James M. Weinberger

Pad Count is a Poor Measure of the Severity of Urinary Incontinence

PURPOSE We analyzed the correlation between pad use, as determined by objective pad count, and the severity of urinary incontinence, as measured by pad weight. MATERIALS AND METHODS We performed a retrospective study of consecutive incontinent patients who wore pads on a daily basis and were instructed to complete a 24-hour pad test. They were told to use the usual pads, change them as usual and place each in a separate plastic bag the day before the scheduled appointment. All pads were weighed and total urine loss was calculated by subtracting dry pad weight from wet pad weight, assuming that a 1 gm weight increase was equivalent to 1 ml of urine loss. The number of pads was correlated to pad weight using the Spearman rank correlation coefficient due to the nonparametric nature of the data. RESULTS The 116 patients included 51 men 39 to 89 years old (mean age 66) and 65 women 27 to 95 years old (mean age 72). When comparing the number of pads used to the gm of urine lost, the Spearman ρ was 0.26 (p=0.005) in the total cohort, and 0.40 and 0.26 (each p<0.05) in males and females, respectively. CONCLUSIONS There was little correlation between the number of pads used and the severity of urinary incontinence (r=0.26). These data suggest that pad count should not be used as an objective measure of incontinence severity. Instead, pad weight on a 24-hour pad test should be used.

Salvage Surgery after Failed Treatment of Synthetic Mesh Sling Complications

PURPOSE We report our experience with the diagnosis and treatment of refractory synthetic sling complications in women. MATERIALS AND METHODS This is a retrospective study of consecutive women with failed treatments for mesh sling complications. Before and after surgery the patients completed validated questionnaires and voiding diaries, and underwent uroflow with post-void residuals, pad test, cystourethroscopy and videourodynamic studies. Treatment was individualized, and results were subdivided into the 2 groups of conditions and symptoms. Outcomes were assessed with the Patient Global Impression of Improvement with success classified as a score of 1, improvement as 2 to 3 and failure as 4 to 7. RESULTS A total of 47 women 35 to 83 years old (mean 60) had undergone at least 1 prior operation (range 1 to 4) to correct sling complications. Original sling composition was type 1 mesh in 36 patients and types 2 and 3 in 11. Surgical procedures included sling incision, sling excision, urethrolysis, urethral reconstruction, ureteroneocystotomy, cystectomy and urinary diversion, and enterocystoplasty. Median followup was 2 years (range 0.25 to 12, mean 3). Overall a successful outcome was achieved in 34 of 47 patients (72%) after the first salvage surgery. Reasons for failure were multiple for each patient. Of the 13 patients with treatment failure 9 subsequently underwent 14 operations. Success/improvement was achieved in 5 women (56%) after continent urinary diversion (1), continent urinary diversion and cystectomy (1), partial cystectomy and augmentation cystoplasty (1), biological sling and sinus tract excision (1), and vaginal mesh excision (1). CONCLUSIONS Success after the initial failure of mesh sling complications repair is possible but multiple surgeries may be required. Each symptom should be addressed separately.

Outcomes of reduction cystoplasty in men with impaired detrusor contractility.

OBJECTIVE To report surgical outcomes in patients with impaired detrusor contractility (IDC) treated with reduction cystoplasty (RC). METHODS This was a retrospective study of consecutive patients with IDC who underwent RC. IDC was defined as a bladder contractility index of <100 and/or a detrusor contraction of insufficient duration resulting in a postvoid residual volume (PVR) >600 mL. Bladder outlet obstruction was defined by a bladder outlet obstruction index (BOOI) >40. All patients had preoperative International Prostate Symptom Score, maximum uroflow (Qmax), PVR, bladder diary, videourodynamics, and cystoscopy. Patients with prostatic obstruction underwent synchronous open prostatectomy. Postoperative Qmax, PVR, need for clean intermittent catheterization (CIC), and Patient Global Impression of Improvement (PGII) score were obtained. Follow-up was at 3 months, 1 year, and yearly thereafter. RESULTS Eight men met inclusion criteria (mean age, 60; range, 43-75 years). Preoperatively, 3 of 8 patients (37.5%) had moderate-sized bladder diverticula, 4 of 8 (50%) had a bladder contractility index <100, and 6 of 8 (75%) had a BOOI <40. Two patients (25%) fulfilled criteria for bladder outlet obstruction (BOOI, 67 and 72). Three (37.5%) underwent synchronous bladder diverticulectomy, and 3 (37.5%) underwent suprapubic prostatectomy. All patients were available for follow-up at 1 year. Seven of 8 (88%) had a successful outcome (PGII ≤2). One patient was unchanged (PGII, 4) and still needed CIC. CONCLUSION All but 1 patient who met specific criteria for RC had excellent outcomes after surgery based on the PGII, PVR, Qmax, and need for CIC. RC is a viable option for properly selected patients with IDC.

A New Staging System for Anterior Urethral Strictures

Introduction: Currently there is no widely accepted staging system for anterior urethral strictures. We developed and evaluated the reliability of an easy to use classification system for anterior urethral strictures in men. Methods: We devised a staging system based on cystoscopic findings of no stricture (stage 0), wide caliber stricture (stage 1), stricture requires gentle dilation with a 16Fr flexible cystoscope (stage 2), stricture cannot be dilated (stage 3) and no visible lumen (stage 4). Content validity was established by a panel of 5 urologists. On 2 separate occasions 3 urologists independently viewed videos obtained during cystoscopy and staged the tightest visible stricture. If multiple strictures were present, the stricture with the smallest visible lumen was used for the purpose of this study. All men who had undergone cystoscopy at our institution between 2011 and 2012 were included in the study. Exclusion criteria were poor video quality and not visualizing the entire urethra during cystoscopy. Results: A total of 101 videos of consecutive cystoscopies were reviewed. Intra‐observer agreement was 76% to 94% (Cohen &kgr; 0.65–0.90) and interobserver agreement was 73% to 82% (Cohen &kgr; 0.51–1.00, 0.69 overall, p <0.001). The intra‐observer and interobserver agreement increased for each stage, with 3 and 4 almost unanimously identified by all 3 observers (Cohen &kgr; 0.93 and 1.00, p <0.001). Conclusions: This new staging system is simple and easy to use, and has excellent intra‐observer and good interobserver reliability. The staging system provides a simple lexicon for describing the appearance of anterior urethral strictures.

Mesh Infection of a Male Sling

A 52-year-old man presented with purulent drainage from the scrotum and medial superior left thigh approximately 5 months after a second surgical procedure to remove fragments of an AdVanceTM male sling from the left thigh. Medical history began 6 years earlier when he underwent robot-assisted laparoscopic prostatectomy for high grade prostate cancer. One year postoperatively he was treated with adjuvant intensity modulated radiation and hormonal therapy for biochemical recurrence. Two years later he underwent the first AdVance sling placement for sphincteric incontinence refractory to conservative measures, and the next year he underwent a second AdVance sling placement for recurrent incontinence. Shortly after the second AdVance sling placement, the patient reported perineal pain as well as purulent drainage from the left thigh. Excision of purulent peri-urethral segments of 2 AdVance male slings and part of the segment of the sling in the left thigh were excised. A second surgery was performed to remove a fragment of the sling in the left thigh because of recurrent drainage. Cystoscopy showed no erosion of the sling into the urinary tract. Magnetic resonance imaging (MRI), the best study to identify sinus tracts, fistulas and abscesses in the perineum or proximal thigh, revealed a 3 cm abscess in the gracilis muscle of the

MP32-17 THE IMPACT OF SOCIAL MEDIA PRESENCE ON ONLINE CONSUMER RATINGS AND SURGICAL VOLUME AMONG CALIFORNIA UROLOGISTS

were compared in terms of real in-hospital charges per surgical episode with a separate pre-ERAS cohort. Mean costs per patient were compared with Wilcoxon-rank sum test and t-test, with p-value < 0.05 considered statistically significant. RESULTS: A total of 257 consecutive patients were evaluated of which 112 were ERAS patients. The median age was 70 years with no difference between the groups (p 1⁄4 0.13). Median length of stay was 6 days (p 1⁄4 0.748). Table 1 lists itemized in-hospital charges. The mean total charges per patient were

PD44-12 FEMALE SEXUAL DYSFUNCTION TREATMENT: A META-ANALYSIS OF THE PLACEBO EFFECT ACROSS RANDOMIZED CONTROLLED TRIALS

63,364 vs. 65,151 in the ERAS vs. preERAS groups, respectively (p 1⁄4 0.412). The variances between the two groups were statistically significantly different (p < 0.001). ERAS patients incurred higher medication costs (

Transvaginal Urethrolysis for Urethral Obstruction

3,505 vs. 2,796, p 1⁄4 0.013). Pre-ERAS patients incurred higher supplies, treatment and miscellaneous charges (all, p < 0.05). Only 11 ERAS patients required intensive care vs. 31 pre-ERAS (p 1⁄4 0.017) with no difference in cost per patient (p1⁄4 0.101). CONCLUSIONS: Fewer patients in the ERAS group required intensive care. ERAS implementation did not increase overall health costs for cystectomy patients when compared to standard care. The ERAS group showed a decrease in cost variance likely due to standardization of care. ERAS elicited savings in supplies, treatment and miscellaneous costs.

1961 VALIDATION OF AN ELECTRONIC BLADDER DIARY APPLICATION

INTRODUCTION AND OBJECTIVES: Sexual dysfunction has a significant impact on quality of life. The use of pornography among females and its impact on sexual dysfunction is poorly described. As an exploratory outcome of a study primarily investigating the relationship between pornography and erectile dysfunction, we attempt to better define pornography use and any contribution to sexual dysfunction in women. METHODS: After IRB approval, all patients presenting to a urology clinic of ages 20-40 years between February and August, 2016 were offered an anonymous survey consisting of self-reported medical history and demographic questions, validated questionnaires and novel questions addressing sexual function, pornography use and addictive behavior. Accrual continues, and we report a planned interim analysis. Descriptive data was compiled, and strength of correlation between subdomains of female sexual function, obsessive or craving behaviors and pornography use were examined. All variables were analyzed with linear regression. RESULTS: Of the first 48 females who agreed to take the survey included in the analysis, the mean age was 28 years. The subjects reported minimal medical comorbidities or risk factors with the most common being depression (16%), PTSD (12%) and smoking (31%). The sample was primarily white (62%), married (60%), heterosexual (81%), and active duty military (58%). The majority of respondents denied pornography use (61%) and 25% used less than weekly. Of those that used pornography, 72% reported duration of 15 minutes or less. The primary access was internet (68%) and phone (55%). The mean Female Sexual Function Inventory total score was 64. There was no observed correlation between female sexual function and pornography use. CONCLUSIONS: Interim results better describe pornography use among females. In a sample of women ages 20-40, pornography use is not uncommon with the main access being through internet or phone. There does not appear to be any correlation between its use and sexual dysfunction as determined by self-reported questionnaire. Further study may better elucidate any relationship between pornography and female sexual dysfunction.

1954 NOCTURIA: WHY DO PEOPLE VOID AT NIGHT?

Bladder outlet obstruction (BOO) in women is rare with an incidence ranging from 2.7 % to 8.3 %. Presentation is variable but may include both storage and voiding symptoms. Consequently, diagnosis can be challenging and may require pressure-flow studies (PFS), video urodynamics, voiding nomograms, or a combination of these techniques. The etiology of female BOO can be anatomic or functional with iatrogenic obstruction following anti-incontinence surgery the most common cause. The two basic approaches used to correct urethral obstruction are sling incision/excision and urethrolysis (retropubic, transvaginal, or suprameatal). Success rates for formal urethrolysis range from 43 % to 94 % and 80 % to 100 % for sling incision. Complications following procedures to relieve obstruction include recurrent stress incontinence and overactive bladder symptoms. Given the complexity of these cases, patients should be closely monitored for symptom resolution.