Kathleen C. Kobashi

Urodynamic studies in adults: AUA/SUFU guideline

PURPOSE The authors of this guideline reviewed the literature regarding use of urodynamic testing in common lower urinary tract symptoms. The findings are intended to assist clinicians in the appropriate selection of urodynamic tests, following an evaluation and symptom characterization. MATERIALS AND METHODS A systematic review of the literature using the MEDLINE® and EMBASE databases (searched from 1/1/90 to 3/10/11) was conducted to identify peer-reviewed publications relevant to using urodynamic tests for diagnosis, determining prognosis, guiding clinical management decisions and improving patient outcomes in patients with various urologic conditions. The review yielded an evidence base of 393 studies after application of inclusion/exclusion criteria. These publications were used to create the evidence basis for characterizing the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinion. RESULTS The evidence-based guideline statements are provided for diagnosis and overall management of common LUTS conditions. CONCLUSIONS The Panel recognizes that each patient presenting with LUTS is unique. This Guideline is intended to serve as a tool facilitating the most effective utilization of urodynamic testing as part of a comprehensive evaluation of patients presenting with LUTS.

Continued Multicenter Followup of Cadaveric Prolapse Repair With Sling.

PURPOSE Since our initial description of the technique of combining a transvaginal sling with a cystocele repair using solvent dehydrated cadaveric fascia lata and bone anchors we have continued to follow our outcomes closely to determine long-term results. We present the updated, multicenter results of the cadaveric prolapse repair with sling. MATERIALS AND METHODS A total of 172 patients 35 to 90 years old (mean age 62.1) have undergone cadaveric prolapse repair with sling with a mean followup of 12.4 months (range 6 to 28). Of these patients 132 (76.7%) completed followup. Repair was performed for grade 2 cystoceles in 73 cases, grade 3 cystoceles in 43 and grade 4 cystoceles in 16. Followup included physical examination (degree of pelvic prolapse), SEAPI scores, complications, patient reported continence, perceived improvement and satisfaction. The latter 2 parameters were obtained using a validated questionnaire. RESULTS Of the 132 patients 15 (11.4%) had grade 1 and 2 (1.5%) had grade 2 cystocele recurrence, which required no further treatment, and 13 (9.8%) had recurrent or de novo apical vaginal prolapse. Preoperative and postoperative SEAPI scores were 5.58 and 0.9, respectively (p <0.001). A total of 90 patients (68.2%) do not use any pads for protection. Of the 132 patients 24 (18.2%) have stress incontinence of any degree, including 14 (10.6%) with pure stress urinary incontinence, 8 (6.0%) report de novo urge incontinence, 26 (19.7%) have persistent urge incontinence, 21 (15.9%) have any degree of urgency without urge incontinence, 28 (21.2%) report resolution of preoperative urgency or urge incontinence symptoms, 7 (5.3%) have mixed incontinence and 1 had prolonged urinary retention requiring urethrolysis. There has been 1 case of osteitis pubis and no osteomyelitis. Of the patients 94 (71.2%) reported greater than or equal to 70% subjective improvement overall, including 12 who were dry preoperatively, 99 (75.0%) were greater than or equal to 70% satisfied, 105 (79.9%) would repeat the surgery and 102 (77.4%) would recommend the surgery to a friend. With regard to continence 31 (23.8%) patients were less than or equal to 50% improved. A total of 108 (81.8%) patients have no stress urinary incontinence, and patient improvement, satisfaction and complication rates have been acceptable. We have been particularly impressed by the results of the cystocele repair. Surgeons must consider that patient perceived improvement and satisfaction level are essential components of the measure of success or failure of a given therapy. CONCLUSIONS With a maximum of 28 months of followup of the cadaveric prolapse repair with sling procedure, we continue to be satisfied with the success of the cystocele repair and the competitive stress urinary incontinence cure rate.

Darifenacin treatment for overactive bladder in patients who expressed dissatisfaction with prior extended-release antimuscarinic therapy

Introduction and objective:  Patient perception of overactive bladder (OAB) treatment outcomes can be a useful indicator of benefit and may help drive persistence on treatment, which is known to be poor in OAB. It remains unclear whether OAB patients dissatisfied with one antimuscarinic can achieve satisfaction with another and supporting data are limited. This study investigated patient‐reported outcomes and clinical parameters during darifenacin treatment in OAB patients who expressed dissatisfaction with prior extended‐release (ER) oxybutynin or tolterodine therapy (administered for ≥ 1 week within the past year).

Surgical Treatment of Female Stress Urinary Incontinence: AUA/SUFU Guideline

Purpose: Stress urinary incontinence is a common problem experienced by many women that can have a significant negative impact on the quality of life of those who suffer from the condition and potentially those friends and family members whose lives and activities may also be limited. Materials and Methods: A comprehensive search of the literature was performed by ECRI Institute. This search included articles published between January 2005 and December 2015 with an updated abstract search conducted through September 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. Results: The AUA (American Urological Association) and SUFU (Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction) have formulated an evidence‐based guideline focused on the surgical treatment of female stress urinary incontinence in both index and non‐index patients. Conclusions: The surgical options for the treatment of stress urinary incontinence continue to evolve; as such, this guideline and the associated algorithm aim to outline the currently available treatment techniques as well as the data associated with each treatment. Indeed, the Panel recognizes that this guideline will require continued literature review and updating as further knowledge regarding current and future options continues to grow.

Iatrogenic obstruction after sling surgery

Sling surgery has supplanted other anti-incontinence procedures as the treatment of choice for stress urinary incontinence. Iatrogenic obstruction after sling surgery is increasingly reported as the procedure becomes more and more popular. The rate of retention (defined as catheter-dependency for at least 28 days) has been estimated at 1–10%. Iatrogenic obstruction after sling surgery has a variable presentation and can include urinary urgency, urgency incontinence, hesitancy, straining to void, weak urinary stream, nocturia, incomplete emptying, frequency, dysuria or urinary tract infections. The evaluation and diagnosis rely upon a thorough patient history, physical examination, a urine flow test and postvoid residual volume. Cystoscopy and pressure-flow studies can also be considered. The single most important factor in the diagnosis of sling-related obstruction or voiding dysfunction is the temporal relationship between the sling procedure and onset of symptoms. Transient urinary retention can be managed with indwelling or intermittent catheter drainage. For those patients with moderate or symptomatic retention, surgical options for treatment include sling loosening, sling incision, sling excision, and urethrolysis.

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion

Introduction: Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials. Materials and Methods: We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented. Results: Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized. Conclusions: The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

The evolution of midurethral slings.

Use of urethral slings in the treatment of incontinence started in the early 20th century. An evolution in understanding the pathogenesis of urinary incontinence led to development of the midurethral sling, which was designed to replace the natural suburethral vectors of support, as described in the integral theory. Since the introduction of tension-free vaginal tape in 1995, multiple other commercially available types of midurethral sling have been introduced. In general, these sling types share the common characteristics of using a thin, type I synthetic mesh inserted at a midurethral level and applied without tension. The midurethral sling procedure has subsequently undergone multiple technical modifications, predominantly alterations to the technique and route used for sling insertion. Despite the variety in techniques, available evidence suggests that all sling types provide efficacious and durable outcomes. Several adverse effects have been reported that are specific to certain techniques, and include the risk of vascular, enteric or nerve injury, lower urinary tract injury, urinary retention or voiding dysfunction, and vaginal erosion. Nonetheless, the midurethral sling provides a safe surgical option overall, and represents a notable advance in the treatment of stress urinary incontinence.

Native tissue repairs in anterior vaginal prolapse surgery: examining definitions of surgical success in the mesh era.

Purpose of review Native tissue repair of the anterior vaginal wall was thought to have a poor success rate based on anatomic outcome. This high rate of anatomic failure was often quoted as the underlying reason for performing mesh-augmented prolapse repair. The purpose of this article is to review the outcomes of native tissue repair of anterior vaginal prolapse repair in the mesh era. Recent findings Success in pelvic organ prolapse surgery has been redefined. The contemporary definition of success includes the absence of symptoms associated with a vaginal bulge, which correlates best with a patients perception of success. When this concept is applied to 12 randomized controlled trials that compared native tissue anterior colporrhaphy and mesh repairs for anterior vaginal wall prolapse, it is apparent that although mesh repair had superior anatomic success (38–93 vs. 27–71%), both mesh and native tissue repair had excellent rates of symptomatic success (75–96 and 62–100%, respectively). Taken together, the overall reoperation rate for native tissue repair was 5.0% compared with 9.0% for mesh-augmented repair. Summary Although anatomic stage 0 results are not achieved in many cases, patients do experience symptomatic relief and improvement in their quality of life, only seeking retreatment in a small proportion of cases with anatomic recurrence. Thus, the definition of success must include subjective symptom-based outcome in addition to anatomic outcome. In addition, the degree of later complications, including additional surgeries, must also be taken into account when defining success based on patient satisfaction.

Estimating the prevalence and economic burden of overactive bladder among Medicare beneficiaries prior to Medicare Part D coverage

ABSTRACT Objective: The goal of this study is to provide annual estimates for the treated prevalence and expenditures attributable to overactive bladder (OAB) in the elderly prior to Medicare Part D drug coverage. Research design and methods: All Medicare claims were extracted for beneficiaries over 65 with continuous coverage for Medicare Parts A and B during 2003–2004. Two OAB definitions were created: (1) the base case included diagnosis codes that narrowly defined OAB, and (2) the sensitivity variant included additional codes indicative of OAB. Descriptive comparisons of baseline characteristics, annual expenditures, and events and procedures were performed for OAB vs. non-OAB subjects meeting the inclusion criteria. CMS expenditures (2004 US dollars) for individuals were totaled and multiple regression techniques were used to estimate costs attributable to OAB after adjusting for demographic characteristics and comorbid conditions. Results: The prevalence of subjects with an OAB diagnosis ranged from 8.8 to 13.6% for the base and sensitivity definitions, respectively. While mean total annual expenditures ranged from

Outcomes following sling surgery: importance of definition of success.

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