Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

SUFU white paper on overactive bladder anticholinergic medications and dementia risk.

AIMS: Anticholinergic medications are widely used in the treatment of overactive bladder (OAB), as well as for short-term treatment of bladder symptoms following a variety of urologic surgeries. Mounting evidence points to an association between anticholinergic medications and the increased risk of incident dementia. The Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) thus convened a committee of subject experts to contextualize the current understanding of the cognitive risks of anticholinergic medications in the urologic patient population and to provide practical clinical guidance on this subject. METHODS: Statements are based on an expert literature review and the committee's opinion. The document has been reviewed and approved by the SUFU board. RESULTS: Chronic use (>3 months) of OAB anticholinergic medications is likely associated with an increased risk of new-onset dementia. Short-term (<4 weeks) use of most OAB anticholinergic medications is likely safe in most individuals. Clinicians should consider potential cognitive risks in all patient populations when prescribing OAB anticholinergics for chronic use. Consideration should be given to progressing to advanced therapy (botulinum toxin or neuromodulation) earlier in the OAB treatment paradigm CONCLUSIONS: The current body of literature supports a likely small but significant increased risk of dementia with chronic exposure to OAB anticholinergic medications. Potential harms should be balanced against potential quality of life improvement with treatment.

Prevention of Urinary Incontinence in Women.

PURPOSE OF REVIEW: Despite available treatments for urinary incontinence, the data regarding prevention is less established. This review sought to identify prevention measures and discuss their underlying evidence base with an attempt to include the most recent updates in the field. RECENT FINDINGS: Urinary incontinence is a prevalent issue among women, particularly surrounding pregnancy and menopause. Interventions regarding pregnancy include not only general health promotion but also potentially interventions such as pelvic floor muscle training and decisions regarding method of delivery. With regard to menopause, the literature suggests avoiding treatments that have adverse effects on continence. Lastly, promoting healthy life style and reducing effects of co-morbid conditions can impact a woman's continence. The literature indicates that preventative strategies exist for urinary incontinence, though the data is limited in this area. Further work is needed to determine the impact of prevention measures and how best to implement them.

Following the crowd: patterns of crowdsourcing on Twitter among urologists.

PURPOSE: To examine patterns of crowdsourcing on the social media platform Twitter among urologists. METHODS: Urologists' public Twitter accounts were reviewed for original posts seeking clinical advice or feedback, and associated reply posts, before and after the 140-character-limit expansion in 2017. Predictors of responses to crowdsourcing requests were determined using multivariable regression. When patient data were posted, we noted whether consent was documented. RESULTS: A total of 276 posts in 23 crowdsourcing requests prior to character-limit expansion were analyzed. Reasons for crowdsourcing included requesting solutions to a clinical dilemma (82 posts, 30%); advice seeking about a surgical plan (77 posts, 28%); surveying colleagues' experiences with a new product (64 posts, 23%); and soliciting feedback about a proposed course of action (53 posts, 19%). Recent completion of training (as a proxy for inexperience) did not appear to disproportionately motivate crowdsourcing; authors' median time in practice was 7 years, and authors practicing for ≤ 7 years initiated 57% of requests. 22 (96%) crowdsourcing requests received ≥ 1 reply. Of 15 requests about a specific patient, eight included imaging, but only one cited patient consent. A second analysis of 184 posts in 17 crowdsourcing requests initiated after character-limit expansion demonstrated significantly more authors replying per request (P = 0.01), but no change in the frequency of patient-specific crowdsourcing or citation of consent. CONCLUSIONS: Urologists are leveraging Twitter for crowdsourcing clinical guidance and experiential knowledge. Nearly all requests were answered, suggesting low barriers to entry for novice users. Even after character-limit expansion, dissemination of potentially identifiable patient data remains a concern.

Older and wiser? Changes in unprofessional content on urologists' social media after transition from residency to practice.

OBJECTIVE: To characterize changes in the frequency and nature of unprofessional content on urologists' Facebook accounts during the transition from residency to practice. METHODS: Facebook was queried with the names of all 2015 US urology graduates 1 year after completion of residency. We identified unprofessional and potentially objectionable content on the public Facebook accounts using a rubric based on professionalism guidelines by the American Urological Association, the American Medical Association and the Accreditation Council for Graduate Medical Education. Comparisons of unprofessional content were made with data from this cohort collected at the completion of residency. To assess how professional identities were reflected on social media, we determined which urologists self-identified as a urologist on Facebook and any changes in their unprofessional content. RESULTS: Of 281 urologists, 198 (70%) had publicly identifiable Facebook accounts. Of these, 85 (43%) contained any unprofessional or potentially objectionable content, including 35 (18%) with explicitly unprofessional content. Examples included images of and references to intoxication, explicit profanity, and offensive comments about patients. Of the 201 Facebook accounts that had been publicly identifiable at the completion of residency, most profiles (182, 91%) had remained public; of the 19 that were no longer public, about half had previously contained unprofessional content. Similarly, of the 80 urologists without public profiles 1 year previously, most (64, 80%) had remained unidentifiable on Facebook; of the 16 accounts that had since become publicly identifiable, half had unprofessional content. Among the urologists on Facebook overall, 11 (6%) had posted new unprofessional or potentially objectionable content since entering practice. Comparing this cohort in practice vs at the completion of residency, there were no significant differences in how many urologists had public Facebook accounts (70% vs 71%) or whose accounts had concerning content (43% vs 40%). The presence of unprofessional content at the completion of residency strongly predicted having unprofessional content later in practice. More urologists overall self-identified as being a urologist on Facebook, and a larger proportion of these profiles also displayed unprofessional content (53% vs 47% 1 year previously). CONCLUSION: Most urologists maintained public Facebook accounts after the transition to practice, and about half of these contained unprofessional or potentially objectionable content. Amidst their increasing self-identification as urologists on social media, the majority of practising urologists had posted concerning content, which could have an impact on their professional identities and public perceptions of the specialty.

Unprofessional content on Facebook accounts of US urology residency graduates.

OBJECTIVE: To characterize unprofessional content on public Facebook accounts of contemporary US urology residency graduates. METHODS: Facebook was queried with the names of all urologists who graduated from US urology residency programmes in 2015 to identify publicly accessible profiles. Profiles were assessed for unprofessional or potentially objectionable content using a prospectively designed rubric, based on professionalism guidelines by the American Urological Association, the American Medical Association, and the Accreditation Council for Graduate Medical Education. Content authorship (self vs other) was determined, and profiles were reviewed for self-identification as a urologist. RESULTS: Of 281 graduates, 223 (79%) were men and 267 (95%) held MD degrees. A total of 201 graduates (72%) had publicly identifiable Facebook profiles. Of these, 80 profiles (40%) included unprofessional or potentially objectionable content, including 27 profiles (13%) reflecting explicitly unprofessional behaviour, such as depictions of intoxication, uncensored profanity, unlawful behaviour, and confidential patient information. When unprofessional content was found, the content was self-authored in 82% of categories. Among 85 graduates (42%) who self-identified as a urologist on social media, nearly half contained concerning content. No differences in content were found between men and women, MD and DO degree-holders, or those who did or did not identify as a urologist (all P > 0.05). CONCLUSION: The majority of recent residency graduates had publicly accessible Facebook profiles, and a substantial proportion contained self-authored unprofessional content. Of those identifying as urologists on Facebook, approximately half violated published professionalism guidelines. Greater awareness of trainees' online identities is needed.

Transvaginal mesh in the media following the 2011 US food and drug administration public health notification update.

AIMS: Prompted by patients' changing perceptions of transvaginal mesh, this study examines how mesh has been reported in the news following the 2011 US Food and Drug Administration (FDA) updated notification about the use of mesh in the treatment of pelvic organ prolapse. METHODS: Two national newspaper databases were queried for articles discussing transvaginal mesh published within 3 years of the FDA announcement. Content analysis included headline subjects, mesh-related complications, quoted sources, and the FDA recommendations. To determine whether more widely read sources publish higher quality reporting, a subgroup analysis was conducted based on newspaper circulation. RESULTS: Ninety-five articles met inclusion criteria. Mesh-related litigation was the most common headline subject (36 articles, 38%), and 54% of all articles referenced legal action. Fifty-seven articles (60%) cited at least one mesh-related complication. Only 18 articles (19%) quoted surgeons who use transvaginal mesh. For the FDA update, 40% of articles that first reported the announcement accurately specified that it applies to mesh for prolapse, not incontinence. This ambiguity persisted: half of all articles cited the warning, but only 23% distinguished between prolapse and incontinence. Higher newspaper circulation did not significantly improve the quality of reporting about the content or context of the FDA's recommendations. CONCLUSIONS: Despite frequent media coverage of transvaginal mesh and its complications since 2011, very few news sources that cited the FDA warning distinguished between prolapse and incontinence. Given prevalent reporting of mesh-related litigation, the findings raise concern about how patients perceive the safety and efficacy of transvaginal mesh, regardless of indication. Neurourol. Urodynam. 36:329-332, 2017. © 2015 Wiley Periodicals, Inc.

State of the Art for Treatment of Vesicovaginal Fistula.

BACKGROUND: Vesico-vaginal fistulae (VVF) remain the most prevalent genitourinary fistula detrimentally impacting quality of life. PURPOSE OF THE REVIEW: The purpose of this review is to examine relevant literature on management of VVF. RECENT FINDINGS: Obstructed labor is the leading cause of VVF in the developing world with most repairs performed via the transvaginal approach. Conversely, the predominate etiology in industrialized nations is iatrogenic injury with an increasing trend towards abdominal repair via a minimally invasive (laparoscopic and robotic) approach. No studies have compared transvaginal repair to minimally invasive transabdominal approaches. Further, an increasing number of authors have developed algorithms to determine optimum surgical approaches and risk factors for persistent incontinence. As surgeons become more facile with laparoscopic and robotic skills, there is a growing trend for minimally invasive surgical management of VVF in developed countries, perhaps widening the disparity gap between developing nations where transvaginal approaches predominate with good success. Further studies are needed to compare transvaginal to minimally invasive transabdominal approaches.

Management of recurrent stress urinary incontinence after burch and sling procedures.

AIMS: To examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow-up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures. METHODS: We performed a secondary analysis of the SISTER and ToMUS trials of participants who underwent primary stress urinary incontinence (SUI) treatment (without prior SUI surgery or concomitant procedures). Using Kaplan-Meier analysis, retreatment-free survival rates by initial surgical procedure were compared. Mean MESA (Medical Epidemiologic and Social Aspects of Aging) stress index was also compared between those retreated for rSUI compared to those not retreated. RESULTS: Half of the women in the SISTEr trial met inclusion criteria for this analysis (329/655, 174 Burch and 155 fascial sling), as did 444/597 (74%) of subjects in ToMUS (221 transobturator midurethral sling (TMUS), and 223 retropubic midurethral sling (RMUS). Types of surgical retreatment included autologous fascial sling (19), synthetic sling (1), and bulking agent (18). Five-year retreatment free survival rates (and standard errors) were 87% (3%), 96% (2%), 97% (1%), and 99% (0.7%) for Burch, autologous fascial sling, TMUS, and RMUS groups respectively (P < 0.0001). For all index surgery groups, the mean MESA stress index at last visit prior to retreatment for those retreated (n = 23) was significantly higher than mean MESA stress index at last visit for those not retreated (n = 645) (P < 0.0001). CONCLUSION: In these cohorts, 6% of women after standard anti-incontinence procedures were retreated within 5 years, mostly with injection therapy or autologous fascial sling. Not all women with rSUI chose surgical retreatment.

A randomized trial of urodynamic testing before stress-incontinence surgery.

BACKGROUND: Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes. METHODS: We performed a multicenter, randomized, noninferiority trial involving women with uncomplicated, demonstrable stress urinary incontinence to compare outcomes after preoperative office evaluation and urodynamic tests or evaluation only. The primary outcome was treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of "much better" or "very much better" on the Patient Global Impression of Improvement. The predetermined noninferiority margin was 11 percentage points. RESULTS: A total of 630 women were randomly assigned to undergo office evaluation with urodynamic tests or evaluation only (315 per group); the proportion in whom treatment was successful was 76.9% in the urodynamic-testing group versus 77.2% in the evaluation-only group (difference, -0.3 percentage points; 95% confidence interval, -7.5 to 6.9), which was consistent with noninferiority. There were no significant between-group differences in secondary measures of incontinence severity, quality of life, patient satisfaction, rates of positive provocative stress tests, voiding dysfunction, or adverse events. Women who underwent urodynamic tests were significantly less likely to receive a diagnosis of overactive bladder and more likely to receive a diagnosis of voiding-phase dysfunction, but these changes did not lead to significant between-group differences in treatment selection or outcomes. CONCLUSIONS: For women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00803959.).

Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment.

PURPOSE: The purpose of this guideline amendment, herein referred to as the amendment, is to incorporate relevant newly published literature to better provide a clinical framework for the diagnosis and treatment of patients with non-neurogenic overactive bladder. MATERIALS AND METHODS: The primary source of evidence for this guideline is the systematic review and data extraction conducted as part of the Agency for Healthcare Research and Quality Evidence Report/Technology Assessment Number 187 titled Treatment of Overactive Bladder in Women (2009). That report searched PubMed, MEDLINE®, EMBASE and CINAHL for English language studies published from January 1966 to October 2008. The AUA conducted additional literature searches to capture populations and treatments not covered in detail by the AHRQ report and relevant articles published through December 2011. The review yielded 151 treatment articles after application of inclusion/exclusion criteria. An additional systematic review conducted in February 2014 identified 72 additional articles relevant to treatment and made up the basis for the 2014 amendment. RESULTS: The amendment focused on four topic areas: mirabegron, peripheral tibial nerve stimulation, sacral neuromodulation and BTX-A. The additional literature provided the basis for an update of current guideline statements as well as the incorporation of new guideline statements related to the overall management of adults with OAB symptoms. CONCLUSIONS: New evidence-based statements and expert opinion supplement the original guideline published in 2012, which provided guidance for the diagnosis and overall management of OAB in adults. An integrated presentation of the OAB guideline with the current amendments is available at www.auanet.org.

Retropubic versus transobturator midurethral slings for stress incontinence.

BACKGROUND: Midurethral slings are increasingly used for the treatment of stress incontinence, but there are limited data comparing types of slings and associated complications. METHODS: We performed a multicenter, randomized equivalence trial comparing outcomes with retropubic and transobturator midurethral slings in women with stress incontinence. The primary outcome was treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). The predetermined equivalence margin was +/-12 percentage points. RESULTS: A total of 597 women were randomly assigned to a study group; 565 (94.6%) completed the 12-month assessment. The rates of objectively assessed treatment success were 80.8% in the retropubic-sling group and 77.7% in the transobturator-sling group (3.0 percentage-point difference; 95% confidence interval [CI], -3.6 to 9.6). The rates of subjectively assessed success were 62.2% and 55.8%, respectively (6.4 percentage-point difference; 95% CI, -1.6 to 14.3). The rates of voiding dysfunction requiring surgery were 2.7% in those who received retropubic slings and 0% in those who received transobturator slings (P=0.004), and the respective rates of neurologic symptoms were 4.0% and 9.4% (P=0.01). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life. CONCLUSIONS: The 12-month rates of objectively assessed success of treatment for stress incontinence with the retropubic and transobturator approaches met the prespecified criteria for equivalence; the rates of subjectively assessed success were similar between groups but did not meet the criteria for equivalence. Differences in the complications associated with the two procedures should be discussed with patients who are considering surgical treatment for incontinence. (ClinicalTrials.gov number, NCT00325039.)

Retropubic versus transobturator slings--are the outcomes changing with time?

The purpose of this review is to review the most current patient reported (subjective) and physician reported (objective) outcomes and adverse events associated with retropubic (RMUS) and transobturator (TMUS) mid-urethral slings. Since the two landmark meta-analyses published in 2010, four new RCT have been published and five have reported long-term outcomes comparing RMUS versus TMUS. Both RMUS and TMUS are safe and have efficacious longer-term outcomes. There is no difference between these slings' subjective outcomes. There is still debate regarding whether RMUS is slightly superior when assessing objective outcomes. Although three trials showed no difference in objective outcomes, results from the largest trial show that RMUS is superior. Further analysis suggests that women with poor urethral function have less favorable outcomes with TMUS and may do better with RMUS. Adverse events are common, and they differ depending on the surgical approach. These new trials confirm previous reported adverse events.

Patient related factors associated with long-term urinary continence after Burch colposuspension and pubovaginal fascial sling surgeries.

PURPOSE: We examined preoperative and postoperative patient related factors associated with continence status up to 7 years after surgery for stress urinary incontinence. MATERIALS AND METHODS: Women randomized to Burch colposuspension or fascial sling surgery and assessed for the primary outcome of urinary continence 2 years after surgery were eligible to enroll in a prospective observational study. Survival analysis was used to investigate baseline and postoperative factors in the subsequent risk of stress urinary incontinence, defined as self-report of stress urinary incontinence symptoms, incontinence episodes on a 3-day diary or surgical re-treatment. RESULTS: Of the women who participated in the randomized trial 74% (482 of 655) were enrolled in the followup study. Urinary continence rates decreased during a period of 2 to 7 years postoperatively from 42% to 13% in the Burch group and from 52% to 27% in the sling group, respectively. Among the baseline factors included in the first multivariable model age (p = 0.03), prior stress urinary incontinence surgery (p = 0.02), menopausal status (0.005), urge index (0.006), assigned surgery (p = 0.01) and recruiting site (p = 0.02) were independently associated with increased risk of incontinence. In the final multivariable model including baseline and postoperative factors, Burch surgery (p = 0.01), baseline variables of prior urinary incontinence surgery (p = 0.04), menopausal status (p = 0.03) and postoperative urge index (p <0.001) were each significantly associated with a greater risk of recurrent urinary incontinence. CONCLUSIONS: Preoperative and postoperative urgency incontinence symptoms, Burch urethropexy, prior stress urinary incontinence surgery and menopausal status were negatively associated with long-term continence rates. More effective treatment of urgency urinary incontinence in patients who undergo stress urinary incontinence surgery may improve long-term overall continence status.

5-year continence rates, satisfaction and adverse events of burch urethropexy and fascial sling surgery for urinary incontinence.

PURPOSE: We characterized continence, satisfaction and adverse events in women at least 5 years after Burch urethropexy or fascial sling with longitudinal followup of randomized clinical trial participants. MATERIALS AND METHODS: Of 655 women who participated in a randomized surgical trial comparing the efficacy of the Burch and sling treatments 482 (73.6%) enrolled in this long-term observational study. Urinary continence status was assessed yearly for a minimum of 5 years postoperatively. Continence was defined as no urinary leakage on a 3-day voiding diary, and no self-reported stress incontinence symptoms and no stress incontinence surgical re-treatment. RESULTS: Incontinent participants were more likely to enroll in the followup study than continent patients (85.5% vs 52.2%) regardless of surgical group (p<0.0001). Overall the continence rates were lower in the Burch urethropexy group than in the fascial sling group (p=0.002). The continence rates at 5 years were 24.1% (95% CI 18.5 to 29.7) vs 30.8% (95% CI 24.7 to 36.9), respectively. Satisfaction at 5 years was related to continence status and was higher in women undergoing sling surgery (83% vs 73%, p=0.04). Satisfaction decreased with time (p=0.001) and remained higher in the sling group (p=0.03). The 2 groups had similar adverse event rates (Burch 10% vs sling 9%) and similar numbers of participants with adverse events (Burch 23 vs sling 22). CONCLUSIONS: Continence rates in both groups decreased substantially during 5 years, yet most women reported satisfaction with their continence status. Satisfaction was higher in continent women and in those who underwent fascial sling surgery, despite the voiding dysfunction associated with this procedure.

Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline.

PURPOSE: The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of non-neurogenic overactive bladder (OAB). MATERIALS AND METHODS: The primary source of evidence for this guideline is the systematic review and data extraction conducted as part of the Agency for Healthcare Research and Quality (AHRQ) Evidence Report/Technology Assessment Number 187 titled Treatment of Overactive Bladder in Women (2009). That report searched PubMed, MEDLINE®, EMBASE and CINAHL for English-language studies published from January 1966 to October 2008. The AUA conducted additional literature searches to capture treatments not covered in detail by the AHRQ report and relevant articles published between October 2008 and December 2011. The review yielded an evidence base of 151 treatment articles after application of inclusion/exclusion criteria. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed. RESULTS: The evidence-based guideline statements are provided for diagnosis and overall management of the adult with OAB symptoms as well as for various treatments. The panel identified first through third line treatments as well as non-FDA approved, rarely applicable and treatments that should not be offered. CONCLUSIONS: The evidence-based statements are provided for diagnosis and overall management of OAB, as well as for the various treatments. Diagnosis and treatment methodologies can be expected to change as the evidence base grows and as new treatment strategies become obtainable.

Treatment success of retropubic and transobturator mid urethral slings at 24 months.

PURPOSE: Longer term comparative efficacy information regarding transobturator and retropubic mid urethral slings is needed. We report 24-month continence rates, complications and symptom outcomes from a randomized equivalence trial. MATERIALS AND METHODS: Primary outcomes were objective (negative stress test, negative pad test and no re-treatment for stress urinary incontinence) and subjective (no self-report of stress urinary incontinence symptoms, no leakage episodes on 3-day bladder diary and no re-treatment for stress urinary incontinence) success at 24 months. The predetermined equivalence margin was ± 12%. RESULTS: Of 597 randomized participants 516 (86.4%) were assessed. Objective success rates for retropubic and transobturator mid urethral slings were 77.3% and 72.3%, respectively (95% CI for difference of 5.1% was -2.0, 12.1), and subjective success rates were 55.7% and 48.3%, respectively (CI for difference of 7.4% was -0.7, 15.5). Neither objective nor subjective success rates met the prespecified criteria for equivalence. Patient satisfaction (retropubic 86.3% vs transobturator 88.1%, p = 0.58), frequency of de novo urgency incontinence (retropubic 0% vs transobturator 0.3%, p = 0.99) and occurrence of mesh exposure (retropubic 4.4% vs transobturator 2.7%, p = 0.26) were not significantly different. The retropubic mid urethral sling group had higher rates of voiding dysfunction requiring surgery (3.0% vs 0%, p = 0.002) and urinary tract infections (17.1% vs 10.7%, p = 0.025), whereas the transobturator group had more neurological symptoms (9.7% vs 5.4%, p = 0.045). CONCLUSIONS: Objective success rates met the criteria for equivalence at 12 months but no longer met these criteria at 24 months. Subjective success rates remained inconclusive for equivalence. Patient satisfaction remained high and symptom severity remained markedly improved. Continued surveillance is important in women undergoing mid urethral sling surgery.

Sexual activity and function in women more than 2 years after midurethral sling placement.

OBJECTIVE: The purpose of this study was to assess prospectively the effects of midurethral sling surgery on sexual function and activity. STUDY DESIGN: Sexual activity and function was assessed in 597 women with stress urinary incontinence who were enrolled in a randomized equivalence trial of retropubic compared with transobturator midurethral slings. Repeated measures analysis of variance was used to assess changes in Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores over a 2-year period. RESULTS: Significant, similar improvements in sexual function were seen in both midurethral sling groups. Mean Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores increased from 32.8 at baseline to 37.6 at 6 months and 37.3 at 24 months (P < .0001). Dyspareunia, incontinence during sex, and fear of incontinence during sex each significantly improved after surgery. Preoperative urge incontinence was associated with abstinence after surgery (P = .02); postoperative urge incontinence negatively impacted sexual function (P = .047). CONCLUSION: Midurethral sling surgery for stress urinary incontinence significantly improves sexual function, although coexistent urge incontinence has a negative impact.

Trends Among Female Pelvic Medicine and Reconstructive Surgery Fellowships and Graduates.

IMPORTANCE: Understanding differences in female pelvic medicine and reconstructive surgery (FPMRS) urology and gynecology-based fellowships is important because both are accredited by the American Board of Medical Subspecialties. OBJECTIVE: The aim of the study was to characterize urology-based and gynecology-based FPMRS fellowships. MATERIAL AND METHODS: An institutional review board-approved 21-item survey was emailed to Accreditation Council for Graduate Medical Education-accredited FPMRS fellowship program directors from January 8 through March 9, 2021. The survey aimed to characterize fellowships through a series of common and specialty-specific questions. Responses were collected with Qualtrics and analyzed using STATA/MP Version 16.1. RESULTS: The response rate was 75% (52/69). Many programs accept both gynecology- and urology-trained applicants (urology-based fellowships, 45.4%; gynecology-based fellowships, 68.3%) since the Accreditation Council for Graduate Medical Education accreditation in 2012. Within the gynecology-based cohort, there have been 10 urology-trained graduates among 7 programs (n = 1-2). Barriers to accepting urology applicants were limited gynecologic knowledge/experience (n = 14) and length of training (n = 11). Thirty-seven (94.8%) reported their graduates log more than 30 hysterectomies and 8.3% (n = 3) log 3 or more urinary diversions.Within the urology-based cohort, there have been 16 gynecology-trained graduates among 4 programs (n = 2-7). Lack of urologic clinical knowledge (n = 4) and training length (n = 2) were cited as barriers to accepting gynecology-trained applicants. Three (27%) reported that their graduates log more than 30 hysterectomies, while 8 (72.7%) reported that graduates log 3 or more urinary diversions. CONCLUSIONS: Despite many FPMRS programs stating that they accept gynecology or urology-trained applicants, few fellows graduate from outside specialty FPMRS training programs. Several barriers were identified that may prevent trainees acceptance outside of their residency specialty. Procedural training experience differs between urology- and gynecology-based fellowships.