Managing female stress urinary incontinence in a post mesh era: What to do and when to refer.

BACKGROUND: Urinary incontinence is a common presentation in general practice and can significantly affect a patient's quality of life. Stress urinary incontinence (SUI) is defined by the International Continence Society as 'the complaint of any involuntary loss of urine on effort or physical exertion (eg sporting activities), or on sneezing or coughing'. There is a key role for primary care providers in the assessment and management of female SUI. OBJECTIVE: To highlight the key diagnostic and management principles of female SUI in general practice and discuss management options. DISCUSSION: SUI can usually be diagnosed based upon clinical history and targeted physical examination. Pelvic floor physiotherapy and lifestyle interventions, including weight modification and management of co-morbidities, are important first-line therapies. Surgical options for both persistent or complex SUI include urethral bulking agents, Burch colposuspension and pubovaginal fascial slings. Synthetic (mesh) mid-urethral slings remain a viable surgical option for women suffering SUI.

What to do about recurrent urinary tract infections: A review of evidence behind emerging therapies.

BACKGROUND: Recurrent urinary tract infections (rUTIs) can be debilitating for patients and pose an increasing challenge in the primary care setting. An efficient approach enables timely access and effective care for patients. Recent research and pharmaceutical developments have provided new avenues for treating this common condition. OBJECTIVE: A narrative review was conducted to provide a targeted overview of contemporary management strategies in rUTIs to assist primary care physicians in managing patients with rUTIs efficiently and effectively. DISCUSSION: Recurrent urinary tract infections require investigation and risk factor identification. Appropriate patient education in the primary care setting, behavioural modifications and commencement of non-antibiotic treatment might reduce rUTI. Certain patients might require referral to a urologist for consideration of other treatment strategies and further investigation.

What credentials are required for robotic-assisted surgery in reconstructive and functional urology?

Introduction: The increasing popularity of robotic assisted surgery (RAS) as it is implemented in to sub specialities poses many challenges to ensuring standards in quality and safety. The area of Reconstructive and Functional Urology (RFU) has a wide range and largely complex heterogeneous procedures. In recent years RFU has started to incorporate RAS as the primary method to undertake these procedures due to improved vision, dexterity, and access to deep cavities. To ensure patient safety majority of institutions maintain minimal requirements to operate using RAS however across specialities and institutions these greatly vary. Methods: A narrative review of all the relevant papers known to the author was conducted. Results: Specific challenges facing RFU is the inability to rely on case numbers as a surrogate means to measure competency as well the ongoing consideration of how to differentiate between surgeons with robotic training and those with the clinical experience specific to RFU. Conclusion: This review explores current models of training and credentialling and assess how it can be adapted to suggest a standardised guideline for RFU to ensure the highest standards of patient care.

Quality of Pre-operative Assessment for Mid Urethral Slings in Women Who Present With Mesh Complications.

OBJECTIVE: To study quality of pre- and post-operative evaluation in women undergoing mid-urethral synthetic sling surgery who subsequently have complications. MATERIALS AND METHODS: Study inclusion was chart availability for preoperative clinical history, examination, urodynamics and/or post-operative visit in women with mesh complications 2014-2021 in a tertiary practice. The primary outcome was compliance with quality indicators and guidelines for preoperative and post-operative clinical evaluation and urodynamics. RESULTS: 122 women had preoperative, 102 urodynamic reports and 108 post-operative charts available for review. Only clinical history and examination showed moderate compliance (71% nature, 57% severity, 87% exam) with quality indicators, all other quality indicators were low. including documentation of counselling of mesh risks (11%) and risks of incontinence surgery (17%) . Compliance with guidelines (optimal care) was also low (bladder diary 61%, all others ≤41%). Post-operative evaluation did not comprehensively screen for complication e.g., flow rate/post-void residual performed in 9%. A significant proportion had an early adverse symptom (55%) or intervention e.g. trimming of exposure (40%) CONCLUSION: Compliance with quality indicators and guidelines was generally low for pre-operative evaluation and urodynamic testing. There was inadequate content and length of post-operative evaluation despite a significant proportion presenting with adverse symptoms at first postoperative follow-up. Future research could target these areas for development of tools to improve compliance and education of health providers.

Early Experience of Transabdominal and Novel Transvaginal Robot-Assisted Laparoscopic Removal of Transvaginal Mesh.

Background: Mesh removal after transvaginal mesh placement has typically involved transvaginal, open pelvic, laparoscopic, or a combination of approaches. Robotic pelvic mesh removal has been described in a small number of cases only. This study aims at determining the feasibility and safety of using robot-assisted laparoscopic surgery in the removal of pelvic mesh via the transabdominal and novel transvaginal approach. Materials and Methods: This is a prospective case series study on women who underwent transabdominal or transvaginal robot-assisted removal of pelvic mesh. Women were offered participation in this study with pelvic mesh and a clinical indication for mesh removal if they were older than the age of 18. Alternative surgical options, including conventional open removal of mesh, were discussed and offered to patients. The primary outcome of this study is the rate of successful removal of mesh and the 30-day complication rates. Ethics approval was obtained for this study. Results: Thirty patients were included in this study. Median age was 62. Median operative and console time was 240 and 148 minutes, respectively. Concomitant reconstructive procedures were performed in 40% of patients. Complete or near-complete mesh removal was achieved in 83.3% of patients. For the remaining patients, partial removal of mesh was performed as planned preoperatively. Three Clavien-Dindo grade 3b complications resulted from mesh removal: concomitant ureteric and bladder injury, omental bleed, and groin wound infection. Conclusion: This study presents the early experience of robotic-assisted removal of transvaginal mesh with a transvaginal or transabdominal approach and demonstrates the feasibility of removal of both retropubic and transobturator mid-urethral synthetic sling as well as transvaginal prolapse meshes with transobturator and sacrospinous mesh arms. Further studies are required to expand understanding on the learning curve, operating times, complication rates, and functional outcome of this operation.

Radiation Exposure During Videourodynamics: Establishing Risk Factors.

OBJECTIVES: The use of fluoroscopy during urodynamics can be helpful in the evaluation of patients with lower urinary tract dysfunction. However, fluoroscopy introduces the potential hazards of ionizing radiation, including malignancy. In this study we analyzed the data for radiation exposure during videourodynamic study (VUDS) at our center; we have also tried to establish the factors associated with increased exposure to radiation during VUDS. METHODS: We reviewed all VUDS from August 2010 to May 2011. Patients were included if they were ≥18 years old and had data recorded on total radiation exposure (radcm2 ). Age, sex, body mass index, fluoroscopy time, diagnosis, and urodynamic findings were recorded. Multivariate linear regression analysis was used to identify independent risk factors that influenced increased radiation exposure. RESULTS: A total of 203 videourodynamic studies were assessed in 106 female and 97 male patients with a mean age of 64.3 and body mass index of 26.8. The average fluoroscopy time was 100.2 sec and exposure was 560.9 radcm2 . The most common indication for videourodynamics was incontinence, 40.9%. On multivariate linear regression analysis body mass index, vesico-ureteral reflux, sex, number of fill cycles, and larger capacity were independent predictors of increased radiation exposure. CONCLUSIONS: We have shown that increased radiation exposure as measure with Dose Area Product during VUDS was significantly associated with larger BMI, female gender, larger bladder capacity, presence of VUR, junior operator, and higher number of fill cycles. Further studies are now underway to attempt to reduce exposure based on these findings.

Correlating Ki67 and other prognostic markers with Oncotype DX recurrence score in early estrogen receptor-positive breast cancer.

AIM: Decisions regarding adjuvant chemotherapy for early breast cancer are complex. Ki67 is increasingly used, in conjunction with conventional prognostic markers, to help decide the use of adjuvant chemotherapy for early breast cancer. Ki67 has been proposed as an economical alternative to Oncotype DX recurrence score (RS), which is a validated prognostic marker for disease recurrence and predictive marker for benefit from chemotherapy. This study aimed to determine in patients where conventional prognostic markers did not provide a clear recommendation for adjuvant chemotherapy, whether Ki67 could be a substitute for RS. METHODS: We reviewed all cases of luminal-type node-negative early breast cancer (T1-2, N0-1mi, M0, estrogen receptor positive, HER2 negative) referred for Oncotype DX testing by the multidisciplinary team at an Australian tertiary private hospital from 14th December 2006 to 31st December 2013, when conventional prognostic markers did not provide a clear recommendation for adjuvant chemotherapy. RS was correlated with Ki67, along with other conventional prognostic markers including tumor size, grade, mitotic rate and lymphovascular invasion. Spearman's rank order correlation coefficient and Pearson product-moment correlation coefficient (r) were used for ordinal and continuous variables, respectively. RESULTS: A total of 58 patients were analyzed, median Ki67 was 15% (range 2-50%) and the median RS was 16 (range 3-65). There was no positive correlation between Ki67 and RS (r = 0.01, P = 0.93). No single conventional prognostic marker was shown to significantly correlate with RS, including tumor size (r = -0.02, P = 0.88), grade (r = 0.10, P = 0.44), mitotic rate (r = -0.07, P = 0.69) and lymphovascular invasion (r = -0.12, P = 0.39). CONCLUSION: Ki67 and conventional prognostic markers do not correlate with Oncotype DX RS. In the setting where conventional prognostic markers do not show a clear indication for or against adjuvant chemotherapy as determined by consensus in a multidisciplinary team, Ki67 is not a substitute for Oncotype DX testing. RS may provide additional information to aid decision making for adjuvant chemotherapy.

Artificial urinary sphincter revision: the role of ultrasound.

OBJECTIVE: To assess the accuracy of office-based ultrasound (US) to identify the fluid status of the AMS 800 artificial urinary sphincter (AUS) pressure-regulating balloon (PRB). METHODS: Patients who underwent AUS revision surgery (removal/replacement) from January 4, 2007, to January 4, 2010, were identified. US were done preoperatively to assess the system fluid status. Intraoperative findings were recorded. Sensitivity and specificity were calculated comparing US results with intra-/postoperative findings. When the PRB was underfilled, the location of the device fluid leak was determined, and the device was removed/replaced. In cases of a full PRB, patients had a cuff downsizing or total removal/replacement. RESULTS: A total of 27 patients were identified. Reasons for not obtaining US included: advanced device age (4), cuff erosion (2), volume determination by other modality (2), cuff site pain (1), isolated pump malfunctions (1), and other (3). Fourteen patients underwent an US before the removal/replacement. By US, PRB was full (21-23 mL) in 43% of the patients and empty/underfilled (0-6 mL) in 57%. US was 100% sensitive and specific determining fluid status. When PRB was full, management consisted of cuff downsizing (3), transcorporal cuff placement (1), and total removal/replacement (2). In all cases of device leak, an entire removal/replacement was performed. The cuff was identified as the site of leak in 50% of cases. CONCLUSION: US is an effective and accurate way of determining the fluid status of the AMS 800 AUS. Given the accuracy of this modality, the system can be filled with saline solution without losing the ability to determine fluid status.

Comparison of urodynamic findings in women with anatomical versus functional bladder outlet obstruction.

OBJECTIVES: To characterize the symptoms and urodynamic findings of anatomical bladder outlet obstruction (AO) and functional bladder outlet obstruction (FO) in women and to determine if future endeavors at defining bladder outlet obstruction in women can group these entities together. METHODS: Retrospective review of all videourodynamic studies was performed on women from March 2003 to July 2009. Women with diagnosis of obstruction were categorized based on the cause of obstruction into 2 groups: AO and FO. Demographic data, symptoms, and urodynamic findings were compared between the 2 groups. RESULTS: One hundred fifty-seven women were identified of which 86 (54.8%) were classified as having AO and 71 (45.2%) were classified as having FO. There were no differences in symptoms between the 2 groups. There was no difference (P=0.5789) in the mean detrusor pressure at maximum flow rate Qmax between AO (38.9 cm H20) and FO (41.0 cm H20). There was a difference in the Qmax between AO and FO (10.6 [0-41.7] and 7.4 [0-35.7] mL/s, respectively; P=0.0044), but there was considerable overlap between the values in these 2 groups. CONCLUSIONS: Anatomical bladder outlet obstruction and FO have similar urodynamic voiding pressure findings, but Qmax was statistically significantly lower in AO. However, there is a large overlap in the Qmax values between the 2 groups. Therefore, future studies that attempt to characterize bladder outlet obstruction in women need not exclude either group.

Urodynamic findings in women with insensible incontinence.

OBJECTIVES: To define the urodynamic study findings among women with insensible urinary incontinence. METHODS: Women complaining of insensible incontinence who underwent urodynamics at our center were identified. Coexisting symptoms of stress incontinence, urgency incontinence and/or mixed incontinence were recorded. The primary outcome was the urodynamic study finding. Urodynamic stress incontinence, detrusor overactivity incontinence, combination of both or neither (no incontinence) were the possible diagnoses. RESULTS: A total of 58% of patients had insensible incontinence alone and 42% had insensible incontinence combined with other urinary incontinence symptoms. Of the patients with insensible incontinence alone, 37% had no incontinence on urodynamics, whereas urodynamic stress incontinence was diagnosed in 52%. Isolated urodynamic stress incontinence was found in 73% of patients with insensible and stress incontinence symptoms. In patients with insensible plus urgency incontinence, isolated detrusor overactivity incontinence and detrusor overactivity incontinence with urodynamic stress incontinence were found in the same percentage of women (40% each). In patients with symptoms including stress urinary incontinence, stress incontinence was the predominant urodynamic finding. CONCLUSIONS: In patients who have incontinence symptoms in addition to insensible incontinence, these symptoms are highly predictive of urodynamic findings. In particular, women with insensible incontinence, concomitant stress incontinence symptoms are most predictive of urodynamic findings (i.e. urodynamic stress urinary incontinence). In contrast, where insensible incontinence represents the only symptom, urodynamic findings vary widely, with a significant proportion having non-diagnostic studies.

Urodynamic differences between dysfunctional voiding and primary bladder neck obstruction in women.

OBJECTIVE: To determine the clinical and urodynamic differences in the presentation and the value of simultaneous fluoroscopy in dysfunctional voiding (DV) and primary bladder neck obstruction (PBNO); the 2 most common causes of non-neurogenic "functional" bladder outlet obstruction in women. METHODS: A review of our urodynamic study database (March 2003 to August 2009) was conducted. DV was diagnosed when increased external sphincter activity was found during voluntary voiding on electromyography (EMG) or fluoroscopy. PBNO was diagnosed when a failure of bladder neck opening was noted on fluoroscopy during voiding. The demographics, symptoms, and urodynamic study parameters were collected. Comparisons were done using chi-square and 2-tailed t-tests. RESULTS: DV was diagnosed in 34 women and PBNO in 16. The patients with DV were younger than those with PBNO (40.9 vs 59.2 years, P < .001). Women with DV showed a clinical trend toward having more storage symptoms than those with PBNO and fewer voiding symptoms. Patients with DV had a greater mean maximal flow rate (12 vs 7 mL/s, P = .027) and lower mean postvoid residual urine volume (125 vs 400 mL, P = .012). No significant differences were found in maximal detrusor pressure, detrusor pressure at maximal flow rate, or detrusor overactivity. EMG showed increased activity during voiding in 79.4% of those with DV and 14.3% of those with PBNO (P < .001). CONCLUSION: Clinically, women with DV and PBNO had similar presentations, although those with PBNO had poorer emptying. The flow rates and patterns seemed to differ between those with DV and PBNO, although the voiding pressures were similar. EMG alone would have given the wrong diagnosis in 20.6% of those with DV (false negative) and 14.3% of those with PBNO (false positive). When fluoroscopy is used to define these entities, the accuracy of EMG to differentiate them is questionable.

Treatment of post-prostatectomy incontinence with male slings in patients with impaired detrusor contractility on urodynamics and/or who perform Valsalva voiding.

PURPOSE: Male slings have emerged as a popular and efficacious treatment for men with post-prostatectomy stress urinary incontinence. Traditionally slings have been used with caution or avoided in men with impaired detrusor contractility or Valsalva voiding because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with post-prostatectomy urinary incontinence who have impaired contractility and/or void with abdominal straining for urodynamics can be safely treated with slings. MATERIALS AND METHODS: A retrospective review of patients with post-prostatectomy urinary incontinence who underwent an initial sling procedure between January 2004 and January 2010 was conducted at a single institution. Preoperative urodynamic characteristics, and postoperative Patient Global Impression of Improvement, post-void residual and noninvasive uroflow data were examined. Patients were grouped by poor bladder contractility or Valsalva voiding status. Exclusion criteria were lack of preoperative urodynamics and/or postoperative post-void residual. A total of 92 patients were analyzed. The variables were compared using the Student t test and the chi-square test. RESULTS: No statistically significant difference was shown in postoperative post-void residual (mean 4 months postoperatively) or urinary retention when comparing by bladder contractility or Valsalva voiding. In the subset of patients with available postoperative uroflow data, there were no differences in postoperative maximum flow rate or voided volume. CONCLUSIONS: Men with post-prostatectomy urinary incontinence with urodynamic findings suggesting impaired contractility or Valsalva voiding can be safely treated with sling surgery if they have normal preoperative emptying.

Review article: Mid-urethral synthetic slings for female stress urinary incontinence.

• Mid-urethral synthetic slings (MUSS) have grown in acceptance and popularity to gain a foremost position in stress urinary incontinence (SUI) surgery. • There are numerous studies that provide a large amount of Level 1 and 2 evidence that support the concept of a sling placed at the level of the mid-urethra. • Long-term follow-up has been published for the original tension-free vaginal tape (TVT) procedure with the most recent publication providing Level 2 evidence with mean follow-up of 11.5 years of 69/91 (77%) of patients from the original series. There was objective cure was in 90% of women and 77% considered themselves subjectively cured, based on the Patient Global Impression of Improvement. • Level 1 evidence with long-term follow-up has been provided comparing colposuspension to TVT at 2 and 5 years. At 5 years for the primary efficacy variable of a negative 1 h stress pad test, there was no difference in success (81% vs 90%). • Two recent meta-analyses provide Level 1 evidence comparing outcomes for retropubic vs transobturator MUSS. One included 18 studies, randomized and cohort: cohort studies had a 12.3% failure rate for transobturator and 13.7% failure for the retropubic approach, randomized studies showed 5.7% failure in the transobturator vs 7.8% in the retropubic group. The other meta-analysis included 11 studies published 2008-2009, which found that the short-term cure rate was borderline inferior for the transobturator tape group (odds ratio 0.62; 95% confidence interval 0.37-1.00), nearly reaching statistical significance (P= 0.05). • This review details further comparator evidence and evidence for use in specific patient groups (elderly, obese, intrinsic sphincter deficiency, mixed UI).

Urinary incontinence.

Urinary incontinence is a major health problem that becomes more common with increasing age. A thorough history and examination can help determine the type of incontinence: stress, urge, mixed, or other. Initial treatments may include lifestyle and behavioral modifications, pelvic floor exercises, and anticholinergic medications. Urologic referral is appropriate when initial treatment measures fail or in complex cases, such as previous incontinence surgery or irradiation.

Tensile strength of surgical knots in abdominal wound closure.

Abdominal wound dehiscence is a surgical catastrophe that can be attributed to patients or technical factors. The technical properties of the monofilament sutures and knots that are commonly used in abdominal closure are poorly understood. The aim of this study was to compare the tensile strength of monofilament sutures tied with conventional knots. To do this, the knot-holding capacity of four types of knots (square, surgeons', Aberdeen and loop) were tested using three types of gauge 1 monofilament suture, namely nylon, polyglyconate and polydioxanone, using a tensiometer. We found that the knot-holding capacity of the loop knot was between twofold and threefold greater than all the other knots examined. In comparing suture types, polyglyconate had the highest knot-holding capacity for all the knots that were examined and there was no difference in the tensile strength of nylon and polyglyconate tied in a square, surgeons' or Aberdeen knot (P < 0.05). In conclusion, our findings suggest that closure of an abdominal wound would be best commenced with a loop knot, using gauge 1 polyglyconate and finished with either an Aberdeen square or surgeons' knot would be appropriate.