Maude Carmel

Long-term efficacy of the bone-anchored male sling for moderate and severe stress urinary incontinence.

Study Type – Therapy (outcomes research)
Level of Evidence 2c

Expression and role of the angiotensin II AT2 receptor in human prostate tissue: In search of a new therapeutic option for prostate cancer

Evidence shows that angiotensin II type 1 receptor (AT1R) blockers may be associated with improved outcome in prostate cancer patients. It has been proposed that part of this effect could be due to angiotensin II type 2 receptor (AT2R) activation, the only active angiotensin II receptor in this situation. This study aimed to characterize the localization and expression of AT2R in prostate tissues and to assess its role on cell morphology and number in prostatic epithelial cells in primary culture.

Change in Overactive Bladder Symptoms After Surgery for Stress Urinary Incontinence in Women.

OBJECTIVE: To assess change in overactive bladder (OAB) symptoms up to 5 years after surgery and to identify associated predictors of change from baseline. METHODS: This is a secondary analysis of data from three multicenter urinary incontinence (UI) surgical trials of women with stress-predominant mixed UI assigned to Burch colposuspension, autologous fascial sling, or retropubic or transobturator midurethral slings. The primary outcome was improvement of 70% or greater from baseline in symptoms measured by the Urinary Distress Inventory–Irritative subscale. Surgical groups were compared within respective trials. Generalized linear models were fit using 1-year and up to 5-year data. RESULTS: Significant improvements in Urinary Distress Inventory–Irritative scores were reported by each surgical group 1 year after surgery (P<.001). Most women (50–71%) reported improvement in OAB symptoms. Improvements were similar between midurethral sling groups at 1 year (65.5% compared with 70.7%, P=.32; odds ratio [OR] 0.83, 95% confidence interval [CI] 0.57–1.20 for retropubic compared with transobturator sling) and throughout the 5-year follow-up period. More women reported OAB symptom improvement after Burch compared with pubovaginal sling (67.9% compared with 56.6%, P=.01; OR 1.59, 95% CI 1.10–2.31 for Burch compared with sling); this group difference at 1 year persisted throughout the 5-year follow-up. At 1-year, 50.0–64.3% of patients reported 70% greater improvement in UI. This proportion declined to 36.5–54.1% at 5 years (P<.001). Preoperative use of anticholinergics and urodynamic parameters was not predictive of OAB symptom change after surgery. CONCLUSION: Most women with stress-predominant mixed UI experienced significant improvement in OAB symptoms after incontinence surgery although this initial improvement diminished over time. Obesity blunted symptom improvement. LEVEL OF EVIDENCE: II

Transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women

We present the surgical management and outcomes of patients who underwent transvaginal neo‐bladder vaginal fistula (NBVF) repair at our institution.

Postoperative Imaging after Surgical Repair for Pelvic Floor Dysfunction

Pelvic floor dysfunction encompasses an extremely common set of conditions, with various surgical and nonsurgical treatment options. Surgical options include injection of urethral bulking agents, native tissue repair with or without bioabsorbable or synthetic graft material, placement of synthetic midurethral slings or use of vaginal mesh kits, and mesh sacrocolpopexy procedures. Numerous different synthetic products with varied imaging appearances exist, and some of these products may be difficult to identify at imaging. Patients often present with recurrent or new symptoms after surgery; and depending on the presenting complaint and the nature of the initial intervention, imaging with ultrasonography (US), magnetic resonance (MR) imaging, voiding cystourethrography, or computed tomography (CT) may be indicated. US and MR imaging can both be used to image urethral bulking agents; US is often used to follow potential changes in bulking agent volume with time. Compared with MR imaging, US depicts midurethral slings better in the urethrovaginal space, and MR imaging is better than US for depiction of the arms in the retropubic space and obturator foramen. Mesh along the vaginal wall may be depicted with both US and MR imaging; however, the distal arms of the mesh traversing the sacrospinous ligaments or within the ischiorectal fossae (ischioanal fossae) are better depicted with MR imaging. Scarring can mimic slings and mesh at both US and MR imaging. MR imaging is superior to US for depiction of sacrocolpopexy mesh and associated complications. Voiding cystourethrography and CT are used less commonly because they rarely allow direct depiction of implanted material. Online supplemental material is available for this article. (©)RSNA, 2016.

Urodynamics findings in transverse myelitis patients with lower urinary tract symptoms: Results from a tertiary referral urodynamic center

To characterize urodynamic findings in patients referred with transverse myelitis (TM) and lower urinary tract symptoms (LUTS), as well as to identify any characteristics predictive of urodynamics findings.

Troubleshooting Sacral Neuromodulation Issues

In the past decade, the use of sacral neuromodulation has increased exponentially. The introduction of the tined lead, the posterior location, and the smaller IPG has changed the frequency and types of complications. These facts explain the reduction of the revision and explantation rates in the most contemporary series, as compared with the earlier data. Infection, pain at the IPG site, and reduced clinical response with or without impedance abnormalities are now the most frequently reported complications. Although infection should be managed with explantation of the entire system, device interrogation should be part of the physician’s algorithm for managing patients with decreased sensation or new onset of pain, in order to check the integrity of the system. Patients who are not improved with new programs will most likely need surgical revision. The implanting physician should be aware of the ways to evaluate and manage complications and suboptimal responses, to appropriately troubleshoot patients, and to reduce the need for surgical revision.

Patterns of Hardware Related Electrode Failures in Sacral Nerve Stimulation Devices

PURPOSE Abnormal electrical impedance in sacral nerve stimulation devices is a cause of device failure. Currently, there is scant literature evaluating the incidence and management of this problem. We evaluated the presentation, characteristics and management of sacral nerve stimulation devices with abnormal electrical impedance. MATERIALS AND METHODS A total of 565 patients were permanently implanted with sacral nerve stimulation devices using a tined lead between 2003 and 2011. Devices were interrogated postoperatively and at followup. Abnormal electrical impedance was classified as open circuit--impedance greater than 4,000 Ω or short circuit--impedance less than 50 Ω and/or equivalence of impedance. Details on presentation, characteristics and management were recorded. RESULTS Of the 565 patients 72 (12.7%) experienced a total of 86 abnormal electrical impedance events, of which 57 (66.2%) were open circuits and 28 (32.5%) were short circuits. One event (1.1%) was a simultaneous open and short circuit. Short circuits presented earlier than open circuits (median 3.5 months, IQR 2-7.5 vs 15, IQR 5.5-30.5, p <0.0001) and required surgical intervention more often (75.0% vs 54.3%, p = 0.09). Patient specific factors, such as trauma history and change in body mass index class, were not associated with abnormal electrical impedance. No electrode failure patterns could be identified. CONCLUSIONS Abnormal electrical impedance occurred in approximately 13% of cases permanently implanted in our series. Short circuits presented earlier and often required surgical intervention. Open circuits presented later and may have potentially been secondary to microfractures that accumulate with time at the sacral plate, resulting in later presentation. Almost a third of patients with abnormal electrical impedance associated with clinical inefficacy were treated conservatively, primarily with reprogramming.

Definition of Success after Surgery for Female Stress Incontinence or Voiding Dysfunction: An Attempt at Standardization

CONTEXT There is currently no standardized definition of success for surgery for stress urinary incontinence (SUI) and voiding dysfunction (VD) in women. OBJECTIVE To review the use of outcome measures (OMs) and definitions of success in the literature on SUI and VD surgery in women in an attempt to provide recommendations for future publications. EVIDENCE ACQUISITION A PubMed search of all English language full-text articles on SUI and VD surgery in women published between 2010 and 2015 was performed. A list of randomized trials and prospective and retrospective studies was obtained. Specific objective and subjective OMs used to define success were reviewed. EVIDENCE SYNTHESIS Some 95 articles met the inclusion criteria for SUI surgery outcomes. Most trials reported outcomes at 12 mo after surgery. The majority (n=48) reported their primary outcomes using both objective and subjective success measures, 24 defined success using subjective OMs alone, and 23 using objective OMs alone. The OMs most frequently used for objective success were a negative cough stress test (CST), a negative pad test, and the absence of retreatment for SUI. The definition of subjective success most often involved questionnaires. The questionnaires most frequently used were Patient Global Impression of Improvement (PGI-I), Urinary Distress Inventory (UDI)/UDI-6, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) and Medical Epidemiologic and Social Aspects of Aging (MESA). Only 11 studies on OMs used for VD surgery were published between 2010 and 2015. The two most common criteria used for success were measurement of postvoid residual urine (PVR) and subjective resolution of VD symptoms. CONCLUSIONS There is great heterogeneity in the definition of success used after surgery for SUI or VD in women. For SUI surgery, we recommend use of the CST and a 1-h pad test for the definition of objective success, and of the UDI/UDI-6, Incontinence Impact Questionnaire (IIQ), Kings Health Questionnaire (KHQ), ICIQ-SF, or PGI-I questionnaire for subjective success. For VD surgery, cure should include measurement of PVR and self-reported resolution of VD symptoms. PATIENT SUMMARY We looked at the definition of success used for surgery for stress urinary incontinence (SUI) and voiding dysfunction (VD) in women. We found that there is great heterogeneity among studies, making study comparison extremely difficult. According to the outcome measures used most frequently, we make recommendations regarding the definition of cure for SUI and VD in women to be used in future publications.

A modified approach to patient's selection with improved clinical outcomes in sacral nerve modulation

INTRODUCTION Since the marketing of the percutaneous permanent tined leads (PPTL), many centres rely solely on these instead of the percutaneous nerve evaluation (PNE) as a screening tool. At our centre, we routinely perform PNE. Moreover, with our limited hospital resources, we have adopted a stricter definition of success in the patient selection process using an improvement of more than 60% as a cut-off point. This study presents our experience with sacral nerve stimulation using PPTL as an adjunct to PNE to improve the outcome of the screening method for patients suffering from refractory voiding dysfunction. METHODS We reviewed the charts of 106 patients who underwent a PNE between 2001 and 2008. The outcome of the procedures, the complication rates and its long-term effect were reviewed. RESULTS Overall, 116 PNE were performed and it was successful in 54%. Forty-five out of the 62 patients with a successful PNE underwent the stage I procedure. Of these, 93% had a successful stage I and were later implanted with the implantable pulse generator (IPG). The remaining 12 patients underwent the simultaneous implantation of the PPTL and IPG using the open procedure and it was successful in 10 of them. CONCLUSION The PNE is a good adjunct to the staged procedure to select the appropriate candidates for sacral nerve stimulation, especially with limited resources.