Karyn Eilber

Eficacia limitada del uso de agente inyectable permanente en el tratamiento de la incontinencia urinaria de esfuerzo tras prostatectomía radical

Resumen es: OBJETIVO: No existen datos suficientes en relacion a la eficacia del tratamiento de la incontinencia urinaria de esfuerzo (IUE) despues de prostatectomia...

Prevalence and correlates of urinary incontinence among older community-dwelling women.

Objectives As the aging population in the United States grows, the investigation of urinary incontinence (UI) issues becomes increasingly important, especially among women. Using data from the California Health Interview Survey (CHIS), we sought to determine the prevalence and correlates of UI among an ethnically diverse population of older community-dwelling women. Methods A total of 5374 female Californians aged 65 years or older participated in a population-based, cross-sectional random-digit-dialing telephone survey. The CHIS 2003 adult survey included 1 question for Californians aged 65 years or older about UI. Additional information collected via the self-reported survey included demographics (age, race/ethnicity, education, and household income), general health data (self-reported health status, height and weight, fall history, and special equipment needs), medical comorbidities, and health behaviors (tobacco use, physical activity, and hormone replacement therapy). Results The estimated statewide female prevalence rate for UI was 24.4%. Prevalence rates increased with age. Urinary incontinence was significantly associated with poorer overall health (adjusted odds ratio [OR], 3.43; P < 0.001), decreased mobility (OR, 1.81; P = 0.004), current use of hormone replacement therapy (OR, 1.72; P < 0.001), being overweight or obese (OR, 1.60; P < 0.001), a history of falls (OR, 1.53; P = 0.002), and a history of heart disease (OR, 1.38; P = 0.010). After adjusting for all health factors, UI was not found to have any significant association with the level of education, household poverty status, or smoking status. Conclusions Urinary incontinence prevalence among this diverse group of older community-dwelling Californian women parallels that of other population-based studies. The CHIS demonstrated that poor health, increased BMI, falls, and decreased mobility are strongly correlated with UI.

The Truth Behind Transvaginal Mesh Litigation: Devices, Timelines, and Provider Characteristics

Objectives Following Food and Drug Administration communications about the safety of transvaginal prolapse, more than 73,000 patients with complications from treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SUI) have filed product liability claims. This research analyzes the transvaginal mesh claims filed in the United States to identify key characteristics that may inform clinical decision-making. Methods We evaluated a 1% random sample from the Bloomberg Law Database: 2000 to 2014 and associated legal documents. Outcomes and measures used included annual rate of claim, mesh type, time interval between surgery and claim, defendants, and surgeon training. Results The search returned 76,865 results, and 2979 were excluded, leaving 73,915 claims. Of 739 claims (1%), 63.3% involved slings for SUI, 13.3% mesh for POP, and 165 (23.2%) involved both. The mesh named most often in claims was retropubic slings at 30.3% and transobturator slings at 27.1%. The number of cases filed increased significantly from 730 in 2011 to 11,798 in 2012, which then almost tripled in 2013 to 34,017. The interval from surgery to claim filing ranged from 4.8 to 5.3 years. Only 12% of implanting surgeons were or became board certified in Female Pelvic Medicine and Reconstructive Surgery. Only 4 cases named providers as codefendants. Conclusions Most legal claims involved slings for SUI and began after the 2011 Food and Drug Administration communication about mesh for POP. The rise in lawsuits does not reflect the acceptably low complication rates for slings for SUI reported in the literature.

Sacral Osteomyelitis After Robotic Sacrocolpopexy.

Background Robotic-assisted abdominal sacrocolpopexy (RASC) is an effective procedure for the surgical treatment of vaginal vault prolapse associated with a rare, but serious, risk of sacral osteomyelitis. Case We report a case of Bacteroides fragilis sacral osteomyelitis after RASC that presented only as back pain. Treatment included intravenous antibiotics and abdominal exploration with removal of sacral mesh. Conclusions Sacral osteomyelitis is a rare complication following RASC and may present only as back pain without constitutional symptoms. Intravenous antibiotics and surgical excision of sacral mesh are routinely performed, but preservation of vaginal mesh is a viable option. The clinician should have a high index of suspicion for osteomyelitis in any patient who presents with back pain after RASC, regardless of absence of other presenting symptoms.

The Role of the Surgeon on Outcomes of Vaginal Prolapse Surgery With Mesh.

Introduction Adverse outcomes after surgery for pelvic organ prolapse (POP) with mesh are often attributed to the mesh material with little attention paid to the influence of surgeon factors. We used a national data set to determine whether surgeon case volume and specialty influenced vaginal prolapse surgery outcomes with mesh. Materials and Methods Public Use File data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with a diagnosis of POP who underwent surgery with mesh between 2007 and 2008 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology, 4th Edition procedure codes. Outcomes were compared by surgeon case volume and specialty. Results From 2007 to 2008, 1657 surgeries for POP were performed with mesh. Low-, intermediate-, and high-volume surgeons performed 881 (53%), 408 (25%), and 368 (22%) of the cases with mesh, respectively. The cumulative reoperation rates for low-, intermediate-, and high-volume providers were 6%, 2%, and 3%, respectively. The difference in reoperation rates between low and intermediate and low- and high-volume surgeons was statistically significant (P = 0.007 and 0.003, respectively). There was no significant difference in reoperation rates between gynecologists and urologists when vaginal mesh was implanted for POP surgery. Conclusions Low-volume surgeons performed most of the vaginal prolapse repairs with mesh and had significantly higher reoperation rates. Surgeon experience must be a consideration when reporting mesh-related complications of POP surgery.

PD54-08 WHAT IS THE IDEAL ANTIBIOTIC PROPHYLAXIS FOR INTRAVESICAL BOTOX INJECTION? A COMPARISON OF TWO DIFFERENT REGIMENS

were assessed at 4,12 and 24 weeks after injection. Treatment consisted of 30 injections distribuited into the detrusor muscle, avoiding trigone. The primary outcome was change in clinical status, including urinary frequency, urgency and urinary urgency incontinence (UUI) episodes. Secondary outcomes were changes in maximum cystometric capacity (MCC), volume at first desire to void (FDV) and post-void residual (PVR). Quality of life (QoL) was assessed using a visual analogue scale (VAS,0-10) and a patient global impression of improvement (PGI-I).Urinary retention, urinary tract infection (UTI) and required clean intermitent catheterization (CIC) were adverse events. RESULTS: A total of 22 patients were randomized to either 300U (n1⁄411) or 500U (n1⁄411) groups. Baseline demographics characteristics were comparable for both groups. All 21 patients reported urgency, with 90% of UUI before treatment. At 12 w, an important reduction in daily UUI episodes was observed in two groups, with 90% of them being dry. Decrease in mean episodes of nocturia and urinary frequency, increase FDV and CCM and a mean reduction in total ICIQOAB were observed. At 24 w, episodes of UUI had returned in 50% (300U) and 0% (500U) (p1⁄40,013). Patients had an impression of significant improvement in 70% (300U) and 88,9% (500U) at 12w; and 50% (300U) and 100% (500U),at 24w. Score of VAS was manteined higher in 500U group. There was a significant increase in mean PVR after treatment (4w) in both groups. Our incidence of UTI was 36,7% (300U) and 34,6% (500U). One patient (500U) required CIC for 2 weeks. CONCLUSIONS: Data from this study suggest 500U improves symptoms and quality of life for longer time than 300U. However, results are not significantly differents to determine which dose is safer. As far we know this is the first study to compare two doses of AbobotulinumtoxinA for refractory idiophatic OAB.

PD17-08 IS VAGINAL MESH A STIMULUS OF AUTOIMMUNE DISEASE?

reviewed to identify patient demographics, perioperative characteristics, complications within 60 days, and short term surgical outcomes. Complications were graded using the Clavien system and those with a grade 1⁄4 3 were classified as major complications. RESULTS: Nineteen patients were identified. Median patient age was 56 years old (range 35-78). Median time from mesh placement to removal was 4.5 years (range 0-13 years). Indications include pelvic pain which was present in all patients in this series and mesh exposure in 8 patients (42%). Median operative time was 228 minutes (range 133362). Median estimated blood loss was 200ml (range 50-1000ml). Median length of stay was 5 days (range 2-9). The rate of minor and major complications within 60 days was 36.8% and 5.3% respectively. One patient had a delayed presentation of ureteral obstruction managed with ureterolysis. There were no cases of bladder or bowel injury. At a median follow up of 296 days no patients required secondary surgery for vault prolapse. CONCLUSIONS: Autologous rectus fascia SC at the time of complete removal of synthetic SC mesh can be accomplished safely with a low rate of major complications. These are short term findings and longer term follow up is needed to assess anatomic and functional outcomes.

PD02-10 TRANSVAGINAL MESH DOES NOT CAUSE CARCINOGENESIS

follow up of 17.9 months. 98 patients were evaluable post-operatively. 47/57 (82%) initially dry patients elected no concomitant MUS, and ultimately 5/47 (11%) of those chose a delayed sling at an average follow up time of 23.9 months. 10/57 (18%) preoperatively dry women elected to undergo a concomitant MUS at the time of RSC. Those undergoing delayed sling reported similar post-operative pad use, UDI-6, QoL, and IIQ-7 scores (Table 1) compared with those not undergoing a sling, suggesting that a delayed sling did not have a negative impact on QoL. Those choosing to undergo concomitant MUS reported more pads per day preoperatively (2.6 vs. 0.4) including pad use from urge incontinence. With regard to satisfaction the patients who were dry pre-operatively and chose no sling scored better (2.25 vs. 6.2, p<0.01) on the IIQ-7 compared with those choosing a concomitant sling. CONCLUSIONS: Patients undergoing RSC without concomitant MUS have similar de-novo SUI rates to those undergoing open colpopexy. There appears to be no advantage to concomitant MUS at the time of RSC for women exhibiting no preoperative SUI.

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

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.

PD50-12 HIGH CATASTROPHIZING IN PATIENTS WITH SELF-REPORTED PAINFUL MESH COMPLICATIONS HAVE POORER OUTCOMES

INTRODUCTION AND OBJECTIVES: Scarring secondary to mesh and prosthetic materials is a serious clinical problem within the GU tract. Fibrotic matrices contain fibronectin; and alpha-smooth muscle actin contributes contraction. Metalloproteinases (MMPs) such as MMP1 and -3 can modulate matrix protein accumulation through degradation. Results from our institution have shown that silica materials can directly induce scarring through the interaction with tissue fibroblasts in vitro. By extension, we hypothesized that other materials may induce fibrotic changes through cellular matrix gene expression. Objectives: 1) to establish a 3D model of human fibroblasts to study patterns of fibroblast response to materials and 2) measure gene expression in human fibroblasts exposed to prosthetic and mesh materials compared to a control. METHODS: Collagen gel was prepared by using 3 mg/ml in final concentration with 0.5% of polyvinyl alcohol (PVA). Mesh or catheter materials and human dermal fibroblasts (70,000 /ml) were added to a collagen gel and seeded in a 24-well plate (0.5 ml of gel in each well) to create a 3D environment for fibroblast response. After polymerization of collagen, another 250,000 cells in 0.5 ml medium were added on the top of gel. Cells were cultured at 37 0C, 5% CO2 for indicated time point. Images of cells were taken under reverse microscopy to determine the pattern of the scarring contraction. Gel cell matrix was harvested and digested with 1 mg/ml of collagenase for 15 minutes, pelleted by centrifugation and RNA was extracted. RT-PCR was performed for 32 cycles to analyze gene expression. RESULTS: After 5 days, fibroblast contractions were identified surrounding prosthetic materials but not within the control. There were increases in type 1 collagen, a-smooth muscle actin and fibronectin expression in fibroblasts exposed to prosthetic materials compared to fibroblasts grown in collagen gel alone. MMP-1 and MMP-3 were also detected. CONCLUSIONS: Fibroblasts exposed to mesh and catheter materials responded with an increase in fibronectin, alpha smooth muscle actin and type 1 collagen that is increased compared to controls. This may indicate why in vivo these materials induce fibrosis. Because fibronectin, type 1 collagen and alpha smooth muscle actin are main components of scarring and their gene expression is elevated, future directions include development of medical devices that could induce downregulation of these genes.