A Review of Urinary Tract Endometriosis.

PURPOSE OF REVIEW: To describe the presenting signs and symptoms of patients with urinary tract endometriosis (UTE), appropriate workup, and to review medical and surgical therapies for symptom palliation and definitive management. RECENT FINDINGS: UTE is a condition that clinicians should maintain a high index of suspicion for, as symptoms can be easily misdiagnosed from other causes. Surgical resection of implants appears to offer safe and durable symptom relief. Urinary tract endometriosis may present with symptoms overlapping with interstitial cystitis, nephrolithiasis, bladder overactivity, or recurrent urinary tract infections, and may or may not be cyclical in nature. Cyclical gross hematuria is considered pathognomonic, though final diagnosis must be made after a pathologic review. Without proper diagnosis and treatment, consequences such as silent renal loss from asymptomatic obstruction may result. After the diagnosis is made, initial therapy can be undertaken with hormonal treatment to palliate symptoms (most commonly in the form of combined oral contraceptives), followed by surgical resection for a definitive treatment option.

A SWOT Analysis of Urology Residency.

PURPOSE OF REVIEW: Residency training is a pivotal educational step on the road to becoming a urologist. It combines both clinical and surgical instruction with the goal of producing proficient and compassionate surgeons and clinicians. In this review, we employ a SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) to investigate the current state of urologic residency training. RECENT FINDINGS: Urology remains an attractive and competitive residency with varied and complex surgical and medical training. Areas for improvement include standardization of evaluation and feedback, improving resident wellness, and expanding the use of surgical simulation. Workforce issues such as the predicted urologist supply deficit and poor readiness to enter the business of medicine can be addressed at the residency level. Failure to attract and retain underrepresented minorities, increasing burden of student debt, and resident burnout are serious threats to our field. Using a SWOT analysis we identify key areas for expansion, underscore valuable strengths, and provide a working roadmap for improvement of these formative years.

The role of perioperative medications in urinary retention following midurethral sling.

AIMS: Postoperative urinary retention (PUR) is a known complication of midurethral sling (MUS) placement. The use of certain perioperative medications may influence the risk of this complication. This study aimed to investigate the association of perioperative medications with urinary retention after MUS. METHODS: This was a retrospective study of women undergoing MUS placement for stress urinary incontinence by a fellowship-trained urologic surgeon between 2015 and 2018, under approval by the Institutional Review Board. Both retropubic and transobturator approaches were included. All patients underwent an active void trial following surgery. Intraoperative medications given by the anesthesia team were retrospectively noted. The Fisher's exact test was used to compare the association of PUR with categorical variables. RESULTS: A total of 82 patients were included, 17 (21%) of whom failed postoperative void trial due to urinary retention. Of 25 patients receiving perioperative scopolamine, 40% failed the postoperative void trial, compared to 12% of patients not receiving scopolamine (p = .048). Groups were then stratified based on scopolamine use due to the observed independent association with PUR. Subgroup analysis revealed a stronger association of postoperative retention with scopolamine in patients undergoing concomitant prolapse surgery. Notably, retention rate and scopolamine use were similar whether patients underwent sling placement alone or in combination with prolapse surgery. Rate of retention was also higher for retropubic versus transobturator slings (36% vs. 9%; p = .005). CONCLUSIONS: Perioperative scopolamine may be associated with an increased risk of postoperative urinary retention following MUS, especially in the setting of a concomitant prolapse surgery.

Nocturnal Enuresis in the Adult.

PURPOSE OF REVIEW: The goal of this paper is to describe the pathophysiology of adult nocturnal enuresis and develop a generalized approach for evaluation and treatment. RECENT FINDINGS: Although nocturnal enuresis (NE) impacts a significant proportion of the adult population, research on this topic remains lacking. In the few existing studies, the management strategy is extrapolated from research on pediatric nocturnal enuresis. Furthermore, treatment approaches highlight the importance of identifying risk factors and contributing pathologies. The modern urologist should understand the complexity of this problem and the variety of techniques to evaluate and treat the adult patient with NE. Adult nocturnal enuresis is multifactorial and may have multiple underlying pathologies. A comprehensive workup requires an understanding of the patient's history and symptomatology and the pathophysiologic processes that can occur. Treatment should first target identifiable etiologies, although a generalized algorithm can then be utilized with behavioral and lifestyle modifications, followed by medical therapy. Future studies will provide a better framework for treating this problem.

Outcomes of Autologous Fascia Pubovaginal Sling for Patients with Transvaginal Mesh Related Complications Requiring Mesh Removal.

PURPOSE: We reviewed the outcomes of the autologous fascial pubovaginal sling as a salvage procedure for recurrent stress incontinence after intervention for polypropylene mesh erosion/exposure and/or bladder outlet obstruction in patients treated with prior transvaginal synthetic mesh for stress urinary incontinence. MATERIALS AND METHODS: In a review of surgical databases at 2 institutions between January 2007 and June 2013 we identified 46 patients who underwent autologous fascial pubovaginal sling following removal of transvaginal synthetic mesh in simultaneous or staged fashion. This cohort of patients was evaluated for outcomes, including subjective and objective success, change in quality of life and complications between those who underwent staged vs concomitant synthetic mesh removal with autologous fascial pubovaginal sling placement. RESULTS: All 46 patients had received at least 1 prior mesh sling for incontinence and 8 (17%) had received prior transvaginal polypropylene mesh for pelvic organ prolapse repair. A total of 30 patients underwent concomitant mesh incision with or without partial excision and autologous sling placement while 16 underwent staged autologous sling placement. Mean followup was 16 months. Of the patients 22% required a mean of 1.8 subsequent interventions an average of 6.5 months after autologous sling placement with no difference in median quality of life at final followup. At last followup 42 of 46 patients (91%) and 35 of 46 (76%) had achieved objective and subjective success, respectively. There was no difference in subjective success between patients treated with a staged vs a concomitant approach (69% vs 80%, p = 0.48). CONCLUSIONS: Autologous fascial pubovaginal sling placement after synthetic mesh removal can be performed successfully in patients with stress urinary incontinence as a single or staged procedure.

Management of failed stress urinary incontinence surgery.

With the increasing volume of surgery being performed for the treatment of female stress urinary incontinence (SUI), especially with the widespread use of midurethral slings (MUS), recurrent urinary incontinence is becoming an increasingly common condition. Various preoperative and intraoperative factors have been associated with failed SUI surgery. Treatment options for failed SUI surgery include conservative management and/or surgical management, which include pubovaginal sling, MUS, retropubic suspension, periurethral bulking agents, and artificial sphincters. The choice of treatment option will depend on the etiology of the patient's failure, patient comorbidities, and patient preference.

Predictors of Nerve Stimulator Success in Patients With Overactive Bladder.

PURPOSE: To identify factors associated with successful sacral nerve stimulator (SNS) trial after SNS implantation for the treatment of medication refractory overactive bladder (OAB). METHODS: Patients undergoing treatment for OAB at Lahey Hospital and Medical Center between 2004 and 2016 were identified. Patients undergoing SNS placement were identified; SNS success was defined as permanent implantation of the SNS. Demographic, clinical and treatment data were extracted from patient charts; uni- and multivariate analyses were conducted to identify factors associated with SNS treatment success. RESULTS: A total of 128 patients were included. On univariate analysis, male sex, prior diagnosis of benign prostatic hyperplasia, and lower volume at first urge on urodynamics (UDS) were associated with unsuccessful SNS trial. On multivariate analysis, male sex (odds ratio [OR], 0.145; 95% confidence interval [CI], 0.036-0.530) and lower volume at first urge on UDS (OR, 0.982; 95% CI, 0.967-0.995) were associated with unsuccessful SNS trial. A threshold value of 100 mL at first urge during preoperative UDS had a specificity of 0.86 in predicting SNS success in men. CONCLUSION: SNS is frequently successful at relieving OAB symptoms. Male patients and those with lower volumes at first urge on UDS, particularly below 100 mL, are more likely to have an unsuccessful SNS trial. Patients in these groups should be counseled on the lower likelihood of SNS success.

New treatments for incontinence.

Urinary incontinence (UI) is a common, yet underdetected and under-reported, health problem that can significantly affect quality of life. UI may also have serious medical and economic ramifications for untreated or undertreated patients, including perineal dermatitis, worsening of pressure ulcers, urinary tract infections, and falls. To prevent incontinence, the urethral sphincter must maintain adequate closure to resist the flow of urine from the bladder at all times until voluntary voiding is initiated and the bladder must accommodate increasing volumes of urine at a low pressure. UI can be categorized as a result of urethral underactivity (stress UI), bladder overactivity (urge UI), a combination of the 2 (mixed incontinence), or urethral overactivity/bladder underactivity (overflow incontinence). The main goal of therapy for the management of UI is to reduce the number of UI episodes, prevent complications, and, if possible, restore continence. This review highlights the existing treatment of stress, urge, mixed, and overflow UI in adult men and women and discusses many of the novel treatments including potential future or emerging therapies.

Good urodynamic practice: keys to performing a quality UDS study.

Urodynamics (UDS) is the dynamic study of the storage and voiding function of the urinary tract. The goal of the UDS study is to identify the cause of a patient's voiding symptoms, assess prognosis or the results of prior therapy, or direct management by collecting quantitative measurements while reproducing the patient's voiding symptoms where appropriate and possible. Several parts of the UDS study are customized for each individual to maximize the utility of the test. This article summarizes the key points to performing a quality UDS study that can evaluate and diagnose disorders of the lower urinary tract.

Design and performance evaluation of a minimally invasive telerobotic platform for transurethral surveillance and intervention.

Bladder cancer, a significant cause of morbidity and mortality worldwide, presents a unique opportunity for aggressive treatment due to the ease of transurethral accessibility. While the location affords advantages, transurethral resection of bladder tumors can pose a difficult challenge for surgeons encumbered by current instrumentation or difficult anatomic tumor locations. This paper presents the design and evaluation of a telerobotic system for transurethral surveillance and surgical intervention. The implementation seeks to improve current procedures and enable development of new surgical techniques by providing a platform for intravesicular dexterity and integration of novel imaging and interventional instrumentation. The system includes a dexterous continuum robot with access channels for the parallel deployment of multiple visualization and surgical instruments. This paper first presents the clinical conditions imposed by transurethral access and the limitations of the current state-of-the-art instrumentation. Motivated by the clinical requirements, the design considerations for this system are discussed and the prototype system is presented. Telemanipulation evaluation demonstrates submillimetric RMS positioning accuracy and intravesicular dexterity suitable for improving transurethral surveillance and intervention.

Intratesticular varicoceles: are they significant?

OBJECTIVE: Varicoceles occur in 15% of adult and adolescent males and are generally considered to be an extratesticular phenomenon. However, an intratesticular component has been reported in up to 2% of adult and 2% of adolescent varicoceles. We sought to determine the incidence of intratesticular varicoceles (ITV) in adolescents in our practice, its significance, associated findings and response to treatment. MATERIALS AND METHODS: We retrospectively reviewed 684 adolescent males who were diagnosed with varicoceles and had at least one Doppler ultrasound (DUS) prior to any surgery to identify those with an intratesticular component. Testicular volumes, maximum vein diameter (MVD) and peak retrograde flow (PRF) were determined by DUS and recorded. RESULTS: A total of 6 (0.9%) patients were found to have an intratesticular component with a mean PRF of 43.7 cm/s, mean MVD of 3.3 mm and mean asymmetry of 20%. Mean PRF, MVD, and asymmetry of those without an intratesticular component who underwent surgery was 44.8 cm/s, 2.9 mm, and 21.8%, respectively (PNS for all parameters). Four of the 6 patients had 2 or more DUS, and all 4 had worsening testicular asymmetry and PRF over time. Five patients underwent laparoscopic varicocelectomy and all five had catch-up testicular growth. One patient refused surgical repair and has had subsequent worsening testicular asymmetry and softening of the testicle. CONCLUSIONS: Our findings suggest that adolescents who present with an intratesticular varicocele in association with testicular asymmetry will develop worse asymmetry over time. Therefore, adolescents with intratesticular varicoceles and initial asymmetry should be scheduled for surgery rather than followed.