Faculty Bibliography

INTRODUCTION AND HYPOTHESIS:Sacral neuromodulation (SNM) is an effective therapy for non-neurogenic overactive bladder, non-obstructive urinary retention, and chronic fecal incontinence. Previous studies have shown SNM revision rates up to 39%, and the factors that predispose to revisions and complications remain incompletely understood. This study is aimed at characterizing reasons for SNM revision over an 18-month period to identify any potential predictors. METHODS:This is a retrospective chart review of patients following SNM implantation from 1 January 2021 to 17 May 2023 at a single academic center with five surgeons. Patient characteristics, procedural specifics, and reasons for revision were examined. Complications were defined as lead migration, infection, pain, or implantable pulse generator (IPG) issues. RESULTS:A total of 127 patients were included for a total of 135 operations. The overall revision rate was 22% (30 out of 135) with a 6.7% explantation rate (9 out of 135). Primary reasons for revision included lead migration (7), infection (3), pain (3), no efficacy (8), IPG malpositioning (3), or desire for an MRI-compatible device (7). Of patients who underwent revisions, patients with complications had a lower BMI at the time of revision (p = 0.05) and were older (p = 0.007) than patients without complications. There were no differences between genders, or with use of an antimicrobial envelope. CONCLUSIONS:The overall revision rates were lower than those in the published literature. Based on changes in BMI between implantation and subsequent revision, weight loss and older age were associated with more complications that necessitated revision. Use of an antimicrobial envelope did not change complication rates. Surgeons should decide whether its use is warranted given the added cost.

INTRODUCTION/UNASSIGNED:The introduction of transvaginal mesh (TVM) in 2002 for pelvic organ prolapse (POP) repair gained initial popularity until official warnings were released about its associated complications. This study compares the changes in practice patterns between Urogynecology and Reconstructive Pelvic Surgery (URPS)-trained and non-URPS-trained urologists following the warnings and eventual ban of TVM for prolapse repair. METHODS/UNASSIGNED:Case logs from 2001 to 2022 were queried from the American Board of Urology. POP repair cases were identified by their Current Procedural Terminology codes and categorized by surgical approach: vaginal with TVM, vaginal without TVM, and abdominal. Urologists were identified as URPS or non-URPS trained. Case log trends were analyzed before and after the initial US Food and Drug Administration (FDA) warning in 2008 and FDA ban in 2019. RESULTS/UNASSIGNED:TVM was rapidly adopted for vaginal POP repair in 2005 as seen by a 9200% increase among URPS urologists and 558% increase among non-URPS urologists. After the 2008 FDA warning against TVM, URPS urologists transitioned from TVM to non-TVM techniques for POP repair sooner than non-URPS urologists. After the TVM ban in 2019, URPS urologists performed significantly more abdominal approach and vaginal approach with TVM for POP repair. CONCLUSIONS/UNASSIGNED:The use of TVM decreased for both URPS and non-URPS urologists in response to the FDA health warnings and eventual ban of TVM for POP. URPS urologists adapted to non-TVM techniques sooner than non-URPS urologists. By 2021, URPS urologists were performing the majority of POP repair cases compared with non-URPS urologists.

BACKGROUND:Adrenal venous sampling is routinely used to lateralize aldosterone hypersecretion but has an unclear role in adrenocorticotropic hormone-independent autonomous hypercortisolism. We define clinical scenarios where adrenal venous sampling provides value for surgical decision-making. METHODS:We performed a single-center retrospective review of patients undergoing adrenal venous sampling for hypercortisolism (January 2012-April 2025). Lateralization was defined by a lateralization ratio >2 using aldosterone as a reference hormone. We also conducted a scoping review of studies describing adrenal venous sampling use in hypercortisolism identified through a comprehensive literature search. RESULTS:Nine patients with isolated hypercortisolism were included, of which 88.9% were female, with a median age of 60 years (range, 41-76). Seven patients presented with mild autonomous cortisol secretion and 2 with overt Cushing's syndrome. Six patients had bilateral adrenal nodules. Mean nodule size was 2.71 ± 0.85 cm. Eight patients underwent a 1-mg dexamethasone suppression test, with all patients meeting the >1.8 μg/dL threshold for elevated serum cortisol (mean dexamethasone suppression test cortisol: 7.13 ± 4.82 μg/dL). Adrenal venous sampling lateralization corresponded to the larger or unilateral nodule in 5 patients, was nonlateralizing in 3, and correctly lateralized to the smaller nodule in 1 patient with similarly sized lesions (1.9 cm versus 2.0 cm), enabling correct-side surgery and resolution of symptoms of overt Cushing's. Seven isolated hypercortisolism patients underwent adrenalectomy, all with benign pathology. Nine studies were included in the scoping review, demonstrating heterogeneous adrenal venous sampling lateralization criteria. CONCLUSION/CONCLUSIONS:Adrenal venous sampling may be useful in select patients with adrenocorticotropic hormone-independent hypercortisolism and similarly sized bilateral adrenal nodules in order to prevent incorrect-side adrenalectomy or unnecessary bilateral adrenalectomy.

BACKGROUND/UNASSIGNED:We reviewed published studies describing postoperative spinal hematomas (ESH) across all spinal levels, with an emphasis on thoracic cases. Postoperative epidural spinal hematomas (ESH) most commonly occur in the thoracic spine, followed by the lumbar and cervical regions. They may arise in association with anticoagulation or antiplatelet therapy, epidural anesthesia or interventional procedures, trauma, or spinal decompression and/or fusion. Thoracic ESH (TESH) represent the highest risk group, with reported incidences ranging from 0.12% to 4.46%. METHODS/UNASSIGNED:We assessed the varied etiologies of ESH/TESH, and analyzed the multitude of risk factors, imaging findings, and optimal timing of surgical intervention for addressing these lesions. RESULTS/UNASSIGNED:Reported incidences of postoperative epidural spinal hematomas (ESH) ranged from 0.1-3%, with pooled studies showing an overall rate of ~0.52-0.69%. Notably, thoracic procedures (TESH) occurred more frequently, with rates ranging from 0.12% to 4.46%. One review of 40 studies found a 0.52% overall incidence of ESH, including 0.84% thoracic, 0.63% lumbar, and 0.32% cervical lesions. Multilevel ESH/TESH hematomas were more common after posterior (0.70%) vs. anterior (0.24%) surgery, and were five-fold more frequent following minimally invasive (1.94%) vs. open procedures (0.42%). CONCLUSIONS/UNASSIGNED:Postoperative epidural spinal hematomas occur in ~0.52-0.69% of spinal procedures, with thoracic lesions showing higher reported rates (0.12%-4.46%). The strongest predictors of neurological recovery included; the rapid recognition of new postoperative neurological deficits, immediate postoperative MR studies, and emergency surgery. We therefore recommend early/STAT diagnosis and surgery for ESH/TESH (i.e. performed as soon as possible rather than simpley within a < 24 h window) to optimize outcomes.

OBJECTIVES/OBJECTIVE:F]FES) positron emission tomography/computed tomography (PET/CT) in patients with estrogen receptor (ER)-positive breast cancer. MATERIALS AND METHODS/METHODS:F]FES PET/CT compared with conventional workup. Pooled proportions of management changes were calculated across the included studies, including subgroup and sensitivity analyses. RESULTS:F]FES PET/CT was beneficial in 39% (95% CI: 24-58%) by improving diagnostic certainty and supporting current treatment options. CONCLUSION/CONCLUSIONS:F]FES PET/CT impacted management in 38% of patients with ER-positive breast cancer. KEY POINTS/CONCLUSIONS:F]fluoroestradiol PET/CT had a substantial impact on the management of patients with ER-positive breast cancer.

In 2024, more than 300,000 women in the United States were diagnosed with invasive breast cancer. Despite significant advances in chemotherapy and radiation, surgery continues to be a central tenet of these patients' care, with most patients requiring surgery for definitive treatment. Postoperative pain control and anxiety surrounding options for pain relief consistently rank as a major concern of patients before surgery. In a nation recovering from an opioid epidemic with more than 100,000 overdose deaths a year, patients and providers alike are looking for nonnarcotic and nonpharmaceutical approaches to mitigate pain. This study is a proof of concept and initial investigation of a novel vibrating device (Relievvr) that is applied directly to the breast to provide sensory input that may modulate patient-perceived discomfort. The study enrolled 22 women undergoing outpatient breast surgery who used the device as part of their postoperative protocol. At 2 weeks postoperatively, 95% of women said they would use the device if they had surgery again, and 95% of women said they would recommend the device to a friend having the same surgery. These findings serve as proof of concept that a vibrating device based on the gate control theory of pain can be a feasible, nonopioid adjunct for managing postoperative breast surgery pain, with high levels of patient satisfaction and ease of use.