used to define factors that were different between early and delayed presenters and multivariable analysis was used to define predictors of presentation >12 months. RESULTS: 482 patients were analyzed, 61% presenting ≤12 months, 39% >12 months. Mean patient age was 52 ± 13 years and mean duration of PD was 17 ± 30 months. Mean measured curvature was 42° ± 19°. Multivariable analysis revealed that delayed presentation patients were significantly more likely to be older (odds ratio [OR] = 4.0), to be in long-term relationships (OR = 3.6), to have dorsal curvature (OR = 2.5), to have curvature <45° (OR = 3.3), to be heterosexual (OR = 2.0), and to have simple deformity (OR = 1.5). CONCLUSIONS: One-third of men with PD presented in a delayed fashion and they tended to be older, to be in long-term relationships, to have dorsal curvature, or to have simple deformity.

Determinants of sexual satisfaction in men with prostate cancer.

OBJECTIVE: There is a growing debate about the important determinants of sexual satisfaction in men. Some authors argue that men's sexual satisfaction correlates with physical functioning variables such as erection quality and ejaculatory time. Other authors have suggested that the limited literature indicates that men's sexual satisfaction is related to psychosocial variables such as relationship satisfaction, depression, or anxiety. This study is the first to our knowledge to explore this question in men with prostate cancer. MATERIALS AND METHODS: This archival, cross-sectional research analyzed quality-of-life, depression, and anxiety data on 352 men with early- and late-stage prostate cancer. Questions from the Functional Assessment of Cancer Therapy Scale-Prostate Cancer Version were used to assess sexual satisfaction, erectile function, and relationship closeness. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression. RESULTS: In general, the subjects reported low sexual satisfaction with a mean score of 2.3 on a 5-point Likert scale (1-5). In the correlational analyses, arthritis, brachytherapy, and depression/anxiety were all negatively associated with sexual satisfaction, while erectile function and relationship closeness were positively associated with sexual satisfaction (P < 0.05). In the subsequent multivariate analysis, erectile function (P < 0.01), relationship closeness (P < 0.05), and depression/anxiety (P < 0.05) remained significant predictors of sexual satisfaction. In this model, erectile functioning produced the largest effect (beta = 0.57) as compared to relationship closeness and depression/anxiety (beta values approximately 0.11). CONCLUSION: In this sample of men with prostate cancer, both physical and psychosocial variables were found to be important determinants of sexual satisfaction. Erectile function appears to have the strongest association with sexual satisfaction; however, variables such as relationship quality, depression, and anxiety are also clearly related to a satisfying sex life in this sample.

Orgasm associated incontinence (climacturia) following radical pelvic surgery: rates of occurrence and predictors.

PURPOSE: Orgasm associated incontinence, that is the inadvertent leakage of urine at orgasm, has received little attention in the literature. We evaluated the rate of occurrence of orgasm associated incontinence following radical pelvic surgery as well as its associated factors and predictors. MATERIALS AND METHODS: From January 2005 to March 2006, 696 patients were evaluated for post-radical pelvic surgery sexual dysfunction. A database was created, and descriptive statistics, chi-square analysis and logistic regression analysis were used to evaluate associated factors and predictors. RESULTS: Of 475 patients 96 (20%) reported orgasm associated incontinence following radical pelvic surgery. The incidence was significantly less in the cystoprostatectomy group than in the open and laparoscopic radical prostatectomy groups (p <0.05). Orgasm associated incontinence was more commonly found within 12 months following surgery vs greater than 12 months (RR 0.81, 95% CI 0.72-0.92, p <0.01) and in patients with orgasm associated pain (RR 1.09, 95% CI 1.01-1.16, p <0.01) and penile length loss (RR 1.32, 95% CI 1.09-1.59, p <0.01). On multivariate analysis all factors associated on univariate analyses remained predictive. Orgasm associated incontinence was not associated with patient age, the degree of nerve sparing, surgical margin status, seminal vesicle or lymph node involvement, preoperative erectile function, nocturnal erections, libido level or daytime continence. CONCLUSIONS: Orgasm associated incontinence occurs in a fifth of men (96 of 475) following radical pelvic surgery. The incidence of orgasm associated incontinence is greater with radical prostatectomy than with radical cystectomy and it is unrelated to the type of prostatectomy performed (open vs laparoscopic). Orgasm associated incontinence is more likely to be reported within year 1 following surgery and in men who complain of orgasmic pain and/or penile shortening.