Faculty Bibliography

Objectives: Obesity is an epidemic affecting 35% of American adults. In women, BMI directly correlates with intra-abdominal and bladder pressure, pelvic floor stress and muscle weakness. Thus, obesity increases the risk for the pelvic floor disorders such as overactive bladder (OAB), urinary incontinence (UI) and other lower urinary tract symptoms (LUTS). Previous studies have shown that gastric bypass and conservative weight loss methods improve UI in obese women; however, studies evaluating change in LUTS after laparoscopic assisted gastric banding (LAGB) are lacking. LAGB differs from gastric bypass in that patients with BMI under morbidly obese can qualify and weight loss is gradual over time. Therefore, we conducted a prospective cohort study to assess for change in LUTS and their impact on quality of life (QOL) after weight loss with LAGB. Methods: Obese women undergoing LAGB were recruited. Demographics, clinical data, and validated questionnaires (MESA, KHQ) were used to evaluate LUTS and QOL preoperatively and 24-36 months postoperatively. Total and domain scores were calculated for each questionnaire. Statistical analysis was conducted using Spearman's rho and Shapiro Wilk's test. Results: All participants maintained or lost weight after LAGB, with a mean preoperative BMI of 43.8 (SD +/-8.3), and mean change in BMI of 12 (SD +/-4). In the MESA, preoperative BMI was associated with urge incontinence (p=0.036), however; a significant improvement was not seen with weight loss. In the KHQ, preoperative BMI was associated with poor general health perception (p=0.006). A trend towards improvement after weight loss was seen (p=0.064). 47 of 92 initially enrolled participants completed follow up questionnaires with a mean age at follow up of 45.7 (SD +/-11.3). Conclusions: While preoperative BMI correlated with worse LUTS and lower QOL scores, a significant improvement after weight loss was not identified. Based on previous studies that correlate BMI with an increased risk for pelvic floor disorders, obese patients are counseled that weight loss alone will significantly improve their symptoms. However, this study suggests it may not and highlights the need to thoroughly assess all factors that may be contributing to bothersome LUTS in obese patients. As such, these patients may benefit from additional interventions, upfront, to achieve symptomatic relief. While this study was limited by an incomplete follow up rate and low baseline LUTS scores, it sheds light on the need to further understand the role of weight loss after LAGB on LUTS and QOL. Studies with larger study populations and control groups are needed to validate the relationship

OBJECTIVE: To explain what role urinary urgency has on urinary frequency in patients with overactive bladder (OAB). MATERIALS AND METHODS: We prospectively enrolled 102 patients with OAB over a 6-week period. Patients were assessed with the OAB-q and a pilot questionnaire to identify which urinary symptoms were most bothersome and what underlying cause subjects attributed urinary frequency to. Associations between epidemiologic characteristics, OAB-q scores, and subject responses to the pilot questionnaire, were examined for statistical significance with the Pearson chi square test. RESULTS: The study population comprised 85% women and 15% men, with mean age 67.4 years and mean OAB-q score 54. Subjects reported their most bothersome symptom was: frequency 24.5%, urgency or urgency incontinence 48.0%, nocturia 27.5%. Of the patients most bothered by frequency, 64% identified the International Continence Society definition of urgency or "fear of leakage" as the underlying reason for their frequency. Overall, 82.4% and 48.0% of patients reported urgency or urgency incontinence as a symptom and most bothersome symptom respectively. However, when patients were specifically asked what drives their urinary frequency, these percentages increased to 89.2% and 63.7%. CONCLUSION: This pilot study confirms that urgency is a large factor underlying the drive to void frequently in OAB, even when patients do not admit to urgency as the most bothersome symptom.

Introduction: Social media networks and websites are an important source of healthcare information exchange. Despite the quantity of information, there is growing evidence for poor quality medical information that may be misleading and biased. Some studies suggest information available online on controversial topics may disperse inaccurate information and contribute to public confusion. Objective: The goal of this study is to examine information available in YouTube videos on a controversial urologic topic, pelvic organ prolapse (POP) repairs with mesh. Methods: A keyword search of ''vaginal POP repair with mesh'' was performed and the first 100 search results examined on 7/29/13. Videos not in English, lacking spoken words, or duration 910 minutes were excluded. Video characteristics including source (legal, medical, other), number of views, time online and duration were recorded. The content of each video was assessed in the following domains: description of POP, management of POP, explanation of the 2011 FDA Safety Communication, and balanced presentation of information. Scores were assigned based on whether the video made a series of objective statements pertaining to each domain, The proportion of statements made in the video per domain was calculated and videos of different sources were compared. Significance was assessed by t test. Results: 51 videos were excluded, and the remaining 49 were viewed. The sources were 69% legal firm, 24% medical institution, and 7% other. The former 2 groups were compared. Videos from medical institutions were older (online for 31.6 vs. 14.2 months, p lt; 0.01), longer (249 vs 99 seconds, p lt; 0.01), and had more views per month (784 vs. 140 , p lt; 0.01) when compared to legal videos. Legal videos explained more aspects of the 2011 FDA Safety Communication (0.22 vs. 0.07; p<0.01). Medical videos did not show a significant difference in addressing aspects of other domains including description of POP (0.25 vs. 0.12, p=0.087, management of POP (0.2 vs. 0.14, p=0.086), or presentation of balanced information (0.10 vs. 0.06; p=.528). Conclusions: The majority of information available in YouTube videos on the topic of vaginal POP repair with mesh is recent, short, and published through legal services that outline the 2011 FDA Safety communication but contain less comprehensive descriptions of POP compared to other videos. However, low overall scores in all domains studied, regardless of source, demonstrate lack of content. This raises questions about the utility of YouTube as a source of information for patients

Objectives: Mesh complications can cause significant morbidity. Fortunately, conservative management can often be successfully employed. However, when conservative measures fail, minimally invasive management strategies should be considered. Few case reports exist and to our knowledge, no long term studies exist in the literature. Herein, we describe our experience with robotic assisted excision of retropubic and intravesical mesh. Methods: The index patient is a 40 year old multiparous female, 8 years status post Gynecare TVT retropubic mid urethral sling, who presented with new onset pelvic pain, recurrent urinary tract infections (UTI), dyspareunia, dysuria and insensible urinary incontinence. Initial work up revealed exposed intravesical mesh with associated large bladder stones. After failing conservative management, the patient underwent robotic excision of retropubic and intravesical mesh. Results: Robotic excision of retropubic mesh was performed, ensuring complete resection of mesh, cystotomy repair and adequate post operative drainage. The patient had an uneventful hospital stay, discharged post operative day (POD) 1. Foley catheter was removed POD 3. Pelvic pain and dysuria resolved at one month follow up. Conclusions: Open, endoscopic and pure laparoscopic techniques have been described, however robotic assisted laparoscopic excision provides optimal manual dexterity, magnification and depth perception. However, there are limitations. The additional cost of robotic surgery is an ongoing area of debate and the issues with access to a robot can be prohibitive. There is a paucity of data on the robotic assisted laparoscopic management of mesh complications. Few case reports exist and to our knowledge no long term studies exist in the literature. In our experience, robotic excision of retropubic mesh is a safe and effective management option for recalcitrant retropubic intravesical mesh exposure

Objective: To identify barriers multiple sclerosis (MS) patients experience in seeking evaluation for urinary symptoms and its relationship to the Actionable Bladder Symptom and Screening Tool (ABSST). Background: The ABSST is used to identify urinary symptoms in patients with MS and may identify patients in need of referral and evaluation for neurogenic overactive bladder symptoms (NDO). Although up to 80% of MS patients may experience urinary symptoms, evaluation by a specialist and treatment are under-utilized in this population. Methods: This was a prospective observational study. 100 patients with MS, but currently not seeing a genitourinary specialist were enrolled from an MS comprehensive center with a Female Pelvic Medicine and Reconstructive Surgery (FPMRS) physician on staff. Patients completed demographic information, a short form of the ABSST and questions to assess barriers to seeking a specialist for bladder problems. An ABSST score >3 met criteria for referral and evaluation. In addition they were asked a single item question about their desire to be evaluated by a specialist for bladder problems. Two-month after enrollment, follow up calls assessed whether patients had seen a specialist to assess their urinary complaints. X² tests were used to compare categorical variables. Results: Of the 100 patients, there were 79 women and 21 men, mean age was 44.5 years and average time since diagnosis of MS was 10.4 years. Ethnicities included 45% Caucasian, 21% African American, 21% Hispanic, 2% Asian, and 11% Other/Multiracial. Overall, 40% of patients indicated that they would want to see a specialist to evaluate their bladder symptoms and 33% of patients had already seen one in the past. Most frequent reasons for seeking prior care were incontinence (46%) and recurrent UTIs (24%). Overall, the most common barriers to seeking care included "Doctor never referred" (18%), "Doctor never asked" (15%), "Had enough problems to deal with" (15%), "Thought there were no treatments available" (12.5%) and "Felt embarrassed" (10%). 40% of men stated "Doctor had never referred or asked" compared to 10% of women (p=0.002). 27 patients had an ABSST Score>3 and were more interested in seeing a specialist compared to those scoring <3 (91% vs. 40%; p= .000). When compared to patients with an ABSST<3, those with an ABSST>3 had a significant difference in level of education (p<0.05), type of mobility used (p<0.05), and employment status (p=0.005). Patients with an ABSST >3 cited limitations associated with insurance, cost, transportation, or inaccessibility more often than those with an ABSST <3 (9% vs. 3%, p=0.009). After 2 months, 49 patients were reached for follow up. Despite persistent or worsening urinary symptoms in some patients, only 1 participant had followed up. Conclusions: The ABSST is a valuable tool to identify MS patients with urinary symptoms and willingness to seek evaluation. Identification of this need alone unfortunately did not result in a significant increase in evaluation, despite ongoing symptoms. This underscores that other barriers, beyond awareness such as communication, costs and logistics, play a tremendous role preventing patients getting the evaluation that is needed. Further work is required to elucidate these factors