Joshua A. Cohn

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction.

ABSTRACT Introduction: Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures

Introduction and hypothesisUrethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement.MethodsThis was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n 13) or based on their last follow-up appointment.Results obtainedNineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n 1), incontinence (onabotulinum toxin injection n 1, rectus fascia autologous sling n 1), prolapse (colpopexy n 1), and pain (trigger-point injection n 1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better.ConclusionsThe management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

Urinary retention and catheter use among U.S. female Medicare beneficiaries: Prevalence and risk factors

To identify the prevalence of and risk factors for urinary retention and catheterization among female Medicare beneficiaries.

Cystectomy for Neurogenic Bladder

Patients with a myriad of neurologic conditions can develop urinary symptoms as a result of impaired bladder function. Conservative management options for neurogenic bladder (NGB) may include catheterization and medical therapy. However, refractory individuals may require more aggressive intervention such as onabotulinumtoxinA injections or bladder augmentation. As a last resort, urinary diversion may be indicated for end-stage lower urinary tract dysfunction secondary to NGB. Urinary diversion may be performed with or without cystectomy. However, leaving the defunctionalized bladder in situ may lead to pyocystis, secondary carcinoma, or pain. As a result, there has been an increasing trend to perform a concomitant cystectomy at the time of urinary diversion. While this eliminates the sequelae of the retained bladder, performing a cystectomy at the time of urinary diversion can also increase the morbidity of the procedure.

Evaluation and Management of Mid-Urethral Sling Complications

Currently, a mid-urethral sling is the standard of care for the treatment of female stress urinary incontinence. However, complications can occur that are unique to polypropylene mesh such as mesh exposure, perforation, or contracture. Other complications such as de novo urgency and/or urgency urinary incontinence (UUI), urinary tract infection, and/or urinary obstruction can also occur. The diagnosis of these complications requires a high index of suspicion, and treatment is critical as these complications can be quite morbid. As such, this review will discuss the most recent literature regarding the intraoperative and post-operative evaluation and management of mid-urethral sling complications.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

OBJECTIVE To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. MATERIALS AND METHODS We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. RESULTS We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. CONCLUSION Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

Health literacy, cognition, and urinary incontinence among geriatric inpatients discharged to skilled nursing facilities

To investigate the association between health literacy and cognition and nursing and patient‐reported incontinence in a geriatric inpatient population transitioning to skilled nursing facilities (SNF).

Postoperative Complications of Patients With Spina Bifida Undergoing Urologic Laparotomy: A Multi-institutional Analysis

OBJECTIVE To characterize perioperative morbidity and mortality in adult patients with spina bifida undergoing laparotomy. PATIENTS AND METHODS We retrospectively studied the postoperative complications of 59 operations of patients with spina bifida undergoing abdominal laparotomies for urologic indications at 3 institutions. We evaluated postoperative complications using the Clavien-Dindo classification scale. RESULTS The overall complication rate was 91.5%. The most common complications were ileus, pressure ulcers, urinary tract infection, and wound infection. Over 40% of the patients developed a class 3 or 4 complication requiring subsequent surgery or intensive care unit admission. The hospital readmission rate was 42% and was correlated with higher-grade complications. On multivariable analysis, only older age was significantly associated with grade of complication. CONCLUSION These data demonstrate that adult patients with spina bifida comprise a unique population that faces an extremely high surgical risk even in centers of excellence. As patients with spina bifida live longer lives, thanks to modern medicine, there is a timely opportunity for research on perioperative management in these patients to improve postsurgical outcomes.

Synthetic Midurethral Slings: Urinary Tract Sequelae

The midurethral sling (MUS) is considered by many to be the standard of care for the treatment of stress urinary incontinence (SUI). Complications from MUS surgery unique to the use of polypropylene mesh may occur including: chronic pelvic pain, dyspareunia, mesh exposure, mesh contracture, neuromuscular injury, and/or organ perforation. In addition, there can be significant urinary tract sequelae such as urinary tract injury, de novo urgency and/or urgency urinary incontinence (UUI), urinary obstruction, and/or urinary tract infection (UTI). Techniques for prevention, diagnosis, and treatment of such urinary tract complications are discussed herein.

Treatment of Pelvic Floor Disorders Following Neobladder

Radical cystectomy remains the gold standard treatment for organ-confined high-grade recurrent or muscle-invasive bladder cancer. Orthotopic neobladder urinary diversion following cystectomy represents an option for patients wishing for continent urinary diversion. Female patients who undergo radical cystectomy with orthotopic bladder substitution are at risk for developing both common and neobladder-specific disorders of the pelvic floor, including urinary incontinence, hypercontinence, vaginal prolapse, and neobladder-vaginal fistula. Each of these sequelae can have significant impact on the patient’s quality of life. Due to the increased frequency of orthotopic neobladder creation in women, subspecialty urologists are more likely to confront such pelvic floor disorders in bladder cancer survivors. This review presents the most current information on the treatment of pelvic floor disorders after orthotopic bladder substitution.