Faculty Bibliography

Introduction: Urodynamics (UDS) is the study of urine transport, storage, and evacuation and is the gold standard in assessment of bladder function. Per AUA guidelines, UDS are not to be used in the initial workup of the uncomplicated patient with OAB, however their role in more complex patients remains uncertain. The primary aim of this study is to assess the impact of UDS on diagnosis and treatment plans of complex patients with OAB.
Method(s): Patients undergoing workup for OAB between 2016 and 2018 were prospectively enrolled and completed a voiding diary and UDS. Physicians first provided a diagnosis and treatment plan based on patient history, clinical data and voiding diary alone. The patients then underwent UDS and the physician provided a diagnosis and treatment plan after reviewing the additional testing. The impact of UDS on diagnosis and treatment plan were analyzed.
Result(s): 26 patients underwent evaluation with voiding diary and UDS with prospective documentation of diagnosis and treatment plan. All patients had previously trialed oral OAB medications10 (38.4%), complained of mixed incontinence 11 (42.3%), or were considering third line therapy 14 (53.8%). After UDS were performed, 13 (50%) had a modification in diagnosis and 11 (42.3%) had a change in treatment plan. The most common change in diagnosis was observation of voiding phase dysfunction in 4 (15.4%). Treatment plans changed for 6 patients with mixed incontinence primarily by elucidating severity of stress vs urgency incontinence when it was difficult to determine from patient report and available clinical data. Plans also changed for 1 patient found to have underactive bladder and 2 with bladder outlet obstruction. 9 (34.6%) patients went on to third line therapy.
Conclusion(s): UDS done for patients with complex OAB symptoms led to modification in patient diagnosis in 50% of patients and change in treatment plan in 42.3%. Change to diagnosis and management plan may reflect the utility of UDS especially in complicated patients (ie mixed incontinence) or who have failed second line therapies

Introduction: Overactive bladder (OAB) affects 10-19% of adults, strongly influencing quality of life. Voiding diaries may provide valuable information on the OAB patient, identifying modifiable behavior factors and the timing and severity of symptoms that can help guide treatment. The primary aim of this prospective cohort study is to report the percent of patients completing a diary, and secondary aim is to assess what factors may predict completion.
Method(s): 93 patients undergoing workup for OAB between 2016 and 2020 were enrolled and asked to complete a three-day voiding diary. They were provided standard written and oral instructions, in addition to urine collection device and a printed diary template. Completed voiding diary, OAB-q questionnaire, and demographic factors were collected and analyzed.
Result(s): Of the 93 patients enrolled, 61 (65.6%) completed at least one day of a voiding diary. Two of these patients (3.3%) returned diaries that could not be interpreted. There was no difference in OAB-q score for those completing diary and those who did not (76.7 vs 79, p=0.86). In addition, no significant differences were seen in age, BMI, ethnicity, gender or prior surgeries between those who did and did not complete the diary.
Conclusion(s): Voiding diaries are used in the workup of OAB to quantify symptoms and determine their cause. We found a completion rate of 65.6% among patients with bothersome OAB. No demographic differences were observed between those who did and did not complete a diary. Further study of barriers to completion could aid in higher capture rates and improved diagnostic evaluation of the OAB patient

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.

OBJECTIVES/OBJECTIVE:The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques. METHODS:Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison. RESULTS:Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis. CONCLUSIONS:Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.

Overactive bladder (OAB) syndrome is a prevalent condition impacting quality of life (QOL), activities of daily living, work productivity, physical and psychological health, sleep, and sexuality. Published guideline recommendations and effective behavioral, pharmacologic, and neuromodulatory therapies exist; however, adherence can be poor. Clinicians have important roles educating patients, setting treatment expectations, and providing follow-up. Determining patient goals, routinely assessing and adjusting therapy, and combining treatment strategies may improve outcomes. We review the benefits and challenges of OAB treatments and propose approaches to improve patient management, with the goals of initiating therapy earlier and achieving better patient satisfaction, functioning, and QOL.

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.

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 compare perioperative and functional outcomes of autologous fascia lata versus rectus fascia pubovaginal sling in female patients with stress urinary incontinence (SUI). METHODS:The charts of all patients undergoing pubovaginal sling for SUI from 2012 to 2017 at a single center were retrospectively reviewed. Patients were divided into 2 groups: those with the sling harvested from the fascia lata (FL group) and those with the sling harvested from the rectus fascia (RF group). RESULTS:Between 2012 and 2017, 105 women underwent pubovaginal slings: 21 using FL and 84 using RF. Operative time did not differ significantly between the FL and RF groups (84 vs 81.9 minutes; P = 0.68). Estimated blood loss was lower in the FL group (91.7 vs 141.6 mL; P = 0.04). There were more wound complications in the RF group, although this was not statistically significant (0% vs 14.3%; P = 0.12). Overall complications were comparable between FL and RF groups (52.4% vs 48.9%; P = 0.81), but the proportion of Clavien grade 2 or greater were higher in the RF group (4.8% vs 20.2%; P = 0.11). Overall, wound complications accounted for 29.3% of postoperative complications in the RF group (12/41). Functional outcomes were comparable between FL and RF groups, with similar rates of patients without SUI symptoms after 1 month (82.4% vs 76.4%; P = 0.74), 1 year (55.6% vs 63.8%; P = 0.76), and at the latest follow-up (66.7% vs 65.8%; P = 0.87). CONCLUSIONS:When compared with rectus fascia for pubovaginal sling, fascia lata may decrease perioperative morbidity, especially wound complications, without compromising functional outcomes.

INTRODUCTION AND HYPOTHESIS/OBJECTIVE:Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling. METHODS:We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery. RESULTS:Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement. CONCLUSIONS:UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.