Howard B. Goldman

Urodynamic studies in adults: AUA/SUFU guideline

PURPOSE The authors of this guideline reviewed the literature regarding use of urodynamic testing in common lower urinary tract symptoms. The findings are intended to assist clinicians in the appropriate selection of urodynamic tests, following an evaluation and symptom characterization. MATERIALS AND METHODS A systematic review of the literature using the MEDLINE® and EMBASE databases (searched from 1/1/90 to 3/10/11) was conducted to identify peer-reviewed publications relevant to using urodynamic tests for diagnosis, determining prognosis, guiding clinical management decisions and improving patient outcomes in patients with various urologic conditions. The review yielded an evidence base of 393 studies after application of inclusion/exclusion criteria. These publications were used to create the evidence basis for characterizing the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinion. RESULTS The evidence-based guideline statements are provided for diagnosis and overall management of common LUTS conditions. CONCLUSIONS The Panel recognizes that each patient presenting with LUTS is unique. This Guideline is intended to serve as a tool facilitating the most effective utilization of urodynamic testing as part of a comprehensive evaluation of patients presenting with LUTS.

Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Nephrectomy

Natural orifice translumenal endoscopic surgery (NOTES) within urology has largely been limited to experimental animal studies and diagnostic procedures in humans. Attempts to complete a pure NOTES transvaginal nephrectomy have thus far been unsuccessful. We report the first clinical experience with pure NOTES transvaginal nephrectomy. A 58-year-old woman presented with recurrent urinary tract infections and an atrophic right kidney. Transvaginal access was obtained through a 3-cm posterior colpotomy. The right kidney was mobilized, the renal hilum was divided, and the specimen was removed through the vaginal incision. Operative time was 420 min. Estimated blood loss was 50 ml. There were no perioperative complications.

Trospium chloride has no effect on memory testing and is assay undetectable in the central nervous system of older patients with overactive bladder

Background:  Muscarinic receptors in the brain play an important role in cognitive function, especially memory, and there is growing awareness that specific antimuscarinic drugs for overactive bladder (OAB) may have adverse central nervous system (CNS) effects. Selection of an antimuscarinic OAB drug with reduced potential for CNS effects could be especially beneficial in the elderly people, in whom even the modest cognitive impairment may negatively affect independence.

The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction.

PURPOSE Urethral obstruction following surgical correction of stress urinary incontinence is not uncommon and urethrolysis is typically used to relieve symptoms. Whether one should resuspend the bladder neck concurrent with urethrolysis is controversial. We evaluate the efficacy of urethrolysis without re-suspension for the treatment of iatrogenic urethral obstruction. MATERIALS AND METHODS From April 1994 to January 1998, 31 women 29 to 78 years old (mean age 60) underwent transvaginal urethrolysis without concomitant re-suspension. The incident procedure was transvaginal urethropexy in 15 patients (48%), retropubic urethropexy in 5 (16%) and pubovaginal sling in 11 (36%). The most common presenting complaints were urinary retention, feeling of incomplete emptying or straining to void in 22 patients (71%) and irritative voiding symptoms in 17 (55%). Mean time from index procedure to urethrolysis was 14 months (range 2 to 36) and mean followup was 7 (range 1 to 27). RESULTS After urethrolysis 26 of 31 patients (84%) voided well or had significant improvement in symptoms. Of the 26 improved patients 6 had stress incontinence. Of these 6 patients 4 responded to periurethral collagen injection and are now dry. When individual variables were analyzed, none was found to be predictive of a successful outcome. CONCLUSIONS Transvaginal urethrolysis without concomitant re-suspension is an effective treatment for iatrogenic urethral obstruction. While 19% of patients may have recurrent incontinence, the majority can be treated with outpatient collagen injections. Overall 77% of patients voided well without incontinence, 7% voided well but with some incontinence and 16% remained obstructed after urethrolysis.

Time to rethink: an evidence-based response from pelvic surgeons to the FDA Safety Communication: "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse"

In July of 2011 the U.S. Food and Drug Administration (FDA) released a safety communication entitled “UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse.” The stated purpose of this communication is to inform health care providers and patients that serious complications with placement of this mesh are not rare and that it is not clear that these repairs are more effective than nonmesh repair. The comments regarding efficacy are based on a systematic review of the scientific literature from 1996–2011 conducted by the FDA. Our review of the literature during this time yields some different conclusions regarding the safety and efficacy of mesh use in prolapse repair. It may be useful to consider this information prior to making recommendations regarding mesh use in prolapse surgery according to the recent UPDATE.

Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits

OBJECTIVE The purpose of this study was to determine the complications, treatments, and outcomes in patients choosing to undergo removal of mesh previously placed with a mesh procedural kit. STUDY DESIGN This was a retrospective review of all patients who underwent surgical removal of transvaginal mesh for mesh-related complications during a 3-year period at Cleveland Clinic. At last follow-up, patients reported degree of pain, level of improvement, sexual activity, and continued symptoms. RESULTS Nineteen patients underwent removal of mesh during the study period. Indications for removal included chronic pain (6/19), dyspareunia (6/19), recurrent pelvic organ prolapse (8/19), mesh erosion (12/19), and vesicovaginal fistula (3/19), with most patients (16/19) citing more than 1 reason. There were few complications related to the mesh removal. Most patients reported significant relief of symptoms. CONCLUSION Mesh removal can be technically difficult but appears to be safe with few complications and high relief of symptoms, although some symptoms can persist.

Management of iatrogenic foreign bodies of the bladder and urethra following pelvic floor surgery

Literature regarding the management of iatrogenic foreign body in the bladder and urethra following female pelvic reconstructive surgery, especially mesh erosion, are sparse. We present our recent experience with the removal of iatrogenic foreign bodies from the bladder and urethra and propose a treatment algorithm.

Urethral Diverticula in 90 Female Patients: A Study With Emphasis on Neoplastic Alterations

PURPOSE Urethral diverticula are uncommon and occur predominantly in women. We examined a large series of female urethral diverticula to determine associated neoplastic alterations and subsequent clinical outcomes. MATERIALS AND METHODS All pathological evaluations of female urethral diverticulectomies performed at our institution between 1981 and 2007 were retrospectively reviewed and the clinicopathological features were correlated. RESULTS During this period 90 women underwent urethral diverticulectomy at our institution. Patient age was 24 to 78 years (mean 45). The most common clinical finding was urinary incontinence (29 of 78 women or 37%). Diverticular size was 0.3 to 5.0 cm (mean 1.7). Neoplastic alterations identified in 5 patients (6%) were glandular in nature, including 1 clear cell and 4 invasive adenocarcinomas. Superficial changes associated with invasive carcinoma included villous adenoma in 1 case, intestinal metaplasia in 2 and high grade dysplasia in 3. An additional 3 patients had extensive intestinal metaplasia. Of the 90 patients the remaining 82 demonstrated benign findings, including nephrogenic adenoma in 10 (11%). All 5 patients with invasive carcinoma underwent anterior pelvic exenteration with urinary diversion. In 2 patients with invasive adenocarcinoma metastatic disease subsequently developed, of which they died. CONCLUSIONS Although most cases of surgically resected diverticula demonstrate benign features, approximately 10% show atypical glandular findings, including invasive adenocarcinoma. Due to the risk of malignancy in a subset of patients careful clinical examination and followup are warranted in all patients to exclude neoplastic disease.

International Continence Society Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure‐flow study

The working group initiated by the ICS Standardisation Steering Committee has updated the International Continence Society Standard “Good Urodynamic Practice” published in 2002.

The Effect of Urodynamic Testing on Clinical Diagnosis, Treatment Plan and Outcomes In Women Undergoing Stress Urinary Incontinence Surgery

PURPOSE We evaluated the influence of preoperative urodynamic studies on diagnoses, global treatment plans and outcomes in women treated with surgery for uncomplicated stress predominant urinary incontinence. MATERIALS AND METHODS We performed a secondary analysis from a multicenter, randomized trial of the value of preoperative urodynamic studies. Physicians provided diagnoses before and after urodynamic studies and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification and nonoperative therapy. Treatment plan changes and surgical outcomes between office evaluation and office evaluation plus urodynamic studies were compared by the McNemar test. RESULTS Of 315 subjects randomized to urodynamic studies after office evaluation 294 had evaluable data. Urodynamic studies changed the office evaluation diagnoses in 167 women (56.8%), decreasing the diagnoses of overactive bladder-wet (41.6% to 25.2%, p <0.001), overactive bladder-dry (31.4% to 20.8%, p = 0.002) and intrinsic sphincter deficiency (19.4% to 12.6%, p = 0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p <0.001). After urodynamic studies physicians canceled surgery in 4 of 294 women (1.4%), changed the incontinence procedure in 13 (4.4%) and planned to modify mid urethral sling tension (more or less obstructive) in 20 women (6.8%). Nonoperative treatment plans changed in 40 of 294 women (14%). Urodynamic study driven treatment plan changes were not associated with treatment success (OR 0.96, 95% CI 0.41, 2.25, p = 0.92) but they were associated with increased postoperative treatment for urge urinary incontinence (OR 3.23, 95% CI 1.46, 7.14, p = 0.004). CONCLUSIONS Urodynamic studies significantly changed clinical diagnoses but infrequently changed the global treatment plan or influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for postoperative urgency urinary incontinence.