Faculty Bibliography

Introduction: The objective of this study was to determine whether patient-reported stress urinary incontinence (SUI) at the time of intradetrusor onabotulinumtoxinA injection (ONA) for urgency urinary incontinence (UUI) had an effect on catheterization rates.
Method(s): This was a retrospective chart review conducted between 1/2010 and 12/2019. Female subjects with either UUI or urgency-predominant mixed urinary incontinence (MUI) were identified for intradetrusor injection of ONA 100 Units. Charts were reviewed for demographic information, past medical and surgical history, the presence of SUI symptoms, post void residual (PVR) before and after ONA injection, need for catheterization (CIC), and subjective response to ONA. Subjects with a diagnosis of neurogenic bladder or baseline catheterization requirement were excluded. CIC was at the discretion of the clinician and was typically recommended if PVR>350mL or <350mL with symptoms of incomplete emptying. Primary outcome was difference in CIC rates between those with MUI and those with UUI at time of ONA. Demographics and outcomes were analyzed using descriptive statistics after assessing for normality. Two-tailed p-values <0.05 were considered to be statistically significant.
Result(s): A total of 177 females were included, of which 72 reported MUI symptoms at the time of ONA and 105 did not (UUI only). Women with MUI were significantly older (74.5 years [67,80] vs 69 years [61.5,78.5], p=0.02) and demonstrated lower pre-ONA PVRs (12.5ml [0,33.75] vs 24ml [0,55], p=0.04) compared to women with UUI only. There was no difference in other demographic characteristics, including proportion of women with prior anti-incontinence procedures (p=0.2) between groups. Following ONA, overall CIC rates were 11.3%. Women with MUI had significantly lower rates of CIC (4.2% vs 16.2%, p=0.015) and lower post-ONA PVRs (49 ml [16.25,129.5] vs 107ml [48.5,199.5], p=0.002) than women with UUI only. Combined subjective improvement or cure rates of UUI symptoms between groups was not different (U

PURPOSE/OBJECTIVE:To evaluate if question phrasing and patient numeracy impact estimation of urinary frequency. MATERIALS AND METHODS/METHODS:We conducted a prospective study looking at reliability of a patient interview in assessing urinary frequency. Prior to completing a voiding diary, patients estimated daytime and nighttime frequency in 3 ways: 1) how many times they urinated 2) how many hours they waited in between urinations 3) how many times they urinated over the course of 4 hours. Numeracy was assessed using the Lipkus Numeracy Scale. RESULTS:Seventy-one patients completed the study. Correlation of estimates from questions 1, 2 and 3 to the diary were not statistically different. Prediction of nighttime frequency was better than daytime for all questions (correlation coefficients 0.751, 0.754 and 0.670 vs 0.596, 0.575, and 0.460). When compared to the diary, Question 1 underestimated (8.5 vs 9.7, p=0.014) while Question 2 overestimated (11.8 vs 9.7, p=0.027) recorded voids on a diary. All questions overpredicted nighttime frequency with 2.6, 2.9 and 3.9 predicted vs 1.6 recorded voids (p <0.001). Although not statistically significant, for each question, the predicted frequency of numerate patients was more correlated to the diary than those of innumerate patients. CONCLUSIONS:When compared to a voiding diary for daytime urinary frequency, asking patients how many times they urinated underestimated, and asking patients how many hours they waited between urinations overestimated the number recorded voids. Regardless of phrasing, patients overestimated nighttime urination. Patients in our functional urology population have limited numeracy, which may impact accuracy of urinary frequency estimation.

OBJECTIVES/OBJECTIVE:To evaluate whether progression to maintenance percutaneous tibial nerve stimulation (PTNS) was related to perceived global impression of improvement (PGII) rather than symptom-specific improvement in patient with overactive bladder (OAB). We hypothesize that PGII will predict continuation of PTNS long-term. METHODS:This prospective observational study included 90 patients with OAB that initiated PTNS. The PGII and overactive bladder short-form questionnaires (OABq-SF) were used to assess bladder symptom severity and improvement. Those that completed the 12-week induction phase were offered to continue PTNS monthly maintenance or pursue other options. The primary outcome was difference in PGII score between those pursuing maintenance therapy versus other options. Descriptive statistics and mixed effect modeling analysis were employed. RESULTS:Seventy patients (78%) completed 12 weeks of PTNS. The majority of completers pursued monthly maintenance (p<0.01) and had significantly lower median PGII scores compared with those who sought alternatives (p<0.01), while OABq-SF scores did not differ significantly (p=0.65). Patients that pursued monthly PTNS maintenance had lower body mass index than those who chose alternative therapies (p<0.01). Only 19% continued PTNS therapy for at least 1 year. CONCLUSIONS:More patients pursued PTNS monthly maintenance over any other therapy, and this was significantly associated with lower PGII scores. Global improvement, and not symptom-specific response, predicts long-term PTNS maintenance. No symptom-specific predictors were identified in those who pursued maintenance over other options. One-year continuation rates are low.

AIM/OBJECTIVE:Venous thromboembolism (VTE) rates in vaginal pelvic organ prolapse (POP) repair are low. Our aim is to evaluate specific risk factors for VTE in patients undergoing vaginal POP repair. METHODS: tests for categorical variables. Multivariate logistic regression was performed to identify factors independently associated with VTE. RESULTS:Of 44 207 women who underwent vaginal POP repair, there were 69 cases of VTE (0.16%). VTE rates for obliterative (0.15%) and functional (0.16%) vaginal POP repair, as well as for repairs with hysterectomy (0.17%) and without hysterectomy (0.12%) were not significantly different (p = .616 and .216, respectively). Multivariate analysis demonstrated predictors for postoperative VTE to be ASA physical status classification ≥ 3 (aOR, 1.99; p = .014), length of stay >75th percentile (aOR, 2.01; p = .007), operative time >3 h (aOR, 2.24; p = .007), and dyspnea (aOR, 3.26, p = .004). CONCLUSION/CONCLUSIONS:Despite the low incidence of VTE after vaginal POP repair, patients with ASA physical status classification ≥ 3, length of stay >75th percentile, operative time >3 h, and dyspnea were at higher risk for VTE. Vaginal POP repair may have independent VTE risk factors not captured in standard risk assessment tools.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:The aim of this study was to assess whether mid-urethral sling (MUS) placement at the time of vaginal prolapse repair compared to vaginal prolapse repair alone is associated with an increase in 30-day postoperative complications. METHODS:Using the American College of Surgeons National Surgical Quality Improvement Database, Current Procedural Terminology codes were used to identify cases of vaginal prolapse repair with and without concomitant MUS from 2012 to 2017. Student's t-test and chi-square test were used to compare differences between the groups. RESULTS:A total of 1469 cases of vaginal prolapse repair with sling were compared to 4566 cases without sling. There was no difference between prolapse repair with sling compared to without sling in mean hospital length of stay (LOS) (1.42 versus 1.32 days, p = 0.65), postoperative urinary tract infection (UTI) (6.1% versus 5.8%, p = 0.670), perioperative blood transfusion (1.1% versus 1.2%, p = 0.673), readmission (2.7% versus 2.6%, p = 0.884) and postoperative wound infection (0.5% versus 0.7%, p = 0.51). There was a higher rate of reoperation (2.2% versus 1.5%, p = 0.049) and venous thromboembolism (VTE) (0.4% versus 0.1%, p = 0.030) in patients undergoing concomitant MUS compared to those undergoing prolapse repair alone. CONCLUSIONS:Compared to prolapse repair alone, the addition of a sling did not increase hospital LOS, UTI, perioperative blood transfusions, readmission or postoperative wound infections. However, concomitant sling was found to be associated with a higher risk of reoperation and VTE.

The implications of estrogen depletion on the lower urinary tract and vagina are relevant to the urologist treating women with genitourinary symptoms. The main symptoms of vaginal estrogen depletion that affect women are dyspareunia and vaginal dryness, recurrent UTIs and lower urinary tract symptoms. Vaginal estrogen can be used to effectively treat these conditions. Vaginal estrogen is available in a variety of formulations. Each formulation has different considerations regarding its use and patients should be actively involved in choosing the right product for them. Contrary to concerns over the risks of oral estrogen, vaginal estrogen has a low risk profile. In terms of contra-indications for use, there are relatively few absolute contraindications for vaginal estrogen. A thorough understanding of vaginal estrogen's safety, efficacy and correct use is essential to the urologist treating the post-menopausal female.

Objective: Intradetrusor onabotulinumtoxinA (ONA) is an effective treatment for urgency urinary incontinence (UUI). A possible adverse effect of ONA is incomplete bladder emptying requiring temporary clean intermittent catheterization (CIC). The goal of this study was to determine whether uncorrected patient-reported stress urinary incontinence (SUI) in those with urgency predominant mixed urinary incontinence (MUI) had an effect on CIC rates.
Method(s): This was a retrospective chart review conducted at a single academic institution between 1/2010 and 12/2019. Unique female subjects were identified by CPT and/or J codes for intradetrusor injection of ONA. Charts were reviewed for demographic information, past medical and surgical history, symptoms of SUI, post void residual (PVR) before and after ONA injection, and whether catheterization was required after index ONA 100 unit injection. Subjects with a diagnosis of neurogenic bladder, urethral stricture, and baseline catheterization requirement were excluded from this analysis. Anti-stress incontinence (ASI) procedures were historic as documented in urogynecologic history prior to index ONA injection. CIC was at the discretion of the clinician, typically with CIC recommended if PVR>350 mL. Patient characteristics and CIC rates were analyzed using descriptive statistics after assessing for normality. Two-sided P values <0.05 were considered to be statistically significant.
Result(s): Of 517 charts, 178 females were included for analysis. The mean age of women was 68.63 (+/-15.2) years. A total of 78 (41.6%) women had UUI but no SUI, 57 (32.0%) reported SUI along with UUI (ie, MUI) without any prior ASI procedure, and 47 (26.4%) reported SUI with prior ASI procedure. Demographic and outcome data are demonstrated in table 1. The overall CIC rate following ONA was 11.23%. We found that a lower proportion of women with uncorrected SUI required CIC following ONA compared to women without SUI or women with previous ASI procedure (P=0.017). The pre-ONA PVR was not significantly different between all three groups (P=0.12) while the post-ONA PVR was significantly higher among women with prior ASI procedure (P<0.001).
Conclusion(s): Rates of CIC are lower among women with uncorrected SUI, despite an overall significantly older population and similar baseline PVRs. This would suggest that a decreased outlet resistance may be protective against urinary retention. This is an important finding to consider when counseling our patients on the risks and benefits of ONA for the treatment of urge-predominant mixed urinary incontinence

OBJECTIVE:To determine the patient-perceived effectiveness and tolerability of mirabegron compared to solifenacin in a multiple sclerosis (MS) population with overactive bladder (OAB) symptoms. MATERIALS AND METHODS/METHODS:MS patients with OAB symptoms who were not on medication for their urinary symptoms at enrollment were prospectively recruited. Patients enrolled in years 1-2 were prescribed mirabegron, whereas patients enrolled in years 3-4 were prescribed solifenacin. At enrollment and 6-week followup, patients completed several patient reported outcome measures (PROMs). The primary outcome was change in Overactive Bladder Questionnaire Short Form (OAB-q SF) symptom severity and minimal clinically important difference (MCID) achievement. The Patient Assessment of Constipation Symptoms (PAC-SYM) was used to assess bowel function over the treatment period. RESULTS:61 patients were enrolled. The majority of the mirabegron (70%) and the solifenacin (69%) group achieved the OAB-q SF symptom severity MCID. The solifenacin group had a statistically significant greater decrease in its end of study OAB-q SF score (Δ = -37.87 versus -20.43, p=0.02). Constipation improved in the mirabegron group and worsened in the solifenacin group (ΔPAC-SYM =-0.38 versus +0.22; p=0.02), with 30% of patients prescribed solifenacin experiencing worsening above the MCID threshold. CONCLUSION/CONCLUSIONS:Among MS patients, we demonstrated similar response rates to mirabegron and solifenacin, with approximately 50-70% achieving each PROM's MCID. Though this small study showed some short-term evidence that improvement in urinary symptom severity was greater with solifenacin, this potential benefit must be weighed against the observed risk of worsening constipation. Further studies are needed to confirm these findings.

Introduction: Percutaneous tibial nerve stimulation (PTNS) is an efficacious treatment option for overactive bladder syndrome (OAB). There is a paucity of data surrounding long-term efficacy of PTNS and limited studies are aimed at characterizing those patients who seek post-PTNS follow up maintenance. The aim of this study was to evaluate those who completed PTNS treatment and continued with posttreatment PTNS maintenance versus alternative therapeutic options.
Method(s): This is a prospective cohort study at a single academic institution. Ninety patients started PTNS according to our clinical protocol. The Patient Global Impression of Severity (PGIS) and Patient Global Impression of Improvement (PGII), and OAB Short Form (OABq-SF) questionnaires were used to assess OAB symptom severity and improvement, respectively. Following 12 sessions, patients were given the choice to continue maintenance PTNS or to pursue other options.
Result(s): Our completion rate was 70/90 (77.8%). Of all patients who continued some type of therapy for OAB, significantly more patients went on to monthly PTNS maintenance compared with all other options (54.3% vs 37.1%, P=0.02). There were no differing demographic features between those who pursued Post-PTNS maintenance and those who chose an alternative therapy. Overall OABq-SF scores improved significantly by the end of treatment but did not differ between those who chose PTNS maintenance and those who pursued another treatment. Medications did not improve the perception of improvement when added to PTNS (P=0.45). Individuals who chose PTNS maintenance showed significant improvement in urgency (3.4 (0.89) to 2.6 (0.89); P=0.049) and incontinence (3.2 (1.72) to 2.7 (1.37); P=0.038) over the initial 12 weeks, while those who chose otherwise did not. Individuals who went on to monthly maintenance showed lower PGII scores compared with those who sought alternatives (2.70 (1.6) vs 3.81 (1.07); P=0.01), despite no difference in starting severity of OAB symptoms (PGIS score 3.33 (0.72) vs 3.33 (0.70); P=1).
Conclusion(s): Patients were more likely to continue maintenance PTNS than any other form of treatment. Despite no predictive characteristics found, favorable improvement subscores in urgency and incontinence were associated with those pursuing maintenance therapy. Overall, those who perceived greater improvement were more likely to pursue long-term PTNS therapy as their OAB treatment of choice