Analysis of British Columbia practice patterns in the management of female stress urinary incontinence with emphasis on mesh use.

INTRODUCTION: Female stress urinary incontinence (SUI) is common and has a profound impact on quality of life. Suburethral slings are the most common treatment for SUI in this population. These can be placed with synthetic mesh or autologous fascia. Mesh-related complications after midurethral sling procedures are documented in the literature but the risk of complications and reoperation is lower than the use of transvaginal mesh for pelvic organ prolapse repair. In this study, we sought to evaluate local practice patterns of management of female SUI with specific emphasis on mesh use. METHODS: A survey created by an expert panel was disseminated to respective provincial societies. RESULTS: Sixty-eight percent of respondents offer midurethral slings in their practice but only 60.6% of these respondents would offer surgical removal of the sling if there were complications, such as mesh erosion or pain. A large portion (39.4%) of respondents are performing transobturator slings as compared to retropubic midurethral slings (36.3%) and only 8.5% have removed the leg component associated with the transobturator sling in their practice. Furthermore, compared to most respondents offering midurethral slings (64.8%), only a minority of surgeons offer alternatives: 23.9% of respondents offer periurethral bulking agent injections, 15.5% offer pubovaginal slings, and 12.7% offer retropubic urethropexies. CONCLUSIONS: Our study supports that surgeons should continue to review surgical risks and alternative treatment options as part of the surgical consent process. As such, surgeons should be able to offer a variety of surgical approaches to manage female SUI.

Nocturnal enuresis in children is associated with differences in autonomic control.

STUDY OBJECTIVES: To assess the relationship between urine osmolality, cardiovascular parameters, and nocturnal enuresis in a population of children undergoing polysomnographic assessment. METHODS: This prospective observational study included consecutive children aged 5-17 years presenting for overnight polysomnography. Children were evaluated using continuous ambulatory blood pressure monitoring to assess heart rate and blood pressure. Urine samples were collected throughout the night to determine urine sodium excretion and osmolality. Comparisons of results were made between children with and without a history of nocturnal enuresis. RESULTS: A total of 61 children were included for analysis; 13 had a history of nocturnal enuresis. Children with nocturnal enuresis had greater disruption in respiratory parameters including higher apnea-hypopnea index (mean difference 12.2 ± 8.8 events/h, p < 0.05), attributable to more central respiratory events (mean difference 5.4 ± 4.9, p < 0.05), and higher variability in both oxygen and carbon dioxide parameters compared to those without nocturnal enuresis. Sleep parameters, urine osmolality, and blood pressure did not differ between groups. Children with nocturnal enuresis showed an increase, rather than a decrease, in heart rate across the night (+5.4 ± 19.1 vs. -6.0 ± 14.8 beats/min, p < 0.05). CONCLUSIONS: Children with a history of nocturnal enuresis have greater respiratory abnormalities, no differences in urine osmolality or blood pressure, and loss of normal heart rate decrease across the night. This pattern suggests that autonomic control, rather than renal or hemodynamic abnormalities, may contribute to the pathophysiology of nocturnal enuresis.

Assessment of Wound Complications After Bulbar Urethroplasty: The Impact of a Lambda Perineal Incision.

OBJECTIVE: To analyze risk factors for wound-specific complications after bulbar urethroplasty, including the association between incision type and complications. METHODS: This is a retrospective review of 829 urethroplasties excluding penile strictures, incomplete data sets, and radiation-induced urethral stenosis. Ninety-day wound complications were reported using the modified Clavien-Dindo classification of postoperative complications. Risk factors for wound complications were evaluated using univariable and multivariable analysis: patient age, positive preoperative urine culture, Charlson comorbidity index ≥ 2, diabetes, body mass index ≥ 35, smoking, and incision type (lambda perineal incision [LPI] vs. midline perineal incision [MPI]). RESULTS: Five hundred forty patients met inclusion criteria; 373 patients with an LPI and 167 patients with an MPI. Ninety-day wound complications (any Clavien grade) occurred in 21% of patients. Multivariable analyses indicated that incision type alone was significantly associated with wound complications (multivariable: MPI OR 0.53 (0.34-0.83), P = .01). The majority of complications were Clavien ≤ 2, which occurred in 23.3% (87 patients) of LPIs compared to 11.9% (20 patients) of MPIs (P = .002). The primary difference between the incisions was superficial wound edge separation (LPI 10.7% [40 patients]; MPI 0%, P < .0001). Early (6-month) urethroplasty success favored the midline incision (LPI 6.2% vs MPI 0%, P = .0003), implying no obvious technical advantage for the lambda incision. Study limitations include a retrospective design and the use of some patient-reported complication outcomes. CONCLUSION: An LPI is independently associated with increased 90-day wound complications after urethroplasty, with no identifiable advantage in urethroplasty outcome.

High risk of sleep disordered breathing in the enuresis population.

PURPOSE: Enuresis is 1 of the most common complaints facing pediatric urologists and it has significant implications with respect to quality of life. Although the pathophysiology is incompletely understood, there is growing evidence that sleep disordered breathing in children, including obstructive sleep apnea, has a fundamental role. There are also potentially fundamental differences between monosymptomatic enuresis, which may be a sleep disorder, and nonmonosymptomatic enuresis, which may relate to a primary bladder storage problem. We prospectively evaluated the incidence of obstructive sleep apnea in patients with enuresis and analyzed differences between patients with monosymptomatic and nonmonosymptomatic enuresis. MATERIALS AND METHODS: A total of 69 children with enuresis were given 3 validated questionnaires to complete, including the Dysfunctional Voiding and Incontinence Symptom Score, the Obstructive Sleep Apnea Quality of Life survey and the Modified Pediatric Sleep Questionnaire. The Dysfunctional Voiding and Incontinence Symptom Score quantifies patient dysfunctional voiding habits. The Obstructive Sleep Apnea Quality of Life survey evaluates patient quality of life in regard to obstructive sleep apnea and its effects. Modified Pediatric Sleep Questionnaire results describe the severity of patient sleep disturbances. RESULTS: The mean Obstructive Sleep Apnea Quality of Life Survey score was 43 and 54% of patients had positive Modified Pediatric Sleep Questionnaire results, indicating that obstructive sleep apnea was prevalent in our population. Those with enuresis and daytime incontinence were significantly more likely to have sleep disordered breathing than those with monosymptomatic enuresis (p <0.05). CONCLUSIONS: Our study confirms the link between sleep disordered breathing and enuresis. All pediatric health care providers should be aware of this risk. The risk may be magnified in patients with concomitant daytime incontinence.