Urodynamic characterization of lower urinary tract symptoms in women less than 40 years of age.

INTRODUCTION: Lower urinary tract symptoms (LUTS) in young women is becoming a more recognized urologic issue that can arise from many causes, each with their own management strategy. The purpose of this study was to determine the rates of various etiologies for LUTS in women under 40 years of age. MATERIALS AND METHODS: Video urodynamic studies (VUDS) were performed in 70 women age 40 years or less with LUTS for greater than 6 months between March 2005 and June 2012 at Weill Cornell Medical College. Patients with culture-proven bacterial urinary tract infections, pelvic organ prolapse greater than grade I, symptoms for less than 6 months, a history of neurologic disease, or previous urological surgery affecting voiding function, were excluded from the analysis. RESULTS: The mean age of the patients was 31.95 ± 5.57. There were 48 patients that presented with more than one urinary symptom (68.57%). The most frequent complaints included: urinary frequency (n = 42, 34.15%), incontinence (n = 26, 21.14%), and urinary urgency (n = 22, 17.89%). The most common urodynamic abnormality was dysfunctional voiding (n = 25, 28.74%), detrusor overactivity (n = 15, 20.00%), bladder outlet obstruction (n = 8, 11.43%). There were no significant differences seen in complaints or AUA symptom and quality of life scores across diagnosis groups. CONCLUSIONS: Persistent LUTS can present in younger women with an unclear etiology, which may be characterized using VUDS. The most common etiology found is dysfunctional voiding followed by detrusor overactivity. This study shows that the etiology can be more accurately determined using VUDs, which can assist in management.

Pathologic Outcomes following Urethral Diverticulectomy in Women.

Purpose. Although most urethral diverticula in women are benign, there is a subset of patients who develop malignant changes. Limited studies report the pathologic findings associated with this relatively rare entity. We describe the clinicopathologic findings of women who underwent urethral diverticulectomy. Methods. A consecutive series of 29 women who underwent surgical resection of a urethral diverticulum were identified between 1992 and 2013. Clinical and radiographic data was collected by retrospective review of patient medical records. All pathological slides were rereviewed by a single urologic pathologist. Results. Of the 14 women with clinical data, 9 (64%) presented with urgency, 7 (50%) with urinary frequency, 3 (21%) with urinary incontinence, and 3 (21%) with dysuria. Mean diverticular size was 2.3 (±1.4) cm. Although one patient (3%) had invasive adenocarcinoma on final pathology, the remaining 28 cases (97%) demonstrated benign features. The most common findings were inflammation (55%) and nephrogenic adenoma (21%). Conclusions. Although most urethral diverticula in women are benign, there is a subset of patients who develop malignancy in association with the diverticulum. In this series, 97% of cases had a benign histology. These findings are important when counseling patients regarding treatment options.

Cost-effectiveness analysis of tension-free vaginal tape vs burch colposuspension for female stress urinary incontinence in the USA.

OBJECTIVE: To compare the cost-effectiveness (CE) of tension-free vaginal tape (TVT) with that of burch colposuspension (BC) for the treatment of female stress urinary incontinence (SUI). MATERIALS AND METHODS: A Markov-chain decision model was created to simulate treatment of SUI with TVT or BC using Treeage Pro 2011 software (Treeage Software Inc., Williamstown, MA, USA). Costing data were obtained from the Medicare Resource-Based Relative Value Scale. Data regarding the success of TVT vs BC were obtained from the peer-reviewed literature, as were corresponding utilities for different continence states. The CE of each procedure was calculated and compared, and sensitivity analyses were performed. RESULTS: At 10-year follow-up, TVT was more cost-effective (CE = $1495/quality-adjusted life year [QALY]) than BC (CE = $1824/QALY). Sensitivity analysis showed that TVT was more cost-effective than BC if the cost of the TVT device was <$3220. If the probability of success after TVT was <42%, then BC became the more cost-effective strategy (CE = $1827/QALY). CONCLUSION: Our study showed that TVT was more cost-effective than BC as a treatment for female SUI. Both cost of TVT device and efficacy of the procedure affect the CE analysis.

The use of synthetic mesh and the management of mesh extrusion in vaginal surgery.

The authors present a review of the literature regarding the management of mesh extrusion in vaginal surgery. As used in traditional surgical techniques, the use of mesh theoretically allows for a broader base of support and eliminates the need to rely on pre-existing weakened fascia. In this article, the different physical properties and types of synthetic mesh used, and their respective advantages and disadvantages in terms of mesh extrusion, are reviewed.

Hysteropexy compared to hysterectomy for uterine prolapse surgery: does durability differ?

INTRODUCTION AND HYPOTHESIS: The aim of this study is to assess the impact of hysterectomy on durability of uterine prolapse repair by comparing hysterectomy/uterosacral cuff suspension (VH) to a new vaginal uterosacral hysteropexy (USH). METHODS: A retrospective chart review of uterine prolapse patients after USH or VH with concomitant procedures as indicated was conducted, analyzing Baden-Walker grading of apex, anterior, and posterior compartments (Kaplan-Meier analysis) Baden et al. (Tex Med 64(5):56-58, 1968). RESULTS: A total of 200 charts met criteria. USH women weighed less, were younger, and more constipated with larger rectoceles. Levator parameters did not differ Romanzi et al. (Neurourol Urodyn 18(6):603-612, 1999). Baden-Walker data were entered at recurrence or minimum of 6 months (2.4 months-10 years; median, 1.5 years). All-apex durability was 96.4%, with no difference between hysteropexy and cuff suspension (96.0% vs. 96.8%, p = 0.90), cystocele (86.8% vs. 93.8%, p = 0.31), or rectocele (97.8% vs. 100%, p = 0.16) at 2 years. CONCLUSION: In uterine prolapse patients, technically similar uterosacral hysteropexy durability did not differ from hysterectomy-based cuff suspension nor between cohorts for cystocele or rectocele.

Mixed incontinence: the misclassification of patients and limitations of clinical trials.

Mixed urinary incontinence (MUI) has become a diagnosis of increased interest in the fields of urology and urogynecology, as drugs and treatments targeting urgency-related and stress-related symptoms are being developed and evaluated. We think the concept of "mixed incontinence" warrants revisiting because confounding clinical conditions exist, which result in a heterogeneous population of patients receiving the same diagnosis. The classification system for patients with signs and symptoms of MUI should undergo refinement. In addition, clinical trials for MUI should clearly delineate the lower urinary tract signs and symptoms found in the study population. Current study outcomes do not apply to the entire mix of patients included under the diagnosis of MUI, thus limiting their value. Investigation into the pathophysiologic basis of MUI and refinement of the definition of MUI are necessary if we are to evaluate the effect of future treatments on stress and urge components.