To mesh or not mesh "apical prolapse," that is the question!

Surgical approaches for pelvic organ prolapse have evolved over the last 30 years and is a popular topic for debate, particularly when discussing apical prolapse. Transvaginal native tissue repairs remain the mainstay of POP surgeries, however, transabdominal approaches continue to evolve. Use of interposition material, such as synthetic polypropylene mesh, is the standard when performing an abdominal sacrocolpopexy, however, use of autologous fascia can be considered. This debate article provides an overview of this subject and highlights the value of different approaches to apical prolapse. The authors were asked to support their approach in various scenarios including:extremes of age, prior hysterectomy and intact uterus, desire to avoid mesh, sexual activity, and presence of comorbidities. In discussing common patient scenarios, ultimate decision making on specific POP surgeries is determined by patient preference and goals.

The Impact of Baseline Functional Bladder Capacity on Short-term Neuromodulation Outcomes.

OBJECTIVE: To evaluate the impact of functional bladder capacity (FBC) on clinical outcomes after a staged neuromodulation procedure. MATERIALS AND METHODS: Adults in our prospective neuromodulation database were evaluated. Data were collected from medical records, voiding diaries (FBC defined as average volume per void), Interstitial Cystitis Symptom Index-Problem Index, Overactive Bladder Questionnaire, and Global Response Assessment over 3 months. Descriptive statistics, Pearson's chi-square tests, Wilcoxon rank sum tests, logistic regression, repeated measures analyses, and Spearman correlation coefficients were performed. RESULTS: Of the 216 patients (mean age 59 years; 84% female), most had urinary urgency and frequency with or without urge incontinence (71%), a sacral lead placement (82%), and implantable pulse generator (IPG) implantation (92%). Baseline FBC was similar between implanted and not implanted patients (P = .17); however implanted patients had a median 19 mL increase in FBC after lead placement compared to a 2.7 mL decrease in explanted patients (P = .0014). There was a strong association between percent change in FBC after lead placement and IPG implantation (P = .021; C-statistic 0.68), but baseline FBC (mL) was not associated. Baseline FBC (mL), or percent change in FBC after lead placement, was not related to symptom improvement. When grouped by baseline FBC < 150 mL and FBC ≥ 150 mL, FBC only improved significantly in the <150 group but both demonstrated significant improvements in symptoms. CONCLUSION: FBC improvements were associated with IPG implantation but not other symptom measures. Patients with low FBC (baseline FBC < 150) also achieved significant improvements in symptoms.

Outcomes of Sacral Neuromodulation in Patients with Prior Surgical Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse.

OBJECTIVES: The aim of this study was to evaluate the efficacy of sacral neuromodulation in patients with prior stress urinary incontinence (SUI) or pelvic organ prolapse (POP) surgery. METHODS: Women in our prospective neuromodulation database were evaluated. Patients with a history of prior SUI/POP surgery were compared to those without. Medical records at baseline were reviewed, and primary outcome was defined as moderate/marked improvement on Global Response Assessment (GRA) at 3 months. Secondary outcomes were measured using bladder diaries and Overactive Bladder Symptom Severity (OABq-SS)/health-related quality of life (HRQOL). Data were analyzed with Pearson χ test, Fisher exact test, Wilcoxon rank-sum test, and repeated-measures analyses. RESULTS: Of 210 subjects, 108 (51%) had prior SUI/POP surgery. Patients with SUI/POP surgery had more prior hysterectomies. At 3 months, there was no difference between groups on GRA outcomes. On the bladder diary, both groups had improvement in median voids per 24 hours, urgency severity, and urge incontinence over 2 years. On the GRA, fewer patients in the SUI/POP group were treatment responders at 12 and 24 months. For urinary urgency, a few in this group were moderately/markedly improved at 6 months, and a higher proportion are reported still leaking urine at 6 and 12 months. Similar proportions in each group reported moderate/marked improvement in leaking. Satisfaction was similar between groups. The OABq-SS/HRQOL scores improved, and there was no difference between the groups. CONCLUSION: Sacral neuromodulation improves bladder symptoms in women with prior SUI/POP surgery, but response may be slightly less in those with prior surgery due to underlying bladder or pelvic floor issues.

The impact of prior back surgery on neuromodulation outcomes: A review of over 500 patients.

AIMS: To evaluate neuromodulation outcomes in patients with prior back surgery. METHODS: Adults in our prospective observational sacral/pudendal neuromodulation study were retrospectively evaluated. History and operative details were reviewed, and outcomes were measured at 3, 6, 12, and 24 months with overactive bladder questionnaire (OAB q) symptom severity (SS)/health related quality of life (HRQOL), interstitial cystitis symptom/problem indices (ICSI - PI), voiding diaries, and global response assessments (GRA). Data were examined with Pearson's χ2 , Fisher's exact, Wilcoxon rank sum tests, and logistic regression multivariate analysis. RESULTS: Five hundred and sixty patients were evaluated (mean age 58.8 ± 17 years; 83% female; 79% had a sacral lead placed), 109 (19%) had history of back surgery; 66 surgeries were lumbar. Back surgery patients were older (mean 63 ± 15 vs. 58 ± 17 years; P = 0.003) and a higher proportion had urge urinary incontinence (UUI) (64% vs. 50% P = 0.008). Generator implant rates were similar (94% vs. 91%; P = 0.34). OABq-SS and HRQOL and ICSI - PI composite scores did not differ between groups at any time point. On bladder diaries, median incontinence episodes daily at baseline and between stages were worse in the prior back surgery group but all bladder diary parameters improved significantly in both groups with the exception of mean voided volume which only improved significantly in the non-back surgery group. Most patients in both groups reported moderate/marked improvement in overall bladder symptoms. CONCLUSIONS: This study suggests that prior back surgery does not appear to impact clinical outcomes; therefore, neuromodulation may be offered in this patient population.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

AIMS: To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM). METHODS: Patients enrolled in our longitudinal neuromodulation database were reviewed. Medical records data, and voiding diaries, Interstitial Cystitis Symptom-Problem Indices (ICSI-PI), and Overactive Bladder Questionnaires (OAB-q) at baseline and 3 months were analyzed with Pearson's χ2 , Fisher's Exact test, Wilcoxon rank tests, and multivariable logistic regression. RESULTS: Of 407 patients, 134 (33%) had at least one reoperation over median 28.9 months follow-up (range 1.6-121.7); 78/407 (19%) were revised, and 56/407 (14%) were explanted. The most common reason for reoperation was lack of efficacy/worsening symptoms (n = 87). The reoperations group had a higher proportion of women (P = 0.049), lower mean body mass index (BMI; P = 0.010), more reprogramming events (P < 0.0001), longer median follow-up (P = 0.0008), and higher proportions with interstitial cystitis (P = 0.013), using hormone replacement therapy (P = 0.0004), and complications (P < 0.0001). Both reoperations/no reoperations groups had similar improvements in ICSI-PI (P < 0.0001 for both), OAB-q severity (P < 0.0001 for both) and quality of life (P < 0.0001 for both). On multivariate analysis, only longer follow-up (P = 0.0011; OR 1.048; CI 1.019, 1.078) and having a complication (P < 0.0001; OR 23.2; CI 11.47, 46.75) were significant predictors of reoperations. In women only, using HRT at time of implant was also predictive of reoperation (P = 0.0027; OR 3.09; CI 1.48, 6.46). CONCLUSIONS: In this largest known series to date, one third of the patients required reoperation and the most common reason was lack of efficacy/worsening symptoms. Ongoing study is needed as the technology continues to evolve. Neurourol. Urodynam. 36:354-359, 2017. © 2015 Wiley Periodicals, Inc.

Number of active electrodes at time of staged tined lead interstim implant does not impact clinical outcomes.

OBJECTIVES: To determine: (1) if obtaining motor response on <4 tined lead electrodes at time of placement affects subjective and objective clinical outcome and (2) voltage requirements to elicit motor response at implant and first postoperative visit number based on number of responding electrodes. METHODS: We reviewed our prospective neuromodulation database to identify patients with unilateral S3 lead placement and motor response (bellows ± toe flexion) on stimulation of 1-4 electrodes, then grouped by number of active electrodes at lead placement. Stage 1 success, reoperation and reprogramming rates, mean voltage at implant and first postoperative visit, and Interstitial Cystitis Symptom/Problem Indices (ICSI-PI) were analyzed using Pearson's Chi-square, Fisher's exact, Kruskal-Wallis or Wilcoxon rank tests. RESULTS: Two hundred forty four patients met inclusion criteria, categorized into 1-2 (n = 25), 3 (n = 48), and 4 active electrodes (n = 171). There were no significant differences between groups in terms of age, indications for neuromodulation, or stage 1 success. At implant, patients with <4 active electrodes required higher mean voltages for motor responses (5.9, 4.9, and 3.9 volts for each group respectively; P < 0.0001). Mean voltages for sensory threshold at first postoperative programming were 1.5 ± 1.5, 0.9 ± 1.0, and 0.8 ± 1.0, respectively (P = 0.08). Overall reoperation rates, and reprogramming sessions at 24 months did not differ (P = 0.72 and P = 0.50). ICSI-PI scores improved similarly in all groups. CONCLUSIONS: Motor response on four electrodes is not necessary for successful stage 1 trial. Despite higher voltage requirements in those with <4 active electrodes at implant, this difference was not observed at initial postoperative programming. Neurourol. Urodynam. 35:625-629, 2016. © 2015 Wiley Periodicals, Inc.

Robotic-assisted laparoscopic mesh sacrocolpopexy.

The current 'gold standard' surgical repair for apical prolapse is the abdominal mesh sacrocolpopexy. Use of a robotic-assisted laparoscopic surgical approach has been demonstrated to be feasible as a minimally invasive approach and is gaining popularity amongst pelvic floor reconstructive surgeons. Although outcome data for robotic-assisted sacrocolpopexy (RASC) is only just emerging, several small series have demonstrated anatomic and functional outcomes, as well as complication rates, comparable to those reported for open surgery. The primary advantages thus far for RASC over open surgery include decreased blood loss and shorter hospital stay.

A candidate serum biomarker for bladder pain syndrome/interstitial cystitis.

Reliable diagnostic markers for Bladder Pain Syndrome/Interstitial Cystitis (IC) currently are not available. This study evaluated the feasibility of diagnosing IC in humans and domestic cats from the spectra of dried serum films (DSFs) using infrared microspectroscopy. Spectra were obtained from films from 29 humans and 34 domestic cats to create classification models using Soft Independent Modeling by Class Analogy (SIMCA). Ultrafiltration of serum improved discrimination capability. The classification models for both species successfully classified spectra based on condition (healthy/sick), and a different set of masked spectra correctly predicted the condition of 100% of the subjects. Classification required information from the 1500-1800 cm(-1) spectral region to discriminate between subjects with IC, other disorders, and healthy subjects. Analysis of cat samples using liquid chromatography-mass spectroscopy revealed differences in the concentration of tryptophan and its metabolites between healthy and affected cats. These results demonstrate the potential utility of infrared microspectroscopy to diagnose IC in both humans and cats.

Abdominal mesh sacrocolpopexy for recurrent triple-compartment pelvic organ prolapse.

OBJECTIVE: To report the short- and intermediate- term outcome of safety and efficacy after abdominal-mesh sacrocolpopexy (MSC) for recurrent anterior, posterior and vault ('triple-compartment') pelvic organ prolapse (POP). PATIENTS AND METHODS: In a database review we identified non-neurogenic women who had MSC for recurrent triple-compartment POP and with a >or=6-month cystographic follow-up. The preoperative evaluation included a history, physical examination, Urogenital Distress Inventory (UDI-6) and visual analogue quality-of-life (QoL) questionnaires, urodynamic studies, and a standing lateral voiding cysto-urethrogram (VCUG) with rest-strain views. All surgery as performed by the same surgeon, using polypropylene (Marlex) mesh. Perioperative data, the VCUG at 6 months, and interval pelvic examinations were recorded. RESULTS: Between 2000 and 2006, 29 postmenopausal women (Caucasian, mean age 64 years, sd 11) underwent MSC. The mean (sd, range) operative duration was 228 (75, 170-340) min, the estimated blood loss 150 (100) mL and the inpatient stay 3 (1) days. At a mean (sd) follow-up of 23 (16) months, the physical examination showed no evidence of POP of grade >or=2, with mean POP-Quantification scores of -2.8 (0.4), -2.9 (0.4) and -9.3 (0.8) for points A(a), A(p) and C, respectively. Two patients (8%) had evidence of grade >or=2 cystocele at the 6-month VCUG. After MSC, four of the six UDI and the QoL scores were significantly lower at the last follow-up than at baseline, with no change in sexual or defecatory function. CONCLUSIONS: The objective and subjective improvement at the short and intermediate follow-up after MSC suggest that this is a safe and effective treatment for recurrent triple-compartment POP.

Rapid communication: bipolar PlasmaKinetic transurethral resection of the prostate: reliable training vehicle for today's urology residents.

BACKGROUND AND PURPOSE: With the improvement of medical therapy and minimally invasive surgical treatments for benign prostatic hyperplasia, the number of transurethral resections of the prostate (TURPs) done in training is decreasing. With fewer TURPs being performed, proficiency in this basic urologic technique has decreased, causing longer resection times. This often leads to a higher risk of fluid absorption, water toxicity, and hyponatremia (TUR syndrome). We examined the safety of bipolar electrocautery TURP (saline TURP) with the Gyrus PlasmaKinetic system using normal saline as irrigant. PATIENTS AND METHODS: Twenty-one men aged 54 to 85 years (median 70.0 years) underwent saline Plasma- Kinetic TURP from June 2002 to August 2003. Serum sodium, chloride, hemoglobin, and hematocrit were measured 1 hour prior to and 1 hour after TURP. Resection time, tissue weights, hospital stay, and catheter time were recorded and analyzed. RESULTS: The median preresection and postresection sodium concentrations were 139.0 mEq/mL and 140.0 mEq/L, respectively (ranges 130-142 mEq/L and 134-143 mEq/L). The corresponding chloride values were 106.5 mEq/L and 109.0 mEq/L (ranges 102-114 mEq/L and 106-116 mEq/L), and the hemoglobin and hematocrit values were 13.4 g/dL and 40.1 g/dL (8.7-15.2 g/dL and 33.7-46.7 g/dL) and 12.0 g/dL and 36.6 g/dL (8.2-14.4 g/dL and 27.5-43.7 g/dL), respectively. The median resection time was 65 minutes (range 45-140 minutes), and the median resected tissue weight was 20 g (range 5-61 g). There was no statistically significant difference between the preresection and postresection sodium concentrations, and no patient exhibited any clinical sign of TUR syndrome. CONCLUSION: Gyrus PlasmaKinetic TURP using normal saline as the irrigant is a safe alternative to and is technically no different from traditional monopolar TURP. The system also provides the longer time needed to train urology residents without compromising patient safety.

Radiation exposure during standing voiding cystourethrography in women.

OBJECTIVES: To calculate the total radiation exposure and effective organ doses from standard protocol voiding cystourethrography (VCUG). METHODS: A prospective series of consecutive, non-neurogenic women underwent a standardized VCUG protocol by the same technologist using a Siemens Sireskop Fluorospot radiographic/fluoroscopic unit. Only studies that followed the protocol were included. The effective dose was calculated using a commercially available dose-modeling program (PCXMC, version 1.5) for risk assessment. RESULTS: A total of 119 studies in 118 women (mean age 60 +/- 13 years, range 30 to 93) were included. Only 15 patients (13%) were premenopausal with in situ reproductive organs. The mean number of images and fluoroscopic time per study was 12.8 +/- 1.4 (lateral images 7.5 +/- 1.3) and 35.8 +/- 11.2 seconds, respectively. The mean effective dose for a single VCUG study was calculated to be 4.3 mSv, of which 26% was from fluoroscopy (1.1 mSv). The dose to the gonads accounted for 50% of the total effective organ dose. Using whole population radiologic risk factors, the total risk detriment, cancer and hereditary, was about 3 per 10,000 patients or a 99.997% chance of no detriment incurred from the study. The genetic and malignant risks were reduced in this cohort of patients, who were older, with most (87%) having no reproductive potential. CONCLUSIONS: Using a standard protocol for adult women, a VCUG study is associated with an acceptable radiation risk.

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience.

OBJECTIVE: To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS). PATIENTS AND METHODS: UDS from consecutive women with symptomatic pelvic organ prolapse were reviewed. The protocol included a 'fill-void' study with a vaginal gauze pack, and then repeated without the pack. Tracings were categorized based on filling cystometrograms (CMGs) and pressure-flow studies (PFS). RESULTS: Of 202 women, 121 with a mean (sd) age of 67 (9.4) years contributed 221 interpretable 'pack, then no-pack' UDS (111 CMGs and 110 PFS); 77 of the women had a moderate cystocele and 44 had a large cystocele. Eighty-five women had urethral hypermobility (UH), and 36 had a well-supported urethra (WSU). The pack unmasked stress urinary incontinence (SUI) in 6% of women, with a mean (sd, range) Valsalva leak-point pressure of 54 (22, 23-90) cmH(2)O. SUI occurred more often in women with UH than WSU. Detrusor overactivity occurred similarly in pack (15%) and no-pack (14%) tracings. Bladder outlet obstruction (BOO) was relieved by the pack in 25 studies and caused by the pack in four. Women with WSU had BOO more often than those with UH (43% vs 22%, P < 0.05), regardless of the presence or absence of the pack. CONCLUSION: Unmasked SUI by pack reduction was uncommon, presumably due to anterior vaginal wall stabilization, as the pack rarely caused BOO. Those with SUI had Valsalva leak-point pressures suggestive of intrinsic sphincter deficiency. The pack did not significantly influence the presence of detrusor overactivity.

An evidence-based approach to the evaluation and management of stress incontinence in women.

PURPOSE OF REVIEW: The aim of this article is to use evidence-based criteria to review recent publications on the evaluation and management of stress urinary incontinence in women. RECENT FINDINGS: Longitudinal studies suggest that a familial predisposition towards stress urinary incontinence may exist. There is mounting evidence that cesarean section may play a protective role against pelvic floor damage due to labor, but this continues to be investigated. Objective parameters in the evaluation of stress urinary incontinence, such as questionnaires, pad test, and urodynamic studies, continue to undergo refinements to become more clinically relevant outcome tools. Non-invasive and minimally-invasive therapies for stress urinary incontinence are expanding. The search continues for the optimal non-autologous material in the pubovaginal sling procedure. Despite concerns over the use of synthetic material and better defined early complications, midurethral slings continue to enjoy popularity with short-term and intermediate success. SUMMARY: Further research into the cause of stress urinary incontinence is necessary. There is still no unified protocol in the evaluation of the condition and its severity. Mid-urethral slings appear to be as efficacious as more established procedures (bladder neck suspensions, pubovaginal slings), but long-term results on safety and efficacy remain scarce.

The role of prolactin in the prostatic inflammatory response to neonatal estrogen.

Estrogen exposure in the neonatal rat has been shown to disrupt the normal morphology and development of the prostate gland. The response to this exposure is manifest in adulthood as epithelial dysplasia and chronic inflammation. This inflammatory response consists of infiltrating T-lymphocytes and macrophages, which is typically observed in chronic prostatitis in both rodents and humans. In our rat model, the developmental hormonal milieu is altered following estrogenization, resulting in transient hyperprolactinemia, which begins prepubertally (postnatal d 21) and persists throughout puberty. The purpose of this experiment was to determine the role of prolactin (PRL) in the altered phenotype of the adult rat prostate exposed to neonatal estrogen. Male Sprague Dawley rat pups (n = 104) were randomized at birth to receive oil or estradiol benzoate on postnatal d 1, 3, and 5. They were further randomized to receive bromocriptine (BrC) pellets or placebo at d 15. Animals were killed at d 90. Serum PRL and testosterone levels, prostate lobe, and hormone-dependent and immune-related tissue weights and histology were examined. Animals receiving BrC had significantly lower PRL levels at d 90, regardless of estrogen status. Prostate lobe and testicular weights were significantly reduced in estrogenized animals vs. controls, and BrC did not abate this response, indicating that growth inhibition is not mediated through hyperprolactinemia. Splenic and thymus weights were greater in estrogenized animals, and this was partially reversed with BrC. Neonatal estrogen exposure resulted in a marked infiltration of CD4+ and CD8a+ lymphocytes in the prostate gland, and this was partially reversed by concomitant BrC treatment. In contrast, the estrogen-induced macrophage infiltration of the prostate was not affected by PRL suppression. These findings indicate that prostatic inflammation and immune cell infiltration in the prostate gland of neonatally estrogenized rats is mediated through a PRL-dependent as well as a PRL-independent mechanism. As prostatic inflammation or prostatitis in humans is associated with benign prostatic hyperplasia and prostatic carcinoma, this animal model may provide mechanistic insight with regards to age-associated prostatic lesions.