Reconstruction of Urethral Sphincter With Polyacrylamide Hydrogel.

IMPORTANCE: Urethral bulking is an alternative to synthetic midurethral sling for the treatment of stress urinary incontinence (SUI) in women. Urethral bulking agents, which are injected in the submucosal tissues of the proximal urethra/bladder neck, have demonstrated less adverse effects with similar satisfaction rates but lower subjective and objective cure rates when compared with midurethral sling. Cystoscopic Reconstruction of External Sphincter Technique (CREST) is a novel technique, which reinforces the natural closure mechanism of the external urinary sphincter (EUS). OBJECTIVE: The aim of the study was to provide safety and efficacy data for injecting polyacrylamide hydrogel (PAHG) in the components of the female EUS. STUDY DESIGN: This was a retrospective chart review of patients using CREST with PAHG as initial treatment for SUI by a single surgeon from January 2022 to October 2022. Exclusion criteria are as follows: younger than 18 years, prior SUI surgery, concomitant pelvic organ prolapse or reconstructive procedure, neurological conditions, or history of radiation. Subjective and objective cure rates were measured by patient-reported symptoms and cough stress test. Urinary retention, postoperative urinary infection, and de novo urinary urgency were assessed. RESULTS: One hundred and thirteen consecutive patients met inclusion criteria with median follow-up of 3 months. Eighty-five percent of participants reported subjective improvement, 69% reported subjective cure, and 69% demonstrated objective cure. Nine patients reported transient postoperative retention, 8 reported postoperative urinary tract infections, and 5 reported de novo urgency. There were no serious adverse events. CONCLUSIONS: CREST is a novel technique for injection of PAHG, into the EUS to treat SUI. Our data suggest that this technique could improve urethral injection outcomes with minimal complications.

Differences in Anorectal Manometry Values Among Women With Fecal Incontinence in a Racially, Ethnically, and Socioeconomically Diverse Population.

IMPORTANCE: Anorectal manometry (ARM) is a valuable diagnostic and therapeutic tool that can both aid in identifying mechanisms contributing to fecal incontinence (FI) and inform management strategies. Consensus on standard reference range values has not been established, and women of varying racial and ethnic backgrounds are not well-represented in the current literature. OBJECTIVE: We aimed to compare ARM values between women of different racial and ethnic groups with FI. STUDY DESIGN: We conducted a retrospective cross-sectional study of women with FI who underwent ARM at a tertiary health system in an urban underserved community between 2016 and 2021. Demographic information and ARM values were collected from the medical record. Socioeconomic status (SES) was represented by the percent of the population living below the poverty line according to zip code using U.S. census data. Anorectal manometry values were compared between racial and ethnic groups, and multivariable logistic regression was conducted to control for patient characteristics. RESULTS: Fifty-eight women were included in the analysis: 33% Hispanic, 22% Black, and 45% White. Hispanic and Black women had higher body mass index and higher rates of diabetes and loose stools and were of significantly lower SES compared with White women. Black and Hispanic women had significantly lower thresholds for volume at first sensation and higher mean anal squeeze pressure. Differences were maintained after controlling for body mass index, diabetes, SES, and diarrhea (P = 0.03 and P = 0.01, respectively). Other ARM values were not significantly different between groups. CONCLUSIONS: Racial and ethnic differences in ARM values among women with FI exist. Further studies are needed to determine whether these differences have an impact on symptom severity, treatment selection and outcomes, and patient satisfaction.

Assessment of Patient Understanding Prior to Urological Procedures.

OBJECTIVE: To evaluate patient understanding of risks, benefits, and alternatives (R/B/A) prior to urological procedures using the teachback method. METHODS: Using a preprocedural phone interview, patients recalled general knowledge and R/B/A of a scheduled procedure. A scoring system compared patient responses to a standardized R/B/A list to analyze the level of understanding, graded as incomplete (<25%), partial (25-75%), or complete (>75%). Following the interview, additional education was provided if understanding was inadequate, and patients were queried regarding their satisfaction. RESULTS: Patients (n = 99) comprised 46% women; 32% Spanish speaking; Mean age was 64 ± 10.9 years. Procedures included were: intravesical botulinum toxin injection (24), mid-urethral sling (9), colpocleisis (4), prostate biopsy (24), ureteroscopy (16), transurethral resection prostate (11), transurethral resection bladder tumor (11). Across all procedures, the average percent of risks identified was 12%, benefits 63%, and alternatives 35%. No patients had complete understanding, but most had partial (73.7%). Patients had significantly higher level of understanding if they were female (P = 0.02), underwent the same procedure previously (P < 0.01) or any surgery within a year (P = 0.02), and were undergoing an in-office procedures (P = 0.03). After the teachback interview, most patients (90%) were satisfied with their understanding. CONCLUSION: In our cohort, patient understanding was alarmingly incomplete and there was substantial benefit in pre-procedural interviews. Our findings highlight the need for improvement in patient education prior to surgery and offers a potential solution using a teachback-based telephone interview.

Combination and Novel Pharmacologic Agents for OAB.

PURPOSE OF REVIEW: To evaluate recent literature on combination and novel pharmacologic therapies for overactive bladder (OAB). RECENT FINDINGS: Combination therapies demonstrating greater efficacy than monotherapy include combination anticholinergics, anticholinergic plus ß-3 agonist, and anticholinergic with behavioral modification, percutaneous tibial nerve stimulation, or sacral neuromodulation. Promising novel therapies include new bladder selective anticholinergics, new ß-3 agonists, and gabapentin. OAB is a symptom complex caused by dysfunction in the interconnected neural, muscular, and urothelial systems that control micturition. Although several therapeutic targets and treatment options exist, complete resolution is not always achieved, discontinuation rate for medical therapy is high, and few patients subsequently progress to third-line treatment options. Recent literature suggests combination therapy diversifying therapeutic targets is more effective than targeting a single pathway and novel treatments targeting additional pathways have promising results.

Medical Treatment of Overactive Bladder.

Overactive bladder is a disruptive urinary condition composed of urgency, frequency, and nocturia, which affects a large proportion of men and women. Symptoms are often associated with a decreased quality of life. After optimizing behavioral strategies, pharmacologic intervention is the next consideration for treatment. Therapeutic agents consist primarily of antimuscarinic and ß-agonist medications, as well as off-label use of antidepressants in some cases. These medications, although effective, can be associated with considerable adverse side effects. Combination therapies along with novel therapeutics and drug targets are under investigation.