Eva Fong

REVIEW ARTICLE: Mid-urethral synthetic slings for female stress urinary incontinence

•  Mid‐urethral synthetic slings (MUSS) have grown in acceptance and popularity to gain a foremost position in stress urinary incontinence (SUI) surgery. •  There are numerous studies that provide a large amount of Level 1 and 2 evidence that support the concept of a sling placed at the level of the mid‐urethra. •  Long‐term follow‐up has been published for the original tension‐free vaginal tape (TVT) procedure with the most recent publication providing Level 2 evidence with mean follow‐up of 11.5 years of 69/91 (77%) of patients from the original series. There was objective cure was in 90% of women and 77% considered themselves subjectively cured, based on the Patient Global Impression of Improvement. •  Level 1 evidence with long‐term follow‐up has been provided comparing colposuspension to TVT at 2 and 5 years. At 5 years for the primary efficacy variable of a negative 1 h stress pad test, there was no difference in success (81% vs 90%). •  Two recent meta‐analyses provide Level 1 evidence comparing outcomes for retropubic vs transobturator MUSS. One included 18 studies, randomized and cohort: cohort studies had a 12.3% failure rate for transobturator and 13.7% failure for the retropubic approach, randomized studies showed 5.7% failure in the transobturator vs 7.8% in the retropubic group. The other meta‐analysis included 11 studies published 2008–2009, which found that the short‐term cure rate was borderline inferior for the transobturator tape group (odds ratio 0.62; 95% confidence interval 0.37–1.00), nearly reaching statistical significance (P= 0.05). •  This review details further comparator evidence and evidence for use in specific patient groups (elderly, obese, intrinsic sphincter deficiency, mixed UI).

Treatment of Post-Prostatectomy Incontinence With Male Slings in Patients With Impaired Detrusor Contractility on Urodynamics and/or Who Perform Valsalva Voiding

PURPOSE Male slings have emerged as a popular and efficacious treatment for men with post-prostatectomy stress urinary incontinence. Traditionally slings have been used with caution or avoided in men with impaired detrusor contractility or Valsalva voiding because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with post-prostatectomy urinary incontinence who have impaired contractility and/or void with abdominal straining for urodynamics can be safely treated with slings. MATERIALS AND METHODS A retrospective review of patients with post-prostatectomy urinary incontinence who underwent an initial sling procedure between January 2004 and January 2010 was conducted at a single institution. Preoperative urodynamic characteristics, and postoperative Patient Global Impression of Improvement, post-void residual and noninvasive uroflow data were examined. Patients were grouped by poor bladder contractility or Valsalva voiding status. Exclusion criteria were lack of preoperative urodynamics and/or postoperative post-void residual. A total of 92 patients were analyzed. The variables were compared using the Student t test and the chi-square test. RESULTS No statistically significant difference was shown in postoperative post-void residual (mean 4 months postoperatively) or urinary retention when comparing by bladder contractility or Valsalva voiding. In the subset of patients with available postoperative uroflow data, there were no differences in postoperative maximum flow rate or voided volume. CONCLUSIONS Men with post-prostatectomy urinary incontinence with urodynamic findings suggesting impaired contractility or Valsalva voiding can be safely treated with sling surgery if they have normal preoperative emptying.

Artificial Urinary Sphincter Revision: The Role of Ultrasound

OBJECTIVE To assess the accuracy of office-based ultrasound (US) to identify the fluid status of the AMS 800 artificial urinary sphincter (AUS) pressure-regulating balloon (PRB). METHODS Patients who underwent AUS revision surgery (removal/replacement) from January 4, 2007, to January 4, 2010, were identified. US were done preoperatively to assess the system fluid status. Intraoperative findings were recorded. Sensitivity and specificity were calculated comparing US results with intra-/postoperative findings. When the PRB was underfilled, the location of the device fluid leak was determined, and the device was removed/replaced. In cases of a full PRB, patients had a cuff downsizing or total removal/replacement. RESULTS A total of 27 patients were identified. Reasons for not obtaining US included: advanced device age (4), cuff erosion (2), volume determination by other modality (2), cuff site pain (1), isolated pump malfunctions (1), and other (3). Fourteen patients underwent an US before the removal/replacement. By US, PRB was full (21-23 mL) in 43% of the patients and empty/underfilled (0-6 mL) in 57%. US was 100% sensitive and specific determining fluid status. When PRB was full, management consisted of cuff downsizing (3), transcorporal cuff placement (1), and total removal/replacement (2). In all cases of device leak, an entire removal/replacement was performed. The cuff was identified as the site of leak in 50% of cases. CONCLUSION US is an effective and accurate way of determining the fluid status of the AMS 800 AUS. Given the accuracy of this modality, the system can be filled with saline solution without losing the ability to determine fluid status.

Comparison of urodynamic findings in women with anatomical versus functional bladder outlet obstruction.

Objectives To characterize the symptoms and urodynamic findings of anatomical bladder outlet obstruction (AO) and functional bladder outlet obstruction (FO) in women and to determine if future endeavors at defining bladder outlet obstruction in women can group these entities together. Methods Retrospective review of all videourodynamic studies was performed on women from March 2003 to July 2009. Women with diagnosis of obstruction were categorized based on the cause of obstruction into 2 groups: AO and FO. Demographic data, symptoms, and urodynamic findings were compared between the 2 groups. Results One hundred fifty-seven women were identified of which 86 (54.8%) were classified as having AO and 71 (45.2%) were classified as having FO. There were no differences in symptoms between the 2 groups. There was no difference (P=0.5789) in the mean detrusor pressure at maximum flow rate Qmax between AO (38.9 cm H20) and FO (41.0 cm H20). There was a difference in the Qmax between AO and FO (10.6 [0–41.7] and 7.4 [0–35.7] mL/s, respectively; P=0.0044), but there was considerable overlap between the values in these 2 groups. Conclusions Anatomical bladder outlet obstruction and FO have similar urodynamic voiding pressure findings, but Qmax was statistically significantly lower in AO. However, there is a large overlap in the Qmax values between the 2 groups. Therefore, future studies that attempt to characterize bladder outlet obstruction in women need not exclude either group.

Urodynamic findings in women with insensible incontinence

To define the urodynamic study findings among women with insensible urinary incontinence.

Radiation Exposure During Videourodynamics: Establishing Risk Factors

The use of fluoroscopy during urodynamics can be helpful in the evaluation of patients with lower urinary tract dysfunction. However, fluoroscopy introduces the potential hazards of ionizing radiation, including malignancy. In this study we analyzed the data for radiation exposure during videourodynamic study (VUDS) at our center; we have also tried to establish the factors associated with increased exposure to radiation during VUDS.

1865 URINARY SYMPTOMS IN YOUNG WOMEN: COMPARING ORAL CONTRACEPTIVE PILL(OCP) USERS AND NON-USERS

Improvement in Stamey score of 1 grade was achieved in 75.4% (107/142) at 1 year, in 75.6% (68/90) at 2 years, in 84.9% (62/73) at 3 years and in 92.9% (39/42) at 4 years. Dry rate (PPWT 2 gms) was 51%, 62% and 74%, and 77% and 50% improved rate was 80%, 86%, 83% and 89% at 1, 2, 3 and 4 years, respectively. IQoL increased from 36.8 (SD 23.1) at baseline compared to 70.0 (SD 25.5), 71.7, 74.1 and 80.6 at 1, 2, 3 and 4 years. Optimal continence was achieved with a mean of 3 adjustments. Mean balloon volumes were 3.9 ml (1.0–11.5 ml). Device or procedure related complications (bladder perforation, port or balloon erosion, balloon migration, port or balloon related discomfort, intermittent urinary retention) were reported in 25% (39/ 156) of subjects at the end of 12 months, 19% (22/116) through year 2, 11.1% (10/90) through year 3 and 13.2% (3/22) through year 4. Of these, the majority were considered to be mild in severity. At 4 years 29 patients had undergone permanent explants of both devices, 43 were lost to follow up and 6 had died of unrelated causes. CONCLUSIONS: Four year data suggest ACT is a simple, safe and minimally invasive effective treatment for recurrent female SUI.

1015 TREATMENT OF POST-PROSTATECTOMY INCONTINENCE WITH MALE SLINGS IN MEN WITH IMPAIRED DETRUSOR CONTRACTILITY AND/OR VALSALVA VOIDING ON URODYNAMICS

INTRODUCTION AND OBJECTIVES: The use of male slings has emerged as a popular and efficacious treatment modality for men with post-prostatectomy incontinence (PPI). Traditionally, slings have been avoided in patients with impaired detrusor contractility because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with PPI who have impaired contractility and/or void with abdominal straining for urodynamics (UDS) can be safely treated with male slings. METHODS: A retrospective review of 123 consecutive patients with PPI who underwent a sling procedure between 1/04 and 1/10 was conducted at a single institution. Preoperative (preop) age, bladder capacity, post void residual (PVR), involuntary detrusor contractions (IDC), maximum flow rate (Qmax), detrusor pressure (Pdet), abdominal pressure (Pabd) and postoperative (postop) Patient Global Impression of Improvement (PGI-I), PVR and noninvasive uroflow were examined. Poor bladder contractility was defined as having bladder contractility index (BCI) 100. Valsalva voiding was defined as a change in Pabd at Qmax from baseline ( Pabd) 20. Exclusion criteria were lack of preop UDS and/or postop PVR or PGI-I. A total of 63 patients were analyzed. The variables were compared using Student’s t-test and chi-square test. RESULTS: No statistically significant difference was shown in postop PVR (mean 4 mos. postop) or urinary retention when comparing by BCI. Comparing by Pabd, a smaller PVR was seen with abdominal voiders, albeit likely clinically insignificant. Table 1 illustrates the preand postop outcomes compared by both BCI and Pabd. 31 patients (BCI 100, n 17 vs BCI 100, n 14) had postop uroflow available and there was no difference in postop Qmax (10.2 vs 13.1, p 0.22) or flow pattern. No patients excluded for incomplete data were treated for obstructive voiding or poor emptying. CONCLUSIONS: The results of this study indicate that men that may not have been traditionally offered a sling based on preop UDS findings can be safely treated with perineal sling. This may be a reflection of how contractility is measured in this population. Prospective studies comparing outcomes of men with impaired contractility that undergo various treatments may also be helpful. TABLE 1: Preand Postoperative Urodynamics Characterics of Male Sling Patients