Jennifer Rothschild

Obesity and Female Stress Urinary Incontinence

The purpose of this article was to review the epidemiology, pathophysiology, and treatment options for stress urinary incontinence in the obese female patient and draw conclusions regarding the optimal treatment of this condition in this unique patient population. Obesity results in increased intra-abdominal pressure and this leads to weakening of the pelvic floor innervation and musculature. Weight loss through lifestyle modification and bariatric surgery improves stress urinary incontinence. Success of stress urinary incontinence surgery in obese women is similar to nonobese patients. Obese women should not be excluded from potentially curative surgery based on their body mass index (BMI) alone.

Difference between Urethral Circumference and Artificial Urinary Sphincter Cuff Size, and its Effect on Postoperative Incontinence

PURPOSE We assessed whether a difference between intraoperative urethral circumference and artificial urinary sphincter cuff size affects postoperative outcomes. MATERIALS AND METHODS We evaluated the medical records of 87 males who underwent implantation of an artificial urinary sphincter between January 2006 and May 2010. A validated questionnaire was completed by 59 patients for long-term followup. The difference between urethral circumference and artificial urinary sphincter cuff size was calculated. Incontinence was recorded as daily pad use. The primary outcome variable was the postoperative decrease in incontinence. Multivariable linear regression was used to model the effect on postoperative incontinence of the difference between urethral circumference and cuff size. RESULTS Mean long-term followup was 4.2 years. Median preoperative incontinence was 8 pads per day and median abdominal leak point pressure was 50 cm H2O. Median urethral circumference was 38 mm and the median difference between urethral circumference and artificial urinary sphincter cuff size was 2.5 mm. Median postoperative incontinence was 1 pad per day. A 1 mm increase in the difference between urethral circumference and cuff size resulted in a 1.6% increase in incontinence by 4.5 months postoperatively (95% CI -3.1-6.2, p = 0.487). Paradoxically, each 1 mm increase improved postoperative continence at long-term followup by 29% (95% CI -15-56, p = 0.162). CONCLUSIONS At 4.5-month followup there was no statistical difference in pad use or patient satisfaction when the difference between urethral circumference and artificial urinary sphincter cuff size was less than 4 mm vs 4 mm or greater. However, at long-term followup the 4 mm or greater group reported statistically significantly better continence and satisfaction than the less than 4 mm group. This study does not support efforts to improve continence by minimizing cuff size but rather suggests that modestly up-sizing the cuff may produce improved long-term outcomes.

Renal Collision Tumor in Association with Xanthogranulomatous Pyelonephritis

Collision tumor is a rare condition in which two neoplasms (usually benign and malignant), both growing in the same general area, collide with each other and become intermingled. We present histopathology and imaging correlation of xanthogranulomatous pyelonephritis coexistent with squamous cell carcinoma and osteogenic sarcoma of the kidney.

Ureteritis cystica: a radiologic pathologic correlation.

Ureteritis cystica (UC) is a benign condition that commonly affects the ureter and can mimic other conditions such as transitional cell carcinoma, blood clots, air bubbles, radiolucent stones, fibroepithelial polyps, and sloughed renal papillae. Radiographically, UC is characterized by multiple small, round, lucent defects, which cause scalloping of the ureteral margins when seen in profile. The scalloping is produced by the projection of the submucosal cysts into the lumen and represents an important differential feature of this disease. We present a case of UC with a radiological pathological correlation.

Vascular complications and gene therapy.

For gene therapy, the last few years have been an exciting period. Encouraging results from several successful gene therapy trials were reported. Children born with a life-threatening immune system disorder, severe combined immune deficiency (SCID), were cured after receiving gene therapy for replacement of their defective adenosine deaminase (ADA) gene. Gene therapy successes related to vascular complications were also reported. The first human gene therapy trial for a blood-vessel disorder was performed successfully, in which copies of an angiogenic gene, the vascular endothelial growth factor (VEGF) gene, were directly delivered to the area surrounding the diseased artery of the leg of a patient with peripheral artery disease. Within a few days, this stimulated the growth of new blood vessels around the blockage in the ailing blood vessel and helped avoid amputation. In 1998, a patient with genetically small arteries became the first to receive VEGF gene therapy in the heart. Multiple copies of a plasmid with the VEGF gene were delivered into the damaged area of the heart, and a few days later angiogenesis ensued that helped bypass the blocked vessel, with markedly reduced chest pain in the patient. Gene therapy is becoming a reality and, more importantly, it appears to be safe and does not require supplementary immuno-suppressing drugs. Gene therapy seems to have begun delivering on its promises.

VesEcho Training System: Suprapubic Catheterization under Ultrasound Guidance

Introduction: Suprapubic catheterization is a fundamental skill for urology residents and trainees. Ultrasound guidance for this procedure is effective for minimizing complications and the British Association of Urological Surgeons guideline recommends use of ultrasound for suprapubic catheterization whenever possible. We developed a novel, cost‐effective and sonographically accurate training model for suprapubic catheterization and incorporated it into our resident training curriculum. Methods: The model consists of the 4 components of the bladder (water balloon), a pelvic bone replica and rectus fascia (nonrebreather masks), all housed within an ultrasound compatible gelatin mold. The model was tested during a resident training course to facilitate instruction of suprapubic catheterization. Surveys were administered before and after training to 13 participating urology residents, assessing the models anatomical and sonographic realism as well as the utility of the curriculum in their education. Results: The simulator model received a mean score of 4.2 out of 5 (SD 0.6, range 3 to 5) for anatomical realism and 4.4 out of 5 for sonographic realism (SD 0.5, range 4 to 5). The value of the simulator as a training tool was rated 4.7 and the overall value of the training course was rated 5 of 5. Regarding change in overall comfort with the procedure, mean total scores (out of 25) significantly increased for all residents after the training course (14.6 to 19.7, 5.1‐point increase, p <0.001). Conclusions: Our novel simulation model and didactic curriculum received positive evaluations from urology residents and increased their comfort with ultrasound guided suprapubic catheterization. It is a sustainable teaching tool and can easily be incorporated into any urology training curriculum.

Prevalence of Peyronie's Disease-Like Symptoms in Men Presenting With Dupuytren Contractures

Introduction Peyronies disease (PD) and Dupuytren contractures (DC) are often comorbid and are believed to have a similar underlying pathophysiologic mechanism. Aim To investigate the prevalence of PD-like symptoms (PDLS) in men with DC. Methods From October 2013 to December 2016, men who were seen and evaluated for DC were offered the opportunity to participate in an anonymous survey. The survey assessed several basic demographic and sexual health factors and included items from the International Index of Erectile Function and the Erection Hardness Scale. Men who reported PDLS were asked a series of questions derived from the Peyronies Disease Questionnaire and for their opinions on theoretical treatment modalities for sexual problems and penile deformity. Main Outcome Measure Prevalence of PDLS in men with DC. Results One hundred forty men with DC were invited to participate; 85 surveys were returned (response rate = 61%). Twenty-two respondents (26%, 95% confidence interval = 17–35) reported PDLS. Approximately one fourth of all respondents had an Erection Hardness Scale score lower than 3. The most common specific PDLS concerns were penile curvature (91%), length loss (55%), narrowing (36%), and hinging (32%). In men with PDLS, 73% felt at least a little bothered by the symptoms when attempting sexual activity and 40% reported having sex less frequently because of the symptoms. Just 27% of men with PDLS had ever used a treatment for a sexual concern. In terms of treatments for penile deformities, 64% of men with PDLS expressed an interest in treatment administered in the form of an in-office procedure; 41% were potentially amenable to a surgical procedure. Conclusion The prevalence of PDLS in men with DC is similar to the prevalence of DC in men diagnosed with PD. A substantial number of these men have distress and would consider standard-of-care treatments for PD. Shindel AW, Sweet G, Thieu W, et al. Prevalence of Peyronies Disease-Like Symptoms in Men Presenting With Dupuytren Contractures. Sex Med 2017;5:e135–e141.

Surgical trends in the correction of female stress urinary incontinence in academic centers within the United States.

There is a lack of data describing the current state of stress urinary incontinence (SUI) procedures in academic centers. Urologists, gynecologists, and urogynecologists perform these operations, but the relative volume each group accounts for is unknown. The purpose of this study was to evaluate the distribution of cases in academic centers between specialties and associated patient characteristics.

Complications and Long-Term Sequelae of Bladder Fistula Repair

Bladder fistulas involve an abnormal connection between bladder and either vagina or intestine. In this review chapter, we cover the etiology, clinical presentation, and various surgical approaches to repairing vesicovaginal and enterovesical fistulas. The long-term sequela after surgical repair includes recurrent incontinence, lower urinary tract symptoms, infection, and vaginal stenosis. Strategies to approach fistula repair to minimize these complications are emphasized.

Complementary Alternative Medicine and Therapies for Overactive Bladder Symptoms: Is There Evidence for Benefit?

Overactive bladder is a complex syndrome that can have a significant symptomatic burden on patients. There are currently treatment options available, although these options may have significant side effects that can further diminish patients’ quality of life. The need for effective therapies that have high patient acceptability and compliance has caused many patients to seek complementary alternative forms of treatment. Herbal medications, which are used worldwide, have been shown to positively impact quality of life and provide symptomatic improvement in patients suffering with overactive bladder. Acupuncture has also been demonstrated to provide short-term relief of overactive bladder symptoms, specifically on quality of life, urgency, and frequency. Homeopathic remedies, though not widely studied, have shown to be effective in the short term for treatment of symptoms related to overactive bladder. These options may be associated with fewer side effects than traditional anti-muscarinic medications and/or surgical interventions. Further research is required to assess the true efficacy of these alternative therapeutic options.