Faculty Bibliography

Objectives: Over the last decade, the mid-urethral sling has become the new gold standard in the management of stress urinary incontinence because of its high success rate and minimally invasive nature. However, postoperative management has not kept pace with the modernization of sling surgery. Currently, there are no standardized postoperative instructions after a sling procedure with or without prolapse repair. The purpose of our study was to better understand the variation of postoperative recommendations given to patients following these procedures and to determine practice patterns among female pelvic medicine specialists across the United States. Methods: With IRB approval, attendants at the 2012 Annual Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) were randomly approached. Physician members of SUFU, AUGS, and the ICS, were asked to respond to two open-ended questions: "What is your usual plan of postoperative restriction after sling?" and "What is your usual plan of postoperative restriction after sling with prolapse repair?" Qualitative data analysis was performed to analyze the data. Results: The survey was completed by 62 surgeons. For sling repairs, four categories of restrictions emerged. These included restriction on sudden increases in intra-abdominal pressure (i.e. lifting, straining from constipation, coughing), limits on exaggerated movements (i.e. exercise, stretching), prevention of suture line trauma (i.e. vaginal penetration, bathing, soaking) and overall patient safety/well being (i.e. no driving, antimicrobial prophylaxis). Clinicians had varied times (0 days, 2 weeks, 4 weeks, 6 weeks) and intensity (i.e. weight, vigor of exercise) for postoperative restrictions. The question pertaining to concurrent prolapse resulted in the same themes. Interestingly, 62.9% of respondents had the same restriction regardless of a concurrent prolapse repair. Of those that differed, the major theme was that restriction was advised for a longer duration of time and in some cases the restriction intensity. No scientific evidence was cited during the interviews, but restrictions were admittedly based on experience (personal and institutional), presumed mechanism of repair, and theoretical risk. Conclusions: Despite the wide use of sling insertions with or without prolapse repairs, postoperative recommendations vary greatly amongst physicians. Most doctors have set arbitrary restrictions that limit several aspects of patient recovery. Further studies are required to establish common postoperative recommendation plans based on evidence based medicine rather than on individual preferences

Objectives: To report the safety and feasibility of robotic abdominal sacrohysteropexy and the associated short term outcomes. Methods: We reviewed the medical records of a consecutive series of robotic uterine sparing procedures from 8/2005-6/2011. 15 women were identified. All procedures utilized a polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip inserted through the broad ligaments to include the anterior uterocervical junction. Complications were classified as intraoperative and early postoperative, which was considered within one month following surgery. Objective success was defined as grade 0 uterine prolapse on the Baden- Walker system. Subjective success was defined as no complaint of vaginal bulge or pressure. Results: The mean age was 51.8 (28-64) years and mean follow-up was 10.8 months. 13 women were parous, 8 women were postmenopausal. Mean BMI was 23.6 (18.6-29.9) kg/m2. Mean operating time was 159.4 (130-201) minutes, mean estimated blood loss was 35 (0-100) ml, and mean length of stay was 1.6 (1-4) days. Anti-incontinence procedures were performed in 53% of women (8/15) and concomitant transvaginal prolapse repair procedures were performed in 33% of women (5/15). No intra-operative complications were noted. Early postoperative complications occurred in 3 cases: 2 patients with wound infection (treated with oral antibiotics) and 1 patient with nausea/vomiting (resolved within 3 days following procedure) and urinary retention (concomitant TVT-O procedure). All patients presented with complaint of vaginal bulge or pressure. Subjective success was achieved in 80% of patients (12/15). Objectively uterine prolapse improved in all patients (15/15) by mean grade of 2.9, cystocele improved in 77% of patients (10/13) by 2.1, and rectocele improved in 80% of patients (8/10) by 2.4. Although 100% objective success was initially obtained, there was one case of recurrent uterine prolapse (grade 2) at 4 months following procedure. This patient was not overly symptomatic and did not require surgical treatment. Conclusions: Robotic abdominal sacrohysteropexy was found to be a safe and feasible surgical treatment option for POP patients who desire uterine preservation. With short-term follow up we found good success but long term follow-up is needed. (Table Presented)

The midurethral sling (MUS) is now the most commonly performed surgical treatment for stress urinary incontinence (SUI), and is considered the gold standard for patients with genuine SUI. This article examines the use of the MUS to treat all forms of SUI, with an emphasis on the nonindex patient (ie, intrinsic sphincter deficiency, lack of urethral hypermobility, mixed incontinence, failed MUS, concomitant prolapse, obesity, and elderly). The efficacy and safety of the MUS to treat SUI is assessed in these specific populations. Based on the available evidence, the discussion attempts to identify populations in whom MUS may not be appropriate.

OBJECTIVE: To determine the clinical and urodynamic differences in the presentation and the value of simultaneous fluoroscopy in dysfunctional voiding (DV) and primary bladder neck obstruction (PBNO); the 2 most common causes of non-neurogenic "functional" bladder outlet obstruction in women. METHODS: A review of our urodynamic study database (March 2003 to August 2009) was conducted. DV was diagnosed when increased external sphincter activity was found during voluntary voiding on electromyography (EMG) or fluoroscopy. PBNO was diagnosed when a failure of bladder neck opening was noted on fluoroscopy during voiding. The demographics, symptoms, and urodynamic study parameters were collected. Comparisons were done using chi-square and 2-tailed t-tests. RESULTS: DV was diagnosed in 34 women and PBNO in 16. The patients with DV were younger than those with PBNO (40.9 vs 59.2 years, P < .001). Women with DV showed a clinical trend toward having more storage symptoms than those with PBNO and fewer voiding symptoms. Patients with DV had a greater mean maximal flow rate (12 vs 7 mL/s, P = .027) and lower mean postvoid residual urine volume (125 vs 400 mL, P = .012). No significant differences were found in maximal detrusor pressure, detrusor pressure at maximal flow rate, or detrusor overactivity. EMG showed increased activity during voiding in 79.4% of those with DV and 14.3% of those with PBNO (P < .001). CONCLUSION: Clinically, women with DV and PBNO had similar presentations, although those with PBNO had poorer emptying. The flow rates and patterns seemed to differ between those with DV and PBNO, although the voiding pressures were similar. EMG alone would have given the wrong diagnosis in 20.6% of those with DV (false negative) and 14.3% of those with PBNO (false positive). When fluoroscopy is used to define these entities, the accuracy of EMG to differentiate them is questionable.

Introduction and Objectives: To determine the utility of urodynamics (UDS) in patients with obstruction secondary to anti-incontinence surgery (AIS). Methods: A retrospective review of all procedures performed to relieve obstruction due to AIS from 01/01-06/11. Patient demographics, UDS findings, type of AIS, indication for intervention, procedure to relieve obstruction, preoperative and postoperative symptoms were recorded. Patients were excluded if this was not the primary procedure to relieve obstruction, if follow up data was missing, or if a neurologic disorderwas present. Patients were grouped into the following categories prior to intervention: UDS diagnosis of obstruction vs. non-diagnostic UDS or no UDS testing and patients with predominantly storage symptoms vs. patients with elevated PVR/retention and voiding symptoms. Outcomes were compared between these groups using SPSS statistical software and chi-square test. Curewas defined as resolution of symptoms for which intervention was indicated at last follow-up. Results: A total of 71 women were included in the analysis. There were 53 women with elevated PVR/retention, 32 (60.3%) were diagnosed with obstruction on UDS, 4 (7.5%) had nondiagnostic UDS and 17 (32%) did not undergo preoperativeUDS. All 18 patients with predominantly storage symptoms underwent UDS. In patients with elevated PVR/retention there was no difference in age, type of AIS procedure, time to intervention, follow up, preoperative voiding symptoms or type of intervention between groups. Patientswho had diagnostic UDS had significantly more storage symptoms than those who had non diagnostic UDS or who did not undergo UDS (81.2%% vs. 18.7% p=0.01). In patients who had storage symptoms and underwent UDS, those without evidence of detrusor overactivity (DO) had significantly greater improvement of their storage symptoms when compared to those with DO (85.7% vs. 53.8%, p=0.02). Overall 90.1% of patients improved and 74.6% were cured. In patients with elevated PVR/Retention there was no difference between groups with respect to improvement in symptoms, overall cure, and overall success according to whether they had diagnostic UDS or not. Conclusion: If voiding symptoms or urinary retention/ elevated PVR are the primary indication for intervention following AIS, it appears UDS are not required to proceed with intervention. If storage symptomsare themain indication for intervention, UDS may be a valuable tool for patient counseling

PURPOSE: Male slings have emerged as a popular and efficacious treatment for men with post-prostatectomy stress urinary incontinence. Traditionally slings have been used with caution or avoided in men with impaired detrusor contractility or Valsalva voiding because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with post-prostatectomy urinary incontinence who have impaired contractility and/or void with abdominal straining for urodynamics can be safely treated with slings. MATERIALS AND METHODS: A retrospective review of patients with post-prostatectomy urinary incontinence who underwent an initial sling procedure between January 2004 and January 2010 was conducted at a single institution. Preoperative urodynamic characteristics, and postoperative Patient Global Impression of Improvement, post-void residual and noninvasive uroflow data were examined. Patients were grouped by poor bladder contractility or Valsalva voiding status. Exclusion criteria were lack of preoperative urodynamics and/or postoperative post-void residual. A total of 92 patients were analyzed. The variables were compared using the Student t test and the chi-square test. RESULTS: No statistically significant difference was shown in postoperative post-void residual (mean 4 months postoperatively) or urinary retention when comparing by bladder contractility or Valsalva voiding. In the subset of patients with available postoperative uroflow data, there were no differences in postoperative maximum flow rate or voided volume. CONCLUSIONS: Men with post-prostatectomy urinary incontinence with urodynamic findings suggesting impaired contractility or Valsalva voiding can be safely treated with sling surgery if they have normal preoperative emptying

OBJECTIVE: To evaluate the utility of estimated tumour volume, number of positive surgical margins (PSMs), and margin location for predicting biochemical failure in patients with PSM, in an attempt to better risk-stratify the heterogeneous group of patients at high risk of biochemical failure after radical prostatectomy (RP) for prostate cancer. PATIENTS AND METHODS: We reviewed our database of 2410 patients who had RP, and isolated 423 with PSMs who had a prostate-specific antigen (PSA) nadir at undetectable levels. Kaplan-Meier curves were used for univariate survival analysis, with the log-rank test used to examine differences between survival curves. Multivariate Cox regression analysis was used to assess the independent main effect of estimated tumour volume, number of PSMs and margin location on biochemical-free survival. RESULTS: Increasing estimated tumour volume was directly associated with increasing risk of biochemical failure in patients with PSMs (P = 0.041). Patients with more than one PSM were at greater risk of biochemical failure than those with one PSM (P = 0.001). Margin location had no effect on biochemical-free survival in patients with PSMs. When incorporated into a multivariate Cox regression model including age, preoperative PSA level and pathological Gleason score, estimated tumour volume and number of PSMs remained independent predictors of biochemical recurrence. CONCLUSIONS: Coupled with other variables before and after RP, both estimated tumour volume and number of PSMs might serve to further discriminate those patients most likely to benefit from immediate adjuvant radiotherapy after RP.

OBJECTIVES: The purpose of this study was to assess the prognostic significance of hydronephrosis on pathologic and clinical outcomes in muscle-invasive bladder cancer. METHODS: We performed a retrospective evaluation of a prospectively maintained cystectomy database and identified patients with hydronephrosis on preoperative imaging. Of a total of 306 patients, 57 (19%) had unilateral hydronephrosis and 17 (6%) had bilateral hydronephrosis. We constructed multivariate Cox regression analysis and Kaplan Meier tables to evaluate the association between preoperative hydronephrosis and clinical outcomes. RESULTS: In patients without hydronephrosis, 41.4% had extravesical disease compared with 56.1% and 64.7% in patients with unilateral or bilateral hydronephrosis, respectively. Mean overall survival (OS) among patients without hydronephrosis, with unilateral hydronephrosis, and with bilateral hydronephrosis was 55.5, 42.1, and 22.2 months, respectively. Five-year OS and disease-specific survival (DSS) was 46%, 35%, and 22% (P = .001) and 68%, 54%, and 35% (P = .002), respectively. Multivariate analysis demonstrated that both unilateral and bilateral hydronephrosis are significant independent risk factors for DSS and OS. Bilateral hydronephrosis was found to have a hazard ratio of 3.87 (95% confidence interval [CI] = 1.71-8.78, P = .001) and 2.75 (95% CI = 1.45-5.18, P = .002) for DSS and OS, respectively. The hazard ratios for unilateral hydronephrosis were 1.7 (95% CI = 1.05-2.87, P = .03) and 1.5 (95% CI = 1.03-2.23, P = .04) for DSS and OS, respectively. CONCLUSIONS: Preoperative hydronephrosis is associated with a significantly poorer prognosis in patients with muscle-invasive bladder cancer. These patients should be appropriately counseled with regard to overall prognosis and the potential benefit of neoadjuvant chemotherapy.