The Evolving Story of Mesh Mid Urethral Slings: The Surgeon's Perspective.

PURPOSE: The objective of this study was to obtain the perspectives of surgeons who treat female stress urinary incontinence (SUI) and better understand their range of experiences with mesh mid urethral sling (MUS) surgery. MATERIALS AND METHODS: This qualitative study recruited gynecologic and urological surgeons who treat SUI. Surgeons were interviewed by phone and in person using a standardized interview guide. Interviews were transcribed, de-identified, and analyzed by 2 independent researchers. The transcripts were coded and summarized using the principles of thematic analysis. The research team came to consensus that a saturation of ideas representing a diverse demographic of surgeons had been achieved. RESULTS: Twenty-four interviews of surgeons from diverse geographic locations and practice types were performed. Many surgeons described MUS surgery as rewarding and favorably impactful for women with SUI, while others grappled with the serious risks associated with MUS surgery. Those who had treated women with life-altering pain after MUS recounted impactful patient stories. Many stated that recognition, acknowledgement, and appropriate referral of complications were fundamental to responsible and ethical care. Some surgeons expressed frustration and concern about the raised level of controversy and anxiety regarding the MUS landscape. All participants expressed that there was substantial room for improvement in multiple domains. Participants also shared their optimal strategies relevant to MUS surgery. CONCLUSIONS: Despite diverse views regarding the role of the MUS, there was agreement among surgeons that the surgeon-patient relationship, thorough informed consent and patient counseling, and accountability are essential when implanting MUSs.

Changes in patient reported outcome measures after treatment for female urethral stricture.

INTRODUCTION: There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. METHODS: American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. RESULTS: Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). CONCLUSION: Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.

Management of Lower Urinary Tract Symptoms after Prostate Radiation.

PURPOSE OF REVIEW: To present urologists with guidance on how to approach and manage lower urinary tract symptoms (LUTS) in patients who have undergone radiation therapy (RT) for prostate cancer. RECENT FINDINGS: There are few studies that specifically examine treatment approaches for LUTS in patients who have undergone prostate cancer RT. LUTS after prostate RT are unique when compared to de novo LUTS. Understanding these distinctions is important for urologists' practice as well as patients' quality of life. Discussion of the risks and management of post-RT LUTS should be included in the shared decision-making process when counseling patients on various treatment options for prostate cancer. Further studies evaluating treatments for storage and voiding symptoms after RT are needed to help guide future care.

Management of extramammary Paget's disease with a staged, modified Mohs technique.

Extramammary Paget's disease (EMPD) is a rare intraepithelial adenocarcinoma arising from apocrine glands. We describe an innovative surgical technique to manage extensive cutaneous malignancies in a notoriously challenging location. The patient is a 78-year-old male who presented with 'jock itch' on his left groin refractory to topical treatment. A shave biopsy of the lesion demonstrated non-invasive EMPD which yielded a urology consult. Rather than the standard wide local excision (WLE), which can lead to positive margins, progression, and recurrence, we used a modified the Mohs technique and staged the procedure, providing excellent oncologic and cosmetic outcomes. The described technique has particular merit with uncertain margin status and when geography of lesions preclude a standard Mohs surgery.

Disagreement in Female Urethral Nomenclature: A Survey Study of Genitourinary Surgeons.

Introduction: Inconsistencies exist in the nomenclature pertaining to the terms dorsal and ventral female urethra. This survey study was devised to demonstrate this inconsistency, and to identify any surgeon characteristics that contribute to this confusion in urologic and gynecologic reconstructive surgeons.Methods: Genitourinary surgeons were anonymously surveyed using email and social media platforms and asked how they would anatomically label 2 distinctly indicated regions of the female urethra using "dorsal" and "ventral" nomenclature. χ2 statistical analyses were used to compare categorical responses.Results: We received a total of 155 responses: 128 urologists, 26 gynecologists, and 1 medical student. The medical student was excluded from the analysis. Responses to the red/dorsal marker were 48% dorsal, 27% ventral, and 25% free response. Responses to the green/ventral marker were 52% ventral, 26% dorsal, and 22% free response. Urologists were more likely than gynecologists to use the correct "dorsal" label (χ2 [1, N = 122] = 33.6, P < .00001) and "ventral" label (χ2 [1, N = 124] = 32.3, P < .00001). There was no statistically significant difference between attendings vs trainees responding either "dorsal" or "ventral" to describe the red marker (χ2 [1, N = 124] = 0.24, P < .63) or the green marker (χ2 [1, N = 122] = 0.21, P < .65).Conclusions: The terms dorsal and ventral female urethra are not consistent between urologist and gynecologist reconstructive surgeons, and efforts to standardize terminology should be made at the residency training level.

Listening to Learn: A Qualitative Analysis of Women's Experiences with Mesh Mid-urethral Sling Surgery.

OBJECTIVE: To improve women's experiences with mesh mid-urethral sling (MUS) surgery for treatment of stress urinary incontinence (SUI), we sought to qualitatively examine patient perspectives of MUS surgery, organize resulting patient-derived themes, and present our findings as potential springboards for future research and quality improvement efforts. METHODS: We conducted semi-structured focus groups and interviews of patients who had undergone mesh MUS surgery at a single tertiary referral institution. Discussions were recorded, transcribed, de-identified, and analyzed using deductive and inductive content analysis. Two researchers independently performed line-by-line coding which was verified by two additional researchers. RESULTS: Eleven women participated. Most sought SUI care after becoming frustrated with their symptoms. However, some participants experienced barriers to care or dismissal of their symptoms by their physicians. While participants expected improvements in SUI symptoms after MUS surgery, some expected improvement or resolution of other pelvic floor-related issues such as bowel symptoms. Despite having improved SUI symptoms, participants described non-SUI symptoms as negative outcomes from their MUS surgery. Overall, participants wished SUI-associated embarrassment could be lessened and suggested public service announcements to help normalize discussion of SUI symptoms. CONCLUSION: Obtaining first-hand information from SUI patients who have undergone MUS surgery provides insights into what matters to patients. Information from this study can help support further investigation into barriers to care for SUI patients and further study into improving counseling on goals and expectations of MUS surgery. The themes complement the current knowledge on MUS by providing insights that can only be collected through open-ended inquiry.

Patient Perpetrated Sexual Harassment of Urologists: A Survey Based Study.

INTRODUCTION: Patient perpetrated sexual harassment has been studied with family physicians, surgical residents and dermatologists with the prevalence ranging from 27% to 77%. To our knowledge this phenomenon has not yet been studied in urology. METHODS: We surveyed urologists in the United States about their age, employment/training status and their experiences of patient perpetrated sexual harassment. Surveys were anonymous and hosted on a web based platform. Pearson chi-square analysis was used to assess risk factors and descriptive statistics were used to describe prevalence. RESULTS: A total of 190 urologists completed the survey. Patient perpetrated sexual harassment was reported by 49.5% of respondents. Women were more likely to report patient perpetrated sexual harassment when compared with men, at 69% and 23%, respectively (p <0.0001). Being a resident/fellow portended higher rates of patient perpetrated sexual harassment compared to staff/attendings, at 69% and 44%, respectively (p=0.004). Respondents 40 years or younger were more likely to have reported patient perpetrated sexual harassment when compared to those 41 years old or older, at 65% and 39%, respectively (p=0.001). CONCLUSIONS: The results of this survey study suggest that the prevalence of patient perpetrated sexual harassment in the field of urology may be high. Professional societies should perform further investigation into this matter. We suggest proactive development of guidelines and protocols to address patient perpetrated sexual harassment in urology.

Listening to Women: A Qualitative Analysis of Experiences after Complications from Mesh Mid-urethral Sling Surgery.

OBJECTIVE: To gain a detailed understanding of women's experiences after undergoing revision surgery for mesh mid-urethral sling (MUS) complications, qualitatively organize those experiences, and present insights as potential springboards for future research. METHODS: We conducted a series of semistructured focus groups and interviews of patients who had undergone mesh MUS revision surgery at a single tertiary referral institution. Discussions were recorded, transcribed, de-identified, and analyzed using deductive and inductive content analysis. Two researchers independently performed line-by-line coding and 2 additional researchers reviewed the codes and transcripts as an audit. RESULTS: Nineteen women participated in the study. Complications from mesh MUS surgery impacted participants psychologically, socially, sexually, and physically. Participants recounted that risks and alternatives to MUS surgery were understated during the informed consent process whereas benefits were overstated. Participants shared insights into negative and positive ways surgeons responded to postoperative complications and how their experiences impacted the patient-surgeon relationship. CONCLUSION: The impact of complications from mesh MUS surgery is broad and can involve multiple domains of a woman's life. Improved pre-operative patient preparedness, empathetic response toward patients who present with complications, prompt referral to surgeons with experience in mesh MUS complications and multidisciplinary care will likely improve the patient experience and can serve as foci for future studies.

Erosion of Mesh Mid-urethral Sling Into a Complex Urethral Diverticulum: Diagnosis, Evaluation, and Surgical Management.

We present a case of an eroded mesh mid-urethral sling into a urethral diverticulum. Preoperative MRI and 3-dimensional translabial ultrasound aided in the identification and surgical approach. Vaginal excision of sling with urethral diverticulectomy and complex urethral reconstruction was performed. To the author's knowledge, this is the first case documented in the literature describing an eroded mesh mid-urethral sling into a urethral diverticulum.

Delayed Presentation of Iliac Vein Injury: A Severe Complication at Retropubic Midurethral Sling Arm Removal.

Midurethral slings are the most common treatment for female stress urinary incontinence. Perioperative vascular injuries during placement of a retropubic midurethral sling (RMUS) are uncommon but have been described. The objective of this case report is to describe a complication of delayed presentation from a vascular injury at the time of retropubic sling arm removal not previously documented in the literature. This life-threating complication should be considered and precautions should be taken at retropubic sling arm removal. Prevention is accomplished by proper visualization of pelvic vasculature and/or eliminating tension on sling before excision.