Faculty Bibliography

PURPOSE OF REVIEW: Pelvic reconstructive surgeons in the fields of urology, gynecology and urogynecology have continually adapted new techniques in pelvic organ prolapse (POP) repair in order to improve both anatomic and subjective outcomes. In the last 5 years, robotic surgery has gained a strong foothold in urologic oncology, gynecologic oncology, cardiothoracic surgery and now in female pelvic medicine. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the 'gold standard' technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. This review article aims to discuss the techniques of robotic prolapse repair as well as morbidity, cost and clinical outcomes. RECENT FINDINGS: The adaptation of minimally invasive approaches to the treatment of POP initially began with laparoscopy, something only those surgeons with extensive and advanced laparoscopic skills are able to accomplish. Access to robotic technology makes conversion from open or laparoscopic to robotic surgery much more feasible for most pelvic floor surgeons. There are currently no published randomized, controlled trials comparing robotic with open or laparoscopic sacrocolpopexy, however, there are several publications reporting both retrospective and prospective series of women undergoing robotic-assisted sacrocolpopexy. SUMMARY: Robotic-assisted pelvic floor surgery has become an important component of the pelvic surgeon's armamentarium in the treatment of symptomatic POP. Those pelvic surgeons without significant expertise in laparoscopy required for sacral dissection and intracorporeal suturing can readily learn the necessary techniques required for robotic surgery.

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

INTRODUCTION AND HYPOTHESIS: We report our experience with surgical excision for treatment of Skene's gland abscess/infection after conservative measures have failed. METHODS: A retrospective review of patients that underwent surgical excision of Skene's gland abscess/infection by a single surgeon from 06/1995 to 09/2008 was performed. Patients were separated into groups based on indication for procedure. Recurrence rate and success rate were calculated. RESULTS: The final study group included 34 patients. After initial excision, 88.2% (30/34) of patients had resolution of symptoms. Recurrence of signs and symptoms that prompted further treatment occurred in 30% (9/30). In those that recurred, 88.8% (8/9) of patients had resolution of symptoms after further therapy. Overall success rate in complete resolution of symptoms after all treatment was 85.3%. Only patients to fail were in the urethral pain and recurrent UTI groups. CONCLUSION: Surgical excision is a safe and effective therapy for the treatment of Skene's gland abscess/infection after conservative measures have failed

A basic understanding of female urethral anatomy is necessary to approach urethral reconstruction from an anatomic standpoint. This article reviews the techniques of female urethral reconstruction based on these anatomic divisions: proximal and bladder neck, midurethra, and distal urethra

PURPOSE: We classified patients lost to followup after mid urethral synthetic sling placement as examples of treatment success or failure based on the Patient Global Impression of Improvement, and compared the outcomes of those who followed up to the outcomes of those who did not. MATERIALS AND METHODS: We reviewed the charts of 217 patients who underwent mid urethral synthetic sling placement. Telephone interviews including the Patient Global Impression of Improvement and the Medical, Epidemiological, and Social Aspects of Aging questionnaires were conducted for patients lacking 3-month followup. RESULTS: Based on the Patient Global Impression of Improvement of the 48 patients who responded 13 (27.1%) were failures. The overall failure rate of patients with at least 3-month followup was 19% (23 of 124). CONCLUSIONS: In our study success rates for patients lost to followup were similar to the rates for those who had routine followup. However, it is uncertain if these data can be applied to other study populations, especially in a randomized controlled trial.

OBJECTIVE: The purpose of our study was to determine the findings at both static and dynamic MRI in women with a clinically suspected urethral abnormality. MATERIALS AND METHODS: MRI of the urethra was performed in 84 women with lower urinary tract symptoms using multiplanar T2-weighted turbo spin-echo and unenhanced and contrast-enhanced gradient-echo sequences. A dynamic true fast imaging with steady-state free precession sequence was performed during straining in the sagittal plane. Images were evaluated by two radiologists for urethral pathology and pelvic organ prolapse. MRI findings were correlated with clinical symptoms using the Fisher's exact and Mann-Whitney tests. RESULTS: Urethral abnormalities were found in 10 of 84 patients (11.9%), including two urethral diverticula, five Skene's gland cysts or abscesses, and three periurethral cysts. Thirty-three patients (39.3%) were diagnosed with pelvic organ prolapse, of whom 29 (87.9%) were diagnosed exclusively on dynamic imaging. In 29 of 33 patients with prolapse (87.9%), the urethra was structurally normal. MRI showed 13 cystoceles and 17 cases of urethral hypermobility not detected on physical examination. Patients with a greater number of vaginal deliveries, stress urinary incontinence, frequency of voiding, and voiding difficulty were statistically more likely to have anterior compartment prolapse (p < 0.05). CONCLUSION: Including a dynamic sequence permits both structural and functional evaluation of the urethra, which may be of added value in women with lower urinary tract symptoms. Dynamic MRI allows detection of pelvic organ prolapse that may not be evident on conventional static sequences