Does choice of anesthesia during stage 1 sacral neuromodulation testing influence outcomes?

INTRODUCTION: Staged sacral neuromodulation (SNM) testing has been shown to have a high rate of progression to permanent implantation for the management of voiding dysfunction. Stage 1 lead placement (SNM-I) can be performed under monitored anesthesia care (MAC) or general anesthesia (GA). MAC allows for interpretation of sensory and motor responses to optimize lead placement while GA only permits for motor assessment. However, patient discomfort and movement can make lead placement challenging during MAC. Herein we evaluate whether the anesthesia type impacts the progression rate to permanent implantation (SNM-II). MATERIALS AND METHODS: A retrospective chart review was performed for patients who underwent SNM-I in the operating room for wet overactive bladder between 2005 and 2023. Patients were divided into two groups based on the type of anesthesia used, MAC or GA. Clinical variables and progression to SNM-II were compared between cohorts. Progression to SNM-II was based on ≥50% symptomatic improvement during a 1-2 week trial period following SNM-I. RESULTS: Of 121 patients included in the study, 95 (79%) underwent MAC and 26 (21%) GA for SNM-I. No difference in the progression rate to SNM-II was noted between groups (MAC, 68/95 patients, 72%; GA, 19/26, 73%; p = 0.39). We also found no difference when comparing the GA group to the 26 most recent MAC patients (MAC, 20/26 patients, 77%; GA, 19/26, 73%; p = 0.48). CONCLUSION: Types of anesthesia for SNM-I did not affect rate of progression to SNM-II. The result lends support to the reliance on motor responses alone for lead placement during SNM-I.

Factors associated with recurrent urinary tract infections in spinal cord injured patients who use intermittent catheterization.

INTRODUCTION: Urinary Tract Infection (UTI) has been cited as the primary cause of morbidity in patients with history of spinal cord injury (SCI). Despite the significance of recurrent UTI (rUTI) in this population, the causative physiologic and patient characteristics are not well described. We sought to assess associations between demographic, clinical and urodynamic variables and rUTI. MATERIALS AND METHODS: The records of 136 individuals with SCI who perform clean intermittent catheterization (CIC) were retrospectively reviewed. All had a video urodynamics study (VUDS) available for analysis. Individuals were divided into non-recurrent (< 3/year) or rUTI (≥ 3/year) groups. Differences between the cohorts were analyzed. Multivariable logistic regression was performed to determine associations between various demographic, clinical, and VUDS variables and rUTI. RESULTS: Self-reported rUTI were noted in 58 of 136 individuals. Of 124 individuals with urinary culture results, African American race (43.3% vs. 22.3%) and 'Other' race (13.3% vs. 8.5%) made up larger proportions in the rUTI group. Female gender (OR 4.96, 95% CI [1.44-17.13]) and African American race (OR 5.16, 95% CI [1.80-14.79]) were increasingly associated with rUTI on multivariable logistic regression. Shorter interval since injury was also significantly associated with recurrent infections with each year since injury indicating diminished likelihood (OR 0.91, 95% CI [0.82-0.99]). There were no significant differences in VUDS variables between groups and none were significant on regression as potential determinants of rUTI. CONCLUSIONS: Patient race, gender, and time since SCI appear to have significant associations with rUTI in individuals with SCI using CIC. However, VUDS variables were not found to be significantly associated with rUTI.

Is a 50% improvement threshold adequate to justify progression from sacral neuromodulation testing to implant?

PURPOSE: A ≥50% subjective improvement in urinary symptoms during sacral neuromodulation testing (SNM-I) is currently used as the indication for progression to second-stage implantation (SNM-II). While most patients will have successful SNM-I and proceed to SNM-II, deterioration in efficacy over time has been reported. It remains unclear if the durability of efficacy is related to the initial symptom reduction. We sought to determine if the degree of improvement after SNM-I is sufficient to predict long-term success. METHODS: The records of all patients who underwent sacral neuromodulation (SNM) for overactive bladder were reviewed. Subjects were divided into those who reported 50%-75% improvement (Group 1) and more than 75% improvement (Group 2) after SNM-I. Differences in clinical variables and long-term device efficacy were compared between groups. RESULTS: Of 213 patients who underwent SNM-I, 137 underwent permanent device implantation. A total of 76 (55%) and 61 (45%) patients reported 50%-75% (Group 1) and more than 75% (Group 2) symptomatic improvement, respectively. With a mean follow-up of 46 months, 44% of Group 1 patients and 68% of Group 2 patients still had a functioning device providing the symptomatic benefit (p = 0.007). Univariate analyses identified the presence of stress urinary incontinence at baseline and having a more than 75% improvement after SNM-I as predictors of long-term functional success. CONCLUSIONS: Compared to patients reporting 50%-75% symptomatic reduction after SNM-I, individuals with a more than 75% improvement during SNM-I were more likely to maintain device efficacy over time. Additional study is warranted to determine if the improvement threshold for progression to SNM-II should be increased.

Intradetrusor botulinum toxin injections (300 units) for the treatment of poorly compliant bladders in patients with adult neurogenic lower urinary tract dysfunction.

AIMS: To evaluate the therapeutic effects of intradetrusor onabotulinum toxin A (BTX) injections in patients with adult neurogenic lower urinary tract dysfunction (ANLUTD) and medically refractory poorly compliant bladders. METHODS: We retrospectively evaluated patients with urodynamic studies (UDS)-proven, medically refractory impaired bladder compliance (≤20 mL/cm H2 O) secondary to spinal myelopathy treated with 300 units of BTX cystoscopically injected into the detrusor muscle. Objective improvement in compliance was defined as an increase ≥5 mL/cm H2 O on repeat urodynamics. Characteristics were compared between patients who demonstrated symptomatic and objective improvement following treatment versus those without. RESULTS: Seventy-one individuals were included in the final analysis. Mean patient age was 37.2 years (range: 18-78) and ANLUTD duration was 14.5 years (range: 1-34). Average pre-injection bladder compliance was 9.2 mL/cm H2 O (range: 3.0-16.7). After treatment with BTX, 37 of 71 (52%) patients reported subjective reductions in lower urinary tract symptoms. Repeat UDS demonstrated objective bladder compliance improvements in 22 of 71 (31%). Individuals with shorter time intervals since neurologic injury responded better to BTX than those with longer durations (P = .032). CONCLUSION: BTX injections significantly improved symptoms and bladder compliance in 31% of ANLUTD patients with medical refractory poorly compliant bladders.

ICS Educational Module: Cough stress test in the evaluation of female urinary incontinence: Introducing the ICS-Uniform Cough Stress Test.

INTRODUCTION: A cough stress test (CST) is recommended in the evaluation of the uncomplicated female patient with the complaint of stress urinary incontinence (SUI) to identify the sign of SUI, and is often used as an outcome measure following SUI treatment. However, there has been no standardization of the performance or reporting of CST. A working group of the International Continence Society (ICS) has developed an educational module, comprising a Powerpoint™ presentation and evidence base manuscript, to instruct on the performance, interpretation, and reporting of the CST in a standardized manner: the ICS-Uniform Cough Stress Test (ICS-UCST). METHODS: The working group performed a PUBMED literature search of articles (observational/experimental and reviews) published prior to 2017 that mentioned a CST. The evidence base examined various variables in performing a CST as well as sensitivity/specificity and positive/negative predictive values of CST. RESULTS: The variables involved in performing/interpreting an ICS-UCST include: patient positioning, degree of bladder filling, number, and forcefulness of coughs, and method of SUI detection. For the ICS-UCST it is recommended that the patient be in a supine/lithotomy position with 200-400 mL of fluid in the bladder. She coughs forcefully 1-4 times and the examiner directly visualizes the urethral meatus for the presence of leakage. Leakage of fluid from the urethral meatus coincident with/simultaneous to the cough(s) is considered a positive test. CONCLUSION: This module provides instructions to educate a uniform CST (the ICS-UCST), with the aim of improving the clinical practice of cough stress testing in female patients with urinary incontinence.

Is mesenteric defect closure needed in urologic surgery using ileum?

INTRODUCTION: Classic surgical teaching advocates for closure of the mesenteric defect (MD) after bowel anastomosis but the necessity is controversial. We sought to evaluate the necessity of MD closure at the time of harvest of ileum for genitourinary reconstructive surgery (GURS) by analyzing the incidence of early and late gastrointestinal adverse events (GIAE) in patients with and without MD closure. MATERIALS AND METHODS: A retrospective review was conducted on patients undergoing urologic reconstruction with ileum to identify incidence of ileus, small bowel obstruction (SBO), gastrointestinal (GI) fistula and stoma complications. Patient and procedure variables were analyzed to identify risk factors for GIAE. RESULTS: A total of 288 patients met inclusion criteria and 93% of GURS was for urinary diversion following cystectomy. MD was closed in 194 cases (67%). Median follow up was 19 months. Early (< 30 day) GIAE rates were 16.5% (n = 32) and 21.3% (n = 20) in the closure and non-closure groups, respectively (p = 0.22). The rate of early ileus/SBO requiring nasogastric tube decompression or laparotomy were similar after closure (15.0%) and non-closure (21.3%) (p = .18). The late GIAE rates were 5.7% (n = 11) and 6.4% (n = 6) in the closure and non-closure cohorts, respectively (p = 0.56). The rate of late SBO were similar and no cases of early or late SBO in either cohort were due to internal herniation. On multivariate analysis, increasing BMI was associated with both early and late GIAE. CONCLUSIONS: After harvesting ileum for urologic reconstruction, the MD can safely be left open as we found no association between non-closure and early or late GIAE..

Less is more-A pilot study evaluating one to three intradetrusor sites for injection of OnabotulinumtoxinA for neurogenic and idiopathic detrusor overactivity.

AIMS: To determine if minimizing the number of onabotulinumtoxinA (BTX) injection sites to one to three locations provides similar clinical efficacy and duration of effect compared to the established technique in treating patients with neurogenic (NDO) or idiopathic detrusor overactivity (IDO). METHODS: Prospective data were collected on BTX naïve patients with NDO or IDO who were intolerant or refractory to oral medications. Patients were treated with 100-300 U of BTX via one to three injection sites. Patients completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) prior to and after treatment. The primary endpoint was defined as ICIQ-SF score improvement of >5 points. Secondary endpoints included subjective success, complete continence, quality of life score, post void residual (PVR), duration of effect and adverse events. RESULTS: Fourty-five patients (22 IDO, 23 NDO) were included. ICIQ-SF score improvement of >5 points was achieved in 73% (IDO 55%, NDO 91%) and the subjective success rate was 69% (50% IDO, 87% NDO). 52% of NDO patients attained complete continence. PVR increased by a mean of 32 and 156 ml in the IDO and NDO groups. Hematuria occurred in 6.7% and symptomatic urinary tract infection occurred in 11.1%. No systemic BTX adverse events occurred. Mean duration of effect was 31 weeks. CONCLUSIONS: Our technique for administering BTX via one to three intradetrusor injection sites has similar clinical efficacy and rates of adverse events compared to the established technique for treating patients with IDO and NDO. Neurourol. Urodynam. 36:1104-1107, 2017. © 2016 Wiley Periodicals, Inc.

Cystectomy and Urinary Diversion for the Management of a Devastated Lower Urinary Tract Following Prostatic Cryotherapy and/or Radiotherapy.

INTRODUCTION: We investigated the outcomes and quality of life measures in men who underwent cystectomy and urinary diversion for devastating lower urinary tract toxicity after prostatic radiotherapy and/or cryotherapy for the treatment of prostate cancer. METHODS: Records of patients who underwent cystectomy and urinary diversion for the management of a devastated lower urinary tract following prostatic radiotherapy or cryotherapy were reviewed retrospectively. A postoperative, retrospective quality of life (QOL) survey was designed specific to this patient subset and obtained by telephone interview. RESULTS: Extirpative surgery with urinary diversion for management of a devastated lower urinary tract was performed on 15 patients with a mean age of 72 years (range 63-82). Toxicities leading to bladder removal included bladder neck contractures, prostatic necrosis, incontinence, osteomyelitis, bladder calculi, fistulae, urethral strictures, abscesses, necrotizing fasciitis, and radiation/hemorrhagic cystitis. The mean number of failed conservative, minimally invasive interventions per patients prior to cystectomy was 3.7 (range 1-12). The average time period from major complication following radiotherapy/cryotherapy to cystectomy was 29.1 months (range 5-65). The QOL survey showed all of the patients who completed the survey (n = 13) would undergo the procedure again and 11 (85%) would have undergone the procedure an average of 13.2 months sooner (range 5-36). CONCLUSION: Toxicities secondary to prostatic radiotherapy or cryotherapy may be debilitating. Our results demonstrate that cystectomy with urinary diversion can improve QOL in patients with a devastated lower urinary tract.

Lower urinary tract dysfunction in patients with dysautonomia.

OBJECTIVE: With the goal of better defining the types of bladder dysfunction observed in this population, we present the chief urologic complaints, results of urodynamic studies, and treatments of patients with dysautonomia-related urinary symptoms. METHODS: All patients with dysautonomia referred to our neurourology clinic between 2005 and 2015 for management of lower urinary tract dysfunction were retrospectively reviewed. Each patient's chief urologic complaint was recorded and used to initially characterize the bladder storage or voiding symptoms. Patient evaluation included history and physical examination, urinalysis, post void bladder ultrasound, and urodynamic studies. Successful treatment modalities that subjectively or objectively improved symptoms were recorded. RESULTS: Of 815 patients with the diagnosis of dysautonomia, 82 (10 %) were referred for evaluation of lower urinary tract dysfunction. Mean age was 47 years (range 12-83) and 84 % were female. The chief complaint was urinary urgency ± incontinence in 61 % and hesitancy in 23 % of patients. Urodynamic findings demonstrated detrusor overactivity ± incontinence in 50 % of patients, although chief complaint did not reliably predict objective findings. Successful objective and subjective treatments were multimodal and typically non-operative. INTERPRETATION: Lower urinary tract dysfunction may develop in at least 10 % of patients with dysautonomia, predominantly females. Bladder storage or voiding complaints do not reliably predict urodynamic findings. Urodynamically, most patients exhibited detrusor overactivity. The majority of patients were successfully managed with medical or physical therapy.

Initial experience with ketamine-based analgesia in patients undergoing robotic radical cystectomy and diversion.

INTRODUCTION: We instituted a ketamine-predominant analgesic regimen in the peri- and postoperative periods to limit the effects of narcotic analgesia on bowel function in patients undergoing radical cystectomy. The primary end points of interest were time to return of bowel function, time to discharge, and efficacy of the analgesic regimen. METHODS: We performed a retrospective chart review of patients undergoing robotic-assisted laparoscopic cystectomy (RARC) with urinary diversion by a single surgeon at our institution from January 1, 2011 to June 30, 2012. Patients receiving the opioid-minimizing ketamine protocol were compared to a cohort of patients undergoing RARC with an opioid-predominant analgesic regimen. RESULTS: In total, 15 patients (Group A) were included in the ketamine-predominant regimen and 25 patients (Group B) in the opioid-predominant control group. Three patients (19%) in Group A discontinued the protocol due to ketamine side effects. The mean time to bowel movement and length of stay in Group A versus Group B was 3 versus 6 days (p < 0.001), and 4 versus 8 days, respectively (p < 0.001). Group A patients received an average of 13.0 mg of morphine versus 97.5 mg in Group B (p < 0.001). CONCLUSIONS: Patients who received our ketamine pain control regimen had a shorter time to return of bowel function and length of hospitalization after RARC. Our study has its limitations as a retrospective, single surgeon, single institution study and the non-randomization of patients. Notwithstanding these limitations, this study was not designed to show inferiority of one approach, but instead to show that our protocol is safe and efficacious, warranting further study in a prospective fashion.

InTone: a novel pelvic floor rehabilitation device for urinary incontinence.

INTRODUCTION: InTone(TM) (InControl Medical) is a nonimplanted vaginal device providing biofeedback and electrical stimulation of pelvic floor muscles. The purpose of this study was to assess its efficacy and usability for treating urinary incontinence (UI). METHODS: Women with UI (stress, urge, mixed) were recruited for this pilot trial. InTone was used 5-6 days a week for 12 weeks. Patients were assessed at baseline and monthly with symptom questionnaires [Urinary Distress Index (UDI6), Incontinence Impact Questionnaire (IIQ7)], bladder diaries. and 24-h pad-weight testing (PWT). Efficacy was assessed by comparing 12-week results to baseline values using chi-square and Wilcoxon rank-sum tests. Usability was assessed with a device-usage log and the System Usability Scale (SUS), which evaluates patients' global impression of usability. RESULTS: Thirty-three women were enrolled; five patients withdrew and were excluded. Median age was 50 years (range 35-69). After 12 weeks of InTone therapy, median UDI6 and IIQ7 scores improved from 50.0 to 29.2 (p < 0.001) and from 42.9 to 14.3 (p < 0.001), respectively. Statistically significant reductions in median PWT (35.5-4.6 g, p < 0.001), median daily pad use (4.0-2.0, p < 0.001), and median daily incontinence frequency (4.3-1.0, p < 0.001) were noted; 68 % of patients achieved a > 50 % reduction in daily pad usage and PWT. Device usability was good, with a median SUS of 86.3 and a median expected use of 107 % (33-140 %). CONCLUSIONS: Twelve weeks of InTone usage resulted in significant objective and subjective reductions in UI. Device usability was very good.

Senior medical student opinions regarding the ideal urology interview day.

INTRODUCTION: Applicant interviews for urology residency positions are a stressful and costly process for students, faculty, and staff. We conducted a prospective survey to better determine what urology applicants perceive as an ideal interview process to gain sufficient knowledge about a training program. METHODS: A questionnaire was anonymously completed by all urology residency applicants interviewing at the Medical College of Wisconsin from 2007 to 2013. Questionnaire subject headings included "ideal interview format," "factors contributing to understanding the residency program," and "factors contributing to final rank list order." RESULTS: Questionnaires were distributed to and completed by 221 senior medical students applying for a urology residency position. Most respondents (>80%) reported they would prefer to partake in 5 to 7 faculty interviews in an office setting with the total interview process spanning half to three-fourths of the workday. Spending time with current residents was considered the most valuable tool to acquire knowledge about a residency program. The most important criteria when ranking a program were resident satisfaction, resident operative experience, and perceived strength of faculty. CONCLUSIONS: Academic urology programs may wish to consider applicant ideals when organizing residency interviews. Interaction with current residents appears to be the most valuable resource allowing applicants to garner knowledge about a urology training program.

Immediate total parenteral nutrition after radical cystectomy and urinary diversion.

INTRODUCTION: The purpose of this study is to determine if administration of total parenteral nutrition (TPN) immediately following radical cystectomy and urinary diversion provides significant recovery benefit when compared to patients who did not receive TPN. METHODS: Retrospective chart review was performed on patients who underwent open radical cystectomy and urinary diversion from February 2002 to June 2010. Patients were divided into 2 cohorts-those who received immediate postoperative TPN and those who did not. Preoperative demographics, length of hospital stay, time until tolerating a regular diet and early postoperative complications of the 2 groups were extracted and compared. RESULTS: One hundred seventy-four patients (104 receiving TPN, 70 without TPN) were available for analysis. No significant difference in preoperative characteristics, length of hospital stay, estimated blood loss, or time until tolerating a general diet between the 2 groups was noted. With regard to complications, the incidence of bacteremia was significantly higher in the TPN vs non-TPN cohort (9% vs 1%, P < 0.05). CONCLUSION: Immediate administration of TPN following radical cystectomy and urinary diversion does not provide a significant postoperative benefit and may lead to an increased risk of bacteremia.

V-Loc urethro-intestinal anastomosis during robotic cystectomy with orthotopic urinary diversion.

INTRODUCTION: Robotic-assisted radical cystectomy (RARC) is an emerging minimally invasive alternative for the treatment of invasive bladder cancer. The V-loc (Covidien, Mansfield, MA) suture is a unidirectional barbed suture that provides even distribution of tension. We determined the rate of urinary leak at the urethro-intestinal anastomosis following orthotopic neobladder construction performed with V-loc suture. METHODS: We retrospectively reviewed charts on all patients that underwent RARC with orthotopic neobladder urinary diversion performed with a V-loc suture from February 2010 to February 2012. The urethro-intestinal anastomosis was evaluated for urinary leak by cystogram at 3 to 4 weeks, postoperatively. RESULTS: In total, 11 patients were available for analysis. The mean patient age was 57.2 years (range: 47-71). The average clinical follow-up was 8 months (range: 4-15). On surgical pathology, 8 (73%) patients had pT2 or less disease, 3 (27%) had pT3/T4 disease, and 1 (9%) had N+ disease. The mean intraoperative blood loss was 315 mL (range: 150-600) and the average operative time was 496 minutes (range: 485-519). No patient (0%) demonstrated a urinary leak at the urethro-intestinal anastomosis on postoperative cystogram. Eight patients (73%) were continent by 4 months, postoperatively. CONCLUSIONS: Orthotopic neobladder urethro-intestinal anastomosis can be performed effectively and safely with V-loc suture with an acceptably low urinary leak rate.

The utility of abdominal ultrasound during percutaneous suprapubic catheter placement.

INTRODUCTION: To evaluate the use of ultrasound (US) at the time of percutaneous suprapubic catheter (SPC) placement. US has been recommended as a way to minimize complications, such as bowel injury, during percutaneous SPC placement, yet there is limited data supporting this recommendation. MATERIALS AND METHODS: A retrospective chart review was performed on patients undergoing percutaneous SPC placement from 2002 to 2011. The method of percutaneous SPC placement (cystoscopic and/or ultrasound guidance, blind) was recorded and patients were subdivided into groups based on the use of US. The need to modify the approach based on US findings and complications such as bleeding or bowel injury were noted and compared between groups. RESULTS: A total of 307 percutaneous SPCs were placed: cystoscopy alone was used in 190 (62%) patients, cystoscopy + US in 86 (28%) patients, US alone in 6 (2%) patients, and 25 (8%) patients had the SPC placed blindly. Previous lower abdominal surgery was noted in 41/92 (45%) of patients with and 32/215 (15%) of patients without US usage. US identified intervening loops of bowel in 5/92 cases (5%), all of whom had a history of lower abdominal surgery. The approach was modified in 2/5 and abandoned in 3/5 based on US findings. Postoperative bleeding occurred in 1/215 (0.5%) of patients with and 1/92 (1%) of patients without US usage. No bowel injuries occurred. CONCLUSIONS: While US may not be needed in most patients, particularly when cystoscopy is used, it may help to avoid bowel injury in patients with a history of lower abdominal surgery.

Duloxetine for the treatment of post-prostatectomy stress urinary incontinence.

OBJECTIVES: Stress urinary incontinence (SUI) is a known complication following prostatectomy. Duloxetine, a combined serotonin/norepinephrine reuptake inhibitor, can decrease SUI by increasing urethral sphincter contractility. We examined the outcomes of patients with mild to moderate post-prostatectomy SUI treated with duloxetine. METHODS: We conducted a retrospective review of men treated with duloxetine to manage mild to moderate post-prostatectomy SUI from 2006 to 2012. All patients received oral duloxetine 30 mg once a week, then 60 mg thereafter. Patients were seen one month later to determine drug efficacy and side effects. RESULTS: In total, 94 men were included in the study. Daily pad usage decreased from 2.9 (range: 1-5) to 1.6 (range: 0-4) (p < 0.05). Incontinence Impact Questionnaire (IIQ-7) scores decreased from 13.0 (range: 6-18) to 7.9 (range: 2-16) (p < 0.05). Linear satisfaction scores improved from 0.8 (range: 0-2) to 2.0 (range: 1-3) (p < 0.05). Following a 1-month duloxetine trial, 33/94 (35%) men reported satisfactory SUI improvement and requested to continue the medication. The drug was discontinued in 61/94 (65%) patients due to poor efficacy in 32/94 (34%), intolerable side effects in 14/94 (15%) or both in 15/94 (16%). Reported side effects included fatigue, light-headedness, insomnia, nausea and dry mouth. CONCLUSIONS: Duloxetine improved post-prostatectomy SUI in 47/94 (50%) men following a 1-month trial. However, only 33/94 (35%) patients were able to tolerate the drug. Duloxetine may be considered a treatment option for men with mild to moderate post-prostatectomy SUI.

Sacral neuromodulation outcomes for the treatment of refractory idiopathic detrusor overactivity stratified by indication: Lack of anticholinergic efficacy versus intolerability.

INTRODUCTION: Patients may fail oral overactive bladder therapies due to either poor drug efficacy or intolerability. We determined if the success of sacral neuromodulation varies if performed secondary to lack of anticholinergic efficacy versus drug intolerability. METHODS: A retrospective review was performed on 152 patients undergoing staged sacral neuromodulation from 2004 to 2010 for refractory idiopathic detrusor overactivity with or without urge incontinence. Outcomes following sacral neuromodulation trials were compared based on the primary indication for anticholinergic failure: lack of drug efficacy versus intolerable side effects. RESULTS: Overall, successful sacral neuromodulation trials were reported in 70% (106/152) of patients. Successful outcomes were noted in 70% (89/128) and 71% (17/24) of patients with poor anti-cholinergic efficacy and drug intolerability, respectively (p = NS). CONCLUSIONS: We found no significant difference in outcome success in patients undergoing sacral neuromodulation trials for refractory detrusor overactivity due to lack of anticholinergic efficacy versus intolerability.

Outcomes of grafted bulbar urethroplasty in men with class II or III obesity.

OBJECTIVE: To evaluate the outcomes of grafted bulbar urethroplasty in class II or III obese patients. MATERIAL AND METHODS: Retrospective chart review was performed for men with World Health Organization class II/III obesity undergoing grafted urethroplasty for management of bulbar strictures from 2003-2010. Extracted data included age, body mass index (BMI), stricture etiology, stricture length/location, number/type of previous therapies, definitive therapy, follow-up, outcome, and complications. Outcomes were compared with a cohort of 20 age-matched nonobese men with bulbar strictures managed with grafted urethroplasty. RESULTS: Fifteen class II/III obese men were included in the study. Obese patient age (43.8 years, range 27-60) and BMI (44.0 kg/m(2), range 35-57) were averaged. Each patient reported a mean of 3.8 previous dilations or urethrotomies (range 0-9). All men were treated with grafted bulbar urethroplasty (11 ventral, 4 dorsal) with oral mucosa (13 buccal, 2 lingual). After a mean follow-up of 29.4 months (range 7-62), the urethral patency rate was 66.7% (10/15). Complications included prolonged urethral leak in 5/15 (33%) and wound infection in 5/15 (33%) patients. Urethral patency rates and complications were significantly higher in class II/III obese patients when compared with the nonobese cohort. CONCLUSION: Obese men demonstrated poorer outcomes after grafted bulbar urethroplasty when compared with published success rates in the general population as well as an aged-matched, nonobese cohort from our institution. Prior failed endoscopic procedures and other medical comorbidities may have also contributed to the observed results in this patient population.

Botulinum toxin outcomes for idiopathic overactive bladder stratified by indication: lack of anticholinergic efficacy versus intolerability.

AIMS: To determine if the outcomes of intradetrusor botulinum toxin A (BTX-A) injections for the management of refractory overactive bladder (OAB) symptoms are different if performed due to lack of anticholinergic efficacy versus medication intolerability. METHODS: Retrospective chart review was performed on all patients undergoing intradetrusor BTX-A (BOTOX®, Allergan Inc., Irvine, CA) injections from 2004 to 2010 for the management of refractory idiopathic OAB with or without urge incontinence. All patients failed anticholinergic medications due to either lack of efficacy or intolerable side effects. Patient outcomes following BTX-A injections (150-200 units) were compared based on the primary reason for discontinuing anticholinergic medications (lack of efficacy vs. intolerability). Successful BTX-A injections were defined as those producing symptomatic OAB improvement warranting future repeat injections upon return of symptoms. RESULTS: A total of 85 patients were included in the study. Overall, 58/85 (68%) reported symptomatic improvement following BTX-A injections. Successful outcomes were reported in 34/57 (60%) patients treated secondary to lack of anticholinergic efficacy versus 24/28 (86%) due to intolerable side effects (P = 0.02). CONCLUSIONS: BTX-A injections are more successful in patients with anticholinergic intolerability as compared to patients with poor medication efficacy (86% vs. 60%, P = 0.02).

Antimuscarinic drugs: review of the cognitive impact when used to treat overactive bladder in elderly patients.

The blockade of muscarinic receptors in the management of overactive bladder (OAB) symptoms provides beneficial as well as adverse effects. The cognitive changes observed are caused by the drugs' ability to cross the blood-brain barrier and bind to muscarinic receptors within the central nervous system (CNS). To date, while not specifically testing for CNS side effects, most of the controlled efficacy trials of multiple OAB medications have not shown significant adverse effects on cognitive function. However, elderly individuals, in whom OAB is more prevalent, often are excluded from these studies. The few trials that have performed cognitive testing in healthy elderly people taking antimuscarinics have clearly shown that oxybutynin can adversely affect cognition. Darifenacin, trospium, solifenacin, and tolterodine appear to have little to no risk of causing CNS side effects in this population. However, caution needs to be used in elderly patients with preexisting dementia.