Lara S. MacLachlan

Design and Performance Evaluation of a Minimally Invasive Telerobotic Platform for Transurethral Surveillance and Intervention

Bladder cancer, a significant cause of morbidity and mortality worldwide, presents a unique opportunity for aggressive treatment due to the ease of transurethral accessibility. While the location affords advantages, transurethral resection of bladder tumors can pose a difficult challenge for surgeons encumbered by current instrumentation or difficult anatomic tumor locations. This paper presents the design and evaluation of a telerobotic system for transurethral surveillance and surgical intervention. The implementation seeks to improve current procedures and enable development of new surgical techniques by providing a platform for intravesicular dexterity and integration of novel imaging and interventional instrumentation. The system includes a dexterous continuum robot with access channels for the parallel deployment of multiple visualization and surgical instruments. This paper first presents the clinical conditions imposed by transurethral access and the limitations of the current state-of-the-art instrumentation. Motivated by the clinical requirements, the design considerations for this system are discussed and the prototype system is presented. Telemanipulation evaluation demonstrates submillimetric RMS positioning accuracy and intravesicular dexterity suitable for improving transurethral surveillance and intervention.

Simple vs complex urethral diverticulum: presentation and outcomes.

OBJECTIVE To determine whether complex anatomic configurations of urethral diverticula (UD), namely circumferential UD (cUD), present differently or confer a worse prognosis as compared with simple UD (sUD). METHODS After institutional review board approval, a retrospective review of patients who underwent transvaginal urethral diverticulectomy at a single institution over an 8-year period was performed. A total of 43 patients were identified, of which 11 were found to have cUD. These lesions were repaired with complete division of the urethra to access the dorsally located portion of the UD, followed by end-to-end anastomosis for urethral reconstruction with a Martius flap and/or autologous fascial pubovaginal sling performed as needed. Presenting symptoms and surgical outcomes were reviewed. RESULTS Mean age was 50.9 years in the cUD vs 52.7 years in the sUD. Patients with cUD were more likely to present with stress urinary incontinence than those with sUD (90.9% vs 56.3%; P = .04). There was no statistical difference in the rate of preoperative urgency, pelvic pain and/or dyspareunia, postvoid dribbling, and urinary tract infection. Postoperatively, patients with cUD were more likely to have a urinary tract infection (27% vs 3%; P = .2); otherwise, rates of postoperative results were similar. CONCLUSION Urethral transection and end-to-end anastomosis for the repair of complex UD is a feasible approach and results in similar clinical outcomes compared with the repair of sUD.

Pelvic Organ Prolapse Surgery in Academic Female Pelvic Medicine and Reconstructive Surgery Urology Practice in the Setting of the Food and Drug Administration Public Health Notifications

OBJECTIVE To understand the effect of the Food and Drug Administration (FDA) public health notifications regarding transvaginal placement of surgical mesh for pelvic organ prolapsed (POP) on surgeon practice patterns in tertiary care academic medical centers. MATERIALS AND METHODS Surgical volume for procedures performed primarily by fellowship trained Female Pelvic Medicine and Reconstructive Surgery at a sampling of 8 academic institutions across the US were collected using current procedural technology codes for POP repair and revision surgeries from 2007 to 2013. SAS statistical software was used to analyze data for trends and to assess differences in number of procedures across years by performing Spearman correlation analysis and Pearsons chi-squared test. Significance of trend was defined as P <.05 for both analysis methods. RESULTS There has been a substantial reduction in transvaginal mesh-augmented repair of POP since the FDA warning statements of 2008 and 2011. Mesh revision surgery has increased over this same period. However, the total number of interventions for POP has remained stable over the study period. Abdominal sacrocolpopexy has increased as a whole but represents only a small percentage of total cases. CONCLUSION Surgical correction of POP comprises a large portion of Female Pelvic Medicine and Reconstructive Surgery practice that continues to evolve in the aftermath of the FDA public health notifications. The utilization of transvaginal placement of surgical mesh augmented POP repair has decreased among practicing urologists at a sampling of academic institutions across the United States. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study; however, such data may provide alternative insights into the reasons for the observed trends.

Good Urodynamic Practice: Keys to Performing A Quality UDS Study

Urodynamics (UDS) is the dynamic study of the storage and voiding function of the urinary tract. The goal of the UDS study is to identify the cause of a patients voiding symptoms, assess prognosis or the results of prior therapy, or direct management by collecting quantitative measurements while reproducing the patients voiding symptoms where appropriate and possible. Several parts of the UDS study are customized for each individual to maximize the utility of the test. This article summarizes the key points to performing a quality UDS study that can evaluate and diagnose disorders of the lower urinary tract.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications.

To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States.

New Treatments for Incontinence

Urinary incontinence (UI) is a common, yet underdetected and under-reported, health problem that can significantly affect quality of life. UI may also have serious medical and economic ramifications for untreated or undertreated patients, including perineal dermatitis, worsening of pressure ulcers, urinary tract infections, and falls. To prevent incontinence, the urethral sphincter must maintain adequate closure to resist the flow of urine from the bladder at all times until voluntary voiding is initiated and the bladder must accommodate increasing volumes of urine at a low pressure. UI can be categorized as a result of urethral underactivity (stress UI), bladder overactivity (urge UI), a combination of the 2 (mixed incontinence), or urethral overactivity/bladder underactivity (overflow incontinence). The main goal of therapy for the management of UI is to reduce the number of UI episodes, prevent complications, and, if possible, restore continence. This review highlights the existing treatment of stress, urge, mixed, and overflow UI in adult men and women and discusses many of the novel treatments including potential future or emerging therapies.

Management of Failed Stress Urinary Incontinence Surgery

With the increasing volume of surgery being performed for the treatment of female stress urinary incontinence (SUI), especially with the widespread use of midurethral slings (MUS), recurrent urinary incontinence is becoming an increasingly common condition. Various preoperative and intraoperative factors have been associated with failed SUI surgery. Treatment options for failed SUI surgery include conservative management and/or surgical management, which include pubovaginal sling, MUS, retropubic suspension, periurethral bulking agents, and artificial sphincters. The choice of treatment option will depend on the etiology of the patient’s failure, patient comorbidities, and patient preference.

Predictors of Nerve Stimulator Success in Patients With Overactive Bladder

Purpose To identify factors associated with successful sacral nerve stimulator (SNS) trial after SNS implantation for the treatment of medication refractory overactive bladder (OAB). Methods Patients undergoing treatment for OAB at Lahey Hospital and Medical Center between 2004 and 2016 were identified. Patients undergoing SNS placement were identified; SNS success was defined as permanent implantation of the SNS. Demographic, clinical and treatment data were extracted from patient charts; uni- and multivariate analyses were conducted to identify factors associated with SNS treatment success. Results A total of 128 patients were included. On univariate analysis, male sex, prior diagnosis of benign prostatic hyperplasia, and lower volume at first urge on urodynamics (UDS) were associated with unsuccessful SNS trial. On multivariate analysis, male sex (odds ratio [OR], 0.145; 95% confidence interval [CI], 0.036–0.530) and lower volume at first urge on UDS (OR, 0.982; 95% CI, 0.967–0.995) were associated with unsuccessful SNS trial. A threshold value of 100 mL at first urge during preoperative UDS had a specificity of 0.86 in predicting SNS success in men. Conclusions SNS is frequently successful at relieving OAB symptoms. Male patients and those with lower volumes at first urge on UDS, particularly below 100 mL, are more likely to have an unsuccessful SNS trial. Patients in these groups should be counseled on the lower likelihood of SNS success.

Other Treatments for Overactive Bladder, Including Intravesical

Some patients with overactive bladder do not respond to adequate trials of first-, second-, and third-line therapies or experience adverse effects that prevent continuation of treatment. Alternatives must be considered for this cohort to achieve satisfactory symptom control. A wide range of oral and intravesical therapies have been tested, many with positive results. In this chapter, we will present scientific trials of agents that have been tested in human subjects. Familiarity with these studies will expand the treatment armamentarium for practicing urologists, better enabling them to treat this challenging group of patients.

MP85-17 FACTORS ASSOCIATED WITH DURABILITY OF THERAPEUTIC BOTULINUM TOXIN A INJECTION FOR OVERACTIVE BLADDER

CONCLUSIONS: This is the first study to demonstrate safety and efficacy of intravesical incobotulinumtoxin A in patients with neurogenic or idiopathic detrusor overactivity. Incobotulinumtoxin A may be an attractive alternative to onabotulinumtoxin A, especially given its lower cost. Small sample size limits this data, however early results suggest improvements in quality of life and bladder dynamics. A larger, prospective study will be required to validate these findings.