Integrating Patient Preferences with Guideline-Based Care in Neurogenic Lower Urinary Tract Dysfunction After Spinal Cord Injury.

Individual and social factors are important for clinical decision-making in patients with neurogenic bladder secondary to spinal cord injury (SCI). These factors include the availability of caregivers, social infrastructure, and personal preferences, which all can drive bladder management decisions. These elements can be overlooked in clinical decision-making; therefore, there is a need to elicit and prioritize patient preferences and values into neurogenic bladder care to facilitate personalized bladder management choices. For the purposes of this article, we review the role of guideline-based care and shared decision-making in the SCI population with neurogenic lower urinary tract dysfunction.

A Retrospective Analysis of Surgical Outcomes and Risk Factors for Persistent Postoperative Symptoms Following Synthetic Mid Urethral Sling Revision.

PURPOSE: The purpose of our study was to describe the symptom profile of patients who presented to a tertiary care hospital for sling revision, define the efficacy of sling removal/revision in alleviating symptoms and identify what factors, if any, contribute to favorable surgical outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent revision of a synthetic mid urethral sling at our institution between 2004 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from analysis. The outcomes assessed were the AUASI (American Urological Association Symptom Index) score, the M-ISI (Michigan Incontinence Symptom Index) score, pad use, post-void residual urine volume, examination findings and subjective improvement. RESULTS: A total of 430 patients met study inclusion criteria, of whom 182, 172 and 40 received a transobturator tape, a retropubic mid urethral sling and a mini-sling, respectively. Patients presented with 4 primary complaints, including mesh exposure or erosion, pain or dyspareunia, incontinence and/or bladder outlet obstruction. Of the patients 77% presented with at least 2 categories of symptoms. Average followup was 15 months. Postoperatively the AUASI score decreased from 19.0 to 14.7 (p <0.001) and the bother score decreased from 5.0 to 3.4 (p <0.001). The M-ISI also improved from total and bother scores of 15.7 and 4.4 to a postoperative average of 13.2 and 3.1 (p = 0.002 and <0.001, respectively). During this time approximately 40% of patients who presented with pain had persistent postoperative discomfort, in 20% with obstruction that condition failed to resolve and recurrent mesh complaints developed in 5% with mesh exposure or erosion. On multivariate analysis preoperative narcotic use was a significant risk factor for persistent postoperative pain (OR 6.9). CONCLUSIONS: Despite complex patient presentations subjective and objective urological symptom measures significantly improve following mid urethral sling revision.