Judith A. Boura

Clinical outcomes of sacral neuromodulation in patients with neurologic conditions.

OBJECTIVEnTo examine the outcomes in patients with and without a comorbid neurologic diagnosis (ND) or neurogenic bladder dysfunction after axa0staged neuromodulation procedure for refractory bladder symptoms.nnnMATERIALS AND METHODSnPatients enrolled in our prospective neuromodulation database study were grouped according to the presence of a coexisting ND. The implantable pulse generator implant rates were evaluated. Those who had received an implantable pulse generator were further evaluated over time for complications, revisions, explantations, and reprogramming sessions collected from the medical records. The symptom changes from baseline over 2 years were measured using patient-completed voiding diaries, the Interstitial Cystitis Symptom-Problem Index, Overactive Bladder Questionnaire, the Medical Outcomes Study short form, 12-item health survey, version 2, physical and mental component subscales, and a scaled global response assessment. The data were examined using Pearsons chi-square test or Fishers exact test, Wilcoxon rank tests, and repeated measures analyses.nnnRESULTSnOf 340 patients, 63 of 71 (88.7%) with an ND and 241 of 269 (89.6%) without an ND had an implantable pulse generator implanted (Pxa0= .82). The NDs consisted of stroke (nxa0= 17), multiple sclerosis (nxa0= 13), Parkinsons disease (nxa0= 10), incomplete spinal cord injury (nxa0= 4), cerebral palsy (nxa0= 1), and others. The complications, revisions/explants, and reprogramming sessions were similar between the 2 groups. Statistically significant improvements were seen in both groups over time on the voiding diary variables (except for incontinence episodes and severity in the ND group), Interstitial Cystitis Symptom-Problem Index, and Overactive Bladder Questionnaire. The short form, 12-item, physical and mental component subscale scores only improved significantly in those without an ND. Most patients (>50%) in both groups reported moderate or marked improvement in overall bladder symptoms at each point using the global response assessments.nnnCONCLUSIONnPatients with neurogenic bladder dysfunction experience benefits after neuromodulation similar to the benefits experienced by those without coexisting neurologic conditions.

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.

Pain in interstitial cystitis/bladder pain syndrome: do characteristics differ in ulcerative and non-ulcerative subtypes?

Introduction and hypothesisKey differences between interstitial cystitis/bladder pain syndrome (IC/BPS) subtypes (with and without Hunner’s ulcer) have been noted. We hypothesized that pain characteristics in women grouped by IC/BPS subtype would differ.MethodsA survey was mailed to 749 women to assess IC/BPS pain and other characteristics. Cystoscopy/hydrodistention reports were reviewed for presence/absence of Hunner’s ulcer. The McGill Pain Questionnaire Short Form© (MPQ-SF), Brief Pain Inventory (BPI), and Interstitial Cystitis Symptom and Problem Indices (ICSI-PI) assessed symptoms. Data were analyzed with Pearson’s chi-square, Fisher’s exact, t tests, and Wilcoxon rank tests.ResultsOf the 214 women that returned a survey (36 ulcerative and 178 non-ulcerative IC/BPS), similar proportions in each group reported that certain foods, exercise, and/or stress triggered symptoms. Fewer ulcerative patients reported pain with vaginal penetration than non-ulcerative (5/33, 15.2xa0% vs 76/160, 47.5xa0%; pu2009=u20090.0006). On the BPI, the ulcerative and non-ulcerative groups reported similar numbers of painful areas (mean 4.1u2009±u20096.1 and 4.1u2009±u20093.8; pu2009=u20090.33), and lower abdominal/pelvic pain was reported most (13/35, 37xa0% vs 79/172, 46xa0%; pu2009=u20090.34) followed by lower back pain (12/35, 34xa0% vs 69/172, 40xa0%; pu2009=u20090.52). Even though ICSI-PI, MPQ-SF, and BPI scores/responses did not differ, on the MPQ-SF the three words most frequently used by ulcerative patients to describe their pain were sharp, stabbing, and hot burning, and in non-ulcerative were aching, cramping, and tender.ConclusionsThese measures did not reveal any significant differences in pain between subtypes. More research is needed in larger samples to determine whether differences exist.

Changes in Sexual Functioning in Women after Neuromodulation for Voiding Dysfunction

INTRODUCTIONnSacral neuromodulation is a well-established treatment for urinary and bowel disorders with potential use for other disorders such as sexual dysfunction.nnnAIMnTo evaluate changes in sexual functioning in women undergoing neuromodulation for voiding symptoms.nnnMETHODSnPatients enrolled in our prospective, observational neuromodulation database study were evaluated. Data were collected from medical records, and patient-completed Female Sexual Function Index (FSFI) and Interstitial Cystitis Symptom-Problem Indices (ICSI-PI) at baseline, 3, 6, and 12 months post-implant. Patients rated overall change in sexual functioning on scaled global response assessments (GRA) at 3, 6, and 12 months post-implant. We grouped women by baseline FSFI scores: less (score<26) and more sexually functional (score≥26). Data were analyzed with Pearsons Chi-square or Fishers Exact test and repeated measures.nnnMAIN OUTCOMES MEASURESnChanges in FSFI and ICSI-PI scores in women grouped by baseline FSFI score<26 and ≥26.nnnRESULTSnOf 167 women evaluated, FSFI scores improved overall from preimplant (mean 13.5±8.5) to 12 months (N=72; mean 15.9±8.9, P=0.004). At baseline and each follow-up point, ICSI-PI scores were similar between groups and improved through time. For patients in the FSFI<26 group there was improvement from baseline to 12-month scores (N=63; 11.9±6.9 to 14.8±8.7; P=0.0006). Improved FSFI domains included desire, orgasm, satisfaction, and pain. Furthermore, of the 74 subjects in this group not sexually active at baseline, 10 became sexually active during follow-up. In the FSFI≥26 group there was slight but statistically significant decline in mean scores between baseline and 12 months (N=9; 27.4±1.1 to 24.5±3.4; P=0.0302); however one had become sexually inactive. A significant decrease was seen in the satisfaction domain.nnnCONCLUSIONSnMany factors affect sexual functioning in women; however sexual function may improve along with urinary symptoms after neuromodulation.

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).

Perioperative experience of pelvic organ prolapse repair with the Prolift® and Elevate® vaginal mesh procedures

Introduction and hypothesisWe compared the operative and immediate postoperative experience of the trocar-based Prolift® and non-trocar-based Elevate® techniques used to repair vaginal prolapse.MethodsA retrospective review of Prolift and Elevate repairs was performed. Baseline characteristics and operative and postoperative variables evaluated included compartment(s) repaired, adjacent organ injury, operative time (OT), change in hemoglobin (ΔH), pain score, narcotic use, length of stay (LOS), and short-term complications. Categorical variables were assessed as counts and percent frequency. Data were compared using chi-squared analysis and paired t test.ResultsProlift (nu2009=u2009143) and Elevate (nu2009=u200977) patients were similar in age (pu2009=u20090.19). Concurrent hysterectomy was done in 22 (15.4xa0%) and 24 (31.2xa0%), respectively, and concurrent midurethral sling placed in 100 (70xa0%) and 50 (65xa0%), respectively. LOS (median, 25th,75th) after anterior/apical compartment repairs was shorter with Elevate, whether with (1.0; 1.0,1.5 vs. 2.0xa0days;1.0, 2.0; pu2009=u20090.003) or without (2.0; 1.0, 2.0 vs. 2.0xa0days; 2.0, 3.0; pu2009=u20090.024) hysterectomy, but no differences in OT, ΔH, pain score, or narcotic use occurred. Posterior compartment mean pain scores were lower with Prolift (3.6xa0±xa02.2 vs. 1.7xa0±xa01.5, pu2009=u20090.035), and three-compartment-repair pain scores were lower with Elevate (0.6xa0±xa01.3 vs 2.5xa0±xa01.9; pu2009=u20090.013). Three bladder injuries occurred with Prolift but none with Elevate.ConclusionsOperative and postoperative experiences were similar between groups; however, Elevate anterior/apical repairs had shorter LOS, which might reflect more aggressive discharge planning. There were no bowel or major vascular injuries, and the Prolift trocar bladder injuries did not alter the surgical procedure.

Secondary surgery after vaginal prolapse repair with mesh is more common for stress incontinence and voiding dysfunction than for mesh problems or prolapse recurrence.

ObjectivesTo explore the need for secondary surgical procedures after transvaginal prolapse repair with mesh.MethodsWomen that had prolapse repair (Prolift® or Elevate®) were reviewed for reoperation and clinical/demographic data such as prior prolapse repair, prolapse grade, operative details, length of stay (LOS) and time to reoperation. Pearson’s Chi-square, Fisher’s exact tests and Wilcoxon rank tests were used.Results77/335 women (23xa0%) had 100 additional procedures. Median (range) time to reoperation was 51 (5–1168)xa0days: four (1xa0%) had primary prolapse surgery at a different site, three (1xa0%) repeat prolapse repair from the same site, 23 (7xa0%) surgery for complications and 50 (15xa0%) had stress urinary incontinence (SUI)/sling-related procedures. When no reoperation versus reoperation groups were compared, mean LOS (1.8 vs. 2.0xa0days; pxa0=xa00.044) and follow-up (228 vs. 354xa0days; pxa0=xa00.002) were longer in the reoperations group; postoperative hemoglobin was lower (10.8 vs. 10.4; pxa0=xa00.031). Patients with a prolapse reoperation were 10xa0years younger (67 vs. 57xa0years; pxa0=xa00.027) than patients that either had a reoperation for other reasons or had no reoperations. Patients with concomitant sling and persistent SUI requiring repeat SUI surgery were older (mean 72 vs. 66xa0years; pxa0=xa00.038), had prior prolapse repair (53 vs. 27xa0%; pxa0=xa00.017) and had anterior compartment mesh (84 vs. 56xa0%; pxa0=xa00.037); median operative times (78 vs. 104xa0min; pxa0=xa00.008) and mean LOS were shorter (median 1.6 vs. 1.9xa0days; pxa0=xa00.045). For patients without concomitant sling, no demographic or perioperative differences were found between those that did (nxa0=xa010) and did not (nxa0=xa086) develop de novo SUI that required reoperation.ConclusionsMost reoperations were for sling management and SUI; few were for mesh complications or prolapse recurrence.

Cystectomy for Ulcerative Interstitial Cystitis: Sequelae and Patients' Perceptions of Improvement

OBJECTIVEnTo evaluate the outcomes after cystectomy for ulcerative interstitial cystitis (IC).nnnMETHODSnMedical records were reviewed for history, operative data, and postoperative events. A mailed survey assessed preoperative symptom severity/duration, providers seen, and symptom changes on 7-point scaled global response assessments. Descriptive statistics were performed.nnnRESULTSnOf 10 women (mean age 64 ± 12.5 years), 9 had cystectomy with ileal conduit and 1 had a neobladder. All had previous cautery of Hunners ulcer (median 3.0 cautery procedures). Maximum bladder capacity at first and last cautery was median 325 and 188 mL, respectively. Median operative time was 321 minutes, blood loss was 200 mL (range, 100-900), 4 of 10 were transfused, and length of stay was 8 days. During a mean follow-up of 3.9 years, 6 patients required 1 or more reoperations, including hernia repair (2), urostomy revision (2), revision of ureteroileal anastomosis (1), small bowel resection (1), and neobladder cutaneous fistula repair (1). Survey respondents (nxa0= 9) reported having seen (mean) 5.4 ± 3.8 providers before cystectomy. Median duration of symptoms was 5 years, and day and nighttime urinary frequencies were 30 and 15 times, respectively. Postoperatively, IC pain had resolved in all patients except for one. On the global response assessments, patients had moderate/marked improvement in overall symptoms (8 of 8), pain (9 of 9), sexual function (4 of 6), and quality of life (8 of 9), 7 of 9 were very satisfied with the treatment, and 8 of 9 would make the same decision again.nnnCONCLUSIONnDespite subsequent reoperations, symptom improvements lead to high levels of satisfaction with cystectomy for IC.

An outbreak of Pseudomonas aeruginosa respiratory tract infections associated with intrinsically contaminated ultrasound transmission gel.

We describe an outbreak of Pseudomonas aeruginosa respiratory tract infections related to intrinsically contaminated ultrasound gel used for intraoperative transesophageal echocardiograms in cardiovascular surgery patients. This investigation led to a product safety alert by the Food and Drug Administration and the development of guidelines for appropriate use of ultrasound gel.

Early onset versus late onset peripherally inserted central venous catheter infections: an analysis of risk factors and microbiology.

The risks and microbiology for peripherally inserted central catheters (PICCs) are less well described than those for traditional central catheters, particularly as they pertain to duration of catheterization. We compared patients with early- and late-onset PICC bloodstream infections at our institution and found significant differences in microbiologic etiologies.