Faculty Bibliography

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

Introduction: The objective of this study was to determine whether patient-reported stress urinary incontinence (SUI) at the time of intradetrusor onabotulinumtoxinA injection (ONA) for urgency urinary incontinence (UUI) had an effect on catheterization rates.
Method(s): This was a retrospective chart review conducted between 1/2010 and 12/2019. Female subjects with either UUI or urgency-predominant mixed urinary incontinence (MUI) were identified for intradetrusor injection of ONA 100 Units. Charts were reviewed for demographic information, past medical and surgical history, the presence of SUI symptoms, post void residual (PVR) before and after ONA injection, need for catheterization (CIC), and subjective response to ONA. Subjects with a diagnosis of neurogenic bladder or baseline catheterization requirement were excluded. CIC was at the discretion of the clinician and was typically recommended if PVR>350mL or <350mL with symptoms of incomplete emptying. Primary outcome was difference in CIC rates between those with MUI and those with UUI at time of ONA. Demographics and outcomes were analyzed using descriptive statistics after assessing for normality. Two-tailed p-values <0.05 were considered to be statistically significant.
Result(s): A total of 177 females were included, of which 72 reported MUI symptoms at the time of ONA and 105 did not (UUI only). Women with MUI were significantly older (74.5 years [67,80] vs 69 years [61.5,78.5], p=0.02) and demonstrated lower pre-ONA PVRs (12.5ml [0,33.75] vs 24ml [0,55], p=0.04) compared to women with UUI only. There was no difference in other demographic characteristics, including proportion of women with prior anti-incontinence procedures (p=0.2) between groups. Following ONA, overall CIC rates were 11.3%. Women with MUI had significantly lower rates of CIC (4.2% vs 16.2%, p=0.015) and lower post-ONA PVRs (49 ml [16.25,129.5] vs 107ml [48.5,199.5], p=0.002) than women with UUI only. Combined subjective improvement or cure rates of UUI symptoms between groups was not different (U

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.

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.

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.