Kobi Stav

Repeat Synthetic Mid Urethral Sling Procedure for Women With Recurrent Stress Urinary Incontinence

PURPOSE We reported and compared the outcomes of repeat mid urethral sling with primary mid urethral sling in women with stress urinary incontinence. MATERIALS AND METHODS A total of 1,225 consecutive women with urodynamic stress incontinence underwent a synthetic mid urethral sling procedure (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Of the patients 91% (1,112) were interviewed via telephone call with a structured questionnaire and were included in the analysis. Mean +/- SD followup was 50 +/- 24 months (range 12 to 114). A comparison between repeat (77, mean age 62 +/- 12 years) and primary (1,035, mean age 60 +/- 13 years) mid urethral sling groups was performed. Repeat sling was placed without removal of the previous sling. RESULTS The preoperative incidence of intrinsic sphincter deficiency was higher in patients who had a repeat mid urethral sling (31% vs 13%, p <0.001). The subjective stress incontinence cure rate was 86% and 62% in the primary and repeat group, respectively (p <0.001). The repeat retropubic approach was significantly more successful than the repeat transobturator approach (71% vs 48%, p = 0.04). The rates of sling related and general postoperative complications were similar between the primary and the repeat groups. However, de novo urgency (30% vs 14%, p <0.001) and de novo urge urinary incontinence (22% vs 5%, p <0.001) were more frequent in the repeat group compared with the primary group. CONCLUSIONS A repeat synthetic mid urethral sling procedure has a significantly lower cure rate than a primary mid urethral sling procedure. The repeat retropubic approach has a higher success rate than the repeat transobturator approach. The incidence of de novo urgency and urge incontinence are significantly higher in repeat procedures.

Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis

Please cite this paper as: Lee J, Dwyer P, Rosamilia A, Lim Y, Polyakov A, Stav K. Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis. BJOG 2011;118:798–805.

Women overestimate daytime urinary frequency: the importance of the bladder diary.

PURPOSE We determined whether women with urinary incontinence reliably report urinary frequency. MATERIALS AND METHODS We retrospectively reviewed the medical records of 1,136 women who underwent a suburethral sling operation from 1999 to 2007. A routine form was used to document medical history, urinary symptoms, physical examination and urodynamics. A total of 601 patients with a mean +/- SD age of 59.2 +/- 11.6 years (range 30 to 91) who completed a bladder diary were included in this study. Patients were categorized into 4 levels of urinary frequency, and medical histories and bladder diaries were compared. The Spearman correlation coefficient was used to determine the degree of agreement between histories and diaries. RESULTS According to the diaries 535 patients (89%) voided 4 to 10 times during the day and 527 (87.6%) voided no more than twice at night. Only 47% of the women were accurate about daytime frequency. On the other hand, 93% of the women were accurate about the nighttime estimation. Of the women 51% overestimated daytime frequency. Overestimation was marked, especially in patients who reported a daytime frequency of greater than 10 voids per day. There was weak correlation between daytime urinary frequency obtained from medical histories and the frequency recorded in diaries (r = 0.31, p = 0.011). However, nighttime urinary frequencies correlated highly (r = 0.79, p = 0.02). Overestimation rates were similar in patients with and without overactive bladder. CONCLUSIONS Our results suggest that half of patients tend to overestimate daytime urinary frequency. However, the accuracy rate of nighttime frequency is much higher. A bladder diary provides invaluable information about urinary frequency and it should be an integral part of the routine assessment in women with lower urinary tract symptoms.

Serum uric acid as a clinically useful nutritional marker and predictor of outcome in maintenance hemodialysis patients

OBJECTIVE The importance of serum uric acid (SUA) for the maintenance of a hemodialysis (MHD) population has not been well established. The aim of this study was to determine if SUA levels are associated with nutritional risk and consequently with adverse clinical outcomes in MHD patients. METHODS This was a 2-y prospective observational study, performed on 261 MHD outpatients (38.7% women) with a mean age of 68.6 ± 13.6 y. We measured prospective all-cause and cardiovascular (CV) hospitalization and mortality, nutritional scores (malnutrition-inflammation score [MIS) and geriatric nutritional risk index (GNRI), handgrip strength (HGS), and short-form 36 (SF36) quality-of-life (QoL) scores. RESULTS SUA positively correlated with laboratory nutritional markers (albumin, creatinine), body composition parameters, HGS (r = 0.26; P < 0.001) and GNRI (r = 0.34; P < 0.001). SUA negatively correlated with MIS (r = -0.33; P < 0.001) and interleukin-6 (r = -0.13; P = 0.04). Patients in the highest SUA tertile had higher total SF-36 scores (P = 0.04), higher physical functioning (P = 0.003), and role-physical (P = 0.006) SF-36 scales. For each 1 mg/dL increase in baseline SUA levels, the first hospitalization hazard ratio (HR) was 0.79 (95% confidence interval [CI], 0.68-0.91) and first CV event HR was 0.60 (95% CI, 0.44-0.82); all-cause death HR was 0.55 (95% CI, 0.43-0.72) and CV death HR was 0.55 (95% CI, 0.35-0.80). Associations between SUA and mortality risk continued to be significant after adjustments for various confounders including MIS and interleukin-6. Cubic spline survival models confirmed the linear trends. CONCLUSIONS In MHD patients, SUA is a good nutritional marker and associates with body composition, muscle function, inflammation, and health-related QoL, upcoming hospitalizations, as well as independently predicting all-cause and CV death risk.

Midurethral sling procedures for stress urinary incontinence in women over 80 years

To compare the safety and efficacy of midurethral sling surgery for management of urinary stress incontinence in women over 80 years versus younger women.

Risk Factors for Trocar Injury to the Bladder During Mid Urethral Sling Procedures

PURPOSE We determined the incidence of and risk factors for bladder injury during mid urethral sling procedures for stress urinary incontinence. MATERIALS AND METHODS At our institution 1,136 consecutive women underwent a mid urethral sling procedure (retropubic in 874 and transobturator in 262) and routine intraoperative cystoscopy between 1999 and 2007, and were followed to determine the clinical outcome. Statistical analysis was performed using the chi-square and independent t tests, and ANOVA to compare patients with and without bladder perforation by baseline characteristics and major risk factors. A total of 45 variables were included in analysis. Multivariate analysis to predict events was done with logistic regression models with stepwise forward selection. RESULTS Bladder injury was noted in 34 patients (3%) and all except 1 were during a retropubic sling procedure (p <0.0001). Of the perforations 32 (94%) were associated with an inexperienced surgeon (p <0.0001). Multivariate analysis revealed that rectocele (OR 6.2), local anesthesia (OR 5.9), body mass index less than 30 kg/m(2) (OR 5.6), previous Cesarean section (OR 3.7) and previous colposuspension (OR 3.2) were significant independent risk factors for perforation. Urethral injury was detected intraoperatively in 2 women (0.2%) with a retropubic sling. CONCLUSIONS Our results indicate that previous Cesarean section, colposuspension, body mass index less than 30 kg/m(2), rectocele and local anesthesia are independent risk factors for bladder perforation during mid urethral sling procedures. This occurs mainly during a retropubic sling procedure and when the surgeon is inexperienced.

Urinary Symptoms Before and After Female Urethral Diverticulectomy-Can We Predict De Novo Stress Urinary Incontinence?

PURPOSE We assessed preoperative and postoperative urinary symptoms, and determined risk factors for de novo stress urinary incontinence after transvaginal urethral diverticulectomy. MATERIALS AND METHODS We reviewed the case records of 25 consecutive women who had transvaginal urethral diverticulectomy. Urinary symptoms were documented before and after surgery with a structured history and examination pro forma. Demographic, clinical and imaging parameters were reviewed to determine any association with preoperative and postoperative symptoms as well as possible risk factors for postoperative stress urinary incontinence. RESULTS The most common presenting symptoms were urinary urgency and frequency (60%), and dyspareunia (56%). On physical examination the most common findings were a tender anterior vaginal wall mass (88%) and urethral discharge (40%). At a mean followup of 15.1 +/- 14.9 months (median 12) the rate of urgency-frequency symptoms and dyspareunia decreased significantly from 60% to 16% and from 56% to 8%, respectively. All the patients who had urge incontinence were cured of this symptom after the operation. De novo stress urinary incontinence developed in 4 patients (16%) postoperatively, and it was mild and only necessitated surgical treatment in 1 patient. A diverticulum larger than 30 mm and proximal urethral location were significant factors (p <0.05) for the development of de novo stress urinary incontinence. CONCLUSIONS Irritative bladder symptoms are common in woman with urethral diverticulum and usually resolve after surgical excision. Stress urinary incontinence developed immediately after the operation, and had a significant association with a proximal urethral location and ultrasonically measured size greater than 30 mm.

Saturation Prostate Biopsy in High Risk Patients After Multiple Previous Negative Biopsies

OBJECTIVES To evaluate the diagnostic value of saturation prostate biopsy in patients with prostate-specific antigen (PSA) greater than 10 ng/mL, PSA velocity greater than 0.75 ng/mL/year, free PSA ratio less than 0.2, and at least 3 sets of negative biopsy specimens. METHODS Twenty-seven patients underwent the procedure with the use of a transrectal approach under general or regional anesthesia. A systematic coverage of the peripheral zone was accomplished by maintaining a fixed distance between punctures (5 mm). In addition, multiple cores were obtained from the transition zone bilaterally, bladder neck, and midline according to a strict preplanned template. RESULTS The mean number of cores obtained per patient was 61.7 +/- 9.5 (range 41 to 76). Average PSA was 19.4 +/- 8.5 ng/mL (range 10.1 to 49). Prostate cancer (Gleason score 3+3) was found in 3 patients (11.1%). All 3 patients who received a diagnosis of cancer had minimal disease affecting less than 1% of a single core sampled from the peripheral zone. Two patients were designated for watchful waiting and 1 patient chose radical prostatectomy. His pathologic specimen contained carcinoma of prostate (Gleason 3+3) in less than 1% of the total prostate volume. All patients were discharged within 24 hours after the procedure. Asymptomatic bacteremia was documented in 1 patient. Two patients had epididymitis develop and were treated conservatively. CONCLUSIONS According to our findings, saturation prostate biopsy has low diagnostic yield in patients who previously had at least 3 sets of negative traditional biopsy specimens. In all the cases, that prostate cancer was found, it had histologic features consistent with biologically insignificant disease.

Urinary bladder stones in women.

Purpose The objective of this study was to review the history, epidemiology, diagnosis, and current management techniques for bladder stones (BS) in women. Methods A MEDLINE search for articles published from 1950 to 2011 was done using a list of terms related to BS including calculi, cystolithiasis, stones, urinary bladder, and women. Results Approximately 5% of all BS occur in women and are usually associated with foreign bodies (sutures, synthetic tapes, or meshes) or urinary stasis. Bladder stones can be asymptomatic but may result in hematuria, recurrent infections, and irritable symptoms. Stones can be detected by x-ray, ultrasound, or computed tomography scan and frequently at the time of routine cystourethroscopy performed during pelvic surgery. Because BS is a sign of an underlying problem, definite treatment of the underlying abnormality is nearly always indicated. The preferred treatment for BS is endoscopic transurethral fragmentation of the stone (cystolithotripsy). Any associated suture or synthetic mesh can be removed or cut flush with the bladder mucosa. Partial resection of the mesh with cystotomy should be considered whenever transurethral treatment failed. When stone burden is large, percutaneous endoscopic disintegration or open suprapubic cystolithotomy is preferable. Extracorporeal shockwave lithotripsy has been demonstrated to be simple, effective, and well tolerated. However, ancillary procedures are required in a significant number of patients. Conclusions The increased usage of synthetic material in reconstructive pelvic floor surgery in women will probably increase the incidence of BS on intravesical foreign bodies. Bladder stones should be ruled out in women investigated for irritable bladder symptoms or recurrent urinary infection. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this CME activity, physicians should be better able to identify risk factors for bladder stones, diagnose bladder stones, and compare the optional treatments for bladder stones in women.

Comparison of Lower Urinary Tract Symptoms Between Women with Detrusor Overactivity and Impaired Contractility, and Detrusor Overactivity and Preserved Contractility

PURPOSE We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility. MATERIALS AND METHODS The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups. RESULTS Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p <0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p <0.01 and 22% vs 7%, p <0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p <0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p <0.001). CONCLUSIONS Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.