Tracey Wilson

Urolume Stents: Lessons Learned

PURPOSE The UroLume (American Medical Systems, Minnetonka, Minnesota) endoprosthesis has been commercially available since 1990 and has been advocated for use in men with urethral stricture disease and detrusor-sphincter dyssynergia due to spinal cord injury. Despite reports of its success and ease of removal, we have noted management problems in several complex cases. MATERIALS AND METHODS We retrospectively analyzed the outcome of 10 men who required several additional procedures or experienced complications following UroLume placement. RESULTS Of the patients 4 had detrusor-sphincter dyssynergia and 6 had urethral stricture disease. All patients with detrusor-sphincter dyssynergia required hospitalization for management of urosepsis within 4 to 10 months of stent placement, and all 4 experienced stent migration requiring placement of a tandem stent (3), bladder neck resection (3) or sphincterotomy (1). Two men were in retention following placement of a second stent and required stent explantation. Of the other 6 men 2 had bulbar and 3 had membranous urethral disease, and 1 had a severe bladder neck contracture following radical retropubic prostatectomy. Strictures recurred within the stent lumen in all 6 men and/or adjacent to it in 3. At least 1 repeat procedure was required in all 6 men (within 6 months in 5), and 1 experienced significant bleeding during open explantation which required perineal urethrostomy. CONCLUSIONS In our referral experience stent migration and recurrent stenosis were noted following UroLume insertion. Placement of a tandem stent was associated with urethral obstruction. In many cases these adverse outcomes may be secondary to improper patient selection. Therefore, judicious use of the UroLume stent and proper case selection are essential since stent removal is not always straightforward.

Three-dimensional ultrasonography: an objective outcome tool to assess collagen distribution in women with stress urinary incontinence

OBJECTIVES To examine the distribution of periurethral collagen by three-dimensional ultrasonography (3D US) and to incorporate this technology into a practical treatment decision tree for women with stress urinary incontinence desiring collagen injection. METHODS Forty-six women who received periurethral collagen injection were assessed with 3D US to document the position and volume of collagen around the urethra. Patients with a good clinical response were observed with serial 3D US scans. Women with no persistent improvement who showed a low volume or asymmetric distribution of collagen were offered repeat injections. When the patient had no improvement despite symmetric or circumferential distribution of collagen with good volume retention, another anti-incontinence treatment was recommended. Group 1 was composed of women who had a good clinical outcome and group 2 of those who did not. A statistical comparison between the two outcome groups was done to determine whether any particular distribution pattern was associated with an increased likelihood of clinical success. RESULTS Of the 46 patients, 21 (46%) were satisfied with their continence after their last periurethral collagen injection, with a median follow-up of 14.0 months (range 2 months to 4.25 years). A significantly greater proportion of patients in group 1 had circumferentially distributed collagen on 3D US compared with those in group 2 (62% versus 20%, P = 0.006). CONCLUSIONS Circumferential distribution of collagen around the urethra is associated with a higher likelihood of clinical success. The assessment of periurethral collagen by 3D US provides an affordable, noninvasive, objective outcome measure that may aid in treatment planning.

Sexual activity and function in women more than 2 years after midurethral sling placement

OBJECTIVE The purpose of this study was to assess prospectively the effects of midurethral sling surgery on sexual function and activity. STUDY DESIGN Sexual activity and function was assessed in 597 women with stress urinary incontinence who were enrolled in a randomized equivalence trial of retropubic compared with transobturator midurethral slings. Repeated measures analysis of variance was used to assess changes in Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores over a 2-year period. RESULTS Significant, similar improvements in sexual function were seen in both midurethral sling groups. Mean Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores increased from 32.8 at baseline to 37.6 at 6 months and 37.3 at 24 months (P < .0001). Dyspareunia, incontinence during sex, and fear of incontinence during sex each significantly improved after surgery. Preoperative urge incontinence was associated with abstinence after surgery (P = .02); postoperative urge incontinence negatively impacted sexual function (P = .047). CONCLUSION Midurethral sling surgery for stress urinary incontinence significantly improves sexual function, although coexistent urge incontinence has a negative impact.

Effects of concomitant surgeries during midurethral slings (MUS) on postoperative complications, voiding dysfunction, continence outcomes, and urodynamic variables.

OBJECTIVE To determine whether concomitant surgeries affected outcomes in a randomized trial comparing retropubic midurethral sling (MUS) vs transobturator MUS. METHODS Subjects (n = 597) were stratified into 4 groups based on type of concomitant surgeries: group I had anterior/apical with or without posterior repairs (n = 79, 13%); group II had posterior repairs or perineorrhaphy only (n = 38, 6%); group III had nonprolapse procedures (n = 34, 6%); and group IV had no concomitant surgeries (n = 446, 75%). Complication rates, voiding dysfunction, objective and subjective surgical failure rates, and changes in urodynamic values (postop minus preop) were assessed and compared in these 4 groups. RESULTS There were no differences in complications, voiding dysfunction, and subjective failure outcomes between these 4 groups. Group I had lower odds ratio of objective surgical failure compared with group IV (OR 0.38, 95% CI 0.18-0.81, P = .05). The OR of failure of all patients undergoing concomitant surgeries (groups I-III) was lower than group IV (OR 0.57, 95% CI 0.35-0.95, P = .03). The change in Pdet@Qmax (from pressure-flow) was significantly higher in group III vs IV (P = .01). The change in Q(max.) (from uroflowmetry) was significantly less in groups I and II vs group IV (P = .046 and .04, respectively). CONCLUSION Concomitant surgeries did not increase complications. Subjects who underwent certain concomitant surgeries had lower failure rates than those undergoing slings only. These data support safety and efficacy of performing concomitant surgery at the time of MUS.

Preoperative voiding detrusor pressures do not predict stress incontinence surgery outcomes

Introduction and hypothesisThe aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery.MethodsOpening detrusor pressure, detrusor pressure at maximum flow (pdet Qmax), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests.ResultsThere were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes.ConclusionsWe found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.

Management of recurrent stress urinary incontinence after burch and sling procedures

To examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow‐up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures.

Perineal surface electromyography does not typically demonstrate expected relaxation during normal voiding

To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms.

Two-Year Outcomes of Sacral Neuromodulation Versus OnabotulinumtoxinA for Refractory Urgency Urinary Incontinence: A Randomized Trial

BACKGROUND Urgency urinary incontinence (UUI) is a chronic condition for which sacral neuromodulation (SNM) (InterStim/Medtronic) and onabotulinumtoxinA (BTX) (BotoxA/Allergan) are utilized. These therapies have not been compared over extended time. OBJECTIVE To compare UUI episodes (UUIE) over 24 mo following SNM or BTX. DESIGN, SETTING, AND PARTICIPANTS Multicenter, open-label, randomized, extension trial (February 2012-July 2016) at nine US medical centers involving 386 women with ≥6 UUIE over 3 d inadequately managed by medications. Participants were clinical responders to treatment: ≥50% reduction in UUIEs after SNM placement or 1 mo post BTX. INTERVENTION SNM (n=194) versus 200 U BTX (n=192). SNM reprogrammings occurred throughout the 24 mo. After 6 mo, two additional BTX injections were allowed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcome: change in mean daily UUIE over 24 mo. SECONDARY OUTCOMES no UUIE, ≥75% and ≥50% UUIE reduction; Overactive Bladder Questionnaire Short Form; Urinary Distress Inventory short form; Incontinence Impact Questionnaire; Patient Global Impression of Improvement; Overactive Bladder Satisfaction of Treatment Questionnaire; and adverse events (AEs). Primary analysis used a linear mixed model. RESULTS AND LIMITATIONS Outcome data were available for 260/298 (87%) clinical responders. No difference in decreased mean UUIE was found over 24 mo (-3.88 vs -3.50 episodes/d,95% confidence interval [CI]=-0.14-0.89; p=0.15), with no differences in UUI resolution, ≥75% or ≥50% UUIE reduction. BTX group maintained higher satisfaction (mean difference=-9.14, 95% CI=-14.38--3.90; p<0.001), treatment endorsement (mean difference=-12.16, 95% CI=-17.7--6.63; p<0.001) through 24 mo. Other secondary measures did not differ. Recurrent urinary tract infections (UTIs) were higher after BTX (24% vs 10%; p<0.01), 6% required intermittent catheterization post second injection. SNM revision and removals occurred in 3% and 9% patients, respectively. CONCLUSIONS Both treatments offered sustainable UUI improvement, and higher BTX dosing had low clean intermittent catheterization rates, but with UTI risk. SNM revision/removal rates were low due to standardized lead placement with strict treatment response definitions. PATIENT SUMMARY We compared a large group of US women with severe urgency urinary incontinence (UUI) who received sacral neuromodulation (InterStim) or onabotulinumtoxinA (Botox A) therapy during a 2-yr period. We found that both therapies had similar success in reducing UUI symptoms, and adverse events were low. However, women in the BotoxA group had higher satisfaction and endorsement with their treatment, but with a higher chance of a urinary tract infection. We conclude that both therapies offer sustained reduction in daily incontinence over 2 yr.

Sacral neuromodulation effects on periurethral sensation and urethral sphincter activity

To characterize the effect of sacral neuromodulation (SNM) on urethral neuromuscular function.

Comparison of flowrates and voided volumes during non-instrumented uroflowmetry and pressure-flow studies in women with stress incontinence.

The Blaivas–Groutz nomogram defines voiding obstruction in women using Qmax from the NIF and the maximum detrusor pressure (Pdetmax) from the PFS. The aim of this study was to understand the relationship between NIF and PFS maximum flow rates in women with stress incontinence.