Jason Gilleran

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience

To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS).

Neuromodulation for overactive bladder

Overactive bladder (OAB) affects millions of people worldwide yet first-line treatments are often poorly tolerated and compliance rates are low. Neuromodulation works via afferent nerve modulation and offers a minimally invasive and reversible alternative treatment option for patients with OAB who have failed first-line therapy. Neuromodulation has revolutionized the management of OAB and is now well established as a safe and effective treatment for those refractory to conservative treatments. Multiple neuroanatomical pathways have been described for sacral neuromodulation including the S3 nerve root, pudendal nerve and tibial nerve. The S3 nerve root is currently the main treatment target and has the most long-term data on safety and efficacy to support its use. However, studies on neuromodulation at the pudendal nerve or posterior tibial nerve have been positive and their role in treatment continues to evolve. Most urologists who are experienced in voiding dysfunction can become proficient in each technique. Patient selection, surgical techniques and postoperative management differ slightly between approaches and urologists should familiarize themselves with these differences. Treatment of OAB should progress from the least to most invasive modality, and neuromodulation provides an attractive option owing to its minimally invasive approach, tolerability, positive outcomes and reversibility.

Does patient age impact outcomes of neuromodulation

We evaluated whether patients stratified by age have the same level of risks/benefits after a staged neuromodulation procedure for refractory voiding symptoms.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM).

An evidence-based approach to the evaluation and management of stress incontinence in women

Purpose of review The aim of this article is to use evidence-based criteria to review recent publications on the evaluation and management of stress urinary incontinence in women. Recent findings Longitudinal studies suggest that a familial predisposition towards stress urinary incontinence may exist. There is mounting evidence that cesarean section may play a protective role against pelvic floor damage due to labor, but this continues to be investigated. Objective parameters in the evaluation of stress urinary incontinence, such as questionnaires, pad test, and urodynamic studies, continue to undergo refinements to become more clinically relevant outcome tools. Non-invasive and minimally-invasive therapies for stress urinary incontinence are expanding. The search continues for the optimal non-autologous material in the pubovaginal sling procedure. Despite concerns over the use of synthetic material and better defined early complications, midurethral slings continue to enjoy popularity with short-term and intermediate success. Summary Further research into the cause of stress urinary incontinence is necessary. There is still no unified protocol in the evaluation of the condition and its severity. Mid-urethral slings appear to be as efficacious as more established procedures (bladder neck suspensions, pubovaginal slings), but long-term results on safety and efficacy remain scarce.

The Impact of Baseline Functional Bladder Capacity on Short-term Neuromodulation Outcomes

OBJECTIVE To evaluate the impact of functional bladder capacity (FBC) on clinical outcomes after a staged neuromodulation procedure. MATERIALS AND METHODS Adults in our prospective neuromodulation database were evaluated. Data were collected from medical records, voiding diaries (FBC defined as average volume per void), Interstitial Cystitis Symptom Index-Problem Index, Overactive Bladder Questionnaire, and Global Response Assessment over 3 months. Descriptive statistics, Pearsons chi-square tests, Wilcoxon rank sum tests, logistic regression, repeated measures analyses, and Spearman correlation coefficients were performed. RESULTS Of the 216 patients (mean age 59 years; 84% female), most had urinary urgency and frequency with or without urge incontinence (71%), a sacral lead placement (82%), and implantable pulse generator (IPG) implantation (92%). Baseline FBC was similar between implanted and not implanted patients (P = .17); however implanted patients had a median 19 mL increase in FBC after lead placement compared to a 2.7 mL decrease in explanted patients (P = .0014). There was a strong association between percent change in FBC after lead placement and IPG implantation (P = .021; C-statistic 0.68), but baseline FBC (mL) was not associated. Baseline FBC (mL), or percent change in FBC after lead placement, was not related to symptom improvement. When grouped by baseline FBC < 150 mL and FBC  ≥ 150 mL, FBC only improved significantly in the <150 group but both demonstrated significant improvements in symptoms. CONCLUSION FBC improvements were associated with IPG implantation but not other symptom measures. Patients with low FBC (baseline FBC < 150) also achieved significant improvements in symptoms.

Posterior Colporrhaphy (With or Without Perineorrhaphy)

Evaluation and management of posterior prolapse can be challenging, as patients with rectocele can present with a variety of non-specific complaints, including vaginal bulge, bowel symptoms such as constipation or bloating, need to splint, perineal ballooning, or pelvic pressure. Unlike the anterior compartment, symptoms do not correlate with anatomy, and thus thorough history and physical exam are critical. Pre-operative radiographic evaluation has a limited role and typically does not change management.

Outcomes for Intermittent Neuromodulation as a Treatment for Overactive Bladder

Purpose of ReviewIn this review, we describe the history and basic science behind intermittent neuromodulation, specifically of the tibial nerve and its neuroanatomic suitability for this approach, as well as the logistics, efficacy, and advantages of peripheral tibial nerve stimulation (PTNS) in both idiopathic and neurogenic overactive bladder (OAB) populations. We also discuss the less commonly used sacral, pudendal, and genital nerves as a means of intermittent neuromodulation for the management of OAB.Recent FindingsIntermittent neuromodulation in the form of PTNS is approved as a third-line treatment of OAB, which affects upwards of 16% of the population of the USA.SummarySeveral studies and clinical trials have demonstrated the effectiveness of PTNS in treating OAB, with the benefit of decreased cost and invasiveness compared to chronic, implantable neurostimulators. This has been explored in various patient populations including patients with idiopathic and neurogenic detrusor overactivity.

Effect of Hormonal Changes on Voiding in the Elderly Woman

Hormonal loss after menopause result in changes that occur to the vaginal epithelium, which shares a common embryological origin with the lower urinary tract. These changes due to hypoestrogenism lead to symptoms of urinary frequency, urgency, incontinence, dysuria, and recurrent urinary tract infections. Replacement of estrogen can provide benefits to some of these conditions, but potential complications associated with the use of unopposed estrogen (including cardiovascular and oncogenic) have given clinicians pause for concern before administering it to patients without adequate counseling. This review article will examine the pathophysiology of the urogenital changes that occur after hormonal loss. We will discuss several well-designed trials that answer questions about the relationship between hormone replacement therapy and overactive bladder, stress incontinence, and recurrent urinary tract infections. In light of the controversy over estrogen therapy and patients’ warranted concerns about the risks, we will also discuss newer hormonal agents, their role in treating this condition, as well as how we counsel patients on a reasonable hormone replacement therapy (HRT) regimen.

Coexisting depressive symptoms do not limit the benefits of chronic neuromodulation: A study of over 200 patients

To examine the relationship between coexisting depressive symptoms and outcomes after staged neuromodulation procedures for refractory urological symptoms.