Risk factors for stress urinary incontinence recurrence after midurethral sling revision.

OBJECTIVES: The purpose of this study was to report the rate of stress urinary incontinence (SUI) recurrence after sling revision, and to determine predictive factors of SUI recurrence. METHODS: We conducted a retrospective cohort study in a single academic center between 2005 and 2022, of patients who underwent sling revision. Four surgical techniques were used for sling revision (loosening, section, partial, and total excision). The primary endpoint was recurrence of SUI at 3 months postoperatively, and the other outcome of interest was the rate of subsequent anti-incontinence surgical procedure. RESULTS: Sixty-nine patients were included for analysis. SUI recurred in 46.4% of patients. Fifteen patients underwent a subsequent anti-incontinence procedure (21.8%). The time to revision was significantly longer in the group with recurrent SUI (median: 84.5 vs. 44.8 months; p = 0.004). The recurrence rate differed significantly depending on the revision technique: 7.7% after sling loosening, 22.2% after sling section, 60% after partial excision, and 66.7% after complete sling removal (p = 0.001). The risk of SUI recurrence was lower for those whose indication of reoperation was voiding dysfunction (27.3% vs. 66.7%; p = 0.002), and was higher for those who underwent a trans-obturator tap rather than a tension-free vaginal tape revision (68.4% vs. 35.7%; p = 0.02). In multivariate analysis, only the revision technique remained significantly associated with the risk of recurrence of SUI (complete excision vs. section: odds ratio = 4.66; p = 0.04). CONCLUSION: The risk of SUI recurrence may differ widely according to the techniques used, and it seems that the less extensive the surgical procedure is, the lower the risk is.

Adjustable Continence Therapy Balloons in Female Patients with Stress Urinary Incontinence: A Systematic Review.

INTRODUCTION: The aim of this study was to perform a systematic review of studies reporting the outcomes of ACT® balloons in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). METHODS: In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) standards, a systematic search of the PubMed (Medline) and Scopus electronic database was performed in June 2022. Terms used for the query were ("female" or "women") and ("adjustable continence therapy" OR "periurethral balloons"). RESULTS: Thirteen studies were included. All were retrospective or prospective case series. The success rates ranged from 13.6% to 68% and the improvement rates from 16% to 83%. The intraoperative complication rate ranged from 3.5 to 25% and consisted of urethral, bladder, or vaginal perforations. The rate of postoperative complications varied from 11 to 56% without major complications. Between 6% and 38% of ACT® balloons were explanted and subsequently reimplanted in 15.2-63% of cases. CONCLUSION: ACT® balloons can be considered as an option to treat SUI due to ISD in female patients with a relatively modest success rate and quite a high complication rate. Well-designed prospective studies and long-term follow-up data are needed to fully elucidate their role.

Google searches for stress urinary incontinence treatment options: a worldwide trend analysis in the synthetic mesh controversy era.

PURPOSE: To analyze trends in worldwide public interest in the treatment options for stress urinary incontinence around the latest FDA 2019 ban on vaginal mesh for prolapse. METHODS: We used the web-based tool Google Trends to analyse online searches related to the following terms: 'pelvic floor muscle exercises', 'continence pessary', 'pubovaginal slings', 'Burch colposuspension', 'midurethral slings', 'injectable bulking agents'. Data were expressed as relative search volume on a scale of 0-100. Comparisons of annual relative search volume and average annual percentage change, were analyzed to assess loss or gain of interest. Finally, we assessed the impact of the last FDA alert. RESULTS: The mean annual relative search volume for midurethral slings was 20% in 2006 and significantly decreased until 8% in 2022 (p < 0.01). A regular decrease interest was recorded for autologous surgeries but a regain of interest for pubovaginal slings was registered since 2020 (+ 2.8%; p < 0.01). Conversely, a steep interest was noted for injectable bulking agents (average annual percentage change: + 4.4%; p < 0.01) and conservative therapies (p < 0.01). When trends were compared before and after the FDA 2019 alert, a lower research volume was found for midurethral slings, while a higher research volume was observed all others treatments (all p < 0.05). CONCLUSION: The online public researches about midurethral slings have considerably decreased following warnings on the use of transvaginal mesh. There seems to be a growing interest in conservative measures, bulking agents, and recently pubovaginal slings.

Comparison of early loosening vs delayed section of mid-urethral slings for postoperative voiding dysfunction.

INTRODUCTION AND HYPOTHESIS: Bladder outlet obstruction (BOO) is a common occurrence after midurethral sling (MUS) insertion and can result in acute or chronic urinary retention or de novo lower urinary tract symptoms (LUTS). However, the management of BOO after MUS is not standardised. The objective of this study was to compare two therapeutic strategies for suspected BOO after MUS. METHODS: Patients who had surgical revision for voiding dysfunction with a post-void residual (PVR) ≥100 ml after MUS in five centres between 2005 and 2020 were included in a retrospective study. Patients were divided into two groups: early sling loosening (EL) vs delayed section/excision of the sling (DS). RESULTS: Seventy patients were included: 38 in the EL group and 32 in the DS group. The postoperative complication rate was comparable in both groups (10.5% vs 12.5%; p = 0.99). At 3 months, the rate of withdrawal from self-catheterisation was similar in the two groups (92.1% vs 100%; p = 0.25) as was the PVR (57.5 vs 63.5 ml; p = 0.09). After a median follow-up of 9 months, there were significantly more patients with resolved voiding dysfunction in the EL group (63.2% vs 31.3%; p = 0.01). The rate of persistent/recurrent stress urinary incontinence (SUI) was higher in the DS group (21% vs 43.7%; p = 0.04). In multivariate analysis, the main predictive factor of recurrent SUI was DS (OR 2.87, 95% CI 1.01-8.60, p = 0.048). CONCLUSIONS: Early loosening of MUS in the case of postoperative voiding dysfunction offers better efficacy than DS of the sling, with a lower risk of recurrent/persistent SUI.

Online Public Interest in Urological Cancers During the COVID-19 Pandemic: What Can "Dr. Google" Teach Us?

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has greatly affected health care priorities. OBJECTIVE: To explore and analyse trends in public online search for urological cancers. DESIGN SETTING AND PARTICIPANTS: We performed a retrospective analysis using the Google Health Trends online tool. Data related to urological cancer terms ("prostate cancer", "kidney cancer", and "bladder cancer") were extracted. We analysed trends for the whole world and for five countries: Italy, the UK, France, Sweden, and the USA. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A join-point regression model was used to define significant changes in trends over time. Week percentage changes (WPCs) were estimated to summarise linear trends. The Mann-Whitney test was used to compare the search volume during the COVID-19 pandemic period (from January 2020 to April 2021) and the equivalent period of 2018 and 2019. RESULTS AND LIMITATIONS: During COVID-19, worldwide online interest decreased significantly for all urological cancers, especially prostate cancer (WPC: -13.9%, p = 0.004; WPC: -5.4%, p < 0.001; and WPC: -4.3%, p < 0.001, for prostate, kidney, and bladder cancers, respectively). The most important decline was observed in the USA. The interest for all cancers was significantly less during the COVID-19 pandemic than in the same periods of 2018 and 2019. CONCLUSIONS: Online interest in urological cancers decreased significantly during the COVID-19 pandemic. Future studies will tell us whether this will translate into worse oncological outcomes. PATIENT SUMMARY: Patients are increasingly searching the Internet to get information on cancer. We explored Google queries during the COVID-19 pandemic and found that online interest decreased significantly for all urological cancers, especially prostate cancer. We do not know yet whether this will translate into worse prognosis for patients.

Review of automated performance metrics to assess surgical technical skills in robot-assisted laparoscopy.

INTRODUCTION: Robot-assisted laparoscopy is a safe surgical approach with several studies suggesting correlations between complication rates and the surgeon's technical skills. Surgical skills are usually assessed by questionnaires completed by an expert observer. With the advent of surgical robots, automated surgical performance metrics (APMs)-objective measures related to instrument movements-can be computed. The aim of this systematic review was thus to assess APMs use in robot-assisted laparoscopic procedures. The primary outcome was the assessment of surgical skills by APMs and the secondary outcomes were the association between APM and surgeon parameters and the prediction of clinical outcomes. METHODS: A systematic review following the PRISMA guidelines was conducted. PubMed and Scopus electronic databases were screened with the query "robot-assisted surgery OR robotic surgery AND performance metrics" between January 2010 and January 2021. The quality of the studies was assessed by the medical education research study quality instrument. The study settings, metrics, and applications were analysed. RESULTS: The initial search yielded 341 citations of which 16 studies were finally included. The study settings were either simulated virtual reality (VR) (4 studies) or real clinical environment (12 studies). Data to compute APMs were kinematics (motion tracking), and system and specific events data (actions from the robot console). APMs were used to differentiate expertise levels, and thus validate VR modules, predict outcomes, and integrate datasets for automatic recognition models. APMs were correlated with clinical outcomes for some studies. CONCLUSIONS: APMs constitute an objective approach for assessing technical skills. Evidence of associations between APMs and clinical outcomes remain to be confirmed by further studies, particularly, for non-urological procedures. Concurrent validation is also required.

Artificial intelligence in functional urology: how it may shape the future.

PURPOSE OF REVIEW: The aim of the present manuscript is to provide an overview on the current state of artificial intelligence (AI) tools in either decision making, diagnosis, treatment options, or outcome prediction in functional urology. RECENT FINDINGS: Several recent studies have shed light on the promising potential of AI in functional urology to investigate lower urinary tract dysfunction pathophysiology but also as a diagnostic tool by enhancing the existing evaluations such as dynamic magnetic resonance imaging or urodynamics. AI may also improve surgical education and training because of its automated performance metrics recording. By bringing prediction models, AI may also have strong therapeutic implications in the field of functional urology in the near future. AI may also be implemented in innovative devices such as e-bladder diary and electromechanical artificial urinary sphincter and could facilitate the development of remote medicine. SUMMARY: Over the past decade, the enthusiasm for AI has been rising exponentially. Machine learning was well known, but the increasing power of processors and the amount of data available has provided the platform for deep learning tools to expand. Although the literature on the applications of AI technology in the field of functional urology is relatively sparse, its possible uses are countless especially in surgical training, imaging, urodynamics, and innovative devices.

Outpatient laparoscopic sacrocolpopexy: Feasibility and patient satisfaction.

OBJECTIVE: Laparoscopic sacrocolpopexy is the standard surgery to correct apical pelvic organ prolapse. It is currently mainly practiced in the context of a conventional hospitalization, but more and more practitioners are developing it as an outpatient procedure. The objective of this study was to evaluate the feasibility of outpatient laparoscopic sacrocolpopexy and patient satisfaction. METHODS: This was a retrospective study comparing outpatients with inpatients who had undergone laparoscopic sacrocolpopexy. The main outcome was the rate of unscheduled visits and the number of early readmissions (i.e., <1 month). Secondary outcomes were complication rates and patient satisfaction. RESULTS: Eighty-four patients were included with 42 women in each group. The rate of unscheduled consultations was 16.7 % (n = 7/42) in the outpatient group and 21 % (n = 9/42) in the inpatient group. 2.4 % (n = 1/42) of outpatients and 4.8 % (n = 2/42) of inpatients were re-hospitalized within a month after surgery. The complication rate was not significantly different between the groups. In the outpatient group, 88.2 % of patients were satisfied compared with 97.5 % in the inpatient group (p = 0.17) CONCLUSIONS: Outpatient laparoscopic sacrocolpopexy can be considered a safe and satisfactory option.

Propensity-score analysis comparing perioperative and functional outcomes between XPS 180 W-photovaporization and GreenLight laser enucleation of the prostate: reasons to discard vaporization and move to enucleation.

PURPOSE: To compare the perioperative and functional outcomes between 180_W XPS GreenLight photoselective vaporization (PVP) and 532-nm GreenLight laser enucleation of the prostate (GreenLEP) in the surgical management of benign prostatic obstruction (BPO). METHODS: Retrospective review of a prospectively maintained international database of patients managed with GreenLight laser surgery (PVP or GreenLEP) was performed. To adjust for potential baseline confounders, propensity-score matching (PSM) was applied at a ratio of 1:1 to compare the perioperative and functional outcomes between the groups. RESULTS: A total of 2,420 patients were included. 1,491 (61.6%) underwent PVP and 929 (38.4%) underwent GreenLEP. Before PSM analysis, patients in the vaporization group were older (p < 0.001), had a lower PSA and prostate volume at baseline (p < 0.001). Using estimated propensity scores, 78 patients in the PVP group were matched 1:1 to the patients in the GreenLEP group. The incidence of overall postoperative complications was comparable between the two groups (19 vs. 16%, p = 0.06). However, after PSM, PVP was found to be associated with a higher rate of overall complications (33 vs. 11%, p = 0.001). At 3 months and at last follow-up the I-PSS, Qmax and PSA had similarly decreased in the two groups with a greater improvement in the GreenLEP group (all p < 0.05). CONCLUSIONS: PVP and GreenLEP are two efficient and safe techniques for treating BPO. However, PVP was associated with longer operative time and higher risk of reoperation on a midterm follow-up compared to GreenLEP.

Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study.

OBJECTIVE: To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy. RESULTS: Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP. CONCLUSIONS: Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.