Do patients experience decisional regret after sacral neuromodulation for refractory overactive bladder?

OBJECTIVE: Success following urological procedures is traditionally defined through objective endpoints. This approach may not capture the impact on patient satisfaction. There is a paucity of literature evaluating patient-centered metrics such as satisfaction and decisional regret in the field of urology. This study investigates long-term satisfaction and decisional regret amongst patients who underwent sacral neuromodulation (SNM) for the treatment of refractory overactive bladder (OAB). MATERIALS AND METHODS: This study retrospectively reviewed patients who underwent SNM for refractory OAB from 2015 to 2022 at a single institution serving an ethnically diverse and underrepresented community. Demographic data were collected through chart review and surveys conducted via telephone calls. Patient satisfaction and decisional regret was measured with the validated modified SDS-DRS scale (satisfaction with decision scale-decision regret scale). Descriptive statistics, Wilcoxan rank sum, and median regression analyses were performed using STATA 15.0 with p < 0.05 as significant. RESULTS: Out of 191 patients who underwent SNM, 63 were unreachable (wrong number in chart, number not in service, patient did not answer, deceased). Eighty-nine out of 128 patients reached agreed to participate (70% response rate). The mean time since surgery was 37.3 ±25.2 months. The median satisfaction with decision score was 4.0 (IQR: 3.7-4.7) with a score of 1 correlating with low satisfaction and a score of 5 correlating with high satisfaction. The median decisional regret score was 2.0 (IQR: 1.2-2.9) with a score of 1 correlating with low decisional regret and a score of 5 correlating with strong decisional regret. Ten patients reported complications after surgery, which was significantly associated with lower SDS and higher DRS scores (p < 0.01), and persisted after adjusting for age, body mass index, sex, and comorbidities (SDS ß coef: -0.84, 95% CI: -1.5 to 0.15, p = 0.02; DRS ß coef: 1.48, 95% CI: 0.55-2.41, p < 0.01). CONCLUSIONS: Patients who underwent SNM for refractory OAB overall had low regret and high satisfaction with their decision at an average 3 years of follow-up. As expected, those who developed postoperative complications had worse scores. The inclusion of patient-centric outcomes is imperative when determining the success of a surgical procedure and is useful for shared decision-making when advancing to third-line therapy for OAB. Longer-term follow-up is necessary to assess durability of high satisfaction and low regret over time.

Food Insecurity Is Associated With Urge Urinary Incontinence: An Analysis of the 2005-2010 National Health and Nutrition Examination Survey.

PURPOSE: Urge urinary incontinence is the involuntary leakage of urine associated with a sudden compelling urge to void. A previous study found an association between urge urinary incontinence and household income, indicating that social determinants of health may influence urge urinary incontinence. Food insecurity is a relevant social determinant of health, as a diet with bladder irritants may worsen urge urinary incontinence symptoms. This study aimed to investigate the association between urge urinary incontinence and food insecurity. MATERIALS AND METHODS: We collected data from the 2005-2010 cycles of the National Health and Nutrition Examination Survey, a nationally representative health survey administered by the Centers for Disease Control and Prevention. The association between urge urinary incontinence and food insecurity was analyzed using survey-weighed logistic regression with adjustments for demographic, socioeconomic status, behavioral, and medical comorbidities covariates. RESULTS: We included 14,847 participants with mean age 50.4±17.9 years; 22.4% of participants reported at least 1 episode of urge urinary incontinence. We found that participants who reported food insecurity had 55% greater odds of experiencing urge urinary incontinence compared to those who have not (OR=1.55, 95% CI=1.33-1.82, P < .001). When comparing diets, food-insecure participants reported significantly less intake of bladder irritants (caffeine and alcohol) compared to food-secure participants. When the sample was stratified by food insecurity status (yes vs no), consumption of caffeine did not differ by urge urinary incontinence status and consumption of alcohol was lower among participants with vs without urge urinary incontinence. CONCLUSIONS: Adults reporting food insecurity in the past year are significantly more likely to experience urge urinary incontinence than those who did not. Consumption of bladder irritants including caffeine and alcohol was significantly less in food-insecure compared to food-secure participants. When the sample was stratified by food insecurity status (yes vs no), consumption of caffeine did not differ by urge urinary incontinence status and consumption of alcohol was lower among participants with vs without urge urinary incontinence. These data indicate that diet alone does not drive the association between urge urinary incontinence and food insecurity. Instead, food insecurity may be a proxy for social inequity, perhaps the greatest driver of disease.

The relationship between fecal incontinence and food insecurity in United States women: an analysis of 2005-2010 National Health and Nutrition Examination Survey.

BACKGROUND: Fecal incontinence is a prevalent debilitating pelvic floor disorder characterized by the involuntary loss of stool. Fecal incontinence is known to be associated with constipation and loose stool, advancing age, chronic comorbidities, and previous anorectal trauma, among other biologic risk factors. The relationship between social determinants of health, such as food insecurity, and fecal incontinence is not well elucidated. OBJECTIVE: This study aimed to investigate the association between fecal incontinence and food insecurity using a nationally representative sample of US adult women. Our secondary aim was to examine the role of diet by assessing dietary differences between participants with and without fecal incontinence and between food-insecure women with and without fecal incontinence. STUDY DESIGN: This study analyzed data from the National Health and Nutrition Examination Survey, a nationally representative series of cross-sectional health surveys. Fecal incontinence was defined as accidental leakage of stool within the last 30 days. Food insecurity was assessed using the household food security measure created by the US Department of Agriculture. Dietary data from the National Health and Nutrition Examination Survey dietary interviews titled "Individual Foods, First Day" and "Individual Foods, Second Day," which estimate the foods and drinks consumed in the preceding 24 hours, were pooled. The association between fecal incontinence and food insecurity was analyzed using logistic regression after controlling for patient characteristics. RESULTS: Overall, 3216 women were included, representing nearly 130 million US women. Of these women, 10.9% had fecal incontinence. There was no significant difference in diet between women with and without fecal incontinence (p>0.05). Food-insecure women in the overall sample reported higher carbohydrate and sugar intake and lower fiber and alcohol intake (all P<.05). Among food-insecure women, those with fecal incontinence had higher calorie and total fats intake than those without fecal incontinence; there was no significant difference in other dietary components (p>0.05). There was a significant association between food insecurity and fecal incontinence, such that women with food insecurity had higher odds of fecal incontinence after adjusting for patient characteristics and diet (odds ratio, 1.76; 95% confidence interval, 1.17-2.66; P=.008). CONCLUSION: Food insecurity was associated with fecal incontinence even after accounting for diet. Understanding the role of social determinants of health in fecal incontinence symptomatology and treatment is important to potentially alleviate symptom burden and improve the quality of life in at-risk populations.

Association between respiratory disease and stress urinary incontinence: An analysis of the 2015-2020 National Health and Nutrition Examination Survey.

INTRODUCTION: There is a logical association between chronic obstructive pulmonary disease (COPD) or asthma with stress urinary incontinence (SUI), given the propensity for coughing which increases intra-abdominal pressure. However, there are few studies examining the association between COPD or asthma and specifically SUI. We aimed to utilize the National Health and Nutrition Examination Survey (NHANES) data from 2015 to 2020 to measure the association between respiratory diseases like COPD and asthma with SUI. METHODS: Data was collected from NHANES, a database representative of the United States population. Participants were included if they were female, older than 20 years, and completed the incontinence survey question. Self-reported history of asthma and COPD diagnosis from a physician, as well as history of incontinence associated with activities such as coughing, lifting, or exercise, were collected. Characteristics of participants were compared using χ2 and Student t-tests. Multivariable logistic regression was performed using a multimodel approach to adjust for sociodemographic and health-related covariates. RESULTS: A total of 9059 women were included in this study. 42.13% reported an episode of SUI in the past year, 6.29% had a COPD diagnosis, and 11.86% had an asthma diagnosis. In the unadjusted analysis, participants with COPD were more likely to report SUI (odds ratio [OR] 3.42, 95% confidence interval [CI] 2.13-5.49, p < 0.001); this association persisted on multivariable analysis (OR 2.87, 95% CI 1.46-5.60, p = 0.003). There was no significant association between asthma and SUI in the unadjusted (OR 1.15, 95% CI 0.96-1.38, p = 0.14) or adjusted model (OR 1.18, 95% CI 0.86-1.60, p = 0.30). CONCLUSION: Although a strong association between COPD and SUI was observed, an analogous one was not found between asthma and SUI. Chronic cough may be more difficult to control with treatment or more common in those with COPD than asthma, explaining this difference. Future research should continue to explore drivers for SUI in large populations to dispel or affirm historically assumed SUI risk factors.

Female Sexual Dysfunction as Measured by Low Sexual Frequency is Associated With Lower Socioeconomic Status: An Analysis of the National Health and Nutrition Examination Survey (NHANES), 2007-2016.

BACKGROUND: Female sexual dysfunction (FSD) is a complex disorder of biopsychosocial etiology, and FSD symptoms affect more than 40% of adult women worldwide. AIM: In this cross-sectional study, we sought to investigate the association between FSD and socioeconomic status (SES) in a nationally representative female adult population. METHODS: Economic and sexual data for women aged 20-59 from the 2007-2016 National Health and Nutrition Examination Survey, a United States nationwide representative database, was analyzed. Poverty income ratio (PIR), a ratio of family income to poverty threshold, was used as a measure of SES, and low sexual frequency was used as a measure of FSD. The association between FSD and SES was analyzed using survey-weighted logistic regression after adjusting for relevant social and gynecologic covariates, such as marital status and history of pregnancy, as well as significant medical comorbidities. OUTCOMES: We found that FSD, as measured by low sexual frequency, was associated with lower SES. RESULTS: Among the 7,348 women of mean age 38.4 (IQR 29-47) included in the final analysis, 26.3% of participants reported sexual frequency of 0-11 times/year and 73.7% participants reported sexual frequency >11 times/year. Participants of PIR <2 were 92% more likely to report sexual frequency ≤11 times/year than those of PIR ≥2 after adjusting for demographics, social history, gynecologic history and significant medical conditions (OR = 1.92; 95% CI = 1.21-3.05; P < .006). CLINICAL IMPLICATIONS: The evaluation and treatment of FSD may benefit from a comprehensive approach that takes SES into account. STRENGTHS & LIMITATIONS: This study is limited by its cross-sectional design, but it is strengthened by a large, nationally representative sample with extensive, standardized data ascertainment. CONCLUSION: Lower SES and lower sexual frequency are directly correlated among female adults in the United States; future studies should focus on social determinants of health as risk factors for FSD. Kim JI, Zhu D, Davila J, et al. Female Sexual Dysfunction as Measured by Low Sexual Frequency is Associated With Lower Socioeconomic Status: An Analysis of the National Health and Nutrition Examination Survey (NHANES), 2007-2016. J Sex Med 2022;19:90-97.

Health disparities and access to advanced therapy for overactive bladder.

AIMS: Refractory overactive bladder (OAB) is among the most common reasons for referral to specialists in voiding dysfunction. Significant racial and ethnic disparities exist in prevalence, severity, and management of OAB, presenting care barriers for marginalized patients. We aim to explicate these disparities and explore the factors that led to their existence and persistence. We will additionally offer suggestions to mitigate such disparities and approach equitable care for our patients. METHODS: This is a narrative review of pertinent articles related to health disparities in OAB. Articles on OAB prevalence stratified by race and ethnicity, and variations in treatment patterns for patients of marginalized backgrounds were identified from the PubMed database. We also included a review of evidence from governmental and historical sources to provide sociocultural context. RESULTS: Patients from marginalized backgrounds are underrepresented in OAB literature. There appear to be differences in symptom severity and prevalence based on race. OAB severity seems closely entwined with social determinants of health. Patients from marginalized populations experience numerous care barriers impeding the treatment of OAB. Finally, White patients are more likely to receive advanced management for OAB. CONCLUSIONS: Numerous health disparities exist in the diagnosis and management of OAB. This review is grounded in societal context: health injustice in the United States ultimately stems from systemic racism. Improving our understanding of care disparities and the systems that allow them to persist will bring us closer to equity and allow our patients from marginalized backgrounds to obtain the evidence-based care they deserve.

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.

The Effect of Social Determinants of Health on Overactive Bladder Symptom Severity.

PURPOSE: Social determinants of health may significantly impact overall health and drive health disparities. We evaluated the association between social determinants of health and overactive bladder severity. MATERIALS AND METHODS: We conducted a multicenter, cross-sectional study of patients presenting to outpatient female pelvic medicine and reconstructive surgery clinics at Montefiore Medical Center (Bronx, New York) and Johns Hopkins Bayview Medical Center (Baltimore, Maryland) from November 2018 to November 2019. Surveys were administered to screen for overactive bladder (Overactive Bladder-Validated 8-Question Screener) and to evaluate social determinants of health. Ordinal logistic regression models were used to examine the association between overactive bladder symptom level and social determinants of health items, while adjusting for age, race, body mass index, parity, history of pelvic surgery and clinical site. RESULTS: A total of 256 patients with a mean±SD age of 58.6±14.2 years and body mass index of 30.4±7.5 kg/m2 were recruited over a 12-month period. Our sample was 33.6% White, 32% Black and 29.3% Hispanic, with 5.1% categorized as other. A higher overactive bladder symptom level was associated with food insecurity (OR 2.51, 95% CI 1.03-6.11), financial strain (OR 1.94, 95% CI 1.06-3.53), difficulty finding or keeping employment (OR 3.14, 95% CI 1.01-9.72) and difficulty concentrating (OR 2.48, 95% CI 1.25-4.95), after adjusting for site, age, race, body mass index, parity and previous pelvic surgery. CONCLUSIONS: In this cross-sectional study, certain social determinants of health were associated with greater overactive bladder severity. Unmet social needs may impact the success of overactive bladder treatment. Urologists should consider collaborating with social work and mental health specialists to better serve patients with overactive bladder and social determinants of health needs.

Patient satisfaction and savings, and clinical outcomes of televisits in female pelvic medicine and reconstructive surgery at an urban academic center.

AIM: To evaluate patient satisfaction and savings, and compare visit outcomes based on chief complaint (CC) of women presenting for a televisit to a female pelvic medicine and reconstructive surgery (FPMRS) clinic at an urban academic center. METHODS: A cross-sectional study of women completing a televisit with an FPMRS specialist at our institution from June 19, 2020 to July 17, 2020 was conducted. A telephone questionnaire was administered to patients to assess satisfaction and savings (travel costs/time avoided). Electronic medical records were reviewed to collect patient demographics and comorbidities, CC, and televisit outcomes (e.g., face-to-face (F2F) exam scheduled, orders placed). Logistic regression was used to analyze predictors of satisfaction and need for F2F follow-up. RESULTS: One hundred eighty-seven of 290 (64.5%) women called completed the survey, of whom 168 (89.8%) were satisfied with their televisit. Eighty-eight (48.1%) saved at least an hour and 54 (28.9%) saved more than $25 on transportation. There were no significant associations between patient characteristics, CC, or televisit outcomes and satisfaction. Ninety-nine (52.9%) televisits resulted in F2F follow-up, with CC of prolapse (odds ratio [OR] = 4.2 (1.7-10.3); p = 0.002), new patient (OR = 2.2 (1.2-4.2); p = 0.01), and Hispanic ethnicity (OR = 3.9 (1.2-13.6); p=.03) as significant predictors. CONCLUSION: Most patients were satisfied with FPMRS televisits at our urban academic center. Televisits resulted in patient travel time and cost savings. Women presenting with prolapse and for new patient visits would likely benefit from initial F2F visits instead of televisits. Televisits are an important mode of health care and in some cases can replace F2F visits.

Associations between Socioeconomic Status and Urge Urinary Incontinence: An Analysis of NHANES 2005 to 2016.

PURPOSE: Urge urinary incontinence significantly impacts quality of life. We investigated the association between urge urinary incontinence and socioeconomic status in a nationally representative adult population. MATERIALS AND METHODS: We analyzed the 2005 to 2016 NHANES (National Health and Nutrition Examination Survey), a United States population based, cross-sectional study. Urge urinary incontinence was determined by self-report of leaking urine before reaching the toilet. Socioeconomic status was represented by the poverty income ratio, which reflects the family income relative to poverty thresholds specific to that year and household size. Survey weighted logistic regression models were used to analyze the relationship between socioeconomic status and the poverty income ratio. Multiplicative terms were applied to test for interaction in prespecified subgroups of interest. RESULTS: A total of 25,553 participants were included in the final analysis, representing 180 million people in the United States. Of the participants 19.4% reported any urge urinary incontinence, 4.2% reported weekly urge urinary incontinence and 1.6% reported daily urge urinary incontinence. In the fully adjusted multivariable models those with a poverty income ratio less than 2.00 showed significantly higher odds of any urge urinary incontinence compared to the group with a poverty income ratio of 2.00 or greater (OR 1.17, 95% CI 1.05-1.30, p=0.003). There was increasing strength of association for weekly and daily urge urinary incontinence (OR 1.31, 95% CI 1.12-1.55, p <0.001, and OR 1.60, 95% CI 1.23-2.09, p=0.001, respectively). Individual interaction analyses revealed no significant effect of female gender, age greater than 50 years, body mass index 30 kg/m2 or greater, or less than a high school education on the association of urge urinary incontinence with the poverty income ratio. CONCLUSIONS: This study revealed a significant association between urge urinary incontinence and socioeconomic status after meaningful adjustment for covariates. Health care interventions targeting low socioeconomic status individuals with urge urinary incontinence are needed to address this disparity.

Strategies to Encourage Medical Student Interest in Urology.

PURPOSE OF REVIEW: Urology residency positions have steadily increased but applications have remained stagnant. This is an alarming trend given the aging general population and thus increased need for urologists. The purpose of this review is to describe barriers and suggest strategies to encourage medical students to pursue urology. RECENT FINDINGS: Barriers to interest in urology include educational factors, such as timing of exposure to urology in medical school, USMLE scores, research experience, and deciding in time for an early match, as well as socioeconomic barriers, such as cost, being underrepresented in medicine, and gender. Steps the urological community can take include increasing involvement in medical school curricula, increasing faculty mentor availability, and broadening students' range of urological experiences. Strategies to encourage interest in urology fall into three categories: creating interest, supporting interest, and removing barriers for students considering urology. Ultimately, the goal is to garner excellent residents in a field that must expand to meet the needs of a growing and aging population.

Urodynamics less likely to change diagnosis and management in uncomplicated overactive bladder.

INTRODUCTION: Given the invasive nature of urodynamics and its unclear impact on altering patient management, we aimed to determine whether performing a urodynamic study (UDS) resulted in a change in either patient diagnosis or treatment offered in women with uncomplicated urinary incontinence. MATERIALS AND METHODS: A retrospective review was performed of all female patients who underwent UDS for urinary incontinence at our practice between January 2014 and 2017. Patients with neurogenic lower urinary tract dysfunction, incomplete emptying, urinary retention, or prior anti-incontinence surgery were excluded. We compared the ICD-10 diagnosis and primary treatment offered in the absence of UDS to their post-UDS diagnosis and recommended therapy. Descriptive statistics, chi-squared, and multivariable analyses were performed. RESULTS: A total of 141 patient charts were analyzed. The indications for UDS were mixed urinary incontinence (MUI) (45.3%), stress urinary incontinence (SUI) (29.1%), and overactive bladder (OAB) (25.5%). A change in diagnosis following UDS was seen in 40.4% of the entire cohort including 53.1% of patients with MUI and 48.8% of those with SUI compared to 8.3% of those with OAB. A change in treatment was seen in 32.6% of patients including 54.9% with MUI, 41.7% with SUI, and 10% with OAB. When compared to patients with SUI on adjusted multivariate logistic regression, those with OAB were less likely to have a change in either diagnosis (OR 0.06 (0.01-0.31)) or management (OR 0.15 (0.04-0.62)). CONCLUSIONS: Diagnosis and management are unlikely to change after UDS in patients presenting with uncomplicated OAB. Conversely, UDS provided important diagnostic information that often changed management in those presenting with MUI and SUI. Our results suggest that UDS may be omitted in patients with uncomplicated refractory OAB in favor of earlier initiation of third line therapies.

Transvaginal repair of Neobladder Vaginal Fistula with Martius Flap.

Introduction: Neobladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women, occurring in 3-5% of women. Possible risk factors for fistula formation include compromised tissue vascularity due to surgical dissection and/or radiotherapy, suture line proximity, local tissue recurrence, and injury to the vaginal wall during dissection. The surgical repair of a NVF can be challenging secondary to vaginal shortening, atrophy, local inflammation from chronic exposure to urinary leakage, and the proximity of the neobladder to the anterior vaginal wall. In this video, we present transvaginal repair of a NVF with Martius flap interposition. Materials and Methods: This is the case of a 47 year old woman with a history of radical cystectomy and creation of a Studer pouch secondary to bladder cancer two years prior who subsequently developed a NVF. Evaluation included an office cystoscopy which demonstrated a 3-4mm left-sided neobladder vaginal fistula at the level of the ileal-urethral anastomosis. No pelvic organ prolapse or evidence of bladder cancer recurrence was appreciated. Results: A vaginal approach for the NVF repair was performed with a Martius flap interposition. A water-tight closure was achieved without any intraoperative or immediate postoperative complications. The urethral Foley was removed at 2 weeks and by 4 weeks the patient did not report any urinary leakage. Conclusions: Neobladder vaginal fistula is a rare complication following cystectomy and orthotopic urinary diversion that can be repaired using a transvaginal approach. A Martius flap interposition is important to augment success of the repair. If a transvaginal approach fails a transabdominal approach or conversion to cutaneous diversion may be necessary.

Prevalence, risk factors, and treatment for women with stress urinary incontinence in a racially and ethnically diverse population.

AIMS: Black women may have lower rates of SUI than Whites, whereas the rate of SUI in Hispanic women varies. Most studies have been conducted in predominantly White populations, making it difficult to evaluate race and SUI. The objective of this study was to estimate the prevalence of SUI in a diverse population and examine racial/ethnic differences in risk factors and treatment. METHODS: This is a retrospective cohort study of women ≥21 years with SUI seen at our medical center from June 1, 2013 to June 30, 2016. Risk factors measured included age, BMI, SES, diabetes, smoking, Charlson comorbidity index, hysterectomy, and pregnancy. SUI management included consultation with a specialist and active treatment (physical therapy, pessary use, or incontinence surgery). ANOVA, chi-square, and multivariable logistic regression were used to evaluate race and SUI. RESULTS: The prevalence rate was 4.65 per 100 women (5557 cases/119 452 women). Hispanics comprised the majority (54.13% n = 3008), followed by Blacks (23.54% n = 1308), Other (12.74% n = 708), and Whites (9.59% n = 532). Black women were less likely to consult with a specialist or undergo treatment compared to White and Hispanic women, which persisted in multivariable analysis. Women classified as other were more likely to undergo active treatment in the logistic regression model. CONCLUSION: SUI prevalence was highest in Hispanics, despite risk factors being more common in Black women. Black women were less likely to consult with a specialist. Mixed or unknown race/ethnicity women were more likely to undergo active treatment. Future studies will evaluate if racial/ethnic differences in SUI management are due to patient preference or provider practices.

Opioid prescribing practices and medication use following urogynecological surgery.

BACKGROUND: Opioid abuse is a growing epidemic in the United States, with opioid overdose becoming a leading cause of death. There is wide variation in prescription practices for post-operative opioids due to absence of guidelines. The purpose of this study is to examine postoperative opioid prescribing patterns after urogynecologic surgery and determine usage and management of opioid pills by patients. MATERIALS AND METHODS: This is an observational, prospective study of female patients (N = 143) who underwent urogynecologic (prolapse or incontinence) surgery from June to December 2017 at a single academic center. Patients were surveyed regarding their pain medication use 30 days postoperatively. Survey questions included preoperative pain medication use, quantity of opioid pills consumed, need for additional opioid prescription, and management of remaining pills. T-test and one-way Anova were used for comparison of continuous variables and chi-squared test used for comparison of categorical variables. RESULTS: Of 143 eligible patients, 99 (69%) responded; 62% of respondent patients underwent vaginal surgery, 22% abdominal surgery with or without vaginal surgery, and 15% underwent other procedures. Postoperatively, 81.8% of patients were prescribed opioids. The average number of tablets prescribed ranged from 12.4 to 17.4 depending on the procedure. 54.3% of patients reported using less than half of their prescribed opioid prescription. Of the patients who had excess opioid tablets, only 8.6% reported discarding their opioids. CONCLUSION: To date, no guidelines exist on prescribing opioids postoperatively. Opioids are overprescribed post-operatively with over half of patients using less than half of the opioids prescribed to them.

Addressing the challenges of reoperative robotic-assisted sacrocolpopexy.

Sacrocolpopexy is the gold-standard repair for apical pelvic organ prolapse (POP). However, over half of women with POP who undergo the surgery experience recurrence, particularly those with higher preoperative stage, younger age, and greater body weight. We address the challenges of repairing recurrent POP in a patient with a prior transabdominal mesh sacrohysteropexy.

The effect of time to release of an obstructing synthetic mid-urethral sling on repeat surgery for stress urinary incontinence.

AIMS: The primary objectives were to describe the rate of repeat surgery for stress urinary incontinence (SUI) after release of an obstructing synthetic mid-urethral sling (MUS) and to evaluate the effect of time from sling placement to sling release on repeat surgery rates. The secondary objective was to assess rates of recurrent and persistent SUI. METHODS: This is a retrospective review of women who underwent synthetic MUS release (incision or excision of segment of sling) from 2005-2013. SUI rates and repeat surgery were ascertained by patient report and urinary distress inventory (UDI-6) questionnaire responses. Data analysis included descriptive statistics and multivariable logistic regression analysis. RESULTS: 107 patients were included. Median time to sling release was 22 months (IQR 5-49 months). 43.2% were transobturator slings. 15/107 patients (14%) underwent repeat surgery for SUI. On multivariable analysis, women were significantly less likely to undergo repeat surgery for SUI when sling release was performed >24 months after initial sling surgery (OR 0.12, 95% CI 0.02-0.85, P = 0.03) compared to release within 3 months. 49% and 77% reported recurrent and persistent SUI after sling release, of which 83% were significantly bothered. CONCLUSION: The repeat surgery rate for SUI was 14%. The rate of recurrent SUI was 49%. Most of these women were significantly bothered. On multivariate analysis, longer interval to sling release was associated with decreased likelihood of repeat surgery for SUI. The reason for a low repeat surgery rate for SUI despite a high rate of bothersome SUI should be explored in future studies. Neurourol. Urodynam. 36:349-353, 2017. © 2015 Wiley Periodicals, Inc.

Robot-assisted extravesical vesicovaginal fistula repair utilizing laparoscopically mobilized omental flap interposition.

INTRODUCTION AND HYPOTHESIS: High vesicovaginal fistulas (VVF) in the setting of good apical support are best repaired via a transabdominal approach. Laparoscopic VVF repair was first reported in 1998. Several series of robot-assisted VVF repairs have since been published. The robot-assisted approach allows repair of high apical vaginal fistulas while avoiding the morbidity of laparotomy, shortening convalescence, and facilitating the use of omental interposition flaps. This video presents the technique for robot-assisted extravesical VVF repair utilizing a laparoscopically mobilized omental flap. METHODS: A 43-year-old woman developed a VVF after a total abdominal hysterectomy for fibroids. Pre-operative CT urogram and office cystoscopy confirmed the diagnosis and ruled out ureteral involvement. She underwent a robot-assisted extravesical VVF repair utilizing a laparoscopically mobilized omental flap. RESULTS: The surgery was uncomplicated, and the patient was discharged on post-operative day 1. A cystogram 2 weeks post-operatively revealed no evidence of a fistula. At 3 months follow-up, the patient denied any urinary incontinence. CONCLUSIONS: Robot-assisted extravesical VVF repair avoids the morbidity of a laparotomy, provides excellent exposure, and avoids a large cystotomy. It maintains vaginal length and allows for significantly better visualization compared with the transvaginal approach. This repair offers improved outcomes for certain patients depending on their history, anatomy, and the surgeon's experience.

Urgency Incontinence before and after Revision of a Synthetic Mid Urethral Sling.

PURPOSE: We evaluate urgency urinary incontinence outcomes for patients who underwent revision of a presumed obstructing synthetic mid urethral sling and examine risk factors for persistent or de novo symptoms after surgery. MATERIALS AND METHODS: From February 1, 2005 to June 1, 2013, 107 women underwent sling revision for new or worsening lower urinary tract symptoms after synthetic mid urethral sling surgery. Patients were grouped based on urgency urinary incontinence symptoms and characteristics associated with persistent or de novo symptoms after revision were examined using logistic regression models. RESULTS: Median followup was 29 months (IQR 12-54) and time to revision was 21 months (IQR 5-48). Patients presenting for sling revision with urgency incontinence (68) were more likely to experience a more than 6-month delay to revision vs those presenting with obstructive voiding symptoms (39) (OR 3.25, 95% CI 1.33-7.92, p <0.01). After revision urgency incontinence persisted in 76.5% (52 of 68) and was associated with a pre-revision need for anticholinergic medication (OR 5.58, 95% CI 1.44-21.39, p=0.01) and smoking (OR 5.21, 95% CI 1.21-22.49, p=0.03). De novo urgency incontinence developed in 43.6% (17 of 39) of patients and was associated with de novo stress incontinence (OR 15.9, 95% CI 3.2-78.3, p <0.01). Women with post-revision urgency incontinence (de novo or persistent) had higher Urogenital Distress Inventory-6 scores than patients with no or resolution of urgency incontinence. CONCLUSIONS: Patients presenting with new or worsening urgency urinary incontinence after sling placement were more likely to undergo delayed revision compared to those presenting with obstructive voiding symptoms. There is a high rate of bothersome persistent and de novo urgency incontinence after sling revision. Patient expectations should be managed accordingly before sling revision.