Reoperation rates for stress urinary incontinence and pelvic organ prolapse in women after undergoing Mid-Urethral sling with or without concomitant colporrhaphy in academic centers within the United States.

In this study, the rates of reoperation for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a mid-urethral sling (MUS) with or without concurrent colporrhaphy were evaluated. An academic faculty practice consortium database was used to identify a cohort of patients treated surgically for SUI with or without concurrent POP repair (apical, anterior, posterior, or a combination of the three) with or without hysterectomy between 2009 and 2011. A total of 20,484 patients matched the criteria. Of patients who underwent a MUS, 7.2% underwent secondary surgery, with a higher rate of 8.6% associated with those who underwent concurrent prolapse repair (Apical repair HR 1.84, p < .01; Anterior compartment repair HR 1.47, p < .01). Concurrent hysterectomy was associated with a lower hazard of secondary prolapse surgery (HR 0.48; p < .01) if the initial surgery involved a complete POP repair. Prolapse mesh repair resulted in a higher hazard of additional surgery (HR 1.43, p < .01). Medicaid insurance was also associated with an increased hazard ratio compared to commercial insurance for secondary surgery (HR 1.32, p < .01). For women undergoing MUS with complete prolapse repair, concurrent hysterectomy is associated with lower secondary surgery rates. Concurrent prolapse repair with mesh is associated with higher secondary surgery rates.Synopsis: For women undergoing MUS (mid-urethral sling) with complete prolapse repair, concurrent hysterectomy is associated with lower secondary surgery rates. Concurrent prolapse repair with mesh is associated with higher secondary surgery rates.Impact StatementWhat is already known on this subject? Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can present at the same time and negatively impact patients' quality of life. There is little data regarding reoperation rates for patients who undergo both MUS and colporrhaphy in one setting.What do the results of this study add? This study found that patients who undergo concurrent MUS (mid-urethral sling) and complete POP repair with the addition of hysterectomy had a lower risk of secondary surgery.What are the implications of these findings for clinical practice and/or further research? Our data can be used by surgeons to counsel patients on the risks of re-operation for SUI for those who would like to undergo concurrent POP repair with or without hysterectomy.

Surgical trends in the correction of female stress urinary incontinence in academic centers within the United States.

AIMS: There is a lack of data describing the current state of stress urinary incontinence (SUI) procedures in academic centers. Urologists, gynecologists, and urogynecologists perform these operations, but the relative volume each group accounts for is unknown. The purpose of this study was to evaluate the distribution of cases in academic centers between specialties and associated patient characteristics. METHODS: A hospital consortium database was used to identify patients treated surgically for SUI between 2009 and 2014. Patient and surgeon variables were evaluated. Patient variables (age, region, insurance, race) and surgeon volume were analyzed. Sub-analysis was conducted to determine concomitant prolapse repairs. RESULTS: Of the 50,315 stress urinary incontinence procedures performed, 22% were performed by urologists. Overall volume dropped 39% and mean surgeon volumes for all three groups decreased with time. Average median volume for urogynecologists (29/year) differed from both urologists (3/year) and non-urogynecologists (2/year). There was a significant difference in rate of concomitant prolapse repairs performed by urogynecologists (56%), gynecologists (54%), and urologists (26%). CONCLUSIONS: These data portray the changing pattern of SUI procedure practice in academic centers. Academic urologists are performing less than 25% of SUI procedures, with an overall decline in number of procedures across all specialties. Urogynecologists and gynecologists are performing a significantly higher proportion of concomitant prolapse repairs. Neurourol. Urodynam. 36:394-398, 2017. © 2015 Wiley Periodicals, Inc.

Difference between urethral circumference and artificial urinary sphincter cuff size, and its effect on postoperative incontinence.

PURPOSE: We assessed whether a difference between intraoperative urethral circumference and artificial urinary sphincter cuff size affects postoperative outcomes. MATERIALS AND METHODS: We evaluated the medical records of 87 males who underwent implantation of an artificial urinary sphincter between January 2006 and May 2010. A validated questionnaire was completed by 59 patients for long-term followup. The difference between urethral circumference and artificial urinary sphincter cuff size was calculated. Incontinence was recorded as daily pad use. The primary outcome variable was the postoperative decrease in incontinence. Multivariable linear regression was used to model the effect on postoperative incontinence of the difference between urethral circumference and cuff size. RESULTS: Mean long-term followup was 4.2 years. Median preoperative incontinence was 8 pads per day and median abdominal leak point pressure was 50 cm H2O. Median urethral circumference was 38 mm and the median difference between urethral circumference and artificial urinary sphincter cuff size was 2.5 mm. Median postoperative incontinence was 1 pad per day. A 1 mm increase in the difference between urethral circumference and cuff size resulted in a 1.6% increase in incontinence by 4.5 months postoperatively (95% CI -3.1-6.2, p = 0.487). Paradoxically, each 1 mm increase improved postoperative continence at long-term followup by 29% (95% CI -15-56, p = 0.162). CONCLUSIONS: At 4.5-month followup there was no statistical difference in pad use or patient satisfaction when the difference between urethral circumference and artificial urinary sphincter cuff size was less than 4 mm vs 4 mm or greater. However, at long-term followup the 4 mm or greater group reported statistically significantly better continence and satisfaction than the less than 4 mm group. This study does not support efforts to improve continence by minimizing cuff size but rather suggests that modestly up-sizing the cuff may produce improved long-term outcomes.

SEAPI Incontinence Classification System: 1-Year Postoperative Results Following Midurethral Sling Placement.

OBJECTIVE: There are limited long-term data that has examined postoperative quality-of-life measures following placement of midurethral sling (MUS) for stress urinary incontinence (SUI). The SEAPI incontinence questionnaire includes 5 data points that rate severity of specific urinary symptoms. Our aim was to describe changes in SEAPI questionnaire outcomes 1 year following sling placement. METHODS: We retrospectively reviewed women who underwent MUS for SUI from 2005 to 2012. We included those women who had completed preoperative and postoperative (>12 months) SEAPI scores. Individual S, E, A, P, I score cure was defined as postoperative score of 0 (>0 preoperative). Logistic regression analysis was used to model the effects of patient characteristics on incontinence cure and S, E, A, P, I scores. RESULTS: A total of 584 women were included. Median follow-up was 25.4 months (12-126.8 months). Follow-up duration and baseline S, P, and I scores were associated with significantly lower odds of overall incontinence cure, whereas rectocele grade has positive association (odds ratio, 1.31; P = 0.040). Type of sling did not impact overall incontinence cure or cure of individual SEAPI scores. CONCLUSIONS: Preoperative S, P, and I scores had negative association with stress incontinence cure. Cure of individual S, E, A, P, I scores was impacted differently by various patient factors. The SEAPI questionnaire provides a unique profile of patient-reported and functional measures in women with SUI and may be helpful in those who undergo MUS.

Identification of Patients with Pentosan Polysulfate Sodium-Associated Maculopathy through Screening of the Electronic Medical Record at an Academic Center.

AIMS: This chart review of a quaternary academic medical center electronic medical record (EMR) aimed to identify patients at risk of development of maculopathy with exposure to pentosan polysulfate sodium (PPS). METHODS: A review of electronic medical records of a quaternary medical center of patients with either documented exposure to PPS or diagnosis of interstitial cystitis (IC) from 2007 to 2019 was performed for retinal imaging and visual acuity; the study was conducted in August of 2019. RESULTS: 216 charts were included for analysis, of which 96 had documented eye exams and 24 had retinal imaging done. We identified three patients with maculopathy in the context of long-term exposure to PPS via chart review, and one additional patient was identified by referral. The median PPS exposure duration was 11 years (range 7 to 19 years). Median logMAR BCVA OD 0.6 range was 0.0-1.9 (approximate Snellen equivalent 20/80 range (20/20-20/1600)) and OS 0.7 range was 0.1-1.9 (approximate Snellen equivalent 20/100 range (20/25-20/1600)). Ultrawidefield color fundus imaging and fundus autofluorescence revealed findings of pigmentary changes and patchy macular atrophy. Optical coherence tomography (OCT) demonstrated outer retinal thinning and increased choroidal transmission coincident with areas of atrophy seen on fundus imaging. CONCLUSIONS: Less than half of patients at risk for development of maculopathy due to exposure to PPS had received eye examinations, suggesting that those at risk are not receiving adequate screening. We found two patients with PPS maculopathy who had relatively preserved central vision, one patient with bitemporal vision loss, and one patient who developed vision loss in both eyes.

The DACRON Ureter: A Case of Ureter to Aorto-Femoral Dacron Graft Fistulization.

We present a case of chronic, severe, intermittent hematuria found to be associated with a ureteral to aorto-femoral bypass fistulization. The graft was directly visualized on ureteroscopy and identified as the source of hematuria during exploratory laparotomy. Ureteral fistulization is a rare etiology of hematuria. Ureteral fistulization to an arterial graft has been reported several times in past decades. However, no cases have reported direct visualization of the dacron graft on ureteroscopy.

VesEcho Training System: Suprapubic Catheterization under Ultrasound Guidance.

INTRODUCTION: Suprapubic catheterization is a fundamental skill for urology residents and trainees. Ultrasound guidance for this procedure is effective for minimizing complications and the British Association of Urological Surgeons guideline recommends use of ultrasound for suprapubic catheterization whenever possible. We developed a novel, cost-effective and sonographically accurate training model for suprapubic catheterization and incorporated it into our resident training curriculum. METHODS: The model consists of the 4 components of the bladder (water balloon), a pelvic bone replica and rectus fascia (nonrebreather masks), all housed within an ultrasound compatible gelatin mold. The model was tested during a resident training course to facilitate instruction of suprapubic catheterization. Surveys were administered before and after training to 13 participating urology residents, assessing the model's anatomical and sonographic realism as well as the utility of the curriculum in their education. RESULTS: The simulator model received a mean score of 4.2 out of 5 (SD 0.6, range 3 to 5) for anatomical realism and 4.4 out of 5 for sonographic realism (SD 0.5, range 4 to 5). The value of the simulator as a training tool was rated 4.7 and the overall value of the training course was rated 5 of 5. Regarding change in overall comfort with the procedure, mean total scores (out of 25) significantly increased for all residents after the training course (14.6 to 19.7, 5.1-point increase, p <0.001). CONCLUSIONS: Our novel simulation model and didactic curriculum received positive evaluations from urology residents and increased their comfort with ultrasound guided suprapubic catheterization. It is a sustainable teaching tool and can easily be incorporated into any urology training curriculum.

Prevalence of Peyronie's Disease-Like Symptoms in Men Presenting With Dupuytren Contractures.

INTRODUCTION: Peyronie's disease (PD) and Dupuytren contractures (DC) are often comorbid and are believed to have a similar underlying pathophysiologic mechanism. AIM: To investigate the prevalence of PD-like symptoms (PDLS) in men with DC. METHODS: From October 2013 to December 2016, men who were seen and evaluated for DC were offered the opportunity to participate in an anonymous survey. The survey assessed several basic demographic and sexual health factors and included items from the International Index of Erectile Function and the Erection Hardness Scale. Men who reported PDLS were asked a series of questions derived from the Peyronie's Disease Questionnaire and for their opinions on theoretical treatment modalities for sexual problems and penile deformity. MAIN OUTCOME MEASURE: Prevalence of PDLS in men with DC. RESULTS: One hundred forty men with DC were invited to participate; 85 surveys were returned (response rate = 61%). Twenty-two respondents (26%, 95% confidence interval = 17-35) reported PDLS. Approximately one fourth of all respondents had an Erection Hardness Scale score lower than 3. The most common specific PDLS concerns were penile curvature (91%), length loss (55%), narrowing (36%), and hinging (32%). In men with PDLS, 73% felt at least a little bothered by the symptoms when attempting sexual activity and 40% reported having sex less frequently because of the symptoms. Just 27% of men with PDLS had ever used a treatment for a sexual concern. In terms of treatments for penile deformities, 64% of men with PDLS expressed an interest in treatment administered in the form of an in-office procedure; 41% were potentially amenable to a surgical procedure. CONCLUSION: The prevalence of PDLS in men with DC is similar to the prevalence of DC in men diagnosed with PD. A substantial number of these men have distress and would consider standard-of-care treatments for PD. Shindel AW, Sweet G, Thieu W, et al. Prevalence of Peyronie's Disease-Like Symptoms in Men Presenting With Dupuytren Contractures. Sex Med 2017;5:e135-e141.

Vascular complications and gene therapy.

For gene therapy, the last few years have been an exciting period. Encouraging results from several successful gene therapy trials were reported. Children born with a life-threatening immune system disorder, severe combined immune deficiency (SCID), were cured after receiving gene therapy for replacement of their defective adenosine deaminase (ADA) gene. Gene therapy successes related to vascular complications were also reported. The first human gene therapy trial for a blood-vessel disorder was performed successfully, in which copies of an angiogenic gene, the vascular endothelial growth factor (VEGF) gene, were directly delivered to the area surrounding the diseased artery of the leg of a patient with peripheral artery disease. Within a few days, this stimulated the growth of new blood vessels around the blockage in the ailing blood vessel and helped avoid amputation. In 1998, a patient with genetically small arteries became the first to receive VEGF gene therapy in the heart. Multiple copies of a plasmid with the VEGF gene were delivered into the damaged area of the heart, and a few days later angiogenesis ensued that helped bypass the blocked vessel, with markedly reduced chest pain in the patient. Gene therapy is becoming a reality and, more importantly, it appears to be safe and does not require supplementary immuno-suppressing drugs. Gene therapy seems to have begun delivering on its promises.

Obesity and female stress urinary incontinence.

The purpose of this article was to review the epidemiology, pathophysiology, and treatment options for stress urinary incontinence in the obese female patient and draw conclusions regarding the optimal treatment of this condition in this unique patient population. Obesity results in increased intra-abdominal pressure and this leads to weakening of the pelvic floor innervation and musculature. Weight loss through lifestyle modification and bariatric surgery improves stress urinary incontinence. Success of stress urinary incontinence surgery in obese women is similar to nonobese patients. Obese women should not be excluded from potentially curative surgery based on their body mass index (BMI) alone.

Infusion therapy and implantables for the urologist.

The specialty of urology has historically adapted to the changing health care environment. Urologists have been quick to adopt new technology, new therapeutics, and devices to render state-of-the-art patient care with improved clinical outcomes. The busy urology practice is now in the position to deliver many novel and unique therapies across multiple disease states. As a result, clinicians can provide state-of-the-art care in a clinic setting and potentially reduce the overall costs of health care delivery. This article reviews some of these potential new opportunities available to the practicing urologist.

Ureteritis cystica: a radiologic pathologic correlation.

Ureteritis cystica (UC) is a benign condition that commonly affects the ureter and can mimic other conditions such as transitional cell carcinoma, blood clots, air bubbles, radiolucent stones, fibroepithelial polyps, and sloughed renal papillae. Radiographically, UC is characterized by multiple small, round, lucent defects, which cause scalloping of the ureteral margins when seen in profile. The scalloping is produced by the projection of the submucosal cysts into the lumen and represents an important differential feature of this disease. We present a case of UC with a radiological pathological correlation.

Renal collision tumor in association with xanthogranulomatous pyelonephritis.

Collision tumor is a rare condition in which two neoplasms (usually benign and malignant), both growing in the same general area, collide with each other and become intermingled. We present histopathology and imaging correlation of xanthogranulomatous pyelonephritis coexistent with squamous cell carcinoma and osteogenic sarcoma of the kidney.