Outcomes of Midurethral Slings in Women with Concomitant Preoperative Severe Lower Urinary Tract Voiding Symptoms.

BACKGROUND: Women with stress urinary incontinence and concomitant obstructive (voiding) lower urinary tract symptoms (LUTS) represent a challenging patient population. Furthermore, their diagnosis and management remain incompletely studied and controversial. We evaluated the outcomes of midurethral sling procedures in women with severe obstructive LUTS. METHODS: We performed a post hoc analysis of women who were part of an institutional review board-approved study of midurethral sling surgery. Preoperatively and at 4-6 weeks postoperatively, patients completed the American Urological Association Symptom Score (AUASS) questionnaire. A postvoid residual urine test was obtained preoperatively, at the time of the voiding trial, and 4-6 weeks postoperatively. Three groups of patients with severe LUTS were then defined: Group A (AUASS ≥20), Group B (voiding subscale ≥12), and Group C (urodynamic obstruction). Patients could be included in more than one group. AUASS was again obtained at a medium-term follow-up of 31.6 months. RESULTS: Of 106 women completing follow-up, 30, 23, and 11 subjects met the criteria for groups A, B, and C, respectively. All had statistically significant improvements in storage and voiding subscales, as well as their stress urinary incontinence. No subject presented with retention or voiding dysfunction at follow-up. These improvements continued at medium-term follow-up with the exception of Group C that failed to demonstrate persistence of statistical improvement in AUASS subscales. CONCLUSION: Patients with stress urinary incontinence and severe voiding LUTS can be treated safely with midurethral sling procedures. In both the short and medium term, these symptoms improve dramatically in the majority of patients.

Increasing patient preparedness for sacral neuromodulation improves patient reported outcomes despite leaving objective measures of success unchanged.

PURPOSE: We assessed how a group shared appointment influenced patient preparedness for sacral nerve stimulation for refractory overactive bladder and/or urge urinary incontinence. We also evaluated subjective and objective outcomes. MATERIALS AND METHODS: Patients considering sacral nerve stimulation were prospectively enrolled and invited to attend a group shared appointment. This 75-minute presentation included a question and answer period with an implanting surgeon and an implanted patient. Control patients received standard office counseling. A patient preparedness questionnaire was completed after the group shared appointment or office counseling. Response to treatment was determined using the postoperative satisfaction questionnaire, Patient Global Impression of Improvement (PGI-I) and voiding diaries. RESULTS: In our study 36 women with a mean ± SD age of 61 ± 15 years underwent sacral nerve stimulation. There was no significant difference in patient demographics between the 19 women who attended the group shared appointment and the 17 controls. Overall preparedness was greater in the shared appointment group (p = 0.043) with better understanding of the purpose of (p = 0.003) and alternatives to (p = 0.043) sacral nerve stimulation. Significantly more women in the shared appointment group than controls felt completely prepared (78.9% vs 29.4%, p = 0.003) and completely satisfied (78.9% vs 35.3%, p = 0.003) with sacral nerve stimulation as well as very much better (68.4% vs 17.6%, p = 0.002) according to the PGI-I. There was no difference between the groups in the number of women with a 50% or greater symptom reduction on voiding diary. CONCLUSIONS: Participating in a group shared appointment before sacral nerve stimulation improved patient preparedness and perceived outcomes of treatment, although there was no difference in objective outcomes based on voiding diary.

Purely transvaginal/perineal management of complications from commercial prolapse kits using a new prostheses/grafts complication classification system.

PURPOSE: Commercial prolapse mesh kits are increasingly used in the management of pelvic organ prolapse. We present our experience with the transvaginal/perineal management of synthetic mesh related complications from prolapse kits. In addition, we used the new ICS/IUGA (International Continence Society/International Urogynecological Association) prostheses/grafts complication classification system to report on our contemporary series. MATERIALS AND METHODS: A retrospective chart review of all patients who underwent surgical removal of transvaginal mesh for mesh related complications after prolapse kit use from November 2006 to April 2010 at 1 institution was performed. We report our contemporary series of mesh complications using the new ICS/IUGA prostheses/grafts complication classification system. Postoperative pain, degree of improvement and presence of continued symptoms were reported by patients at last followup. RESULTS: A total of 23 patients underwent transvaginal removal of mesh during the study period. Mean patient age was 61 years. Median period of latency to mesh related complication was 10 months (range 1 to 27). Indications for mesh removal included vaginal/pelvic pain (39%), dyspareunia (39%), vaginal mesh extrusion/exposure (26%), urinary incontinence (35%), recurrent pelvic organ prolapse (22%), bladder mesh perforation with recurrent urinary tract infection (22%), rectal mesh perforation (4%), ureteral perforation injury (4%), retained foreign body (surgical sponge) in the bladder (4%) and vesicovaginal fistula (9%), with most patients citing more than 1 reason. CONCLUSIONS: Although technically difficult in some cases, purely transvaginal mesh excision appears to be safe with resolution of almost all presenting symptoms. Although slightly cumbersome, the new ICS/IUGA prostheses/graft complication classification system can be used to report and more accurately characterize mesh complications.

Laparoendoscopic single-site (LESS) hysteropexy.

Uterine prolapse is one of the common reasons for hysterectomy throughout the world. However, recent data has shown that uterine-sparing techniques appear to be equivocal to that of hysterectomy. Older reports of intra-abdominal uterine suspension describe open approaches and more recent descriptions involve robotic and laparoscopic approaches utilizing mesh. We describe the first reported laparoendoscopic single-site (LESS) sacral hysteropexy utilizing a strip of polypropylene mesh placed posteriorly on the uterus and attached to the sacral promontory. A 45-year-old female with grade 3 uterine prolapse, cystocele, and rectocele underwent the procedure. The procedure involved access utilizing a single-port system placed transumbilically, and dissection using articulating laparoscopic instruments. The hysteropexy was completed by placing a 3-cm wide strip of polypropylene mesh along the posterior vaginal wall and cervicouterine junction, and suturing the proximal end to the anterior longitudinal ligament overlying the sacral promontory. The patient was discharged home within 18 h of the procedure. At 6 month follow-up, the patient has excellent anatomic support, with no evidence for recurrence of prolapse. LESS hysteropexy appears to be a safe, effective procedure for uterine prolapse and provides patients with excellent outcome with no visible scar. Additional studies will determine whether the LESS approach provides any benefit when compared with robotic or traditional laparoscopic approaches with respect to blood loss, pain, and time of full recovery.

Mid-urethral slings in female incontinence: Current status.

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring one's choice of MUS to the individual patient and her unique clinical parameters remains the best option.

Force of stream after sling therapy: safety and efficacy of rapid discharge care pathway based on subjective patient report.

PURPOSE: We evaluated the safety of a mid urethral sling postoperative care pathway using patient subjective reporting of force of stream to minimize length of stay and catheter placement. MATERIALS AND METHODS: Women undergoing solitary mid urethral sling surgery were prospectively enrolled in our study. Force of stream after the sling therapy protocol consisted of retrograde bladder filling with 300 ml fluid within 1 hour after surgery. Patients rated force of stream compared to baseline on a visual analog scale. Those with a force of stream of 50% or greater were immediately discharged home regardless of post-void residual urine volume. Only those unable to void and those rating force of stream less than 50% with post-void residual urine volume greater than 500 ml were discharged home with a catheter. Patients were telephoned within 1 week of surgery and seen 4 to 6 weeks postoperatively. The primary outcome was unexpected visits to the emergency room or office for voiding dysfunction or urinary retention. RESULTS: A total of 114 women were prospectively enrolled in our study, of whom 105 (92.1%) passed the protocol and were discharged home without a catheter. Of the patients 14 were discharged home with increased post-void residual urine volume (range 152 to 427 ml) but no catheter, representing those who would have been discharged with a catheter by many traditional voiding protocols. According to protocol 9 patients were discharged with a catheter. No patient presented to the emergency room or office in urinary retention or with voiding dysfunction before the scheduled visit. CONCLUSIONS: Patients who report a force of stream of 50% or greater can be safely and rapidly discharged home after an uncomplicated mid urethral sling procedure regardless of post-void residual urine volume. Scanned post-void residual urine volume does not add much value in those who can void. By following the force of stream after sling therapy protocol patients can be discharged home less than 3 hours after mid urethral sling surgery.

Surgically corrected urethral diverticula: long-term voiding dysfunction and reoperation rates.

OBJECTIVES: To present the largest reported cohort of women with urethral diverticula and to evaluate the surgical outcomes and long-term voiding symptoms after urethral diverticulectomy. Studies evaluating the outcomes after urethral diverticulectomy have been limited by small patient numbers and short-term follow-up. METHODS: Women who had undergone diverticulectomy at our institution from 1996 to 2008 were mailed surveys. Urinary bother was assessed using the Urogenital Distress Inventory 6-item questionnaire, and patients were asked to report subsequent urethral or vaginal surgery and the number of urinary tract infections within the previous year. To determine the rate of surgical recurrence, the charts of women not responding to the survey were reviewed. RESULTS: A total of 122 women were identified as having undergone urethral diverticulectomy during the study period. Of these, 13 (10.7%) had an eventual recurrence that required repeat surgical excision. Patients with a proximal diverticulum, multiple diverticula, or previous pelvic or vaginal surgery (excluding previous diverticulectomy) were more likely to develop recurrence (P = .01, P = .03, and P < .001, respectively). For the 61 women (50%) responding to our survey, the mean follow-up was 50.4 months. Of these 61 women, 24 (39.3%) had had a urinary tract infection within the previous year, with 14 (23%) women having had ≥3 within the previous year. Also, 16 (26.2%) had persistent pain or discomfort with urination. The mean ± SD total Urogenital Distress Inventory-6 score was 31.1 ± 25.5 for the survey responders. CONCLUSIONS: To our knowledge, our study represents the largest study with the longest follow-up after urethral diverticulectomy. Patients with proximal or multiple diverticula and those with previous pelvic surgery should be counseled appropriately regarding the risks of recurrence and persistent voiding dysfunction.

Incidence of perioperative urinary tract infection after single-dose antibiotic therapy for midurethal slings.

OBJECTIVES: A recent Best Practice Statement published by the American Urological Association (AUA) recommends that antibiotic therapy in patients undergoing midurethral synthetic slings (MUS) should be 24 hours or less. Subjects at our institution are routinely administered a single dose of intravenous antibiotics before MUS surgery. We prospectively evaluated urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing MUS who receive single-dose antibiotic therapy. METHODS: Adult female patients who were undergoing MUS for stress or mixed urinary incontinence were prospectively included and received a single-dose of an intravenous antibiotic in accordance with the AUA Best Practice Statement. Subjects requiring additional procedures for prolapse were excluded. Baseline characteristics and preoperative and postoperative postvoid residual (PVR) were documented. Subjects were contacted within 1 week of surgery, and seen in the office at 1 month, when a urinalysis was performed, and urine culture sent if subjects were symptomatic. RESULTS: A total of 101 subjects underwent solitary MUS and received a single dose of intravenous antibiotics. Overall, 6 (5.9%) subjects developed a UTI within 1 month of surgery. Patients who developed a UTI were more likely to have elevated PVRs at the preoperative office visit (62.2 vs 26.8 mL, P = .004). CONCLUSIONS: Our study has demonstrated that the rate of perioperative UTI after MUS with one perioperative dose of intravenous antibiotics is low. Patients with an elevated preoperative PVR may be at an increased risk of developing a UTI. Single-dose antibiotic administration is safe and effective at preventing perioperative UTI in subjects undergoing solitary MUS.

Fallopian tube prolapse presenting as a peritoneovaginal fistula.

INTRODUCTION: Peritoneovaginal fistula is an extremely rare cause of persistent vaginal leakage following a hysterectomy. Likewise, fallopian tube prolapse is an uncommon but known complication of hysterectomy. Fallopian tube prolapse resulting in peritoneal leakage has yet to be reported in the literature. CLINICAL CASE: A 27-year-old female presented with a two year history of continuous leakage per vagina. The leakage started shortly after an abdominal hysterectomy. Examination noted clear fluid emanating from a vaginal lesion located at the level of the vaginal cuff. An extensive workup ruled out vesicovaginal and ureterovaginal fistula. Surgical exploration noted that the lesion was a prolapsed fallopian tube, which was resected vaginally. DISCUSSION: This is the first reported case of peritoneovaginal fistula associated with a prolapsed fallopian tube. CONCLUSION: Vaginal resection of the fallopian tube remnant and reclosure of the vaginal cuff results in cure of the leakage.

Pure transvaginal removal of eroded mesh and retained foreign body in the bladder.

INTRODUCTION AND HYPOTHESIS: We present a pure transvaginal approach to the removal of eroded mesh and a retained foreign body involving the bladder secondary to placement of transvaginal mesh for management of pelvic organ prolapse (POP) using a mesh kit. METHODS: Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit was performed. A U-shaped incision was made in the anterior vaginal wall; mesh was identified, divided in the midline, and then dissected from the bladder. Additionally, a retained foreign body was removed from the bladder. The bladder was closed in three layers transvaginally. RESULTS: Removal of eroded mesh and foreign body within the bladder was completed with all operative steps performed transvaginally. Follow-up cystogram was normal. There were no postoperative complications. CONCLUSIONS: Transvaginal removal of mesh erosion and retained foreign body involving the bladder is feasible and allows for rapid return to normal function.

Does periprostatic block reduce pain during transrectal prostate biopsy? A randomized, placebo-controlled, double-blinded study.

INTRODUCTION: Currently, the use of local anesthetic at the time of transrectal ultrasound-guided biopsy of the prostate is not universally accepted, as the needle injection itself causes pain. In prior studies, lidocaine was compared to placebo in separate patient groups. We present the first study to evaluate both lidocaine and placebo injected in each patient. MATERIALS AND METHODS: Fifty patients received periprostatic injections of both lidocaine and placebo, randomized to separate sides of the prostate, in a randomized, double-blind, placebo-controlled trial design. Injections were delivered at the angle between the seminal vesicle and prostate on each side. Patients graded pain on a visual analog scale (VAS) (0-10) after injections and after each biopsy. Patients were surveyed to evaluate overall pain and discomfort before discharge. We used Student's t-test to compare the mean VAS scores between lidocaine and placebo. RESULTS: The mean (SD) VAS after biopsy was 1.9 (1.4) on the lidocaine side and 2.3 (1.4) on the placebo side (P = 0.202). Pain after the injection itself was similar to pain after biopsy, with the mean (SD) VAS of 2.4 (1.6) and 2.2 (1.7) after lidocaine and placebo injections, respectively (P = 0.546). None of the differences were statistically significant. Twenty-nine (59.2%) patients reported no pain at the time of discharge. CONCLUSIONS: Pain experienced during transrectal biopsy of the prostate is mild and is not significantly lowered with periprostatic nerve block. Pain from injection itself is similar to pain from core biopsies. Pain from transrectal ultrasound-guided biopsy of the prostate is well tolerated with no anesthesia.

Single-port transvesical excision of foreign body in the bladder.

OBJECTIVES: To present a novel technique to remove intravesical polypropylene mesh through a single laparoscopic port placed directly into the bladder. METHODS: A Triport single-site access system was placed transvesically and carbon dioxide was used for insufflation of the bladder. A combination of straight and articulating laparoscopic instruments was used to dissect the mesh away from the bladder mucosa and transect each end for complete removal of foreign bodies. Mucosal reapproximation was performed on the latter case. RESULTS: Two patients were managed adequately in the outpatient setting. No suprapubic catheters were necessary, and patients were discharged within 23 hours. CONCLUSIONS: Removal of foreign bodies of the bladder through a single transvesical laparoscopic port is technically feasible. This procedure offers excellent visualization of mesh material, especially near the bladder neck where these foreign bodies often reside. This approach offers patients a minimally invasive approach through a single small incision.

Retropubic synthetic midurethral slings: techniques and outcomes.

Retropubic midurethral slings have evolved to become one of the standard therapies for treatment of stress urinary incontinence. The current slings can be placed through a small vaginal incision, with minimal dissection, in the ambulatory setting. With improvements in technique, complications are minimal. Although the tension-free vaginal tape has the most prospective data in the literature, the suprapubic arc sling appears to have equal cure and complication rates in shorter-term studies. Other retropubic slings have a paucity of data, and long-term equivalency studies have yet to be reported. This article describes the techniques of the most commonly performed retropubic synthetic slings and reports on efficacy and outcomes based on recently published studies.

NOTES transvaginal nephrectomy: first human experience.

OBJECTIVES: To present the operative outcomes of the first natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy. METHODS: A 57-year-old woman with hypertension, right-sided flank pain, and radiographic evidence of an atrophic right kidney consented for NOTES transvaginal nephrectomy. Pneumoperitoneum was achieved with a Veress needle inserted deep in the umbilicus. Under direct vision, a colpotomy was made and a transvaginal port positioned. Using standard and articulating operating instruments inserted transvaginally, the kidney was mobilized and the renal hilum was controlled with an endovascular stapler. The kidney was placed in a laparoscopic retrieval bag and extracted through the vaginal incision. Salient demographic and operative data were obtained. RESULTS: NOTES transvaginal nephrectomy was successfully completed, with all the operative steps performed transvaginally. Dense pelvic adhesions from a prior hysterectomy necessitated the use of a 5-mm umbilical port during vaginal port placement and for retraction of the ascending colon during division of the renal hilum. No intraoperative complications occurred. Operative time was 307 minutes, with 124 minutes dedicated to vaginal port placement and 183 minutes dedicated to adhesiolysis and nephrectomy. The duration of hospitalization was 23 hours. The visual analog pain scale score was 1 of 10 on postoperative day 2. CONCLUSIONS: Our experience shows that NOTES transvaginal nephrectomy is technically feasible. Access to the peritoneal cavity should be performed under visual guidance and after insufflation through the umbilicus. Additional experience is needed to better define patient selection criteria and indications for NOTES transvaginal urologic surgery.

Neuromodulation and female sexual function: does treatment for refractory voiding symptoms have an added benefit?

INTRODUCTION AND HYPOTHESIS: Women undergoing InterStim implantation for overactive bladder (OAB) or painful bladder syndrome (PBS) were prospectively evaluated to determine if neuromodulation has any effect on female sexual function (FSF). METHODS: Sexually active women in our InterStim database completed a female sexual function index (FSFI) preoperatively and at 6 months. RESULTS: Of 105 women, 54 have 6-month follow-up data. Of these, 27 were sexually active preoperatively and at follow-up. The mean (standard deviation (SD)) FSFI improved from 18.7 (6.8) preoperatively to 21.0 (6.0) postoperatively; however, this was not statistically significant (p = 0.220). Subgroup analysis of patients with OAB revealed that mean (SD) FSFI preoperatively was 18.6 (8.0) and 22.4 (6.4) at 6 months (p = 0.257). In the PBS group, mean (SD) FSFI was 18.8 (6.3) preoperatively and 18.7 (5.8) at 6 months (p = 0.98). CONCLUSIONS: Neuromodulation does not significantly improve FSF in a heterogenous population. Additional studies are needed to confirm the findings in our study.

Dilemmas in diagnosing pelvic pain: multiple pelvic surgeries common in women with interstitial cystitis.

We determined the prevalence of pelvic surgeries in women with interstitial cystitis (IC) compared to community-based controls through responses to a survey from 215 women with IC and 823 controls. Women with IC had a statistically higher prevalence of hysterectomies (cases=42.3%, controls=21.4%), bladder suspensions (cases=21.9%, controls=5.7), pelvic or genital surgeries other than cystoscopy (cases=26.5%, controls=16.2%), and laparoscopic pelvic surgeries (cases=22.8%, controls=8.3%). Women with IC more commonly had been diagnosed with endometriosis (cases=25.6%, controls=9.8%) and fibroids (cases=24.2%, controls= 16.3%). Of women with IC who had hysterectomies, 68% of the hysterectomies were done before their diagnosis of IC, and only 21% were done after their IC diagnosis. The diagnosis of IC occurred 1-5 years after hysterectomy in most cases. Women with IC have significantly more pelvic surgeries than controls. The majority of these surgeries were done before the diagnosis of IC and may be performed for pain related to undiagnosed IC.

Inguinal herniation of a transplant ureter: rare cause of obstructive uropathy.

We present a rare case of late renal allograft failure from ureteral obstruction resulting from inguinal herniation. A 72-year-old man presented with an elevated creatinine and hydroureteronephrosis of a transplanted kidney on ultrasound. Noncontrast computed tomography demonstrated an inguinal hernia containing ureter, and a nephrostomy tube was placed. The hernia and ureter were temporarily reduced during antegrade stent insertion. Creatinine normalized and we performed inguinal herniorrhaphy with polypropylene mesh. The ureter was not reimplanted. Renal function remained stable after nephrostomy tube removal. Simple herniorrhaphy without ureteral reimplantation may fix the case of ureteral obstruction from inguinal herniation.

Bladder herniation through suprapubic incision for penile prosthesis.

To our knowledge, we present the first case of bladder herniation after insertion of an inflatable penile prosthesis. A 65-year-old man presented with a suprapubic bulge. He had his third inflatable penile prosthesis placed 1 year earlier. He had no voiding complaints but requested surgical intervention because the hernia was cosmetically undesirable. After the hernia sac was opened the majority of the bladder was found within it. The defect was repaired with Gore-Tex mesh and the reservoir replaced. One must consider bladder involvement in ventral hernias after penile prosthesis insertion, and a preoperative cystogram might assist in identifying hernia contents.