Ashley King

Comprehensive Evaluation of Anterior Elevate System for the Treatment of Anterior and Apical Pelvic Floor Descent: 2-Year Followup

PURPOSE The Elevate® Anterior and Apical Prolapse Repair System is a polypropylene mesh that is anchored through sacrospinous ligament and obturator fascia fixation points. We present a comprehensive evaluation of this prolapse repair system through 2 years with a focus on safety, operative characteristics, and anatomical, subjective and quality of life outcomes. MATERIALS AND METHODS A total of 42 women underwent repair of stage II or greater anterior/apical compartment prolapse using the repair system, of whom 2 were lost to followup. Anatomical outcomes were assessed using POP-Q (Pelvic Organ Prolapse Quantification) staging. Subjective and quality of life outcomes were assessed by the validated ICIQ (International Consultation on Incontinence Questionnaire)-VS (Vaginal Symptoms), ICIQ-FLUTS (Female Lower Urinary Tract Symptoms) and IIQ-7 (Incontinence Impact Questionnaire-7). Additional outcomes included a 3-day bladder diary and cough test with outcomes assessed preoperatively, at 6 weeks, and at 1 and 2 years. RESULTS Mean ± SD blood loss was 93 ± 55 cc and mean operative time was 58 ± 27 minutes. POP-Q points Aa, Ba and C improved from 0.9, 0.8 and -1.3 preoperatively to -2.1, -2.7 and -6.1 cm at 2 years, respectively (each p <0.05). Four patients experienced anatomical recurrence, which was associated in 2 with symptomatic recurrence on the ICIQ-VS. Statistically significant improvements in the ICIQ-VS, ICIQ-FLUTS and IIQ-7 were seen throughout followup. Adverse events included leg pain, vaginal exposure and urinary retention in 1, 2 and 5 patients, respectively. CONCLUSIONS The Elevate Anterior and Apical Prolapse Repair System was associated with good anatomical restoration and significant improvements in validated symptom and quality of life indexes through 2 years of assessments. Our experience suggests that the system is a safe, effective surgical procedure in appropriately selected patients. Long-term followup is important, given the FDA (Food and Drug Administration) warning regarding the use of surgical mesh in the repair of pelvic organ prolapse.

The Influence of Psychiatric Comorbidities and Sexual Trauma on Lower Urinary Tract Symptoms in Female Veterans

PURPOSE We characterized the association of psychiatric comorbidities and sexual trauma with lower urinary tract symptoms in women. MATERIALS AND METHODS Consecutive women (121) referred for evaluation of lower urinary tract symptoms to a specialized urology clinic were given validated questionnaires including the Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7. These data were then analyzed according to psychiatric comorbidities, history of sexual trauma, age, race and obstetric history. Baseline incidence of psychiatric comorbidity and sexual trauma was also compared to a control population (1,298) from which all patients were referred. RESULTS Women referred for evaluation of lower urinary tract symptoms had higher rates of psychiatric comorbidities (64.5% vs 25.9%, p <0.001) and sexual trauma (49.6% vs 20.1%, p <0.001) compared to those in the primary care clinic. Total survey scores for the Incontinence Impact Questionnaire-7 were significantly higher for patients with psychiatric comorbidities and sexual trauma (11.05 +/- 0.84) compared to scores of patients with neither of these conditions (7.6 +/- 1.02, p = 0.010). Stepwise multivariate regression analyses demonstrated that higher Urogenital Distress Inventory-6 scores were associated only with age younger than 50 years and history of miscarriage, and that higher Incontinence Impact Questionnaire-7 scores were associated only with psychiatric comorbidities and history of miscarriage. CONCLUSIONS Psychiatric comorbidities and sexual trauma are prevalent in female veterans presenting for evaluation of lower urinary tract symptoms and psychiatric comorbidities are associated with greater quality of life impact.

Satisfaction in patients undergoing concurrent pelvic floor surgery for stress urinary incontinence and pelvic organ prolapse.

Objective Simultaneous repair of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) is common. In these cases, determinants of patient satisfaction are complicated given that surgical success may be achieved in one component but not the other. We sought to assess satisfaction in patients undergoing multiple pelvic surgeries. Methods We performed a review of 89 women undergoing concomitant POP repair and midurethral sling (MUS) placement. Focus was placed on patient-reported satisfaction rates. Validated measures were used to evaluate outcomes after MUS [International Consultation on Incontinence Questionnaire (ICIQ)-Female Lower Urinary Tract Symptoms, SUI item; pad use] and POP repair (ICIQ-Vaginal Symptoms; POPQ stage). Results At 1-year evaluation, 78 (88%) women reported satisfaction. Assessment identified combined cure of both POP/SUI in 64 (72%) patients, in contrast to failure of MUS, POP repair, and both repairs in 15 (17%) patients, 9 (10%) patients, and 1 (1%) patient, respectively. Subset analysis revealed dissatisfaction in 5% (3/64) of patients achieving complete cure of both SUI and POP. In contrast, 40% (6/15) were dissatisfied if there was failure to cure SUI, 22% (2/9) if failure to cure POP, and the patient with failure of both was not dissatisfied. The ICIQ-Vaginal Symptoms domain score for vaginal bulge was the only assessed outcome demonstrating a statistical relationship with patient-reported satisfaction. Conclusions Among women achieving cure of both SUI and POP via concurrent surgical repair, 95% reported satisfaction. Interestingly, a variety of outcomes measures fail to correlate with satisfaction. Further, in patients with complete cure of concurrent pelvic surgeries, a percentage still report dissatisfaction, highlighting the complicated nature of patient satisfaction.

Expert Training with Standardized Operative Technique Helps Establish a Successful Penile Prosthetics Program for Urologic Resident Education

INTRODUCTION The challenge of resident education in urologic surgery programs is to overcome disparity imparted by diverse patient populations, limited training times, and inequalities in the availability of expert surgical educators. Specifically, in the area of prosthetic urology, only a small proportion of programs have full-time faculty available to train residents in this discipline. AIM To examine whether a new model using yearly training sessions from a recognized expert can establish a successful penile prosthetics program and result in better outcomes, higher case volumes, and willingness to perform more complex surgeries. METHODS A recognized expert conducted one to two operative training sessions yearly to teach standardized technique for penile prosthetics to residents. Each session consisted of three to four operative cases performed under the direct supervision of the expert. Retrospective data were collected from all penile prosthetic operations before (February, 2000 to June, 2004: N = 44) and after (July, 2004 to October, 2007: N = 79) implementation of these sessions. MAIN OUTCOME MEASURES Outcomes reviewed included patient age, race, medical comorbidities, operative time, estimated blood loss, type of prosthesis, operative approach, drain usage, length of stay, and complications including revision/explantation rates. Statistical analysis was performed using Students t-tests, Fishers tests, and survival curves using the Kaplan-Meier technique (P value ≤ 0.05 to define statistical significance). RESULTS Patient characteristics were not significantly different pre- vs. post-training. Operative time and estimated blood loss significantly decreased. Inflatable implants increased from 19/44 (43.2%, pre-training) to 69/79 (87.3%, post-training) (P < 0.01). Operations per year increased from 9.96 (pre-training) to 24 (post-training) (P < 0.01). Revision/explantation occurred in 11/44 patients (25%, pre-training) vs. 7/79 (8.9%, post-training) (P < 0.05). CONCLUSIONS These data demonstrate that yearly sessions with a recognized expert can improve surgical outcomes, type, and volume of implants and can reduce explantation/revision rates. This represents an excellent model for improved training of urologic residents in penile prosthetics surgery.

Vaginal Symptoms and Sexual Function After Tension-free Vaginal Tape-obturator Placement: Minimum 12-Month Follow-up

OBJECTIVE To examine the effect of the tension-free vaginal tape-obturator (TVT-O) on sexual function and vaginal symptoms. The effect of anti-incontinence surgery on vaginal symptoms and sexual function is controversial; these assessments are increasingly important given the Food and Drug Administration warning regarding the use of transvaginal surgical mesh. MATERIALS AND METHODS A retrospective review of 42 patients undergoing TVT-O with a minimum 1-year follow-up data was performed. The outcomes were assessed at baseline and 1 year postoperatively using validated questionnaires, including the International Consultation on Incontinence Questionnaire-Vaginal Symptoms, a validated measure assessing the impact of vaginal symptoms and sexual matters on quality of life and treatment outcomes. The International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms and Incontinence Impact Questionnaire, Short Form were used to assess the incontinence and quality of life outcomes, respectively. RESULTS Statistically significant improvements were seen in the vaginal symptoms (from 9.7 to 6.0, P=.01), sexual matters (from 16.7 to 6.9, P=.01), and quality of life (from 3.0 to 1.1, P=.001) domains on the International Consultation on Incontinence Questionnaire-Vaginal Symptoms from the baseline to 1-year assessment. Of 20 sexually active patients at baseline, 18 reported continued sexual activity postoperatively, with 2 patients reporting an absence of sexual activity because of other factors. Six patients who were not sexually active at baseline because of vaginal symptoms had resumed sexual activity at 1 year. Statistically significant improvement in vaginal soreness and a trend toward improvement in the abdominal pain domain score were seen. CONCLUSION TVT-O sling placement was associated with symptom stability or improvement in validated measures of sexual function and vaginal symptoms. These data do not support the concerns regarding worsening sexual function and vaginal symptoms after TVT-O sling placement.

A Survey of Ethically Challenging Issues in Urological Practice

PURPOSE We surveyed ethical attitudes among urological and nonurological practitioners, allowing for thought and discussion regarding ethical issues in a larger audience. MATERIALS AND METHODS With input from an academic urologist, a senior medical student and a hospital ethics committee member, a survey was created which asked for multiple choice responses to 3 demographic questions (practice type, age, location) and 10 ethically challenging clinical questions. Surveys were distributed online or via mail to 5 groups including academic urologists, urologists in private practice, medical students, hospital risk managers/attorneys and members of a bioethical society. Surveys were analyzed according to demographic variables. RESULTS Surveys were sent out to 1,447 individuals and 340 responses were received (24%). There were statistically significant differences in the responses to several questions based on practice type, age and practice location. There was a lack of consistency in answer choices with greater than 50% agreeing on a single answer choice for only 4 of 10 questions (40%). CONCLUSIONS This is the first study to our knowledge which attempts to objectively categorize ethical attitudes in a broad based survey of urologists and nonurologists, and challenges members of our profession to study their own responses to these ethical issues.

Pain Related to Transvaginal Mesh Placed for Stress Urinary Incontinence and Pelvic Organ Prolapse

Since the Food and Drug Administration (FDA) released the safety communication regarding transvaginal mesh used for prolapse repair, the focus on complications related to transvaginal mesh has been heightened. Various complications can occur after transvaginal mesh placed for either stress incontinence or pelvic prolapse; however, persistent pain after mesh placement for stress urinary incontinence and pelvic prolapse, including vaginal pain, dyspareunia, suprapubic pain, and thigh pain, can incur significant morbidity for the patient. Evaluation and treatment options are reviewed.

MP33-08 RESOLUTION OF URGENCY URINARY INCONTINENCE AFTER INCISION OF AN OBSTRUCTING SYNTHETIC SLING

INTRODUCTION AND OBJECTIVES: Women with iatrogenic obstruction after synthetic sling placement often present with de novo or worsening urgency, frequency, and urgency urinary incontinence (UUI). The objective of this study was to determine the optimal time for sling incision to achieve resolution of urgency urinary incontinence. METHODS: 72 women who had a synthetic mid-urethral sling placed, developed de-novo or worsening urgency urinary incontinence, and then underwent sling incision for obstruction, were included in the study. On follow-up, women were administered UDI-6 and satisfaction questionnaires. ROC analysis was utilized to determine a statistically significant time point for sling incision with regard to resolution of urgency urinary incontinence. This cut-off was used to create early and delayed incision groups, which were compared using Wilcoxon rank-sum test for continuous variables and chi-square test for categorical variables. Multivariable logistic regression analysis was used to evaluate the association between early vs. delayed sling incision surgery and resolution of UUI and persistence of UUI while adjusting for age, BMI, diabetes, smoking status, vaginal parity, and sling approach. RESULTS: Median age was 55 (95%CI 51-59). Median number of months of follow-up after sling incision was 22 (95%CI 15-31). Median number of months from sling placement to sling incision was 25 (95%CI 16-32). ROC analysis revealed statistical significance using a cutpoint for resolution of UUI at 24 months. Rate of resolution of UUI was lower in the delayed incision group. UUI was more severe in the delayed incision group. See Table. Multivariable regression analysis revealed that women who underwent delayed incision were more likely to have persistent urgency urinary incontinence compared to women who underwent early incision (OR 2.13, 95% CI 0.42-10.8), though this was not statistically significant. CONCLUSIONS: Delayed sling incision results in lower rates of resolution of UUI. Women with de-novo or worsening UUI, presumably related to iatrogenic obstruction, should undergo sling incision sooner, rather than later. Women considering sling incision beyond 24 months should be counseled regarding lower rates of UUI resolution.

Incontinence: Evaluation of a midurethral single incision sling

The MiniArc™ sling is a next generation midurethral sling that is placed through a single incision with anchoring tips that fix into the obturator muscles. A new study reports 12-month success rates for this sling ranging from 85–91%, depending on the outcome measure evaluated, with a low rate of adverse events. Despite these encouraging results, long-term data are needed to demonstrate distinct advantages of the MiniArc™ over existing slings, combined with proven efficacy and safety.