Marisa M. Clifton

Evaluation and Management of Pelvic Organ Prolapse in Elderly Women.

Pelvic organ prolapse is a common disease in elderly patients. The most important symptom is vaginal bulge (bulge sensation or the sensation of something coming down through the vaginal introitus). This symptom is not different than in the general population. Diagnosis can be confirmed using just vaginal examinations to identify the presence of protrusion beyond the hymen, and is not different than in the general population. Different treatment options are available, including observation, nonsurgical, and surgical techniques. Pessaries and colpocleisis are the treatment options used more often in elderly patients than in the general population.

Impact of Age and Comorbidities on Use of Sacral Neuromodulation

Purpose: We investigated the influence of patient age on sacral nerve stimulation trial outcomes, device implantation and treatment durability. Materials and Methods: We analyzed a database of all sacral nerve stimulation procedures performed between 2012 and 2014 at a high volume institution for associations of patient age with sacral nerve stimulation indication, trial stimulation success, device revision and device explantation. Results: In a cohort of 356 patients those with nonobstructive urinary retention and urgency‐frequency were younger than patients with urgency urinary incontinence. Trial stimulation success did not differ by age in stage 1 and percutaneous nerve evaluation trials (p = 0.51 and 0.84, respectively). Logistic regression identified greater odds of trial success in females compared to males (OR 2.97, 95% CI 1.32–6.04, p = 0.009) and for urgency urinary incontinence compared to urgency‐frequency (OR 3.02, 95% CI 1.39–6.50, p = 0.006). In analyzed patients there were 119 surgical revisions, including battery replacement, and 53 explantations. Age was associated with a decreased risk of revision with 3% lower odds per each additional year of age (OR 0.97, 95% CI 0.95–0.98, p <0.0001). While age did not influence explantation, for each body mass index unit there was a 5% decrease in the odds of explantation (OR 0.95, 95% CI 0.91–0.98). Conclusions: In contrast to previous studies, older patients experienced no difference in the sacral nerve stimulation response in stimulation trials and no difference in the implantation rate. Furthermore, age was modestly protective against device revision. This suggests that age alone should not negatively predict sacral nerve stimulation responses.

Sacral Neuromodulation Implant Infection: Risk Factors and Prevention

Device infection is one of the most common complications of sacral nerve stimulator placement and occurs in approximately 3–10% of cases. Infection is a serious complication, as it often requires complete explantation of the device. Not much is known regarding risk factors for and methods of preventing infection in sacral nerve stimulation. Multiple risk factors have been linked to device infection including prolonged percutaneous testing and choice of preoperative antibiotic. Methods of infection prevention have also been studied recently, including antibiotic-impregnated collage and type of skin preparation. This review will discuss the recent literature identifying risk factors and means of preventing infection in sacral nerve stimulation. Finally, we will outline a protocol we have enacted at our institution which has resulted in an incidence of infection of 1.6%.

Erosion of prolene sutures into the bladder after abdominal sacrocolpopexy

Abdominal sacrocolpopexy is a common procedure for apical prolapse with a success rate of 78 – 100 % [1]. Vaginal mesh extrusion is a well-known risk of this procedure with a rate of approximately 3.4 % [2, 3]. Erosion or perforation of sacrocolpopexy mesh into the bladder is much less common. We present here the case of a patient who experienced multiple separate prolene suture erosions managed endoscopically.

Urethrovaginal fistula closure

Introduction and hypothesisIn the developed world, urethrovaginal fistulas are most the likely the result of iatrogenic injury. These fistulas are quite rare. Proper surgical repair requires careful dissection and tension-free closure. The objective of this video is to demonstrate the identification and surgical correction of an urethrovaginal fistula.MethodsThe case presented is of a 59-year-old woman with a history of pelvic organ prolapse and symptomatic stress urinary incontinence who underwent vaginal hysterectomy, anterior colporrhaphy, posterior colporrhaphy, and synthetic sling placement. Postoperatively, she developed a mesh extrusion and underwent sling excision. After removal of her synthetic sling, she began to experience continuous urinary incontinence. Physical examination and cystourethroscopy demonstrated an urethrovaginal fistula at the midurethra. Options were discussed and the patient wished to undergo transvaginal fistula repair.ResultsThe urethrovaginal fistula was intubated with a Foley catheter. The fistula tract was isolated and removed. The urethra was then closed with multiple tension-free layers. This video demonstrates several techniques for identifying and subsequently repairing an urethrovaginal fistula. Additionally, it demonstrates the importance of tension-free closure.ConclusionsUrethrovaginal fistulas are rare. They should be repaired with careful dissection and tension-free closure.

Motor Response Matters: Optimizing Lead Placement Improves Sacral Neuromodulation Outcomes

Purpose: We sought to determine the usefulness of motor responses during sacral neuromodulation lead placement by testing the hypothesis that a greater number of motor responses during intraoperative electrode testing would be associated with more durable therapy. Materials and Methods: We retrospectively reviewed all sacral neuromodulation lead placements at a large academic center from 2010 to 2015. Included in study were all unilateral sacral lead placements for which the presence or absence of a motor response was documented discretely for each electrode. Motor responses were quantified into separate subscores, including bellows and toe response subscores (each range 0 to 4) for a possible maximum total score of 8 when combined. Revision surgery was the primary outcome. Univariate and multivariate analyses were performed for factors associated with lead revision. Results: A total of 176 lead placements qualified for analysis. Mean ± SD cohort age was 58.4 ± 15.9 years, 86.4% of the patients were female and 93.2% had undergone implantation for overactive bladder. Median followup was 10.5 months (range 2 to 36). Overall 34 patients (19%) required lead revision. Revision was negatively associated with the total electrode response score (p = 0.027) and the toe subscore (p = 0.033) but not with the bellows subscore (p = 0.183). Predictors of revision on logistic regression included age less than 59 years at implantation (OR 5.5, 95% CI 2–14) and a total electrode response score less than 4 (OR 4.2, 95% CI 1.4–12.8). Conclusions: Fewer total electrode responses and specifically fewer toe responses were associated with sacral neuromodulation lead revision. These data suggest that placing a lead with more toe responses during testing may result in more durable sacral neuromodulation therapy.

MP50-10 PREDICTING POSTOPERATIVE FEVER AND SYSTEMIC INFLAMMATORY RESPONSE SYNDROME AFTER URETEROSCOPY

METHODS: We retrospectively reviewed our first 75 cases with the 7.7Fr disposable flexible digital ureteroscope and identified any problems, difficulties, or complications related to the scope itself. RESULTS: Of the 75 patients, 47 were female 28 were male; 39 cases were left sided, 30 were right sided, and 6 were bilateral. The reasons for ureteroscopy include stone disease in 60 pts, ureteral stricture disease in 5 patients, and upper tract transitional cell carcinoma (TCC) in 10 patients. There was difficulty in getting up the ureter (ureterovesical junction) in 3 patients; one due to distal ureteral narrowing requiring balloon dilation, the other 2 due to proximal ureter narrowing requiring stenting. Passage of the scope was relatively effortless in the remaining retrograde URS patients. Two patients underwent antegrade ureteroscopy through an established nephrostomy tract to treat ureteroenteric anastomotic strictures. There was mild interference in the video system during laser lithotripsy of hard stones (calcium oxalate monohydrate but did not prevent treatment. But the system was incompatible with the use of electrocautery. During fulguration of upper tract TCC, the system continually shut down during the use of a 3Fr electrode. Another difficulty with visualization occurred during antegrade ureteroscopy for 2 ureteroileal anastomotic strictures. Due to problems with distant focusing, there was difficulty identifying the true lumen past the stricture, which lead to inaccurate incision of the soft tissue resulting in extravasation in both cases. CONCLUSIONS: This new disposable ureteroscope works well for routine ureteroscopy with laserlithotripsy but should not be used with electrocautery and avoided for antegrade incision of ureteroenteric anastomotic strictures. Its strength is in near focusing rather than distant focusing which is fine for stones but not for the latter situation.

MP29-02 NEUROMETER MEASUREMENT OF CURRENT PERCEPTION (CPT) AND PAIN TOLERANCE THRESHOLDS (PTT) IN PATIENTS WITH PAINFUL BLADDER SYNDROME BEFORE AND AFTER TREATMENT WITH CYCLOSPORINE

INTRODUCTION AND OBJECTIVES: There are few studies to investigate time-dependent changes in urine markers before and after fulguration or hydrodistention for the treatment of interstitial cystitis (IC) with or without Hunner lesions (HL), respectively. Thus we measured forty-one urine markers in HL type IC (HIC) or non-HL type IC (NHIC) patients before and after the treatment. METHODS: Urine specimensandbladder tissueswere collected from 10 NHIC patients before hydrodistention, 10 HIC patients before fulguration and 10 age and gender-matched controls before surgical treatments including transurethral resection of the prostate (n1⁄43) or tension-free vaginal tape operations (n1⁄47). Urine specimens were also collected in IC patients six and twelve months after the treatment. Multiplex analyses of 41 cytokines, chemokines and growth factors were performed with a MIPPLIPLEX immunoassay kit. All participants completed the O’Leary-Sant score including symptom indexes (OSSI) andproblem indexes (OSPI), and visual analogscale (VAS)pain score. In addition, the expression of interleukin-1 receptor antagonist (IL-1Ra) in the bladder was evaluated using an immunohistochemistry. RESULTS: Before the treatment, vascular endothelial growth factor (VEGF) and IL-1a were significantly increased in HIC and NHIC patients compared with controls, and CXCL8 and CXCL10 were significantly increased in HIC patients compared with controls although there were no significant differences in 41 urine markers between HIC and NHIC patients. IL-1Ra mainly expressed in the bladder epithelium was significantly decreased in HIC patients compared with NHIC patients or controls. Urine IL-1Ra was significantly increased in HIC and NHIC patients twelve months after the treatment compared with pretreatment values whereas there were no significant changes in other urine markers before and after the treatment. OSSI, OSPI and VAS scores were significantly decreased in HIC and NHC patients six and twelve months after the treatment compared with pretreatment scores, and significantly correlated positively with urine IL-1Ra levels in NHIC patients, but not in HIC patients. CONCLUSIONS: The increases in angiogenesis-associated proteins such as VEGF and CXCL10 and inflammatory cytokines including IL-1amay be important for the development of IC. IL-1Ra acting asananti-inflammatory cytokineagainst IL-1wasmainly expressed in the urothelium and may be positively correlated with the bladder pain symptom. In addition, the increase in urine IL-1Ra induced by hydrodistention or fulguration may contribute to the alleviation of IC symptoms.

Overactive Bladder: Non-neurogenic

Overactive bladder (OAB) is a clinical diagnosis defined by the International Continence Society as the presence of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of a urinary tract infection (UTI) or other obvious pathology. Urodynamic studies (UDS) are not required for patients with straightforward OAB; however, they can be useful in patients with refractory OAB symptoms, symptoms suggestive of outlet obstruction or voiding dysfunction, elevated post-void residual, and history of previous continence surgery, as well as in patients who have difficulty describing the type of incontinence they have. The objective of this chapter is to provide an overview of overactive bladder and discuss the UDS findings in patients with OAB symptoms.

Treatment of vaginal stenosis with fasciocutaneous Singapore flap

IntroductionVaginal stenosis is an unfortunate complication that can occur after pelvic radiation therapy for gynecologic or colorectal malignancies. Treatment is challenging and can require significant reconstructive surgery. The objective of this video is to present a case of vaginal stenosis after radiation and describe vaginal reconstruction with a fasciocutaneous Singapore flap.MethodsWe describe the case of a 42-year-old woman with a history of stage 3 colorectal cancer who underwent partial colectomy, chemotherapy, and pelvic radiation. She subsequently developed a rectovaginal fistula requiring repair with a right-sided gracilis flap. When her stenosis recurred, she underwent vaginal reconstruction with a medial thigh flap.ResultsThe Singapore flap is a pudendal thigh flap centered on the labial crural fold with a base at the perineal body. As the cutaneous innervation is spared, this flap is sensate. This technique is one option for patients with complex vaginal stenosis who have failed conservative management. However, it is imperative the patient perform vaginal dilation postoperatively and maintain close follow-up with her surgeon, as vaginal stenosis can recur.ConclusionsPostradiation vaginal stenosis is a complex condition to treat; however, vaginal reconstruction with a thigh flap can provide excellent cosmetic and functional results.