Faculty Bibliography

AIMS/OBJECTIVE:To evaluate the impact of a protocol for standardized image capture during video urodynamics (VUD) on radiation exposure. Secondly, to categorize radiation exposure by condition warranting VUD and to identify clinical variables that correlate with increased radiation exposure. METHODS:One hundred fifty patients underwent VUD using our standardized protocol. All images were taken using low dose and pulsed settings. Four images are captured: one scout image, one filling image, one voiding image, and one post-void image. If the patient is unable to void with the catheter in place, the catheter is removed and a second image is taken during an attempt at unintubated flow. If vesicoureteral reflux (VUR) is identified, an alternate protocol is entered to document parameters. The mean radiation exposure measured in dose area product (DAP), fluoroscopy time, and number of images were noted and compared with previously published fluoroscopy data collected at our institution before protocol implementation. RESULTS:taking 5.2 images in 4.5 seconds. Protocol implementation leads to a 51.2% reduction in radiation exposure calculated by mean DAP (P < .0001) and a 96.5% reduction in fluoroscopy time (P < .0001). The presence of VUR, fluoroscopy time, and body mass index (BMI) > 25 were associated with higher radiation exposure (P < .0001). CONCLUSION/CONCLUSIONS:Implementation and adherence to a standardized protocol for fluoroscopy led to a reduction in radiation exposure fluoroscopy time. The presence of VUR, fluoroscopy time, and BMI > 25 were associated with higher radiation exposure.

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

OBJECTIVES/OBJECTIVE:Stress urinary incontinence is highly prevalent and sling surgery has increased since 2000. Urethrolysis traditionally had been standard management of complications after anti-incontinence surgery; however, partial excision is a less aggressive option. This study describes the different populations in a contemporary cohort that undergo sling excision and urethrolysis and their surgical outcomes. METHODS:Chart analysis was performed on patients assigned Current Procedural Terminology codes for removal or revision of sling for stress incontinence, urethrolysis, or revision of graft at our institution from 2010 to 2015. Demographics, indications, outcomes, and subsequent treatment were evaluated. RESULTS:A total of 110 patients underwent surgery and were included. Partial excision was performed on 82 patients and urethrolysis on 28 patients. About 32.7% had prior revision, and median length to revision was 3.1 years. Overall success was 75.0% for urethrolysis and 86.6% for partial excision. Without concomitant sling placement, stress incontinence developed in 25.0% of urethrolysis and 21.6% of partial excision patients. New onset overactive bladder symptoms developed in 21.4% of urethrolysis patients and 7.3% of partial excision, which was significantly different (P = 0.039). CONCLUSIONS:Both approaches had good success, 75.0% for formal urethrolysis and 86.6% for partial excision. New onset urgency was lower for partial excision, but rates of all other complications were similar. These procedures are often used for different patient populations, and thus, outcomes are not meant to be directly compared. Future work on sling revision should report these procedures separately.

PURPOSE OF REVIEW/OBJECTIVE:Due to recent concerns over the use of synthetic mesh in pelvic floor reconstructive surgery, there has been a renewed interest in the utilization of non-synthetic repairs for pelvic organ prolapse. The purpose of this review is to review the current literature regarding pelvic organ prolapse repairs performed without the utilization of synthetic mesh. RECENT FINDINGS/RESULTS:Native tissue repairs provide a durable surgical option for pelvic organ prolapse. Based on recent findings of recently performed randomized clinical trials with long-term follow-up, transvaginal native tissue repair continues to play a role in the management of pelvic organ prolapse without the added risk associated with synthetic mesh. In 2019, the FDA called for manufacturers of synthetic mesh for transvaginal mesh to stop selling and distributing their products in the USA. Native tissue and non-synthetic pelvic organ prolapse repairs provide an efficacious alternative without the added risk inherent to the utilization of transvaginal mesh. A recent, multicenter, randomized clinical trial demonstrated no clear advantage to the utilization of synthetic mesh. Furthermore, transvaginal native tissue repairs have demonstrated good long-term efficacy, particularly when anatomic success is not the sole metric used to define surgical success.

OBJECTIVE:This study assessed stress urinary incontinence (SUI) outcomes after sling excision for urinary tract perforation or vaginal exposure, and compared the outcomes of concomitant versus staged autologous fascia pubovaginal sling (AFPVS). METHODS:A retrospective chart review of all patients who underwent midurethral sling (MUS) excision for urinary tract perforation or vaginal exposure at a tertiary referral center between 2010 and 2015 was performed. Therapeutic strategies were categorized as concomitant AFPVS, staged AFPVS, and no anti-incontinence procedure. RESULTS:In all, 32 patients were included for analysis: 13 with vaginal tape exposure (40.6%) and 19 with urinary tract tape exposure (59.4%). In patients who had SUI prior to sling excision (43.8%), the rate of resolved or improved SUI postoperatively was higher in the concomitant AFPVS group than in those who underwent sling excision alone (83.3% vs 12.5%, respectively; P = 0.03). Of 18 patients with no SUI prior to sling excision, 12 experienced recurrent SUI after sling removal (66.7%). The rate of recurrent SUI was lower in patients with vaginal MUS exposure than urinary tract MUS perforation, but this did not reach statistical significance (57.1% vs 72.7%, respectively; P = 0.63). The rates of resolved SUI after AFPVS were comparable in patients with concomitant and staged AFPVS (66.7% vs 71.4%, respectively; P = 0.99). CONCLUSIONS:Many patients with MUS perforations or exposures will have SUI at initial presentation or develop SUI after removal of the synthetic sling. The decision to perform a concomitant AFPVS or to stage the surgical management of SUI can be individualized.

OBJECTIVES/OBJECTIVE:To investigate trends in stress urinary incontinence (SUI) surgery before and after the 2011 FDA notification and the 2014 AUGS/SUFU position statement. METHODS:A retrospective chart review was performed to identify patients presenting for evaluation of SUI by two Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialists between June 1, 2010 and May 31, 2017. Rates of surgical treatment modality (synthetic midurethral slings (MUS) vs. autologous fascial pubovaginal sling (AFPVS) vs. bulking agents) were analyzed at 6 month intervals. RESULTS:Over 14 six-month intervals, the number of new patients presenting for evaluation of SUI increased consistently. There was a decrease in the proportion of new patients who underwent anti-incontinence surgical procedures, specifically MUS, between December 2011 and December 2013. After the integration of the 2014 AUGS/SUFU position statement in patient counseling, this trend reverted and we noted a sustained increase in the proportion of patients electing surgical management. This paralleled an increase in new patient visits for SUI and MUS. The number AFPVS remained stable throughout the study period. Conversely, MUS composed the highest proportion of procedures performed, accounting for 60 % to 87.2% off all anti-incontinence procedures. CONCLUSION/CONCLUSIONS:After the FDA Public Health Notification in 2011, we observed a decline in the number of new patients presenting with SUI electing surgical management, specifically MUS. However, after the AUGS/SUFU position statement publication and integration into counseling, we observed a reversal in the previous year's trends, noting a resurgence of MUS utilization.

PURPOSE/OBJECTIVE:To assess the urodynamic findings in patients with Parkinson disease (PD) with overactive bladder symptoms. METHODS:We performed a retrospective chart review of all PD patients who were seen in an outpatient clinic for lower urinary tract symptoms (LUTS) between 2010 and 2017 in a single-institution. Only patients who complained of overactive bladder (OAB) symptoms and underwent a video-urodynamic study for these symptoms were included. We excluded patients with neurological disorders other than PD and patients with voiding LUTS but without OAB symptoms. RESULTS:We included 42 patients (29 men, 13 women, 74.5±8.1 years old). Seven patients (16.7%) had a postvoid residual (PVR) bladder volume >100 mL and only one reported incomplete bladder emptying. Detrusor overactivity (DO) was found in all 42 patients (100%) and was terminal in 19 (45.2%) and phasic in 22 patients (52.4%). Eighteen patients had detrusor underactivity (DU) (42.3%). Later age of PD diagnosis was the only parameter associated with DU (P=0.02). Patients with bladder outlet obstruction (BOO) were younger than patients without BOO (70.1 years vs. 76.5 years, P=0.004), had later first sensation of bladder filling (173.5 mL vs. 120.3 mL, P=0.02) and first involuntary detrusor contraction (226.4 mL vs. 130.4 mL, P=0.009). CONCLUSION/CONCLUSIONS:DO is almost universal in all patients with PD complaining of OAB symptoms (97.1%). However, a significant percentage of patients also had BOO (36.8%), DU (47%), and increased PVR (16.7%) indicating that neurogenic DO may not be the only cause of OAB symptoms in PD patients.

OBJECTIVE:To characterize the current evaluation, and efficacy of treatments in patients with the primary complaint of nocturia. METHODS:A retrospective chart review was performed of new patient encounters seen in a tertiary urology practice from May 2010 to September 2016 with the primary diagnosis of nocturia (ICD-9 788.43 and ICD-10 R35.1). RESULTS:595 patients were identified. 403 met inclusion criteria. The median patient reported that nocturia episodes were 4 (1-20). 192 patients (48%) reported previous treatment for nocturia. After the index visit, a bladder diary (BD) was utilized in 50% of patients, with a 62% (n = 124) completion rate at follow-up visit. On BD analysis, the most common etiologies of nocturia were nocturnal polyuria 76% (n = 90) and overactive bladder in 21% (n = 26). Patient reported improvement with therapy after BD completion was 46% (n = 34), similar to patients without voiding diaries (43% improvement, n = 153). Anticholinergics and alpha blockers were the most commonly recommended drug, but no specific medication was associated with nocturia improvement. Oral desmopressin was used in 5% of patients. CONCLUSION/CONCLUSIONS:Nocturia is a common condition and very commonly patients have sought treatment prior to presentation. Bladder diaries were recommended to half of the patients. Patient reported that improvement did not seem to correlate with completion of a bladder diary. Though most patients had NP the use of desmopressin was very low. Current treatments used in managing nocturia may lack efficacy.

Introduction: To date, only very few series have aimed to assess the outcomes of botulinum toxin injections in patients with Parkinson's Disease (PD). The aim of this study was to assess the safety and efficacy of intradetrusor onabotulinum toxin A injections for the treatment of overactive bladder (OAB) in patients with PD.
Method(s): All PD patients who underwent intradetrusor injections of onabotulinum toxin A (BoNT-A) for storage symptoms between 2010 and 2017 were included in a retrospective study. A 100 U dose of BoNT-A (Botox, Allergan Irvine, CA) was used for the first injection in all patients. The primary endpoint was clinical success defined as any subjective improvement in OAB symptoms self-assessed by the patients four weeks after the injections.
Result(s): Out of 24 patients analyzed, 19 reported improvement of their OAB symptoms four weeks after the first injection (79.2%) with complete resolution of urgency urinary incontinence in 7 patients (29.1%; p<0.001). The average post-void residual (PVR) increased significantly after the first injection from 17.6 to 125.3 ml (p<0.001). Three of the patients had to start clean intermittent catheterization (CIC) after the first injection (12.5%). Out of 49 injections in total, only five caused incomplete bladder emptying requiring the use of CIC (10.2%). Higher pre-injection PVR was significantly associated with both a lower chance of symptomatic improvement (p=0.04) and a higher risk of incomplete bladder emptying with institution of CIC (p=0.047).
Conclusion(s): Botox appeared effective in PD patients with a relatively low rate of retention requiring CIC. Higher preoperative PVR was the stronger predictor of both treatment failure and postoperative urinary retention requiring CIC while urodynamic obstruction was also associated with treatment failure in male patients. Intradetrusor injections of BoNT-A 100 U appeared as a safe and effective option in PD patients with OAB symptoms and a low PVR before the injection