Elizabeth T. Brown

The Impact of Urethral Risk Factors on Transcorporeal Artificial Urinary Sphincter Erosion Rates and Device Survival

PURPOSE We report the impact of urethral risk factors on erosion rates and device survival outcomes after transcorporeal artificial urinary sphincter placement. MATERIALS AND METHODS We performed a retrospective analysis of all transcorporeal artificial urinary sphincters placed at a single institution between January 2000 and May 2014. We assessed patient demographic, comorbid diseases and surgical characteristics for risk factors considered poor for device survival. Risk factors were compared to postoperative complications requiring explantation, including cuff erosion, infection and device revision. RESULTS A total of 37 transcorporeal artificial urinary sphincters were placed in 35 men. Placement was performed as a primary procedure in 21 of 37 cases (56.8%) and as salvage in the remainder. In this transcorporeal population there were 7 explantations (18.9%) due to erosion in 4 cases, cuff downsizing in 2 and infection in 1. Median followup from implantation to last followup was 8.5 months (range 0.9 to 63). Median time from artificial urinary sphincter placement to explantation was 17.3 months (range 0.9 to 63) and time specifically to transcorporeal erosion was 7.4 months (range 0.9 to 26). On univariate analysis no parameters were associated with sphincter cuff erosion but a history of an inflatable penile prosthesis was associated with a higher device explantation rate (60% vs 12.5%, p=0.04). No associations were revealed on multivariate logistic analysis. All 4 cuff erosion cases demonstrated greater than 2 urethral risk factors, including prior radiation therapy in all. The probability of cuff erosion in patients with 2 or more urethral risk factors was 1.65 times the probability of erosion in those with 0 or 1 urethral risk factor (95% CI 1.3, 2.2). The proportion of patients free of erosion at 35 months was 100% in those with 0 or 1 urethral risk factor and 64% in those with 2 or more risk factors (log rank test p=0.00). Similarly the proportion of patients free of explantation at 35 months was 100% in those with 0 or 1 urethral risk factor and 52% in those with 2 or more (log rank test p=0.02). CONCLUSIONS Transcorporeal artificial urinary sphincter implantation is generally reserved for complex and high risk cases but favorable functional results were demonstrated. However, patients with multiple urethral risk factors face a higher risk of erosion and device loss.

Pelvic Organ Prolapse Surgery in Academic Female Pelvic Medicine and Reconstructive Surgery Urology Practice in the Setting of the Food and Drug Administration Public Health Notifications

OBJECTIVE To understand the effect of the Food and Drug Administration (FDA) public health notifications regarding transvaginal placement of surgical mesh for pelvic organ prolapsed (POP) on surgeon practice patterns in tertiary care academic medical centers. MATERIALS AND METHODS Surgical volume for procedures performed primarily by fellowship trained Female Pelvic Medicine and Reconstructive Surgery at a sampling of 8 academic institutions across the US were collected using current procedural technology codes for POP repair and revision surgeries from 2007 to 2013. SAS statistical software was used to analyze data for trends and to assess differences in number of procedures across years by performing Spearman correlation analysis and Pearsons chi-squared test. Significance of trend was defined as P <.05 for both analysis methods. RESULTS There has been a substantial reduction in transvaginal mesh-augmented repair of POP since the FDA warning statements of 2008 and 2011. Mesh revision surgery has increased over this same period. However, the total number of interventions for POP has remained stable over the study period. Abdominal sacrocolpopexy has increased as a whole but represents only a small percentage of total cases. CONCLUSION Surgical correction of POP comprises a large portion of Female Pelvic Medicine and Reconstructive Surgery practice that continues to evolve in the aftermath of the FDA public health notifications. The utilization of transvaginal placement of surgical mesh augmented POP repair has decreased among practicing urologists at a sampling of academic institutions across the United States. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study; however, such data may provide alternative insights into the reasons for the observed trends.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications.

To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States.

Phenotyping women with detrusor underactivity by presumed etiology: Is it plausible?

Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies.

The Impact of Pallidal and Subthalamic Deep Brain Stimulation on Urologic Function in Parkinson's Disease.

Deep Brain Stimulation (DBS) is an established adjunctive surgical intervention for treating Parkinsons disease (PD) motor symptoms. Both surgical targets, the globus pallidus interna (GPi) and subthalamic nucleus (STN), appear equally beneficial when treating motor symptoms but effects on nonmotor symptoms are not clear. Lower urinary tract symptoms (LUTS) are a common PD complaint. Given prior data in STN‐DBS, we aimed to further explore potential benefits in LUTS in both targets.

Perioperative complications of conduit urinary diversion with concomitant cystectomy for benign indications: A population‐based analysis

Beyond single‐institution case series, limited data are available to describe risks of performing a concurrent cystectomy at the time of urinary diversion for benign end‐stage lower urinary tract dysfunction. Using a population‐representative sample, this study aimed to analyze factors associated with perioperative complications in patients undergoing urinary diversion with or without cystectomy.

Temporal Trends in Conduit Urinary Diversion With Concomitant Cystectomy for Benign Indications: A Population-based Analysis

OBJECTIVE To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity for concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single-institution reports, limited data are available to describe how concurrent cystectomy is employed on a national level. MATERIALS AND METHODS A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Using multivariate logistic regression models, we identified hospital- and patient-level characteristics associated with concomitant cystectomy with urinary diversion. RESULTS There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (P < .001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs community hospitals), in older patients, in male patients, in the Medicare population (vs private insurance and Medicaid), and in those with certain diagnoses. CONCLUSION There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, although the indications driving this clinical decision appear inconsistent.

An update on the use of transdermal oxybutynin in the management of overactive bladder disorder

Antimuscarinic medications are used to treat nonneurogenic overactive bladder refractory to nonpharmacologic therapy. Side effects such as dry mouth, constipation, blurred vision, dizziness, and impaired cognition limit the tolerability of therapy and are largely responsible for high discontinuation rates. Oxybutynin is a potent muscarinic receptor antagonist whose primary metabolite after first-pass hepatic metabolism is considered largely responsible for its associated anticholinergic side effects. Transdermal administration of medications bypasses hepatic processing. Specifically with oxybutynin, whose low molecular weight permits transdermal administration, bioavailability of the parent drug with oral administration is less than 10%, whereas with transdermal delivery is a minimum of 80%. The result has been an improved side effect profile in multiple clinical trials with maintained efficacy relative to placebo; however, the drug may still be discontinued by patients due to anticholinergic side effects and application site reactions. Transdermal oxybutynin is available as a patch that is changed every 3–4 days, a gel available in individual sachets, or via a metered-dose pump that is applied daily. The transdermal patch was briefly available as an over-the-counter medication for adult women, although at this time all transdermal formulations are available by prescription only.

New evidence in the treatment of overactive bladder.

Purpose of review Overactive bladder (OAB) in women is highly prevalent. It can be very bothersome and affect quality of life. Treatment differs significantly depending on the clinical presentation, and includes behavioural modification, medicinal therapies and surgical procedures. New treatment options have become available in recent years, and can offer great benefit to patients with persistent, bothersome OAB. Recent findings First-line management for OAB consists of lifestyle and behavioural therapy, followed by antimuscarinic therapy or oral beta-3 agonists. Sacral neuromodulation, onabotulinumtoxinA and posterior tibial nerve stimulation are additional well tolerated and efficacious treatment options that should be considered in carefully selected, refractory OAB patients. These recent advances in OAB therapy are discussed in this review. Summary The treatment of OAB is often complex, and can require trials of multiple different treatment modalities. Although the treatment advances discussed in this review have augmented treatment of OAB, the condition continues to negatively impact quality of life for our ageing female population. Clinical trials and development of novel therapies continue to be paramount.

Underactive bladder in women: is there any evidence?

Purpose of review Underactive bladder (UAB) is a clinical symptom complex only recently gaining recognition as a clinical diagnosis. Lack of consensus agreement on a definition of UAB has limited its recognition and diagnosis in clinical practice. The purposes of this review are to: present existing definitions of UAB, review recent data regarding clinical and urodynamic diagnosis of the condition, and examine up-to-date hypotheses regarding its pathophysiology, with a focus on women. Recent findings The process to develop a consensus definition for UAB as a clinical symptom complex is ongoing. Symptoms associated with UAB, such as weak stream, straining to void, and history of urinary retention are well correlated to detrusor underactivity on urodynamics, which frequently develops in elderly women. In addition to aging, UAB may be the end stage of a variety of contributing pathologic conditions such as diabetes and ischemic disease. In some women, UAB may result from a progression from overactive bladder to UAB. Summary Existing evidence supports UAB in women as a symptom complex with a clinical and pathophysiologic profile distinguishable from other lower urinary tract-associated clinical conditions. Consensus definitions of clinical and urodynamic diagnostic parameters will be essential to more widespread recognition of UAB.