Ekene Enemchukwu

Safety and Efficacy of Sling for Persistent Stress Urinary Incontinence After Bulking Injection

OBJECTIVES To evaluate the impact of injectable agents on subsequent incontinence surgery outcomes to assess safety and efficacy of this treatment combination. Periurethral bulking agents are a minimally invasive treatment option for stress urinary incontinence (SUI), but often lack durability necessitating further surgical intervention. METHODS Retrospective review of 43 patients with SUI following bulking agent who underwent subsequent sling placement from November 2000 to September 2009 were evaluated for demographics, symptoms, urodynamics (UDS), bulking agent characteristics, concomitant procedures, pad requirements per day (PPD), subjective outcomes, and complications. RESULTS Mean patient age was 67 years, with mean follow-up of 37.3 months. All demonstrated SUI, and mixed urinary incontinence (MUI) was noted in 81.4%. Almost half (48.8%) had undergone a prior antiincontinence procedure. Mean number of injections was 3. After a bulking injection, 25 autologous fascia pubovaginal slings, 13 midurethral slings, and 5 biological pubovaginal slings were placed. Concomitant pelvic surgery was performed in 37.2%. Postoperatively, mean PPD decreased from 5.3 to 0.65, with a 60.5% subjective cure rate (no pads or leakage under any circumstances). No association was seen between number or type of injection, or type of sling with regards to patient outcomes. Results were significantly related to concomitant surgery (P = .007). SUI recurred in 8 patients (18.6%), which was not statistically associated with other parameters. Complications included urinary retention (8 patients) de novo urgency (1 patient), UTI (4 patients), abdominal wound infection (3 patients), and cystotomy (1 patient). CONCLUSIONS Prior treatment with bulking agents does not appear to negatively affect outcomes for future antiincontinence surgery in our patient population.

Comparative Revision Rates of Inflatable Penile Prostheses Using Woven Dacron® Fabric Cylinders

PURPOSE American Medical Systems (AMS) CX and LGX penile prostheses use woven Dacron® fabric to produce girth, and length and girth expansion, respectively. Cylinder expansion, while desirable, can result in wear of the material which, over time, may lead to device failure. Therefore, we compared girth and length expanding vs girth expanding cylinder survival rates. In addition, we determined the impact of parylene coating on penile prosthesis revision performed for mechanical reasons. MATERIALS AND METHODS All patient information forms from AMS 700™ CX and LGX/Ultrex penile prosthesis implantation performed in the United States from January 1997 through August 2008 were retrospectively analyzed (55,013). Device failure was defined as time to first revision. Survival rates of the 2 groups were analyzed and compared, and survival curves were generated. RESULTS AMS 700 Ultrex/LGX parylene and CX parylene devices demonstrated equivalent estimated survival rates (88.7% vs 89.5%, respectively, log rank p=0.6811). The parylene coated CX and Ultrex/LGX devices outperformed the nonparylene coated devices on survival analysis. CONCLUSIONS This analysis demonstrated no significant difference in 7-year survival between current generation girth expanding (700 CX) and length and girth expanding (700 LGX/Ultrex) prostheses. This analysis also demonstrated that the parylene coating of the cylinder wall contact surfaces significantly reduced the revision rate of the 700 CX and 700 LGX/Ultrex inflatable penile prostheses.

Autologous Pubovaginal Sling for the Treatment of Concomitant Female Urethral Diverticula and Stress Urinary Incontinence

OBJECTIVE To describe our experience with concomitant repair of urethral diverticula and stress urinary incontinence (SUI) with autologous pubovaginal sling (PVS). METHODS A retrospective chart review between January 2006 and 2013 identified 38 women undergoing concomitant diverticulectomy and rectus sheath PVS. Patient demographics, presenting symptoms, prior urethral surgery, concomitant procedures, postoperative outcomes, and complications were evaluated. RESULTS The mean duration of symptoms was 56.7 months. Eleven patients presented with recurrent diverticula and 5 patients had prior SUI surgery (3 midurethral slings, 1 PVS, and 1 bulking agent). One patient had a prior urethrolysis. All other slings were cut or excised at the time of surgery. All women had demonstrable SUI on cough stress test or urodynamics. The mean follow-up was 12.7 months. All postoperative voiding cystourethrograms were negative for contrast extravasation. One patient required prolonged (>4 weeks) suprapubic tube drainage for urinary retention. Four others required an additional 1 week of suprapubic tube drainage. Eighteen patients (47%) reported mixed urinary symptoms. Of these, 9 had complete resolution, whereas 9 experienced significant improvement. Overall, 97.3% reported resolution of their dysuria, dyspareunia, and pain symptoms and 90% reported complete resolution of their SUI symptoms. There were 2 urethral diverticula recurrences and 2 SUI recurrences. Perioperative complications, including hemorrhage, sling erosion, or urethrovaginal fistulas, were not observed. CONCLUSION Concomitant PVS placement is a safe and effective treatment option for SUI in patients undergoing urethral diverticulectomy. The risks and benefits should be weighed and management individualized.

Rates and Risk Factors for Future Stress Urinary Incontinence Surgery After Pelvic Organ Prolapse Repair in a Large Population Based Cohort in California

OBJECTIVES To determine the rate and risk factors for future stress urinary incontinence (SUI) surgery in a large population-based cohort of previously continent women following pelvic organ prolapse (POP) repair without concomitant SUI treatment. METHODS Data from the Office of Statewide Health Planning and Development were used to identify all women who underwent anterior, apical, or combined anteroapical POP repair without concomitant SUI procedures in the state of California between 2005 and 2011 with at least 1-year follow-up. Patient and surgical characteristics were explored for associations with subsequent SUI procedures. RESULTS Of 41,689 women undergoing anterior or apical POP surgery, 1,504 (3.6%) underwent subsequent SUI surgery with a mean follow-up time of 4.1 years. Age (odds ratio [OR] 1.01), obesity (OR 1.98), use of mesh at the time of POP repair (OR 2.04), diabetes mellitus (OR 1.19), white race, and combined anteroapical repair (OR 1.30) were associated with increased odds of future SUI surgery. CONCLUSION The rate of subsequent surgery for de novo SUI following POP repair on a population level is low. Patient and surgical characteristics may alter a womans individual risk and should be considered in surgical planning.

MP79-18 TRENDS IN THE MANAGEMENT OF OVERACTIVE BLADDER IN THE UNITED STATES FROM 2003-2015

A rise in Mirabegron use in 2012 coincides with a decline in anticholinergic use for management of OAB, suggesting that providers are increasingly utilizing Mirabegron. Chemodenervation increased over time since 2010 while PTNS and SNS use remained low. Further research is needed to determine whether newer oral therapies are more efficacious or whether third line therapies are not being fully utilized. Raveen Syan MD, Chiyuan A. Zhang, MS, Kai Dallas MD, Ekene Enemchukwu MD, MPH Stanford University, School of Medicine, Department of Urology

Tibial Nerve and Sacral Neuromodulation in the Elderly Patient

Purpose of ReviewThis article aims to review sacral and tibial neuromodulation outcomes in elderly patients. Safety and efficacy of these two neuromodulatory treatments for both urinary and fecal indications are addressed.Recent FindingsRecent data assessing sacral neuromodulation (SNM) for refractory overactive bladder and urge urinary incontinence (UUI) demonstrates that older patients have similar outcomes and complication rates when compared to the general population. For both urinary and fecal indications, SNM has been shown to significantly increase quality of life in older patients. Age has additionally not been a factor affecting tibial nerve stimulation outcomes.SummaryLimited data specifically addresses use of tibial and sacral neuromodulation in elderly patients. Available studies suggest that both treatment options are safe and effective in the older population for urinary and fecal indications, although further study is necessary.

Racial and Socioeconomic Disparities in Short-term Urethral Sling Surgical Outcomes

OBJECTIVE To evaluate the association of racial and socioeconomic factors with the risk of adverse events in the first 30 days following urethral sling placement. METHODS We accessed nonpublic data from the Office of Statewide Health Planning and Development in California from 2005 to 2011. All female patients who underwent an ambulatory urethral sling procedure in the entire state of California over the study period were identified (Current Procedural Terminology 57288). Our main outcome was any unplanned hospital visits within 30 days of the patients surgery in the form of an inpatient admission, revision surgery, or emergency department visit. RESULTS A total of 28,635 women who underwent outpatient urethral sling placement were identified. Within 30 days, 1628 women (5.7%) had at least 1 unplanned hospital visit. In the adjusted multivariate model, black race and Medicaid insurance status were both independently associated with increased odds of having an unplanned hospital visit (odds ratio 1.80, P < .01 and odds ratio 1.53, P < .01, respectively). This significance persisted even when controlling for patient comorbidities, demographics, and facility characteristics. CONCLUSION We found that, similar to what has been reported in other fields, disparities in outcomes exist between socioeconomic and racial groups in the field of urogynecology.

Abdominal Imaging Following Urinary Reconstruction: Recommendations and Pitfalls

Radiologic imaging after urinary diversion is an essential part of the postoperative surveillance. Both early and late complications can be subtle. The primary goals are to evaluate for any upper tract abnormalities, tumor recurrence, or surgical complications. It is imperative that the urologist be aware of the radiologic evaluation of the most common urinary diversions, expected anatomic changes, and the various complications that may manifest following diversion.

1181 TREATMENT OF RECURRENT STRESS URINARY INCONTINENCE AFTER MID URETHRAL SYNTHETIC SLING WITH A PUBOVAGINAL SLING, A SINGLE INSTITUTION EXPERIENCE

• IRB approval was obtained prior to the study. • Retrospective review of 114 patients who underwent a pubovaginal sling from 2006 through 2010. • Procedure performed: • two incisions, harvest of rectus fascia (8cm x 2cm), retropubic vaginal dissection-inclusive of dissection of endopelvic fascia • Patients were evaluated for demographics, past medical history, subjective outcomes, and complications. 11 (50%) reported no urinary urgency while 9 (41%) reported continued or worsening symptoms of urgency.