Redefining the Spectrum of Pentosan Polysulfate Retinopathy: Multimodal Imaging Findings from a Cross-Sectional Screening Study.

PURPOSE: There is growing evidence of a direct association between pentosan polysulfate (PPS) therapy and the development of macular changes. Using standardized visual acuity (VA) testing and multimodal imaging, we investigated the impact of PPS therapy on vision and described an expanded spectrum of imaging findings among PPS users. DESIGN: Cross-sectional screening study. PARTICIPANTS: Thirty-nine patients who were current or recent users of PPS. METHODS: The participants underwent a brief eye examination and answered a comprehensive medical and ophthalmic history questionnaire. Color fundus photography, fundus autofluorescence (FAF), and spectral-domain OCT (SD-OCT) were performed. The images were evaluated by expert graders at Wisconsin Reading Center. Abnormalities were categorized as definite toxicity (DT) if seen on both FAF and SD-OCT and as questionable toxicity (QT) if seen on either FAF or SD-OCT. MAIN OUTCOME MEASURES: ETDRS and Snellen VA, the dosage and duration of PPS exposure, and the prevalence of retinal toxicity on imaging. RESULTS: The mean ETDRS and Snellen VA of the study cohort were 85 letters and 20/22, respectively. The mean PPS daily dose was 282 mg (range, 88-400 mg), whereas the mean cumulative dose was 915 g (range, 19-3650 g) over a mean period of 8.8 years (range, 2 months-25 years). There was evidence of retinopathy in 41% of the eyes; DT was identified in 24 eyes (31%) and QT in 8 eyes (10%). Retinal pigment epithelium (RPE) abnormalities (thickening or thinning or both) were present in all eyes with DT. Retinal pigment epithelium atrophy was seen in 7 eyes (9%). In addition to well-established findings, the unique SD-OCT features of this cohort included interdigitation zone abnormalities and the presence of a flying saucer-type defect. Fundus autofluorescence abnormalities were seen in 24 eyes (30.8%), with 20 (66.7%) of these exhibiting abnormalities located outside the central subfield and extending beyond the arcades. CONCLUSIONS: Findings from the masked grading of multimodal imaging at a centralized reading center suggest a wider phenotypic spectrum of structural abnormalities among patients taking PPS. Macular changes selectively involve the RPE and outer retina, with a range of findings often seen beyond the arcades. The subtle and atypical findings in this cohort should prompt clinicians to consider lowering the threshold for diagnosing PPS retinopathy.

Urethral Masses.

Urethral and periurethral masses in women include both benign and malignant entities that can be difficult to clinically differentiate. Primary urethral carcinoma is rare and the optimal treatment modality may vary depending on the stage at presentation. Because cancer-free survival is poor, clinicians shouldhave a high index of suspicion when evaluating a urethral mass. Some benign-appearing urethral masses may be safely observed. Surgical resection is an effective option that should be used based on patient preference and symptoms, and for suspicious lesions.

Better together: multidisciplinary approach improves adherence to pelvic floor physical therapy.

INTRODUCTION AND HYPOTHESIS: To determine whether consultation with pelvic floor physical therapy (PFPT) at the time of initial urogynecologic evaluation increases adherence to PFPT and to identify factors associated with PFPT attendance and completion. METHODS: We performed a retrospective chart review of all patients evaluated for new urogynecology consultation at our institution in a 1-year period, abstracting data about demographics, diagnoses, and PFPT referral, attendance, and completion. Descriptive analyses compared patients who were referred to, attended, and completed PFPT, stratified by whether they saw PFPT the same day as their initial urogynecologic consultation. Logistic regression identified factors associated with PFPT attendance, completion, and referral. RESULTS: PFPT referral was made for 35% (335/958), of whom 67% attended and 42% completed PFPT. Patients who saw PFPT the same day as their first urogynecology visit were significantly more likely to attend PFPT than those who did not (91% vs. 61%, p < 0.001), but completion rates did not differ (49% vs. 41%, p = 0.15). PFPT attendance was higher among women who saw a PFPT the same day as their initial urogynecology appointment (p < 0.001) and among those aged ≥ 65 years (p = 0.015). Age ≥ 65 years and white, non-Hispanic race/ethnicity were associated with PFPT completion. Patients with a diagnosis of pelvic organ prolapse or urinary incontinence and those seen in multidisciplinary clinic were more likely to be referred to PFPT. CONCLUSIONS: PFPT consultation at the time of initial urogynecologic evaluation improves attendance of initial PFPT appointment, but does not improve completion rates.

Assessing the Variability in Insurance Coverage Transparency for Male Sexual Health Conditions in the United States.

OBJECTIVE: To determine the degree of transparency of health insurance policies regarding coverage of male sexual health conditions, we examined the publicly available policy coverage documents of the largest U.S. medical insurance plans. METHODS: We selected 2 index patients across the male sexual health spectrum: (1) a phosphodiesterase type 5 refractory erectile dysfunction (ED) patient requiring intracavernosal injection therapy or penile prosthesis and (2) a 50-year-old male patient with laboratory-confirmed, symptomatic hypogonadism requiring testosterone replacement therapy as defined by endocrine society criteria. We researched the policy documents regarding coverage for standard therapies. We used breast reconstruction after mastectomy as a control. RESULTS: We queried the publicly available policy statements for 84 of the largest health-care plans in the United States. Whereas breast reconstruction policies are publicly available for 94% of the plans examined, policies of only 39% of the plans for advanced ED treatment options and 62% for hypogonadism are publicly available. Of the plans that had publicly accessible data for ED coverage, 85% viewed penile prosthesis and intracavernosal injection as medically necessary, whereas 91% viewed androgen replacement as medically necessary for our index patient. CONCLUSION: There is a lack of transparency among medical insurers regarding coverage of ED and hypogonadism in stark contrast to reconstructive breast surgery.

Consumption of sweetened, dried cranberries may reduce urinary tract infection incidence in susceptible women--a modified observational study.

BACKGROUND: Urinary tract infections (UTIs) are one of the most common bacterial infections, and over 50% of women will have a UTI during their lifetimes. Antibiotics are used for prophylaxis of recurrent UTIs but can lead to emergence of drug-resistant bacteria. Therefore, it is reasonable to investigate nutritional strategies for prevention of UTIs. Cranberry juices and supplements have been used for UTI prophylaxis, but with variable efficacy. Because dried cranberries may contain a different spectrum of polyphenolics than juice, consuming berries may or may not be more beneficial than juice in decreasing the incidence of UTIs in susceptible women. The primary objectives of this study were to determine if consumption of sweetened, dried cranberries (SDC) decreases recurrent UTIs and whether this intervention would alter the heterogeneity, virulence factor (VF) profiles, or numbers of intestinal E. coli. METHODS: Twenty women with recurrent UTIs were enrolled in the trial and consumed one serving of SDC daily for two weeks. Clinical efficacy was determined by two criteria, a decrease in the six-month UTI rates pre- and post-consumption and increased time until the first UTI since beginning the study. Strain heterogeneity and virulence factor profiles of intestinal E. coli isolated from rectal swabs were determined by DNA fingerprinting and muliplex PCR, respectively. The numbers of intestinal E. coli eluted from rectal swabs pre- and post-consumption were also quantified. RESULTS: Over one-half of the patients did not experience a UTI within six months of SDC consumption, and the mean UTI rate per six months decreased significantly. Kaplan-Meier analysis of infection incidence in women consuming SDC compared to patients in a previous control group showed a significant reduction in time until first UTI within six months. The heterogeneity, VF profiles, and prevalence of intestinal E. coli strains were not significantly different after cranberry consumption. CONCLUSIONS: Results of this study indicate a beneficial effect from consuming SDC to reduce the number of UTIs in susceptible women. Because there were no changes in the heterogeneity or VF profiles of E. coli, additional studies are needed to determine the mechanism of action of SDC for reduction of UTIs.

The iatrogenic ureterovaginal fistula.

A 46-year-old woman underwent a robotic-assisted laparoscopic hysterectomy with bilateral salpingo-oophorectomy for the treatment of endometriosis. Two weeks postoperatively, she presented with pelvic pain and vaginal drainage. A right ureterovaginal fistula was diagnosed with the assistance of computed tomography (CT) urography and nephrostogram.

Retropubic versus transobturator midurethral synthetic slings: does one sling fit all?

The purpose of this article is to evaluate the recent evidence base for the choice between transobturator and retropubic approaches to midurethral slings used to treat stress urinary incontinence. While the retropubic and transobturator approaches to midurethral sling surgery for stress urinary incontinence demonstrate equivalent efficacy across a number of randomized controlled trials, they do not appear to be equivalent when particular patient populations are considered separately. The retropubic approach appears to be a better option in patients with intrinsic sphincter deficiency and limited urethral mobility.

Contemporary length of stay and resource utilization when using a fast-track regimen for mid-urethral sling surgery.

OBJECTIVES: To evaluate the length of stay and need for postoperative laboratory monitoring in a fast-track regimen, as despite the excellent safety profile of the tensionless synthetic midurethral sling, many advocate routine in-house postoperative monitoring of both vital signs and laboratory values. METHODS: A retrospective chart review was performed of all patients presenting for isolated, midurethral sling surgery by a single surgeon from February 2005 to July 2007. Patients followed a perioperative care pathway. Hospital charts were reviewed for the following data: date and time of admission to recovery, date and time of discharge, age, anesthetic, whether postoperative laboratory work was ordered, transfusion of blood, emergency room visits within 30 days, readmissions within 7 and 30 days, and whether the patient was discharged with a catheter. RESULTS: A total of 112 procedures were performed. Twenty-six cases were excluded because of either concomitant surgical procedures (22) or incomplete data (4), resulting in 86 patients. The median age was 52 years (range 34-89). The mean length of stay was 2.42 hours and the median was 2.15 hours. No postoperative laboratory tests were ordered and no transfusions were required. One patient presented to the emergency room within 30 days and was admitted for chest pain. Of 86 patients, 79 (92%) were discharged home without a catheter. CONCLUSIONS: When following the fast-track regimen, the tensionless midurethral sling can be performed safely in the outpatient setting without postoperative laboratory work and with a median recovery to discharge time of < 3 hours.

Sexual function is related to body image perception in women with pelvic organ prolapse.

INTRODUCTION: A previous study demonstrated that women seeking treatment for advanced pelvic organ prolapsed (POP) reported decreased self-perceived body image and decreased quality of life. AIMS: To determine the relationship between: (i) sexual function and POP, (ii) self-perceived body image and POP; and (iii) sexual function and self-perceived body image in women with prolapse. METHODS: After IRB approval, consecutive women with POP stage II or greater presenting for urogynecologic care at one of eight academic medical centers in the United States were invited to participate. In addition to routine urogynecologic history and physical examination, including pelvic organ prolapse quantification (POPQ), consenting participants completed three validated questionnaires: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to assess sexual function; Modified Body Image Perception Scale (MBIS) to assess self-perceived body image; Prolapse subscale of Pelvic Floor Distress Inventory (POPDI-6) to assess condition specific bother from POP. Pearson's correlations were used to investigate the relationship between independent variables. MAIN OUTCOME MEASURES: Sexual function and modified body image score and its correlation with symptoms of POP. RESULTS: Three hundred eighty-four participants with a mean age of 62 +/- 12 years were enrolled. Median POPQ stage was 3 (range 2-4). 62% (N = 241) were sexually active and 77% (N = 304) were post-menopausal. Mean PISQ-12, MBIS, and POPDI scores were (33 +/- 7, 6 +/- 5, 39 +/- 23, respectively). PISQ-12 scores were not related to stage or compartment (anterior, apical, or posterior) of POP (P > 0.5). Worse sexual function (lower PSIQ-12 scores) correlated with lower body image perception (higher MBIS scores) (rho = -0.39, P < 0001) and more bothersome POP (higher POPDI scores) (rho = -0.34, P < 0001). CONCLUSIONS: Sexual function is related to a woman's self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a woman's perception of her body image than to actual topographical changes from POP.

Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits.

OBJECTIVE: The purpose of this study was to determine the complications, treatments, and outcomes in patients choosing to undergo removal of mesh previously placed with a mesh procedural kit. STUDY DESIGN: This was a retrospective review of all patients who underwent surgical removal of transvaginal mesh for mesh-related complications during a 3-year period at Cleveland Clinic. At last follow-up, patients reported degree of pain, level of improvement, sexual activity, and continued symptoms. RESULTS: Nineteen patients underwent removal of mesh during the study period. Indications for removal included chronic pain (6/19), dyspareunia (6/19), recurrent pelvic organ prolapse (8/19), mesh erosion (12/19), and vesicovaginal fistula (3/19), with most patients (16/19) citing more than 1 reason. There were few complications related to the mesh removal. Most patients reported significant relief of symptoms. CONCLUSION: Mesh removal can be technically difficult but appears to be safe with few complications and high relief of symptoms, although some symptoms can persist.

Sacral neuromodulation in the older woman.

In the last 10 years, sacral neuromodulation has evolved from an experimental therapy to a safe and proven treatment option for patients with a variety of complex lower urinary tract disorders. It is currently Food and Drug Administration approved for the following indications: intractable urge incontinence, urgency-frequency, and nonobstructive urinary retention. Herein, we will discuss some of the factors complicating incontinence treatment in the elderly population paying particular attention to sacral neuromodulation, its history, indications, and applications within the elderly female population.

Bilateral extravesical ureteral reimplantation in toilet trained children: Is 1-day hospitalization without urinary retention possible?

PURPOSE: Bilateral extravesical ureteral reimplantation has been associated with urinary retention. We developed a critical pathway and modification of surgical technique to determine whether the bilateral extravesical procedure could be performed in toilet trained children with patients discharged home after a 1-day hospitalization and without urinary retention. MATERIALS AND METHODS: A total of 50 consecutive toilet trained children were evaluated after undergoing bilateral extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distally as possible so that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished. No surgical dissection occurs in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. A child is required to fulfill 5 strict criteria to be discharged from the hospital. RESULTS: Patient age ranged from 1.9 to 12.8 years (mean 4.9), with 37 girls and 13 boys participating. All patients were discharged home on postoperative day 1. All patients were able to void postoperatively without any instances of urinary retention. None of the children had acute urinary tract infections or required rehospitalization. All patients had radiographic resolution of the vesicoureteral reflux on postoperative voiding cystourethrogram. CONCLUSIONS: To our knowledge this is the first study to demonstrate that bilateral extravesical ureteroneocystostomy can be performed in selected patients without postoperative urinary retention and with uniform hospital discharge in 1 day. The critical pathway and limited dissection extravesical approach are essential for this success.