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2.
J Urol ; : 101097JU0000000000000740, 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31909689

RESUMO

PURPOSE: One risk of removal of a tined sacral neuromodulation lead is breakage, resulting in a retained lead fragment. This study reports lead breakage rate, 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: 464 tined lead removals were included, with 35 lead breaks identified, for a rate of 7.5% (35/464). 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 interval since implant 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% (18/27) broke in the tined region, and 81% (22/27) were ghost leads. Most patients, 80% (28/35), with retained lead fragments received another implant. Only one 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 interval 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.

3.
Urology ; 135: 38-43, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31600558

RESUMO

OBJECTIVE: To evaluate differences in adverse events (AE) in asymptomatic patients with a positive urine dip (UD) at time of intradetrusor onabotulinumtoxinA (BTX-A) injection vsthose with a defined negative UD. MATERIALS AND METHODS: All intradetrusor BTX-A injections were retrospectively reviewed at a single institution between 2016 and 2018. Exclusion criteria included an indwelling catheter, recent positive urine culture, recent antibiotic course, or absence of UD on the day of injection. A positive UD was defined using 7 different definitions with varying combinations of any level of positive blood, leukocyte esterase, or nitrite. Negative UDs were defined those excluded from the positive UD group. We compared multiple positive UD-defined groups to their respective negative UD cohorts with regards to outcomes and demographics. RESULTS: A total of 212 patients underwent 335 cycles of BTX-A injections over a 2-year period. The average age was 65 years (range: 21-90). The majority received 100 units (73%) of BTX-A for a non-neurogenic diagnosis (73%). The overall rate of AEs, urinary tract infection, and urinary retention was 14.6%, 9%, and 3%, respectively. In all groups, the most common AE was urinary tract infection followed by urinary retention. There were no major Clavien-Dindo-defined complications. There was no statistically significant difference in the total or categorical AE rates between positive and negative UD groups using all 7 definitions of a positive UD (P = .05-1.0). CONCLUSION: These data do not support the practice of obtaining a preprocedure UD in asymptomatic patients undergoing intradetrusor BTX-A injection for any indication; test results are unable to predict outcomes or AEs.


Assuntos
Toxinas Botulínicas Tipo A/efeitos adversos , Fármacos Neuromusculares/efeitos adversos , Bexiga Urinária Hiperativa/tratamento farmacológico , Retenção Urinária/epidemiologia , Infecções Urinárias/epidemiologia , Administração Intravesical , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas/terapia , Toxinas Botulínicas Tipo A/administração & dosagem , Feminino , Humanos , Injeções Intramusculares/efeitos adversos , Injeções Intramusculares/métodos , Masculino , Pessoa de Meia-Idade , Fármacos Neuromusculares/administração & dosagem , Estudos Retrospectivos , Bexiga Urinária/efeitos dos fármacos , Bexiga Urinária/fisiopatologia , Bexiga Urinária Hiperativa/fisiopatologia , Retenção Urinária/etiologia , Infecções Urinárias/etiologia , Infecções Urinárias/urina , Urodinâmica/efeitos dos fármacos , Adulto Jovem
4.
J Urol ; 203(1): 185-192, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31347955

RESUMO

PURPOSE: Sacral neuromodulation is a guideline recommended treatment of urinary dysfunction and fecal incontinence in patients in whom conservative treatments have failed. Historically sacral neuromodulation has been delivered using a nonrechargeable device with an average life span of 4.4 years. Surgery is required to replace the implanted neurostimulator due to battery depletion. Implantation of a long-lived implanted neurostimulator can eliminate the need for replacement surgeries, potentially reducing patient surgical risks and health care costs. The Axonics r-SNM System™ is a miniaturized, rechargeable sacral neuromodulation system designed to deliver therapy for at least 15 years. The ARTISAN-SNM (Axonics® Sacral Neuromodulation System for Urinary Urgency Incontinence Treatment) study is a pivotal study using rechargeable sacral neuromodulation therapy to treat urinary urgency incontinence. Six-month results are presented. MATERIALS AND METHODS: A total of 129 eligible patients with urinary urgency incontinence were treated. All participants were implanted with a tined lead and the rechargeable sacral neuromodulation system in a nonstaged procedure. Efficacy data were collected using a 3-day bladder diary, the validated ICIQ-OABqol (International Consultation on Incontinence Questionnaire Overactive Bladder quality of life) questionnaire and a participant satisfaction questionnaire. Therapy responders were identified as participants with a 50% or greater reduction in urinary urgency incontinence episodes compared to baseline. We performed an as-treated analysis in all implanted participants. RESULTS: At 6 months 90% of participants were therapy responders. The mean ± SE number of urinary urgency incontinence episodes per day was reduced from 5.6 ± 0.3 at baseline to 1.3 ± 0.2. Participants experienced a clinically meaningful 34-point improvement on the ICIQ-OABqol questionnaire. There were no serious device related adverse events. CONCLUSIONS: The Axonics r-SNM System is safe and effective with 90% of participants experiencing clinically and statistically significant improvements in urinary urgency incontinence symptoms.


Assuntos
Neuroestimuladores Implantáveis , Incontinência Urinária de Urgência/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fontes de Energia Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Qualidade de Vida , Sacro , Incontinência Urinária de Urgência/fisiopatologia
6.
J Urol ; : 101097JU000000000000057601, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31841072
7.
Urology ; 132: 213, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31238047

RESUMO

OBJECTIVE: To describe a novel surgical option for cystolithiasis management in female patients with no urethral access and prior abdominal surgeries. We present a 51-year-old female with a history of traumatic spinal cord injury with pelvic fractures and resultant neurogenic bladder. She underwent transabdominal bladder neck closure and bladder augmentation with continent diversion 2 years prior. CT abdomen/pelvis demonstrated a 3 cm stone and significant amount of bowel anterior to the bladder. METHODS: Pouchoscopy was performed via ureteroscope through the catheterizable stoma to assess stone location and mobility. A 14F-Foley was inserted for intraoperative decompression. An inverted-U incision was made on the anterior vaginal wall overlying the bladder base. Sharp and blunt dissection was performed in an avascular plane to dissect the vagina off of the bladder. Electrocautery was utilized to open perivesical tissue and the detrusor layer transversely. Further sharp dissection of perivesical tissue was achieved using Metzenbaum scissors. The bladder was filled via stoma Foley to improve visualization of bladder mucosa. Cystotomy was made and the 3 cm stone was removed, intact, using a Babcock. The bladder was closed in 2 layers with absorbable suture in running fashion. The bladder was refilled and the closure was watertight. The outer detrusor layer was closed with running locking 2-0 Polysorb, and a separate layer of perivesical tissue was closed over our 2-layer bladder closure using simple interrupted stitches. The vaginal flap was closed with running-locking 2-0 Polysorb. RESULTS: Operative time was 55 minutes. Estimated blood loss was 25 cc. The patient was discharged on postoperative-day 0 with a 14F-Foley in the catheterizable channel. The Foley was removed at the 3-week postoperative visit and patient resumed self-catheterization. No postoperative imaging was required. No complications were reported within 1 year. CONCLUSION: We demonstrate the feasibility of transvaginal cystolithotomy in females with bowel overlying bladder and no urethral access.


Assuntos
Cálculos da Bexiga Urinária/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Urológicos/métodos , Vagina
9.
Urology ; 123: 112-113, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30598199
10.
Int Urogynecol J ; 30(2): 239-244, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29600400

RESUMO

INTRODUCTION AND HYPOTHESIS: We sought to determine whether baseline characteristics predict which overactive bladder (OAB) patients benefit from fesoterodine 8 mg versus 4 mg. METHODS: In double-blind, placebo-controlled, flexible-dose trials, baseline characteristics of OAB patients with ≥ 1 urgency urinary incontinence (UUI) episodes/24 h who escalated from fesoterodine 4 mg to 8 mg were evaluated. Possible dose-escalation predictors (age; sex; previous antimuscarinic use; UUI, micturitions, and urgency episodes/24 h; race; body mass index; time to dose escalation; OAB duration) were compared in escalators versus non-escalators. Patients from fixed-dose trials with dose-escalator characteristics were identified (matched dose-escalator sample) to assess changes from baseline with fesoterodine 4 mg, 8 mg, and placebo. RESULTS: In flexible-dose trials, significant predictors of fesoterodine dose escalation were younger age (≤ 65.8 years), greater number of baseline micturitions (≥ 13.1) and urgency episodes/24 h (≥ 10.9), greater OAB duration (≥ 9.1 years), and more frequent previous antimuscarinic use (58.3%), but not baseline UUI episodes/24 h. In the matched dose-escalator sample (fesoterodine 4 mg: n = 215; 8 mg: n = 198; placebo: n = 217), change from baseline in UUI episodes significantly improved with fesoterodine 8 mg versus 4 mg (P = 0.043) and with both doses versus placebo (P < 0.001). Dry mouth and constipation rates were higher with fesoterodine 8 mg. CONCLUSIONS: Dose-escalator patients had a significantly greater UUI response with fesoterodine 8 mg versus 4 mg. Given the potential for adverse events, fesoterodine 4 mg is recommended to start; however, patients with UUI and identified predictors may benefit from initial treatment with fesoterodine 8 mg or rapid dose escalation.


Assuntos
Compostos Benzidrílicos/administração & dosagem , Bexiga Urinária Hiperativa/tratamento farmacológico , Agentes Urológicos/administração & dosagem , Fatores Etários , Idoso , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Fatores de Tempo , Resultado do Tratamento , Bexiga Urinária Hiperativa/patologia
11.
Neurourol Urodyn ; 38(1): 398-406, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30350875

RESUMO

AIMS: To report the recommendations of the 6th International Consultation on Incontinence (ICI) on post-prostatectomy urinary incontinence. METHODS: The 6th ICI committee on surgical treatment of urinary incontinence in men assessed and reviewed the outcomes of surgical therapy and updated the prior recommendations published in 2013. Articles from peer-reviewed journals, abstracts from scientific meetings, and literature searches by hand and electronically formed the basis of this review. The resulting guidelines were presented at the 2016 ICI meeting in Tokyo, Japan. RESULTS: Voiding diary and pad tests are valuable for assessing quantity of leakage. Cystoscopy and/or urodynamics may be useful in guiding therapy depending on the type of incontinence and presumed etiology. Artificial Urinary Sphincter (AUS) is the preferred treatment for men with moderate to severe stress urinary incontinence (SUI) after RP. Male slings are an acceptable approach for men with mild to moderate SUI. Much discussion centers on the definition of moderate SUI. Injectable agents have a poor success rate in men with SUI. Options for recurrent SUI due to urethral atrophy after AUS implantation include changing the pressure balloon, downsizing the cuff and increasing the amount of fluid in the system. Infection and/or erosion demand surgical removal or revision of all or part of the prosthesis. CONCLUSIONS: Although there are several series reporting the outcomes of different surgical interventions for PPUI, there is still a need for prospective randomized clinical trials. Recommendations for future research include standardized workup and outcome measures, and complete reporting of adverse events at long-term.

12.
Urol Clin North Am ; 46(1): 31-40, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30466700

RESUMO

The synthetic midurethral sling has become the gold standard for treatment of stress urinary incontinence since its introduction more than 20 years ago. With its utilization, the incidence of mesh-related complications has also increased. Mesh exposure and perforation are 2 common mesh complication scenarios that pelvic floor surgeons should be prepared to treat. This article highlights preoperative, perioperative, and postoperative factors to minimize the chance of vaginal wall mesh exposure or perforation of mesh into the lower urinary tract. It also summarizes common presenting symptoms, suggested evaluation and a range of treatment options.


Assuntos
Falha de Equipamento , Slings Suburetrais/efeitos adversos , Telas Cirúrgicas/efeitos adversos , Incontinência Urinária por Estresse/cirurgia , Remoção de Dispositivo , Feminino , Humanos , Reoperação , Fatores de Risco , Procedimentos Cirúrgicos Urológicos
13.
Urology ; 123: 108-113, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30201299

RESUMO

OBJECTIVE: To determine whether a positive troponin is a predictor of intermediate- and long-term mortality in patients undergoing major urologic surgeries at our institution. METHODS: This is a retrospective analysis of patients undergoing major urologic surgery at the Cleveland Clinic from 2010-2015. Patients were stratified by the presence and maximum value of troponin blood-draw, if performed within 30 days of surgery. Survival analysis was performed using Kaplan-Meier function (univariate) and Cox regression analysis (continuous) to assess mortality risk. RESULTS: Within 30 days of surgery, 1305 (15.5%) patients a troponin drawn, and 304 (3.6%) of them had an abnormal troponin level (>0.01 ng/mL). Patients with positive troponin drawn for cause within 30 days of surgery had a significantly decreased overall survival at 5 years of 70.6% (95% CI 62.6, 77.2) when compared to patients with negative troponin (81.7% [95% CI 77.4, 85.3]) and no troponin drawn (90.4% [95% CI 89.0, 91.6]). CONCLUSION: For cause serum troponin blood draw and peak levels demonstrated a positive correlation with all-cause mortality in patients undergoing major urologic surgeries Prospective studies are needed to better understand the utility of postoperative troponin as predictive marker of mortality.


Assuntos
Troponina I/sangue , Procedimentos Cirúrgicos Urológicos/mortalidade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Valor Preditivo dos Testes , Estudos Retrospectivos , Análise de Sobrevida , Fatores de Tempo
14.
Curr Urol Rep ; 19(11): 91, 2018 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-30196438

RESUMO

PURPOSE OF REVIEW: Third-line therapies for patients with overactive bladder (OAB) can improve symptoms for those who have failed conservative therapies. Options include percutaneous tibial nerve stimulation (PTNS), cystoscopic injection of onabotulinumtoxinA (BTX-A), and sacral neuromodulation (SNM). This paper aims to review the current literature on the treatment of patients with idiopathic OAB who have undergone BTX-A injections and have not responded or have undesirable side effects from the therapy. RECENT FINDINGS: There are no randomized control trials examining the role of concurrent medical therapy and BTX-A; rather, there are observational studies in the neurogenic population. Furthermore, there are two observational studies on the role of SNM in BTX-A refractory idiopathic OAB patients demonstrating its safety and efficacy. There are many options available to the patient who fails BTX-A. Further research in this specific patient population is necessary to determine why patients have suboptimal responses and to delineate the next step in treatment.


Assuntos
Inibidores da Liberação da Acetilcolina/administração & dosagem , Toxinas Botulínicas Tipo A/administração & dosagem , Terapia por Estimulação Elétrica , Plexo Lombossacral , Nervo Tibial , Bexiga Urinaria Neurogênica/terapia , Bexiga Urinária Hiperativa/terapia , Terapia Combinada , Humanos , Bexiga Urinaria Neurogênica/tratamento farmacológico , Bexiga Urinária Hiperativa/tratamento farmacológico
15.
Urology ; 120: 80-85, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30016633

RESUMO

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.


Assuntos
Meios de Contraste/administração & dosagem , Cistografia/métodos , Fluoroscopia/métodos , Administração Intravesical , Adulto , Antropometria , Meios de Contraste/efeitos adversos , Cistografia/efeitos adversos , Método Duplo-Cego , Feminino , Fluoroscopia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Solução Salina/administração & dosagem , Razão Sinal-Ruído , Uretra/diagnóstico por imagem , Bexiga Urinária/diagnóstico por imagem , Urodinâmica
16.
J Urol ; 200(5): 1088-1092, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29852181

RESUMO

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.


Assuntos
Neuroestimuladores Implantáveis , Plexo Lombossacral/diagnóstico por imagem , Imagem por Ressonância Magnética/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Projetos Piloto , Estudos Prospectivos
17.
Can J Urol ; 25(3): 9307-9312, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29900817

RESUMO

INTRODUCTION: Robotic surgical procedures have become more common in female pelvic reconstruction. Purported benefits of robotic assisted pelvic floor reconstruction (RAPFR) procedures include shorter hospital stay, faster recovery, lower blood loss, and decreased postoperative pain. Following RAPFR procedures, the current accepted practice is discharge after a one-night hospitalization. We assessed whether same day discharge (SDD) affects the short term safety of and patient satisfaction with robotic assisted pelvic floor reconstructive procedures, relative to those who remain hospitalized overnight. MATERIALS AND METHODS: We retrospectively reviewed the charts of women who underwent RAPFR procedures between October 2015 and October 2016. A same day discharge protocol for RAPFR was initiated in July 2016. To date, 10 patients have undergone SDD. These patients were compared to the consecutive patients from the prior 9 months who stayed overnight. To evaluate short term safety, we reviewed the medical record for any unscheduled Cleveland Clinic emergency department (ED) and/or office visits within 30 days of the RAPFR procedure. We then sent a mailed survey to all patients, querying their pelvic organ prolapse-related PGI-I and also offering a postoperative satisfaction questionnaire. Demographic, perioperative, postoperative data and survey results were compared using Student's t test and Fisher's exact test. RESULTS: In our series, 38 patients (95%) underwent robotic assisted sacrocolpopexy (RASC). Only 2 (5%) had a different RAPFR procedure, a robotic assisted vaginal mesh excision. Concomitant robotic assisted supracervical hysterectomy (SCH) was performed in 9 patients (30%) in the overnight group, whereas 1 of the SDD patients underwent SCH (10%). Demographics and operative characteristics did not differ between groups. Ultimately, patients in the SDD group were no more likely than the overnight group to require an unscheduled ED or office visit in the early postoperative period. With respect to satisfaction, no significant differences were observed between groups, with both groups noting substantial improvement in POP symptoms following surgery. CONCLUSIONS: In this pilot study, same day discharge after RAPFR procedures appears to be safe and feasible. RAPFR procedures were well-tolerated, with no difference in ED or non-urology office visits occurring during the early post-operative period in our series, regardless of length of stay. Patient satisfaction was equivalent between groups and universally high.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Alta do Paciente , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Perda Sanguínea Cirúrgica , Estudos de Coortes , Bases de Dados Factuais , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Duração da Cirurgia , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/terapia , Segurança do Paciente , Prolapso de Órgão Pélvico/diagnóstico , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
19.
Neurourol Urodyn ; 37(5): 1823-1848, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29641846

RESUMO

AIMS: Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel. METHODS: Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group. RESULTS: The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research. CONCLUSIONS: These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.


Assuntos
Terapia por Estimulação Elétrica , Sacro , Bexiga Urinária Hiperativa/terapia , Incontinência Urinária/terapia , Retenção Urinária/terapia , Consenso , Humanos
20.
Urology ; 114: 71-76, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29305202

RESUMO

OBJECTIVE: To evaluate the frequency with which preoperative medical evaluations lead to changes in perioperative management of patients undergoing radical cystectomy and to examine the impact of an evidence-based algorithm on referral utilization. MATERIALS AND METHODS: A retrospective review of 176 patients undergoing radical cystectomy in 2013-2014 was conducted. Patients referred for additional preoperative medical or cardiology evaluation were identified and the incidence of diagnostic testing or management changes resulting from such evaluations were determined. The impact of an evidence-based algorithm on referral utilization and identification of patients undergoing changes in perioperative management was examined. RESULTS: Of 176 patients, 111 underwent additional preoperative medical evaluation, with 2.7% undergoing additional diagnostic testing and 8.1% experiencing resultant changes in medical management. Perioperative management changes were minor in scope, with the majority (65%) involving management of hypertension or hypokalemia. Perioperative outcomes were similar between patients undergoing urologic evaluation alone and patients referred for additional preoperative medical evaluation. Applying a referral algorithm incorporating the American College of Cardiology guidelines would have avoided 72% of all medical referrals and reduced direct hospital costs of preoperative evaluations by 74%, while still capturing 94% of all patients who underwent perioperative management changes and all patients with diagnostic findings necessitating surgical delay. CONCLUSION: Preoperative medical evaluation of patients undergoing radical cystectomy infrequently yields perioperative management changes. The algorithm presented would significantly reduce overutilization and direct hospital costs while capturing patients most likely to benefit from additional medical evaluation.


Assuntos
Algoritmos , Cistectomia/métodos , Cistectomia/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Encaminhamento e Consulta/estatística & dados numéricos , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Estudos de Coortes , Medicina Baseada em Evidências , Feminino , Seguimentos , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Cuidados Pré-Operatórios/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Estados Unidos , Neoplasias da Bexiga Urinária/patologia
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