Can Urodynamic Parameters Predict Sling Revision for Voiding Dysfunction in Women Undergoing Synthetic Midurethral Sling Placement?

OBJECTIVE: The objective of the study was to evaluate the utility of urodynamic studies performed before primary midurethral sling placement for stress urinary incontinence in predicting the need for subsequent sling release for voiding dysfunction. METHODS: The health records of women managed with primary synthetic midurethral sling placement at Mayo Clinic (Rochester, MN) from January 1, 2002, to December 31, 2012, were reviewed. The primary outcome was surgical sling release for postoperative voiding dysfunction (ie, prolonged retention, elevated postvoid residual volumes with new voiding symptoms, or de novo onset or worsening of overactive bladder symptoms). Logistic regression models were used to evaluate associations between potential clinical risk factors and the primary outcome. RESULTS: Overall, 1629 women underwent primary synthetic midurethral sling placement during the study time frame, including 1081 patients (66%) who underwent a preoperative multichannel urodynamic evaluation. A sling release for voiding dysfunction was performed for 51 patients (3.1%) at a median of 1.9 months postoperatively (interquartile range, 1.3-9.3 months). Patients undergoing sling release were significantly more likely to have had retropubic sling placement (P = 0.003) and concomitant prolapse surgery (P = 0.005). On univariate analysis, no urodynamic parameters were associated with the risk of sling release; evaluated parameters included peak flow rate (P = 0.20), postvoid residual volume (P = 0.37), voiding without detrusor contraction (P = 0.96), and detrusor pressure at maximal flow (P = 0.23). CONCLUSIONS: Sling release for voiding dysfunction was rare in our cohort. No urodynamic parameters were associated with the risk of sling release.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline.

PURPOSE: Male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is common in men and can have negative effects on quality of life (QoL). It is the hope that this Guideline becomes a reference on the effective evidence-based surgical management of LUTS/BPH. MATERIALS AND METHODS: The evidence team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies indexed between January 2007 and September 2017. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/). RESULTS: This Guideline provides updated, evidence-based recommendations regarding management of LUTS/BPH utilizing surgery and minimally invasive surgical therapies; additional statements are made regarding diagnostic and pre-operative tests. Clinical statements are made in comparison to what is generally accepted as the gold standard (i.e. transurethral resection of the prostate [TURP]-monopolar and/or bipolar). This guideline is designed to be used in conjunction with the associated treatment algorithm. CONCLUSIONS: The prevalence and the severity of LUTS increases as men age and is an important diagnosis in the healthcare of patients and the welfare of society. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future surgical options continues to expand.

Autologous rectus fascia sling placement in the management of female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Autologous pubovaginal sling placement remains a treatment option in index patients, given high, long-term success rates. This video reviews the technical considerations for performing an autologous rectus fascia sling. METHODS: The patient is a 47-year-old woman with stress urinary incontinence (SUI) refractory to conservative management. First, a 10-cm rectus fascial segment is harvested and prepped with placement of nonabsorbable stay sutures for later sling passage. Then, an inverted U-shaped incision is made in the anterior vaginal wall based on the bladder neck, and perforation of the endopelvic fascia is performed. Following passage of the sling in the retropubic space, it is secured to periurethral tissue. Cystoscopy is then used to evaluate for bladder perforation and to confirm sling tensioning. RESULTS: The patient was discharged on the same day of surgery with a suprapubic tube in place, which was removed on postoperative day 7 after passing a capping trial. At 6 weeks' follow-up, the patient had complete resolution of SUI, with no de novo urgency symptoms, and could empty her bladder to completion. CONCLUSION: Autologous pubovaginal sling placement remains an effective treatment option for the management of female SUI. This video highlights important technical considerations for this procedure.

Evaluation and Management of Testosterone Deficiency: AUA Guideline.

PURPOSE: There has been a marked increase in testosterone prescriptions in the past decade resulting in a growing need to give practicing clinicians proper guidance on the evaluation and management of the testosterone deficient patient. MATERIALS AND METHODS: A systematic review utilized research from the Mayo Clinic Evidence Based Practice Center and additional supplementation by the authors. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/). RESULTS: This guideline was developed by a multi-disciplinary panel to inform clinicians on the proper assessment of patients with testosterone deficiency and the safe and effective management of men on testosterone therapy. Additional statements were developed to guide the clinician on the appropriate care of patients who are at risk for or have cardiovascular disease or prostate cancer as well as patients who are interested in preserving fertility. CONCLUSIONS: The care of testosterone deficient patients should focus on accurate assessment of total testosterone levels, symptoms, and signs as well as proper on-treatment monitoring to ensure therapeutic testosterone levels are reached and symptoms are ameliorated. Future longitudinal observational studies and clinical trials of significant duration in this space will improve diagnostic techniques and treatment of men with testosterone deficiency as well as provide more data on the adverse events that may be associated with testosterone therapy.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion.

PURPOSE: To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. MATERIALS AND METHODS: We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. RESULTS: At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6 women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. CONCLUSIONS: Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.

AUA White Paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

INTRODUCTION: Medication related problems are common but may be preventable outcomes of prescribing choices. Risks associated with medications in the older adult population are greater due to changes in physiological function with age or disease. Older adults and those with significant comorbidities are often excluded from the clinical trials used to develop medications. In 2012 the American Geriatrics Society published the most recent update of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Several medications included in sections of the Beers Criteria are frequently used in clinical urology, including nitrofurantoin, alpha-1 blocker medications, and antimuscarinic anticholinergic medications for the treatment of urge incontinence and overactive bladder. We describe the challenges and considerations that are useful in prescribing medications for geriatric patients. METHODS: A literature review was performed targeting publications from 2003 to 2013 on the topics of the Beers Criteria, potentially inappropriate medications and specific urological medications included in the current version of the Beers Criteria. An expert panel was convened to evaluate this information and create this white paper with the purpose of educating the urological community on these issues. RESULTS: The rationale for the creation and implementation of the Beers Criteria and its implications for urological practice are reviewed. Careful examination of the Beers Criteria can help clinicians avoid potentially inappropriate prescribing choices for their geriatric patients. We also identified that the HEDIS® high risk medications list of potentially inappropriate medications has been implemented as a negative quality indicator, even though this was not an original purpose of the Beers Criteria. In other words, decisions of denial of coverage and/or requirements for preauthorization are being made using the Beers Criteria as justification by third party payers and other entities. CONCLUSIONS: The Beers Criteria were developed to improve prescribing practices for older adult patients to reduce or avoid potential risks and complications. We encourage clinicians to educate themselves about the Beers Criteria recommendations and associated initiatives that are aimed at improving the care of older adult patients. Urologists should have a key role in the development, evaluation, implementation and analysis of practice measures and the resulting policies.

Efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial.

BACKGROUND: Telemedicine in an ambulatory surgical population remains incompletely evaluated. OBJECTIVE: To investigate patient encounters in the outpatient setting using video visit (VV) technology compared to traditional office visits (OVs). DESIGN, SETTING, AND PARTICIPANTS: From June 2013 to March 2014, 55 prescreened men with a history of prostate cancer were prospectively randomized. VVs, with the patient at home or at work, were included in the outpatient clinic calendar of urologists. INTERVENTION: Remote VV versus traditional OV. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: An equivalence analysis was used to assess the primary outcome, visit efficiency as measured by time studies. Secondary outcomes were patient/provider satisfaction and costs. RESULTS AND LIMITATIONS: There were 28 VVs and 27 OVs. VVs were equivalent in efficiency to relative to OVs, as measured by patient-provider face time (mean 14.5 vs 14.3min; p=0.96), patient wait time (18.4 vs 13.0min; p=0.20), and total time devoted to care (17.9 vs 17.8min; p=0.97). There were no significant differences in patient perception of visit confidentiality, efficiency, education quality, or overall satisfaction. VVs incurred lower costs, including distance traveled (median 0 vs 95 miles), travel time (0 vs 95min), missed work (0 vs 1 d), and money spent on travel ($0 vs $48; all p<0.0001). There was a high level of urologist satisfaction for both VVs (88%) and OVs (90%). The major limitation was sample size. CONCLUSIONS: VV in the ambulatory postprostatectomy setting may have a future role in health care delivery models. We found equivalent efficiency, similar satisfaction, but significantly reduced patient costs for VV compared to OV. Further prospective analyses are warranted. PATIENT SUMMARY: Among men with surgically treated prostate cancer, we evaluated the utility of remote video visits compared to office visits for outpatient consultation with a urologist. Video visits were associated with equivalent efficiency, similar satisfaction, and significantly lower patient costs when compared to office visits. We conclude that video visits may have a future role in health care delivery models.

AUA Quality Improvement Summit 2014: Conference Proceedings on Infectious Complications of Transrectal Prostate Needle Biopsy.

INTRODUCTION: The AUA Quality Improvement Summit is a continuing AUA effort to provide education around issues related to quality improvement and patient safety. Due to the rapidly increasing rates of hospitalization following prostate needle biopsy, Infectious Complications of Transrectal Prostate Needle Biopsy was selected as the inaugural topic. METHODS: The information is largely unpublished data provided by the presenting physicians. Infection rates are predominantly self-reported with protocols specified by the physicians' home institutions. Beyond the identified speakers, the open forum of this summit allowed for input from a majority of the participants. RESULTS: Current hospitalization rates for transrectal prostate needle biopsy infections vary widely from 0.5% to 6%. Antibiotic resistance of coliform organisms appears to be a major risk of these infectious complications. Prophylactic protocols also vary widely among the represented institutions. Antibiotic resistance profiles showed extreme regional variation and, as such, a prophylactic antibiotic protocol should be based on the current local antibiogram in order to reduce infection rates. Opinions vary in relation to the specific antibiotics appropriate for an augmented antibiotic prophylaxis, in the use of rectal swab and prebiopsy enema, and povidone-iodine preparation of the rectal vault. Standardization of the transrectal antibiotic prophylaxis across practices has been proven to reduce the infectious complications rates. CONCLUSIONS: Urologists should monitor the prostate biopsy infection rates of the practice and consult the current local antibiogram. Physicians should query patients to assess whether they are at high risk for resistant organisms. If so, prophylactic protocols might be intensified.

Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper.

PURPOSE: Given the lack of urology specific directives for the periprocedural management of anticoagulant and antiplatelet medications, the AUA (American Urological Association) and ICUD (International Consultation on Urological Disease) named an international multidisciplinary panel to develop consensus based recommendations. MATERIALS AND METHODS: A systematic literature review was queried by a methodologist for 3 questions. 1) When and in whom can anticoagulant/antiplatelet prophylaxis be stopped in preparation for surgery? 2) What procedures can be safely performed without discontinuing anticoagulant/antiplatelet prophylaxis? 3) What periprocedural strategies can adequately balance the risk of major surgical bleeding vs the risk of major thrombotic event? Hematology and cardiology guidelines, and 79 articles were selected for full review. RESULTS: Multidisciplinary management of anticoagulant/antiplatelet medications for patients with recent thromboembolic events, mechanical cardiac valves, atrial fibrillation and cardiac stents would reduce the high morbidity and mortality of inexpertly discontinuing or modifying these lifesaving therapies. No elective procedures requiring interruption of dual antiplatelet therapies should be performed with a recent bare metal or drug eluting stent. The risk of significant bleeding complications is low for patients who require continuation of aspirin for ureteroscopy, transrectal prostate biopsies, laser prostate outlet procedures and percutaneous renal biopsy. Open extirpative prostate and renal procedures can be performed with a low risk of significant hemorrhage for patients on aspirin and those requiring heparin based bridging strategies. The current literature does not give direction on the timing of the resumption of anticoagulant/antiplatelet prophylaxis other than that it be resumed as soon as the risk of bleeding has decreased. CONCLUSIONS: A total of 2,674 nonredundant article abstracts were obtained and assessed for relevance to key questions outlined by the panel. Overall 106 articles were selected for full text review and accepted or rejected based on the relation to the topic, quality of information and key questions. A total of 79 articles were accepted. Reasons for rejection (27 articles) included abstract only (12), insufficient information or unrelated to topic (13) and redundancy (2). We extracted study design, patient population, followup period and results from accepted articles, which serve as the evidence base.

Urologic manifestations of Erdheim-Chester disease.

OBJECTIVE: To describe the urologic manifestations of Erdheim-Chester disease (ECD). ECD is a rare multisystem disorder of non-Langerhans cell histiocytosis. In addition to classic long bone involvement, the retroperitoneum is a well-established site of disease infiltration. Herein, we present the urologic manifestations and outcomes of ECD in a large series of patients. METHODS: We identified 47 patients diagnosed with ECD between 1996 and 2012 at our institution. The medical records and imaging for these patients were reviewed for urologic involvement, including perirenal soft tissue encasement, renal atrophy, hydronephrosis, chronic renal insufficiency, diabetes insipidus, and lower urinary tract symptoms. RESULTS: At diagnosis, the median patient age was 57 years (interquartile range 49, 68), and median follow-up after diagnosis was 3 years (interquartile range 1.8, 7.3). There were 31 male patients (66%) and 16 female patients (34%). The majority of these patients (37, 79%) demonstrated evidence of urologic involvement from ECD, requiring urologic surgery in 13 (28%). This urologic involvement included retroperitoneal infiltration (28, 60%), worsening lower tract urinary symptoms from diabetes insipidus (21, 45%), hydronephrosis (10, 21%), and chronic kidney disease (18, 38%). CONCLUSION: The incidence of urologic involvement with ECD is higher than previously reported in the published data. Urologists should be aware of this disorder, as it might mimic other retroperitoneal diseases and might contribute to lower urinary tract symptoms, hydronephrosis, renal atrophy, and chronic kidney disease.

Efficacy of holmium laser enucleation of the prostate in patients with non-neurogenic impaired bladder contractility: results of a prospective trial.

OBJECTIVE: To examine the outcomes of men with detrusor underactivity or acontractility undergoing holmium laser enucleation of the prostate (HoLEP). METHODS: A prospective case series between 2009 and 2012 was performed to examine short-term outcomes of men with urodynamic evidence of detrusor hypocontractility or acontractility because of a non-neurogenic etiology and concurrent benign prostatic obstruction (BPO), undergoing HoLEP. RESULTS: Fourteen patients with detrusor hypocontractility and 19 patients with acontractility and evidence of BPO underwent HoLEP during the study period. Median age was 71.5 and 75 years, respectively. Preoperatively, 5 (35.7%) men with hypocontractility and 19 (100%) men with acontractility had catheter-dependent urinary retention for a median of 3 and 9 months, respectively. At a median follow-up of 24.7 months, all 5 (100%) men with hypocontractility and 18 of 19 (94.7%) men with acontractility were voiding spontaneously without the need for intermittent catheterization. Individuals with hypocontratile bladders had statistically significant improvements in American Urological Association Symptom Index (21.5 vs 3; P = .014), maximum urine flow (Qmax, 10 vs 21 mL/s; P = .001), and postvoid residual (250 vs 53 mL; P = .007) from baseline to postoperative assessments. In patients with an acontractile bladder, 15 of 19 (78.9%) displayed significant return of detrusor contractility, whereas 4 of 19 (21.1%) were voiding exclusively by Valsalva effort on follow-up urodynamic study. Postoperatively, patient satisfaction, as ascertained by American Urological Association Symptom Index, was high for both groups. CONCLUSION: Intermediate follow-up results indicate that HoLEP is a viable management option for men with BPO and detrusor hypocontractility. Furthermore, detrusor acontractility does not appear to adversely affect postoperative results, with return of spontaneous urination and demonstration of detrusor contractility allowing for efficient voiding, in over 95% of patients.

Risk of repeat anti-incontinence surgery following sling release: a review of 93 cases.

PURPOSE: Sling procedures are the most common surgery for stress urinary incontinence in women. Lower urinary tract symptoms are well documented complications of these procedures that develop in 5% to 20% of patients. A common treatment for postoperative urinary retention and bothersome obstructive voiding symptoms after anti-incontinence surgery is sling release. While previous studies indicated the risk of recurrent stress urinary incontinence after surgical release of slings, there is a paucity of data on how many patients require repeat anti-incontinence procedures. MATERIALS AND METHODS: After receiving institutional review board approval we retrospectively reviewed the records of 143 consecutive female sling release procedures performed by 2 subspecialized urologists at our clinic from January 2000 through August 2012. A total of 121 patients underwent documented followup at our clinic, of whom 93 were treated with sling release for obstruction or retention after sling placement. We identified the characteristics of this patient population, specifically the incidence of subsequent anti-incontinence procedures. RESULTS: Mean ± SD patient age was 58 ± 13.2 years and median patient followup after surgical sling release was 32 months (IQR 6, 67). Of the 93 patients 13 (14%) required a repeat anti-incontinence procedure after sling release at a median of 3 months. CONCLUSIONS: Sling release remains an important treatment option in patients with obstruction after anti-incontinence surgery. Only a small percent of patients require repeat anti-incontinence surgery for recurrent stress urinary incontinence.

Effectiveness of medical and surgical therapies for lower urinary tract symptoms in the community setting.

UNLABELLED: Study Type - Therapy (outcomes research) Level of Evidence 2c. What's known on the subject? and What does the study add? It is known that benign prostatic hyperplasia is a common condition affecting most men by the age of 80 years. There are multiple treatment options available, including both medical and surgical interventions. However, what is not known is how affective the different types of interventions are in the general population. Previous studies have focused on centre-specific data. What is unique about our study is that it is a prospective cross-section analysis of a community cohort of men. Through this study we were able to assess the outcomes in the general population as opposed to in a high-volume surgical centre. Our findings show that in this community medical management was poor at symptomatic improvement, whereas surgical intervention produced the best improvement. OBJECTIVE: • To describe the use and symptomatic outcomes of different therapies for lower urinary tract symptoms (LUTS) in a community-based population of men followed for 17 years. PATIENTS AND METHODS: • Data from a randomly selected cohort of 2184 men, aged 40-79 years in 1990, from Olmsted County, Minnesota, USA were included in the study. Participants completed a questionnaire similar to the American Urological Association Symptom Index (AUASI) and reported on incontinence. • Men were followed biennially through 2007 (median follow-up: 13.7 years; Q1, Q3: 8.8, 15.7). Medical and surgical treatments for LUTS were reported on biennial questionnaires and abstracted from community medical records. RESULTS: • Overall, 610 (28%) men received medical or surgical therapy for treatment of LUTS. Patients undergoing vaporization and transurethral resection of the prostate (TURP) had the highest pre-intervention AUASI scores (P < 0.001) and the most rapid increase in scores over time (P= 0.002) compared with those treated with medications or no therapy. After intervention, symptom progression slowed in all treatment groups. • However, the greatest improvement in AUASI score (median % change) was observed in the TURP group: -27.45%. The TURP group also reported a significant decrease in incontinence after surgery (% change): TURP: -22.58%. CONCLUSION: • All therapies were effective at slowing the progression of LUTS, but only TURP patients reported a significant decrease in both LUTS and incontinence after therapy.

Normal penile, scrotal, and perineal anatomy with reconstructive considerations.

A broad overview is provided of the normal anatomy of the male genitalia to offer the best surgical outcomes in cases related to congenital abnormalities, trauma, cancer-related extirpation, and aesthetics. Neural and vascular anatomy is discussed in depth due to its critical role in maintaining function and in assuring tissue viability.

Lower urinary tract leiomyoma: is excision necessary?

INTRODUCTION/OBJECTIVES: Our objective was to review our experience with lower urinary tract leiomyomata to determine if presentation, exam and imaging allows for stratification of the treatment of this rare lesion. MATERIALS AND METHODS: A retrospective review of current practice was performed from the Mayo Clinic Rochester database identifying 13 female patients and 10 males from 1995-2008, focusing on the clinical presentation, cystoscopic findings, imaging and operative approaches. RESULTS: Symptomatic patients had larger lesions, were more likely to be females, or had midline periurethral or bladder neck lesions. Cystoscopic findings were uniformly described as submucosal polypoid lesions without surrounding erythema or mucosal involvement, a hallmark in the differential. There were no cases of rapid growth of these lesions. There were no recurrences after complete excision with follow up ranging in some cases for up to 4 years. CONCLUSIONS: Lower urinary tract urethral leiomyomata are benign lesions that can be clearly differentiated on the basis of modern imaging from malignant or other benign lesions. While these lesions can cause obstructive voiding symptoms, resection or excision is required only for relief of symptoms, and not for tissue confirmation. In comparison to the presentation of leiomyosarcoma, this benign mass presents with slowly progressive symptoms, is firm but with rounded contours on exam, mucosal ulceration is absent. Imaging confirms benign appearing, albeit, ectopic muscle tissue. Rare forms of metastatic uterine smooth muscle tumors are also easily differentiated from this lesion. Adoption of a conservative approach for the asymptomatic and benign appearing lesion appears prudent.

Surgery for urethral cancer.

Primary urethral cancers represent less than 1% of genitourinary malignancy. Given this is an uncommon disease, there are limited data to guide diagnostic and treatment strategies. Surgical extirpation remains the standard for most patients, with the addition of chemotherapy and radiation therapy in select patients. The surgical approach to urethral cancer depends largely on the location and extent of the tumor.

Cystoscopic injections of dextranomer hyaluronic acid into proximal urethra for urethral incompetence: efficacy and adverse outcomes.

OBJECTIVES: To determine whether dextranomer/hyaluronic acid would be more efficacious or would produce fewer complications when using the material in a standard proximal-urethra cystoscopically-directed injection technique. Injectable periurethral bulking agents are an alternative to stress incontinence surgery. Dextranomer, a highly hydrophilic dextran polymer, solubilized in a base of nonanimal stabilized hyaluronic acid, has been approved as an injectable agent for the treatment of childhood vesicoureteric reflux (Deflux, Q-Med AB, Uppsala, Sweden), and in Europe for women with stress urinary incontinence (SUI) (Zuidex, Q-Med AB, Uppsala, Sweden). A previous multicenter trial demonstrated nonequivalence compared with bovine glutaraldehyde cross-linked collagen with a high complication rate. We sought to determine whether the failure of the treatment lay in the material itself or the use of a blind, midurethral injection technique. METHODS: A retrospective case series of 56 patients undergoing cystoscopically guided bladder neck injections of dextranomer/hyaluronic acid with follow-up in 42, included 35 women with intrinsic sphincter deficiency (ISD), 4 men with postprostatectomy incontinence, 2 men with sphincteric denervation secondary to spinal cord injury, and 1 woman with sphincteric failure after a neobladder. Outcome assessment used gender-appropriate International Consultation on Incontinence Questionnaire, clinical records, and/or urodynamic assessment. RESULTS: Of 35 women with ISD, 4 developed pseudoabscess formation with outlet obstruction requiring multiple operative interventions. Patient-defined treatment failure occurred in all 4 carefully selected postprostatectomy incontinent men, and in 23 of 35 females with ISD. CONCLUSIONS: Complications with cystoscopically injected dextranomer hyaluronic acid at the bladder neck occurred at a high rate, and using a validated questionnaire, the efficacy of dextranomer hyaluronic acid applied in this manner for ISD was poor.

Update of AUA guideline on the surgical management of female stress urinary incontinence.

PURPOSE: We updated the 1997 American Urological Association guideline on female stress incontinence. MATERIALS AND METHODS: MEDLINE searches of English language publications from 1994 and new searches of the literature published between December 2002 and June 2005 were performed using identified MeSH terms. Articles were selected for the index patient defined as the otherwise healthy woman who elected to undergo surgery to correct stress urinary incontinence or the otherwise healthy woman with incontinence and prolapse who elected to undergo treatment for both conditions. RESULTS: A total of 436 articles were identified as suitable for inclusion in the meta-analysis, and an additional 155 articles were suitable for complications data only due to insufficient followup of efficacy outcomes in the latter reports. Surgical efficacy was defined using outcomes pre-specified in the primary evidence articles. Urgency (resolution and de novo) was included as an efficacy outcome due to its significant impact on quality of life. The primary efficacy outcome was resolution of stress incontinence measured as completely dry (cured/dry) or improved (cured/improved). Complications were analyzed similarly to the efficacy outcomes. Subjective complications (pain, sexual dysfunction and voiding dysfunction) were also included as a separate category. CONCLUSIONS: The surgical management of stress urinary incontinence with or without combined prolapse treatment continues to evolve. New technologies have emerged which have impacted surgical treatment algorithms. Cystoscopy has been added as a standard component of the procedure during surgical implantation of slings.

Medium-term comparison of continence rates after rectus fascia or midurethral sling placement.

OBJECTIVE: The purpose of this study was to compare continence rates after placement of rectus fascia or midurethral slings. STUDY DESIGN: We performed a retrospective cohort study of 242 women who underwent rectus fascia (n = 79) or midurethral (n = 163) sling procedures to treat urinary incontinence. Outcome was based on responses to validated questionnaires and need for interim treatment for incontinence. Survival free of incontinence was estimated using the Kaplan-Meier method. Associations between patient factors and survival free of incontinence were evaluated by fitting Cox proportional hazards models. RESULTS: Women with rectus fascia slings were more likely to report any leakage of urine (P = .04) and were 13 times more likely to require urethrolysis (P < .001) than patients with midurethral slings. Patient satisfaction was lower in the rectus fascia sling group compared with the midurethral sling group (P = .01). CONCLUSION: Midurethral slings appear to be more effective than rectus fascia slings and are less likely to cause postoperative voiding complications.