Dean S. Elterman

Changes in Pelvic Organ Prolapse Surgery in the Last Decade among United States Urologists

PURPOSE Surgical correction of pelvic organ prolapse underwent transformation in the last decade. Training in pelvic organ prolapse surgery, the ease of mesh kit use, and Food and Drug Administration warnings about mesh have influenced practice patterns. We investigated trends in pelvic organ prolapse procedures. MATERIALS AND METHODS Case logs of pelvic organ prolapse procedures, mesh use and pessary placement were obtained from the American Board of Urology for 2003 to 2012. We evaluated associations between surgeon characteristics and the use of pelvic organ prolapse procedures. RESULTS Of 6,355 nonpediatric urologists applying for certification or recertification 2,192, representing a 10% annual sample of all urologists, reported performing pelvic organ prolapse procedures during the study period. The number of procedures increased steadily from 930 in 2003 to 6,978 in 2012. The number of colporrhaphies increased from 806 to 2,670 and the number of colpopexies increased from 32 to 1,414 between 2003 and 2012. The number of vaginal colpopexies increased from 24 to 1,016 during the study period. The number of sacrocolpopexies increased from 8 to 398 with exponential increases in laparoscopic sacrocolpopexy (282 cases by 2012). Mesh insertion increased from 10 cases reported by applicants in 2005 to 1,552 reported in 2012 (p <0.0005). Mesh revision, first reported in 2007 with 52 performed, consistently increased to 214 in 2012. Urologists trained in female urology performed a median of 16 pelvic organ prolapse procedures, double the number reported by surgeons trained in other urological fellowships. Urologists of the female gender also reported performing approximately 8 more procedures annually than male urologists. CONCLUSIONS The number of pelvic organ prolapse operations done by urologists increased dramatically in the last decade with a similar increase in mesh use. More colpopexies are now performed with laparoscopic sacrocolpopexy showing an exponential increase. The recent trend of mesh revision is notable with a much faster rate of increase than mesh insertion.

Midurethral sling is the dominant procedure for female stress urinary incontinence: analysis of case logs from certifying American Urologists.

OBJECTIVE To investigate contemporary trends in the use of midurethral sling procedures for the surgical correction of female stress urinary incontinence over the past decade. METHODS Annualized case log data for female incontinence surgeries from certifying and recertifying urologists were obtained from the American Board of Urology. Descriptive analysis of the number and type of cases per year was performed. Associations between surgeon characteristics and the use of female incontinence procedures were evaluated. RESULTS A total of 6355 nonpediatric urologists applied for certification or recertification between 2003 and 2012. Two-thirds (4185) reported performing any procedures for female incontinence. Procedures sharply increased from 4632 in 2003 to 7548 in 2004, then remained relatively stable between 2005 and 2012 (range, 8014-10,238 cases). Traditional procedures decreased from 17% of female incontinence procedures in 2003 to 5% in 2004 to <1% since 2010 (P <.0005). Midurethral sling procedures have risen sharply from 3210 procedures in 2003 to 7200 in 2012 (P <.0005). Endoscopic injection treatments have remained stable. CONCLUSION Midurethral slings have been widely adopted by urologists over the last decade. Increase in sling usage coincided with a drastic decline in traditional repairs, implying that the newer midurethral slings were replacing these traditional procedures for the treatment of female incontinence. In addition, the fact that the use of periurethral injections did not change significantly during this time period indicates that increased sling usage is responsible for most of the decline in traditional repairs.

Optimizing the management of benign prostatic hyperplasia.

One of the challenges facing primary care physicians and specialists as the population ages is the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). While as many as 18% of men in their 40s report bother from an enlarged prostate, that figure rises dramatically, whereby 50% of men in their 50s and 90% of men in their 90s will complain of bothersome symptoms related to an enlarged prostate. Studies have shown that BPH is a progressive disease, which if left untreated can result in worsening of symptoms, acute urinary retention and renal failure. Until about 20 years ago the only management option available to urologists was surgery. In the early 1990s medical therapy emerged as the predominant treatment for BPH. Therapy may be tailored to target symptoms and progression of disease.

Comparison of Techniques for Transurethral Laser Prostatectomy: Standard Photoselective Vaporization of the Prostate Versus Transurethral Laser Enucleation of the Prostate

BACKGROUND AND PURPOSE Transurethral laser enucleation of the prostate (TLEP) using the potassium-titanyl-phosphate (KTP) laser offers an alternative technique to traditional photovaporization. The study objective was to determine the comparative efficacy between transurethral photovaporization of the prostate (PVP) with a TLEP technique using the 80W 532 nm KTP laser. PATIENTS AND METHODS A series of 97 vs 170 patients who underwent PVP vs TLEP, respectively, with the KTP laser system at Weill Cornell Medical College from September 2001 to May 2009 was studied retrospectively. Outcome measures included laser time, prostate volume lased per unit time, International Prostate Symptom Score (IPSS), postvoid residual (PVR), and maximum flow rate (Qmax). Statistical analyses were performed using the Shapiro-Wilk, Mann-Whitney, Wilcoxon, and unpaired t tests. RESULTS Baseline parameters were similar between groups, although volume was greater in the TLEP group (83 vs 63 cc, P=0.04). Median laser time was longer in the TLEP group (90 vs 50 min, P<0.001) with a higher median energy used (308 vs 165 kJ, P<0.001). The volume lased per unit time was shorter, however, for TLEP (0.92 cc/min) than for PVP (1.26 cc/min). A greater median number of fibers were used in TLEP (2.5 vs 2.0, P=0.001). Improvements in median IPSS and PVR were seen in the TLEP group (5.0, P<0.001; 55.5, P=0.02, respectively) but not in the PVP group (P=0.40 and 0.30). Median Qmax and prostate-specific antigen (PSA) level improved similarly in both groups. Final IPSS was lower for the TLEP group (P<0.001), but other final parameters were statistically equivalent. CONCLUSIONS In our series, both PVP and TLEP techniques were safe and effective. Although changes in Qmax and PSA were similar between the two techniques, improvement in urinary symptoms and PVR was superior with the TLEP technique. The TLEP technique was a more efficient method for laser prostatectomy.

WATER II (80-150 mL) procedural outcomes

To present early safety and feasibility data from a multicentre prospective study (WATER II) of aquablation in the treatment of symptomatic men with large‐volume benign prostatic hyperplasia (BPH).

How 'male health' fits into the field of urology.

The shorter life span and poorer health of men compared with women is concerning, affecting spouses, families, and communities. Physicians and policy makers have identified a growing need for a gender-specific focus on the unique health needs of boys and men and accompanying services. Mens health has emerged as a new discipline that is responsible for a gender-specific approach to health-services delivery, government policy, research, and advocacy. The urologic community has taken a leadership role in this specialty by defining the issues that face men in the 21st century, bringing together disparate areas of clinical care and research, and collaborating with stakeholders (such as primary care physicians and specialists from other disciplines) to create and implement mens health initiatives.

Interventions to address sexual problems in people with cancer

BACKGROUND Sexual dysfunction in people with cancer is a significant problem. The present clinical practice guideline makes recommendations to improve sexual function in people with cancer. METHODS This guideline was undertaken by the Interventions to Address Sexual Problems in People with Cancer Expert Panel, a group organized by the Program in Evidence-Based Care (pebc). Consistent with the pebc standardized approach, a systematic search was conducted for existing guidelines, and the literature in medline and embase for the years 2003-2015 was systematically searched for both systematic reviews and primary literature. Evidence found for men and for women was evaluated separately, and no restrictions were placed on cancer type or study design. Content and methodology experts performed an internal review of the resulting draft recommendations, which was followed by an external review by targeted experts and intended users. RESULTS The search identified 4 existing guidelines, 13 systematic reviews, and 103 studies with relevance to the topic. The present guideline provides one overarching recommendation concerning the discussion of sexual health and dysfunction, which is aimed at all people with cancer. Eleven additional recommendations made separately for men and women deal with issues such as sexual response, body image, intimacy and relationships, overall sexual functioning and satisfaction, and vasomotor and genital symptoms. CONCLUSIONS To our knowledge this clinical practice guideline is the first to comprehensively evaluate interventions for the improvement of sexual problems in people with cancer. The guideline will be a valuable resource to support practitioners and clinics in addressing sexuality in cancer survivors.

Multicentre international experience of 532-nm laser photoselective vaporization with GreenLight XPS in men with very large prostates

To describe peri‐operative results, functional outcomes and complications of laser photoselective vaporization, using the GreenLight system, of prostate glands ≥200 mL in volume.

Publicly funded overactive bladder drug treatment patterns in Ontario over 15 years: An ecological study

INTRODUCTION Medication is an important option for patients with overactive bladder (OAB), with four different drugs approved over the last 10 years, including the first non-anticholinergic treatment, mirabegron. We set out to describe the number and rate of users of medication for the management of OAB over the last 15 years among residents of Ontario, Canada covered by the public drug programs. METHODS We conducted a population-based, repeated cross-sectional study examining quarterly publically funded prescription claims for OAB medications from January 2000 to June 2016 in Ontario, Canada. RESULTS We report two major changes in prescription patterns for OAB. The first was the rise of newer, more selective anticholinergics (tolterodine, solifenacin, and darifenacin) replacing oxybutynin. This led to a 54.8% reduction in the rate of users of oxybutynin over the study period from 10.4 users/1000 beneficiaries in 2000 to 4.7 users/1000 beneficiaries in 2016. Recently, we saw the emergence of mirabegron as the most commonly prescribed treatment for OAB. By the final quarter of the observation period, mirabegron was the most commonly used OAB treatment with 25.0% (n=19 411) of all OAB medication users in Ontario (n=77 660). CONCLUSIONS Our findings highlight the rapid uptake of novel agents and a major shift in the treatment of OAB over the last three years.

Men’s mental health: Connection to urologic health

Historically, the specialty of urology has focused on single-system diseases. In recent years, however, there has been increasing recognition of the interconnectivity between the various systems, such as cardiovascular disease, metabolic syndrome, erectile dysfunction and prostate cancer. This constellation of disease/syndrome and dysfunction may place urologists at the centre of mens overall health concerns. As urologists considering taking on a leadership role in mens health, they should also consider their potential in helping men suffering from the significant burden of a mental health disorder. Urologists may have a unique opportunity to identify mental health issues in their male patients, influence healthy behaviour change, and successfully refer men, who might otherwise not seek help, to appropriate medical/psychological care.