A career exploration didactic and simulation-based session increases student knowledge in and exposure to urology.

INTRODUCTION: Though urology attracts well-qualified applicants, students are not typically provided exposure to this smaller specialty until later in their medical education. While simulation-based training continues to supplement medical education, there is a lack of programming to teach specialty-specific procedural skills to medical students and those outside the specialty. We report a half-day simulation and didactic-based approach to increase exposure to urology to interested second-year medical students. METHODS: A half-day didactic- and simulation-based session was offered to second-year medical students (N=57). After a didactic-based overview of the specialty performed by urology providers and a surgical educator, the students participated in small-group simulations, including hands-on simulations. The students completed a post-curriculum survey measuring knowledge gains and soliciting feedback on the session. RESULTS: Students were 57.1% Caucasian, 66.7% female, with a mean age of 24.2 years; 80% stated they were potentially interested in pursuing a surgical specialty such as urology prior to the start of the session. Students reported pre- to post-curriculum gains in knowledge (mean=37%) about a career in urology and basic urologic procedures (p<0.001). Participants were also likely to recommend the curriculum to their peers (p<0.001). CONCLUSIONS: Given that exposure to urology in medical school is usually limited and offered later in training, a half-day didactic- and simulation-based experience for second-year students provides an early introduction and experience within the specialty and its common bedside procedures.

Effect of pulse width variations on sacral neuromodulation for overactive bladder symptoms: A prospective randomized crossover feasibility study.

INTRODUCTION/BACKGROUND: The pulse width (PW) parameter in sacral neuromodulation (SNM) is understudied, with no evidence-based guidance available on optimal PW for urinary indications. The aim of this prospective, randomized, single-blinded, 3 × 3 cross over design study was to estimate the effect of two PW settings (60 µs, 420 µs) compared to the industry standard (210 µs) on SNM efficacy, quality of life, and device parameters in patients who were stable and satisfied with their SNM treatment. METHODS/MATERIALS: Eligible patients were previously implanted and had urge incontinence or urgency-frequency with satisfaction on SNM at time of enrollment. Patients completed a 3-day voiding diary, validated questionnaires, and device interrogations with sensory threshold assessment at baseline and after a 4-week period on each of the three PW settings, to which they were randomized. Eighteen participants completed the study, as called for by power analysis. RESULTS: Eighteen patients were enrolled in the study. Mean age was 68 years and implant duration at the time of participation was 4.4 years. While PW variations did not produce significant differences in overall objective outcomes, device parameters, including sensory threshold amplitude and battery life differed significantly. Shortened PW necessitated higher amplitude while conserving battery life. Stimulus sensation location, quality, and intensity did not differ between PW. Standard PW was chosen by 11 patients after the study, 5 chose extended, and 2 chose shortened. Those who chose alternative PW achieved significant reductions in urinary frequency from enrollment -2.23 voids/day (p = 0.015). Upon sub-analysis, patients reporting "much better" or "very much better" on extended PW achieved significant reductions in urinary frequency and nocturia at 5.6 and 0.4, compared to 8.5 and 2.16 at baseline (p = 0.005, p = <0.001). Whereas those reporting "much better" or "very much better" on shortened PW achieved significant reductions in urinary frequency at 5.15 compared to 7.35 (p = 0.026). There were no adverse events or complications. CONCLUSIONS: Overall SNM effectiveness was unchanged with alternative PW; however, 39% of patients preferred alternative to standard PW and achieved significant improvements in urinary symptoms with such. Shorter PW can also provide savings in estimated battery life without sacrificing therapeutic efficacy.

The role of pulse width manipulation compared to program changes alone for unsatisfactory sacral neuromodulation therapy: A retrospective matched-cohort analysis.

AIM: Pulse width (PW) influences neuromodulation by its impact on nerve fiber recruitment. A paucity of data regarding the manipulation of PW in sacral neuromodulation (SNM) exists. This study describes the clinical features and outcomes of PW manipulation for unsatisfactory SNM therapy. METHODS: A retrospective, single-institution review was performed of reprogrammed SNM patients between 2010 and 2019. Two cohorts were created: those with PW changes ± program changes and age-matched controls with program changes alone. Patients lacking follow-up and non-InterStim II models were excluded. RESULTS: Out of 710 SNM interrogations, 147 (20.7%) had PW changes and 80 met inclusion criteria. Most PW changes were shortened (61/80, 76.3%). Clinical features did not differ between cohorts except by indication for reprogramming. The most common indication for PW change was painful stimulation (34/80, 43%), whereas in controls it was suboptimal efficacy (76/80, 95%). Clinical success was stratified by indication. There was a higher improvement in efficacy in the PW cohort (61%, 17/28 vs. 36%, 27/76, p = .02). PW manipulation successfully relieved painful stimulation in 50% (17/34 vs. 0/3, p = .23), which was more likely with a shortened compared to extended PW (14/15, 93.3% vs. 0/6, 0%, p < .01). PW resulted in improvement in localization of the stimulus in 94% (17/18 vs. 0/1, p = .10). The subsequent lead revision or explant was significantly higher in the PW cohort (43% vs. 25%, p = .03). CONCLUSION: PW manipulation may aid the salvage of unsatisfactory SNM therapy. These findings represent an initial assessment of the role of PW in SNM, particularly regarding the efficacy and painful stimuli. The further prospective investigation is warranted.

What Is New in Neuromodulation?

Neuromodulation encompassing sacral and peripheral modalities is an established, effective, and safe higher-order treatment option approved in the USA for managing refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. This review highlights the most recent literature, indications, treatment durability, and the latest innovations in this field. Regarding sacral neuromodulation (SNM), recent work suggests improved parameters for optimal lead placement, increased data to support the lasting effects of treatment, and novel applications of this technology to other pelvic disorders. In addition, there are emerging technologies with smaller MRI compatible devices. Newer data on percutaneous tibial nerve stimulation (PTNS) suggests it may be more beneficial for certain patients. With new technology, implantable tibial nerve stimulators are ushering in a new frontier of nerve stimulation in the comfort of the patient's home.

Efficacy, Side Effects, and Monitoring of Oral Cyclosporine in Interstitial Cystitis-Bladder Pain Syndrome.

OBJECTIVE: To evaluate the efficacy of oral cyclosporine A (CyA) in the treatment of refractory interstitial cystitis-bladder pain syndrome (IC-BPS) and to assess safety using drug level and renal function monitoring. MATERIALS AND METHODS: Patients with IC-BPS who failed at least 2 prior treatments were enrolled in an open-label study of oral CyA. Medication was started at 3 mg/kg divided twice daily for 3 months. Dose was adjusted based on side effects and the drug level was measured 2 hours after the morning dose (C2). The primary end point was moderate or marked improvement of global response assessment or >50% improvement on the Interstitial Cystitis Symptom Index (ICSI) or Interstitial Cystitis Problem Index at 3 months. RESULTS: Twenty-two of 26 patients completed the 3-month follow-up; 18 completed the poststudy evaluation. The median symptom duration was 66 months (12-336). At 3 months, 31% (8/26) improved by global response assessment, 15% (4/26) had >50% improvement in the ICSI score, and 19% (5/26) had an improvement in the Interstitial Cystitis Problem Index score. Hunner lesions (HLs) predicted an improvement in the ICSI score (odds ratio = 15.4, 95% confidence interval: 1.7-224.6, P = .01), with 75% (3/4) of the responders having HL. Two patients withdrew because of hypertension or elevated serum glucose. The mean nuclear glomerular filtration rate declined at 3 months (98.9 ± 31.6 vs 84.2 ± 25.5 mL/min/1.73 m2, P = .01) and reversed to baseline after discontinuation of treatment. C2 levels did not correlate with symptoms but allowed dose reduction in 11 patients. CONCLUSION: Per American Urological Association guidelines, CyA can be effective in a proportion of patients with refractory IC-BPS. Patients with HL are more likely to benefit. Monitoring of C2 rather than trough levels can lead to dose reduction, thereby minimizing toxicity.

Impact of Age and Comorbidities on Use of Sacral Neuromodulation.

PURPOSE: We investigated the influence of patient age on sacral nerve stimulation trial outcomes, device implantation and treatment durability. MATERIALS AND METHODS: We analyzed a database of all sacral nerve stimulation procedures performed between 2012 and 2014 at a high volume institution for associations of patient age with sacral nerve stimulation indication, trial stimulation success, device revision and device explantation. RESULTS: In a cohort of 356 patients those with nonobstructive urinary retention and urgency-frequency were younger than patients with urgency urinary incontinence. Trial stimulation success did not differ by age in stage 1 and percutaneous nerve evaluation trials (p = 0.51 and 0.84, respectively). Logistic regression identified greater odds of trial success in females compared to males (OR 2.97, 95% CI 1.32-6.04, p = 0.009) and for urgency urinary incontinence compared to urgency-frequency (OR 3.02, 95% CI 1.39-6.50, p = 0.006). In analyzed patients there were 119 surgical revisions, including battery replacement, and 53 explantations. Age was associated with a decreased risk of revision with 3% lower odds per each additional year of age (OR 0.97, 95% CI 0.95-0.98, p <0.0001). While age did not influence explantation, for each body mass index unit there was a 5% decrease in the odds of explantation (OR 0.95, 95% CI 0.91-0.98). CONCLUSIONS: In contrast to previous studies, older patients experienced no difference in the sacral nerve stimulation response in stimulation trials and no difference in the implantation rate. Furthermore, age was modestly protective against device revision. This suggests that age alone should not negatively predict sacral nerve stimulation responses.

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long-term extension study.

AIMS: To present final efficacy/safety results from a prospective, long-term extension trial of onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO); patients received treatment for up to 4 years. METHODS: Patients who completed a 52-week, phase III trial of onabotulinumtoxinA for NDO were eligible to enter a 3-year, multicenter, open-label extension study of intradetrusor onabotulinumtoxinA (200U or 300U). Patients were treated "as needed" based on their request and fulfillment of prespecified qualification criteria (≥12 weeks since previous treatment and a UI episode threshold). Assessments included change from study baseline in UI episodes/day (primary efficacy measure), volume/void, and Incontinence Quality of Life (I-QOL) total score (week 6); duration of effect; adverse events (AEs); and initiation of de novo clean intermittent catheterization (CIC). Data are presented for up to six treatments. RESULTS: OnabotulinumtoxinA 200U consistently reduced UI episodes/day; reductions from baseline ranged from -3.2 to -4.1 across six treatments. Volume/void consistently increased, nearly doubling after treatment. I-QOL improvements were consistently greater than twice the minimally important difference (+11 points). Overall median duration of effect was 9.0 months (200U). Results were similar for onabotulinumtoxinA 300U. Most common AEs were urinary tract infections and urinary retention. De novo CIC rates were 29.5, 3.4, and 6.0% (200U), and 43.0, 15.0, and 4.8% (300U) for treatments 1-3, respectively; de novo CIC rates were 0% for treatments 4-6. CONCLUSIONS: OnabotulinumtoxinA treatments consistently improve UI, volume/void, and QOL in patients with UI due to NDO in this 4-year study, with no new safety signals. Neurourol. Urodynam. 36:368-375, 2017. © 2015 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc.

Transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women.

AIM: We present the surgical management and outcomes of patients who underwent transvaginal neo-bladder vaginal fistula (NBVF) repair at our institution. METHODS: Between 2002 and 2012, eight patients underwent transvaginal NBVF repair. The surgical management entailed placing a Foley catheter into the fistula tract. A circumferential incision was made around the fistula tract after which a plane between the serosa of the neobladder and the vaginal epithelium was created. Interrupted polyglycolic acid sutures were used to close the fistula. An additional layer of vaginal wall, Martius, or omental flap was interposed before vaginal wall closure. A urethral catheter was placed for a minimum of 14 days and removed after a negative cystogram and pelvic exam with retrograde neobladder filling without leakage. RESULTS: All patients presented with a fistula following radical cystectomy with orthotopic ileal neobladder. Two patients had failed two prior transvaginal fistula repairs. A unilateral Martius flap was used in five patients and an omental flap was used in one patient. The surgery was successful in all patients. After a mean follow up of 33 months [4-117], five patients underwent or are waiting to undergo management of stress urinary incontinence with bulking agents. No patient had a recurrent fistula. CONCLUSIONS: Management of NBVF is challenging but cure is possible using a transvaginal approach. Most patients will suffer from incontinence after the repair because of a short and incompetent urethra. Patients should be counseled about the high probability of requiring a secondary procedure to achieve continence.

Urologic applications of botulinum toxin.

The neuromuscular blocker botulinum toxin has a wide variety of medical applications, including overactive bladder and neurogenic detrusor overactivity in patients in whom drug therapy fails or is not well tolerated. Botulinum toxin therapy for these conditions has been shown to be safe and effective in several large multicenter randomized controlled trials. Off-label uses in urology include detrusor external sphincter dyssynergia and pelvic pain syndromes.

Evaluation of patients' perceptions of mesh usage in female pelvic medicine and reconstructive surgery.

OBJECTIVE: To evaluate if new patients presenting to a female pelvic medicine and reconstructive surgery clinic are aware of the US Food and Drug Administration (FDA) announcement regarding transvaginal mesh placement for pelvic organ prolapse repair and do they believe there is a mesh recall. METHODS: A voluntary anonymous 25-question survey was administered to new-clinic patients. Participants were aged at least 18 years and had either urinary incontinence or pelvic organ prolapse. Appropriate statistical tests were performed for continuous and categorical variables. Logistic regression was used for univariate and multivariable analysis. Significance was considered for P values <.05. RESULTS: Two hundred fourteen surveys were included for final analysis. Of the 214 patients, 157 (73.4%) had urinary incontinence as their sole presentation. Of 204 patients, 126 (61.8%) were aware the FDA-released information regarding mesh use in transvaginal surgery, and 88 of 169 (52%) believed there is a "recall" on mesh being used for transvaginal surgery. Of 156 patients, 108 (69.2%) listed television as a source of information. On multivariable analysis, television as a source was significantly associated with awareness of the FDA announcement (odds ratio, 7.12; 95% confidence interval, 2.69-18.84; P = .0001) and belief in a "recall" (odds ratio, 3.01; 95% confidence interval, 1.28-7.06; P = .01). CONCLUSION: Although almost 2 of 3 participants were aware of the FDA announcement, more than half falsely believed there was a recall. Television was significantly associated with both awareness of the FDA announcement and belief in a recall suggesting patients derive most of their perceptions from the television.

Is there an association between polypropylene midurethral slings and malignancy?

OBJECTIVE: To examine any association between polypropylene mesh used in midurethral slings and malignancy in humans. Macroporous, monofilament polypropylene midurethral slings have been established as a safe and effective treatment for stress urinary incontinence. However, despite long-term studies supporting the efficacy and safety of midurethral slings, there have been concerns regarding the general risks of using mesh in transvaginal surgery. In addition, concerns have recently been raised about synthetic midurethral slings and a possible link with malignancy. Therefore, the goal of this work was to further assess any association between polypropylene mesh slings and malignancy. MATERIALS AND METHODS: All sling procedures performed at our institution from 2004 to 2013 were retrospectively reviewed. From within this group, the International Classification of Disease codes for urethral cancer, vaginal cancer, and bladder cancer were reviewed. RESULTS: From 2004-2013, 2545 procedures were performed. Of these, 2361 (96.3%) underwent polypropylene midurethral sling placement. Average follow-up after sling placement was 42.0 ± 38.6 months, with follow-up extending up to 122.3 months. The rate of bladder cancer after the sling procedure was 1 of 2361 (0.0%), with the same rate of vaginal cancer. No sarcomas were noted. CONCLUSION: Overall, the rate of malignancy after polypropylene mesh midurethral sling placement in our series was 0.0% (2 of 2361). With a mean follow-up of almost 4 years and follow-up extending up to a maximum of 122.3 months, our series does not support any association between the polypropylene mesh used for midurethral slings and the development of malignancy in humans.

Mutation screen of LOXL1 in patients with female pelvic organ prolapse.

OBJECTIVES: The LOXL1 (lysyl oxidase-like 1) gene encodes a copper-dependent monoamine oxidase that catalyzes the deamination of a lysine residue in the cross-linking of tropoelastin monomers to form elastin. LOXL1-KO mice do not deposit normal elastic fibers in their genitourinary tract resulting in postpartum pelvic organ prolapse and lower urinary tract dysfunction with decreased bladder capacity and lower voiding pressure. We sought to identify which single nucleotide polymorphisms in the LOXL1 coding sequence play a role in female pelvic organ prolapse. METHODS: A total of 66 patients were screened, 48 in the case group and 18 in the control group. The 7 exons of LOXL1 were evaluated for any polymorphisms. RESULTS: Three missense sequence changes (Arg141Leu, Gly153Asp, and Ser159Ala) and 3 silent mutations (Asp292Asp, Ala320Ala, and Ile521Ile) were identified. None of these polymorphisms were found to differ significantly in frequency in the case group compared with the control group. CONCLUSIONS: Our findings do not support an association of any LOXL1 exonal single nucleotide polymorphisms with the diagnosis of female pelvic organ prolapse.

Simple sling incision for the treatment of iatrogenic bladder outlet obstruction.

INTRODUCTION AND HYPOTHESIS: Bladder outlet obstruction (BOO) is reported to occur in 15 % of women after anti-incontinence surgery. In the past, iatrogenic BOO from slings was treated with urethrolysis. However, urethrolysis is not without morbidity, including significant bleeding, urethral injury, and recurrent stress urinary incontinence (SUI). Several studies have shown simple sling incision to be as effective as urethrolysis with less morbidity and lower rates of recurrent SUI. [1-3] METHODS: We demonstrate the technique of transvaginal simple sling incision in two patients, one with a synthetic midurethral sling, and one with a biologic bladder-neck sling. RESULTS: Simple sling incision is an effective and less morbid treatment than urethrolysis for iatrogenic urethral obstruction; 70-90 % of women will have significant improvement in obstructive voiding symptoms. Recurrent SUI is seen in approximately 20 % of women after sling incision. CONCLUSIONS: This video shows that simple sling incision is an effective, simple, and safe treatment for women with iatrogenic BOO after sling surgery and should be used as a first-line treatment.

Increasing patient preparedness for sacral neuromodulation improves patient reported outcomes despite leaving objective measures of success unchanged.

PURPOSE: We assessed how a group shared appointment influenced patient preparedness for sacral nerve stimulation for refractory overactive bladder and/or urge urinary incontinence. We also evaluated subjective and objective outcomes. MATERIALS AND METHODS: Patients considering sacral nerve stimulation were prospectively enrolled and invited to attend a group shared appointment. This 75-minute presentation included a question and answer period with an implanting surgeon and an implanted patient. Control patients received standard office counseling. A patient preparedness questionnaire was completed after the group shared appointment or office counseling. Response to treatment was determined using the postoperative satisfaction questionnaire, Patient Global Impression of Improvement (PGI-I) and voiding diaries. RESULTS: In our study 36 women with a mean ± SD age of 61 ± 15 years underwent sacral nerve stimulation. There was no significant difference in patient demographics between the 19 women who attended the group shared appointment and the 17 controls. Overall preparedness was greater in the shared appointment group (p = 0.043) with better understanding of the purpose of (p = 0.003) and alternatives to (p = 0.043) sacral nerve stimulation. Significantly more women in the shared appointment group than controls felt completely prepared (78.9% vs 29.4%, p = 0.003) and completely satisfied (78.9% vs 35.3%, p = 0.003) with sacral nerve stimulation as well as very much better (68.4% vs 17.6%, p = 0.002) according to the PGI-I. There was no difference between the groups in the number of women with a 50% or greater symptom reduction on voiding diary. CONCLUSIONS: Participating in a group shared appointment before sacral nerve stimulation improved patient preparedness and perceived outcomes of treatment, although there was no difference in objective outcomes based on voiding diary.

Patterns of hardware related electrode failures in sacral nerve stimulation devices.

PURPOSE: Abnormal electrical impedance in sacral nerve stimulation devices is a cause of device failure. Currently, there is scant literature evaluating the incidence and management of this problem. We evaluated the presentation, characteristics and management of sacral nerve stimulation devices with abnormal electrical impedance. MATERIALS AND METHODS: A total of 565 patients were permanently implanted with sacral nerve stimulation devices using a tined lead between 2003 and 2011. Devices were interrogated postoperatively and at followup. Abnormal electrical impedance was classified as open circuit--impedance greater than 4,000 Ω or short circuit--impedance less than 50 Ω and/or equivalence of impedance. Details on presentation, characteristics and management were recorded. RESULTS: Of the 565 patients 72 (12.7%) experienced a total of 86 abnormal electrical impedance events, of which 57 (66.2%) were open circuits and 28 (32.5%) were short circuits. One event (1.1%) was a simultaneous open and short circuit. Short circuits presented earlier than open circuits (median 3.5 months, IQR 2-7.5 vs 15, IQR 5.5-30.5, p <0.0001) and required surgical intervention more often (75.0% vs 54.3%, p = 0.09). Patient specific factors, such as trauma history and change in body mass index class, were not associated with abnormal electrical impedance. No electrode failure patterns could be identified. CONCLUSIONS: Abnormal electrical impedance occurred in approximately 13% of cases permanently implanted in our series. Short circuits presented earlier and often required surgical intervention. Open circuits presented later and may have potentially been secondary to microfractures that accumulate with time at the sacral plate, resulting in later presentation. Almost a third of patients with abnormal electrical impedance associated with clinical inefficacy were treated conservatively, primarily with reprogramming.

Purely transvaginal/perineal management of complications from commercial prolapse kits using a new prostheses/grafts complication classification system.

PURPOSE: Commercial prolapse mesh kits are increasingly used in the management of pelvic organ prolapse. We present our experience with the transvaginal/perineal management of synthetic mesh related complications from prolapse kits. In addition, we used the new ICS/IUGA (International Continence Society/International Urogynecological Association) prostheses/grafts complication classification system to report on our contemporary series. MATERIALS AND METHODS: A retrospective chart review of all patients who underwent surgical removal of transvaginal mesh for mesh related complications after prolapse kit use from November 2006 to April 2010 at 1 institution was performed. We report our contemporary series of mesh complications using the new ICS/IUGA prostheses/grafts complication classification system. Postoperative pain, degree of improvement and presence of continued symptoms were reported by patients at last followup. RESULTS: A total of 23 patients underwent transvaginal removal of mesh during the study period. Mean patient age was 61 years. Median period of latency to mesh related complication was 10 months (range 1 to 27). Indications for mesh removal included vaginal/pelvic pain (39%), dyspareunia (39%), vaginal mesh extrusion/exposure (26%), urinary incontinence (35%), recurrent pelvic organ prolapse (22%), bladder mesh perforation with recurrent urinary tract infection (22%), rectal mesh perforation (4%), ureteral perforation injury (4%), retained foreign body (surgical sponge) in the bladder (4%) and vesicovaginal fistula (9%), with most patients citing more than 1 reason. CONCLUSIONS: Although technically difficult in some cases, purely transvaginal mesh excision appears to be safe with resolution of almost all presenting symptoms. Although slightly cumbersome, the new ICS/IUGA prostheses/graft complication classification system can be used to report and more accurately characterize mesh complications.

Improvement of bowel dysfunction with sacral neuromodulation for refractory urge urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Sacral nerve stimulation (SNS) is approved for urologic indications in the USA and, recently, fecal incontinence. This study described concomitant bowel dysfunction and improvements in bowel and urinary symptoms and quality of life (QOL) in women with refractory urge urinary incontinence (UUI) receiving SNS. METHODS: Women (N = 36) with refractory UUI receiving SNS were prospectively enrolled. Surveys and exams were completed at baseline and follow-up, with symptom and QOL scores measured using validated scales (0-100, none-worst). RESULTS: A total 24 women were followed up at a median of 4.0 months post-implantation. Of these, 20 (83%) had bowel dysfunction, 13 (54%) used bowel medications at baseline, and 11 (45%) continued them after SNS. The mean/median urinary (54.8 to 32.6) and bowel (23.4 to 14.1) symptom scores improved significantly, as did urinary (64.2 to 14.3) but not bowel (2.4 to 0.0) QOL scores. CONCLUSIONS: Bowel dysfunction is common in women with refractory UUI. SNS improves urinary symptoms and QOL, but improvement in bowel symptoms does not translate into significant QOL changes.

Improved sexual and urinary function in women with sacral nerve stimulation.

OBJECTIVES: Urinary and sexual function improve following sacral nerve stimulation (SNS) for refractory overactive bladder. No significant associations between these changes have been found. Whether improvements in sexual function are independent of or secondary to improvements in urinary function remains unclear. The aim of this study was to analyze changes in urinary and sexual function in a homogeneous sample of patients undergoing SNS for urge urinary incontinence and subsequently identify associations between the two. MATERIALS AND METHODS: A prospective database was created. Enrollees underwent a full history and physical examination at the first office visit. Multiple-day voiding diaries with validated and investigator-designed questionnaires were administered at baseline and follow-up as standard implantation procedures and to assess changes in urinary and sexual function, respectively. Analyses were completed using data from patients who were sexually active at baseline and follow-up. RESULTS: Statistically significant improvements in urinary and sexual function occurred according to multiple metrics. Patient global impression scales categorized all patients' urinary conditions as improved, with most being less severe. Validated urinary symptom and quality of life scores improved significantly. After treatment, most patients were incontinent less often with sexual activity and felt less restricted from sexual activity by fear of incontinence. Validated quantification of sexual function demonstrated significant improvements in overall sexual function, arousal, and satisfaction. No significant associations between changes in urinary and sexual function were noted; however, trends appeared to exist between the two. CONCLUSIONS: Improved sexual function was not significantly associated with improved urinary function after SNS despite apparent trends between the two. Larger samples are required to definitively demonstrate this conclusion.

Force of stream after sling therapy: safety and efficacy of rapid discharge care pathway based on subjective patient report.

PURPOSE: We evaluated the safety of a mid urethral sling postoperative care pathway using patient subjective reporting of force of stream to minimize length of stay and catheter placement. MATERIALS AND METHODS: Women undergoing solitary mid urethral sling surgery were prospectively enrolled in our study. Force of stream after the sling therapy protocol consisted of retrograde bladder filling with 300 ml fluid within 1 hour after surgery. Patients rated force of stream compared to baseline on a visual analog scale. Those with a force of stream of 50% or greater were immediately discharged home regardless of post-void residual urine volume. Only those unable to void and those rating force of stream less than 50% with post-void residual urine volume greater than 500 ml were discharged home with a catheter. Patients were telephoned within 1 week of surgery and seen 4 to 6 weeks postoperatively. The primary outcome was unexpected visits to the emergency room or office for voiding dysfunction or urinary retention. RESULTS: A total of 114 women were prospectively enrolled in our study, of whom 105 (92.1%) passed the protocol and were discharged home without a catheter. Of the patients 14 were discharged home with increased post-void residual urine volume (range 152 to 427 ml) but no catheter, representing those who would have been discharged with a catheter by many traditional voiding protocols. According to protocol 9 patients were discharged with a catheter. No patient presented to the emergency room or office in urinary retention or with voiding dysfunction before the scheduled visit. CONCLUSIONS: Patients who report a force of stream of 50% or greater can be safely and rapidly discharged home after an uncomplicated mid urethral sling procedure regardless of post-void residual urine volume. Scanned post-void residual urine volume does not add much value in those who can void. By following the force of stream after sling therapy protocol patients can be discharged home less than 3 hours after mid urethral sling surgery.