Nirit Rosenblum

Managing the urethra at transvaginal pelvic organ prolapse repair: a urodynamic approach.

PURPOSE We evaluated the protocol that we use to determine whether a mid urethral synthetic sling will be placed at transvaginal pelvic organ prolapse repair. MATERIALS AND METHODS A total of 140 patients underwent transvaginal repair for stage 2 to 4 pelvic organ prolapse, of whom 105 were treated according to the protocol and had a minimum 3 months of followup or required earlier intervention. Urodynamics were performed without prolapse reduction. When stress urinary incontinence was not identified, a pessary was placed and the study was repeated. Patients were designated as having urodynamic, occult or no stress urinary incontinence. Patients with urodynamic or occult stress urinary incontinence underwent a simultaneous mid urethral synthetic sling procedure, while those without urodynamic or occult stress urinary incontinence did not. Charts were reviewed to determine whether further intervention was required for stress urinary incontinence or obstruction. RESULTS The risk of intervention due to obstruction after receiving a mid urethral synthetic sling was 8.5%. The risk of intervention for stress urinary incontinence in patients with no clinical, urodynamic or occult stress urinary incontinence and no mid urethral synthetic sling was 8.3%. The risk of intervention for stress urinary incontinence in patients with clinical stress urinary incontinence but no urodynamic or occult stress urinary incontinence and no mid urethral sling was 30%. CONCLUSIONS Using our urodynamic protocol to manage the urethra at transvaginal pelvic organ prolapse repair the risk of intervention due to obstruction is essentially equal to the risk of intervention due to stress urinary incontinence when no clinical, urodynamic or occult stress urinary incontinence was present and no mid urethral synthetic sling was placed. In patients who report clinical stress urinary incontinence preoperatively despite no urodynamic or occult stress urinary incontinence there is a much higher rate of further intervention for stress urinary incontinence.

THE ROLE OF PREOPERATIVE EPOETIN ALFA IN MEN UNDERGOING RADICAL RETROPUBIC PROSTATECTOMY

PURPOSE The safety and effects on hematocrit of recombinant human erythropoietin (epoetin alfa) were evaluated in men undergoing radical retropubic prostatectomy. MATERIALS AND METHODS Between February 1, 1997 and November 2, 1998, 305 men with clinically localized adenocarcinoma of the prostate underwent radical retropubic prostatectomy performed by a single surgeon (H. L.). Of these men 283 with a baseline hematocrit of less than 48% received 600 IU/kg. epoetin alfa 14 days (-14) and 7 days (-7) before radical retropubic prostatectomy. Hematocrit was measured at baseline on day -14, on day -7, just before anesthesia induction on day 0, immediately postoperatively and on the day of discharge home. The number of allogeneic units transfused, and all intraoperative and postoperative complications were recorded. RESULTS Mean hematocrit at baseline on day -14 and at induction on day 0 was 42.9% and 45.8%, respectively (p = 0.0001). The frequency of hematocrit decreasing, showing no change or increasing 0.1 to 1.9, 2.0 to 3.9 or greater than 4.0 hematocrit points was 16.5%, 0.5%, 23%, 22% and 38%, respectively. Of the men 17% had no increase in hematocrit. A weak correlation existed between baseline hematocrit and the erythropoietic response to epoetin alfa (r2 = 0.06). Mean change in hematocrit after treatment with epoetin alfa in the quartile baseline hematocrit groups 34.2 to 41.4, 41.5 to 43.2, 43.3 to 44.9 and 45.0 to 48.0 hematocrit points was 3.71, 2.45, 3.86 and 1.02 hematocrit points, respectively. Of the surgical candidates 22 (9.1%) achieved an induction hematocrit of greater than 51%. Of the 283 men receiving epoetin alfa 21 (7.4%) also received an allogeneic transfusion. The transfusion rate did not correlate with induction hematocrit. The only adverse cardiovascular event was an uncomplicated postoperative pulmonary embolus. CONCLUSIONS Our prospective study demonstrates that epoetin alfa given preoperatively in 2 doses of 600 IU/kg. is safe for significantly increasing hematocrit in men before radical retropubic prostatectomy. It is intuitive that the significant increase in hematocrit decreases the requirement for allogeneic blood transfusion.

MRI of Pelvic Floor Dysfunction: Dynamic True Fast Imaging with Steady-State Precession Versus HASTE

OBJECTIVE The objective of our study was to retrospectively compare the degree of pelvic organ prolapse shown on dynamic true fast imaging with steady-state precession (FISP) versus HASTE sequences in symptomatic patients. MATERIALS AND METHODS Fifty-nine women (mean age, 57 years) with suspected pelvic floor dysfunction underwent MRI using both a sagittal true FISP sequence, acquired continuously during rest alternating with the Valsalva maneuver, and a sagittal HASTE sequence, acquired sequentially at rest and at maximal strain. Data sets were evaluated in random order by two radiologists in consensus using the pubococcygeal line (PCL) as a reference. Measurement of prolapse was based on a numeric grading system indicating severity as follows: no prolapse, 0; mild, 1; moderate, 2; or severe, 3. A comparison between sequences on a per-patient basis was performed using a Wilcoxons analysis with p < 0.05 considered significant. RESULTS Overall, 66.1% (39/59) of patients had more severe prolapse (>or= 1 degrees ) based on dynamic true FISP images, with 28.8% (17/59) of the cases of prolapse seen exclusively on true FISP images. Only 20.3% (12/59) of patients had greater degrees of prolapse on HASTE images than on true FISP images, with 10.2% (6/59) of the cases seen exclusively on HASTE images. A statistically significant increase in the severity of cystoceles (p < 0.01) and urethral hypermobility (p < 0.01)-with a trend toward more severe urethroceles (p < 0.07), vaginal prolapse (p < 0.09), and rectal descent (p < 0.06)-was shown on true FISP images. CONCLUSION Overall, greater degrees of organ prolapse in all three compartments were found with a dynamic true FISP sequence compared with a sequential HASTE sequence. Near real-time continuous imaging with a dynamic true FISP sequence should be included in MR protocols to evaluate pelvic floor dysfunction in addition to dynamic multiplanar HASTE sequences.

Comparison of two different doses of preoperative recombinant erythropoietin in men undergoing radical retropubic prostatectomy

OBJECTIVES To determine whether the response to recombinant erythropoietin is dose dependent in men undergoing radical prostatectomy and to elucidate the relative cost-effectiveness of two dosing regimens. METHODS A prospective, open-label study comparing the effectiveness, cost, and safety of two different doses of recombinant erythropoietin was performed in men undergoing radical retropubic prostatectomy. The first 100 men received 600 IU/kg (high dose) of epoetin alfa. A second group of 100 men received 300 IU/kg (low dose). All men received two doses of erythropoietin on preoperative days 14 and 7, provided their baseline hematocrit levels were less than 48%. Hematocrit levels were measured at baseline (more than 14 days before surgery), at the time of anesthesia induction, in the recovery room postoperatively, on the first postoperative day, and on the morning of discharge. RESULTS The mean increase in hematocrit from baseline to induction for the high and low-dose groups was 4.50 and 4.69, respectively (P = 0.7225). Six men (6%) in the high-dose group and seven (7%) in the low-dose group required allogenic blood transfusions. The mean cost of high and low-dose epoetin alfa was

Post-urethral suspension obstruction.

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Urodynamics for Clinically Suspected Obstruction After Anti- Incontinence Surgery in Women

656, respectively. The cost per percentage point increase in hematocrit in the low-dose group was significantly less than in the high-dose group. No thromboembolic events occurred in the high or low-dose group. CONCLUSIONS In men undergoing radical retropubic prostatectomy, the administration of epoetin alfa on preoperative days 14 and 7 was a safe and effective treatment strategy for reducing the risk of allogenic blood transfusions. The 300 IU/kg dosing regimen was significantly more cost effective than the 600 IU/kg dosing regimen.

Robotic approaches to prolapse surgery.

Urethral obstruction is a consequence of surgery to treat stress incontinence in women. Although its incidence is relatively low, it still presents a challenging problem for the urologist. Recent work has focused on clarifying the etiology and incidence of this condition, as well as providing new definitions on bladder-outlet obstruction in women. In addition, effective, less invasive ways of treating this condition have been described.

Surgical management of Skene’s gland abscess/infection: a contemporary series

PURPOSE We determined the usefulness of urodynamics in patients with obstruction secondary to anti-incontinence surgery. MATERIALS AND METHODS We retrospectively reviewed the records of all procedures performed from January 2001 to June 2011 to relieve obstruction due to anti-incontinence surgery. Patients were excluded from study if they underwent prior procedures to relieve obstruction, followup data were missing or a neurological disorder was present. Patients were grouped into categories before intervention, including urodynamics diagnostic of obstruction vs nondiagnostic urodynamics vs no urodynamics testing. We also separated patients with predominantly storage symptoms and those with incomplete emptying. RESULTS A total of 71 women were included in analysis. Of 54 women who presented with increased post-void residual urine volume 33 (61%) were diagnosed with obstruction on urodynamics, urodynamics was not diagnostic in 4 (7.4%) and 17 (32%) did not undergo urodynamics preoperatively. All 18 patients with predominantly storage symptoms underwent urodynamics. In patients with incomplete emptying there was no difference between the groups in storage or voiding symptom improvement, overall cure or success according to whether diagnostic urodynamics were or were not done. Of patients with storage symptoms who underwent urodynamics those without evidence of detrusor overactivity had significantly greater storage symptom improvement than those with detrusor overactivity (85.7% vs 53.8%, p = 0.02). CONCLUSIONS When voiding symptoms or urinary retention is the primary indication for intervention after anti-incontinence surgery, urodynamic findings are not predictive of outcomes after intervention to relieve obstruction. If storage symptoms are the main indication for intervention, urodynamics may be valuable for patient counseling.

Anatomy of Pelvic Support

Purpose of review Pelvic reconstructive surgeons in the fields of urology, gynecology and urogynecology have continually adapted new techniques in pelvic organ prolapse (POP) repair in order to improve both anatomic and subjective outcomes. In the last 5 years, robotic surgery has gained a strong foothold in urologic oncology, gynecologic oncology, cardiothoracic surgery and now in female pelvic medicine. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the ‘gold standard’ technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. This review article aims to discuss the techniques of robotic prolapse repair as well as morbidity, cost and clinical outcomes. Recent findings The adaptation of minimally invasive approaches to the treatment of POP initially began with laparoscopy, something only those surgeons with extensive and advanced laparoscopic skills are able to accomplish. Access to robotic technology makes conversion from open or laparoscopic to robotic surgery much more feasible for most pelvic floor surgeons. There are currently no published randomized, controlled trials comparing robotic with open or laparoscopic sacrocolpopexy, however, there are several publications reporting both retrospective and prospective series of women undergoing robotic-assisted sacrocolpopexy. Summary Robotic-assisted pelvic floor surgery has become an important component of the pelvic surgeons armamentarium in the treatment of symptomatic POP. Those pelvic surgeons without significant expertise in laparoscopy required for sacral dissection and intracorporeal suturing can readily learn the necessary techniques required for robotic surgery.

Uterine sparing robotic-assisted laparoscopic sacrohysteropexy for pelvic organ prolapse: safety and feasibility.

Introduction and hypothesisWe report our experience with surgical excision for treatment of Skene’s gland abscess/infection after conservative measures have failed.MethodsA retrospective review of patients that underwent surgical excision of Skene’s gland abscess/infection by a single surgeon from 06/1995 to 09/2008 was performed. Patients were separated into groups based on indication for procedure. Recurrence rate and success rate were calculated.ResultsThe final study group included 34 patients. After initial excision, 88.2% (30/34) of patients had resolution of symptoms. Recurrence of signs and symptoms that prompted further treatment occurred in 30% (9/30). In those that recurred, 88.8% (8/9) of patients had resolution of symptoms after further therapy. Overall success rate in complete resolution of symptoms after all treatment was 85.3%. Only patients to fail were in the urethral pain and recurrent UTI groups.ConclusionSurgical excision is a safe and effective therapy for the treatment of Skene’s gland abscess/infection after conservative measures have failed.