Alex Kavanagh

Advances in basic science methodologies for clinical diagnosis in female stress urinary incontinence

We provide an overview of advanced imaging techniques currently being explored to gain greater understanding of the complexity of stress urinary incontinence (SUI) through better definition of structural anatomic data. Two methods of imaging and analysis are detailed for SUI with or without prolapse: 1) open magnetic resonance imaging (MRI) with or without the use of reference lines; and 2) 3D reconstruction of the pelvis using MRI. An additional innovative method of assessment includes the use of near infrared spectroscopy (NIRS), which uses non-invasive photonics in a vaginal speculum to objectively evaluate pelvic floor muscle (PFM) function as it relates to SUI pathology. Advantages and disadvantages of these techniques are described. The recent innovation of open-configuration magnetic resonance imaging (MRO) allows images to be captured in sitting and standing positions, which better simulates states that correlate with urinary leakage and can be further enhanced with 3D reconstruction. By detecting direct changes in oxygenated muscle tissue, the NIRS vaginal speculum is able to provide insight into how the oxidative capacity of the PFM influences SUI. The small number of units able to provide patient evaluation using these techniques and their cost and relative complexity are major considerations, but if such imaging can optimize diagnosis, treatment allocation, and selection for surgery enhanced imaging techniques may prove to be a worthwhile and cost-effective strategy for assessing and treating SUI.

Quantification of pelvic floor muscle strength in female urinary incontinence: A systematic review and comparison of contemporary methodologies

There remains no gold standard for quantification of voluntary pelvic floor muscle (PFM) strength, despite international guidelines that recommend PFM assessment in females with urinary incontinence (UI). Methods currently reported for quantification of skeletal muscle strength across disciplines are systematically reviewed and their relevance for clinical and academic use related to the pelvic floor are described.

Management of patients with stress urinary incontinence after failed midurethral sling

Surgical failure rates after midurethral sling (MUS) procedures are variable and range from approximately 8-57% at five years of followup. The disparity in long-term failure rates is explained by a lack of long-term followup and lack of a clear definition of what constitutes failure. A recent Cochrane review illustrates that no high-quality data exists to recommend or refute any of the different management strategies for recurrent or persistent stress urinary incontinence (SUI) after failed MUS surgery. Clinical evaluation requires a complete history, physical examination, and establishment of patient goals. Conservative treatment measures include pelvic floor physiotherapy, incontinence pessary dish, commercially available devices (Uresta®, Impressa®), or medical therapy. Minimally invasive therapies include periurethral bulking agents (bladder neck injections) and sling plication. Surgical options include repeat MUS with or without mesh removal, salvage autologous fascial sling or Burch colposuspension, or salvage artificial urinary sphincter insertion. In this paper, we present the available evidence to support each of these approaches and include the management strategy used by our review panel for patients that present with SUI after failed midurethral sling.

Procedure Choice in Primary Versus Recurrent Prolapse: A Study of Fellowship-Trained Surgeons

Objective This retrospective study describes procedures of choice in management of patients with primary prolapse compared with recurrence prolapse patients by fellowship-trained surgeons. Methods Surgically managed primary and recurrent prolapse cases from 2012 to 2015 at Houston Methodist Hospital were reviewed. Baseline characteristics, compartment defects, and stage were compared. Mean interval from the index surgeries to management of prolapse recurrence was recorded. In recurrence cases, mesh complaints were noted if present. Primary outcome was the procedure type used to manage cases of recurrence and primary prolapse. Logistic regression was used to determine odds ratio (OR) for the procedure of choice in recurrence and primary repairs of prolapse. Results Of 386 cases reviewed, 379 met criteria for inclusion; 25.8% of repairs were for recurrence. Recurrence patients were significantly older than primary cases (mean, 63.6 vs 60.5; P = 0.03) and had been postmenopausal for longer (P = 0.004). Median time interval to surgical management of recurrence was 8 years. Thirty percent of recurrence patients treated previously by mesh had mesh complaints. There was no difference in the distribution of defects or stage. Sacrocolpopexy was more frequently used to manage recurrent prolapse (OR, 2.6334; P < 0.0005). Vaginal mesh repairs showed no difference in utilization. Uterosacral ligament fixation (OR, 0.347; P = 0.002) was used more often in primary prolapse. Anterior colporrhaphy (OR, 0.398; P = 0.0005) and uterosacral ligament fixation (OR, 0.347; P = 0.002) were performed less in recurrence cases. Conclusion Fellowship-trained urogynecologists at this institution utilize sacrocolpopexy mesh more frequently in recurrent prolapse, and uterosacral ligament fixation was used more frequently in primary prolapse cases.

Outcomes in Pelvic Organ Prolapse Surgery in Women Using Chronic Antithrombotic Therapy

Introduction Chronic antithrombotic therapy is common among patients requiring surgery for pelvic organ prolapse because of age and comorbidities. The impact of chronic anticoagulation on postoperative complications in pelvic organ prolapse surgery has not been investigated. This study aims to determine if patients on chronic antithrombotic therapy are at increased risk for postoperative complications. Methods This retrospective cohort study included women having prolapse surgery from 2012 to 2015, identified by Current Procedural Terminology codes, excluding patients undergoing concomitant major nonurogynecologic procedures. Baseline characteristics were compared and all procedures performed, operative duration, estimated blood loss, and length of hospitalization. Complications (blood transfusion, intensive care unit admission, reoperation, readmission, hematoma, thromboembolic event, and infection) were compared in women on chronic antithrombotic therapy and controls. Logistic regression determined odds ratio (OR) for complications in patients on chronic antithrombotics. Complications were graded by the Clavien-Dindo classification. Results A total of 388 charts were reviewed, and 386 patients met inclusion criteria. Twenty-one of the 386 patients were on chronic antithrombotic therapy. Chronic antithrombotic therapy increased overall complications (OR, 6.8; P < 0.0005), blood transfusion (OR, 165; P < 0.001), intensive care unit admission (OR, 19.10; P < 0.004), hospital readmission (OR, 20.7; P < 0.0005), vaginal hematoma (OR, 554.1; P < 0.001), infection (OR, 22.44; P < 0.004), and complications that required specific additional follow-up (OR, 9.42; P < 0.0005). There were no thromboembolic events. Antithrombotic therapy did not significantly increase reoperation rates (OR, 3.8; P = 0.275). Findings were maintained when adjusting for covariates of age and body mass index. Conclusions Postoperative surgical complications after prolapse repair procedures are increased in patients who use chronic antithrombotic medication, the majority of cases are successfully managed conservatively.

Case ‒ Uretero-internal iliac artery fistula presenting with multiple negative angiographic studies

We report a rare case of a patient presenting with visible, unexplained hematuria and share the diagnostic challenges faced in the setting of multiple angiographic studies that failed to demonstrate an uretero-internal iliac artery fistula. Uretero-arterial fistulas (UAF) are rare, but well-recognized, with increasingly common risk factors (Table 1). 1 Due to its rarity, delay to diagnosis is common, when investigating recurrent hematuria with multiple negative investigations. 1,2

A comprehensive review of adult enuresis

Nocturnal enuresis (NE) is a combined symptom of nocturia and urinary incontinence. In this review, we aim to summarize the current literature on NE in terms of its definition, diagnosis, and management. Recommended diagnostic evaluation of NE includes a focused history and physical examination, urinalysis, and when indicated, ultrasound examination, flow rate, urine volume chart, urodynamics, and cystoscopy. Therapeutic options include lifestyle modification and medications (i.e., desmopressin and anticholinergics).

Relevance of open magnetic resonance imaging position (sitting and standing) to quantify pelvic organ prolapse in women

INTRODUCTION In pelvic organ prolapse (POP), posture and gravity impact organ position and symptom severity. The advanced magnet configuration in open magnetic resonance imaging (MRO) allows patients to be imaged when sitting and standing, as well in a conventional supine position. This study evaluated if sitting and standing MRO images are relevant as a means of improving quantification of POP because they allow differences in organ position not seen on supine imaging to be identified. METHODS Forty women recruited from a university urogynecology clinic had MRO imaging (0.5 T scanner) with axial and sagittal T2-weighted pelvic scans obtained when sitting, standing, and supine. Pelvic reference lines were used to quantify the degree of POP, and the relevance of imaging position on the detection of POP compared. RESULTS Images from 40 participants were evaluated (20 with POP and 20 asymptomatic controls). Our results indicate that the maximal extent of prolapse is best evaluated in the standing position using H line, M line, mid-pubic line, and perineal line as reference lines to determine POP. CONCLUSIONS MRO imaging of symptomatic patients in a standing position is relevant in the quantification of POP. Compared with supine images, standing imaging identifies that greater levels of downward movement in the anterior and posterior compartments occur, presumably under the influence of posture and gravity. In contrast, no appreciable benefit was afforded by imaging in the sitting position, which precluded use of some reference lines due to upward movement of the anorectal junction.

Dysfunctional voiding: Challenges of disease transition from childhood to adulthood

Enuresis and voiding dysfunction are common referral conditions in the pediatric urology clinic.1,2 According to the International Continence Society, incontinence refers to any type of involuntary leakage of urine, and dysfunctional voiding is involuntary intermittent contractions of the striated sphincter during voiding in neurologically normal individuals.1 These frequent problems in the pediatric setting have known propensity to persist, evolve, and change during adulthood.3,4 Obstructive symptoms are the most frequent presentations later in life.1 Little interest has been put on the transition of these patients from childhood to adult life. Recognizing the association between pediatric and adult symptoms is the first step in this difficult transitioning process.

Pelvic dural ectasia leading to bilateral ureteric obstruction in the pediatric patient

Large pelvic cysts and moderate to severe hydroureteronephrosis were found after investigating hypertension in a 16-year-old child with Marfans and known pelvic dural ectasia. Follow-up magnetic resonance imaging demonstrated extensive ectasia of the dural sac at the sacral level with displacement of the bowel, bladder and bilateral ureteric obstruction with accompanying hydroureteronephrosis that was advanced compared to prior imaging. Postural headaches secondary to cerebrospinal fluid leak and progressive hydroureteronephrosis prompted a combined neurosurgical and urologic resection of the pelvic masses. In this report, we discuss the preoperative evaluation and management of this rare form of bilateral ureteric obstruction.