Is it the Surgeon? A Re-examination of Mid-urethral Sling Complications.

OBJECTIVE: To identify potential technical factors during initial mid-urethral sling (MUS) placement that contribute to subsequent sling revision procedures. METHODS: A retrospective chart review was performed examining synthetic MUS reoperations at a single institution from 2008-2020. The implanting surgeon's operative note, when available, was critically reviewed with respect to trocar placement, sling location, and tensioning technique. The reoperative report was reviewed for aberrant intraoperative findings relating to the index surgery. RESULTS: A total of 306 women underwent revision of their MUS. Operative reports from the implanting surgeon were available for 276 (90.2%) women. Review of index operative reports revealed 47 unambiguous descriptions of improper technique, including 19 cases of described excessive tensioning and 2 cases of MUS placement despite noted urethral injury during the index case. Indications for reoperation were clinical obstruction (63%), pain (40%), and mesh erosion/exposure (33%). In 186 (67.4%) women, there was an intraoperative finding during the revision that likely contributed to the need for reoperation. Among these 186 women, 110 (59.1%) slings were noted to have been placed too proximally, 78 (41.9%) were over-suspended, and 57 (30.6%) were placed too deep in the periurethral fascia. CONCLUSION: Review of the index operative note and findings at operative re-exploration of MUS surgeries, often reveals evidence that the initial MUS implantation was technically suboptimal. Such findings suggest that intraoperative surgical technique is a critically important factor contributing to postoperative complications in MUS surgery. This underscores the importance of surgical training and adherence to surgical principles during the placement of a synthetic MUS.

Do urodynamics predict urinary retention after sling placement in the complex patient: the value of reproducing symptoms on urodynamics.

INTRODUCTION AND HYPOTHESIS: To examine urinary retention (UR) after female urethral sling placement in patients with or without detrusor underactivity (DU) or Valsalva voiding whose urodynamics (UDS) accurately reproduced voiding symptoms to determine whether the reproduction of voiding symptoms on UDS in those with DU is predictive of UR after sling placement. METHODS: We performed a review of patients undergoing urethral sling procedures for stress urinary incontinence (SUI) looking specifically at the occurrence of short- and long-term urinary retention. Preoperative UDS data were obtained from a prospectively acquired UDS database in which patients were directly queried at the time of the UDS study about whether the filling and/or storage phase of the study reproduced their usual symptoms. RESULTS: Of the 141 women who had a urethral sling procedure, 124 (87.9%) had preoperative UDS. Of those who had UDS, 41 (33%) had de novo UR at some point postoperatively. Compared to those without DU, patients with DU and/or Valsalva voiding were more likely to have UR (75.6% vs. 56.6%, p = 0.04). There was no difference in association of UR in patients with DU/Valsalva voiding whose UDS reproduced voiding symptoms compared to those with DU/Valsalva voiding whose UDS did not reproduce symptoms (OR 1.01, CI 0.32-3.19, p 0.98). CONCLUSIONS: This study found that patients with DU/Valsalva voiding had an increased association with UR but did not find reproduction of symptoms on UDS to correlate with UR in either those with DU/Valsalva voiding or with normal bladder contractility.

The Infant Born to a Woman with Gestational Diabetes.

Gestational diabetes mellitus (GDM) is defined as glucose intolerance with onset during pregnancy. During pregnancy, women with GDM develop insulin resistance, which results in altered glucose tolerance. As a result, there are frequent episodes of hyperglycemia and high levels of circulating amino acids, increasing the transfer of nutrients to the fetus. This article discusses the role of the mother-baby nursing in the care of neonates born to women with gestational diabetes.

Inflatable Penile Prosthesis Insertion in Men with Severe Intracorporal Fibrosis.

OBJECTIVES: To retrospectively review a series of men who underwent attempted inflatable penile prosthesis (IPP) insertion into severely scarred corpora, and to analyze the surgical techniques and instruments that contributed to a successful outcome. PATIENTS AND METHODS: All IPP procedures done by a high-volume prosthetic surgeon during a 5-year period were retrospectively reviewed. Fourteen patients with severe intracorporal fibrosis underwent 15 attempted IPP insertion procedures, and are the subject of this review. RESULTS: A standardized surgical approach was employed for all patients. Thirteen of the 15 procedures were successful (i.e., an IPP was inserted, with satisfactory cylinder position). One procedure failed due to corporal obliteration. One patient underwent an initial failed attempt, but was successfully implanted 10 months later. Two of the 14 patients (14%) developed peri-prosthetic infection and were explanted. CONCLUSION: IPP insertion into scarred corpora is difficult and occasionally impossible. We have developed a standardized surgical approach for these cases, using limited corporal excavation, followed by the use of sequential Uramix and then Carrion-Rossello cavernotomes, that we feel has improved our chance of a successful implant. However, due to the rarity of these cases, it is not possible to make definitive statements concerning the optimal surgical technique.

The Diagnostic and Treatment Patterns of Urologists in the United States for Interstitial Cystitis/Painful Bladder Syndrome.

INTRODUCTION: Interstitial cystitis/bladder pain syndrome is not completely understood, making it challenging to diagnose and treat. The current literature elucidating this disease process is inconsistent. Without a clear consensus regarding management it is important to evaluate how urologists are treating these patients. METHODS: Urologists across the United States completed a 19-item survey addressing diagnostic and treatment methods for interstitial cystitis. Participation was voluntary and no compensation was provided to complete the survey. RESULTS: A total of 95 surveys were completed and returned between December 2012 and January 2013. Of the respondents 92% considered themselves general urologists and most preferred to manage interstitial cystitis/bladder pain syndrome themselves with only 33% referring these patients. Of the respondents 47% believed that the etiology of interstitial cystitis is still unknown. Cystoscopy with hydrodistention was the most common approach to diagnosis (70% of respondents) followed closely by validated symptoms scores (65%). Oral medication was the most commonly used treatment (92% of respondents), of which pentosan polysulfate was the most commonly used agent. Oral medication was followed by intravesical treatment and bladder hydrodistention at 77% and 74% of respondents, respectively. Most urologists ultimately used multimodal therapy. AUA (American Urological Association) guidelines were followed by only 15% of respondent urologists. CONCLUSIONS: The treatment of patients with interstitial cystitis/bladder pain syndrome is variable and many urologists use multiple modalities for diagnosis and treatment. This variability in diagnosis and/or treatment reflects the deficiency of our current understanding of this disease process. Until the pathophysiology is better delineated diagnosis and treatment will remain without consensus.