The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder.

PURPOSE: The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process, which will maximize symptom control and quality of life, while minimizing adverse events and burden of disease. METHODS: An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements. RESULTS: This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including non-invasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB. CONCLUSION: Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

Cosmetic and functional impact of fascia lata harvest for use in surgery for stress urinary incontinence.

INTRODUCTION: There has been increased interest in using autologous tissues since the Food and Drug Administration banned transvaginal mesh for pelvic organ prolapse in 2019. Our study aims to assess patients' perspective of functional and cosmetic impact on the fascia lata harvest site in patients undergoing fascia lata harvest for the treatment of stress urinary incontinence (SUI). METHODS: This is a prospective survey study of a retrospective cohort of patients who underwent a fascia lata pubovaginal sling between 2017 and 2022. Participants completed a survey regarding the functional and cosmetic outcomes of the harvest site. RESULTS: Seventy-two patients met the inclusion criteria. Twenty-nine patients completed the survey for a completion rate of 40.3%. For functional symptoms, 24.1% (7/29) of patients reported leg discomfort, 10.3% (3/29) reported leg weakness, 10.3% (3/29) reported a bulge, 17.2% (5/29) reported scar pain, 14.8% (4/27) reported scar numbness, and 17.2% (5/29) reported paresthesia at the scar. For cosmetic outcomes, 72.4% (21/29) reported an excellent or good scar appearance. On the PGI-I, 75.9% (22/29) reported their condition as very much better (48.3%, 14/29) or much better (27.6%, 8/29). CONCLUSIONS: The majority of patients reported being satisfied with the functional and cosmetic outcomes of their harvest site as well as satisfied with the improvement in their SUI. Less than 25% of patients report harvest site symptoms, including leg weakness, scar bulging, scar pain, scar numbness, or paresthesia in the scar. This is important in the context of appropriate preoperative discussion and counseling regarding fascia lata harvest.

Evaluation of ChatGPT for Pelvic Floor Surgery Counseling.

IMPORTANCE: Large language models are artificial intelligence applications that can comprehend and produce human-like text and language. ChatGPT is one such model. Recent advances have increased interest in the utility of large language models in medicine. Urogynecology counseling is complex and time-consuming. Therefore, we evaluated ChatGPT as a potential adjunct for patient counseling. OBJECTIVE: Our primary objective was to compare the accuracy and completeness of ChatGPT responses to information in standard patient counseling leaflets regarding common urogynecological procedures. STUDY DESIGN: Seven urogynecologists compared the accuracy and completeness of ChatGPT responses to standard patient leaflets using 5-point Likert scales with a score of 3 being "equally accurate" and "equally complete," and a score of 5 being "much more accurate" and much more complete, respectively. This was repeated 3 months later to evaluate the consistency of ChatGPT. Additional analysis of the understandability and actionability was completed by 2 authors using the Patient Education Materials Assessment Tool. Analysis was primarily descriptive. First and second ChatGPT queries were compared with the Wilcoxon signed rank test. RESULTS: The median (interquartile range) accuracy was 3 (2-3) and completeness 3 (2-4) for the first ChatGPT query and 3 (3-3) and 4 (3-4), respectively, for the second query. Accuracy and completeness were significantly higher in the second query (P < 0.01). Understandability and actionability of ChatGPT responses were lower than the standard leaflets. CONCLUSIONS: ChatGPT is similarly accurate and complete when compared with standard patient information leaflets for common urogynecological procedures. Large language models may be a helpful adjunct to direct patient-provider counseling. Further research to determine the efficacy and patient satisfaction of ChatGPT for patient counseling is needed.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Current Utilization and Perceptions of Formal Education of Point-of-care Ultrasound in Urology.

OBJECTIVE: To assess the extent of formal point-of-care ultrasound (POCUS) training, current utilization of POCUS, and contemporary perceptions of POCUS amongst urologists. METHODS: A survey including questions regarding demographics, prior ultrasound education, current ultrasound utilization in practice/training, perceived optimal POCUS utilization, and the perception of formal ultrasound training was developed. The survey was disseminated to residency program directors (PDs) via the SAU and members of AUA subsection organizations. Data were collected via Redcap. RESULTS: A total of 40 PDs and 159 other respondents completed the survey with approximately half (51%) in an academic practice and two-thirds (68%) with more than 10years in practice. PD response rate was 28%, and general response rate was 2%. Among all respondents, 95% (186/196) and 82% (160/194) agreed/strongly agreed formal POCUS training would be worthwhile during and after residency. Among urology residency PDs, 93% (37/40) agreed/strongly agreed that formal POCUS training is worthwhile in residency. The majority of respondents used some form of ultrasound in practice (77%, 154/199). However, only 37% (72/199) of all respondents had prior formal POCUS training, and 19% (5/26) of PDs reported formal training in their programs. Of respondents without formal training, 63% (80/127) reported interest in pursuing formal training. CONCLUSION: POCUS is widely utilized in many practices. Yet, most urologists have not participated in formal POCUS training and most programs do not have curricula. Urologists have favorable opinions of the utility, safety, and efficacy of POCUS and desire training.

Successful Integration of Blinded Interviews for Resident Selection: Applicant and Faculty Perspective.

OBJECTIVE: To evaluate interviewer and interviewee perceptions of semiblinded interviews performed during 2021-2022 and 2022-2023 urology matches at our institution. Traditional interviews, where interviewers have access to the entire application, are open to significant bias. Blinded interviews are common in industry but under explored in resident selection. METHODS: Interviewers had access to a limited portion of the application (personal statement and letters of recommendation). Applicants were ranked by faculty based solely on their interview and these documents. Following the interview, a survey was given to applicants and faculty regarding their experience. RESULTS: A total of 67 applicants and 10 faculty responded to the questionnaire. Among applicants, 51% felt that blinding of interviewers offered a better assessment of fit into our program (39% neutral), while 37% felt they had improved eye contact with the interviewer (51% neutral) and that interviewers had improved (66%) or similar (19%) knowledge of their application in relation to nonblinded interviews. All but one faculty member felt able to accurately assess a candidate with the information provided, and 80% felt that the blinded interview allowed them to focus more on the applicant during the interview (20% neutral). CONCLUSION: Semiblinded interviews allow for accurate assessment of applicants and decrease bias in the interview process. Overall applicants and faculty were highly receptive to blinded interviews. Reducing the amount of information available to the interviewer allowed them to spend more time on the materials provided, leading to both improved eye contact and improved engagement between participants.

The Impact of the Virtual Interview on Candidate Experience and Outcomes: Society of Academic Urologists National Survey of Interns Who Participated in the 2020-2021 Urology Match.

OBJECTIVE: To examine retrospective experiences with the virtual interview (VI) process among postgraduate year 1 (PGY1) urology residents who participated in the 2020-2021 American Urologic Association (AUA) Match cycle. METHODS: A 27-question survey created by a Society of Academic Urologists Taskforce on VI was distributed to PGY1 residents from 105 institutions between February 1, 2022 and March 7, 2022. The survey asked respondents to reflect on the VI process, cost concerns, and how experiences at their current program aligned with prior VI representation. RESULTS: A total of 116 PGY-1 residents completed the survey. The majority felt the VI represented the following domains well: (1) institution/program culture and strengths (74%), (2) representation of all faculty/disciplines (74%), (3) resident quality of life (62%), (4) personal fit (66%), (5) quality of surgical training and volume (63%), and (6) opportunities to meet residents (60%). Approximately 71% of respondents did not match at their home program or a program they visited in-person. Within this cohort, 13% agreed important aspects of their current program were not translated virtually, and they would not have prioritized the program had they been able to visit in-person. In total, 61% ranked programs they ordinarily might not have listed during an in-person interview season. Overall, 25% deemed financial costs a "very important" consideration during the VI process. CONCLUSION: The majority of PGY1 urology residents reported key components of their current program translated well from the VI process. This platform offers a method of overcoming conventional geographic and financial barriers associated with the in-person interview process.

Understanding the Urology Program Directors Perspective on the Current Resident Selection Process: The Society of Academic Urologists National Survey of Urology Program Directors.

OBJECTIVE: The traditional residency selection process was altered dramatically by the SARS CoV-2 (COVID-19) pandemic. For the 2020-2021 application cycle in-person interviews were transitioned to the virtual format. What was thought to be a temporary transition has now become the new standard with continued endorsement from the Association of American Medical Colleges (AAMC) and the Society of Academic Urologists (SAU) for virtual interviews (VI). We sought to assess the perceived efficacy and satisfaction of the VI format from the urology residency program director's (PDs) perspective. DESIGN: A designated SAU Taskforce on "Optimizing the Applicant Experience in the Virtual Interview Era" developed and refined a survey composed of 69 questions on VI and was distributed to all urology program directors (PD) of member institutions of the SAU. The survey focused on candidate selection, faculty preparation, and interview day logistics. PDs were also asked to reflect on the impact of VI on their match results, recruitment of underrepresented minorities and female gender, and what their preference would be for future applications cycles. PARTICIPANTS: Urology residency PDs (84.7% response rate) between January 13, 2022 - February 10, 2022 were included in the study. RESULTS: Most programs interviewed a total of 36 to 50 applicants (80%), with an average of 10 to 20 applicants per interview day. The top 3 ranked criteria for interview selection reported by urology PDs surveyed included letters of recommendation, clerkship grades, and USMLE Step 1 score. The most common areas of formal training for faculty interviewers were diversity, equity and inclusion (55%), implicit bias (66%), and review of the SAU guidelines on illegal questions (83%). Over half (61.4%) of PDs believed that they were able to accurately represent their training program through the virtual platform, while 51% felt that VI did not afford similar assessments of applicant as in-person interviews. Two-thirds of PDs believed the VI platform improve access for all applicants to attend interviews. Focusing on the impact of the VI platform for recruitment of underrepresented minorities (URM) and female gender applicants, 15% and 24% reported improved visibility respectively for their program, and 24% and 11% reported increased ability to interview URM and female gender applicants respectively. Overall, in-person interviews were reported to be preferred by 42%, and 51% of PDs desired VIs to be included in future years. CONCLUSIONS: PDs opinion and role of the VIs into the future is variable. Despite uniform agreement of cost savings and belief that VI platform improves access for all, only half of PDs expressed interest of the VI format being continued in some form. PDs note limitation of VI in the ability to comprehensively assess applicants as well as the in-person format. Many programs have begun to incorporate vital training in the areas of diversity equity and inclusion bias, and illegal questions. There is a role for continued development and research on ways to optimize virtual interviews.

Effect of Holistic Review, Interview Blinding, and Structured Questions in Resident Selection: Can we Predict Who Will Do Well in a Residency Interview?

OBJECTIVE: To examine the Urology residency application process, particularly the interview. Historically, the residency interview has been vulnerable to bias and not determined to be a predictor of future residency performance. Our goal is to determine the relationship between pre-interview metrics and post-interview ranking using best practices for Urology resident selection including holistic review, blinded interviews, and structured behaviorally anchored questions. METHODS: Applications were assessed on cognitive (Alpha Omega Alpha, class rank, junior year clinical clerkship grades) and non-cognitive attributes (letters of recommendation [LOR], personal statement [PS], demographics, research, personal characteristics) by reviewers blinded to USMLE scores and photograph. Interviewers were blinded to the application other than PS and LORs. Interviews consisted of a structured behaviorally anchored question (SBI) and an unstructured interview (UI). Odds ratios were determined comparing pre-interview and interview impressions. RESULTS: Fifty-one applicants were included in the analysis. USMLE step 1 score (average 245) was associated with Alpha Omega Alpha, class rank, junior year clinical clerkship, and PS. The UI score was associated with the LOR (P = .04) whereas SBI scores were not (P = .5). Faculty rank was associated with SBI, UI, and overall interview (OI) scores (P < .001). Faculty rank was also associated with LOR. Resident impression of interviewees were associated with faculty interview scores (P = .001) and faculty rank (P < .001). CONCLUSION: Traditional interviews may be biased toward application materials and may be balanced with behavioral questions. While Step 1 score does not offer additional information over other PI metrics, blinded interviews may offer discriminant validity over a PI rubric.

Best Practices for Reducing Bias in the Interview Process.

PURPOSE OF REVIEW: Objective measures of residency applicants do not correlate to success within residency. While industry and business utilize standardized interviews with blinding and structured questions, residency programs have yet to uniformly incorporate these techniques. This review focuses on an in-depth evaluation of these practices and how they impact interview formatting and resident selection. RECENT FINDINGS: Structured interviews use standardized questions that are behaviorally or situationally anchored. This requires careful creation of a scoring rubric and interviewer training, ultimately leading to improved interrater agreements and biases as compared to traditional interviews. Blinded interviews eliminate even further biases, such as halo, horn, and affinity bias. This has also been seen in using multiple interviewers, such as in the multiple mini-interview format, which also contributes to increased diversity in programs. These structured formats can be adopted to the virtual interviews as well. There is growing literature that using structured interviews reduces bias, increases diversity, and recruits successful residents. Further research to measure the extent of incorporating this method into residency interviews will be needed in the future.

Evaluating the Whole Applicant: Use of Situational Judgment Testing and Personality Testing to Address Disparities in Resident Selection.

PURPOSE OF REVIEW: Urology program directors are faced with increasing numbers of applications annually, making holistic review of each candidate progressively more difficult. Efforts to streamline evaluation using traditional cognitive metrics have fallen short as these do not predict overall resident performance. Situational judgment tests (SJTs) and personality assessment tools (PATs) have been used in business and industry for decades to evaluate candidates and measure non-cognitive attributes that better predict subsequent performance. The purpose of this review is to describe what these assessments are and the current literature on the use of these metrics in medical education. RECENT FINDINGS: SJTs relative to PATs have more original research. Data suggests that SJTs decrease bias, increase diversity, and may be predictive of performance in residency. PATs are also emerging with data to support use with ability to assess fit to program and certain traits identified more consistently among high-performing residents and correlation to performance on ACGME milestones. PATs may be more coachable than SJTs. SJTs and PATs are emerging as techniques to supplement the current resident application review process. Early evidence supports their use in undergraduate medical education as does some early preliminary results in graduate medical education.

Urethral Pathology in Women.

PURPOSE OF REVIEW: This paper describes the differences in benign, malignant, and iatrogenic urethral pathology in women and reviews common presenting symptoms and management strategies. RECENT FINDINGS: The advancement of magnetic resonance imaging has led to MRI becoming the imaging modality of choice for urethral pathology. Urethral pathology is rare, and there remains a paucity of evidence-based literature for management. Urologists and gynecologists must be familiar with common benign urethral pathology, the most common of which includes urethral diverticula, Skene's gland cyst, urethral prolapse, and caruncle. Further case series are providing further insights to the management of these rare entities. Urologists and gynecologists must understand the most common urethral pathologies and be able to identify the most appropriate treatment approach. It is essential to be able to differentiate these entities from malignancy and obtain a thorough surgical history to identify possible iatrogenic causes.

The Impact of Visiting Rotations on the Urology Residency Match: Insights and Perspectives From the 2021-2022 Applicants.

OBJECTIVE: To survey 2022 Urology Residency Match applicants on their away rotation experiences to better understand the impact of pandemic changes, including the one in-person away rotation limit, on interviews and match outcomes. METHODS: An anonymous post-match online survey was distributed to applicants of study-participating institutions. Data was prospectively collected regarding respondent demographics, away rotation experiences, interviews, utilization of preference signaling, and overall match outcomes. RESULTS: In total, 230 applicants completed the survey. Respondents prioritized geography (28.1%), program reputation (26.1%), and early notification (25.6%) as the top factors in determining whether to accept a rotation offer. The majority (93%) participated in a single away rotation, with nearly all respondents being offered a virtual interview from the program where they completed a visiting clerkship. Of those who declined away rotation offers, 56% were not offered an interview at the program they declined an offer from. The majority matched at either their home institution (20.8%), a program where they submitted a preference signal (22.2%), or a program where they completed an in-person away rotation (13%). Despite 46.3% of respondents reporting that their match outcome was negatively affected by the ability to rotate at only one away rotation, the majority were satisfied (70%) with their rotation selection based on match results. CONCLUSIONS: For applicants, participation in visiting rotations plays a significant role in the match process. Further research regarding mechanisms to optimize the away rotation application process is needed as the capacity to do visiting electives expands in the post-pandemic environment.

Does Antimicrobial Prophylaxis in Patients with Specific Comorbidities Reduce the Risk of Infection after Simple Cystourethroscopy?

INTRODUCTION: We evaluated whether antimicrobial prophylaxis decreases rates of post-procedural infection (urinary tract infection or sepsis) after simple cystourethroscopy for patients with specific comorbidities. METHODS: We utilized Epic® reporting software to conduct a retrospective review of all simple cystourethroscopy procedures performed by providers in our urology department from August 4, 2014 to December 31, 2019. Data collected included patient comorbidities, antimicrobial prophylaxis administration and incidence of post-procedural infection. Mixed effects logistic regression models were utilized to estimate the effects of antimicrobial prophylaxis and patient comorbidities on the odds of post-procedural infection. RESULTS: Antimicrobial prophylaxis was given for 7,001 (78%) of 8,997 simple cystourethroscopy procedures. Overall, 83 (0.9%) post-procedural infections occurred. The estimated odds of post-procedural infection were lower when antimicrobial prophylaxis was given compared to those without prophylaxis (OR 0.51, 95% CI 0.35-0.76; p <0.01). The number needed to treat with antimicrobial prophylaxis to prevent 1 post-procedural infection was 100. None of the comorbidities evaluated showed significant benefit from antimicrobial prophylaxis for prevention of post-procedural infection. CONCLUSIONS: Overall, the rate of post-procedural infection after simple office cystourethroscopy was low (0.9%). Though antimicrobial prophylaxis decreased the odds of post-procedural infection overall, the number needed to treat was high (100). Antibiotic prophylaxis was not shown to significantly reduce the risk of post-procedural infection in any of the comorbidity groups we evaluated. These findings suggest that the comorbidities evaluated in this study should not be used to recommend antibiotic prophylaxis for simple cystourethroscopy.

Tethered spinal cord syndrome in adults in the MRI era: recognition, pathology, and long-term objective outcomes.

OBJECTIVE: Tethered cord syndrome (TCS) has been well described in pediatric patients. Many recent reports of TCS in adult patients have grouped retethering patients with newly diagnosed ones without separately analyzing each entity and outcome. The authors reviewed their experience of newly diagnosed adult TCS patients to identify and explore TCS misdiagnosis, recognition, subtype pathology, and individual objective outcomes. METHODS: This study included 24 adult patients (20 female and 4 male) who fit the criteria of being newly diagnosed and aged 20 years and older (age range 20-77 years). Preexisting dermal sinus was present in 6 patients, hypertrichosis in 5, skin tag/cleft/dimple and fatty subcutaneous masses in 5, scoliosis in 2, and neurological abnormalities in 4 patients. The pathology consisted of TCS with taut filum in 8 patients, conus lipoma with TCS in 7, diastematomyelia in 7, and cervical cord tethering in 2 patients. Of the 24 study patients, nondermatomal low-back or perineal pain occurred in 19 patients, bladder dysfunction in 21, and motor, sensory, and reflex abnormalities in 21 patients. Aggravating factors were repeated stretching, multiple pregnancies, heavy lifting, and repeated bending. Urological evaluation included bladder capacity, emptying, postvoid residuals, detrusor function, pelvic floor electromyography (EMG), bladder sensitivity, and sphincter EMG, which were repeated at 6 months and 1 year postoperatively. The follow-up was 1 to 30 years. Detailed postoperative neurological findings and separate patient outcome evaluations were recorded. Four of the 24 patients did not have an operation. RESULTS: Resolution of pain occurred in 16 of the 19 patients reporting low-back or perineal pain. Motor and sensory complaints resolved in 17 of 20 patients. Regarding bladder dysfunction, in the 20 patients with available data, bladder function returned to normal in 12 patients, improved in 3 patients, and was unchanged in 5 patients. If the symptom duration was less than 6-8 months, there was recovery of all parameters of pain, bladder dysfunction, and neurological deficit, and recovery from hyperreflexia matched that from neurological deficit. Fifteen patients were employed preoperatively and returned to work, and an additional 3 others who were unable to work preoperatively were able to do so postoperatively. CONCLUSIONS: Most adults with newly diagnosed TCS have unrecognized neurocutaneous abnormalities and neurological deficits. The triad of nondermatomal sacral or perineal pain, bladder dysfunction, and neurological deficit should not be confused with hip or degenerative lumbosacral disease. Addressing the primary pathology often leads to successful results.

Performing Medical Education Research in Urology: Challenges and Opportunities.

PURPOSE OF REVIEW: The Accreditation Council for Graduate Medical Education (ACGME) mandates educating resident physicians in evidence-based medicine (EBM) as a core program requirement. However, despite the significant emphasis placed on EBM, graduate medical education is far from evidence-based, and urology is a specialty where medical education research (MER) is particularly sparse. We want to articulate the challenges and opportunities with performing meaningful medical education research in urology training programs. RECENT FINDINGS: Some studies suggest that the rigor of MER could be much stronger. The nature of GME requires researchers to use alternative study designs. Further, the unique role of residents as both learner and study subject and the dual role of faculty as researcher and educator pose challenges to carrying out research. There is a tremendous opportunity for improvement and innovation in both quality and efficiency of urology resident education. Rigorous MER is required to advance this opportunity, and the fundamental key is development of mentors and collaboration.

A timeline of female stress urinary incontinence: how technology defined theory and advanced treatment.

BACKGROUND: Prevailing theories and treatments of female stress urinary incontinence are built on 120 years of evolution in understanding the structure and function of the female bladder neck and urethra and of considering why treatments failed. In our management of patients, it is important to understand and appreciate how our management of female stress urinary incontinence has evolved and which treatments have prevailed as we advance our knowledge for future treatments. AIMS: The purpose of this review is to describe how advances in technology impacted and shaped prevailing theories or understanding of the pathophysiology of stress urinary incontinence and influences our treatment approach. MATERIALS AND METHODS: An extensive literature search was performed from 1900 to present identifying articles that discussed technological advancements in female urology, theories of female stress incontinence, and treatments. RESULTS: The literature from the 20th century to the present shows a nonlinear evolution of the pathophysiological mechanism of stress urinary incontinence (SUI) from a notion of SUI and secondary to a simple anatomic finding to consideration of the effects of neurophysiologic pathways on SUI. Slings, however, have been a staple in the management of SUI. CONCLUSIONS: The pubovaginal sling (PVS) is a procedure that, with minor modifications (graft size, suture preference) has withstood the test of time and maintained its place in the armamentarium of SUI treatment for 100 years. It is therefore imperative that we continue to educate our residents and fellows on the surgical techniques and indications for use of the PVS.

Urinary tract infection and drug-resistant urinary tract infection after intradetrusor onabotulinumtoxinA injection versus sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: Intradetrusor onabotulinumtoxinA (BTX) and sacral neuromodulation (SNM) are effective treatments for refractory urgency urinary incontinence/overactive bladder (UUI/OAB). BTX carries a risk of urinary tract infection (UTI), which is concerning for the development of multidrug resistant (MDR) UTI. We hypothesized that BTX might carry a higher risk of UTI and MDR UTI compared with SNM and that UTI and MDR UTI risk might increase after repeat BTX injection. METHODS: This retrospective cohort study included women undergoing BTX or SNM for refractory UUI/OAB in 2012-2016. UTI and MDR UTI were assessed up to 1 year post-treatment or until repeat treatment and compared between initial BTX and SNM and between repeat BTX injections. Univariate analyses included Chi-squared and Fisher's exact tests and generalized linear models (GLM) with logit link function. Multivariate analyses used GLM to assess the best predictor variables for any UTI. RESULTS: One hundred and one patients were included (28 BTX, 73 SNM). Rates of UTI (39.3% [95% CI 21.5, 59.4] BTX vs 37.0% [95% CI 26.0, 49.1] SNM) were similar in the two groups at all time intervals. One MDR UTI occurred after SNM. Risk of UTI did not increase with repeat BTX (11 out of 28 [39.3%], 6 out of 17 [35.3%], and 4 out of 7 [57.1%] after 1, 2, and ≥ 3 treatments respectively; p = 0.62). Multivariate analysis found that history of recurrent UTI (OR 2.5, 95%CI 0.98-6.39) and prolapse repair (OR 4.6, 95%CI 1.23-17.07) had increased odds of UTI. CONCLUSIONS: Rates of UTI were similar in patients undergoing BTX and SNM. MDR UTI was rare. Patients with prior prolapse repair or recurrent UTI may be at a higher risk of UTI after either procedure.

Prospective Randomized Feasibility Study Assessing the Effect of Cyclic Sacral Neuromodulation on Urinary Urge Incontinence in Women.

OBJECTIVES: The aim of this prospective, randomized, multicenter, single-blind, 4 × 4 crossover study was to estimate the effect of 4 InterStim cycling settings (continuous, 16 seconds on/8 seconds off, 10 minutes on/10 minutes off, and 30 minutes on/23.5 hours off) on efficacy, Global Response Assessment, and safety. METHODS: Eligible women implanted for at least 3 months for urgency urinary incontinence (UI) were enrolled, and daily diaries were collected. General linear mixed models were used to estimate the cycling effect on efficacy. Quality of life measured by Global Response Assessment (subjects' perception of effectiveness) and safety were summarized. RESULTS: Primary efficacy analysis was based on the first 24 subjects who completed unique randomization sequences. Mean age was 64 years, and mean implant duration was 2.8 years. Results showed no significant cycling (P = 0.3773) or period (P = 0.0800) effect on UI. There was a statistically significant interaction between cycling and period (P = 0.0032). In the first period, subjects on 10 minutes on/10 minutes off had significantly fewer UI episodes compared with subjects on 16 seconds on/8 seconds off (P = 0.0026); this difference was not observed in any other period or sensitivity analyses. No cycling effect was found on urgency or pad usage. When programmed to 10 minutes on/10 minutes off, 54% of subjects felt their incontinence symptoms improved compared with when they entered the study, followed by 42% on 30 minutes on/23.5 hours off, 38% on 16 seconds on/8 seconds off, and 29% on continuous. Safety was similar across cycling settings. CONCLUSIONS: The results suggest that patients with overactive bladder who have been implanted with sacral neuromodulation devices and are receiving substantial benefit may perceive further optimization by switching to cycling settings.