Robotic sacrocolpopexy for the management of pelvic organ prolapse: a review of midterm surgical and quality of life outcomes.

INTRODUCTION: Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with durable success rates. The aim of our study was to review subjective and objective outcomes including complications after robotic assisted laparoscopic sacrocolpopexy for the repair of symptomatic pelvic organ prolapse. METHODS: Single-site retrospective cohort study of women undergoing robotic assisted laparoscopic sacrocolpopexy with and without concomitant robotic assisted supracervical hysterectomy was performed. Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 questionnaires were used preoperatively and postoperatively to evaluate patient subjective data, respectively. We established a strict improvement of greater than 70% on questionnaire's total score to determine clinical improvement. RESULTS: Complications were assessed at 6 months and 127 women were included in our review. Mesh extrusion occurred in 3 (2.4%) patients. Other complications reported were bowel injury (2.4%), readmission rate (2.4%), wound infection (1.6%), and postoperative hernia at port site (1.6%). Objective and subjective outcomes were assessed at 1 year in 92 women. Although there was no recurrent apical prolapse at 1 year, anterior prolapse was present in 7 patients. Clinical improvement was present in 72% by Pelvic Floor Impact Questionnaire-7 and in 68% by Pelvic Floor Distress Inventory-20. Predictors of poor clinical outcomes were lysis of adhesions (OR, 5.83; 95% confidence interval [CI], 1.2-27.4; P = 0.026), urethrolysis (OR, 11.91; 95% CI, 1.2-117.9; P = 0.034), current smoking (OR, 7.9; 95% CI, 1.1-58.7; P = 0.042), and older age (OR, 1.1; 95% CI, 1.0-1.18; P = 0.044). CONCLUSIONS: Robotic assisted laparoscopic sacrocolpopexy represents a safe and effective surgical therapy to manage symptomatic apical pelvic organ prolapse. Serious complication rates are low but not rare when assessing short-term outcomes.

Retropubic versus transobturator slings--are the outcomes changing with time?

The purpose of this review is to review the most current patient reported (subjective) and physician reported (objective) outcomes and adverse events associated with retropubic (RMUS) and transobturator (TMUS) mid-urethral slings. Since the two landmark meta-analyses published in 2010, four new RCT have been published and five have reported long-term outcomes comparing RMUS versus TMUS. Both RMUS and TMUS are safe and have efficacious longer-term outcomes. There is no difference between these slings' subjective outcomes. There is still debate regarding whether RMUS is slightly superior when assessing objective outcomes. Although three trials showed no difference in objective outcomes, results from the largest trial show that RMUS is superior. Further analysis suggests that women with poor urethral function have less favorable outcomes with TMUS and may do better with RMUS. Adverse events are common, and they differ depending on the surgical approach. These new trials confirm previous reported adverse events.

The fate of synthetic mid-urethral slings in 2013: A turning point.

INTRODUCTION: Since the introduction of the first retropubic tension-free synthetic sling to treat stress urinary incontinence (SUI), newer approaches, different techniques and new devices have been created. Transobturator and single-incision sling (SIS) techniquespara-were developed with the goal of diminishing the rate of complications andspeeding the recovery phase. METHODS: For this review we searched Medline for relevant papers, with an emphasis on meta-analysis and randomised controlled trials (RCTs). Specially selected reports were identified to address both 'index patients' (defined as those with genuine SUI and no previous anti-incontinence procedure or other genitourinary sign or symptom that might affect her SUI) and, briefly, non-index patients. Two authors independently reviewed papers for eligibility. RESULTS: Level 1 evidence from a Cochrane review and two meta-analyses indicated that subjective outcomes with the mid-urethral sling (MUS) were similar to those from colposuspension. However, the MUS was better than colposuspension when assessing objective outcomes (Level 1). MUS are equally effective as autologous pubovaginal slings (Level1). Two meta-analyses suggest that retropubic MUS (RMUS) might be better than transobturator MUS when assessing objective outcomes. Five more recent RCTs with longer term outcomes showed high success rates and only one reported a significant advantage for the RMUS in women with intrinsic sphincteric deficiency. One meta-analysis addressing the SIS showed inferior outcomes to the MUS (Level 1). New and improved SIS techniques have been used, but long-term outcomes are limited and results are still controversial when compared to the MUS. CONCLUSION: MUS are still the standard to treat the index patient as previously stated by the American and European Associations of Urology. Currently data are lacking to define which sling and what approach works best. Complications are significantly different between sling types and are dependent on technique.

Preliminary results of a dose-finding study for botulinum toxin-A in patients with idiopathic overactive bladder: 100 versus 150 units.

AIMS: To evaluate the clinical outcomes of two different doses of BTX-A in patients with I-OAB. METHODS: This investigator initiated, randomized trial was designed to evaluate clinical differences in outcomes for 100 versus 150 U BTX-A in patients with I-OAB. Patients with OAB-Wet and OAB-Dry were randomized to receive 100 or 150 U BTX-A intra-detrusor injection. For patients with OAB-Wet, the primary outcome of interest was change in daily UUI episodes, and for those with OAB-Dry the primary outcome measure was change in number of daily voids as determined by 3-VD. Statistical comparisons were made both pre- and post-injection and also between different treatment groups to assess the superiority of one dose versus the other. RESULTS: Forty-four patients enrolled in the study; 10 OAB-Dry and 12 OAB-Wet patients received 100 U and another 10 OAB-Dry and 12 OAB-Wet patients received 150 U. No significant differences in outcome measure were noted between those receiving 100 versus 150 U. Patients with OAB-Wet tended to be completely dry more frequently if they received the 150 U dose, but this was not statistically significant. No differences in urodynamics outcomes were noted between the groups. QOL was significantly improved in both groups with no difference between the different doses. CONCLUSIONS: In patients with I-OAB, preliminary results indicate that 100 U BTX-A and 150 U BTX-A are equivalent in terms of symptom reduction and QOL improvement.

The impact of lower urinary tract symptoms and urinary incontinence on female sexual dysfunction using a validated instrument.

INTRODUCTION: Lower urinary tract symptoms (LUTS) is a common problem in women and frequently coexists with female sexual dysfunction (FSD). However, the relationship of LUTS and FSD is poorly characterized. AIM: To evaluate the relationship of LUTS and urinary incontinence (UI) to FSD using a validated instrument, the female sexual function index (FSFI). METHODS: We performed an institutional review board-approved retrospective evaluation of 236 female patients over a 3-year time-period who completed an FSFI-validated questionnaire and underwent urodynamics (UDS) evaluation for LUTS or UI. Patients were categorized based upon history and physical exam into different LUTS groups. Additionally, the presence or absence of UI, detrusor overactivity (DO), stress urinary incontinence, and maximal cystometric capacity (MCC) > or <200 mL on UDS were used to further evaluate these patients. FSFI domain and total scores were compared between the different LUTS groups. MAIN OUTCOME MEASURE: FSFI scores were evaluated for women with similar clinical LUTS diagnosis and UDS findings. The Kruskal-Wallis nonparametric test and the Dwass-Steel test determined statistical significance and performed multiple pairwise comparisons between the different voiding dysfunction groups and those with normal UDS (Leak-/DO-/urodynamic stress incontinence-). RESULTS: The mean age of the cohort was 49.5 (range 18-69), and there was no statistically significant difference in mean age within each LUTS subgroup. MCC < 200 mL did not significantly impair female sexual function. Patients with clinical diagnosis of overactive bladder (OAB)-Dry had the highest sexual function while those with mixed urinary incontinence had the worst. Additionally, women with UI and DO had the greatest degree of FSD, which was significantly worse than those with normal UDS. Additionally, for women with or without UI, the presence of DO on UDS resulted in a trend toward worse sexual function. CONCLUSIONS: The sexual function of women is negatively impacted by the presence of LUTS, with UI and DO causing the greatest degree of FSD. The sexual domains most affected are desire, lubrication, orgasm, and sexual satisfaction.

Repeated botulinum toxin injection for idiopathic overactive bladder: will chemodenervation become a long-term solution?

Botulinum toxin A (BTX-A) has emerged as a novel treatment option for idiopathic overactive bladder (OAB) refractory to antimuscarinic agents. The clinical needs of refractory OAB patients have been recently met by sacral neuromodulation and augmentation enterocystoplasty. Important features of BTX-A should include safety, efficacy, and ease of delivery during long-term repeated usage. This article reviews the role of repeated BTX-A injections in the treatment of idiopathic OAB.

Safety and tolerability of sedation-free flexible cystoscopy for intradetrusor botulinum toxin-A injection.

PURPOSE: Intradetrusor botulinum toxin-A injection is a promising emerging therapy for neurogenic and idiopathic overactive bladder that is refractory to current antimuscarinic agents. We evaluated a sedation-free procedure using flexible endoscopy to perform intradetrusor botulinum toxin-A injection using a validated pain score to assess the tolerability of this technique. MATERIALS AND METHODS: Five men and 22 women with idiopathic overactive bladder refractory to antimuscarinics were prospectively evaluated and randomized to 100 U (14) or 150 U botulinum toxin-A (13). Subjects underwent BTA injection with intravesical lidocaine using a 14Fr Olympus flexible cystoscope, which accommodates a 27 gauge flexible Olympus injection needle. Patients were evaluated with the visual analog scale to evaluate discomfort during and 15 minutes after the procedure. Procedure time was recorded. RESULTS: In 22 female patients the mean pain score was 3.1 (range 0 to 10) during the procedure and 0.7 (range 0 to 7) 15 minutes after the procedure. In 5 male patients the mean pain score was 1.6 (range 0 to 3.5) during the procedure and 0.0 with all reporting no pain 15 minutes after the procedure. Mean procedure time was 4.5 minutes (range 4 to 6). Only 1 of the 27 patients requested sedation before any subsequent injections. CONCLUSIONS: Sedation-free intradetrusor botulinum toxin-A injection using intravesical lidocaine and flexible endoscopy is a well tolerated and safe procedure to perform in an office setting.

Staging rectourinary fistulas to guide surgical treatment.

PURPOSE: Surgical management for rectourinary fistulas remains a reconstructive challenge. There are few guidelines to direct the surgeon to the most successful and least morbid technique. We developed a rectourinary fistula staging system that allows selection of the most appropriate technique for the patient. We present the details of the staging system and surgical outcomes. MATERIALS AND METHODS: From July 1999 to July 2005 we treated 14 male patients with rectourinary fistula. Mean patient age was 68 years (range 62 to 73). Etiology was rectal injury during open radical prostatectomy in 5 patients, laparoscopic prostatectomy in 1, radiation induced fistula for prostate cancer treatment (brachytherapy and external beam radiation therapy) in 2, neoadjuvant external beam radiation therapy in 2, ischial decubitus ulcer in 3 with spinal cord injury, and cryotherapy and external beam radiation therapy in 1. Cases were staged as stage I--low (less than 4 cm from anal verge and nonirradiated), stage II--high (more than 4 cm from anal verge and nonirradiated), stage III--small (less than 2 cm irradiated fistula), stage IV--large (more than 2 cm irradiated fistula) and stage V--large (ischial decubitus fistula). Diverting colostomy was performed for stages III to V 6 weeks before definitive therapy. RESULTS: Patients were discharged home after 48 hours. A 22Fr urethral catheter maintained bladder drainage for 3 weeks until cystogram confirmed rectourinary fistula closure. Complications were superficial wound infection and postoperative reexploration of the gracilis flap due to bleeding in 1 case each. All patients were cured after a single operation. CONCLUSIONS: The surgical challenges of a variety of rectourinary fistula repairs can be managed with minimal morbidity and a high success rate using proper staging to guide urinary tract reconstruction.