Prevalence of colorectal symptoms and anal incontinence in patients with pelvic organ prolapse attended at an outpatient urogynecology service.

Objective: To analyze data of patients with symptomatic pelvic organ prolapse evaluated with PFDI20 and its subscales to report the prevalence of lower gastrointestinal symptoms and anal incontinence in the population of a public hospital and analyze its impact on quality of life. Methods: Cross-sectional study of patients with symptomatic POP. Patients were evaluated with demographic data, POP-Q, pelvic floor ultrasonography, urological parameters, and pelvic floor symptoms (PFDI-20), and quality of life (P-QoL) surveys. Patients were classified as CRADI-8 "positive" for colorectal symptoms, with responses "moderate" in at least 3 and/or "severe" in at least 2 of the items in the CRADI-8 questionnaires. Results: One hundred thirteen patients were included. 42.5% (48) were considered positive for colorectal symptoms on CRADI-8. 53.4% presented anal incontinence. No significant differences were found in sociodemographic variables, POP-Q stage, ultrasound parameters, or urological parameters. Positive patients had a significantly worse result in PFDI-20, POPDI (48 vs 28; p<0.001), UDI6 (51 vs 24; p<0.001), and in the areas of social limitation (44.4 vs 22.2; p = 0.045), sleep- energy (61.5 vs 44.4; p = 0.08), and severity (56.8 vs 43.7, p=0.015) according to P-QoL. Conclusion: Moderate or severe colorectal symptoms are seen in 40% of patients with symptomatic POP in our unit. Full evaluation of pelvic floor dysfunction symptoms should be performed routinely in urogynecology units.(FONIS SA12I2I53 - NCT02113969).

Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital.

Objective: To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications. Methods: A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022. Results: Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I. Conclusion: SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

Levator Ani Avulsion in Ultrasound Increases Recurrence in Sacrospinous Fixation.

IMPORTANCE: Pelvic floor translabial ultrasound (TLUS) can identify levator ani muscle (LAM) avulsion and ballooning, which some studies have shown to be possible risk factors for prolapse recurrence. Our group uses TLUS to counsel patients preoperatively. If any of these risk factors exist, we offer sacrocolpopexy over vaginal repair. However, some patients, even though they have these possible risk factors, prefer to undergo vaginal surgery. OBJECTIVE: The objective of this study was to determine if TLUS LAM avulsion and/or ballooning are risk factors for composite outcome recurrence in patients undergoing sacrospinous ligament fixation for pelvic organ prolapse. STUDY DESIGN: This was a retrospective observational study. All patients with vaginal apical repair with sacrospinous ligament fixation with preoperative TLUS were included. Demographics, clinical characteristics, and follow-up were analyzed. Multivariable logistic regression analysis was performed for composite outcome that included TLUS risk factors, age, Pelvic Organ Prolapse Quantification System measurements and stage, and variables with P < 0.1 in the univariate analysis. RESULTS: Eighty-two patients were included. All patients had symptomatic vaginal bulge; 65.4% had stage III prolapse. Concomitant hysterectomy was performed in 54.3%. Median follow-up was 20 months (interquartile range, 8-35 months); 19.8% had LAM avulsion, and 43.2% had ballooning. Anatomic recurrence rate was 23.5%, symptomatic was 22.2%, and reoperation was 1.2%. The composite recurrence rate was 29.6%. In the multivariable logistic regression analysis, unilateral/bilateral avulsion in TLUS was found to be a significant risk factor for composite outcome with an odds ratio of 4.33 (confidence interval, 1.219-15.398; P = 0.023). CONCLUSIONS: Composite outcome of recurrence in our study was 29.6%. Avulsion on TLUS increased the risk of recurrence of pelvic organ prolapse by fourfold.

Reparación quirúrgica por vía vaginal de fístulas vesicovaginales: una experiencia exitosa / Vaginal surgical repair of vesico-vaginal fistulas: a successful experience

OBJETIVO: Se presenta una serie de casos de reparación por vía vaginal de fístula vesicovaginal (FVV) de nuestro centro. MATERIAL Y MÉTODOS: Estudio observacional descriptivo. Se evaluaron todas las pacientes con reparación quirúrgica de FVV en el Centro de Innovación de Piso Pélvico del Hospital Sótero del Río entre 2016 y 2022. RESULTADOS: Se reportaron 16 casos, de los cuales el 81,3% fueron secundarios a cirugía ginecológica. En todos se realizó la reparación por vía vaginal, con cierre por planos. En el 94% (15/16) se logró una reparación exitosa en un primer intento. El tiempo de seguimiento poscirugía fue de 10 meses (rango: 3-29). No hubo casos de recidiva en el seguimiento. Una paciente presentó fístula de novo, la cual se reparó de manera exitosa en un segundo intento por vía vaginal. Se reportaron satisfechas con la cirugía 15 pacientes, con mejoría significativa de su calidad de vida. Una paciente reportó sentirse igual (6,3%), pero sus síntomas se debían a síndrome de vejiga hiperactiva que la paciente no lograba diferenciar de los síntomas previos a la cirugía. CONCLUSIÓN: Las FVV en los países desarrollados son secundarias a cirugía ginecológica benigna. La cirugía por vía vaginal en nuestra serie demostró una alta tasa de éxito, con mejora significativa en la calidad de vida de las pacientes.

OBJETIVE: We present a case series of vesico-vaginal fistulas (VVF) vaginal repair in our center. MATERIAL AND METHODS: Descriptive observational study. All patients with surgical repair of VVF at the Centro de Innovación en Piso Pélvico of Hospital Sótero del Río were evaluated between September 2016 and September 2022. RESULTS: 16 cases were reported. 81.3% were secondary to gynecological surgery. In all cases, a vaginal repair was performed, with a layered closure. 94% (15/16) had no contrast extravasation at the time of examination, confirming fistula closure. The follow-up time was 10 months (range: 3-29). There were no cases of recurrence during follow-up. 1 patient presented de novo fistula which was successfully repaired in a second attempt vaginally. 15/16 patients reported being satisfied with the surgery, with significant improvement in quality of life. 1 patient reported feeling the same (6.3%), but her symptoms were due to overactive bladder syndrome that the patient could not differentiate from the symptoms prior to surgery. CONCLUSION: VFV in developed countries are mainly secondary to benign gynecological surgery. Vaginal surgery in our series achieved a significant improvement in the quality of life of patients.

Adherencias del capuchón del clítoris al glande: una condición poco estudiada y poco examinada / Clitoral hood adhesions to the glans penis: an understudied and under-examined condition

INTRODUCCIÓN: El clítoris es una de las estructuras vulvares menos examinadas, pese a su relevancia en la vida sexual y sus importantes relaciones anatómicas. Las adherencias del capuchón del clítoris han sido descritas y clasificadas según la exposición del glande, siendo relacionadas con trastornos del deseo sexual. La inervación del clítoris depende de raíces de S3-S4, siendo posible que síntomas frecuentes del piso pélvico tengan relación con esta condición. Realizamos un análisis retrospectivo de pacientes de policlínico de piso pélvico entre noviembre de 2021 y abril de 2022. Se incluyeron 100 pacientes con adherencias al ingreso. RESULTADOS: Promedio de edad 45,8 ± 15,5 años. Las adherencias fueron el 19% leves, el 62% moderadas y el 18% graves. Los principales síntomas eran mal vaciado vesical (38%), dolor (28%), disfunción sexual (39%) y síntomas irritativos vesicales (43%); solo una paciente fue asintomática. El área visible promedio del clítoris era de 20,7 ± 13,7 mm2. CONCLUSIONES: Las adherencias del capuchón del clítoris son un hallazgo común, muchas veces no diagnosticadas, por lo que su evaluación debe ser parte de la exploración física. Pueden asociarse a sintomatología de piso pélvico.

INTRODUCTION: The clitoris is one of the least examined vulvar structures despite its relevance in sexual life and important anatomical relationships. Clitoral hood adhesions have been described in the literature, classified based on glans exposure, and related to sexual desire disorders. The innervation of the clitoris depends on the roots of S3-S4, and frequent pelvic floor symptoms may be associated with this condition. We retrospectively analyzed the clinical record of patients admitted to a pelvic floor clinic between November 2021 and April 2022. One hundred patients with adhesions at the time of admission were registered. RESULTS: Average 45.8 ± 15.5 years. Clitoral hood adhesions were mild (19%), moderated (62%), or severe (18%). The main symptoms were voiding dysfunction symptoms (38%), pain (28%), sexual dysfunction (39%), and irritative bladder symptoms (43%); only one patient was asymptomatic. The visible area of the clitoris was 20.7 ± 13.7 mm2. CONCLUSIONS: Adhesions of the clitoral hood are often undiagnosed, and its analysis should be part of the physical exam. Clitoral hood adhesions could be associated with pelvic floor symptoms.

Manejo exitoso de síndrome de vejiga hiperactiva refractaria con toxina botulínica A / Successful management of refractory overactive bladder syndrome with botulinum toxin A

Introducción: El síndrome de vejiga hiperactiva (VHA) afecta hasta al 43% de las mujeres. La terapia escalonada incluye cambios de hábitos, fármacos y neuromodulación. Hasta el 40% de las pacientes llegan a requerir terapia avanzada alternativa, como toxina botulínica (TB). Objetivo: Reportar los resultados del tratamiento con toxina botulínica en mujeres con VHA refractaria a tratamiento de primera y segunda línea, en un hospital público en Chile. Método: Estudio de cohorte retrospectivo desde una base de datos recolectada prospectivamente del Hospital Sótero del Río entre 2018 y 2022. Se incluyeron 33 pacientes con tratamiento farmacológico y neuromodulación previa, con una edad promedio de 57 años, sometidas a inyección cistoscópica de TB a detrusor, analizando datos demográficos, antecedentes y complicaciones. Se realizó seguimiento con frecuencia miccional, paños/día, escala de gravedad de Sandvik (ISI) y encuesta Patient Global Impression Improvement (PGI-I). Resultados: Los datos comparativos pre/post TB, respectivamente, fueron: frecuencia miccional diurna 11/6 y nocturna 5/1; paños/día 5/3; ISI 8/3. Veinte de 33 mujeres refirieron estar excelente o mucho mejor (PGI-I). Conclusiones: Es posible realizar manejo con TB en mujeres con VHA refractaria a primera y segunda línea, con buenos resultados e impacto significativo en la calidad de vida.

Introduction: Overactive bladder syndrome (OABS) affects up to 43% of women. Staggered therapy includes habit changes, drugs, and peripheral neuromodulation. Up to 40% of patients may require advanced alternative therapy such as botulinum toxin A (BT). Objective: To report the results of treatment with TB in women with OABS refractory to first- and second-line treatment in a public hospital in Chile. Method: Retrospective cohort study from prospectively collected database from Hospital Sótero del Río between 2018 and 2022. Thirty-three patients with previous pharmacological treatment and neuromodulation were included, with an average age of 57 years, undergoing cystoscopic injection of TB to detrusor. Demographic data, history, and complications were analyzed. Follow-up was performed with voiding frequency, cloths/day, Sandvik Severity Scale (ISI) and Patient Global Impression Improvement (PGI-I) survey. Results: Comparative data pre/post TB, respectively showed: daytime voiding frequency 11/6 and nighttime 5/1; cloths/day 5/3; ISI 8/3. 20 of 33 women reported being excellent or much better (PGI-I). Conclusions: TB management in women with OABS refractory to first- and second-line treatment has good results and significant impact on quality of life.

Agentes de abultamiento en incontinencia de orina de esfuerzo femenina: una alternativa a las mallas suburetrales / Bulking agents in female stress urinary incontinence: an alternative to suburethral mesh

OBJETIVO: Presentar una serie de casos de agentes de abultamiento (AA) de nuestro centro. MATERIAL Y MÉTODOS: Estudio retrospectivo. Se evaluaron todos los casos operados con AA entre 2017 y 2022. La inyección de AA se realizó en quirófano, bajo sedación con anestesia local periuretral o raquídea. La inyección se realizó con uretroscopia, 0,5 cc en 4 puntos periuretrales (horas 2, 5, 7 y 10). Se analizaron datos demográficos, quirúrgicos y de seguimiento. RESULTADOS: 15 casos. 13/15 presentaron incontinencia urinaria mixta. Solo dos casos tenían incontinencia de orina de esfuerzo pura. El procedimiento fue ambulatorio. La mediana del tiempo operatorio fue 15 minutos (15-20). La mediana de seguimiento fue 5 meses (1-9). El índice de severidad preoperatorio promedio fue 10,6 y en el seguimiento fue 2,79. La Escala de Mejoría Global mostró mejoría en 12/15, y 12/15 estaban satisfechas con la cirugía con mejoría en la calidad de vida. CONCLUSIÓN: Los AA son una opción quirúrgica efectiva, con una tasa de éxito del 80% en otros reportes, siendo similar con nuestra casuística. Ofrecer esta opción es posible a la hora de hablar de terapias alternativas.

OBJECTIVE: To present a case series of bulking agents (BA) from our center. MATERIAL AND METHODS: Retrospective study. All cases operated with BA between 2017 and 2022 were evaluated. A BA injection was performed in the operating room, under periurethral local anesthesia sedation or spinal anesthesia. The injection was performed with urethroscopy, 0.5 cc in 4 periurethral points (hours 2, 5, 7 and 10). Demographic, surgical, and follow-up data were analyzed. RESULTS: 15 cases were reported. 13/15 patients presented with mixed urinary incontinence. Only 2 cases had pure stress urinary incontinence. The procedure was ambulatory. Median operative time was 15 minutes (15-20). Median follow-up was 5 months (1-9). The average preoperative Sandvik Severity Index was 10.6 and in follow-up was 2.79. The PGI showed improvement in 12/15, and 12/15 were satisfied with the surgery with quality-of-life improvement. CONCLUSION: BA are an effective surgical option, with a success rate of 80%, according to other reports, being similar with our casuistry. Offer this option is possible at the moment of discussing alternative therapies.

Hematoma retropúbico masivo posterior a TVT: enfrentamientos diferentes para una complicación infrecuente / Massive retropubic hematoma after TVT: different approaches for an uncommon complication

INTRODUCCIÓN: La TVT (tension-free vaginal tape) es una cirugía efectiva, pero no exenta de riesgos. Las complicaciones vasculares ocurren en un 0,9-1,7%; solo el 0,33% se presentan como hematoma masivo, en general asociado a la lesión de variante anatómica corona mortis (CM). OBJETIVO: Reportar tres tipos de manejo en pacientes con hematomas masivos después de cirugía para la incontinencia. MÉTODO: Revisión de casos de hematomas masivos tras TVT. Análisis de tres casos con diferente manejo. RESULTADOS: 1086 pacientes operadas en 10 años, 1% hematomas sintomáticos, 0,36% hematomas masivos. Se presentan tres casos. Caso 1: presenta inestabilidad hemodinámica sin respuesta a volumen ni vasoactivos, requirió laparotomía exploradora y se encontró un vaso sangrante retropúbico, compatible con CM, y un hematoma de 1000 cc. Caso 2: hipotensión que responde a volumen, asintomática al día siguiente de alta, reingresó 12 días después con caída de 6 puntos en la hemoglobina y la tomografía computarizada (TC) mostró un hematoma de 550 cc; recibió drenaje percutáneo. Caso 3: asintomática, alta el primer día posoperatorio, reingresa al quinto día con descenso de 4 puntos en la hemoglobina y la TC informa hematoma de 420 cc, que drena espontáneamente por vía vaginal. Todas las pacientes recibieron 14 días de antibióticos, y permanecieron continentes. CONCLUSIONES: Los hematomas retropúbicos masivos son una complicación poco frecuente. Su manejo considera la estabilización hemodinámica, el control del sangrado y el drenaje.

INTRODUCTION: TVT (tension-free vaginal tape) is an effective surgery, not without risks. Vascular complications occur in 0.9 to 1.7%, of which 0.33% present as massive hematoma, generally associated with injury of an anatomical variant, Corona Mortis (CM). OBJECTIVE: To report three types of management in patients with massive hematomas after anti-incontinence surgery. METHOD: Review of cases of massive hematomas after TVT surgery. Analysis of three cases with different management. RESULTS: 1086 patients operated in 10 years, 1% symptomatic hematomas, 0.36% massive. Three cases are presented. Case 1: hemodynamic instability without response to volume or vasoactive agents, required reoperation with exploratory laparotomy, a retropubic bleeding vessel, compatible with CM, and hematoma 1000 cc was found. Case 2: hypotension responds to volume, asymptomatic at next day in discharge conditions, she was readmitted 12 days later with falled 6-point in Hb, and CT showed hematoma 550 cc; she received percutaneous drainage. Case 3: asymptomatic, discharge on the first day after TVT, readmitted on the 5th day with falled 4-point in Hb, CT informed hematoma 420 cc, spontaneously drains vaginally. Patients received 14 days of antibiotics, remained continent. CONCLUSIONS: Massive retropubic hematomas are an infrequent complication, and management considers hemodynamic stabilization, bleeding control and drainage.

Screening of COVID-19 cases through a Bayesian network symptoms model and psychophysical olfactory test.

The sudden loss of smell is among the earliest and most prevalent symptoms of COVID-19 when measured with a clinical psychophysical test. Research has shown the potential impact of frequent screening for olfactory dysfunction, but existing tests are expensive and time consuming. We developed a low-cost ($0.50/test) rapid psychophysical olfactory test (KOR) for frequent testing and a model-based COVID-19 screening framework using a Bayes Network symptoms model. We trained and validated the model on two samples: suspected COVID-19 cases in five healthcare centers (n = 926; 33% prevalence, 309 RT-PCR confirmed) and healthy miners (n = 1,365; 1.1% prevalence, 15 RT-PCR confirmed). The model predicted COVID-19 status with 76% and 96% accuracy in the healthcare and miners samples, respectively (healthcare: AUC = 0.79 [0.75-0.82], sensitivity: 59%, specificity: 87%; miners: AUC = 0.71 [0.63-0.79], sensitivity: 40%, specificity: 97%, at 0.50 infection probability threshold). Our results highlight the potential for low-cost, frequent, accessible, routine COVID-19 testing to support society's reopening.

Caracterización de pacientes con antecedente de colposuspensión de Burch que consultan en uroginecología / Characterization of patients with a background of Burch colposuspension consulting in urogynecology

INTRODUCCIÓN Y OBJETIVOS: La incontinencia de orina de esfuerzo (IOE) es una patología muy frecuente. El tratamiento estándar corresponde al uso de cintas medio uretrales. Dentro de las técnicas quirúrgicas clásicas se encuentra la colposuspensión de Burch (CSB), poco frecuente en la actualidad. El objetivo de este estudio es describir las características de las pacientes con antecedentes de una CSB que consultan en la unidad de Uroginecología. MÉTODOS: Revisión tipo transversal de los datos ingresados a la unidad de Uroginecología del Hospital Dr. Sótero Del Río desde 2007 al 2019. Análisis descriptivo de los antecedentes de las pacientes con antecedente de CSB. RESULTADOS: Durante el periodo analizado, 63 pacientes presentaban antecedentes de CSB. La edad promedio fue 68 años, 88% eran post menopáusicas, 60% fueron sometidas a histerectomía y 24% a cirugías por prolapso (POP). La paridad promedio fue 3 hijos, 15% tuvieron al menos un parto por fórceps. Un 51% consultó por IOE, 54% por vejiga hiperactiva (VH) y 56% por sensación de bulto o peso. El 38% consultó por incontinencia de orina mixta, 37% por IOE + POP y 41% por VH + POP. 22% fueron reoperadas, 16% por medio de TVT y 6% por TOT. CONCLUSIONES: El antecedente de CSB es infrecuente en nuestra población. Similar a lo descrito en la literatura, más de un 50% de las pacientes consultó por síntomas de recurrencia y por complicaciones como POP y VH. Próximos estudios deberían evaluar si el antecedente de CSB es un factor de riesgo de complicaciones quirúrgicas o recurrencia.

INTRODUCTION AND OBJECTIVES: Stress urinary incontinence (SUI) is a common pathology. The standard treatment corresponds to the mid urethral slings. Among the classic surgical techniques is Burch colposuspension (CSB), currently rare. The objective of this study is to describe the characteristics of the patients with a previous history of CSB who consult in the Urogynecology unit. METHODS: Cross sectional review of the data of all the patients admitted to the Urogynecology unit of the Dr. Sótero Del Río Hospital from 2007 to 2019. Descriptive analysis of the antecedents of the patients with a history of CSB. RESULTS: During the analyzed period, 63 patients had a history of CSB. The average age was 68 years. 88% were postmenopausal, 60% underwent hysterectomy, and 24% underwent prolapse (POP) surgery. The average parity was 3, 15% had at least one forceps delivery. 51% consulted for SUI, 54% for overactive bladder (OAB) and 56% for sensation of lump or weight. 38% consulted for mixed urine incontinence, 37% for SUI + POP and 41% for OAB + POP. 22% were reoperated, 16% through TVT and 6% through TOT. CONCLUSION: The history of CSB is infrequent in our population. Similar to that described in the literature, more than 50% of the patients consulted for recurrence symptoms and complications such as POP and OAB. Future studies should assess whether a history of CSB is a risk factor for surgical complications or recurrence.

17-Year Single Center Retrospective Review of Rate, Risk Factors and Outcomes of Lead Breakage during Sacral Neuromodulation Lead Removal.

PURPOSE: One risk of removal of a tined sacral neuromodulation lead is breakage, resulting in a retained lead fragment. We report lead breakage rates, risk factors and outcomes of retained fragments. MATERIALS AND METHODS: We report on 464 tined lead removals from 2002 to 2018. Clinical and surgical factors were reviewed and appropriate statistical analysis performed. Retained fragments were reviewed for fragment description and long-term complications. RESULTS: A total of 464 tined lead removals were included, with 35 lead breaks identified, for a rate of 7.5% (35). Factors associated with breakage included male gender (OR 6.58, 95% CI 2.54-17.01, p=0.001) and diabetes (OR 2.42, 95% CI 1.05-5.58, p=0.019). A shorter time since implantation was protective (OR 0.86, 95% CI 0.76-0.98, p=0.002). There was no difference in breakage rate based on age, weight, history of prior revision, bilateral leads, reason for lead removal, surgical technique or surgeon. Of the 35 breaks 27 had imaging available. Of these 66% (18) broke in the tined region and 81% (22) were ghost leads. Most patients (80%, 28 of 35) with retained lead fragments received another implant. Only 1 patient had a related complication of additional surgery for pain related to the fragment. CONCLUSIONS: There is a low rate of tined lead breakage during lead removal. However, it is higher than the manufacturer estimate. Protective factors include a shorter time between implant and lead revision. The most common location for lead breakage is in the region of the tines, most are ghost fragments and long-term complications are uncommon.

Fluoro-urodynamic Image Interpretation Is Not Altered by Using Dilute Intravesical Contrast.

OBJECTIVE: To determine if using one 250 mL bottle of intravesical contrast followed by sterile saline alters interpretation of fluoroscopic images during fluoro-urodynamics. MATERIALS AND METHODS: Subjects were randomized to receive 250 mL of intravesical contrast followed by sterile saline until maximal cystometric capacity vs non-dilute intravesical contrast alone during fluoro-urodynamics. Interpreters, blinded to study group, graded images on an ordinal rank scale rating confidence in image interpretation. Primary endpoint was differences in image interpretation between the two groups using visual grading characteristics curves and contrast-to-noise ratios (CNR). Secondary endpoints were obtaining anthropometric data such as body mass index and waist circumference to determine predictors of CNR in a multivariate multiple regression analysis. RESULTS: 26 subjects were randomized to receive dilute intravesical contrast and 22 non-dilute contrast; two subjects were unable to complete the study. There was no difference in baseline characteristics between the two groups. Visual grading characteristics demonstrated no difference in readability of the fluoroscopic images between groups and CNR was not statistically different between the two groups. No correlation was identified between CNR and waist circumference or body mass index. CONCLUSION: Interpretation of fluoro-urodynamic images and image quality was not altered with using of 250 mL of contrast followed by saline. Expert reviewers did not perceive a difference in their confidence to distinguish between the two groups. Fluoro-urodynamics can be reliably performed using only 250 mL of contrast without compromising the ability to read the fluoroscopic images.

Can Lumbosacral Magnetic Resonance Imaging be Performed Safely in Patients with a Sacral Neuromodulation Device? An In Vivo Prospective Study.

PURPOSE: We sought to determine the safety of sacral neuromodulation in patients during lumbosacral 1.5 Tesla magnetic resonance imaging. MATERIALS AND METHODS: We prospectively recruited patients with a sacral neuromodulation implant who required lumbosacral 1.5 Tesla magnetic resonance imaging. Before imaging the patients completed validated urinary symptom questionnaires and a survey regarding the usual sacral neuromodulation sensation. The implantable pulse generator was interrogated, and impedances, battery life and stimulus amplitude sensory thresholds were assessed before and after magnetic resonance imaging. Devices were switched off before the patient entered the scanner. Patients were monitored during the study and magnetic resonance imaging related adverse events questionnaires were completed after imaging. Validated questionnaires were repeated 1 month after magnetic resonance imaging to assess for changes in sacral neuromodulation therapeutic efficacy. RESULTS: A total of 11 patients were enrolled in the study. Lower back pain, which was noted by 6 of the 11 patients (55%), was the most common indication for imaging. Immediately after magnetic resonance imaging only 1 patient reported mild discomfort during imaging at the site of the implantable pulse generator. This discomfort was present only during the scan and not afterward. Two patients reported warmth at the implantable pulse generator site during the scan, which was also present only during scanning. Patients did not report any other adverse events. There were no major changes in impedance or battery life after magnetic resonance imaging. Stimulus amplitude sensory thresholds and stimulation localization were unchanged. Validated questionnaires 1 month after imaging did not show worsening scores compared to scores before imaging. CONCLUSIONS: No significant adverse events occurred in patients implanted with a Medtronic InterStim™ II device who underwent a 1.5 Tesla lumbosacral magnetic resonance imaging scan. Therapeutic efficacy of sacral neuromodulation was unchanged 1 month after imaging.

Motor Response Matters: Optimizing Lead Placement Improves Sacral Neuromodulation Outcomes.

PURPOSE: We sought to determine the usefulness of motor responses during sacral neuromodulation lead placement by testing the hypothesis that a greater number of motor responses during intraoperative electrode testing would be associated with more durable therapy. MATERIALS AND METHODS: We retrospectively reviewed all sacral neuromodulation lead placements at a large academic center from 2010 to 2015. Included in study were all unilateral sacral lead placements for which the presence or absence of a motor response was documented discretely for each electrode. Motor responses were quantified into separate subscores, including bellows and toe response subscores (each range 0 to 4) for a possible maximum total score of 8 when combined. Revision surgery was the primary outcome. Univariate and multivariate analyses were performed for factors associated with lead revision. RESULTS: A total of 176 lead placements qualified for analysis. Mean ± SD cohort age was 58.4 ± 15.9 years, 86.4% of the patients were female and 93.2% had undergone implantation for overactive bladder. Median followup was 10.5 months (range 2 to 36). Overall 34 patients (19%) required lead revision. Revision was negatively associated with the total electrode response score (p = 0.027) and the toe subscore (p = 0.033) but not with the bellows subscore (p = 0.183). Predictors of revision on logistic regression included age less than 59 years at implantation (OR 5.5, 95% CI 2-14) and a total electrode response score less than 4 (OR 4.2, 95% CI 1.4-12.8). CONCLUSIONS: Fewer total electrode responses and specifically fewer toe responses were associated with sacral neuromodulation lead revision. These data suggest that placing a lead with more toe responses during testing may result in more durable sacral neuromodulation therapy.

Natural history of pelvic organ prolapse in symptomatic patients actively seeking treatment.

INTRODUCTION AND HYPOTHESIS: At our institution many symptomatic patients must wait months or years for surgery. Our aim was to determine the rates of clinically significant pelvic organ prolapse (POP) progression and identify risk factors associated with POP progression. METHODS: Data from a prospectively maintained database of POP patients evaluated between 2008 and 2013 were analyzed. Women with symptomatic POP and two or more POP-Q examinations prior to surgery were included. POP progression was defined as having any of the POP-Q points Aa, Ba, C, D, Ap or Bp above the hymen at the baseline examination and at or below the hymen at the follow-up examination. Multivariable logistic analysis was preformed and the results are presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Of consecutive patients evaluated between July 2008 and June 2013, 388 met the inclusion criteria and were included. The median time between the POP-Q examinations was 9.9 months (IQR 7.8 to 13.8 months). The POP progression rate was 29.1% (95% CI 24.6-33.6%). Predictors of progression included age (OR 1.7, 95% CI 1.01-2.87) and the baseline status of points Ba, C, Bp and gH (OR 1.91, 95% CI 1.01-3.62; OR 0.53, 95% CI 0.3-0.94; OR 0.54, 95% CI 0.32-0.93; OR 2.15, 95% CI 1.13-4.1; respectively). POP-Q point correlations showed that anterior and posterior compartment points evolve with apical compartment points and gH evolves with both the anterior compartment and the apex. CONCLUSIONS: Up to 29.1% of symptomatic patients with POP showed clinically significant progression over a median follow-up of 9.9 months. The likelihood of progression was not significantly associated with time. Those ≥60 years of age as well as those with point Ba ≥4 cm or gH ≥5 cm at baseline were at increased risk of POP progression.

Removal of Sacral Nerve Stimulation Devices for Magnetic Resonance Imaging: What Happens Next?

INTRODUCTION: Sacral neuromodulation (SNM) devices (Medtronic, Minneapolis, MN, USA) are not approved to undergo magnetic resonance imaging (MRI) of sites other than the head. When MRIs are required, devices are often removed prior to imaging. We reviewed the prevalence of device removal for MRI at a large academic institution and the subsequent clinical course of these patients. METHODS: A retrospective review of all SNM explants from 2009-2015 was performed. Cases explanted for MRI were analyzed to collect demographics, clinical characteristics, and postremoval management. Descriptive statistics were calculated. RESULTS: Ninety patients underwent SNM device removal, with 21 (23%) occurring for MRI. At explant, 20 patients (95%) were female and median age was 66 years. Suboptimal symptom control from SNM was noted in seven (33%) of these patients preoperatively. Of those explanted, six (29%) required MRI for neurologic and 10 (48%) for orthopedic concerns. The remaining MRI indications included abdominal masses (10%), genitourinary disease (5%), surveillance for prior malignancy (5%), and cardiac disease (5%). Only 16 (76%) patients explanted ultimately underwent MRI. MRI results impacted clinical management in 9/16 (56%) of the imaged patients. Only two (10%) of explanted patients underwent device replacement. CONCLUSIONS: In patients receiving SNM therapy, device removal for MRI is most commonly due to orthopedic and neurologic pathologies. About half of the MRIs performed impacted non-GU clinical management. It is of paramount importance to confirm the necessity of MRI before removing a functional SNM device. Since SNM replacement was rare in this cohort, research is needed on the safety of various MRI types with SNM devices in vivo.

Real-Time Changes in Brain Activity during Sacral Neuromodulation for Overactive Bladder.

PURPOSE: We performed functional magnetic resonance imaging to identify changes in brain activity during sacral neuromodulation in women with overactive bladder who were responsive to therapy. MATERIALS AND METHODS: Women recruited into the study had nonneurogenic refractory overactive bladder, responded to sacral neuromodulation and had had a stable program for at least 3 months with no subsequent overactive bladder treatment. Enrolled patients completed validated symptom and quality of life instruments before functional magnetic resonance imaging. Stimulus settings were recorded, devices were switched off for a 5-day washout and instruments were repeated. Three functional magnetic resonance imaging scans with simultaneous sacral neuromodulation stimulation were performed below, at and above stimulus sensory threshold using a block design. This yielded brain activity maps represented by changes in blood oxygenation level dependence. A total of 5 stimulator off and 4 stimulator on cycles of 42 seconds each were imaged. Group analysis was done using a single voxel p value of 0.05 with a false-positive error of 0.05 on cluster analysis. RESULTS: Six of the 13 patients enrolled completed functional magnetic resonance imaging. Median age was 52 years (range 36 to 64). Urinary symptoms and voiding diary data worsened with washout. Overall brain activation generally progressed with increasing stimulation amplitude. However, activation of the right inferior frontal gyrus remained stable while deactivation of the pons and the periacqueductal gray matter only occurred with subsensory stimulation. Sensory stimulation activated the insula but deactivated the medial and superior parietal lobes. Suprasensory stimulation activated multiple structures and the expected S3 somatosensory region. All devices had normal impedance after functional magnetic resonance imaging. CONCLUSIONS: Functional magnetic resonance imaging confirmed that sacral neuromodulation influences brain activity in women with overactive bladder who responded to therapy. These changes varied with stimulus intensity.