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.

Patient perceived effectiveness of a new male sling as treatment for post-prostatectomy incontinence.

PURPOSE: Objective measures show the AdVance() sling provides some benefit in post-prostatectomy incontinence. To our knowledge no validated, patient determined outcomes have been used to assess this procedure. We described the patient perceived effectiveness and postoperative complications. MATERIALS AND METHODS: A retrospective chart review was followed by a telephone survey consisting of the Patient Global Impression of Improvement, Patient Global Impression of Severity, and questions about recommending the surgery, daily pad use and complications. Successful outcomes were Patient Global Impression of Improvement responses of very much better or much better without further incontinence treatment. Objective success is defined as pad-free or a reduction to 2 or less pads daily. RESULTS: A total of 35 patients received the sling a median of 25 months after prostatectomy. Telephone surveys were administered a mean of 35 weeks after the sling procedure and 33 patients were contacted. Of the cases 18 (51.4%) and 21 (60%) were patient determined and objective successes, respectively. Of the patients with subjective treatment failure 3 would recommend the surgery to a friend and 12 were undecided or would not. Furthermore, no patients with subjective treatment failure were pad-free and 10 (58.8%) had pads that were mostly wet on changing. For the entire population a reduction in median daily pad use from 2.5 to 1 was observed as well as a strong association (p <0.01) between Patient Global Impression of Improvement and Patient Global Impression of Severity responses. Three individuals pursued further treatment with bulking agents and 3 had retention that resolved. CONCLUSIONS: The AdVance sling is safe, and demonstrates similar subjective and objective outcomes. The procedure can benefit some individuals with post-prostatectomy incontinence and, therefore, may be another treatment option for this condition.

Single-port laparoscopic abdominal sacral colpopexy: initial experience and comparative outcomes.

OBJECTIVES: To determine the efficacy and safety of single-port laparoscopic abdominal sacral colpopexy (ASC) for the treatment of female pelvic organ prolapse (POP). METHODS: A retrospective cohort study was performed to assess perioperative outcomes among women who were treated for symptomatic POP with laparoscopic, robotic, or single-port laparoscopic ASC. All patients underwent preoperative history and physical examination including POP quantification (POP-Q) staging and urodynamics. ASC with or without anti-incontinence surgery was performed via the aforementioned approaches. Demographic and perioperative data were obtained. Patients were followed up postoperatively at 3 and 6 months with POP-Q evaluation. Statistical analysis was performed. RESULTS: From October 2005 to July 2008, 30 female patients with symptomatic Stage II (6 patients), Stage III (23 patients), or Stage IV (1 patient) POP were treated with laparoscopic (10), robotic (10), or single-port laparoscopic (10) ASC. Mean age of the entire cohort was 61.1 years. Mean body mass index was 26.7 kg/m(2). Seventeen patients demonstrated stress urinary incontinence and underwent concomitant sling placement. No intraoperative complications were encountered. No significant difference was noted in the 3 cohorts with respect to operative time, blood loss, mean visual analog pain score at discharge, or duration of hospitalization. At 6 months following surgery, 27 patients underwent follow-up POP-Q, with all patients demonstrating excellent apical support and prolapse reduction. CONCLUSIONS: Single-port laparoscopic ASC offers comparable efficacy and superior cosmesis compared to alternative approaches. Long-term follow-up is needed to confirm durability of repair.

Admission for nephrolithiasis in pregnancy and risk of adverse birth outcomes.

OBJECTIVE: Nephrolithiasis occurring during pregnancy may be associated with an elevated risk of preterm delivery and other adverse birth outcomes. The goal of this study was to describe the association between these outcomes and admission for nephrolithiasis during pregnancy. METHODS: We performed a retrospective cohort study using birth certificate records linked to Washington State hospital discharge data from 1987-2003 to compare pregnant women admitted for nephrolithiasis and randomly selected pregnant women without nephrolithiasis. The main outcomes of interest were preterm delivery, premature rupture of membranes at term or before 37 weeks of gestation, low birth weight, and infant death. RESULTS: A total of 2,239 women were admitted for nephrolithiasis, yielding a cumulative incidence of 1.7 admissions per 1,000 deliveries. Women admitted for nephrolithiasis during pregnancy had nearly double the risk of preterm delivery compared with women without stones (adjusted odds ratio 1.8, 95% confidence interval 1.5-2.1). However, they were not at higher risk for the other outcomes investigated. A total of 471 (25.9%) women had one or more procedures for kidney stones during prenatal hospitalization. Undergoing a procedure and the trimester of admission did not affect the risk of preterm delivery. CONCLUSION: Although the incidence of nephrolithiasis requiring hospital admission during pregnancy is relatively low, these women have an increased risk of preterm delivery. This has potential implications for counseling of pregnant women with kidney stones requiring hospital admission. Additionally, it may prompt definitive treatment of small, asymptomatic stones in women during reproductive years.

Complications of scrotal surgery for benign conditions.

OBJECTIVES: Frequent complications have been reported after scrotal surgery. We reviewed our experience to determine the complication rates, risk factors, and how our experience might differ from other series. METHODS: We reviewed all scrotal surgery for benign conditions at the Veterans Affairs Puget Sound Health Care System from 1998 to 2004. The abstracted data included indications, comorbidities, perioperative antimicrobial use, operative procedures, use of drains, and complications. RESULTS: Ninety-five patients underwent 110 procedures, including hydrocelectomy (55%), spermatocelectomy (15%), epididymectomy (4%), and bilateral or combination procedures (27%). Preoperative antimicrobial administration was documented before 80 (73%) of the 110 procedures. The follow-up ranged from 0 to 85 months (mean 36). Complications occurred after 22 (20%) of the 110 procedures and included recurrences (6%), hematomas (5%), and infections (3.6%), with 95% of complications occurring after hydrocelectomy (odds ratio 9.1, 95% confidence interval 1.1 to 71.6). The potential patient and surgical risk factors considered were immunocompromised status, undergoing a bilateral procedure, a high American Society of Anesthesiologists score, body mass index, and the use of drains. CONCLUSIONS: Our overall complication rate was 20%, with most occurring after hydrocele surgery (chi-square, P = 0.01). The 3.6% wound infection rate was substantially lower than that in recent series in which preoperative antimicrobial agents were not prescribed. In the absence of a prospective clinical trial, these findings suggest that scrotal procedures might merit consideration of routine antimicrobial prophylaxis.

Incidence of primary urethral carcinoma in the United States.

OBJECTIVES: Primary urethral carcinoma is rare, and the demographic correlates of its incidence have not been examined using population-based data. METHODS: The National Cancer Institute Surveillance, Epidemiology, and End Results database was used to identify persons diagnosed with primary urethral carcinoma from 1973 to 2002. During this period, the Surveillance, Epidemiology, and End Results program included population-based tumor registries in nine geographic areas that represented approximately 10% of the U.S. population. The incidence rates were tabulated for the major histologic subtypes according to age, sex, and race. RESULTS: Primary urethral carcinoma was identified in 1075 men and 540 women, with an annual age-adjusted incidence rate of 4.3 per million and 1.5 per million, respectively. The annual incidence rate increased with age to a peak of 32 per million men and 9.5 per million women in the 75 to 84-year age group. The rate was 5.0 per million and 2.5 per million for African Americans and whites, respectively. The histologic types were transitional cell carcinoma in 888 patients (55%), squamous cell carcinoma in 348 (21.5%), and adenocarcinoma in 265 (16.4%). The incidence of the three primary histologic types varied by race and sex. CONCLUSIONS: In the United States, the incidence of urethral carcinoma is relatively higher in men and African Americans, with a histologic profile differing from that previously described.

Renal medullary carcinoma: clinical, pathologic, immunohistochemical, and genetic analysis with pathogenetic implications.

OBJECTIVES: To investigate the pathologic, clinical, and genetic features of renal medullary carcinomas (RMCs) in search of clues to their pathogenesis. METHODS: We analyzed 40 RMCs for clinical features, for immunohistochemical expression using a panel of markers, and for genetic changes using comparative genomic hybridization. RESULTS: Patients presented at 5 to 32 years of age, and 82% were African American. All patients tested had sickle cell trait or disease. Seven patients presented with suspected renal abscess or urinary track infection without a clinically recognizable mass. Of the 15 tumors able to be analyzed, all were positive for epithelial markers CAM 5.2 and epithelial membrane antigen. All were negative for high-molecular-weight cytokeratin 34betaE12. Cytokeratins 7 and 20 and carcinoembryonic antigen were heterogeneous and variable. Ulex was focally positive in a minority of cases. Eight of 12 tumors showed significant positivity for TP53 protein (greater than 25% nuclear positivity). All tumor tested (n = 8) were strongly positive for vascular endothelial growth factor and hypoxia inducible factor. Of nine tumors analyzed for genetic gains and losses using comparative genomic hybridization, eight showed no changes and one showed loss of chromosome 22. Survival ranged from 2 weeks to 15 months (mean 4 months). CONCLUSIONS: These findings suggest that RMC is clinically and pathologically distinct from collecting duct carcinoma. The hypothesis that chronic medullary hypoxia secondary to hemoglobinopathy may be involved in the pathogenesis of RMC is suggested by strong vascular endothelial growth factor and hypoxia inducible factor expression and positivity for TP53.