Temporal trends in the incidence of severe pelvic fracture urethral injuries in the United States from 1998 to 2014.

OBJECT: To use a contemporary population-based cohort to investigate temporal trends in the national incidence of pelvic fracture urethral injuries (PFUIs) in the United States. METHODS: Using the NIS (National Inpatient Sample), we identified patients with a severe PFUI by a combination of an ICD-9 diagnosis code for pelvic fracture (808.xx) and ICD-9 procedure code for suprapubic tube (57.17 or 57.18) from 1998 to 2014. We compared the annual rates of PFUIs and the annual rates of pelvic fractures alone. RESULTS: An estimated total of 6052 ± 347 males with PFUIs were identified. The average age was 38.4 ± 0.5 years. 9.1% ± 0.8% of patients died while hospitalized. In the time frame studied, the rate of PFUI significantly decreased during from 532 patients in 1998 to 255 patients in 2014. Sensitivity analysis excluding patients with bladder repairs identified a similar trend. The annual rate of PFUI per 1000 pelvic fractures has also decreased from 14.6 ± 1.6 in 1998 to 6.5 ± 0.9 in 2014 (p = 0.001). CONCLUSIONS: In this population level study, the number of severe PFUIs has decreased in the United States from 1998 to 2014, which coincides with the implementation and enforcement of seat belt and air bag regulations. Given the rarity of these cases, there is a strong need for collaborative efforts in research and teaching at tertiary care centers for reconstructive urology.

A Critical Analysis of Bulbar Urethroplasty Stricture Recurrence: Characteristics and Management.

PURPOSE: We evaluated the management of recurrent bulbar urethral stricture disease after urethroplasty at our institution. MATERIALS AND METHODS: We performed an institution review board approved, retrospective case study of our urethroplasty database to collect stricture related and postoperative information with an emphasis on bulbar urethral stricture disease recurrence after urethroplasty between 1996 and 2012. Repair types included primary anastomotic, augmented anastomotic and onlay repair. Recurrence, which was defined as the need for intervention, was diagnosed with cystoscopy or retrograde urethrogram. RESULTS: We identified 437 men who underwent urethroplasty of bulbar urethral stricture disease as performed by 2 surgeons from January 1996 to December 2012. Of the men 395 had available followup data. Recurrence was identified in 25 men (6.3%), of whom all presented with symptoms, including a weak stream in 23, urinary tract infection in 1 and pyelonephritis in 1. Median time to recurrence was 10 months. Recurrence was initially treated endoscopically in 23 of 25 cases (92%), dilatation in 12 and visual urethrotomy in 11. In 5 patients (22%) further recurrence developed after endoscopic treatment, which was managed by repeat urethroplasty in 2, self-calibration only in 2 and visual urethrotomy with subsequent self-calibration in 1. We identified 2 distinct phenotypes of recurrent stricture, including type A-short focal recurrence, which may be salvaged with an endoscopic procedure, and type B-the long graft length type, which is less likely to be salvaged with endoscopy. CONCLUSIONS: Recurrence after urethroplasty is most likely to develop within the first 12 months. Type A short focal recurrence may be managed by a salvage endoscopic procedure, including dilation or visual urethrotomy. These data on the phenotype of recurrence may be useful for patient treatment.

Female urethral injuries associated with pelvic fracture: a systematic review of the literature.

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta-analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms 'female pelvic fracture urethroplasty', 'female urethral distraction', 'female pelvic fracture urethral injury' and 'female pelvic fracture urethra girls.' Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty-one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very-low-quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure.

PURPOSE: We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling. MATERIALS AND METHODS: We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis. RESULTS: A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31). CONCLUSION: In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

The evolution of urethroplasty for bulbar urethral stricture disease: lessons learned from a single center experience.

PURPOSE: We reviewed the evolution of repairs for bulbar urethral stricture disease and analyzed changes in outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of 429 men who underwent urethroplasty for bulbar urethral stricture disease from January 1996 to September 2011. Patient demographics, stricture related details, and intraoperative and postoperative information were collected. We used 1-way ANOVA for differences in age and stricture length, the Fisher exact test for differences in recurrence rates, and the t-test and chi-square test with the Bonferroni correction for subgroup analysis. RESULTS: Of the 429 men 384 (90%) had followup data available. Buccal mucosa surpassed penile skin as our preferred tissue for augmented anastomotic repairs by 1999. It was accompanied by an improved recurrence rate (21.6% vs 5.8%, p = 0.002). The average length of strictures treated with excision and primary anastomosis increased after 2004 (1.29 vs 1.54 cm, p = 0.05) but this was not associated with a significant change in the recurrence rate (3.0% vs 6.9%, p = 0.27). CONCLUSIONS: The transition from penile skin to buccal mucosa for augmented anastomotic repair was relatively abrupt. We have become more aggressive when performing excision and primary anastomosis with respect to stricture length. These changes resulted in improved outcomes. Continuing review of our practices, awareness of results reported by others and intuition contributed to our changes but prospective analysis will be the best way to continually improve outcomes.

Comparison of diary-derived bladder and sleep measurements across OAB individuals, primary insomniacs, and healthy controls.

INTRODUCTION AND HYPOTHESIS: Can diary-derived bladder and sleep measurements differentiate individuals with overactive bladder syndrome (OAB) from individuals with primary insomnia and healthy controls? METHODS: Bladder- and sleep-diary data were compared in nine OAB, ten insomnia, and five control individuals. One-way analysis of variance (ANOVA) was used for normally and Kruskal-Wallis test for nonnormally distributed variables, followed, when significant effects were found, by pairwise comparisons. RESULTS: OAB individuals woke up as frequently as insomniacs, but their awakenings were respectively shorter in duration (18.6 vs. 38.1 min.) and were predominantly initiated by nocturic events (89.2 vs. 23.9 % respectively). Regardless, their reported quality of sleep was as impaired as for the insomniacs. Furthermore, smaller mean volume voided awakenings were evident not only in those with OAB but also in insomniacs compared to controls. CONCLUSIONS: Bladder- and sleep-diary data provide means to differentiate those with OAB from those with insomnia and healthy controls. Awakenings in OAB individuals were shorter than those with insomnia and much more likely due to the need to void. Thus, a reduction in the number of nocturic voids could be the most appropriate sleep-related outcome for nocturia therapy in individuals with OAB. In addition, limited nocturnal bladder capacity, though expected in OAB, was unexpectedly found in insomnia, possibly reflecting the role of consciousness (wakefulness at night) in modulating bladder sensation.

Outcomes following artificial sphincter implantation after prior unsuccessful male sling.

PURPOSE: Despite the proven success and durability of the artificial urinary sphincter many patients elect an AdVance® sling as the initial treatment of male stress incontinence. We determined whether sling placement would change the outcome of an ensuing artificial urinary sphincter. MATERIALS AND METHODS: A total of 29 patients with stress urinary incontinence after failed sling placement were treated with an AMS 800® artificial urinary sphincter between January 2006 and May 2011. A control group of 136 men with a primary artificial urinary sphincter was used for comparison. Preoperative and postoperative evaluation included demographic variables, voiding diary, 24-hour pad weight, urodynamic characteristics, operative time, estimated blood loss, complication rate, followup and cuff selection. RESULTS: There was no statistical difference in urodynamic characteristics, operative variables or the complication rate. Pad use was reported as less than 1 pad daily in 96% of patients (28 of 29) with a secondary artificial urinary sphincter at 3-month followup. At 20.7 months 6.9% of patients (2 of 29) treated with an artificial urinary sphincter after the male sling required revision of the artificial urinary sphincter. The overall complication rate in the control group was 8.8% (12 of 136 patients) with a 2.2% infection rate (3 of 136). The overall complication rate in the artificial urinary sphincter plus male sling group was 6.9% (2 of 29 patients) with a 0% infection rate. CONCLUSIONS: Patients who require an artificial urinary sphincter after an initial male sling seem to fare as well as those who undergo primary artificial urinary sphincter implantation.

Multiple pudendal sensory pathways reflexly modulate bladder and urethral activity in patients with spinal cord injury.

PURPOSE: Electrical stimulation of pudendal afferents can evoke reflex bladder contractions with relaxation of the external urethral sphincter in cats. This voiding reflex is mediated by pudendal sensory fibers innervating the penile and prostatic urethra that engage spinal and spinobulbospinal micturition pathways, respectively. However, clinical translation of this potential therapy in individuals with spinal cord injury is limited by the lack of evidence showing analogous reflex mechanisms in humans. We investigated excitatory pudendal-to-bladder reflexes in 7 individuals with chronic spinal cord injury. MATERIALS AND METHODS: We recorded isovolumetric bladder pressure and perineal electromyogram in response to intraurethral electrical stimulation at varying amplitudes and frequencies. RESULTS: Selective electrical stimulation of the proximal (29.7 ± 11.6 cm H(2)O) and distal urethral (23.3 ± 9.28 cm H(2)O) segments evoked sustained reflex bladder contractions in different subsets (3 each) of participants. In contrast, the corresponding reflex perineal electromyogram revealed a differential activation pattern between proximal and distal intraurethral stimulation (normalized electromyogram of 1.3 ± 0.2 and 0.3 ± 0.1, respectively, p <0.05). CONCLUSIONS: To our knowledge we report the first clinical evidence of 2 independent excitatory pudendal-to-bladder reflex pathways, which in turn differentially modulate efferent pudendal output. Each reflex mechanism involves complex interaction of multiple sensory inputs and may provide a neural substrate to restore micturition after spinal cord injury.

Detrusor overactivity persisting at night and preceding nocturia in patients with overactive bladder syndrome: a nocturnal cystometrogram and polysomnogram study.

PURPOSE: Nocturia, a common symptom of overactive bladder syndrome, is associated with substantial adverse consequences and yet its pathophysiology has hardly been studied and the capacity to treat it remains limited. We established methods to study the physiology of overactive bladder associated nocturia and better understand this phenomenon. MATERIALS AND METHODS: We recorded simultaneous, time aligned, nocturnal cystometrogram and polysomnogram data during a single night at a sleep laboratory in 9 patients with overactive bladder and detrusor overactivity on daytime cystometrogram, in 10 patients with insomnia and in 5 healthy controls. RESULTS: We safely recorded simultaneous polysomnography/nocturnal cystometrography data accurately during the sleep period. Nocturnal detrusor overactivity occurred significantly less often in patients with insomnia and controls than in patients with detrusor overactivity plus overactive bladder (p = 0.02) and only in the 10 minutes before nocturia events in the latter (0%, 0% and 67%, respectively, p = 0.002). Patients with detrusor overactivity plus overactive bladder were awake for a shorter period before nocturia events (p <0.001) and had a greater percent of nocturia associated awakenings. Patients with insomnia had more awakenings unrelated to nocturia. Nocturnal polyuria, another cause of nocturia, was not significantly associated with nocturnal detrusor overactivity. CONCLUSIONS: Sleep and bladder pressure physiology may be safely monitored during the sleep period accurately. Nocturnal detrusor overactivity occurs in association with nocturia in most patients with detrusor overactivity plus overactive bladder, does not generally occur during sleep and is not due to sleep disturbance or nocturnal polyuria. This study may provide a foundation for research on overactive bladder related nocturia pathophysiology and treatment.

Management of difficult cases in female urology and neurourology at the Reed M. Nesbit society meeting. Festschrift in honor of Edward J. McGuire, MD.

This is a panel discussion of seven complex urologic cases in female urology and neurourology. Differences in diagnosis and management are discussed by this international panel of experts.

Conditional and continuous electrical stimulation increase cystometric capacity in persons with spinal cord injury.

AIMS: Individuals with spinal cord injury (SCI) exhibit neurogenic detrusor overactivity (NDO) causing high intravesicle pressures and incontinence. The first aim was to measure changes in maximum cystometric capacity (MCC) evoked by electrical stimulation of the dorsal genital nerve (DGN) delivered either continuously or conditionally (only during bladder contractions) in persons with SCI. The second aim was to use the external anal sphincter electromyogram (EMG(EAS)) for real-time control of conditional stimulation. METHODS: Serial filling cystometries were performed in nine volunteers with complete or incomplete supra-sacral SCI. Conditional stimulation was delivered automatically when detrusor pressure increased to 8-12 cmH(2)O above baseline. MCCs were measured for each treatment (continuous, conditional, and no stimulation) and compared using post-ANOVA Tukey HSD paired comparisons. Additional treatments in two subjects used the EMG(EAS) for automatic control of conditional stimulation. RESULTS: Continuous and conditional stimulation increased MCC by 63 +/- 73 ml (36 +/- 24%) and 74 +/- 71 ml (51 +/- 37%), respectively (P < 0.05), compared to no stimulation. There was no significant difference between MCCs for conditional and continuous stimulation, but conditional stimulation significantly reduced stimulation time (174 +/- 154 sec, or 27 +/- 17% of total time) as compared to continuous stimulation (469 +/- 269 sec, 100% of total time, P < 0.001). The EMG(EAS) algorithm provided reliable detection of bladder contractions (six of six contractions over four trials) and reduced stimulation time (21 +/- 8% of total time). CONCLUSIONS: Conditional stimulation generates increases in bladder capacity while substantially reducing stimulation time. Furthermore, EMG(EAS) was successfully used as a real-time feedback signal to control conditional electrical stimulation in a laboratory setting.

Outcome of a randomized, double-blind, placebo controlled trial of botulinum A toxin for refractory overactive bladder.

PURPOSE: We determined the effectiveness of cystoscopic administration of botulinum-A toxin compared to placebo for the treatment of urinary incontinence in subjects with idiopathic overactive bladder. MATERIALS AND METHODS: Subjects were recruited from the Division of Urogynecology at the University of Rochester. Inclusion criteria were overactive bladder refractory to anticholinergic medications, multiple daily incontinence episodes and a 24-hour pad weight of 100 gm or greater. Subjects with low leak point pressures, increased post-void residual volume or neurological etiologies were excluded from study. Subjects were randomized to placebo or to 1 of 2 doses of botulinum-A toxin. The detrusor was injected at 8 to 10 sites above the trigone. Evaluations were performed at baseline, and at 3 and 6 weeks after injection, and included bladder diaries, pad weights, quality of life questionnaires and urodynamic studies. RESULTS: A total of 22 subjects participated in stage 1 of this 2-stage study. We report on the outcomes of stage 1 of this study. Because stage 2 is still ongoing and investigators remain blind to the doses of botulinum-A toxin, the 2 botulinum-A toxin groups were combined for this report. There were no differences in mean baseline measurements between the 2 groups. Statistically significant improvements in daily incontinence episodes, pads changed per day and quality of life questionnaires were seen in the botulinum-A toxin group with no changes in the placebo group. No change in nocturia, daily voiding frequency, peak flow or detrusor pressure was seen in either group. Of 15 subjects 4 (26%) receiving botulinum-A toxin had a post-void residual volume of 200 cc or greater and 1 subject required intermittent catheterization. Four subjects experienced a urinary tract infection, 2 (13%) in the botulinum-A toxin group and 2 (28%) in the placebo group (not significant). CONCLUSIONS: Botulinum-A toxin can significantly reduce urge urinary incontinence due to overactive bladder at 6 weeks. However, there is a risk of urinary retention requiring self-catheterization.

Early vs late midline sling lysis results in greater improvement in lower urinary tract symptoms.

OBJECTIVE: Lower urinary tract symptoms (LUTS) occur in 5-20% of women after antiincontinence procedures. Symptoms include complete urinary retention or storage, voiding, and postmicturition symptoms. The goal of this study was to determine the effect of time from sling placement to midline sling lysis on overall improvement in LUTS. STUDY DESIGN: After institutional review board approval, we conducted a retrospective cohort analysis of 112 subjects undergoing midline sling lysis from January 1997-September 2007. The inclusion criteria were women with a vaginal midline sling lysis for LUTS after a prior pubovaginal or midurethral sling. We excluded any subject with sling erosion without LUTS and those who underwent a repeated sling at the time of lysis. We compared subjects who had an early sling lysis (< or = 1 year from sling to lysis) to a late sling lysis (> 1 year). The primary outcome was based on the subject's report of overall improvement in symptoms. We abstracted data on demographics, presenting symptoms, physical examination, date of antiincontinence procedure, date of midline sling lysis, and postoperative symptoms. Statistical analysis consisted of Student t test, chi(2) test, Fisher exact test, and multivariate logistic regression. RESULTS: Of 112 subjects, 74 (66%) had an early sling lysis and 38 (34%) had a late sling lysis. These 2 groups were similar in age, menopausal status, presence of preoperative LUTS, anterior colporrhaphy at the time of lysis, and presence of an eroded sling. The early lysis group had a higher percentage of midurethral slings (36% vs 8%; P = .001), a lower rate of preoperative complete retention (70% vs 89%; P = .001), and a lower rate of prior urethrolysis (16% vs 45%; P = .003). No significant difference in follow-up time was found between early lysis compared with late lysis (49 +/- 89 months vs 43 +/- 71 months; P = .73). Ten (8.9%) subjects developed recurrent stress urinary incontinence after sling lysis, which was independent of time to lysis. In all, 94 (84%) subjects had improvement in their LUTS after midline sling lysis. Overall improvement occurred more often in the early sling lysis group compared with the late sling lysis group (91% vs 71%; P = .01). This finding retained significance in a multivariate logistic regression model, which included age, prior urethrolysis, preoperative complete retention, and type of sling (odds ratio, 4.0; 95% confidence interval, 1.2-13.2). CONCLUSION: Based on this large cohort, patients may benefit from earlier midline sling lysis within 1 year for LUTS after a pubovaginal or midurethral sling procedure. The development of recurrent stress urinary incontinence after midline sling lysis is relatively low.

Erectile function after posterior urethroplasty for pelvic fracture-urethral distraction defect injuries.

OBJECTIVE: To determine the specific effect of pelvic fracture-urethral distraction defect (PFUDD) injuries on erectile function (EF) in men after pelvic fractures, and to compare EF to that found in other studies of men who sustained pelvic fractures, as currently the relationship between erectile dysfunction (ED) and PFUDD has not been elucidated using validated questionnaires. PATIENTS AND METHODS: With approval from the institutional review board, patients who sustained a PFUDD injury and had a posterior urethroplasty from 1990 to 2004 were identified from a database. Patients were contacted by telephone, and those who were willing to participate were given the International Index of Erectile Function (IIEF) questionnaire. Using unpaired Student's t-tests, IIEF scores were compared to normal controls, and to results of other studies of men sustaining pelvic fractures. RESULTS: In all, 26 men completed the IIEF, among whom EF was compromised in 14 (54%), including eight with severe ED (31%). Orgasmic function and ejaculation was maintained. Men with a PFUDD had significantly worse EF than men in other series with pelvic fractures. CONCLUSIONS: Men who sustain a PFUDD are at significantly greater risk of ED than those with no urethral distraction injury. Men with PFUDD injuries represent a target population for early penile rehabilitation programmes.

Ejaculatory profiles and fertility in men after posterior urethroplasty for pelvic fracture-urethral distraction defect injuries.

OBJECTIVE: In men who sustain a pelvic fracture-urethral distraction defect (PFUDD) injury, repairing the urethra involves a complicated urethral anastomosis located posteriorly at the junction of the membranous and prostatic urethra. In this study we performed a post- operative semen analysis and questionnaire study to determine the effect of PFUDD injuries and PFUDD repair on ejaculatory function and fertility in these men. PATIENTS AND METHODS: With institutional review board approval, patients who had PFUDD repairs by one surgeon from 1990 to 2004 were identified from a database. Patients were contacted and given a questionnaire eliciting details about their ejaculatory function and history of fertility. Those interested in future paternity were asked to provide semen for analysis. RESULTS: In all, 32 men were contacted; all claimed to have antegrade ejaculation, although five reported having a lower ejaculatory volume than before their injury, and one claimed that his ejaculate was delayed. We assessed fertility in 19 men, six of whom had either infertility or abnormal semen analyses. CONCLUSIONS: All men in the present series who had PFUDD injuries repaired had antegrade ejaculation. Although six of 19 had either infertility or an abnormal semen analysis, it appears that the risk of damage to the ejaculatory ducts from either a PFUDD or the subsequent urethral reconstruction is low. However, other associated injuries at the time of the pelvic fracture might place these men at greater risk of infertility.

Surgical excision of eroded mesh after prior abdominal sacrocolpopexy.

OBJECTIVE: We previously described an endoscopic-assisted transvaginal mesh excision technique. This study compares surgical outcomes after transvaginal mesh excision vs endoscopic-assisted transvaginal mesh excision. In addition, we reviewed our postoperative outcomes with excision via laparotomy. STUDY DESIGN: This was an inclusive retrospective analysis of patients presenting to our institution from 1997 to 2006 for surgical management of vaginal erosion of permanent mesh after sacrocolpopexy. Three techniques were utilized: transvaginal, endoscopic-assisted transvaginal, and laparotomy. For the patients undergoing transvaginal excision, data recorded included number and type of excisions performed, number of prior excisions performed at outside facilities, intraoperative and postoperative complications (including blood transfusions, pelvic abscess, or bowel complications), use of postoperative antibiotics, persistent symptoms of vaginal bleeding and discharge at follow-up, and demographic characteristics. The intraoperative and postoperative complications and the postoperative symptoms were recorded for the laparotomy cases. RESULTS: Thirty-one patients underwent transvaginal mesh excision during this time period: 17 endoscopic-assisted transvaginal and 14 transvaginal without endoscope assistance. In addition, a total of 7 patients underwent abdominal excision via laparotomy. Comparison of the 2 vaginal methods revealed no difference in the demographics or success rate, with success defined as no symptoms at follow-up. Endoscopic-assisted transvaginal excision was successful in 7 of 17 patients and transvaginal without endoscopic assistance in 9 of 13 patients (1 patient excluded for lack of follow-up data) for a total vaginal success rate of 53.3%. No intraoperative and only minor postoperative complications occurred with either vaginal method. Three patients underwent 3 vaginal attempts to achieve complete symptom resolution. The average follow-up time for the entire vaginal group was 14 months. Seven patients ultimately required abdominal excision and all had symptom resolution, however, not without complications. Two patients had bowel injury during lysis of adhesions requiring bowel resection in 1 case and repair in another, 1 had a postoperative wound infection with breakdown, 1 was readmitted for postoperative fever requiring antibiotics, and 1 had an acute coronary syndrome requiring transfer to the cardiology service. CONCLUSION: Transvaginal excision of mesh with or without endoscopy appears to be a safe and less invasive method for excision of eroded vaginal mesh after prior abdominal sacrocolpopexy. Up to 3 vaginal excision attempts may be necessary to achieve symptom resolution, and complete removal of mesh will likely improve outcomes with the transvaginal technique. Although abdominal excision can be considered the gold standard for excision of eroded mesh, it is not without potentially increased morbidity.

A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery.

OBJECTIVE: The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery. STUDY DESIGN: Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery. RESULTS: Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02). CONCLUSION: Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.

A Critical Evaluation of the Utility of Imaging After Urethroplasty for Bulbar Urethral Stricture Disease.

OBJECTIVE: To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type. MATERIALS AND METHODS: We performed a retrospective review to collect stricture-related and postoperative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week, with a repeat pcRUG if extravasation was noted. RESULTS: We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons: GDW, ACP). We identified 437 patients and 407 (93%) had follow up data. The mean stricture length was 1.97 cm ± 1.2 cm. In those patients who underwent excision and primary anastomosis (EPA) (n = 232, 57%), we performed the1st pcRUG 1 week earlier compared to those who underwent augmented anastomotic repair (n = 150, 37%) or onlay repair (n = 25, 6%). There was no difference in extravasation rates among all repair types at first pcRUG. The overall rate of extravasation on the first postoperative pcRUG significantly decreased in all patients (0.98% vs 5%, P = .0008) and in those who underwent EPA (5.6% vs 0.4%, P = .0016) when the Foley catheter remained for an extra week. CONCLUSION: Men who undergo bulbar urethroplasty have a low extravasation rate (2.2%) 3 weeks postoperatively and those who underwent EPA benefited from an additional week of catheterization.

Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery.

OBJECTIVE: This study was undertaken to evaluate the response to sacral neuromodulation in women with refractory, nonobstructive urinary urge incontinence after stress incontinence surgery. STUDY DESIGN: We reviewed the medical records of women in whom sacral neuromodulation was performed for worsening or de novo urinary urge incontinence after a stress incontinence procedure. All patients had undergone preliminary test stimulation. Demographics, surgical and urogynecologic history, including bladder diary and pad weight test, and urodynamic parameters were evaluated. RESULTS: Of 34 women, 22 (65%) responded to the test stimulation and underwent permanent lead implant. There was no difference between responders and nonresponders with respect to type of stress incontinence surgery. Incontinence or urodynamic parameters were not different between responders and nonresponders. Factors that were predictive of a positive response were women aged less than 55 years (P = .01), the test stimulation performed within 4 years of the stress incontinence procedure (P = .01), and evidence of pelvic floor muscle activity (P = .03). CONCLUSION: Sacral neuromodulation is a viable option for the treatment of refractory urinary urge incontinence that occurs after stress urinary incontinence surgery. Older women with no pelvic floor activity who are remote from their incontinence surgery may have a suboptimal response.