William Stuart Reynolds

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction.

ABSTRACT Introduction: Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

Phenotyping women with detrusor underactivity by presumed etiology: Is it plausible?

Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies.

Contemporary Comparison Between Retropubic Midurethral Sling and Autologous Pubovaginal Sling for Stress Urinary Incontinence After the FDA Advisory Notification

OBJECTIVE To compare the efficacy and safety in a contemporary cohort of women who were offered either a pubovaginal sling (PVS) or a synthetic midurethral sling (MUS) after the U.S. Food and Drug Administration notification and made an informed decision on procedure option. METHODS A total of 201 women were given the option between a PVS and an MUS. Prior anti-incontinence surgery and concomitant surgery other than hysterectomy were not allowed. Minimal follow-up was 12 months. Patients were prospectively followed with validated quality of life questionnaires. Cure, voiding complaints, and complications were compared between the groups. RESULTS Ninety-one women (45%) underwent PVS and 110 underwent MUS (55%). Median follow-up was 13.8 months. There was no difference in baseline characteristics between the groups except for the prevalence of urge incontinence. Subjective improvement in questionnaire scores was significant for both groups. Cure rate was accomplished in 75.8% of the PVS group patients compared with 80.9% of the MUS group patients (hazard ratio, 1.35; 95% confidence interval, 0.69-2.7; P = .38). Complications and voiding difficulty were similar between the groups. CONCLUSION In this contemporary cohort of women considered suitable candidates for either a PVS or an MUS, both offer comparable efficacy and complication rates. PVS may be safely offered to patients who would otherwise be good candidates for MUS if they are concerned with the implantation of mesh.

Autologous Pubovaginal Sling for the Treatment of Concomitant Female Urethral Diverticula and Stress Urinary Incontinence

OBJECTIVE To describe our experience with concomitant repair of urethral diverticula and stress urinary incontinence (SUI) with autologous pubovaginal sling (PVS). METHODS A retrospective chart review between January 2006 and 2013 identified 38 women undergoing concomitant diverticulectomy and rectus sheath PVS. Patient demographics, presenting symptoms, prior urethral surgery, concomitant procedures, postoperative outcomes, and complications were evaluated. RESULTS The mean duration of symptoms was 56.7 months. Eleven patients presented with recurrent diverticula and 5 patients had prior SUI surgery (3 midurethral slings, 1 PVS, and 1 bulking agent). One patient had a prior urethrolysis. All other slings were cut or excised at the time of surgery. All women had demonstrable SUI on cough stress test or urodynamics. The mean follow-up was 12.7 months. All postoperative voiding cystourethrograms were negative for contrast extravasation. One patient required prolonged (>4 weeks) suprapubic tube drainage for urinary retention. Four others required an additional 1 week of suprapubic tube drainage. Eighteen patients (47%) reported mixed urinary symptoms. Of these, 9 had complete resolution, whereas 9 experienced significant improvement. Overall, 97.3% reported resolution of their dysuria, dyspareunia, and pain symptoms and 90% reported complete resolution of their SUI symptoms. There were 2 urethral diverticula recurrences and 2 SUI recurrences. Perioperative complications, including hemorrhage, sling erosion, or urethrovaginal fistulas, were not observed. CONCLUSION Concomitant PVS placement is a safe and effective treatment option for SUI in patients undergoing urethral diverticulectomy. The risks and benefits should be weighed and management individualized.

Temporal summation to thermal stimuli is elevated in women with overactive bladder syndrome

This study sought to provide a preliminary assessment of whether spinally mediated afferent hyperactivity (i.e., central sensitization) might contribute to manifestations of overactive bladder syndrome (OAB) in women as indexed by elevated temporal summation of evoked heat pain stimuli.

Pubovaginal sling materials and their outcomes

Stress urinary incontinence (SUI) is the most common type of urinary incontinence, and approximately 200 different methods have been described for its surgical management. A better understanding of the pathophysiology of SUI has led to the development of surgical therapies focused on creating a strong suburethral supportive layer and urethral resistance. The most important advantage of the pubovaginal sling (PVS) procedure is that it restores urethral resistance during stress maneuvers to prevent incontinence, while improving urethral coaptation at rest and allowing for spontaneous micturition. Various autologous, allograft, xenograft and synthetic materials have been used for the PVS. The autologous PVS procedure for the treatment of SUI offers the highest success rate and is the most commonly used PVS surgical method. Unlike xenograft and allograft materials, the autologous procedure does not result in a tissue reaction and is associated with a low rate of material-related complications.

Trans-Vaginal Mesh Revision: A Comprehensive Review on Etiologies and Management Strategies with Emphasis on Postoperative Pain Outcomes

The use of polypropylene mesh to augment surgery aimed to correct pelvic organ prolapse and stress urinary incontinence stems largely from the high recurrence rates of native tissue repairs. While objective outcomes were improved, mesh related complications began to emerge that included mesh exposures, extrusions, dyspareunia and other pain issues. However, the indication for and benefit of surgical intervention(s) to address these complications are lacking. We aim to review to current literature regarding postoperative pain outcomes following vaginal mesh revision. Evidence based literature indicates that mesh complications are not rare and surgery that aims to address them generally have an overall benefit. However, studies available are generally small case series of a retrospective nature with short follow up. Some themes are evident: there is a long lag period from mesh insertion to removal; there is a lack of a true denominator of total mesh insertions making it hard to gauge the real scope of the problem; mesh material found not along the expected trocar path or coursing close to neurovascular structures thus raises the possibility of technical errors during insertion. Transvaginal mesh revision(s) for mesh complications generally have a positive effect on pain outcomes, but better controlled studies are needed. Additionally, since technical issues may be a factor in the development of mesh complications, rigorous training and sufficient surgical case volume should be emphasized.

Health literacy, cognition, and urinary incontinence among geriatric inpatients discharged to skilled nursing facilities

To investigate the association between health literacy and cognition and nursing and patient‐reported incontinence in a geriatric inpatient population transitioning to skilled nursing facilities (SNF).

Synthetic Midurethral Slings: Urinary Tract Sequelae

The midurethral sling (MUS) is considered by many to be the standard of care for the treatment of stress urinary incontinence (SUI). Complications from MUS surgery unique to the use of polypropylene mesh may occur including: chronic pelvic pain, dyspareunia, mesh exposure, mesh contracture, neuromuscular injury, and/or organ perforation. In addition, there can be significant urinary tract sequelae such as urinary tract injury, de novo urgency and/or urgency urinary incontinence (UUI), urinary obstruction, and/or urinary tract infection (UTI). Techniques for prevention, diagnosis, and treatment of such urinary tract complications are discussed herein.

Advances in the Treatment of Urinary Incontinence in Women

Urinary incontinence in women is quite prevalent today and management can be costly. Urinary incontinence can be minimal or quite bothersome, limiting activities of daily living. It is subdivided into urgency urinary incontinence, stress urinary incontinence, and mixed urinary incontinence. As such, treatment can vary immensely depending on the clinical presentations, ranging from behavioral modification to medicinal therapies to surgical procedures. First-line management for all urinary incontinence includes lifestyle and behavioral modifications. Historically, treatment options for urgency urinary incontinence were predominantly antimuscarinics, while more recent therapies include oral beta-3 agonist administration, sacral neuromodulation, onabotulinumtoxinA injection, and posterior tibial nerve stimulation. Stress urinary incontinence can be treated with a variety of urethral bulking agent injections or sling-based procedures using mesh, autologous fascia, or cadaveric fascia, as well as urethral intrasphincteric injections of autologous muscle-derived cells in new clinical trials. These recent advances that have been developed to help better curb urinary incontinence are discussed in this review.