The impact of prior back surgery on neuromodulation outcomes: A review of over 500 patients.

AIMS: To evaluate neuromodulation outcomes in patients with prior back surgery. METHODS: Adults in our prospective observational sacral/pudendal neuromodulation study were retrospectively evaluated. History and operative details were reviewed, and outcomes were measured at 3, 6, 12, and 24 months with overactive bladder questionnaire (OAB q) symptom severity (SS)/health related quality of life (HRQOL), interstitial cystitis symptom/problem indices (ICSI - PI), voiding diaries, and global response assessments (GRA). Data were examined with Pearson's χ2 , Fisher's exact, Wilcoxon rank sum tests, and logistic regression multivariate analysis. RESULTS: Five hundred and sixty patients were evaluated (mean age 58.8 ± 17 years; 83% female; 79% had a sacral lead placed), 109 (19%) had history of back surgery; 66 surgeries were lumbar. Back surgery patients were older (mean 63 ± 15 vs. 58 ± 17 years; P = 0.003) and a higher proportion had urge urinary incontinence (UUI) (64% vs. 50% P = 0.008). Generator implant rates were similar (94% vs. 91%; P = 0.34). OABq-SS and HRQOL and ICSI - PI composite scores did not differ between groups at any time point. On bladder diaries, median incontinence episodes daily at baseline and between stages were worse in the prior back surgery group but all bladder diary parameters improved significantly in both groups with the exception of mean voided volume which only improved significantly in the non-back surgery group. Most patients in both groups reported moderate/marked improvement in overall bladder symptoms. CONCLUSIONS: This study suggests that prior back surgery does not appear to impact clinical outcomes; therefore, neuromodulation may be offered in this patient population.

Understanding clinic options for overactive bladder.

Overactive bladder (OAB) is a symptom complex of urinary frequency, nocturia and urgency with or without urgency incontinence that adversely impacts patient's quality of life. Conservative management begins in the outpatient clinic, often with significant improvement and patient satisfaction. In this review we will discuss the evaluation of OAB and review treatment options focusing on behavioral modification, medical therapy, and neuromodulation. These treatment options are offered in a stepwise fashion, remembering that more than one may be needed and can be used concomitantly.

Outcomes of Sacral Neuromodulation in Patients with Prior Surgical Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse.

OBJECTIVES: The aim of this study was to evaluate the efficacy of sacral neuromodulation in patients with prior stress urinary incontinence (SUI) or pelvic organ prolapse (POP) surgery. METHODS: Women in our prospective neuromodulation database were evaluated. Patients with a history of prior SUI/POP surgery were compared to those without. Medical records at baseline were reviewed, and primary outcome was defined as moderate/marked improvement on Global Response Assessment (GRA) at 3 months. Secondary outcomes were measured using bladder diaries and Overactive Bladder Symptom Severity (OABq-SS)/health-related quality of life (HRQOL). Data were analyzed with Pearson χ test, Fisher exact test, Wilcoxon rank-sum test, and repeated-measures analyses. RESULTS: Of 210 subjects, 108 (51%) had prior SUI/POP surgery. Patients with SUI/POP surgery had more prior hysterectomies. At 3 months, there was no difference between groups on GRA outcomes. On the bladder diary, both groups had improvement in median voids per 24 hours, urgency severity, and urge incontinence over 2 years. On the GRA, fewer patients in the SUI/POP group were treatment responders at 12 and 24 months. For urinary urgency, a few in this group were moderately/markedly improved at 6 months, and a higher proportion are reported still leaking urine at 6 and 12 months. Similar proportions in each group reported moderate/marked improvement in leaking. Satisfaction was similar between groups. The OABq-SS/HRQOL scores improved, and there was no difference between the groups. CONCLUSION: Sacral neuromodulation improves bladder symptoms in women with prior SUI/POP surgery, but response may be slightly less in those with prior surgery due to underlying bladder or pelvic floor issues.

Secondary surgery after vaginal prolapse repair with mesh is more common for stress incontinence and voiding dysfunction than for mesh problems or prolapse recurrence.

OBJECTIVES: To explore the need for secondary surgical procedures after transvaginal prolapse repair with mesh. METHODS: Women that had prolapse repair (Prolift(®) or Elevate(®)) were reviewed for reoperation and clinical/demographic data such as prior prolapse repair, prolapse grade, operative details, length of stay (LOS) and time to reoperation. Pearson's Chi-square, Fisher's exact tests and Wilcoxon rank tests were used. RESULTS: 77/335 women (23%) had 100 additional procedures. Median (range) time to reoperation was 51 (5-1168) days: four (1%) had primary prolapse surgery at a different site, three (1%) repeat prolapse repair from the same site, 23 (7%) surgery for complications and 50 (15%) had stress urinary incontinence (SUI)/sling-related procedures. When no reoperation versus reoperation groups were compared, mean LOS (1.8 vs. 2.0 days; p = 0.044) and follow-up (228 vs. 354 days; p = 0.002) were longer in the reoperations group; postoperative hemoglobin was lower (10.8 vs. 10.4; p = 0.031). Patients with a prolapse reoperation were 10 years younger (67 vs. 57 years; p = 0.027) than patients that either had a reoperation for other reasons or had no reoperations. Patients with concomitant sling and persistent SUI requiring repeat SUI surgery were older (mean 72 vs. 66 years; p = 0.038), had prior prolapse repair (53 vs. 27%; p = 0.017) and had anterior compartment mesh (84 vs. 56%; p = 0.037); median operative times (78 vs. 104 min; p = 0.008) and mean LOS were shorter (median 1.6 vs. 1.9 days; p = 0.045). For patients without concomitant sling, no demographic or perioperative differences were found between those that did (n = 10) and did not (n = 86) develop de novo SUI that required reoperation. CONCLUSIONS: Most reoperations were for sling management and SUI; few were for mesh complications or prolapse recurrence.

Computed tomography findings in patients with pediatric blunt renal trauma in whom expectant (nonoperative) management failed.

OBJECTIVE: To determine whether the features on a computed tomography (CT) scan can predict the need for urologic intervention in a pediatric blunt renal trauma population initially treated with expectant management. MATERIALS AND METHODS: A review of a prospective database of pediatric patients sustaining renal trauma from 1991 to 2003 was performed. The data reviewed included the mechanism of injury, injury grade, CT findings, operative intervention, and complications. Parametric statistical analysis was used to compare the CT findings and outcomes. RESULTS: A total of 72 children presented with blunt renal injury, of whom 61 met the study criteria. Of the 61 patients, 50 had grade I-III, 10 had grade IV, and 1 had grade V injuries. No children with grade I-III injuries required operative intervention. Of the 10 patients with grade IV injuries, 4 had medial contrast extravasation from the collecting system on their original CT scan, 3 of whom required intervention. Intervention initially consisted of delayed endoscopic procedures at 3, 9, and 33 days after injury. All 3 patients (100%) developed complications in their management, and 2 (66%) required open surgical intervention. The 1 patient with grade V injury underwent nephrectomy because of hemodynamic instability. CONCLUSION: Grade IV renal injuries with medial contrast extravasation are associated with urologic intervention at greater rates than those without extravasation. Delayed treatment of this finding could be associated with greater than expected complication rates and renal loss, and early/aggressive treatment should be considered. This knowledge could improve the specificity of "expectant" nonoperative management of pediatric renal injury.

Urologic trauma guidelines: a 21st century update.

Trauma is the leading cause of death between the ages of 1 and 44 years in the USA. While stabilization of life-threatening injuries is the primary goal in the evaluation of all trauma patients, subsequent diagnosis and treatment of secondary injuries are requirements for good trauma care. The genitourinary system is involved in 10% of trauma cases, and these injuries can be associated with considerable morbidity and mortality. Accordingly, physicians involved in the initial evaluation and subsequent management of trauma patients should be aware of the diagnosis and treatment of injuries that can occur in the genitourinary system. In 2009, the European Association of Urology provided specific recommendations for the evaluation, diagnosis and management of genitourinary trauma. Here, we review and discuss these recommendations in order to provide a concise summary for clinicians involved in the evaluation and management of trauma patients and their associated genitourinary injuries.