How I Handle Retreatment of LUTS Following a Failed MIST.

PURPOSE OF REVIEW: The goal of this paper is to review retreatment management after failed minimally invasive treatment (MIST) of various technologies. RECENT FINDINGS: A failed MIST can be defined by the return, persistence, or worsening of LUTS, as documented by symptom scores. Persistence, development, or recurrence of comorbidities such as recurrent urinary tract infection (UTI), retention, stones, hematuria, and incontinence can also signal a failed MIST. The common etiology for MIST failure is the preoperative consequence of long-term bladder outlet obstruction (BOO) on the bladder function. Close monitoring of therapies with antimuscarinics or beta-agonists can be empirically utilized if post-void bladder residual (PVR) is low. If there is a high PVR, urodynamic studies and cystoscopy can be used to determine overactive bladder (OAB), BOO, or necrosis. Depending on the timing of the observed BOO/OAB, subsequent retreatments involving transurethral debridement, medical and behavioral therapies, or repeat surgical debulking can be employed.

Changes in pelvic organ prolapse surgery in the last decade among United States urologists.

PURPOSE: Surgical correction of pelvic organ prolapse underwent transformation in the last decade. Training in pelvic organ prolapse surgery, the ease of mesh kit use, and Food and Drug Administration warnings about mesh have influenced practice patterns. We investigated trends in pelvic organ prolapse procedures. MATERIALS AND METHODS: Case logs of pelvic organ prolapse procedures, mesh use and pessary placement were obtained from the American Board of Urology for 2003 to 2012. We evaluated associations between surgeon characteristics and the use of pelvic organ prolapse procedures. RESULTS: Of 6,355 nonpediatric urologists applying for certification or recertification 2,192, representing a 10% annual sample of all urologists, reported performing pelvic organ prolapse procedures during the study period. The number of procedures increased steadily from 930 in 2003 to 6,978 in 2012. The number of colporrhaphies increased from 806 to 2,670 and the number of colpopexies increased from 32 to 1,414 between 2003 and 2012. The number of vaginal colpopexies increased from 24 to 1,016 during the study period. The number of sacrocolpopexies increased from 8 to 398 with exponential increases in laparoscopic sacrocolpopexy (282 cases by 2012). Mesh insertion increased from 10 cases reported by applicants in 2005 to 1,552 reported in 2012 (p <0.0005). Mesh revision, first reported in 2007 with 52 performed, consistently increased to 214 in 2012. Urologists trained in female urology performed a median of 16 pelvic organ prolapse procedures, double the number reported by surgeons trained in other urological fellowships. Urologists of the female gender also reported performing approximately 8 more procedures annually than male urologists. CONCLUSIONS: The number of pelvic organ prolapse operations done by urologists increased dramatically in the last decade with a similar increase in mesh use. More colpopexies are now performed with laparoscopic sacrocolpopexy showing an exponential increase. The recent trend of mesh revision is notable with a much faster rate of increase than mesh insertion.

Safety of Tamsulosin: A Systematic Review of Randomized Trials with a Focus on Women and Children.

INTRODUCTION: Although tamsulosin is indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH), it has also been assessed in clinical studies for other conditions/symptoms and in other populations such as women and children. In this systematic review of randomized studies, the overall safety of tamsulosin was assessed, focusing on these understudied populations. METHODS: Literature searches were conducted using Embase, Medline, and PubMed (inception-December 2015). A study was included if patients were randomized to receive treatment with any dose of tamsulosin capsules, tablets, or an oral controlled absorption system and numerical safety results were reported. RESULTS: Overall, 160 articles involving 46,072 participants met the inclusion criteria. Of these, four studies included women only and three included children. The mean [standard deviation (SD)] age ranged from 7.3 (4.2) to 76.8 (7.1) years. The studies (n; %) evaluated healthy subjects (18; 11%) or patients with lower urinary tract symptoms/BPH (90; 56%), ureteral stones/renal colic (42; 26%), prostatitis (4; 3%), or other conditions (6; 4%). Patients discontinued tamsulosin primarily because of adverse events (AEs) or insufficient response. AEs in women and children were abdominal pain, asthenia, constipation, dizziness, dry mouth, drowsiness, dyspepsia, headache, incontinence, nasal congestion, nausea, orthostatic hypotension, and somnolence. Due to heterogeneity across studies, statistical analysis could not be conducted. DISCUSSION: No unexpected AEs were observed in an all-comers population treated with tamsulosin for various conditions/symptoms. The overall safety profile in women and children seemed to be generally consistent with the profile in men, the indicated population.

Trends and Utilization of Laser Prostatectomy in Ambulatory Surgical Procedures for the Treatment of Benign Prostatic Hyperplasia in New York State (2000-2011).

INTRODUCTION: There has been a significant change in surgical treatment of benign prostatic hypertrophy (BPH) over the last two decades. Most importantly, laser surgery (coagulation, vaporization, or enucleation) has been growing in popularity as an alternative to standard transurethral prostatectomy (TURP) or other procedures. Our goal was to analyze the trends of BPH surgeries and compare outcomes of laser surgery to TURP, the two most common alternative surgeries. MATERIALS AND METHODS: We used the New York Statewide Planning and Research Cooperation System (SPARCS) data to identify patients diagnosed as having BPH who underwent BPH-related surgery from October 2000 to December 2011. Age, insurance, individual comorbidities, and average hospital volumes were assessed. Bivariate and multivariate regression models were used to analyze predictors of laser use. In-hospital outcomes were then compared between laser and TURP in a balanced propensity-matched cohort. RESULTS: Ninety thousand six hundred seventy patients underwent BPH surgery. Laser surgery usage increased from 6.4% to 44.5% over 10 years (p<0.0001). TURP declined significantly from 72.2% to 48.3% (p<0.0001). Patients with Medicaid were less likely to undergo laser therapy than those with private insurance (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48, 0.69). Mid- and high-volume institutions were more likely to use laser treatment than low-volume centers (OR: 2.26, 95% CI: 1.22, 4.2; OR: 4.07, 95% CI: 1.75, 9.46, respectively). In the matched cohort, both laser and TURP patients had similar complication rates with more frequent electrolyte disorders in TURP patients (2.9% vs 2.3%, p=0.001). CONCLUSIONS: TURP remains the most common procedure. However, the rate of use has declined over time. In contrast, laser use has significantly increased. Laser treatment was utilized more in younger patients, in those privately insured, in hospitals with high volumes of BPH procedures, and in patients with fewer comorbid conditions. Both surgeries are safe with no differences in terms of occurrences of morbidity and complications.

International variation in artificial urinary sphincter use.

OBJECTIVE: To analyze international trends in artificial urinary sphincter (AUS) use, indications for placement, and application by gender. METHODS: We conducted a retrospective review of data derived from patient information forms sent to American Medical Systems. There were 86 140 unique cases from March 1975 through December 2008, including all indications. RESULTS: AUS use increased worldwide from 1975 (90 procedures) through 2008 (4818 procedures). In 2008, patients with postprostatectomy incontinence (PPI) accounted for 61% (2907/4751) of AUS use compared to 12% (8/66) in 1975. Artificial urinary sphincter annual implant rates in women were much lower than in men, decreasing from 298 procedures in 1990 to 67 in 2008. Artificial urinary sphincter implants in the United States for men alone accounted for the majority (62%, 2995/4818) of worldwide artificial urinary sphincter use in 2008. Conversely, artificial urinary sphincter use has recently started declining in other areas, including South America and Canada. Frequency of artificial urinary sphincter surgery varied dramatically from less than 0.01 per 100 000 population in Brazil to 0.99 in the United States. Of surgeons performing artificial urinary sphincter implants in 2008, case volumes in and outside of the United States were similarly low: 56% in the United States and 52% outside the United States performed only 1 artificial urinary sphincter implant, whereas 76% in the United States and 73% outside the United States did fewer than 3. CONCLUSION: Artificial urinary sphincter use has continued to increase internationally over the study period, especially for patients with PPI. However, artificial urinary sphincter use exhibits considerable regional variation, and most surgeons performed very low annual case volumes of implants.

Pubovesical fistula: a rare complication after treatment of prostate cancer.

OBJECTIVE: To characterize the clinicopathologic features of patients who developed pubovesical fistula (PVF) after treatment of prostate cancer and to identify some possible methods of reducing the incidence of this rare complication for which no well-established guidelines exist. METHODS: We identified men at 2 centers who presented with PVF after prostate cancer treatment from January 2000 to December 2010. Prostate cancer was treated with radiotherapy (RT) or radical prostatectomy, or both. Patients with bladder neck contracture (BNC) received endoscopic treatment. The demographic and clinical data were collected. RESULTS: Of the 12 patients who presented with PVF, the treatment of prostate cancer was external beam RT in 8 (5 of whom underwent subsequent salvage radical prostatectomy) and radical prostatectomy (followed by salvage RT) in 4. All patients developed BNC requiring endoscopic treatment. The median interval between primary endoscopic treatment of BNC and the development of PVF was 35.9 months (range 0.6 to 97). The most common presenting symptom was suprapubic or groin pain. Of the 12 patients, 10 ultimately required cystectomy with urinary diversion. CONCLUSION: The treatment of prostate cancer with RT followed by the development of BNC requiring endoscopic intervention appears to be associated with PVF development Despite conservative measures, patients who developed PVF often required cystectomy with urinary diversion. To avoid PVF, care should be taken during endoscopic intervention for BNC in patients who have received RT for prostate cancer. PVF should be on the differential diagnosis of patients with a history of RT and BNC who develop pubic pain or recurrent urinary tract infection.