Matthew Rutman

Failure of Sacral Nerve Stimulation Due to Migration of Tined Lead

PURPOSE Stimulation of the sacral nerves is a commonly used treatment for frequency, urgency, urge incontinence, retention and other types of voiding dysfunction. Minimally invasive placement of a percutaneous permanent quadripolar tined lead into the sacral foramen has been described. No lead migration has been reported. We report on our experience with lead migration and the subsequent failure of InterStim in a large cohort of patients with a focus on possible diagnostic and salvage techniques. MATERIALS AND METHODS Between February 2002 and April 2005 tined lead electrodes were implanted in the S3 foramen in 235 patients using the InterStim system. Patients with a good response during the testing phase (greater than 50% improvement) underwent placement of an implantable pulse generator. Position was confirmed by radiographic evaluation intraoperatively. Sacral radiographs were obtained at the first postoperative visit, after IPG placement and whenever there was a change in symptomatic response. RESULTS There were 5 patients (2.1%) in whom treatment failed after a successful trial of stimulation due to lead migration. This was seen as early as 3 weeks and as late as 8 months. Migration of the lead occurred between first and second stage implantation in 1 of the 5 cases, and occurred after the second stage in 4 of 5. Anterior migration was noted in 4 patients and posterior migration was noted in 1. CONCLUSIONS Lead migration after placement of the tined lead can occur and thus sacral radiographs should be routinely used. This complication can be easily resolved without significant morbidity to the patient.

Long-Term Durability of the Distal Urethral Polypropylene Sling Procedure for Stress Urinary Incontinence: Minimum 5-Year Followup of Surgical Outcome and Satisfaction Determined by Patient Reported Questionnaires

PURPOSE We report on the long-term outcomes of the distal urethral polypropylene sling. MATERIALS AND METHODS We performed a prospective study of all consecutive patients who underwent a distal urethral polypropylene sling procedure between November of 1999 and April of 2000 for treatment of SUI. Surgical outcome was determined by patient self-assessment, and included symptom, bother and quality of life questionnaires. Physicians were blinded to patient responses. All patients had a minimum 5-year followup. Every patient treated was included in reporting outcomes in the intent to treat analysis. RESULTS There were 69 patients treated a minimum of 5 years before the analysis. Cases lost to followup were defined as treatment failures. At a minimum followup of 5 years patient determined subjective success rate was 88%. More than 5 years after surgery 72% of patients reported no symptoms of SUI and 74% reported never being bothered by SUI. Patients reported an overall mean improvement of symptoms of 81%, and quality of life due to urinary symptoms between pleased and mostly satisfied. CONCLUSIONS The distal urethral polypropylene sling procedure has low morbidity and excellent durability in treating patients with SUI.

180 W vs 120 W lithium triborate photoselective vaporization of the prostate for benign prostatic hyperplasia: a global, multicenter comparative analysis of perioperative treatment parameters.

OBJECTIVE To evaluate the surgical performance of the new Greenlight XPS-180 W laser system (American Medical Systems, Minnetonka, MI) and the effect of prostate volume (PV), in comparison with the former HPS-120 W system, for the treatment of benign prostatic hyperplasia by photo-selective vaporization of the prostate. METHODS Between July 2007 and March 2012, 1809 patients underwent laser photo-selective vaporization of the prostate (1187 patients with the use of HPS-120 W and 622 patients with the use of XPS-180 W) at 7 international centers. All data were collected prospectively. Comparative analysis was performed between XPS and HPS according to PV measured by transrectal ultrasound. RESULTS The XPS compared with HPS, allowed significantly reduced laser and operative time (29.6 minutes vs 65.8 minutes and 53 minutes vs 80 minutes, respectively; P <.01 for both). The number of fiber used during the procedures was significantly reduced with the XPS system (1.11 vs 2.28; P <.01), whereas total energy delivered was lower (250.2 kJ vs 267.7 kJ; P = .043). Overall, the mean operative time, mean laser time, and mean energy were all significantly increased according to PV >80 mL vs <80 mL. However, when stratified according to PV, XPS demonstrates significant advantages compared with HPS, regardless of prostate size in all operative parameters (P <.01). CONCLUSION The new XPS-180 W system exhibits significant advantages in all surgical parameters compared with the HPS-120 W system. Overall, with XPS-180 W and HPS-120 W, mean operative time, laser time, and energy usage increased according to PV. This suggests that preoperative evaluation of PV by transrectal ultrasound should be mandatory.

Photoselective Vaporization of the Prostate for Benign Prostatic Hyperplasia Using the 180 Watt System: Multicenter Study of the Impact of Prostate Size on Safety and Outcomes

PURPOSE We evaluated photoselective vaporization of the prostate using the GreenLight™ XPS™ 180 W system for benign prostatic hyperplasia treatment in a large multi-institutional cohort at 2 years. We particularly examined safety, outcomes and the re-treatment rate in larger prostates, defined as a prostate volume of 80 cc or greater, to assess the potential of photoselective vaporization of the prostate as a size independent procedure. MATERIALS AND METHODS A total of 1,196 patients were treated at 6 international centers in Canada, the United States, France and England. All parameters were collected retrospectively, including complications, I-PSS, maximum urinary flow rate, post-void residual urine, prostate volume, prostate specific antigen and the endoscopic re-intervention rate. Subgroup stratified comparative analysis was performed according to preoperative prostate volume less than 80 vs 80 cc or greater on transrectal ultrasound. RESULTS Median prostate size was 50 cc in 387 patients and 108 cc in 741 in the prostate volume groups less than 80 and 80 cc or greater, respectively. The rate of conversion to transurethral prostate resection was significantly higher in the 80 cc or greater group than in the less than 80 cc group (8.4% vs 0.6%, p <0.01). I-PSS, quality of life score, maximum urinary flow rate and post-void residual urine were significantly improved compared to baseline at 6, 12 and 24 months of followup without significant differences between the prostate size groups. The re-treatment rate at 2 years reported in 5 of 411 patients was associated with the delivery of decreased energy density (2.1 vs 4.4 kJ/cc) in the group without re-treatment. CONCLUSIONS Photoselective vaporization of the prostate using the XPS 180 W system is safe and efficacious, providing durable improvement in functional outcomes at 2 years independent of prostate size when treated with sufficient energy.

KTP/LBO Laser Vaporization of the Prostate

Laser-based treatments have emerged in the past 15 years as an alternative to transurethral resection of the prostate (TURP) for treatment of symptomatic benign prostatic hyperplasia. Increasing demand for a minimally invasive procedure to alleviate lower urinary tract symptoms with greater efficacy and fewer side effects has led to the introduction of various lasers. The excellent clinical outcomes, low morbidity, technical simplicity, and cost-effectiveness of GreenLight laser photoselective vaporization have made this technology a valid and efficacious clinical alternative to TURP.

Spiral Sling Salvage Anti-Incontinence Surgery in Female Patients With a Nonfunctional Urethra: Technique and Initial Results

PURPOSE Female patients with severe urethral incompetence are a unique surgical challenge. Urethral closure and continent diversion are often the next step in the treatment of these patients. We present a technique that provides circumferential coaptation of the urethra as a salvage procedure in this severe subset of patients. MATERIALS AND METHODS We prospectively evaluated 47 patients who had a spiral sling. A 1 x 15 cm piece of soft polypropylene mesh was prepared with a zero polyglactin suture applied at each end. A clamp was used to pass the mesh between the urethra and pubis. The ends of the mesh were crossed at the ventral aspect of the urethra, creating a complete circle around the urethra. The sutures were transferred to the suprapubic area and tied without tension. The surgical outcome was determined by patient self-assessment, including symptom, bother and quality of life questionnaires. RESULTS Mean patient age was 59 years. At presentation patients had undergone a mean of 2.6 incontinence procedures and wore a mean of 6 pads daily. Mean daily pad use decreased to 0.9 (p <0.005). Preoperatively mean SUI symptom severity and bother scores were 2.8 and 2.9, respectively, on a scale of 0--none to 3--severe. Postoperatively these values decreased to 0.6 and 0.4, respectively (each p <0.005). There was a mean 87% overall improvement in symptoms. CONCLUSIONS The spiral sling is an effective salvage transvaginal procedure that may be considered in a small subset of female patients with a nonfunctional urethra as a last resort before urethral closure procedures.

Can We Predict if Overactive Bladder Symptoms Will Resolve After Sling Surgery in Women With Mixed Urinary Incontinence

Persistent overactive bladder and urgency urinary incontinence after sling surgery (pubovaginal sling or midurethral sling) in women with mixed urinary incontinence (MUI) is devastating to patients and frustrating to surgeons who perform anti-incontinence surgery. To better predict the outcomes of sling surgery in women with MUI, preoperative parameters need to be examined to accurately predict postsurgical outcomes. In this review article, we will explore recent literature exploring possible preoperative predictors of persistent overactive bladder and urgency urinary incontinence after sling surgery in women with MUI.

Assessment of energy density usage during 180W lithium triborate laser photoselective vaporization of the prostate for benign prostatic hyperplasia. Is there an optimum amount of kilo-Joules per gram of prostate?

To assess the effect of energy density (kJ/mL) applied on adenoma during photoselective vaporization of the prostate (PVP) treatment for benign prostate hyperplasia (BPH) on functional outcomes, prostate‐specific antigen (PSA) reduction and complications.

How Do Urodynamics Findings Influence the Treatment of the Typical Patient With Overactive Bladder

Overactive bladder (OAB) is a clinical symptom complex whose hallmark is the symptom of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence. Historically, urodynamics (UDS) evaluation has not been recommended in the initial evaluation of OAB, since it is defined primarily by clinical symptoms. As the pathophysiology of the OAB complex has become more clearly elucidated from recent studies, the role of UDS has again become a topic of discussion as a tool that can provide objective data to reflect these new findings. The utility of UDS in the diagnosis and treatment of OAB is still evolving, but in certain clinical scenarios, especially when empiric treatment has failed, it can provide definitive information that can identify associated pathologies and/or alter the treatment course. Herein, we will discuss the current literature regarding use of UDS in OAB patients and offer our own opinions as to its use.

Female Outlet Obstruction after Anti-Incontinence Surgery

Numerous surgical options are available for the management of stress urinary incontinence in women, including urethral bulking agents, pubovaginal slings, retropubic bladder neck suspensions, midurethral slings, and even artificial urinary sphincters. We discuss the incidence, etiology, diagnosis, evaluation, and management of bladder outlet obstruction after anti-incontinence surgery in women. This problem presents with a wide range of symptoms. Urodynamic evaluation is not always diagnostic but can be helpful. Management options range from conservative to invasive. The optimal timeline for intervention is still not well defined, but general guiding principles of management are presented and a comprehensive review of current literature is presented.