How to Avoid and Deal with Pelvic Mesh Litigation.

Medical malpractice as it relates to transvaginal mesh implantation adds another level of responsibility when deciding on surgical options to repair stress urinary incontinence or pelvic organ prolapse. As mesh is a viable option for repair, the informed consent process must involve a time commitment to discuss thoroughly the knowns and unknowns about mesh, and potentially must cover other aspects related to surgery: FDA classification of mesh, experience, potential off label usage, and conflicts of interest. A therapeutic alliance must be developed between physician and patient to allay possible fears about the intrinsic uncertainty of surgery. Proper risk assessment of the patient and pre-operative judgment as to when and if mesh implantation is appropriate are decisions that must be documented. Resolution of a conflict from a complication can be dealt with formally or informally. Above all, sharp skills, good communication, broad knowledge base of mesh surgeries, complication management, knowledge of guidelines, along with methodical documentation can mitigate or avert mesh-related litigation.

How small can we go? Percutaneous nephrolithotomy using 6F nephroureteral catheter.

OBJECTIVES: To retrospectively examine our percutaneous nephrolithotomy pathway to determine the efficacy of a 6F antegrade nephroureteral catheter (NUC). METHODS: The records of 99 consecutive patients who underwent percutaneous nephrolithotomy from 1998 to 2000 were reviewed. All patients were admitted the day before percutaneous nephrolithotomy and underwent placement of a nephrostomy tube. The following day, after balloon dilation of the access tract and performance of the procedure through a 30F sheath, an internal-external 6F NUC was left in place. Nephrostograms were performed on postoperative day 1, and, if negative for extravasation or residual stones, the stent was removed. The postoperative parameters included the length of stay, intravenous narcotic use, complications, and time to removal of the indwelling stent. RESULTS: The average procedure time was 103 minutes (range 30 to 300), with a mean stone size of 1.7 cm. The average length of stay was 2.5 days, with postoperative intravenous narcotic use lasting 1.7 days. Of the 99 NUCs placed, 82% were removed by postoperative day 2. Eleven patients had either renal (n = 8) or ureteral (n = 3) extravasation requiring prolonged stenting, and nine had residual stones requiring a second-look procedure. Multivariate analysis demonstrated that prolonged narcotic use, days with an indwelling stent, and longer procedure times correlated significantly with a longer length of stay (P <0.001). The proportion of minor and major complications was 18% and 5%, respectively. CONCLUSIONS: The results of our study have indicated that the 6F NUC minimizes postoperative intravenous narcotic use and expedites both recovery and discharge. Because it is the smallest nephroureteral catheter reported to date for this use, we recommend it be incorporated into prospective studies with validated pain questionnaires.

Synthetic biomaterials for pelvic floor reconstruction.

Pelvic organ prolapse and stress urinary incontinence increase with age. The increasing proportion of the aging female population is likely to result in a demand for care of pelvic floor prolapse and incontinence. Experimental evidence of altered connective tissue metabolism may predispose to pelvic floor dysfunction, supporting the use of biomaterials, such as synthetic mesh, to correct pelvic fascial defects. Re-establishing pelvic support and continence calls for a biomaterial to be inert, flexible, and durable and to simultaneously minimize infection and erosion risk. Mesh as a biomaterial has evolved considerably throughout the past half century to the current line that combines ease of use, achieves good outcomes, and minimizes risk. This article explores the biochemical basis for pelvic floor attenuation and reviews various pelvic reconstructive mesh materials, their successes, failures, complications, and management.

Increasing incidence and importance of HIV/AIDS and gonorrhea among men aged >/= 50 years in the US in the era of erectile dysfunction therapy.

OBJECTIVE: With the advent of effective pharmacotherapy for erectile dysfunction, the risk of sexually transmitted diseases is a possible consequence, especially in the older population. We wanted to review the incidence of sexually transmitted diseases in the older population in an attempt to correlate this with the advent of these new drugs. MATERIAL AND METHODS: Publicly available information on the incidence of HIV, AIDS and gonorrhea was retrieved from the websites of the Centers for Disease Control (CDC), the State of Florida Department of Health, the Senior HIV Intervention Project and the National Association on HIV Over Fifty. National case incidences of HIV and AIDS in men between 1996 and 2000 were examined for trends. National and Florida state trends were compared and, in Florida, Palm Beach, Broward and Dade counties in particular were selected because of their traditionally large retiree population. In addition, the national and Florida state incidences of gonorrheal infection were examined for trends. Statistics on national sildenafil (Viagra) prescriptions were obtained via a personal communication with a regional healthcare representative from Pfizer. RESULTS: According to the CDC, at the end of 1998 >10% of new AIDS cases nationally were in individuals aged >50 years. In the late 1990s, new AIDS cases rose faster in middle-aged and older adults than in people aged >40 years. Many of the newly diagnosed cases of AIDS may have contracted HIV before the age of 50 years; however, many individuals are newly becoming infected above the age of 50 years. Of the reported AIDS cases in 1996 in individuals aged >/= 50 years, 48% were aged 50-54 years, 26% were aged 55-59 years, 14% were aged 60-64 years and 12% were aged >/= 65 years; 84% of these cases were male, and blacks accounted for the greatest proportion of cases (43%). In the US, 7.5 million prescriptions for sildenafil were written in 1998, 9.5 million in 1999, 12 million in 2000 and 15.5 million in 2001. The age breakdown for these prescriptions was as follows: 40-49 years, 23%; 50-59 years, 35%; and 60-69 years, 25%. CONCLUSIONS: The past decade saw rises in heterosexual transmission of HIV and i.v. drug use, especially in the population aged >50 years. The CDC reports that the incidence of new HIV infection is stabilizing in men aged 30-39 years and even falling in men aged 20-29 years. Gonorrhea is well known to increase infectivity for HIV and other STDs. Although the rates of gonorrhea infection fell throughout the early 1990s, they increased by 9% between 1997 and 1999. The number of sildenafil prescriptions has increased by almost 80% over the last few years. Although there may be multiple contributory factors for these findings, to our knowledge this is the first paper in the urologic literature to examine such trends in the older male population, especially in the light of newly available medications for erectile dysfunction.

Theories of prostatitis etiology.

Prostatitis reflects a broad spectrum of prostatic infections, both acute and chronic. Chronic prostatitis, known as National Institutes of Health category III or chronic pelvic pain syndrome, broadly defines a disease that is still poorly understood, and as a consequence, difficult to treat. Typical symptoms include pelvic pain and voiding dysfunction. Infection is often cited as the cause of this condition, despite frequent negative cultures. A close look at the local prostatic microenvironment may yield clues. The role of inflammatory mediators and what stimulates them can point to potential sites of prevention. A genetic link or relationship to other diseases may prove to be part of the cause. Furthermore, a neurologic source, whether anatomic or psychologic, has been strongly debated. Ultimately, it may become clear that chronic prostatitis represents the final common result of a disease that originates from a cascade of multiple stimuli.