Alex Gomelsky

Histopathological evaluation of the uterosacral ligament: is this a dependable structure for pelvic reconstruction?

To explore, by histological examination, whether the uterosacral ligament complex is an adequate support structure for vaginal vault suspension and other reconstructive procedures of the female pelvis.

Update on the treatment of overactive bladder.

Purpose of review As overactive bladder (OAB) is a prevalent and chronic medical condition that greatly impacts an individuals quality of life, novel therapeutic options are always welcome. Recent findings Recent evidence suggests that newer antimuscarinic agents are not only superior to placebo, but may also have a role in treating OAB symptoms in children and men with lower urinary tract symptom. Dose escalation for trospium and fesoterodine has shown to be both efficacious and safe. Adverse events typically exceed those of placebo but infrequently lead to cessation of therapy. Long-term outcomes of sacral nerve stimulation for refractory OAB have been recently reported. Although the overall satisfaction with this therapy is high, more than 50% may experience chronic pain; however, this adverse event also does not frequently lead to device removal. Percutaneous tibial nerve stimulation continues to display superiority to sham treatment and benefits similar to antimuscarinic therapy may be observed. This therapy is well tolerated and durable outcomes have been seen at 12 months of follow-up. Recent evidence suggests that a dose of 100 U per botulinum neurotoxin type A injection may optimally balance symptom improvement and incidence of voiding difficulty. Summary Treatment modalities for OAB continue to evolve and the abundance of options can only benefit the individuals with this condition.

Vaginal mesh update.

Purpose of review As more women undergo repairs of pelvic organ prolapse (POP), an ever-increasing scrutiny has been placed on repairs utilizing vaginal mesh. We aim to review the current literature regarding mesh POP repairs and discuss the Food and Drug Administration controversy. Recent findings Evidence-based literature indicates that the objective success of standard (plication-type) repairs in the anterior compartment may not be durable, and that augmentation with nonabsorbable, synthetic mesh may be superior. Augmentation in the posterior compartment may not present a clear advantage over standard repair. Transvaginal mesh used for POP repair may be associated with adverse sequelae, such as erosion, extrusion, and infection. Additionally, there is concern regarding potential long-term outcomes such as dyspareunia, chronic pelvic pain, and vaginal distortion, which may occur even in the absence of frank extrusion. Recent warnings by the Food and Drug Administration regarding adverse events after transvaginal mesh implantation have led to a call for an increase in the premarket testing and postmarket surveillance of these products. Summary Although the use of transvaginal mesh may improve anatomical outcomes over standard repairs, the subjective improvement may be similar. Furthermore, the recent warnings regarding mesh placement may lead to a greater level of regulation of these products.

Urodynamic effects of once-daily tadalafil in men with LUTS secondary to clinical BPH.

Lower urinary tract symptoms (LUTS) are common and increase with age in men with benign prostatic hypertrophy (BPH). Erectile dysfunction (ED) also increases with age and is often a comorbid condition with BPH. Treatment with phosphodiesterase type 5 (PDE5) inhibitors aimed at decreasing breakdown of nitric oxide (NO) is a mainstay of treatment for ED. Because NO has been found to mediate male prostatic and urinary function in multiple ways, there is increasing interest in PDE5 inhibitors addressing concomitant LUTS. Several studies have shown significant improvement in LUTS after treatment with PDE5 inhibitors; however, concern exists that PDE5 inhibitors exert their beneficial effects through impairment of bladder function. Because limited invasive urodynamic data exist to address these queries, tadalafil’s impact on bladder function was recently evaluated. Results indicate that tadalafil treatment had no negative impact on bladder function, as measured by detrusor pressure at maximum flow or any other urodynamic parameter assessed.

Antibiotic Prophylaxis in Urologic Prosthetic Surgery

The implantation of prosthetic devices is an ever-increasing practice in urologic surgery. The most common devices are penile prostheses, artificial urinary sphincters, synthetic pubovaginal slings, and bone anchors used for pelvic floor reconstruction and incontinence surgery. While their efficacy has been supported over time, infection and rejection are severe complications. Explantation of the entire prosthetic device has been the standard treatment of such complications, often necessitating long-term antibiotics and prolonged recovery before future reimplantation. The dense inflammatory response associated with prosthetic surgery may obliterate tissue planes and further complicate reoperative efforts. These factors support the need for effective antibiotic prophylaxis, with the goal of preventing bacterial seeding of the prosthesis during implantation. Antibiotic regimens should be effective against biofilm-forming bacteria, especially S. epidermidis and P. aeruginosa, and vancomycin should be a mainstay. Prevention of intraoperative infection by treating existing skin and urinary tract reservoirs and employing strict sterile technique cannot be overemphasized. While data is scant, it appears that routine prophylaxis prior to dental procedures, in patients with urologic prostheses, is unwarranted; however, if the patient is immunocompromised or has severe comorbidities, prophylaxis should be employed.

Overactive bladder in males

The prevalence of overactive bladder (OAB) symptoms is considerable in both men and women and the impact on quality of life (QOL) is equally substantial. Ironically, despite nearly equal prevalence, OAB symptoms in men are infrequently treated, and often with medical therapies aimed at bladder outlet obstruction (BOO). In this review, we examine the pathophysiology of OAB and its evaluation in the context of benign prostatic hypertrophy and concomitant BOO. We then consider the efficacy and safety of individual therapeutic options for lower urinary tract symptoms in men, focusing on the mainstays of medical therapy: α-adrenergic blockers, 5-α reductase inhibitors, and antimuscarinic agents. Finally, we aim to comment on new therapeutic strategies and targets that may one day be available for the treatment of male OAB.

Treatment of mixed urinary incontinence in women.

Purpose of review Deciding on an optimal therapy for mixed urinary incontinence (MUI) is challenging, as a single-treatment modality may be inadequate for alleviating both the urge and stress component. A MEDLINE search was conducted regarding English-language literature pertaining to the treatment for MUI focusing on literature within the last 18 months. Recent findings Behavioral therapy and lifestyle modification, such as moderate weight loss and caffeine reduction, should be considered first-line options for all women with MUI. The addition of pelvic floor muscle therapy may have an additional salutary effect. Treatment of the urge component with antimuscarinics is effective; however, the stress component is likely to persist after therapy. Treatment with vaginal estrogen cream may help in the short-term, but long-term benefits are unknown. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI; however, it appears that women with MUI may have lower cure rates compared to women with pure stress urinary incontinence. Summary The optimum treatment of MUI may often require multiple treatment modalities. Although surgery may often have a positive impact on both components, its routine implementation should be approached with caution and patients should be carefully selected and counseled.

Treatment of mixed urinary incontinence.

Introduction Mixed urinary incontinence (MUI) is a prevalent condition and imposes a significant impact on a womans quality of life. Treatment is often challenging, as a single modality may be inadequate for alleviating both the urge and stress component. Materials and methods A MEDLINE search was conducted regarding English-language literature pertaining to the pathophysiology, diagnosis of, and treatment for MUI. Non-English language articles were considered if they could be translated into English using GOOGLE translator. Results The identification of an ideal single treatment has also been made more challenging by the poor characterization of the pathophysiology of MUI. Behavioral and lifestyle modification, as well as pelvic floor muscle therapy, should be considered first-line options for all women with MUI. Treatment of the urge component with anti-muscarinics is effective; however the stress component is likely to persist after therapy. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI, with emerging evidence suggesting that transobturator MUS may be associated with lower rates of de novo and persistent urge component compared to other procedures. The presence of concomitant, preoperative detrusor overactivity has not been consistently associated with postoperative outcomes. Conclusions The optimum treatment of MUI may often require multiple treatment modalities. While surgery may have a positive impact on both the urge and stress component, its implementation should be approached with caution and patients should be carefully selected. Detailed informed consent in women with MUI cannot be overstated.

Considerations in Male Overactive Bladder

Overactive bladder (OAB) and storage lower urinary tract symptoms (LUTS) are highly prevalent in men and may present alone, or in the setting of bladder outlet obstruction (BOO). If the symptoms are not highly bothersome, initial treatment may be conservative and focused on behavioral modification. In those men with predominantly voiding LUTS and/or evidence of BOO, treatment will be aimed at reducing bladder outlet resistance either pharmacologically or surgically. In those men with predominantly bothersome storage LUTS and low post-void residual urine volume, further treatment is aimed at increasing bladder capacity and reducing detrusor overactivity. This is initially accomplished with pharmaceutical agents, with surgical measures reserved for those with treatment failure or significant medication-related side effects. For those men with both bothersome storage and voiding LUTS, combination therapy has been shown to be both effective and safe. Despite deficits in our understanding of the pathophysiological connection between BOO and OAB, as well as often insufficient data to support a particular treatment regimen, the treatment options for LUTS are largely effective and safe. As with any condition, more conservative options should be attempted first, and further treatment can be tailored to the individual patient.

Midurethral sling: is there an optimal choice?

Purpose of review Midurethral slings (MUS) are the most common procedure performed for female stress urinary incontinence (SUI). Several variations have been introduced and evidence supporting the optimal approach for outcomes is necessary. Recent findings The bottom-up approach to the retropubic MUS may have higher subjective cure rates and lower rates of bladder puncture, voiding dysfunction, and vaginal extrusion compared to the top-bottom approach. Short-term and medium-term cure after retropubic and transobturator approaches are similar, whereas the retropubic approach may have better outcomes in the long term. The transobturator approach, however, appears to be associated with less bladder puncture, vascular injury, and postoperative voiding dysfunction, albeit at the expense of greater groin pain. De-novo storage symptoms and impact on sexual function are similar. The single incision mini sling (SIMS) may offer similar cure rates as the transobturator approach, with lower rates of early postoperative pain. SIMS offers inferior cure rates compared with the retropubic MUS. Summary The bottom-up retropubic MUS may currently be the ‘optimal’ MUS procedure; however, the transobturator MUS should also be considered. Long-term results are currently emerging and detailed informed consent is required regardless of the approach.