To mesh or not mesh "apical prolapse," that is the question!

AIMS: The management of pelvic organ prolapse (POP) involves both nonsurgical and surgical management. Views on best surgical approach for apical prolapse is an evolving field based on recent evidence and events related to transvaginal mesh. METHODS: At the 97th Annual Meeting of the North Central Section of the American Urological Association (Scottsdale, AZ, USA), this topic was discussed and debated. The following article summarizes the concepts presented that day as well as the interactive debate with three perspectives on apical prolapse surgeries. The authors were asked to support their approach in various scenarios including: extremes of age, prior hysterectomy and intact uterus, desire to avoid mesh, sexual activity, and presence of comorbidities. RESULTS: Surgical approaches for POP have evolved and is a popular topic for debate, particularly when discussing apical prolapse. Transvaginal native tissue repairs remain the mainstay of POP surgeries; however, transabdominal approaches continue to evolve. Use of interposition material, such as synthetic polypropylene mesh, is the standard when performing an abdominal sacrocolpopexy, however, use of autologous fascia can be considered. Small series have demonstrated the safety and efficacy of autologous fascia-based repairs; however, larger studies with longer follow-up are needed. CONCLUSIONS: There are a variety of surgical strategies to repair POP. Ultimate decision making on specific surgeries should be determined by patient preference and goals after appropriate counseling on all options.

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study.

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher's Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel.

Quality of life outcomes in peri-urethral calcium hydroxylapatite injection.

INTRODUCTION AND HYPOTHESIS: Peri-urethral calcium hydroxylapatite injection is an established treatment for patients with stress urinary incontinence. Information is limited regarding calcium hydroxylapatite treatment and quality of life (QOL) outcomes. We hypothesize that patients might improve QOL after peri-urethral calcium hydroxylapatite injection, which was reflected in validated questionnaires. METHODS: The peri-urethral calcium hydroxylapatite injection billing code was used to identify patients who underwent injection from 2011-2013. Female patients who completed the American Urological Association Symptom Score (AUASS), the AUASS QOL and Michigan Incontinence Symptom Index (M-ISI), and the bother score (M-ISI bother), or pad count at baseline and follow-up were included. Change in questionnaire scores and pads were assessed using the paired t test. RESULTS: Sixty patients underwent 1 (30), 2 (63) or 3 (7 %) peri-urethral calcium hydroxylapatite injections performed by a single surgeon. Thirty-seven patients provided questionnaires and 38 provided pad counts, all with a mean age of 75 years. The overall AUASS, AUASS QOL, and overall M-ISI scores improved in 67.6, 54.8, and 61.3 % respectively (4.5 ± 7.9, 1.3 ± 1.7 and 5.5 ± 8.6 respectively). The M-ISI bother score improved in 44.8 % with a mean improvement of 0.5 ± 2.9, but did not reach significance. There was a 1.7 ± 3.7 decrease in the mean number of pads used daily after the procedure (p = 0.006) and 19 % experienced transient urinary retention. CONCLUSIONS: Peri-urethral calcium hydroxylapatite injections can improve urinary QOL scores in patients with initial and recurrent stress urinary incontinence. This short-term retrospective analysis suggests that larger long-term studies focusing on QOL outcomes are needed to evaluate the effect of peri-urethral calcium hydroxylapatite has on incontinence-specific QOL.

A Primer for Primary Care Physicians Managing Neurogenic Bladder Patients.

Primary care plays an important role in caring for neurogenic bladder patients. Clinicians should assess neurogenic bladder patients for common urologic symptoms/signs and refer to urology if refractory or safety issues are identified.

Differences in sacral neuromodulation device infection rates based on preoperative antibiotic selection.

INTRODUCTION AND HYPOTHESIS: After SNM implantation the most significant complication that can occur is wound infection, which typically requires removal of all components. Such infections have been reported in 5-11 % of patients, but little is known about risk factors. The objective of this analysis is to determine our postoperative wound infection rate after SNM implantation, and examined various potential predictive factors. Our hypothesis is that perioperative antibiotic selection is related to the risk of infections. METHODS: A retrospective review was performed of all patients who underwent SNM implantation by one of three surgeons from 2007 to 2010. Preoperative antibiotics were administered according to surgeon preference, and included cefazolin alone, vancomycin alone, or vancomycin with gentamicin. Predictors of wound infection were evaluated using multivariate techniques. Variables examined included preoperative antibiotic regimen, surgeon, location (outpatient surgery center vs university hospital), gender, comorbidities (diabetes mellitus, immunosuppression and smoking), history of urinary tract infections, and preoperative skin preparation. RESULTS: A total of 136 patients underwent SNM implantation, and 8 (5.9 %) experienced infections that required device explantation. Cefazolin alone was less effective in preventing infection compared with the other antibiotic regimens (p = 0.03). The odds of having an infection in cefazolin-treated patients was 7.3 times that of other patients treated with another antibiotic regimen. Seven out of the eight infections with explant grew Staphylococcus aureus resistant to cephalosporins. None of the other variables proved to be a statistically significant contributor. CONCLUSIONS: Preoperative antibiotic selection was a significant factor in preventing subsequent infection and explantation following SNM placement.

Diversity in Urology, Are We Moving in the Right Direction?: Analysis of American Urologic Association Urology Residency Match Statistics 2019-2023.

Analysis of the urology match statistics provides a window into the future of the urology workforce. Match statistics from 2019 to 2023 were analyzed to determine whether the efforts to promote diversity in 2020 have been impactful. The popularity in the field of urology among all racial/ethnic groups peaked interest in application in 2022. However despite an increase in URIM applicants over the last 5 years, 2023 URM applicants have 1/3 the odds of matching into urology as white applicants.

Genital Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Neobladder & Paravaginal Repair.

OBJECTIVE: Vaginal prolapse is a known complication after radical cystectomy, requiring additional procedures in 10% of the patients.1 This results from loss of level I and II vaginal support due to the removal of pelvic structures. In addition, a neobladder urinary diversion, with Valsalva voiding, predisposes to vaginal prolapse. A genital-sparing approach with paravaginal repair can help prevent such complications. METHODS: The genital sparing technique preserves the uterus, fallopian tubes, ovaries, and vagina, while paravaginal repair involves suturing of the lateral vaginal wall to the arcuate fascia located on the medial aspect of the obturator internus muscle. The procedure begins by placing the patient in a lithotomy position, with a steep Trendelenburg. Standard 6 port cystectomy configuration is utilized with an additional 15 mm port for bowel anastomosis. Initially, the ureters and lateral bladder space are mobilized. Posteriorly a dissection plane is developed separating the bladder from the anterior vaginal wall. Distal dissection is carefully performed in that plane to avoid disrupting the urethral-external sphincter complex. Then the bladder is dropped from anterior attachments, the Dorsal venous complex (DVC) and bladder neck are exposed. Urethra is transected distal to the bladder neck, after circumferential mobilization, to complete the cystectomy, again avoiding disruption of the continence mechanism, and opening the endo-pelvic fascia. Cystectomy and pelvic lymph node dissection are completed in a standard fashion. The arcuate fascia is identified bilaterally for level I paravaginal repair. The lateral aspect of the paravaginal tissue is secured to this ligament, using 3 interrupted Polydioxanone (PDS) sutures, bilaterally. An ileal "Hautman's W pouch" neobladder is constructed using 50 cm of the small intestine, similar to the previously reported technique.2 Bricker-type uretero-ileal anastomosis is performed over a double J stent. Bowel continuity is restored by a side-to-side anastomosis using endo-GIA (gastrointestinal anastamosis EndoGIATM ) staplers. RESULTS: No intra or postoperative complications were noted. Robot dock time was 8 hours and 23 minutes with an EBL of 100 mL. The patient was discharged on post operative day (POD) 6 and Foley catheter with ureteral stents was removed on POD 27 after a cystogram confirmed no leaks. At 6-month follow-up, the patient reported good continence using a single pad, voiding every 3-4 hours. Fluoro-urodynamics demonstrated 651 mL capacity, low-pressure voiding, minimal residual urine, and no reflux. No prolapse was noted on fluoroscopy and pelvic examination with the Valsalva maneuver. The patient reported a good satisfaction level, regarding her urinary symptoms. CONCLUSION: We report satisfactory short-term outcomes of a feasible technique to prevent postcystectomy prolapse; however, long-term follow-up of a larger cohort can help establish its efficacy.

Workforce Diversity in Female Pelvic Medicine and Reconstructive Surgery: An Analysis of the American Urological Association Census Data.

OBJECTIVE: To describe the current state of workforce diversity in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) using the 2014-2019 American Urological Association (AUA) census data. MATERIALS: We evaluated FPMRS workforce diversity using the AUA census data from 2014 to 2019. Underrepresented in medicine (URiM) groups were categorized as individuals who self-identified as non-Hispanic Black/African American, Hispanic, Multiracial, and Other. The FPMRS workforce was then compared to the overall urologic workforce and the other urologic subspecialties (oncology, pediatric urology, and endourology) and assessed by AUA section. RESULTS: In 2019, 602 urologists self-identified as FPMRS providers. Of these 12.4% (n = 74) were categorized as URiM urologists compared to 8% of the overall urologic workforce. Women who represent 9.9% of all urologists were overrepresented in FPMRS workforce (46.5%). FPMRS had the largest proportion of URiM and women urologists when compared to the other subspecialty areas. CONCLUSION: The FPMRS urologic subspecialty has the highest percentage of women and URiM urologists compared to all other urologic subspecialty areas. Engagement initiatives and targeted programs may offer insights into this trend. Further research is required to determine the impact of such programs in attracting URiM and women to FPMRS.

Comparison of Urinary Tract Infection Incidence Following Intradetrusor OnabotulinumtoxinA in Office Versus Operating Room Settings.

IMPORTANCE: Urinary tract infection (UTI) is a known complication of intradetrusor onabotulinumtoxinA (BTX) injection. However, whether administering intradetrusor BTX in different clinical settings affects the risk of postprocedural UTI has not been investigated. OBJECTIVES: The objective of this study was to assess differences in the incidence of postprocedural UTI in women who received intradetrusor BTX in an outpatient office versus an operating room (OR). STUDY DESIGN: We performed a retrospective chart review of intradetrusor BTX procedures at a single institution between 2013 and 2020. Demographic data, comorbidities, and perioperative data were abstracted. The primary outcome was UTI defined as initiation of antibiotics within 30 days following BTX administration based on clinician assessment of symptoms and/or urine culture results. Univariate analysis of patients with and without UTI was performed. RESULTS: A total of 446 intradetrusor BTX procedures performed on female patients either in an outpatient office (n = 160 [35.9%]) or in an OR (n = 286 [64.1%]) were included in the analysis. Within 30 days of BTX administration, UTI was diagnosed after 14 BTX procedures (8.8%) in the office group and 29 BTX procedures (10.1%) in the OR group ( P = 0.633). De novo postprocedural urinary retention occurred in more women who were treated in the office than in the OR (13 [9.6%] vs 3 [1.3%], P < 0.001). CONCLUSIONS: Selecting the appropriate setting for BTX administration is dependent on multiple factors. However, the clinical setting in which intradetrusor BTX is administered may not be an important factor in the development of postprocedural UTI, and further research is warranted.

Should an anti-incontinence procedure be routinely performed at the time of pelvic organ prolapse repair? An evidence-based review.

The concept of prophylactic anti-incontinence surgery for women undergoing prolapse repair has been a popular and controversial debate in recent years. This article provides an evidence-based review of the current literature to determine the proper evaluation of the patient with prolapse, the predictive quality of preoperative urodynamics, and the selection of the appropriate anti-incontinence procedure. Based on this review, the midurethral sling predominates as the procedure of choice; however, there is poor evidence to suggest that routine usage of a prophylactic sling is warranted in treatment of the patient with pelvic organ prolapse.

Evaluating and managing urinary incontinence after prostatectomy: beyond pads and diapers.

Men who become persistently incontinent after undergoing prostatectomy have a variety of options for regaining control, ranging from behavioral changes to surgery. To determine the best therapy, one should define the problem with a thorough urologic evaluation.

Understanding the Economic Impact of Neurogenic Lower Urinary Tract Dysfunction.

Neurogenic bladder is a chronic and disabling condition associated with multiple comorbidities and a widespread economic impact. Literature on cost of care and resource utilization is sparse and heterogeneous. Nonstandardized approaches, impact perspectives, and types of costs are used to describe the economic implications of neurogenic bladder. The financial toll is difficult to ascertain due to indirect and intangible costs exacerbated by the underlying disability. Health resource utilization based on clinical manifestations of neurogenic bladder may serve as an alternative measure. Understanding the multifold economic implications and health resource utilization patterns of neurogenic bladder may guide improvement of treatment strategies.

Unusual presentation of an obstetrical urethrovaginal fistula secondary to improper catheter placement.

Vesicovaginal and urethrovaginal fistulas related to obstetrical causes are exceptionally rare in the developed world. We report a case of 23-year-old woman with a urethrovaginal fistula, which developed after a cesarean delivery because of an inappropriately placed urethral catheter. Diagnostic evaluation and surgical approach are discussed.

Evaluation and management of refractory overactive bladder.

The refractory overactive bladder patient is a complex new entity for the urologic community. We present the most current review of this difficult subject matter with an emphasis on evaluation and new treatment options such as sacral neuromodulation and botulinum toxin injection. It is hoped that in this new era of medical innovation, extirpation and reconstruction of the bladder will become historic in nature and refractory therapy can be transitioned to the office and outpatient operation rooms.

Salvage of sildenafil failures referred from primary care physicians.

PURPOSE: Sildenafil citrate is an effective first line agent for most causes of erectile dysfunction. Primary care providers (PCPs) write the majority of these prescriptions and most failures of sildenafil therapy are subsequently referred to urologists for alternative therapies. Often it is concluded that the drug is ineffective when in actuality the failure is do to inadequate patient education. We examined patients referred from PCPs who were nonresponders to sildenafil therapy and attempted to convert them to responders through reeducation. MATERIALS AND METHODS: In a 2-year period 253 sildenafil nonresponders were evaluated by the same urologist (GNS). Patient reeducation consisted of viewing a brief videotape, personal instruction and detailed instruction sheets for the patient and his partner. Outcome measures were obtained through patient self-reporting of the Sexual Health Inventory for Men and a global assessment question. Responders were identified as those who answered positively latter or had a statistical improvement in the score of the former. RESULTS: Of the 253 patients reeducated 17 were excluded due to contraindications. Of the remaining nonresponders 41.5% achieved salvage with reeducation. Incorrect administration accounted for 81% of the failures. Average time with the physician was 12 minutes and 94% of the patients continued to respond at 26 months. CONCLUSIONS: Approximately 40% of patients with sildenafil failures referred from PCPs can be converted to responders through reeducation. Incorrect drug administration was the most common reason for correctable failure. Reeducation can be done in an efficient manner. New package materials may improve sildenafil outcomes and compliance.