Foreign body granuloma development after calcium hydroxylapatite injection for stress urinary incontinence: A literature review and case report.

Objectives: To present a case of foreign body granuloma (FBG) development after injection of calcium hydroxylapatite as a urethral bulking agent and to review all documented cases of this phenomenon in the literature. Methods: We analyzed a new case of calcium hydroxylapatite-induced FBG. We also conducted a literature review of the PubMed, Embase, CINAHL, and Web of Science databases through March 2022. Reports were included if they contained stress urinary incontinence patients that developed an FBG after calcium hydroxylapatite injection. The cases were reviewed for presenting symptoms, patient demographics, granuloma details, and surgical treatment. Results: We screened 250 articles and included six articles between 2006 and 2015 in addition to the present case. The median age of the patients was 65.5 years (range 45-93), and all patients were female. The most common presenting symptoms and the proportion of patients affected were difficulty voiding (4/8), recurrent urinary incontinence (3/8), and dyspareunia (2/8). The median time between the first CaHA injection and discovery of the FBG was 5 months (range 1-50). The median longest dimension of the FBGs was 1.85 cm (range 1.0-3.0). The 8 masses observed were evenly distributed throughout the urethra, with 3 in the bladder neck, 2 in the midurethra, and 3 in the distal urethra. Surgical excision was the predominant management choice, with some variation in technique. Conclusions: Severe, persistent lower urinary tract symptoms after calcium hydroxylapatite injection may indicate an FBG, which has been successfully managed with surgical excision.

Autologous rectus fascia sling for treatment of stress urinary incontinence in women: A review of the literature.

AIMS: Stress urinary incontinence (SUI) is common in the adult females. Surgical treatment options include synthetic mid-urethral sling (MUS), autologous sling, bulking agents, and Burch colposuspension. The autologous pubovaginal sling (PVS) has re-emerged in response to complications of synthetic MUSs and FDA communications regarding the use of vaginal mesh. This resulted in patients' fear related to vaginal mesh and drop in number of patients seeking surgical treatment of SUI. PVS has re-emerged as an option for treatment of primary SUI. The aim of this review is to familiarize, disseminate information, and share tips for the practicing female pelvic surgeons related to the practice of the autologous fascia sling. METHODS: We reviewed the literature related to the autologous sling. We used the following data bases and search engines: GoPubMed (Transinsight), Cochrane reviews (Wiley Interscience), google scholar (google), and Scopus (Elsevier). Because it is the most commonly investigated and utilized, we focused on the autologous rectus fascia sling. We also focused on the retropubic sling approach because the literature on transobturator rectus fascia sling is sparse. RESULTS: Out of 307 articles related to the subject found, 22 articles were included and the rest were excluded. CONCLUSION: ARFS is a valid primary method of treatment for female SUI. Also, it is used in particular indications such as patients with intrinsic sphincter deficiency (ISD), prior pelvic irradiation, failed and/or complicated synthetic MUS, and violated urethral lumen.

The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review.

OBJECTIVE: To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research. METHODS: We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: 'detrusor underactivity', 'underactive bladder', 'post voiding residual', 'post micturition residual', 'acontractile bladder', 'detrusor failure', and 'detrusor areflexia'. RESULT: DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function. CONCLUSION: Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.

Paraurethral Leiomyoma in a 20 Year-old Woman: A Case Report.

We present the case of a 20 year-old woman with a vulvar mass, found to be a paraurethral leiomyoma. She subsequently underwent supermedial-approach paraurethral mass excision, distal urethral reconstruction and cystourethroscopy. Paraurethral leiomyoma make up approximately five percent of urethral tumors. This case depicts the presentation and treatment of a paraurethral leiomyoma in one of the youngest women reported in the literature.

Arabic validation of the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR).

INTRODUCTION AND HYPOTHESIS: Our aim was to translate then assess the reliability of the culturally adapted Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire, International Urogynecological Association (IUGA)-Revised (PISQ-IR) to assess sexual health among Arabic-speaking women with pelvic floor disorders. METHODS: PISQ-IR was modified to consider cultural characteristics of the Middle East. The final reliability study included 172 women with urinary incontinence (UI) and/or pelvic organ prolapse (POP). Participants completed the questionnaire twice: at enrollment and 2 weeks later. RESULTS: Among sexually active women, good internal consistency was observed for five of the six scales in the adapted instrument: Global Quality (Cronbach's coefficient α = 0.86), Condition Impact (α = 0.87), Desire (α = 0.82), Condition Specific (α = 0.74), and Partner Related (α = 0.75). Internal consistency was acceptable for the Arousal Orgasm subscale (α = 0.66). However, among not sexually active women, internal consistency was poor (α <0.6) for all four scales. Lin's concordance correlation coefficient measuring agreement between test and retest measurements [Lin's concordance correlation coefficient (CCC); a value of 1 represents perfect agreement] ranged from 0.81 to 0.87 for the not sexually active scales, except for condition impact (CCC = 0.63.) For sexually active women, CCC was typically stronger, ranging from 0.85 to 0.96. CONCLUSIONS: PISQ-IR questionnaire is easy to administer and reliable for assessing sexual function in sexually active Arabic women with POP and UI, but internal consistency is poor for Arabic women not sexually active.

Transurethral Electrovaporization of Bladder Diverticulum: An Alternative to Open or Laparoscopic Bladder Diverticulectomy.

We used transurethral electrovaporization of the diverticular mucosa as the primary treatment for an acquired bladder diverticulum in a female patient. The bladder diverticulum was secondary to bladder outlet obstruction from a previous pubovaginal sling. In comparison to either open or laparoscopic bladder diverticulectomy, transurethral electrovaporization of the bladder diverticulum was effective in significantly reducing the diverticular size while being less invasive, requiring a short operative time, and a quick patient recovery.

The management of genitourinary fistula in the third millennium.

BACKGROUND: A vesicovaginal fistula (VVF) is an abnormal fistulous tract between the bladder and vagina, causing continuous loss of urine via the vagina. VVF is a relatively uncommon condition, but there is a drastically higher prevalence in the developing world. Furthermore, iatrogenic postoperative VVF is most common in developed countries, compared to mainly obstetric trauma in developing countries. In this review we focus on the development of current management techniques for VVF. METHODS: Medline was searched to identify articles related to urogenital fistulae, including VVF. Based on these reports we focus on the aetiology, clinical presentation, diagnosis and management of VVF. This in-depth review includes the optimal surgical timing, different surgical approaches (including minimally invasive techniques such as laparoscopic and robotic surgery), recommendations for postoperative care, surgical complications, and the need for further research in the use of robotic surgery to treat this condition. RESULTS: In all, 60 articles were identified and included in this review; eight were related to the aetiology, 12 to diagnosis, and 40 to the management of VVF. A thorough evaluation of VVF is imperative for planning the repair. Although the surgeonís experience typically influences the surgical approach, special situations will dictate the best approach. CONCLUSION: The treatment of genitourinary fistulae with robotic assistance continues to develop, but further research is necessary to fully understand the use of this technology.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up.

INTRODUCTION AND HYPOTHESIS: We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded. RESULTS: Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one. CONCLUSIONS: The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts.

A systematic review and meta-analysis of Macroplastique for treating female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Macroplastique® (polydimethylsiloxane injection) is a minimally invasive urethral bulking agent with global clinical literature describing its use over 20 years. This study critically assessed the safety and effectiveness outcomes for adult women treated with Macroplastique for stress urinary incontinence (SUI) through a systematic review and meta-analysis. METHODS: A systematic review of the scientific literature from 1990 to 2010 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to quantitatively summarize the safety and effectiveness of Macroplastique for female SUI. A total of 958 patients from 23 cohorts were eligible for inclusion and were analyzed. Random-effects models were used to estimate the improvement and cure rates following treatment at three time periods: short-term (<6 months), mid-term (6-18 months), and long-term (>18 months). Expanded models assessed the effect of reinjection rate on successful treatment outcomes. Adverse event rates were aggregated and reported. RESULTS: Improvement rates were 75 % [95 % confidence interval (CI), 69-81] in the short-term, 73 % (95 % CI, 62-83) in the mid-term, and 64 % (95 % CI, 57-71) long-term. Cure/dry rates were 43 % (95 % CI, 33-54), 37 % (95 % CI, 28-46), and 36 % (95 % CI, 27-46) over the same respective follow-up periods. Higher study reinjection rates were associated with improved long-term SUI outcomes. No serious adverse events were reported. CONCLUSIONS: This quantitative review supports Macroplastique as an effective, durable, and safe treatment option for female SUI. Meta-analytic evidence suggests that long-term therapeutic benefit is frequently maintained, with some patients requiring reinjection.

Risk factors for male slings: a comparative study of two techniques.

OBJECTIVE: To improve patient selection for male slings. Our primary aim was to identify preoperative risk factors for failures. Our secondary aim was to compare bone-anchored male sling (BAMS) to transobturator male sling (TOMS) and patient satisfaction accordingly. METHODS: A retrospective review was performed from 2000 to 2010 of males who received male slings. Exclusions had follow-up<1.5 months. Data examined included demographics, urodynamic parameters, pad usage, presence of detrusor overactivity (DO), and previous urethral diseases. Failure was defined as ≥4 pads used per day or ≤50% improvement by Patient Global Impression of Improvement (PGI-I). Preoperative risk factors for failure were analyzed for statistical significance. RESULTS: Sixty-four patients (mean age, 69.8±9.2 years) were analyzed. Forty-one received BAMS and 23 received TOMS with median follow-up of 46 months (range, 1.5-112) and 18 months (range, 3-33), respectively (P=.01). Perioperative decrease in pad usage was statistically significant in the TOMS group (range, 4.0-1.8, P=.00) compared with the BAMS group (range, 4.3-3.9, P=.37). Failure rate was 68.3% (28/41) in BAMS and 30.4% (7/23) in TOMS (P=.01). The PGI-I demonstrated increased satisfaction with TOMS (P=.005). Preoperative risk factors suggest increased pad usage, low maximal urethral closure pressure (MUP), low abdominal leak point pressure (ALPP), decreased functional length (FL), and presence of DO and urethral disease favor failure. CONCLUSIONS: Patients with preoperative risk factors, such as increased pad usage, low MUP, low ALPP, decreased FL, and presence of DO and urethral disease may not be appropriate sling candidates. Findings support TOMS, whichhas fewer failures and higher patient satisfaction but may be secondary to improved patient selection.

Percutaneous nerve evaluation in women: lessons learned.

OBJECTIVES: : The primary aim of this study was to identify patient characteristics potentially affecting response to office-based percutaneous nerve evaluation (PNE). Secondarily, we aimed to identify appropriate candidates to undergo office-based PNE. METHODS: : A retrospective chart review was conducted from 2000 to 2011 of female patients who underwent office-based PNE. Data were separated into 3 groups based on outcome: success, equivocal, and failure. Data examined included patient demographics, voiding dysfunction diagnosis, comorbidities, evidence of previous pelvic nerve injury, systemic hormonal status, and neurological insult of such varieties as stroke and Parkinson disease. All data were analyzed using χ analysis and analysis of variance. P < 0.05 was considered statistically significant. RESULTS: : One hundred twelve women underwent office-based PNE. Seventy-four patients (66.1%) had a successful outcome, 15 (13.4%) had an equivocal outcome, and 23 patients (20.5%) failed PNE trial. Neurological insult was the only factor of significance identified in those patients with an equivocal or unsuccessful trial of office-based PNE. After categorizing body mass index according to the World Health Organization's 2011 guidelines, no significance was found for body mass index between successful outcomes, equivocal outcomes, and failures. CONCLUSIONS: : Our cohort demonstrates that those patients who had an equivocal or failed outcome of office-based PNE were more likely to have a neurological insult. Patients with neurological insult who are considered appropriate candidates for neuromodulation trial should undergo staged implantation with quadruple tined lead in the operating room to provide these patients with the greatest opportunity for successful outcome.

The role of synthetic slings in male stress incontinence.

OBJECTIVE: Our primary aim was to compare the outcomes of synthetic bone-anchored male slings (BAMS) and transobturator male slings (TOMS), to identify preoperative risk factors for failure, and to evaluate patient satisfaction with each procedure. PATIENTS AND METHODS: Charts were reviewed retrospectively of patients who underwent synthetic BAMS or TOMS from 2000 to 2011. Data were categorised into groups based on outcomes of 'dry', 'improved' and 'failure'. Success was defined as completely dry or an improvement by >50% in daily pad use. The data analysed included demographics, daily pad use before and after surgery, previous urethral insult, type of prostatectomy, and urodynamic study variables. Data were analysed using logistical regression, the t-test and chi-square analysis, where appropriate. RESULTS: Sixty-eight men were analysed (30 in each group; eight patients were excluded). Daily pad use for the TOMS group changed from 3.5 before to 1.5 after surgery (P = 0.001), whilst the BAMS group was unchanged from 3.9 to 3.5 (P = 0.747). The TOMS group had a success rate of 23/30 (77%) and a mean (SD) patient global impression of improvement score of 1.67 (0.90), whilst the BAMS group had a success rate of 11/30 (37%) and mean (SD) score of 2.64 (1.12). Urethral insult (P = 0.001) and preoperative pad use (P = 0.047) were significant predictors of failure. CONCLUSION: TOMS gave better outcomes than BAMS in both performance and patient satisfaction. Patients with a greater severity of incontinence and evidence of urethral insult before surgery should be counselled about the likelihood of suboptimal outcomes with any type of sling placement.

Bladder mass "collagenoma".

Large bladder masses are typically found to be malignant in nature. We present a case of a large bladder neck mass as a result of previous imprecise collagen injection for urethral bulking. The patient was successfully treated as an outpatient with transurethral excision of the collagen mass combined with post-operative anticholinergic therapy.

Sacral neuromodulation outcomes in patients with urge urinary incontinence and concomitant urge fecal incontinence.

OBJECTIVES: : To study the efficacy and safety of sacral neuromodulation (SNM) in women with dual urge incontinence (DUI). METHODS: : Women with simultaneous urge urinary and urge fecal incontinence (FI) were prospectively identified and tested to determine eligibility for SNM. Those who experienced at least 50% improvement in their urinary symptoms were offered a full implant. Changes in FI were not considered. Validated questionnaires were administered at baseline and during follow-up. Preimplant urodynamic data were collected. Adverse events were recorded. RESULTS: : A total of 11 women had DUI. All had greater than 50% improvement in their urinary symptoms and underwent full implantation. Average age was 76 years. Median follow-up was 14 months. There were statistically significant improvements in validated questionnaire scores. No women were able to achieve complete simultaneous urinary and fecal continence. Six women (54%) were able to achieve at least a 50% improvement simultaneously in both their urinary and fecal symptoms. Two women (18%) only experienced a significant improvement in their urinary symptoms. One (9%) only experienced significant improvement in her FI. Two (18%) experienced no significant improvement in either their urinary or fecal symptoms. The urodynamic findings did not correlate with outcome. Two patients had transient implant pain. One implant was removed due to lack of efficacy at patient's request. CONCLUSIONS: : SNM is a safe and effective treatment for DUI. In patients with DUI, complete continence rates may be lower than with either type of incontinence alone. DUI may be the end-organ manifestations of a common neurologic pathway-overactive stimulation or underactive inhibition.

Rectourethral fistula stenting: a technique for better fistula visualization and efficient repair.

In this study, the authors present a technical tip for better and easier visualization of rectourethral fistula both during dissection and fistula closure. In this technique, a small-caliber ureteral catheter is used for catheterization of the fistulous tract under direct urethroscopic guidance. Five cases were treated using this technique. All cases had either brachytherapy as a monotherapy or combined brachytherapy and external beam radiotherapy. All cases had the fistula completely healed except for one failed case that had a 2-cm fistula.

Do women have realistic expectations of treatment for stress urinary incontinence?

AIMS: Our objective was to determine what women find acceptable regarding treatment and outcomes for treatment of stress urinary incontinence (SUI), and correlate this to age, distress and quality of life (QOL). MATERIALS AND METHODS: This prospective cross-sectional IRB-approved study evaluated women with primary SUI. One hundred sequential women (mean age, 53.8 years) answered questionnaires on initial interview, including the Urogential Distress Inventory (UDI-6), the American Urologic Association QOL questionnaire, as well as other validated questions regarding treatment options and possible outcomes. Statistical analysis was performed using Chi Squared, Fisher Exact, and t tests as well as the Wilcoxon Rank Score. RESULTS: Of the 100 women who submitted questionnaires, 22% overall expected a complete cure, 57% a good improvement, 12% to be able to cope better, and 9% expected any improvement at all. We found this to be a realistic expectation of possible outcomes of treatment, with 79% expecting a good improvement or cure for their SUI. The women were also asked what type of treatment they found acceptable for their SUI: 22% found a major surgery acceptable, 39% found a minor surgery acceptable, 32% found a clinical procedure acceptable, and 7% found medication acceptable. The majority of women (71%) found a minor surgery, like a transobturator tape, or a clinical procedure, like collagen injection, most desirable. These results were then analyzed for correlation to age, degree of distress (measured by UDI-6), and QOL (measured by AUA QOL score). CONCLUSIONS: Overall women have realistic expectations of treatment for SUI. They are willing to accept varied results depending on their distress regarding incontinence. Choices regarding treatments are influenced by age, severity and quality of life. It may be beneficial to include the UDI-6, age and QOL score as a part of the work up and planning for treatment of SUI to better meet patient's expectations.

Urethral diverticulum after tension-free vaginal tape procedure: case report.

This study presents the third case in the literature of a urethral diverticulum after the tension-free vaginal tape (TVT) procedure, with an additional finding of the diverticulum developing distal to the tape. A 54-year-old woman, with 3 years' status post-TVT, presented with urinary tract infection and infravesical obstruction. Urethrocystoscopy revealed a urethral diverticulum just distal to the sling site. Transvaginal diverticulectomy and excision of the sling was done, with improvement of symptoms at 1-year follow-up.