Implications of the FDA statement on transvaginal placement of mesh: the aftermath.

The release of the U.S. Food and Drug Administration (FDA) safety communication on the use of transvaginal mesh (TVM) for pelvic organ prolapse (POP) has resulted in changes in the pelvic reconstruction community. This monograph reviews the implications of the FDA statements over the last 18-24 months. Recent findings show that there have been significant developments in the areas of regulatory mandates, media and medico-legal activity, and statements from surgical societies. In summary, well-publicized communications from the FDA and major medical organizations are defining a change in the use of TVM for POP.

Colpocleisis for advanced pelvic organ prolapse.

OBJECTIVE: To characterize our experience with colpocleisis in a urologic setting because it has not been documented broadly in the urologic literature. METHODS: Retrospective review of demographics, urodynamics, presenting symptoms, complications, and outcomes for patients undergoing colpocleisis from 2001-2010 was performed. A questionnaire including the short forms of the Urinary Distress Inventory and Pelvic Organ Prolapse Distress Inventory (POPDI-6), and the Patient Global Impression of Improvement was sent to consenting patients. RESULTS: Fifty-three patients were identified. Examinations were all POP-Q stage 3 or greater or Baden Walker grade 3 or higher; 73.6% underwent total colpocleisis and 26.4% Le Fort; 60.4% underwent concomitant sling. Complications included 1 patient requiring transfusion, 1 with pulmonary embolus, 1 needing clot evacuation, and 1 requiring intraoperative cystotomy repair. There was no postoperative de novo urgency, no recurrence of prolapse, and no chronic urinary retention. In patients not undergoing urethral sling, stress urinary incontinence persisted in 4 patients and occurred de novo in 1. Mean follow-up was 9.3 months. Twenty-two surveys were returned: 90.9% described their condition as much or very much better on Patient Global Impression of Improvement. The average POPDI-6 score was 9.1. Frequency and urgency were the most common complaints leading to bother on the UDI-6 (33.3%). Most of these responders had a preoperative urge component. CONCLUSION: In a selected patient population, colpocleisis is safe and efficacious. Persistent lower urinary tract symptoms comprise the highest frequency of complaints after colpocleisis, and this must be included in patient counseling. In an aging patient population with expected increase in demand for pelvic floor reconstruction, colpocleisis is a useful approach for the urologist.

Bowel evisceration through the bladder neck in a paraplegic female secondary to urethral coitus.

INTRODUCTION: Urethral coitus is rarely reported in the literature. The majority of reported cases have been secondary to vaginal agenesis or hymenal anomalies. AIM: We report a case of urethral coitus in a paraplegic patient with a patulous urethra resulting from chronic indwelling catheter use, with the unfortunate presentation of bladder rupture and evisceration per urethra. To our knowledge, this is the only report of urethral coitus due to sequelae from an indwelling catheter, as well as the only report of the subsequent complication of bowel evisceration per urethra. RESULTS: After initial temporization at an outside facility, we were able to perform primary cystorrhaphy. There was no need for bowel resection. The patient has chosen to defer her decision on permanent reconstruction. CONCLUSIONS: Urethral coitus is rare and the subsequent ramifications can be devastating, particularly in neurologically impaired patients. This unusual case speaks to the importance of properly caring for the neurogenic bladder.

Does estrogen have any real effect on voiding dysfunction in women?

For many years, estrogen has been used to treat lower urinary tract dysfunction in postmenopausal women. The data supporting this practice vary. Large multi-institutional studies have shown little role for systemic estrogens in the treatment of urinary incontinence. Vaginal estrogen preparations show superiority to systemic estrogens for the treatment of irritative voiding symptoms in meta-analysis, but there is significant study heterogeneity and the practice remains debatable. Data from randomized controlled trials support estrogen use in the prevention of recurrent urinary tract infections. This article reviews the relevant literature addressing the role of estrogen therapy in urinary incontinence, irritative voiding symptoms, and recurrent urinary tract infections.

Safety and efficacy of sling for persistent stress urinary incontinence after bulking injection.

OBJECTIVES: To evaluate the impact of injectable agents on subsequent incontinence surgery outcomes to assess safety and efficacy of this treatment combination. Periurethral bulking agents are a minimally invasive treatment option for stress urinary incontinence (SUI), but often lack durability necessitating further surgical intervention. METHODS: Retrospective review of 43 patients with SUI following bulking agent who underwent subsequent sling placement from November 2000 to September 2009 were evaluated for demographics, symptoms, urodynamics (UDS), bulking agent characteristics, concomitant procedures, pad requirements per day (PPD), subjective outcomes, and complications. RESULTS: Mean patient age was 67 years, with mean follow-up of 37.3 months. All demonstrated SUI, and mixed urinary incontinence (MUI) was noted in 81.4%. Almost half (48.8%) had undergone a prior antiincontinence procedure. Mean number of injections was 3. After a bulking injection, 25 autologous fascia pubovaginal slings, 13 midurethral slings, and 5 biological pubovaginal slings were placed. Concomitant pelvic surgery was performed in 37.2%. Postoperatively, mean PPD decreased from 5.3 to 0.65, with a 60.5% subjective cure rate (no pads or leakage under any circumstances). No association was seen between number or type of injection, or type of sling with regards to patient outcomes. Results were significantly related to concomitant surgery (P = .007). SUI recurred in 8 patients (18.6%), which was not statistically associated with other parameters. Complications included urinary retention (8 patients) de novo urgency (1 patient), UTI (4 patients), abdominal wound infection (3 patients), and cystotomy (1 patient). CONCLUSIONS: Prior treatment with bulking agents does not appear to negatively affect outcomes for future antiincontinence surgery in our patient population.

Infant communicating hydroceles--do they need immediate repair or might some clinically resolve?

PURPOSE: Infant hydroceles that are communicating by history (fluctuation in size) or examination (reducible fluid) are often repaired soon after presentation. We have followed a series of infant boys with such hydroceles and reviewed their early natural history. MATERIALS AND METHODS: Since 1998, we have followed 174 infant boys presenting with an apparent communicating hydrocele without immediate surgical repair. All boys were initially seen before 18 months of age and most (168) by 12 months. Most had been full term at delivery, although 32 had been premature (<37 weeks' gestational age) and 11 extremely so (<32 weeks). Most boys (120) had bilateral hydroceles at presentation. RESULTS: Of the 110 boys followed to disposition, 69 (62.7%) had complete resolution without surgery by a mean age of 11.7 months. Forty-one patients (37.3%) underwent surgery for correction at a mean age of 14 months because of persistence in size or development of a hernia. Six developed a hernia during observation, none of whom had any episode of incarceration. Only 2 patients with apparent resolution subsequently had recurrence with a hernia. Age at presentation and gestational age at birth showed no effect on resolution. The hydroceles of 64 boys had improved in size after a mean follow-up of 13.9 months when last seen. CONCLUSIONS: Many infant hydroceles that are communicating by history or examination do resolve clinically without surgery and deserve observation. Progression to hernia was rare in our experience and did not result in incarceration. Consequently, little risk is taken by initial observation.

Successful bilateral testicular sparing surgery for benign teratoma.

Pediatric testicular tumors are well suited for testicular sparing surgery due to the high incidence of non-malignant lesions in this population and the observed low incidence of recurrence or complication. Bilateral pediatric testicular tumors have been rarely reported; however, testicular sparing surgery, if possible, is an attractive alternative to radical orchiectomy in an effort to preserve testicular parenchyma and function. To our knowledge, we present the first reported case of successful bilateral testicular sparing surgery.

Renal peripheral neuroectodermal tumor presenting at age 78: case report.

Primitive neuroectodermal tumor (PNET) of the kidney is a rare and aggressive tumor, often presenting in advanced stages and progressing rapidly. Renal PNET (rPNET) may affect a wide age spectrum, but the majority of cases are in young adults. We present a case of advanced rPNET in a 78-year-old woman. To our knowledge, this is the most advanced age of presentation of this neoplasm to date. We report on her presentation and management, and discuss the current clinical management of this tumor.

Community associated methicillin resistant staphylococcal infections in a pediatric urology practice.

PURPOSE: Methicillin resistant Staphylococcus aureus is a virulent organism that has seen a rapid increase in prevalence. Community associated methicillin resistant S. aureus is discussed frequently in the infectious disease community. However, there has been little mention of this entity in the urological literature. MATERIALS AND METHODS: We reviewed the records of patients presenting with skin/soft tissue infections or documented methicillin resistant S. aureus infection treated at an academic pediatric urology practice between October 2004 and August 2006. RESULTS: A total of 12 patients were included (33% female, 67% male). Mean patient age was 49 months (range 8 to 202). Of the patients 11 (92%) presented with spontaneous infection and 1 (8%) presented with a wound infection. Abscess location was inguinal in 4 patients (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). The most common presenting sign at referral was fluctuance (30%). While all patients eventually required surgical drainage, initial treatment by the primary care physician consisted of observation on oral antibiotics in 7 patients (58%). A total of 10 cultures (83%) revealed methicillin resistant S. aureus and 2 cultures (17%) were negative. Mean hospital stay was 5 days (range 0 to 16). Postoperatively, most patients (58%) were discharged home on oral trimethoprim-sulfamethoxazole. Mean followup was 4 months (range 0 to 15). Recurrence was seen in 3 patients at 1 to 15 months postoperatively (mean 6.3). CONCLUSIONS: Methicillin resistant S. aureus is increasing in the community and will likely be seen more often in pediatric and adult urological practices. The regional differences among bacterial strains make a standardized approach to these cases difficult. However, increased awareness of this virulent organism is necessary to deliver prompt and successful treatment.

An inverse relation between COX-2 and E-cadherin expression correlates with aggressive histologic features in prostate cancer.

The identification of biomarkers in prostatic carcinoma has yielded important data regarding prognosis and has aided in increasing diagnostic accuracy. Additionally, this approach has yielded important insights into the biology of prostatic carcinoma. In this study, we report that the expression of the cyclooxygenase isoenzyme, COX-2, is significantly increased in prostatic carcinoma, whereas that of the cell adhesion molecule, E-cadherin, is decreased. The expression of COX-2 was positively correlated with higher tumor stage, and the presence of carcinoma in surgical margins at prostatectomy. Conversely, the expression of E-cadherin was inversely related to these prognostic indicators. Lastly, the expressions of COX-2 and E-cadherin were very strongly and inversely correlated. These results provide important insights into the biologic underpinnings of prostate carcinoma; and further studies into COX-2 expression in prostate core biopsies may show utility in preprostatectomy prognostication. Furthermore, these results may provide a rational basis for therapeutic intervention and chemoprevention with COX-2 inhibitor therapy in prostate carcinoma.