Leslie Rickey

The Effect of Urodynamic Testing on Clinical Diagnosis, Treatment Plan and Outcomes In Women Undergoing Stress Urinary Incontinence Surgery

PURPOSEnWe evaluated the influence of preoperative urodynamic studies on diagnoses, global treatment plans and outcomes in women treated with surgery for uncomplicated stress predominant urinary incontinence.nnnMATERIALS AND METHODSnWe performed a secondary analysis from a multicenter, randomized trial of the value of preoperative urodynamic studies. Physicians provided diagnoses before and after urodynamic studies and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification and nonoperative therapy. Treatment plan changes and surgical outcomes between office evaluation and office evaluation plus urodynamic studies were compared by the McNemar test.nnnRESULTSnOf 315 subjects randomized to urodynamic studies after office evaluation 294 had evaluable data. Urodynamic studies changed the office evaluation diagnoses in 167 women (56.8%), decreasing the diagnoses of overactive bladder-wet (41.6% to 25.2%, p <0.001), overactive bladder-dry (31.4% to 20.8%, p = 0.002) and intrinsic sphincter deficiency (19.4% to 12.6%, p = 0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p <0.001). After urodynamic studies physicians canceled surgery in 4 of 294 women (1.4%), changed the incontinence procedure in 13 (4.4%) and planned to modify mid urethral sling tension (more or less obstructive) in 20 women (6.8%). Nonoperative treatment plans changed in 40 of 294 women (14%). Urodynamic study driven treatment plan changes were not associated with treatment success (OR 0.96, 95% CI 0.41, 2.25, p = 0.92) but they were associated with increased postoperative treatment for urge urinary incontinence (OR 3.23, 95% CI 1.46, 7.14, p = 0.004).nnnCONCLUSIONSnUrodynamic studies significantly changed clinical diagnoses but infrequently changed the global treatment plan or influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for postoperative urgency urinary incontinence.

Sexual activity and function in women more than 2 years after midurethral sling placement

OBJECTIVEnThe purpose of this study was to assess prospectively the effects of midurethral sling surgery on sexual function and activity.nnnSTUDY DESIGNnSexual activity and function was assessed in 597 women with stress urinary incontinence who were enrolled in a randomized equivalence trial of retropubic compared with transobturator midurethral slings. Repeated measures analysis of variance was used to assess changes in Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores over a 2-year period.nnnRESULTSnSignificant, similar improvements in sexual function were seen in both midurethral sling groups. Mean Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores increased from 32.8 at baseline to 37.6 at 6 months and 37.3 at 24 months (P < .0001). Dyspareunia, incontinence during sex, and fear of incontinence during sex each significantly improved after surgery. Preoperative urge incontinence was associated with abstinence after surgery (P = .02); postoperative urge incontinence negatively impacted sexual function (P = .047).nnnCONCLUSIONnMidurethral sling surgery for stress urinary incontinence significantly improves sexual function, although coexistent urge incontinence has a negative impact.

Patient satisfaction after midurethral sling surgery for stress urinary incontinence.

OBJECTIVE: To identify factors that may contribute to patient satisfaction with outcome in women who received retropubic and transobturator midurethral slings. METHODS: Satisfaction was assessed 12 months postsurgery as a planned analysis in 597 participants from a multicenter randomized trial comparing retropubic with transobturator midurethral slings using the Incontinence Surgery Satisfaction Questionnaire. Significantly related variables associated with satisfaction in univariable analyses were entered into multivariable logistic regression models to test their independent association with satisfaction. RESULTS: One year after surgery, 264 (88.6%) in the retropubic group and 263 (88.0%) in the transobturator group completed satisfaction questionnaires. Both treatment groups demonstrated a high level of satisfaction with respect to urine leakage (retropubic 85.9% compared with transobturator 90.0%; P=.52), urgency to urinate, frequency of urination, capability of physical activity, social activity, ability to engage in sexual activity, and from an emotional standpoint. Baseline characteristics associated with reduced satisfaction were higher Medical, Epidemiologic, and Social Aspects of Aging Questionnaire urgency subscale scores, detrusor overactivity, and diabetes mellitus. The severity of both objective (frequency of incontinence episodes, pad test weight) and subjective (Incontinence Impact Questionnaire and Urogenital Distress Inventory score) measures of incontinence at baseline and the patients perceptions of preoperative severity of incontinence and expectations of achieving postoperative cure or improvement were not statistically different between satisfied and unsatisfied patients. In the final multivariable model, satisfaction was associated with overall treatment success (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.29-5.13], greater reduction in Urogenital Distress Inventory (OR 0.97, 95% CI 0.96-0.98) and Incontinence Impact Questionnaire scores (OR 0.99, 95% CI 0.98-0.99), and fewer complications (OR 0.55, 95% CI 0.30-0.99). CONCLUSION: The high level of satisfaction seen after midurethral sling procedures is associated with greater objective and patient-perceived improvement of stress incontinence and fewer complications. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00325039. LEVEL OF EVIDENCE: II

Preoperative voiding detrusor pressures do not predict stress incontinence surgery outcomes

Introduction and hypothesisThe aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery.MethodsOpening detrusor pressure, detrusor pressure at maximum flow (pdet Qmax), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests.ResultsThere were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes.ConclusionsWe found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.

Perineal surface electromyography does not typically demonstrate expected relaxation during normal voiding

To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms.

The Pelvic Floor Complication Scale: a new instrument for reconstructive pelvic surgery

OBJECTIVEnThe purpose of this study was to develop and test a unique, new pelvic floor surgery complication scale and compare it with an existing validated measure.nnnSTUDY DESIGNnSurgeons from 2 clinical trials networks rated complications based on perceived patient bother, severity, and duration of disability to develop a pelvic floor complication scale (PFCS). PFCS scores were calculated for subjects in 2 multicenter pelvic floor surgical trials. The PFCS and modified Clavien-Dindo scores were evaluated for associations with length of hospitalization, satisfaction, and quality-of-life measures (health utilities index, short form-36, urogenital distress inventory, and incontinence impact questionnaire).nnnRESULTSnWe calculated PFCS scores for 977 subjects. Higher PFCS and Clavien-Dindo scores similarly were associated with longer length of hospitalization (P < .01), lower satisfaction (P < .01), lower Health Utilities Index scores (P = .02), lower short form-36 scores (P = .02), higher urogenital distress Inventory scores (P < .01), and incontinence impact questionnaire scores (P < .01) at 3 months. No associations were present at 1 year.nnnCONCLUSIONnThe PFCS compares favorably to the validated modified Clavien-Dindo instrument.

Condition-specific quality of life 24 months after retropubic and transobturator sling surgery for stress urinary incontinence

Aims To compare quality of life (QoL) and factors associated with QoL change after retropubic (RMUS) and transobturator midurethral slings (TMUS) using the Incontinence Impact Questionnaire (IIQ) and the International Consultation on Incontinence Questionnaire (ICIQ). Methods Five hundred ninety-seven women in a multicenter randomized trial of RMUS versus TMUS were examined. The IIQ and the ICIQ were obtained at baseline and at 12 and 24 months. Repeated-measures analysis of variance tested for differences by treatment group over time. Multivariable analysis identified factors associated with QoL change at 12 months postoperative, controlling for treatment group and baseline QoL. Results Improvement in IIQ was associated with the following: treatment success, younger age, improvement in stress urinary incontinence (SUI) symptom severity, and bother (all P < 0.05). Improvement in ICIQ was associated with treatment success, younger age, improvement in SUI symptom severity and bother, lower body mass index, and no reoperation (all P < 0.05). Improvement of the IIQ was stable over time (P = 0.35) for both treatment groups (P = 0.66), whereas the ICIQ showed a small but clinically insignificant decline (P = 0.03) in both treatment groups (P = 0.51). Conclusions Postoperative QoL was improved after RMUS and TMUS. Measures of QoL functioned similarly, although more surgically modifiable urinary incontinence factors predicted improvement with the IIQ.

Surgical Preparation: Are Patients “Ready” for Stress Urinary Incontinence Surgery?

Introduction and hypothesisPatient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life.MethodsThe ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1xa0year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment’s effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ).ResultsBased on PPQ question 11, 4 out of 5 (81xa0%) of women reported they “agreed” or “strongly agreed” that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearmans ru2009=u20090.13, pu2009=u20090.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (rsu2009=u20090.11, pu2009=u20090.02) and larger PGI-S improvement (increase; pu2009=u20090.008).ConclusionsApproximately half (48xa0%) of women “strongly agreed” that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.

Reliability and responsiveness of the Urgency Severity and Life Impact Questionnaire (USIQ)

Introduction and hypothesisThe aims of this study are (1) to assess the reliability (test–retest) of the Urgency Severity and Life Impact Questionnaire (USIQ) and (2) to test the effect of extended-release tolterodine on symptoms of urinary urgency using this validated instrument.MethodsTo measure reliability, women with overactive bladder (OAB) completed the USIQ on two separate occasions, prior to treatment for OAB. To assess the responsiveness, the USIQ participants completed the above-mentioned questionnaires prior to and following 4xa0weeks of treatment for OAB with extended-release tolterodine.ResultsUSIQ-S and USIQ-QoL scores at the two visits did not differ significantly. Repeated measures of USIQ-S and USIQ-QoL demonstrated a moderate to excellent intraclass correlation coefficient (0.64–0.74; Pu2009<u20090.0001 and 0.48–0.91, Pu2009<u20090.0001, respectively). A significant decrease in mean USIQ-S and USIQ-QOL (71u2009±u200914 vs. 44u2009±u200919, Pu2009<u20090.0001 and 51u2009±u200922 vs. 39u2009±u200910, Pu2009<u20090.01, respectively) scores following treatment with tolterodine.ConclusionsThis valid, reliable measure can be used in clinical practice and research trials to measure urgency severity.

Robotic objective structured assessment of technical skills: a randomized multicenter dry laboratory training pilot study.

Study Objective The goal of this study was to determine if a robotic dry laboratory curriculum for gynecology and urology residents improved their basic robotic skills. Methods After the institution-specific institutional review board approval or exemption, 165 residents from 8 gynecology and/or urology programs were enrolled. Residents underwent standardized robotic orientation followed by dry laboratory testing on 4 unique robotic tasks. Residents were block randomized by program to unstructured or structured training programs. Regardless of group, residents were expected to practice for 15 minutes twice monthly over 7 months. Errors, time to completion, and objective structured assessment of technical skills global rating scores were recorded for each task before and after the training period. Statistics were calculated using the Student t tests, Pearson correlation, and analysis of variance with STATA systems (version 11.2). Results A total of 99 residents completed both the pretraining and posttraining testing. A mean of 4 (range, 0–15) 15-minute training sessions per resident was self-reported. The structured group had faster posttraining times on the transection task, although the unstructured group had higher posttraining scores on the knot-tying task. Conclusions Overall, the residents’ robotic skills improved after participating in a dry laboratory curriculum; however, robotic availability, duty hour restrictions, and clinical responsibilities limit the curriculum implementation.