Multicentered Assessment of Clinical Outcomes and Factors Associated With Failure of the Adjustable TransObturator Male System (ATOMS).

OBJECTIVE: To assess postoperative outcomes from the Adjustable TransObturator Male System (ATOMS) and identify factors influencing failure to achieve continence. PATIENTS AND METHODS: A multicentered analysis was performed on all patients treated for postprostatectomy incontinence using the third-generation ATOMS at 9 Canadian tertiary referral centers. The primary outcome was continence (defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively and 0 pads for those requiring 1 pad preoperatively). Secondary outcomes included improvement (>50% change in pad use), patient satisfaction, explantation, and postoperative complications. RESULTS: Two hundred and eighty nine patients with a mean age of 68.9 years were analyzed. Pre-operatively mean pad per day use was 4.2 (1-12), 31.5% of patients reported severe incontinence (≥5 pads/day), 33.9% had concurrent radiotherapy and 19.4% had failed previous incontinence surgery. Overall continence rate was 73.3% (n = 212) at a mean follow-up of 19.6 months. More than eighty nine percent (89.3%) (n = 258) of patients experienced >50% improvement, 84.4% (n = 244) of patients were satisfied with the results of surgery. More than seven percent (7.9%) (n = 23) required device explantation. On multivariate Cox regression analysis, concurrent radiotherapy (hazard ratio [H.R.] 2.3, P < .001), diabetes (H.R. 2.2, P = .007) and increased pre-operative pad usage (H.R. 1.1, P = .02) were each associated with failure to achieve continence, while patient age (P = .60), obesity (P = .08), prior urethral stenosis (P = .56), and prior incontinence surgery (P = .13) were not. Radiation therapy was also associated with device explantation (H.R. 2.7, P = .02). CONCLUSION: ATOMS is a safe and efficacious for treatment of postprostatectomy incontinence. However, patients with prior radiation, increased pre-operative pad use, or diabetes are less likely to achieve continence.

Randomized, controlled trial of laser vs. bipolar plasma vaporization treatment of benign prostatic hyperplasia.

INTRODUCTION: Prostate vaporization technology is becoming a standard of care for treatment of moderate, symptomatic benign prostatic hyperplasia (BPH). We compared two transurethral prostate vaporization technologies with respect to cost, efficiency, efficacy, safety, and surgical team satisfaction. METHODS: Fifty-five patients meeting standardized symptom criteria for BPH were randomized to either Olympus Plasma ButtonTM or Biolitec EVOLVE® diode laser vaporization. Primary outcome of cost with secondary outcomes of clinical efficacy, resection time, surgical team satisfaction, and safety were analyzed. Followup was carried out at six and 12 weeks. Patient factors included baseline, as well as six- and 12-week International Prostate Symptom Score (IPSS) with quality of life (QoL) scores. We recorded surgical team satisfaction with a Likert-style survey investigating ease of set-up, reliability, efficiency, and ability to reach desired endpoint. All complications or side effects detected within three months and the resulting management were included in the cost analysis. RESULTS: Mean cost per patient was $3418 for the Olympus group and $4564 for Biolitec (p<0.05). Surgical vaporization time was significantly less for the Olympus group, 24.3 vs. 33.5 minutes (p<0.05). Surgical and nursing staff preferred the Olympus device (p<0.05). IPPS symptom improvement and complication rates were similar between groups. Patients in the Biolitec arm had more intraoperative bleeding episodes requiring conversion to monopolar transurethral resection of the prostate (TURP) (three vs. none). CONCLUSIONS: In a head-to-head randomized trial, Olympus Plasma Button transurethral vaporization was more cost-effective, faster, and preferred by surgical staff when compared to Biolitetec Diode Laser vaporization. Both devices showed similar safety and efficacy.

Canadian Urological Association position statement on the use of transvaginal mesh.

Stress incontinence (SUI) and pelvic organ prolapse (POP) are common conditions. There is high-level evidence that midurethral mesh slings for stress incontinence are effective and safe; however, the rare but serious potential risks of this surgery must be discussed with the patient. The use of transvaginal mesh for prolapse repair does not appear to be supported by the current evidence, and its use should be restricted to specialized pelvic floor surgeons and specific clinical situations.

The role of preoperative urodynamics in stress urinary incontinence surgery.

The routine use of urodynamics prior to incontinence surgery continues to be debated. The evidence available from randomized, control trials suggests that preoperative urodynamics do not improve surgical outcomes and are not cost-effective.

Choosing the right sling for your patient.

Recent data has demonstrated a one in five lifetime risk of a woman requiring stress urinary incontinence (SUI) surgery. Currently, most women opt for a synthetic midurethral sling (MUS), with over 3.6 million placed worldwide. This article attempts to identify whether a gold standard exists with regards to surgical correction of female SUI. When considering which sling type to use for which incontinent woman, the published data demonstrates excellent results for both synthetic mesh (retropubic or transobturator routes) and fascial pubovaginal slings for most patients. Intrinsic sphincter deficiency does appear to be better treated with the use of a retropubic approach, although still with less than stellar results. With little to differentiate, the treatment of most female SUI may be solely based on which sling the surgeon feels most comfortable performing. Currently, most urologists and gynecologists favour synthetic MUS over fascial slings in surgical-naïve patients; however, recent U.S Food and Drug Administration (FDA) warnings concerning the use of mesh in transvaginal surgery have patients questioning the safety of synthetic MUS for the treatment of SUI.

An analysis of the readability of patient information materials for common urological conditions.

INTRODUCTION: Health literacy has been shown to be an important determinant of outcomes in numerous disease states. In an effort to improve health literacy, the Canadian Urological Association (CUA) publishes freely accessible patient information materials (PIMs) on common urological conditions. We sought to evaluate the readability of the CUA's PIMs. METHODS: All PIMs were accessed through the CUA website. The Flesch Reading Ease Score (FRES), the Flesch-Kincaid Grade Level (FKGL), and the number of educational graphics were determined for each PIM. Low FRES scores and high FKGL scores are associated with more difficult-to-read text. Average readability values were calculated for each PIM category based on the CUA-defined subject categorizes. The five pamphlets with the highest FKGL scores were revised using word substitutions for complex multisyllabic words and reanalyzed. The Kruskal-Wallis test was used to identify readability differences between PIM categories and paired t-tests were used to test differences between FKGL scores before and after revisions. RESULTS: Across all PIMs, FRES values were low (mean 47.5, standard deviation [SD] 7.47). This corresponded to an average FKGL of 10.5 (range 8.1-12.0). Among PIM categories, the infertility and sexual function PIMs exhibited the highest average FKGL (mean 11.6), however, differences in scores between categories were not statistically significant (p=0.38). The average number of words per sentence was also highest in the infertility and sexual function PIMs and significantly higher than other categories (mean 17.2; p=0.01). On average, there were 1.4 graphics displayed per PIM (range 0-4), which did not vary significantly by disease state (p=0.928). Simple words substitutions improved the readability of the five most difficult-to-read PIMs by an average of 3.1 grade points (p<0.01). CONCLUSIONS: Current patient information materials published by the CUA compare favourably to those produced by other organizations, but may be difficult to read for low-literacy patients. Readability levels must be balanced against the required informational needs of patients, which may be intrinsically complex.

Examining Penile Sensitivity in Neonatally Circumcised and Intact Men Using Quantitative Sensory Testing.

PURPOSE: Little is known about the long-term implications of neonatal circumcision on the penile sensitivity of adult men, despite recent public policy endorsing the procedure in the United States. In the current study we assessed penile sensitivity in adult men by comparing peripheral nerve function of the penis across circumcision status. MATERIALS AND METHODS: A total of 62 men (age 18 to 37 years, mean 24.2, SD 5.1) completed study procedures (30 circumcised, 32 intact). Quantitative sensory testing protocols were used to assess touch and pain thresholds (modified von Frey filaments) and warmth detection and heat pain thresholds (a thermal analyzer) at a control site (forearm) and 3 to 4 penile sites (glans penis, midline shaft, proximal to midline shaft and foreskin, if present). RESULTS: Penile sensitivity did not differ across circumcision status for any stimulus type or penile site. The foreskin of intact men was more sensitive to tactile stimulation than the other penile sites, but this finding did not extend to any other stimuli (where foreskin sensitivity was comparable to the other sites tested). CONCLUSIONS: Findings suggest that minimal long-term implications for penile sensitivity exist as a result of the surgical excision of the foreskin during neonatal circumcision. Additionally, this study challenges past research suggesting that the foreskin is the most sensitive part of the adult penis. Future research should consider the direct link between penile sensitivity and the perception of pleasure/sensation. Results are relevant to policy makers, parents of male children and the general public.

Percutaneous antegrade nephroscopic holmium laser pyelotomy: Novel endourologic technique for removal of extruded ureteral stent.

Ureteral stent malposition outside of the urinary tract is a very uncommon complication of retrograde or antegrade ureteral stent insertion. There are few reports of open, laparoscopic or endourologic approaches to remove malpositioned stents. We present a novel technique for the removal of an extruded retroperitoneal ureteral stent using percutaneous antegrade nephroscopic holmium laser pyelotomy. This previously undescribed procedure represents a new soft tissue application of the holmium laser.

Intrapouch injections of botulinum toxin type A for the management of unit contractions of a continent urinary diversion.

A 43-year-old woman presented with abdominal pain associated with incontinence from her Indiana pouch continent urinary diversion due to significant unit contractions. The patient's symptoms were refractory to conservative management, including oral and intrapouch antimuscarinic agents. Prior to surgical reconstruction, a trial of intrapouch injections of botulinum toxin type A (BT-A) significantly improved both the abdominal pain and the incontinence. The benefit lasted about 6 months and was subsequently repeated for recurrent symptoms. To our knowledge, this is the first reported case of the management of complications of a continent urinary diversion with BT-A injections.