Alana Murphy

Prevalence of Stress Urinary Incontinence in Women with Multiple Sclerosis

Purpose The purpose of this study was to determine the prevalence of stress urinary incontinence (SUI) in women with multiple sclerosis (MS) and to what degree these women are bothered by their SUI, since there is a paucity of literature regarding the nature of SUI in this unique population of women. Methods We conducted a prospective Institutional Review Board approved study. Women scheduled for outpatient follow-up appointments at a dedicated MS center were asked to complete a questionnaire regarding urinary incontinence. Urgency urinary incontinence (UUI) and SUI were defined as an answer of slightly, moderately or greatly to the Urogenital Distress Inventory (UDI-6) question #2 and question #3, respectively. Impact of SUI on physical activity was determined by Incontinence Impact Questionnaire (IIQ-7) question #2. Results A total of 55.9% (80/143) women had SUI, 70.6% (101/143) women had UUI, and 44.8% (64/143) women had mixed urinary incontinence. The mean age was 45.8 years old (range, 20 to 72 years). Women with SUI were significantly older (mean, 47.2 vs. 41.9; P=0.023) and there was a trend towards a greater body mass index (mean, 29.3 vs. 26.5; P=0.057). Women with SUI had significantly higher IIQ-7 scores compared to women without SUI (P<0.001). Impact of urinary incontinence on physical activity was also found to be significantly greater in women with SUI (mean IIQ-7 question #2, 0.96 vs. 0.35; P<0.001). Conclusions The prevalence of SUI in women with MS is 55.9% and the presence of SUI has a significant impact on their quality of life. A comprehensive urologic evaluation of a woman with MS should include assessment of SUI.

Development and validation of a ureteral anastomosis simulation model for surgical training.

Objective To develop and validate a new ureteral anastomosis simulation model. Methods We designed a training model to simulate the task of ureteral anastomosis required for ureteroneocystostomy that is suitable for robotic and laparoscopic approaches. Face validity was measured using questions related to surgical authenticity and educational value of the model. Construct validity was measured by comparing scores using Global Operative Assessment of Laparoscopic Skills Scale (GOALS) scale between “procedure experts,” “robotic experts,” and “trainees” groups. One-way analysis of variance was used to compare differences in the scores and operating times between the 3 groups. Associations between previous surgical experience and performance scores were measured using the Spearman rho correlation coefficient. Results Four urologists experienced with robotically assisted ureteroneocystostomies were included in the procedure experts group. The robotic experts group consisted of 5 gynecologists experienced in robotic surgery. The trainees group consisted of 12 urology and gynecology upper-level residents and fellows. All experts agreed or strongly agreed that the model was authentic to the live procedure and a useful training tool. Mean (SD) total GOALS scores were significantly better for the procedure experts group compared to the robotic experts group and to the trainees group (P=0.02 vs P=0.004, respectively). The robotic experts group’s GOALS scores were also significantly higher than that of the trainees group (P=0.05). There were no differences in mean times required to complete the procedure. Surgical experience moderately correlated with scores on all 3 assessment scales. Conclusions Superior performance on the model by more experienced surgeons demonstrates evidence of construct validity. This authentic and useful model allows surgeons to learn and practice the ureteral anastomosis portion of the ureteral reimplantation surgeries before operating on a live patient.

Mid-urethral slings in female incontinence: Current status.

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring ones choice of MUS to the individual patient and her unique clinical parameters remains the best option.

Clinical Trials Report: Low-dose Oral Desmopressin for Nocturia

Introduction: According to the International Continence Society, nocturia is the need to awaken to void one or more times at night [1]. Nocturnal polyuria (NP) is a subclassification of nocturia characterized by nocturnal urine volume that is over 33% of the 24-hour voided volume. Nocturia is a common manifestation of bladder outlet obstruction (BOO) due to prostatic enlargement and one of the most common reasons for interrupted sleep in the adult population [2, 3]. Interrupted sleep can lead to fatigue during waking hours and impairment in daily activities. The act of getting out of bed during the night to void has been linked to a greater risk of hip fractures in older patients [4]. Such a negative impact on quality of life (QOL) can be especially pronounced in elderly adults. The normal diurnal rhythm of decreased urine production at night is not uniformly preserved in the elderly. This phenomenon may be secondary to decreased secretion of antidiuretic hormone (ADH) during the night in this population. Desmopressin is a synthetic analogue of ADH that acts as an antidiuretic by increasing water absorption in the distal and collecting tubules of the kidney. Although a previous study demonstrated that desmopressin does not affect baseline levels of ADH, the administration of desmopressin may compensate for reduced ADH secretion and help restore a normal diurnal rhythm of urine production [5]. Several studies have demonstrated that desmopressin is effective for the treatment of nocturnal enuresis and central diabetes insipidus [6]. Desmopressin also has been shown to significantly reduce nocturia in elderly patients [7, 8]. The study by Wang and colleagues enhances the current literature supporting the use of desmopressin for nocturia with the addition of a welldesigned trial with focus on an elderly male population, longterm follow-up, and uniform use of low-dose desmopressin.

Complications of Anterior Compartment Repair

Transvaginal repair of anterior compartment prolapse was popularized by Kelly in the early twentieth century [1]. While this plication technique has generally fallen out of favor for the treatment of stress urinary incontinence (SUI), the same principles are utilized in contemporary anterior compartment repairs. In addition to a traditional colporrhaphy, the role of mesh in anterior compartment repair continues to evolve, with current evidence supporting superior anatomic results with mesh repairs but at the cost of higher complications rates. This chapter will focus on complications associated with anterior repairs. The specific complications associated with the use of mesh in vaginal surgery will be discussed in detail in another chapter.