Bacterial Cultures at the Time of Artificial Urinary Sphincter Revision Surgery in Clinically Uninfected Devices: A Contemporary Series.

PURPOSE: We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies. MATERIALS AND METHODS: We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization. RESULTS: Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%. CONCLUSIONS: Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.

H2 Activation by Non-Transition-Metal Systems: Hydrogenation of Aldimines and Ketimines with LiN(SiMe3 )2.

In recent years, H2 activation at non-transition-metal centers has met with increasing attention. Here, a system in which H2 is activated and transferred to aldimines and ketimines using substoichiometric amounts of lithium bis(trimethylsilyl)amide is reported. Notably, the reaction tolerates the presence of acidic protons in the α-position. Mechanistic investigations indicated that the reaction proceeds via a lithium hydride intermediate as the actual reductant.

AMS-800 Artificial urinary sphincter in female patients with stress urinary incontinence: A systematic review.

AIMS: To perform a systematic review of studies reporting the outcomes of AMS-800 artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency (ISD). METHODS: A systematic literature search of the Medline and Embase databases was performed in June 2018 in accordance with the PRISMA statement. No time limit was used. The protocol was registered in PROSPERO (CRD42018099612). Study selection and data extraction were performed by two independent reviewers. RESULTS: Of 886 records screened, 17 were included. All were retrospective or prospective non-comparative case series. One study reported on vaginal AUS implantation, 11 on open AUS implantation, two on laparoscopic AUS implantation, two on robot-assisted AUS implantation and one compared open and robot-assisted implantations. The vast majority of patients had undergone at least one anti-incontinence surgical procedure prior to AUS implantation (69.1-100%). The intraoperative bladder neck injury rates ranged from 0% to 43.8% and the intraoperative vaginal injury rates ranged from 0 to 25%. After mean follow-up periods ranging from 5 to 204 months, the complete continence rates ranged from 61.1% to 100%. The rates of explantation, erosion and mechanical failure varied from 0% to 45.3%, 0% to 22.2% and 0% to 44.1%, respectively. CONCLUSIONS: AMS-800 AUS can provide excellent functional outcomes in female patients with SUI resulting from ISD but at the cost of a relatively high morbidity. High level of evidence studies are needed to help better define the role of AUS in the female SUI armamentarium.

Meroterpenoid Synthesis via Sequential Polyketide Aromatization and Cationic Polyene Cyclization: Total Syntheses of (+)-Hongoquercin A and B and Related Meroterpenoids.

(+)-Hongoquercin A and B were synthesized from commercially available trans, trans-farnesol in six and eleven steps, respectively, using dual biomimetic strategies with polyketide aromatization and subsequent polyene functionalization from a common farnesyl-resorcylate intermediate. Key steps involve Pd(0)-catalyzed decarboxylative allylic rearrangement of a dioxinone ß,δ-diketo ester to a ß,δ-diketo dioxinone, which was readily aromatized into the corresponding resorcylate, and subsequent polyene cyclization via enantioselective protonation or regioselective terminal alkene oxidation and cationic cyclization of enantiomerically enriched epoxide to furnish the tetracyclic natural product cores. Analogues of the hongoquercin were synthesized via halonium-induced polyene cyclizations, and the meroterpenoid could be further functionalized via saponification, hydrolytic decarboxylation, reduction, and amidation reactions.

Can time to failure predict the faulty component in artificial urinary sphincter device malfunctions?

OBJECTIVE: Artificial urinary sphincter malfunctions can occur in any of the individual components. Preoperative identification of the malfunctioning component can be valuable for patient counseling and surgical planning. The optimal strategy for repair of failed artificial urinary sphincter components is debated given the relative rarity of the situation. The aim of the present study was to evaluate the relationship of time to failure with failed artificial urinary sphincter component and to compare our outcomes of specific component versus complete device replacement. METHODS: From 1983 to 2011, 1805 artificial urinary sphincter procedures were carried out at Mayo Clinic (Rochester, Minnesota, USA), of which 1072 patients underwent primary artificial urinary sphincter placement. Clinical variables, including time to failure, were evaluated for association with component failure. Bootstrap analysis was used to estimate the differences in time to reach a fixed percentage of component failure. RESULTS: A total of 115 patients experienced device failure at a median follow up of 4.2 years. Urethral cuff, abdominal reservoir, scrotal pump and tubing malfunction occurred in 53 (4.9%), 26 (2.4%), 11 (1%) and 25 (2.3%) patients, respectively. Increasing age at the time of primary surgery was protective of cuff malfunction (hazard ratio 0.97, P = 0.04). Time to 3% urethral cuff failure outpaced other component failures (P < 0.05). Secondary failure-free rates after whole device versus specific component revisions were comparable (P = 0.38). CONCLUSIONS: Clinical predictors for artificial urinary sphincter failure continue to be difficult to establish. Although single component versus entire device replacement have similar outcomes, if pursuing single component revision, we recommend cuff-first interrogation in devices in place for >3 years, as this represents the most likely component to fail.

Artificial urinary sphincter revision for urethral atrophy: Comparing single cuff downsizing and tandem cuff placement.

OBJECTIVE: To compare outcomes for single urethral cuff downsizing versus tandem cuff placement during artificial urinary sphincter (AUS) revision for urethral atrophy. MATERIALS AND METHODS: We identified 1778 AUS surgeries performed at our institution from 1990-2014. Of these, 406 were first AUS revisions, including 69 revisions for urethral atrophy. Multiple clinical and surgical variables were evaluated for potential association with device outcomes following revision, including surgical revision strategy (downsizing a single urethral cuff versus placing tandem urethral cuffs). RESULTS: Of the 69 revision surgeries for urethral atrophy at our institution, 56 (82%) were tandem cuff placements, 12 (18%) were single cuff downsizings and one was relocation of a single cuff. When comparing tandem cuff placements and single cuff downsizings, the cohorts were similar with regard to age (p=0.98), body-mass index (p=0.95), prior pelvic radiation exposure (p=0.73) and length of follow-up (p=0.12). Notably, there was no difference in 3-year overall device survival compared between single cuff and tandem cuff revisions (60% versus 76%, p=0.94). Likewise, no significant difference was identified for tandem cuff placement (ref. single cuff) when evaluating the risk of any tertiary surgery (HR 0.95, 95% CI 0.32-4.12, p=0.94) or urethral erosion/device infection following revision (HR 0.79, 95% CI 0.20-5.22, p=0.77). CONCLUSIONS: There was no significant difference in overall device survival in patients undergoing single cuff downsizing or tandem cuff placement during AUS revision for urethral atrophy.

Artificial urinary sphincter urethral erosions: Temporal patterns, management, and incidence of preventable erosions.

INTRODUCTION: The artificial urinary sphincter (AUS) is the mainstay of surgical treatment for male stress urinary incontinence. Although urethral erosions are a known complication, their temporal distribution and optimal management have not been well characterized. We seek to evaluate the timing, etiologies, and management of urethral erosions in primary AUS implantations. MATERIALS AND METHODS: 1802 male patients underwent AUS procedure at Mayo Clinic (Rochester) from 1983 to 2011, including 1082 primary placements. Of primary placements, 63 had a urethral erosion of their device requiring explanation and were included in our analysis. All cases of urethral erosion were confirmed at the time of explantation through cystoscopy and direct visualization. At our institution, explantation is typically performed without primary urethral repair. RESULTS: There were 63 cases (5.8%) of urethral erosions of primary AUS devices during the study time frame. The median age at AUS implantation was 74 years (interquartile range [IQR] 68-77 years) and median time to explantation was 21 months (IQR 5-59 months). The temporal trend of AUS erosions demonstrates a peak in the 1st year, with a gradual tapering of cases thereafter, persisting beyond 10 years. Three of 36 (8.3%) patients with follow-up developed a urethral stricture. Overall, 32/63 patients (51%) underwent salvage AUS reimplantation at a median of 7.1 months (IQR 3.1-12.9 months). CONCLUSIONS: Urethral erosions tend to occur early (within 1-2 years), with gradual tapering over time. However, continued vigilance is needed after AUS placement to decrease late erosions. These data can be used for counseling and to help guide follow-up care of patients with AUS.

Long-Term Quality of Life and Functional Outcomes among Primary and Secondary Artificial Urinary Sphincter Implantations in Men with Stress Urinary Incontinence.

PURPOSE: There remains a paucity of data regarding subjective and functional outcomes after artificial urinary sphincter implantation. Therefore, we evaluated long-term differences in quality of life after primary and secondary artificial urinary sphincter surgery. MATERIALS AND METHODS: Men were invited to participate in a mail-in survey assessing artificial urinary sphincter status, patient satisfaction and urinary control. Patients with primary (467) and secondary (122) artificial urinary sphincter devices without an event were included in the study. Differences between the cohorts including quality of life (10-point scale, maximum 100) and functional outcomes were evaluated. RESULTS: Overall 229 (49%) patients with primary and 49 (40%) with secondary artificial urinary sphincters completed the survey at a median of 8.3 years. Patients with primary and secondary artificial urinary sphincter devices reported similar artificial urinary sphincter quality of life (score 74 vs 74). There were no significant differences in urinary continence outcomes including use of 1 pad or less daily (56% vs 55%), frequency of leakage 1 time or more per day (81% vs 71%) or degree of minimal leakage related bother (64% vs 55%). At less than 5 vs 10 or more years there was a significant reduction in artificial urinary sphincter quality of life (86 vs 73, p=0.007). Urinary continence also declined with time, including perceived urinary control (85% vs 53%, p=0.004), minimal leakage related bother (76% vs 59%, p=0.05) and use of 1 pad or less daily (67% vs 55%, p=0.07). On univariate analysis no clinical variables, including secondary revision, were associated with satisfaction or continence outcomes. CONCLUSIONS: We noted a high level of artificial urinary sphincter quality of life, acceptable urinary control and no difference in functional outcomes between men undergoing primary or secondary artificial urinary sphincter surgery. However, the time related decline in satisfaction and continence highlights the need for patient counseling regarding long-term artificial urinary sphincter functional outcomes.

The Impact of Prior Radiation Therapy on Artificial Urinary Sphincter Device Survival.

PURPOSE: The literature on artificial urinary sphincter device survival in individuals with a history of radiation therapy is conflicting. We assess device survival outcomes among individuals after prior radiation therapy exposure undergoing primary artificial urinary sphincter placement. MATERIALS AND METHODS: An institutional review board approved database of all patients who underwent artificial urinary sphincter surgery from 1999 to 2011 was used to assess device survival in patients treated with radiotherapy compared to individuals without radiotherapy exposure. Hazard regression and competing risk analysis were used to determine the association between radiation therapy and device outcomes. RESULTS: From 1999 to 2011 a total of 872 patients underwent artificial urinary sphincter surgery at our institution. Of these patients 489 underwent primary artificial urinary sphincter placement, with 181 of 489 (37%) having received radiation therapy. Patients with prior radiation therapy were older (median age 72.0 vs 70.1 years, p <0.01) and had a higher median body mass index (29.4 vs 28.6 kg/m(2), p <0.03) than those without radiation exposure. Rates of diabetes mellitus and hypertension were similar between the 2 groups. There was no significant difference in overall device survival between individuals who received radiation therapy and those without radiation therapy exposure, with 1 and 5-year device survival rates of 92% vs 90% and 77% vs 74%, respectively (p=0.24). CONCLUSIONS: While individuals who underwent radiation therapy were significantly older and had a higher body mass index, device survival was not significantly different between the 2 groups when using a cuff size greater than 3.5 cm. These findings will assist the urologist with the preoperative counseling of men undergoing primary artificial urinary sphincter placement with a history of radiation therapy.

Artificial Urinary Sphincter Mechanical Failures-Is it Better to Replace the Entire Device or Just the Malfunctioning Component?

PURPOSE: We evaluate the characteristics of artificial urinary sphincter mechanical failures and compare outcomes based on the surgical revision strategy, replacing only the failed component or the entire device. MATERIALS AND METHODS: A total of 1,802 male patients with stress urinary incontinence underwent artificial urinary sphincter procedures from 1983 to 2011 at our institution, of which 1,082 were primary placements. Of these patients 125 experienced mechanical device malfunction. Multiple clinical and surgical variables were evaluated for a potential association with device malfunction. In addition, we evaluated for predictors of failure of the revised device, including time from primary artificial urinary sphincter to revision surgery and surgical revision strategy (single component vs entire device), with failure defined as any tertiary surgery. RESULTS: At a median followup of 4.2 years (IQR 0.8, 7.9) 125 patients experienced device malfunction. The urethral cuff was the most common component failure (46.1%), followed by abdominal reservoir (22.6%), tubing (21.7%) and pump (9.6%). There was no association of time from primary surgery to revision for mechanical failure (HR 0.89, p=0.33) or revision strategy (HR 0.47, p=0.15) with the risk of tertiary surgery. Additionally, as there was no significant interaction between these variables (HR 1.11, p=0.39), no cutoff could be identified at which one revision technique produced significantly improved device survival compared to another. However, there was a trend toward improved 3-year device survival after replacement of the entire device vs a single component (76% vs 60%, p=0.11). CONCLUSIONS: No cutoff in time to mechanical failure could be identified to guide decision making in the management of mechanical artificial urinary sphincter failure. Likewise, it is unclear if replacing the entire device, rather than the single malfunctioning component, alters device survival. As such, further studies are needed. However, given the current trend toward improved overall device survival, the limited additional risk and the lack of adequate clinical predictors for tertiary surgery, we would advocate for replacement of the entire device when possible.

Is the Care Transitions Measure Associated with Readmission Risk? Analysis from a Single Academic Center.

BACKGROUND: It is widely hypothesized that improvement in transitions of care will reduce unplanned hospital readmissions. However, the association between the Care Transitions Measure, the national quality metric for transitions of care and readmission risk, has not been established. OBJECTIVE: We aimed to determine the association between the Care Transition Measure and readmission. DESIGN: This was a single-center, prospective cohort study. PARTICIPANTS: Convenience sample of 2,963 patients enrolled in the "Bridging the Divides" program, a longitudinal care management program for patients with coronary revascularization, from 2013 to 2014. Of these, 1594 (54 %) patients completed a post-discharge Care Transition Measure questionnaire. INTERVENTION: Care Transition Measure scores were collected by trained research staff blinded to study hypothesis, by telephone, within 30 days of discharge. Higher Care Transition Measure scores reflect a higher quality transition of care. MAIN MEASURES: 30-day readmission was measured. KEY RESULTS: Of the1594 patients that completed the Care Transition Measure survey, 1216 (76 %) received percutaneous coronary intervention and 378 (24 %) received coronary artery bypass grafting. Mean Care Transition Measure scores were significantly lower among patients who had a prior admission (77.2 vs. 82.1, p < 0.001) and those with ≥ 5 comorbidities (77 vs. 82.6 vs. 81.6, p < 0.001). Mean scores were significantly lower among patients who were readmitted within the percutaneous coronary intervention subgroup (73 vs. 80.9, p < 0.001) and the total study population (74.6 vs. 81.1, p < 0.001) compared to those who were not readmitted. This was not the case in the coronary artery bypass grafting subgroup (78.5 vs. 81.7, p = 0.29). After multivariable adjustment, every ten-point increase in the Care Transition Measure score was associated with a 14 % reduction in readmission risk (adjusted odds ratio 0.86, 95 % CI 0.78-0.95). CONCLUSIONS: The Care Transition Measure is strongly associated with readmissions, which strengthens its validity. However, its association with patient variables linked with readmission and its inconsistent association with readmission across clinical groups raises concerns that scores may be influenced by patient characteristics.

Outcomes of artificial urinary sphincter placement in octogenarians.

OBJECTIVE: To evaluate the impact of patient age on device outcomes among patients undergoing primary artificial urinary sphincter. METHODS: A total of 1081 male patients who underwent primary artificial urinary sphincter placement from 1983 to 2011 were analyzed, including 91 men (8%) who were aged >80 years at the time of surgery. Revisions and explanations were compared between men stratified by decade of life. Hazard ratios adjusting for competing risks were used to determine the association with age and artificial urinary sphincter device outcomes (infection/erosion, urethral atrophy and malfunction), while overall device failure was estimated using Kaplan-Meier and Cox regression analysis. RESULTS: Patients aged >80 years were more likely to have coronary disease (P = 0.009), diabetes mellitus (P = 0.04), hypertension (P = 0.002) and lower body mass index (P < 0.0001). On multivariable analysis, patients aged >80 years were significantly more likely to experience device erosion or infection compared with a reference of patients aged <60 years (hazard ratio 4.13; P = 0.046), whereas there was no difference in those patients aged 60-70 years or 70-80 years compared with the reference group (P = 0.56 and 0.45). There was no significant difference in overall device survival between the age-stratified groups (P = 0.26). CONCLUSIONS: Although overall artificial urinary sphincter device survival is similar, patients aged >80 years are more likely to experience erosion or infection compared with younger patients. Despite this, the overall device failure rate is low, and artificial urinary sphincter might be considered for appropriately selected and counseled octogenarians.

Autologous transobturator urethral sling placement for female stress urinary incontinence.

PURPOSE: We describe and evaluate a transobturator approach to urethral sling placement using autologous rectus fascia for the management of female stress urinary incontinence. MATERIALS AND METHODS: We performed a feasibility study of 10 cases of autologous transobturator mid urethral sling placement for stress urinary incontinence. The procedure includes an anterior vaginal dissection performed in the standard fashion for a mid urethral sling and harvest of a strip of rectus fascia. A trocar is passed through each obturator foramen and the fascial stay sutures are retracted through the skin incisions. The sling is appropriately tensioned and the stay sutures are tied. Patient outcomes were measured by a 24-hour pad weight test and ICIQ-FLUTS score. RESULTS: Median patient age was 57 years (IQR 48, 69.5) and median body mass index was 30.3 kg/m(2) (IQR 25.2, 32.4). Median followup was 4 months (range 3 to 5). All patients demonstrated a reduction in leakage with 80% being completely dry (0 gm on 24-hour pad test and not wearing pads). Overall there was significant improvement in postoperative vs preoperative 24-hour pad weight (p=0.02). Likewise, all subscores of the ICIQ-FLUTS were significantly improved after surgery, including frequency (p=0.006), voiding (p=0.04) and incontinence (p=0.002). Of the 9 eligible cases 6 (67%) were performed on an outpatient basis. One patient performed intermittent self-catheterization for 24 hours after sling placement. No patients experienced severe (Clavien III-V) postoperative complications or required urethrolysis. CONCLUSIONS: Autologous transobturator urethral sling placement appears to be technically feasible with excellent short-term outcomes. Longer followup and larger series are needed for validation.

Perioperative Complications following Artificial Urinary Sphincter Placement.

PURPOSE: We evaluated perioperative complications in patients undergoing primary artificial urinary sphincter placement and the potential impact of these complications on device outcomes. MATERIALS AND METHODS: During the 2-year period from 2012 to 2014 we retrospectively evaluated the outcomes of 197 consecutive artificial urinary sphincter implantation procedures performed at our institution for post-prostatectomy incontinence. Of these cases 100 that were primary implantations comprise the study cohort. Perioperative complications, defined as those occurring within 6 weeks postoperatively, were classified by the Clavien-Dindo classification. After office evaluation at 6 weeks patients were followed for symptoms. Patient followup was obtained through office examination and telephone correspondence. RESULTS: Patients undergoing primary artificial urinary sphincter implantation had a median age of 71.5 years (IQR 66, 76). The overall rate of any complication (Clavien I-V) within 6 weeks of surgery was 35%, including urinary retention in 31% of cases, cellulitis in 1%, device infection in 2% and urethral erosion in 2%. No significant differences in pertinent clinical comorbidities such as age (p = 0.69), hypertension (p = 0.95), coronary artery disease (p = 0.57), diabetes mellitus (p = 0.17), body mass index (p = 0.47), prior pelvic radiation therapy (p = 0.45), prior urethral sling placement (p = 0.91) or transcorporeal urethral cuff placement (p = 0.22) were found between patients with and without complications. Median followup was similar between those with and without postoperative urinary retention (p = 0.14). Postoperative urinary retention was associated with adverse 6-month device survival (76% vs 89%, p = 0.04). CONCLUSIONS: The most common complication of artificial urinary sphincter placement is urinary retention. Serious adverse events following artificial urinary sphincter placement are rare. Postoperative urinary retention is associated with adverse short-term device survival rates.

Holmium laser excision for urinary mesh erosion: a minimally invasive treatment with favorable long-term results.

INTRODUCTION AND HYPOTHESIS: Mesh erosion into the urinary tract following surgery for stress urinary incontinence is a potentially serious complication. Traditional open resection is complicated and potentially morbid. Therefore, we sought to evaluate the long-term patient outcomes following transurethral endoscopic excision using the holmium laser (TEEH). METHODS: A retrospective series of ten patients who had undergone TEEH at our institution between May 2011 and July 2014 were identified. Nine had a prior urethral sling placed, and one had suture erosion following a Marshall-Marchetti-Krantz procedure. Outcomes assessed included resolution of symptoms, successful treatment of exposed mesh on repeat cystoscopy, and recurrence of stress urinary incontinence. Patients were followed up through office examination, cystoscopy and/or through written or telephone correspondence. RESULTS: The median age of the patients at the time of surgery was 58 years (IQR 54 - 66 years). The median time from anti-incontinence surgery to onset of symptoms was 12 months (IQR 1 - 72 months). Patients with mesh erosion most commonly presented with irritative voiding symptoms (60%). The median follow-up was 27 months (IQR 14 - 32 months) with 80% of patients reporting symptomatic improvement. Eight patients underwent follow-up cystoscopy with anatomic success (resolution of erosion on cystoscopy) after one procedure in five patients (63%). The anatomic success rate was higher for bladder erosions than for urethral erosions (80% vs. 33%). Notably, three patients experienced recurrent stress urinary incontinence following TEEH, with one patient undergoing repeat anti-incontinence surgery. CONCLUSIONS: TEEH is a viable, minimally invasive option for management of urinary mesh erosions. Notably, there is a risk of recurrent stress urinary incontinence following laser mesh excision.

An Interdepartmental Care Model to Expedite Admission from the Emergency Department to the Medical ICU.

BACKGROUND: Early evidence suggests that multidisciplinary programs designed to expedite transfer from the emergency department (ED) may decrease boarding times. However, few models exist that provide effective ways to improve the ED- to-ICU transition process. In 2012 Christiana Care Health System (Newark, Delaware) created and implemented an interdepartmental program designed to expedite the transition of care from the ED to the medical ICU (MICU). METHODS: This quasi-experimental study compared ED length of stay (LOS), MICU LOS, and overall hospital LOS before and after the MICU Alert Team (MAT) intervention program. The MAT consisted of a MICU nurse and physician assistant, with oversight by a MICU attending physician. The ED triggered the MAT after patients were stabilized and determined to require MICU admission. Following bedside face-to-face hand off, the MAT providers then assumed responsibly of a patient's care. If no MICU bed was available, the MAT cared for patients in the ED until they were transferred to the MICU. RESULTS: ED LOS was reduced by 30% (2.6 hours) from baseline (p < .001). There were no significant differences in MICU LOS (p = .26), overall hospital LOS (p = .43), or mortality (p = .59). ED LOS was shortened (p < .001) at each increasing level of MICU bed availability (31% when 0 MICU beds available; 26% when 1 or more MICU beds available). Time series analysis identified a 1.5-hour drop in ED LOS (p = .02) for patients transferred from the MICU immediately following intervention implementation and was sustained over time. CONCLUSION: Early outcomes demonstrate that the MAT intervention can reduce ED LOS for critically ill patients. Additional studies should determine optimal approaches to improve clinical outcomes.

Long-term quality of life outcomes and retreatment rates after robotic sacrocolpopexy.

OBJECTIVE: To evaluate the long-term outcomes and potential predictors of treatment failure after robotic sacrocolpopexy. METHODS: We identified 70 consecutive patients from 2002 to 2012 with symptomatic post-hysterectomy vaginal vault prolapse that underwent robotic sacrocolpopexy. Multiple clinical and surgical variables were evaluated for potential association with treatment failure, which was defined as any repeat operation for recurrent prolapse or mesh-related complications. RESULTS: The median age at surgery was 67 years (interquartile range 59-74 years) and median follow up was 72 months (interquartile range 39-114 months). Overall, six out of 70 patients (8.6%) underwent a total of six secondary surgeries, including four for recurrent prolapse (two anterior repairs, one posterior repair, one apical) and two mesh complications. No patient-related factors were associated with the risk of repeat surgery: age (P = 0.45), diabetes mellitus (P = 0.24), tobacco use (P = 0.61) or prior prolapse surgery (P = 0.1) on univariate analysis. Freedom from repeat prolapse surgery or surgery for mesh complication was 98% at 1 year, 95% at 3 years and 90% at 6 years. At last follow up, 80% of patients reported that they would or probably would recommend robotic sacrocolpopexy to a family member or friend. CONCLUSIONS: Robotic sacrocolpopexy is associated with excellent long-term outcomes. Recognition of long-term success is important for preoperative patient counseling.

Factors associated with intraoperative conversion during robotic sacrocolpopexy.

OBJECTIVE: To evaluate for potential predictors of intraoperative conversion from robotic sacrocolpopexy (RSC) to open abdominal sacrocolpopexy. PATIENTS AND METHODS: We identified 83 consecutive patients from 2002-2012 with symptomatic high-grade post-hysterectomy vaginal vault prolapse that underwent RSC. Multiple clinical variables including patient age, comorbidities (body-mass index [BMI], hypertension, diabetes mellitus, tobacco use), prior intra-abdominal surgery and year of surgery were evaluated for potential association with conversion. RESULTS: Overall, 14/83 cases (17%) required conversion to an open sacrocolpopexy. Patients requiring conversion were found to have a significantly higher BMI compared to those who did not (median 30.2 kg/m(2) versus 25.8 kg/m(2); p=0.003). Other medical and surgical factors evaluated were similar between the cohorts. When stratified by increasing BMI, conversion remained associated with an increased BMI. That is, conversion occurred in 3.8% (1/26) of patients with BMI ≤ 25 kg/m(2), 14.7% (5/34) with BMI 25-29.9 kg/m(2) and 34.7% (8/23) with BMI ≥ 30 kg/m(2) (p=0.004). When evaluated as a continuous variable, BMI was also associated with a significantly increased risk of conversion to an open procedure (OR 1.18, p=0.004). CONCLUSIONS: Higher BMI was the only clinical factor associated with a significantly increased risk of intra-operative conversion during robotic sacrocolpopexy. Recognition of this may aid in pre-operative counseling and surgical patient selection.

Long-term device outcomes of artificial urinary sphincter reimplantation following prior explantation for erosion or infection.

PURPOSE: We evaluated clinical outcomes in patients treated with artificial urinary sphincter reimplantation after artificial urinary sphincter explantation for erosion or infection. MATERIALS AND METHODS: We identified 704 consecutive artificial urinary sphincter implantation procedures performed at our institution from 1998 to 2012, including 497 (71%) as primary implantation and 138 (20%) as revision surgery for device malfunction. A total of 69 patients (10%) had undergone at least 1 prior artificial urinary sphincter explantation secondary to urethral erosion and/or device infection, of whom 36 (52%) were treated with 2 to 5 prior reimplantation procedures. Patient followup was performed through office examination, or written or telephone correspondence. RESULTS: Patients treated with artificial urinary sphincter reimplantation had a median age of 78 years (IQR 72, 80) and a median followup of 34 months (IQR 5, 61). Artificial urinary sphincter reimplantation was done a median of 9 months (IQR 6, 13) after explantation. Patients treated with reimplantation after erosion or infection were more likely to require repeat explantation than those with primary implantation (13 of 69 or 19% vs 32 of 497 or 6.4%, p = 0.002). However, when evaluating repeat procedures, the 5-year device survival rate after reimplantation due to erosion or infection vs primary implantation was 68% vs 76% (p = 0.38). CONCLUSIONS: Our findings suggest that artificial urinary sphincter reimplantation after explantation for urethral erosion and/or device infection is associated with an increased rate of recurrent erosion/infection requiring repeat explantation. However, in appropriately selected and counseled patients clinically acceptable long-term device use can be achieved.