Ryan M. Krlin

Treatment of overactive bladder: what is on the horizon?

There is still a need to develop additional effective and well-tolerated therapies for the treatment of overactive bladder (OAB). The purpose of this review is to discuss alternative therapies for idiopathic OAB that employ a unique mechanism of action or offer a novel application of an existing therapy. We performed a comprehensive literature review to identify alternative therapies and potential future treatments for idiopathic OAB. The use of botulinumtoxin for idiopathic OAB is on the rise and FDA approval will likely be granted in the future. New innovations in neuromodulation hold the promise of less invasive and more patient-controlled therapies. A number of novel medications, such as β-adrenoreceptor agonists, or medications with alternative indications, such as phosphodiesterase inhibitors, have been identified as potential therapies for OAB. In addition, novel drug delivery systems, such as vaginal inserts, are also in development and may provide an attractive mechanism to deliver medications with proven efficacy. While conservative measures such as behavioral modification and pelvic floor exercises remain first-line therapy for OAB, anti-muscarinics are the mainstay of medical treatment. For patients with idiopathic OAB refractory to traditional first-line therapies, a number of promising new treatments are on the horizon.

Selective Management of the Urethra at Time of Pelvic Organ Prolapse Repair: An Assessment of Postoperative Incontinence and Patient Satisfaction

PURPOSE Management of the urethra in women without stress urinary incontinence during pelvic organ prolapse repair can be approached selectively or with a prophylactic suburethral sling. We report on patient satisfaction and outcomes in patients who underwent selective urethral management during pelvic organ prolapse repair. MATERIALS AND METHODS Patients undergoing repair of advanced apical and/or anterior compartment pelvic organ prolapse underwent prolapse reduction to screen for stress urinary incontinence. Patients with clinical, occult and urodynamic stress urinary incontinence underwent a sling procedure. Those without stress urinary incontinence did not undergo sling surgery. Patients completed responses to the UDI-6 (Urogenital Distress Inventory, PGI-I (Patient Global Impression of Improvement) and MESA (Medical, Epidemiological, and Social Aspects of Aging). Cost analysis of selective urethral management was completed. RESULTS A total of 42 patients met the study inclusion criteria and 30 completed responses to all questionnaires. Patients were separated into prolapse repair only (14) and prolapse repair with sling (16) groups. In the prolapse repair only group 1 patient required a subsequent sling. Mean UDI-6, MESA urge and MESA stress scores were 3.71, 1.29 and 3.14 in the prolapse repair only group, and 2.31 (p=0.219), 2.69 (p=0.244) and 3.00 (p=0.918) in the prolapse repair with sling group, respectively. The PGI-I revealed no statistical difference between the groups. A total cost savings of

Pro: the contemporary use of transvaginal mesh in surgery for pelvic organ prolapse.

55,804 was achieved using selective urethral management. CONCLUSIONS Patients undergoing prolapse repair only have continence and satisfaction outcomes that appear equivalent to those who underwent concomitant prolapse repair and sling. The decision to perform a concomitant sling at the time of prolapse repair should be tailored to the patient.

Surgical repair of pelvic organ prolapse in elderly patients.

Purpose of review This review will focus on the strengths of transvaginal mesh-augmented repairs over traditional native tissue repairs with an emphasis on the more recent literature. Recent findings Recent attention from the Food and Drug Administration has prompted a re-evaluation of the use of commercial mesh kits in pelvic organ prolapse (POP) repair. Mesh kits for POP repair were recently reclassified from Class 2 medical devices to Class 3 medical devices, a policy change that will prompt additional trials for POP repair in the future. The statements published by the FDA and the reclassification of mesh kits have generated a debate regarding the use of mesh in POP repairs. Summary Higher complication rates involving mesh exposures have been documented in the past leading to the recent controversy; however, current mesh studies with longer term follow-up show lower and acceptable exposures with improved objective and subjective outcomes.

Mid-urethral slings in female incontinence: Current status.

Purpose of review Epidemiologic data suggests that our population greater than 65 years of age will nearly double. In addition, the incidence of women undergoing surgery for pelvic organ prolapse will rise. Chronologic age does not preclude a woman from undergoing a reconstructive procedure, yet the preoperative assessment should be approached most judiciously with great care to insure patient is maximally medically prepared for surgery. Recent findings Surgical procedures in this review include: the abdominal sacral colpopexy, anterior repair, posterior repair, sacrospinous ligament fixation, uterosacral suspension, and iliococcygeus fixation. The advent of robotic surgery has decreased the perioperative morbidity of several of these procedures. However, the risk of more severe complications does appear higher following robotic procedures, when compared with vaginal procedures. Summary Intuitively, one would surmise that there is a point where vaginal surgery should be considered as the primary procedure based on age, risk and durability of the surgery – unfortunately that age is not clear. Thus, the proper selection of prevalence of organ prolapse surgery can only be done after careful discussion with the patient and including the patient in the selection process as much as possible.

Utility of postoperative laboratory studies after female pelvic reconstructive surgery

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring ones choice of MUS to the individual patient and her unique clinical parameters remains the best option.