Real-Time Changes in Brain Activity during Sacral Neuromodulation for Overactive Bladder.

PURPOSE: We performed functional magnetic resonance imaging to identify changes in brain activity during sacral neuromodulation in women with overactive bladder who were responsive to therapy. MATERIALS AND METHODS: Women recruited into the study had nonneurogenic refractory overactive bladder, responded to sacral neuromodulation and had had a stable program for at least 3 months with no subsequent overactive bladder treatment. Enrolled patients completed validated symptom and quality of life instruments before functional magnetic resonance imaging. Stimulus settings were recorded, devices were switched off for a 5-day washout and instruments were repeated. Three functional magnetic resonance imaging scans with simultaneous sacral neuromodulation stimulation were performed below, at and above stimulus sensory threshold using a block design. This yielded brain activity maps represented by changes in blood oxygenation level dependence. A total of 5 stimulator off and 4 stimulator on cycles of 42 seconds each were imaged. Group analysis was done using a single voxel p value of 0.05 with a false-positive error of 0.05 on cluster analysis. RESULTS: Six of the 13 patients enrolled completed functional magnetic resonance imaging. Median age was 52 years (range 36 to 64). Urinary symptoms and voiding diary data worsened with washout. Overall brain activation generally progressed with increasing stimulation amplitude. However, activation of the right inferior frontal gyrus remained stable while deactivation of the pons and the periacqueductal gray matter only occurred with subsensory stimulation. Sensory stimulation activated the insula but deactivated the medial and superior parietal lobes. Suprasensory stimulation activated multiple structures and the expected S3 somatosensory region. All devices had normal impedance after functional magnetic resonance imaging. CONCLUSIONS: Functional magnetic resonance imaging confirmed that sacral neuromodulation influences brain activity in women with overactive bladder who responded to therapy. These changes varied with stimulus intensity.

What is the gold standard for posterior vaginal wall prolapse repair: mesh or native tissue?

Reports in the literature of high recurrence rates after native tissue repair for pelvic organ prolapse led to the development of alternative techniques, such as those using synthetic mesh. Transvaginal mesh (TVM) delivery systems were implemented in search of better outcomes. Despite reported recurrence as low as 7.1 % after posterior colporrhaphy, mesh kits were developed to correct posterior compartment prolapse. There is a paucity of data to substantiate better results with TVM for rectocele repair. Three randomized controlled trials comparing native tissue repair to synthetic mesh reported posterior compartment outcomes and two of these failed to show a significant difference between groups. Complications of TVM placement are not insignificant and mesh extrusion was reported in up to 16.9 %. Based on currently available data, native tissue repairs have similar outcomes to synthetic mesh without the risks inherent in mesh use and remain the standard of care for the typical patient.

Differential diagnosis of overactive bladder in men.

PURPOSE: We determined the differential diagnosis of concomitant pathological conditions in men with overactive bladder symptoms. MATERIALS AND METHODS: We performed an observational, descriptive study to elucidate the differential diagnosis in men with overactive bladder symptoms using a previously validated overactive bladder symptom questionnaire. All patients provided an extensive history, completed the self-administered questionnaire and a 24-hour voiding diary, and underwent physical examination, 24-hour pad test, uroflowmetry, post-void residual urine measurement, cystoscopy and urodynamics. Selection criteria were developed to assign cases to a category, including idiopathic overactive bladder, benign prostatic enlargement, benign prostatic obstruction, neurogenic bladder, bladder cancer, prostate cancer treatment complications, urethral stricture, bladder stones and bladder diverticulum. RESULTS: Of 122 men who met selection criteria for overactive bladder detrusor overactivity was identified in 99 (79%) on urodynamics. The differential diagnosis was benign prostatic enlargement in 40 men (32%), benign prostatic obstruction in 27 (22%), complications of prostate cancer treatment in 25 (20%), neurogenic bladder in 13 (11%), urethral stricture in 7 (6%), idiopathic overactive bladder in 6 (5%), bladder stone in 2 (2%), bladder cancer in 1 (1%) and bladder diverticulum in 1 (1%). CONCLUSIONS: Overactive bladder is a complex diagnosis with many underlying, contributing urological pathologies. It should be considered a symptom complex and not a syndrome. Knowledge of the differential diagnosis in men with overactive bladder symptoms would hopefully provide clinicians with a diagnostic rubric to more specifically treat such patients with improved success.

Fluoro-urodynamic Image Interpretation Is Not Altered by Using Dilute Intravesical Contrast.

OBJECTIVE: To determine if using one 250 mL bottle of intravesical contrast followed by sterile saline alters interpretation of fluoroscopic images during fluoro-urodynamics. MATERIALS AND METHODS: Subjects were randomized to receive 250 mL of intravesical contrast followed by sterile saline until maximal cystometric capacity vs non-dilute intravesical contrast alone during fluoro-urodynamics. Interpreters, blinded to study group, graded images on an ordinal rank scale rating confidence in image interpretation. Primary endpoint was differences in image interpretation between the two groups using visual grading characteristics curves and contrast-to-noise ratios (CNR). Secondary endpoints were obtaining anthropometric data such as body mass index and waist circumference to determine predictors of CNR in a multivariate multiple regression analysis. RESULTS: 26 subjects were randomized to receive dilute intravesical contrast and 22 non-dilute contrast; two subjects were unable to complete the study. There was no difference in baseline characteristics between the two groups. Visual grading characteristics demonstrated no difference in readability of the fluoroscopic images between groups and CNR was not statistically different between the two groups. No correlation was identified between CNR and waist circumference or body mass index. CONCLUSION: Interpretation of fluoro-urodynamic images and image quality was not altered with using of 250 mL of contrast followed by saline. Expert reviewers did not perceive a difference in their confidence to distinguish between the two groups. Fluoro-urodynamics can be reliably performed using only 250 mL of contrast without compromising the ability to read the fluoroscopic images.

Urogynecological conditions associated with overactive bladder symptoms in women.

INTRODUCTION: Overactive bladder symptoms (OAB) affect 9-43% of women and are associated with underlying disorders, including pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The aim of this study is to identify urogynecological conditions associated with OAB symptoms. METHODS: This prospective, institutional review board-approved study included women referred to a tertiary centre with lower urinary tract symptoms (LUTS). All women completed the self-administered OAB questionnaire (OABSS). Those with an OABSS ≥8, the cutoff, were considered to have OAB symptoms. Patients underwent a history and physical examination (including Baden-Walker prolapse grading and stress test), 24-hour voiding diary, pad test (for urinary incontinence), urinalysis, and uroflow with post-void residual volume. Patients were classified clinically into the following: idiopathic OAB, SUI, POP, bladder outlet obstruction (BOO) neurogenic bladder (NGB), recurrent urinary tract infection (UTI), and miscellaneous. RESULTS: In total, 148 women met the inclusion criteria with a mean age of 67 years. Only 27% had no comorbid conditions and were considered idiopathic OAB. Associated urogynecological conditions included SUI in 37%, POP in 26%, miscellaneous conditions in 18%, recurrent UTI in 11%, NGB in 9%, and BOO in 8%. Some patients met criteria for more than one category, thus the total is greater than 100%. CONCLUSIONS: In a tertiary care setting, a significant proportion of women with OAB symptoms have underlying conditions that may cause or contribute to their symptoms. Appropriate evaluation is desirable to enhance our understanding of the relationship of these conditions to the diagnosis, treatment, outcomes, and pathophysiology of OAB.

Videourodynamics: indications and technique.

Videourodynamics combines fluoroscopic voiding cystourethrography with multichannel urodynamics to better evaluate lower urinary tract symptoms. This article reviews current literature and guidelines outlining the indications for obtaining this specialized study as well as technique. Appropriate and judicious use of fluoro-urodynamics lends to improved diagnostic acumen in a well-selected patient population; however, clinicians must be mindful of the added cost, safety concerns, and limitations of its use.

Controversies in the management of mesh-based complications: a urology perspective.

Since the introduction of the synthetic midurethral sling, several transvaginal mesh delivery systems have been developed for treating stress incontinence and pelvic organ prolapse. Widespread use of these "kits" has introduced a new dilemma of mesh-specific complications that female pelvic surgeons must manage. Differing treatment techniques have been described and controversy exists as to which method is preferred for vaginal mesh extrusion, mesh perforations, pelvic pain, and dyspareunia. This article addresses the differing management strategies for mesh complications after reconstructive surgery and highlights the available literature on the success of each option.