Benjamin Dillon

Transvaginal Mesh Kits—How “Serious” Are the Complications and Are They Reversible?

OBJECTIVE To review the merit of the U.S. Food and Drug Administration-issued warnings on the use of transvaginal mesh in women with pelvic organ prolapse because of escalating complications. MATERIALS AND METHODS On institutional review board approval, we reviewed the data from 2 tertiary institutions managing complications of transvaginal mesh. The data recorded included mesh type, details of surgical removal, and patient-reported clinical outcomes. RESULTS From 2006 to March 2011, 58 women were evaluated. Their mean age was 54.6 years (range 32-80), with a mean follow-up of 13 months (range 6-67). The mean interval to mesh excision surgery from the original prolapse surgery was 21 months (range 2-60). Of the 58 women, 35 (60%) had undergone concurrent midurethral sling surgery with the transvaginal mesh surgery. Also, 21 of the 58 patients (36%) had undergone initial mesh removal attempts before their referral to either tertiary institution. Most women presented with multiple complaints, with mesh extrusion the most frequently reported (n=43 [74%]). Of the 58 women, 17 (29%) required re-excision of residual mesh, 13 once and 4 twice. Five women developed recurrent symptomatic pelvic organ prolapse (7%). The residual rate of dyspareunia and pelvic pain was 14% and 22%, respectively. Fourteen women (24%) were treated successfully, with complete resolution of all presenting symptoms. CONCLUSION As outlined in the Food and Drug Administration notifications, patients should be forewarned that some transvaginal mesh complications are life altering and might not always be surgically correctable.

Renal deterioration in multiple sclerosis patients with neurovesical dysfunction.

Objectives: Our aims were to determine the prevalence of renal ultrasound (RUS) abnormalities over time in multiple sclerosis (MS) patients with lower urinary tract symptoms (LUTS). Methods: Data were examined retrospectively from MS patients with LUTS, from 2000–2009. Study inclusion requirements were both baseline urodynamics (UD) and RUS data, with followup RUS at ≥ 12 months. Age, time since diagnosis (TSD), MS subtype and the UD/RUS results were evaluated for associations. Results: At presentation, 173 subjects underwent UD and RUS, but only 89 had a repeat RUS at ≥ 12 months. Median followup was 61 months. Initial RUS abnormalities were found in 10 (5.8%) subjects. At followup, upper urinary tract (UUT) abnormalities were seen in 11 (12.4%) subjects. Patients > 49 years old were more likely to have an abnormality (OR 0.181, 95% CI 0.037–0.892, p = 0.04). Patients with abnormal compliance were also more likely to have an abnormal followup RUS (OR 0.185, 95% CI 0.037–0.924, p = 0.04). No other demographic or UD factor was associated with RUS abnormalities. Conclusions: The development of structural UUT changes is low in MS patients. Urodynamic studies are useful for LUTS treatment strategies in complicated patients, but UD does not appear to have much impact with regard to upper tract changes.

Long-Term Functional Outcomes Following Nonradiated Vesicovaginal Repair

PURPOSE We investigated the long-term impact on bladder and sexual symptoms in women with prior vesicovaginal fistula repair, particularly those previously treated before referral. MATERIALS AND METHODS After receiving institutional review board approval we reviewed the charts of women who underwent nonradiated vesicovaginal fistula repair for demographics, surgical approach (vaginal or abdominal) and functional outcomes with a minimum 6-month followup. Patients lost to followup were reached by a structured phone interview and/or mailed validated lower urinary tract questionnaires, including the UDI-6 (Urogenital Distress Inventory-6), IIQ-7 (Incontinence Impact Questionnaire-7) and FSFI (Female Sexual Function Index). Three surgical groups were compared, including naïve-no prior repair, recurrent-1 prior repair and other-more than 2 repairs with the hypothesis of worse outcomes with more repairs. RESULTS From 1996 to 2011 vesicovaginal fistula repair was performed in 66 patients, including in 42 as primary treatment (vaginal vs abdominal approach in 31 vs 11), in 14 as secondary treatment, and in 10 who underwent more than 2 repairs. Mean patient age was 45 years (range 24 to 87), mean body mass index was 29 kg/m(2) (range 19 to 43) and mean followup was 55 months (range 6 to 198). The overall repair success rate was 97%. There was no difference in functional outcomes in questionnaire responders among the 3 groups for lower urinary tract symptoms (62% on UDI-6/IIQ-7). However, for FSFI (33% of patients) there was female sexual dysfunction in patients who underwent transabdominal repair and in women with 2 repairs. CONCLUSIONS Long-term followup of patients with vesicovaginal fistula repair indicated no differences in lower urinary tract outcomes at a mean 7-year followup between primary and recurrent repairs. There was a difference in sexual function, although it was not statistically significant. Sexual activity among responders was low.

A Surprisingly Low Prevalence of Demonstrable Stress Urinary Incontinence and Pelvic Organ Prolapse in Women with Multiple Sclerosis Followed at a Tertiary Neurogenic Bladder Clinic

PURPOSE We report the prevalence of stress urinary incontinence and pelvic organ prolapse in patients with multiple sclerosis referred to a tertiary care neurogenic bladder clinic. MATERIALS AND METHODS We queried an institutional review board approved neurogenic bladder database for urodynamic and demographic data on patients with multiple sclerosis followed for lower urinary tract symptoms in a 12-year period. Demographic information included multiple sclerosis classification, age at initial visit, body mass index, parity and pelvic examination findings. Prolapse was defined as stage 2 prolapse or greater. Stress urinary incontinence was defined as urodynamic stress incontinence and/or incontinence on a supine stress test. RESULTS Included in analysis were 280 women with a mean age of 50 years and a mean 13-year history of multiple sclerosis. Relapse remitting multiple sclerosis was noted in 40% of patients, while 45 (16%) had stress urinary incontinence. Women with stress urinary incontinence had a higher average maximum urine flow (14 vs 9 ml per second, p <0.003), higher voided volume (272 vs 194 cc, p = 0.018) and higher body mass index (30 vs 25 kg/m(2), p <0.005). Overall, 23 women (9%) had pelvic organ prolapse, including 2 (9%) with posterior prolapse only, 8 (35%) with anterior prolapse only and 13 (56%) with posterior and anterior prolapse. There was no difference in age, body mass index or multiple sclerosis subtype between women with vs without pelvic organ prolapse. CONCLUSIONS The 14% prevalence of demonstrable stress urinary incontinence and 9% rate of pelvic organ prolapse are markedly lower than published historical data on an age matched cohort without multiple sclerosis. The surprisingly low prevalence of stress urinary incontinence and pelvic organ prolapse in women with multiple sclerosis may be attributable to decreased activity, a neurogenically enhanced vesicourethral unit or other functional or anatomical etiologies.

Management of two synthetic midurethral slings eroded into the urethral lumen

Mesh complications, both erosions and extrusions, are becoming more common in the practice of urology. We present the case of a 58-year-old woman who presented with lower urinary tract symptoms (LUTS) and recurrent urinary tract symptoms following treatment for stress urinary incontinence and who was found to have two slings eroded into her urethral lumen. The slings were debulked in the urethra using the holmium laser, thereby avoiding a more complex urethral reconstruction.

Urodynamics: Role in Incontinence and Prolapse: A Urology Perspective

Changes in pelvic floor as well as urethral anatomy and function occur with aging, which can result in prolapse and urinary incontinence. Aside from the socially debilitating impact incontinence has on patients lives, it significantly affects the health care systems economically. Rates of incontinence and pelvic organ prolapse (POP) in women of this age demographic is estimated to be 30% to 94%, and 1 in 8 women may require surgical repair for POP or incontinence by their eighth decade, with a reoperation rate of 30%. This article reviews the role of UDS in the evaluation of urinary incontinence and POP.

Martius labial fat pad procedure: technique and long-term outcomes

Surgical technique in this case used anMLFP after completing a transvaginal urethrolysis to fill the space around the urethra and prevent rescarring. A vertical incision (average 8 cm) is made over the labia majora from the level of the mons pubis down toward the level of the fourchette, depending on the length of fat pad required. The incision is deepened to the level of the labial fat pad, which can be gently grasped with a Babcock clamp and mobilized on an inferior pedicle, providing a posteroinferior blood supply to the graft based on branches from the external pudendal artery. Blood supply for the MFLP varies with description of both superior and inferior blood supplies. We and others have used the posteroinferior blood supply, while others have preferred a superior blood supply. Both approaches seem to provide well-vascularized fat-pad grafts. Dissection is continued laterally and medially with attention to avoid being too superficial medially to prevent skin retraction and secondary deformation. Once a sufficient length is achieved, the flap is gradually divided superiorly. The fat pad graft is then detached posteriorly off the underlying ischiocavernosus and bulbocavernosus muscles, leaving a broad base inferiorly to preserve vascularity. After mobilization is completed, a figure-of-eight absorbable suture is placed at the extremity of the flap to facilitate transfer alongside the vaginal wall (Fig. 1). A vaginal tunnel is created with long Metzenbaum scissors and/or a ring forceps and widened to accept at least two fingers to offset compression of the blood supply. The pedicle graft MFLP once tunnelled can be secured in place with absorbable sutures. The incision is closed in layers over a small labial drain, which is removed within 24–48 h postoperatively (Fig. 2). Labial incision is barely noticeable in the long term (Fig. 3).

When Are Urodynamics Indicated in Patients with Stress Urinary Incontinence

Despite technical and procedural advances in urodynamics over the past decade, the role of urodynamics in women with stress urinary incontinence (SUI) remains controversial. Many of these advancements have been the result of multicentric studies in the United States, such as the UITN and PFDN, which will be highlighted in this article. It appears to be the consensus that urodynamics may not be needed in pure stress incontinence. Urodynamics can be valuable in unmasking stress urinary incontinence in prolapse, although its impact on the ultimate management of occult incontinence remains debated. This article reviews the indications for urodynamic testing in women with SUI but will exclude more complex conditions such as mixed or recurrent incontinence which are outside the scope of this review.

Adult Onset Nocturnal Enuresis: Identifying Causes, Cofactors and Impact on Quality of Life

The objectives of the present study were: (i) Evaluate common co‐pathologies associated with, and potentially contributing to adult onset Nocturnal enuresis (NE) in a tertiary referral population; and (ii) quantify its impact on QoL with validated questionnaires.

Complications Following the Insertion of Two Synthetic Mid-urethral Slings and Subsequent Removal

To determine outcomes after removal of two synthetic mid‐urethral slings (MUS) at a tertiary care center.