Defecation versus pre- and post-defecation Valsalva maneuvers for dynamic MR assessment of pelvic floor dysfunction.

PURPOSE: To compare prevalence and severity of multi-compartment pelvic floor dysfunction between supine magnetic resonance defecography with defecation (MRD) and supine dynamic MRI during Valsalva, both with and without rectal distention. METHODS: This was an IRB-approved, HIPAA-compliant retrospective review of consecutive patients referred for MR Defecography. MRD protocol included imaging at rest, during pre-defecation Valsalva (Pre-DV), defecation (Def), and post-defecation Valsalva (Post-DV). The Post-DV images were performed after complete evacuation either during the defecation acquisition or, in cases where patient was unable to defecate during the examination, in a conventional toilet. Size of cystocele, vaginal prolapse, anorectal (AR) descent, and enterocele were measured on all acquisitions relative to the pubococcygeal line. Rectocele size was recorded in anteroposterior dimension. The presence or absence of rectal intussusception (RI) was documented. The prevalence, absolute size, and grades of prolapse, rectocele, and RI were compared between the acquisitions using pair-wise ANOVA, Friedman, Dunn pair-wise, and Cochran-Mantel-Haenszel tests. RESULTS: 30 patients were included in the final analysis. Higher prevalence of cystocele, vaginal prolapse, enterocele, AR descent grade 2 or higher, rectocele grade 2 or higher, and RI were seen on Def compared to Post-DV and Pre-DV. Cystocele, vaginal prolapse, enterocele, AR descent, and rectocele sizes were significantly larger on Def compared to Post-DV by 0.7-1.95 cm (p ≤ 0.007). Prolapse in all compartments and rectocele size were significantly larger on Def compared to Pre-DV (p < 0.0001). Cystocele, vaginal prolapse, and enterocele sizes were significantly larger on Post-DV compared to Pre-DV (p < 0.0001). There were significant differences in grading of all types of prolapse and rectocele between the various acquisitions of MRD (p < 0.0001). Cystocele, AR descent, and rectocele grades were significantly higher on Def compared to Post-DV (p range ≤ 0.0002). Grading of all types of prolapse and rectocele was significantly higher on Def compared to Pre-DV (p < 0.0001). Cystocele, vaginal prolapse, and enterocele grades were all significantly higher on Post-DV compared to Pre-DV (p ≤ 0.0007). CONCLUSION: Defecation images during supine MRD elicit higher prevalence and size of prolapse of all pelvic compartments in comparison to both pre- and post-defecation Valsalva images. Post-defecation Valsalva images show larger size of anterior and middle compartment prolapse than pre-defecation Valsalva images. Functional evaluation of pelvic floor dysfunction with MRI should include image acquisition during defecation. If Valsalva images are acquired, these should be performed after the defecation acquisition and without rectal distention.

Complications Following the Insertion of Two Synthetic Mid-urethral Slings and Subsequent Removal.

OBJECTIVE: To determine outcomes after removal of two synthetic mid-urethral slings (MUS) at a tertiary care center. METHODS: Following IRB approval, a retrospective chart review of non-neurogenic, symptomatic women requiring re-operation after ≥2 MUS was performed. Data reviewed by a third party included: demographics, prior anti-incontinence surgery, complications, pelvic/urinary symptoms, subsequent investigations, surgical repair and outcomes (including UDI-6/IIQ-7 questionnaires) at a minimum 6 months follow-up. Cure was defined as being continent, no dyspareunia, and no additional surgical therapy. RESULTS: Between 2007 and 2014, 21 women met the inclusion criteria. Mean age was 57 years (range: 40-82) and mean follow-up was 30.2 months (range: 6-78). The majority of patients presented with one or more symptoms of voiding dysfunction (95%), urinary incontinence (86%), irritative voiding symptoms (62%), dyspareunia (57%), recurrent urinary tract infections (UTIs) (29%), vaginal extrusion (20%) and erosion involving the urinary tract (5%). Patients had a mean of 2 prior anti-incontinence procedures (range 2-3). Over two-thirds had a combination of retropubic and transobturator MUS. Mean number of pre-operative investigations was 3.5 (1-6) including voiding cystourethrogram, cystoscopy and urodynamics. Two patients had complete remission, 14 partial remission, and five failed. Mean postoperative total UDI-6 and IIQ-7 scores at last clinic visit were 10 (range: 0-16/SD 4.1) and 11 (range: 0-28/SD 10.3), respectively. CONCLUSION: The management of women with suboptimal outcomes following two synthetic MUS from transvaginal excision results in modest symptomatic improvement but low permanent complete remission and frequent need for additional therapies.

Quality of life after suprapubic catheter placement in patients with neurogenic bladder conditions.

AIMS: To evaluate quality of life in patients with neurogenic bladder (NGB) conditions who have elected to undergo suprapubic catheterization (SPC), as well as assess adverse events (AEs) related to the procedure. METHODS: This is a retrospective review from a database of NGB patients from 1/1/2003 to 6/30/2013. Patients who underwent SPC placement were invited to complete a validated, single item Patient Global Impression of Improvement (PGI-I) questionnaire. Success or positive response was defined as 1 or 2 on a scale of 1-7. All patients were included in the assessment of AEs. RESULTS: Of the 128 patients who underwent SPC, 89 patients (54 female, 35 male) met inclusion criteria. Response rate to the PGI-I questionnaire was 65.2% (58/89). Mean age at the time of SPC placement was 54.4 years (± 14.4). The mean time from SPC placement to PGI-I questionnaire was 48.3 months (Range 4.4-128.4). Overall, success was seen in 49/58 patients (84.5%). Only 5.2% (3/58) patients reported a negative PGI-I (score 5/7). There was an 18.8% rate of short term complications, with the majority of these being classified as Clavien I. There was one Clavien IIIb complication (0.8%), which consisted of a small bowel perforation. CONCLUSIONS: SPC is an effective bladder management in carefully selected NGB patients who have failed other options. Over 80% considered the SPC to have improved their urological quality of life with a mean time to questionnaire of 4 years. Severe AEs are rare, though can be particularly serious in this group of neurologically impaired patients. Neurourol. Urodynam. 35:831-835, 2016. © 2015 Wiley Periodicals, Inc.

Influence of rectal gel volume on defecation during dynamic pelvic floor magnetic resonance imaging.

PURPOSE: To evaluate effects of altering rectal contrast volume on defecatory effort during magnetic resonance defecography (MRD). METHODS: We assessed defecation qualitatively and quantitatively as a function of rectal distention (group A: 180 cc, n=31; group B: 120 cc, n=31). Quantitative evaluation comprised measuring rectal area on midline sagittal images pre- and post-defecation. RESULTS: Resting rectal area was significantly higher for group A than for group B (35.2 vs. 28.3 cm(2), P<.0001). Post-defecation rectal area and change in area (pre- to post-defecation) were not significantly different. Subjective evaluation showed no significant difference. CONCLUSION: Decreasing rectal gel volume from 180 to 120 cc did not compromise defecation performance during MRD.

Are women with advanced pelvic organ prolapse treated by open mesh sacrocolpopexy at risk of secondary incisional hernia?

INTRODUCTION: Our purpose was to determine whether vaginal hernia is a predisposing factor for incisional hernia (IH) in a cohort of women with symptomatic pelvic organ prolapse (POP) who underwent corrective repair by open mesh sacrocolpopexy (MSC) and had long-term follow-up to determine their rate of subsequent IH. METHODS: Following IRB approval, the charts of women entered into a longitudinal database and who underwent open MSC at a tertiary institution were reviewed. Data collected included demographics, MSC and IH details, and long-term outcome. Patients were excluded if the follow-up after MSC was < 1 year. Data were reviewed by a neutral investigator who was not involved in patient care (FA). RESULTS: From 1999 to 2012, 75 of 88 women met inclusion criteria, with mean follow-up of 65 (48-84) months. Thirteen were either lost to follow-up or had follow-up < 1 year. Seven women underwent symptomatic IH repair, with a mean onset of IH diagnosis after MSC at 18 (range 8-72) months. Five repairs were done via an open approach, and two were repaired laparoscopically. No IH recurrence was noted at a mean of 41 (range 14-75) months after IH repair. No risk factors were identified in the IH group compared with those who did not form a secondary IH. CONCLUSIONS: In this longitudinal series, IH after open MSC occurred in 9.3%, a rate comparable with that reported in women undergoing abdominal procedures through midline or Pfannenstiel incisions.

Durability of collagen injection for stress urinary incontinence in women proven by transvaginal 3-dimensional ultrasound.

OBJECTIVE: The aim of this study is to evaluate the durability of collagen injection (CI) using serial 3-dimensional (3D) transvaginal ultrasound (US) in women with sufficient improvement of stress urinary incontinence (SUI) symptoms not requiring additional treatment. METHODS: After the institutional review board approval, a retrospective review of prospectively followed patients who underwent CI was conducted. Eligible patients received 3 or less consecutive CI for SUI with no reinjection afterward during the follow-up period and had a minimum follow-up of 1 year from the last CI. Serial 3D US was obtained for collagen volume and configuration at baseline (6-8 weeks postoperatively) and approximately every 12 months thereafter as clinically indicated. RESULTS: Of 191 eligible patients from 1/99 to 6/11, 67 (35%) met the inclusion criteria. The mean age was 67 years (42-90 years) with mean follow-up from the time of last CI at 43 months (12-149 months). A total of 283 three-dimensional US were performed, with the mean of 4 (2-11) per patient. The mean number of injections was 1.4 (1-3) with a mean injected volume at 5.8 mL (2-18 mL). The volume retention rate compared with the baseline volume was 84% (12%-100%), with a decrease in mean collagen volumes between the baseline and last follow-up visit (3.2 vs 2.7 mL; P = 0.008). Collagen volume decreased by a mean of 0.11 mL for each year past the final injection (P = 0.0015) by mixed-effect model analysis. CONCLUSIONS: Although believed to be nondurable, CI was found to be objectively stable over time by transvaginal 3D US in a subset of women with durably improved SUI symptoms.

Meshology: a fast-growing field involving mesh and/or tape removal procedures and their outcomes.

Stress urinary incontinence and pelvic organ prolapse are two of the commonest conditions affecting women today. It is associated with significant compromise to quality of life. Through the years, there has been an evolution of technique and graft material to augment repairs for durability. Transvaginal placements of synthetic mid-urethral slings and vaginal meshes have largely superseded traditional tissue repairs in the current era because of presumed efficacy and ease of implant with device 'kits'. The use of synthetic material has generated novel complications, including mesh extrusion, pelvic and vaginal pain and mesh contraction. In this review, our aim is to discuss the management and outcomes associated with mesh removal. In addition, we will briefly review the safety communications issued by the US FDA on transvaginal mesh placement and a new classification system for complications arising from the use of synthetic graft endorsed by both the International Continence Society and International Urogynecological Association.

Long-term outcomes of autologous pubovaginal fascia slings: is there a difference between primary and secondary slings?

INTRODUCTION: To report our long-term pubovaginal slings (PVS) outcomes between primary (PVS1) and secondary (PVS2) autologous fascia PVS, with the hypothesis that outcomes in PVS1 will be better than in PVS2. MATERIALS AND METHODS: IRB approved retrospective study of women undergoing PVS between 1996 and 2011 with minimum 6 months follow-up. Data reviewed included demographics, questionnaires that is, UDI-6, IIQ-7, QOL, prior anti-incontinence procedure, associated repairs, urodynamic findings and repeat procedures. Primary outcome and surgical success defined by: (1) QOL ≤ 3, (2) UDI question 3 on SUI ≤ 1, and (3) no SUI re-treatment/operation. Secondary outcomes included all other patient reported outcome measures (PROM). RESULTS: Of 110 patients, 84 had follow-up. Mean age was 61 years (38-88) and median follow-up was 89 months (7-189). Demographic findings and type of fascia used were similar between the two groups. Mean postoperative scores were not statistically significant for total UDI-6 score (P = 0.62), IIQ-7 (P = 0.30) and QOL (P = 0.35) between groups, but was statistically significant compared to baseline (P = 0.001) as expected. Twelve patients, 3 in PVS1 and 9 in PVS2 underwent subsequent procedures. Surgical success rate was 76% in PVS1 and 52% in PVS2 for those with completed questionnaires. Overall, 78% (28) in PVS1 and 69% (33) in PVS 2 required no further surgical intervention at last follow-up. CONCLUSION: At long-term follow-up of average 7.4 years, primary and secondary PVS patients had comparable favourable functional outcomes with low morbidity. However, secondary PVS patients had lower success rates as per our definition with higher rate of additional procedures.

Overcoming the challenges of characterizing normal urodynamic parameters in middle-aged and older women.

INTRODUCTION: To describe urodynamic study (UDS) findings in middle-aged and older women with various lower urinary tract symptoms (LUTS) who were found to have a normal study interpretation. MATERIALS AND METHODS: Following institutional review board approval, UDS tracings of non-neurogenic women who were tested for various LUTS and whose study was interpreted as normal were reviewed. Demographic data, indications for UDS, and UDS parameter findings were extracted. UDS was conducted according to an established protocol using a 6F dual-lumen catheter (ICS guidelines) with a Laborie system and interpreted with a pre-existing template to standardize each reading. The fill-void study was frequently repeated during the same UDS session to confirm normal findings. Study interpretation was done by a neutral reviewer with UDS expertise. RESULTS: From 2000-2012, 42 middle-aged women, who had been coded as having a normal study, were retrospectively reviewed from a database of over 2200 studies. The majority were Caucasian, with mean age 63 (range 42-85), mean body mass index 24.5 (20-37), mean parity 2 (0-4), and 67% were post-menopausal. Of the 42 patients, 28 underwent a second fill-void study. UDS findings were reported based on clinical indication for UDS: 1) incontinence, 2) pelvic organ prolapse, or 3) other LUTS symptoms. UDS findings were consistent between first and second studies. CONCLUSIONS: UDS parameters from a cohort of middle-aged and older women with normal findings could serve as reference values when interpreting urodynamic studies or for designing an age-comparable nomogram.

A prospective analysis of consultation for difficult urinary catheter insertion at tertiary care centres in Northern Alberta.

BACKGROUND: Difficult urinary catheterization (DUC) is a frequent reason for urologic consultation. Literature regarding DUC is limited. The objective of the study is to examine the current practice pattern of DUC and identify strategies to reduce its incidence and related adverse events. METHODS: This is a prospective observational study of consultation for DUC at tertiary care centres in Edmonton, Alberta between October 2010 and February 2011. All urologic consultations for DUC in adults at the 2 tertiary hospitals were enrolled. Patients were managed according to the current regional standard of care established prior to the study. A clinical encounter questionnaire (CEQ) was completed by the urology service regarding details of the consultation and patient factors. CEQ results were tabulated and analyzed for trends, areas of strengths and weakness in the consultation process. RESULTS: In total, 89 patients were accrued to the study. Mean age was 67 years and 91% were male. Seventeen percent of patients had history of previous DUC and 65% had urologic history. Forty-two percent of patients had catheter placement without any auxiliary tools. Adverse events, including urosepsis, bladder perforation, hydrouterus, paraphimosis and urethral trauma, were experienced by 37% of patients. Significant urethral injury as a result of catheterization attempts occurred in 32%. Forty-one percent of consultations were classified as inappropriate and 53% occurred between 5 pm and 6:30 am. CONCLUSION: DUC is associated with significant patient morbidity and may often be preventable. This study highlights the need for implementation of preventive strategies, widespread education and increased awareness regarding catheter care.

Priapism in an infant with sickle cell trait after cardiac transplant.

We report a case of priapism in a 6-month-old boy of African descent who had been receiving intravenous sildenafil, a phosphodiesterase-5 inhibitor. An orthotopic cardiac transplantation had been performed at 6 months of age, 2 months after he had received a Berlin heart. The pre-, peri-, and postoperative care required multiple transfusions, and postoperative pulmonary hypertension required treatment with intravenous sildenafil. He developed a series of prolonged, semitumescent erections (30-180 minutes) that resolved spontaneously without the need for urologic intervention. Subsequent investigations revealed he was a carrier of a sickle cell gene. Although the precise etiology of the prolonged penile erection is unclear, it was likely secondary to the use of sildenafil and the sickle cell trait.

Diagnosing detrusor sphincter dyssynergia in the neurological patient.

Detrusor sphincter dyssynergia (DSD) is variant of neurogenic bladder dysfunction caused by suprasacral neurological abnormalities and may be associated with serious complications if unrecognised. This paper focuses on the clinical features as well as challenges and limitations in the diagnosis of DSD.

Do catheter washouts extend patency time in long-term indwelling urethral catheters? A randomized controlled trial of acidic washout solution, normal saline washout, or standard care.

PURPOSE: Blockage of long-term indwelling catheters with mineral deposit is an ongoing management issue, but evidence on optimal management is lacking. Our purpose was to examine whether catheter washouts prevent or reduce catheter blockage. DESIGN: A multisite randomized controlled trial. SUBJECTS AND SETTING: Adults with long-term indwelling catheters that required changing every 3 weeks or less, living in the community, and requiring supportive or continuing care were recruited. Participants were randomly assigned to 1 of 3 groups: control (usual care, no washout), saline washout, or commercially available acidic washout solution (Contisol Maelor Pharmaceuticals Ltd, Wrexham, UK). METHODS: At baseline visit, the catheter was changed and participants were followed weekly for 8 weeks, with checks for catheter patency and urine pH. Participants randomized to saline or commercial solution had a weekly washout with the appropriate solution. Endpoints were 8 weeks (completion data), 3 or more catheter changes in the 8-week period, or symptomatic urinary tract infection (UTI) requiring antibiotics. The study hypothesis was that catheter life would be extended by 25% in the commercial solution group. It was not possible to blind participants or research nurses to washout versus no intervention, but participants in the saline and washout solution groups were blinded to solution type. RESULTS: One hundred twelve potential participants were screened; 73 were enrolled, randomized, and included in the final analysis. Of these, 53 completed the full 8 weeks of data collection; 16 terminated early because of 3 catheter changes or self-reported 'UTI'. Other reasons for termination were hematuria, latex sensitivity, deceased/severe illness, or personal choice. Analysis of variance was used to analyze mean differences on demographic variables and mean number of weeks in study. Kaplan-Meier survival curve analysis showed no statistical difference between the groups in time to first catheter change. CONCLUSION: At this time, the evidence is insufficient to state whether catheter washout with saline or Contisol is more effective than usual care with no washout in preventing blocking. No increased risk of UTI was associated with washout regimes.