Search

Objective: To assess baseline UTI knowledge, interest in health resources, and platform preferences for information acquisition and dissemination., Materials and Methods: Adult women who had a UTI in the past 12 months were recruited from Researchmatch.org to participate in a web-based quantitative study. Women with recurrent UTI (rUTI) were compared to women with a history of UTI (without rUTI)., Results: Six hundred and eighty-seven women were included in the study of which 27.4% (N = 188) had rUTI. Regarding knowledge, significantly more women without rUTI believe UTIs are caused by lack of cleanliness and that most women suffer from UTIs. Significantly more women with rUTI believe that UTIs are inherited and that getting older is associated with getting more UTIs. Regarding barriers to health information, significantly more women without rUTI feel that information is too complex and language barriers exist. More than 90% of subjects utilize their healthcare provider (HCP) for health information and most prefer office-based HCPs for health information. More than 50% of women with rUTI would like to receive UTI health updates., Conclusion: Misinformation exists regarding causes, management, and prevention of UTIs. This study identified perceived barriers as well as preferred educational platforms with the hope that this will drive improvements in UTI-related health education., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To determine whether women overactive bladder symptoms would report more frequent unhealthy toileting behaviors., Methods: A community-based sample of adult women was electronically recruited to complete the Toileting Behavior Scale and the International Consultation on Incontinence Questionnaire - Overactive Bladder module, as well as clinical and demographic questionnaires. The associations between overactive bladder and toileting behavior subscales were assessed as continuous variables using Spearman's rank correlation and as dichotomous variables with multivariable logistic regression., Results: Of the 6562 adult women included in the analytic sample, 1059 (16.1%) were classified as having overactive bladder. Of the toileting behavior subscales, convenience voiding had the highest, positive association with overactive bladder score (r = 0.301, P < .0001). On multivariable logistic regression, women with overactive bladder (OAB) were more likely to report behaviors of convenience voiding (odds ratio [OR] 1.13, confidence intervals [CI] 1.11-1.15), delayed voiding (OR 1.05, CI 1.02-1.08), straining to void (OR 1.05, CI 1.03-1.07), and position preference (OR 1.13, CI 1.08-1.18)., Conclusion: OAB symptoms were associated with specific toileting behaviors of convenience voiding, delayed voiding, straining to void, and position preference. Further investigation is needed to determine if toileting behaviors are a risk factor for OAB or a compensatory adaptation to mitigate symptoms., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To identify nonclinical factors affecting postoperative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction., Methods: Adult patients with neurogenic bladder undergoing benign GU reconstruction between October 2010 and November 2015 were included. Patients were excluded if a diversion was performed for malignancy, if patients had a history of radiation or if a new bowel segment was not utilized at the time of the operation. Clinical and nonclinical factors were abstracted from the patients' electronic medical records. Health literacy was assessed via the Brief Health Literacy Screen (BHLS), a validated 3-question assessment. Education, marital status, and distance from the medical center were also queried., Results: Forty-nine patients with a neurogenic bladder undergoing complex GU reconstruction met inclusion and exclusion criteria. On average, patients lived 111 miles (standard deviation 89) from the hospital. Overall, mean BHLS score was 10.4 (standard deviation 4.6) with 35% of patients scoring a BHLS of ≤9. Mean years of educational attainment was 9.7, and only 31% of patients completed high school education. In the first month after surgery, 37 patients (76%) experienced a complication, and 22% were readmitted; however, analysis of complication data did not identify an association between any nonclinical variables and complication rates., Conclusion: Nonclinical factors including unmarried status, poor health literacy, and marked distance from quaternary care are prevalent in patients with neurogenic bladder undergoing complex GU reconstruction. To mitigate these potential risk factors, the authors recommend acknowledgment of these factors and multidisciplinary support perioperatively to counteract them., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To evaluate if follow-up cystography alters clinical management in patients after treatment of traumatic bladder ruptures., Methods: Patients with uncomplicated blunt trauma bladder ruptures between 2000 and 2014 were identified in our institutional trauma registry. Primary management strategies consisted of either cystorrhaphy or catheter drainage. Primary outcome analyzed was occurrence of positive follow-up cystogram. Secondary outcomes were use of follow-up cystography and time to negative cystogram., Results: One hundred forty patients were identified with a median follow-up of 6.2 months (interquartile range [IQR] 3.0-32.4). Eighty-two patients (58.6%) had extraperitoneal (EP) ruptures, 49 had intraperitoneal (IP) ruptures (35.0%), and 9 had combined EP/IP rupture (6.4%). Fifty-six EP patients were managed with catheter drainage, whereas all other patients underwent cystorrhaphy. Thirty-five cystorrhaphy patients (42%) had no imaging before catheter removal. Forty-nine patients (58%) had cystograms at a median of 15.0 days (IQR 10.0-22.0) after cystorrhaphy, with only 1 patient having a persistent leak. Forty-six catheter drainage EP patients (82%) had negative cystograms at a median of 19.0 days (IQR 15.0-33.0). Of the 10 patients with persistent extravasation, 7 required operations for related complications, whereas 3 had negative imaging at a median of 38.0 days (IQR 25.8-66.8), with a mean of 2.8 cystograms before a negative study., Conclusion: Follow-up cystography after cystorrhaphy for uncomplicated blunt trauma-associated bladder ruptures rarely, if ever, provides unanticipated clinical information. For catheter drainage EP patients, cystography remains clinically valuable, as at least 18% of patients will have signs of continued extravasation. The optimal timing of cystography and catheter removal remains unknown., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown., Materials and Methods: We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates., Results: We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation., Conclusion: Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To evaluate our experience with urinary-cutaneous fistulae (UCFs) in patients following conservative management of extraperitoneal bladder ruptures (EBRs) caused by blunt trauma., Materials and Methods: Patients with blunt-trauma related EBR who underwent primary management with urethral catheter drainage alone from 2000 to 2015 were identified in our institutional trauma registry. The demographics, the hospital courses, and the outcomes of patients who developed UCF were analyzed., Results: A total of 96 patients with EBR were identified, of which 56 (58%) were managed with urethral catheter drainage. 10 patients (18%) developed major urologic complications including urosepsis (2), infected pelvic hardware (1), persistent extravasation without cutaneous fistulization (1), and UCF formation (6). Of the patients with UCF, the median time to diagnosis of EBR was 1.5 days (range 0-12), whereas the median time to diagnosis of UCF was 11 days (range 3-31). Two patients developed UCF to the perineum, whereas 4 developed UCF to the thigh. Four (66.7%) underwent nonurologic operations without cystorrhaphy before the development of UCF. One patient died without a resolution of her fistula. The remaining 5 patients all required operative repair, with a median time to repair from diagnosis of 21 days (range 2-106). The median time to resolution from diagnosis was 64 days (range 35-155)., Conclusion: UCFs are an under-reported but morbid complication of the nonoperative management of EBR. Although rare, UCF in this setting should prompt surgical intervention given the potential for prolonged convalescence and a low probability of spontaneous resolution., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To characterize perioperative morbidity and mortality in adult patients with spina bifida undergoing laparotomy., Patients and Methods: We retrospectively studied the postoperative complications of 59 operations of patients with spina bifida undergoing abdominal laparotomies for urologic indications at 3 institutions. We evaluated postoperative complications using the Clavien-Dindo classification scale., Results: The overall complication rate was 91.5%. The most common complications were ileus, pressure ulcers, urinary tract infection, and wound infection. Over 40% of the patients developed a class 3 or 4 complication requiring subsequent surgery or intensive care unit admission. The hospital readmission rate was 42% and was correlated with higher-grade complications. On multivariable analysis, only older age was significantly associated with grade of complication., Conclusion: These data demonstrate that adult patients with spina bifida comprise a unique population that faces an extremely high surgical risk even in centers of excellence. As patients with spina bifida live longer lives, thanks to modern medicine, there is a timely opportunity for research on perioperative management in these patients to improve postsurgical outcomes., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the contemporary epidemiology of blunt trauma lower urinary tract injury (LUTI) and to evaluate outcomes in patients with and without associated pelvic fracture (PF)., Methods: Patients presenting to our level I trauma center with PF and/or LUTI from blunt trauma from 2000 to 2014 were identified in our institutional trauma registry. Demographics, mechanism of injury, fracture configurations, hospital course, and outpatient disposition were analyzed., Results: Of 5518 PF patients, 233 (4.2%) had LUTI. Thirty-four patients had non-PF LUTI. There were 3.2% of men and 3.3% of women with PF who had bladder injuries (P = .94). Urethral injury was more common in men (2.0% vs 0.05%; relative risk 43.1). Pubic arch fractures were present in 87% of patients with urethral injuries, although only 1.5% of patients with pubic arch fractures had urethral injury. Isolated acetabular fractures were never associated with urethral injury and associated with only 2.6% of bladder injuries. Extraperitoneal bladder ruptures were more common in the PF group as compared to the non-PF LUTI group (39.1% vs 14.7%, P < .01). Intensive care unit length of stay and hospital length of stay for PF vs non-PF patients were 7.1 ± 8.1 vs 2.8 ± 5.3 days (P < .01) and 13.5 ± 13.4 vs 7.7 ± 8.4 days (P = .01), respectively., Conclusion: These data suggest that the contemporary incidence of PF LUTI is lower than previously reported. The presence of PF in patients with LUTI is associated with more severe overall injuries, longer hospital stays, and increased rates of inpatient complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity for concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single-institution reports, limited data are available to describe how concurrent cystectomy is employed on a national level., Materials and Methods: A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Using multivariate logistic regression models, we identified hospital- and patient-level characteristics associated with concomitant cystectomy with urinary diversion., Results: There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (P < .001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs community hospitals), in older patients, in male patients, in the Medicare population (vs private insurance and Medicaid), and in those with certain diagnoses., Conclusion: There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, although the indications driving this clinical decision appear inconsistent., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy and safety in a contemporary cohort of women who were offered either a pubovaginal sling (PVS) or a synthetic midurethral sling (MUS) after the U.S. Food and Drug Administration notification and made an informed decision on procedure option., Methods: A total of 201 women were given the option between a PVS and an MUS. Prior anti-incontinence surgery and concomitant surgery other than hysterectomy were not allowed. Minimal follow-up was 12 months. Patients were prospectively followed with validated quality of life questionnaires. Cure, voiding complaints, and complications were compared between the groups., Results: Ninety-one women (45%) underwent PVS and 110 underwent MUS (55%). Median follow-up was 13.8 months. There was no difference in baseline characteristics between the groups except for the prevalence of urge incontinence. Subjective improvement in questionnaire scores was significant for both groups. Cure rate was accomplished in 75.8% of the PVS group patients compared with 80.9% of the MUS group patients (hazard ratio, 1.35; 95% confidence interval, 0.69-2.7; P = .38). Complications and voiding difficulty were similar between the groups., Conclusion: In this contemporary cohort of women considered suitable candidates for either a PVS or an MUS, both offer comparable efficacy and complication rates. PVS may be safely offered to patients who would otherwise be good candidates for MUS if they are concerned with the implantation of mesh., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To characterize the presentation and symptom progression culminating in urinary diversion after radiotherapy for prostate cancer at a tertiary care reconstructive urology practice., Materials and Methods: Retrospective review of electronic medical records was performed for all patients between 2005 and 2011 who underwent urinary diversion for urologic complications of radiation therapy for treatment of prostate cancer. We analyzed demographics, type of radiation, presenting symptoms, diagnostic evaluation, and surgical interventions., Results: Of the 30 patients identified, 20% underwent external beam radiotherapy, 37% underwent brachytherapy, and 43% underwent combination therapy. Average time from radiation treatment until presentation to our institution was 4.6 years. Overall indications for urinary diversion included fistula (37%), end-stage bladder (20%), devastated outlet (27%), and a combination of end-stage bladder and devastated outlet (17%). Types of urinary diversion included cystectomy with conduit diversion, conduit diversion alone, and chronic indwelling suprapubic catheter. Eight patients additionally required bowel diversion for intractable gastrointestinal symptoms. Patients underwent an average of 4.4 procedures attempting to salvage native voiding function before urinary diversion., Conclusion: The reported need for urinary diversion after radiation therapy for prostate cancer is rare and thus indications have not been well characterized. We found that all of our patients with rectourethral fistula had prior placement of brachytherapy seeds. External beam radiotherapy resulted in a higher incidence of end-stage bladder dysfunction, whereas brachytherapy seed placement was more commonly associated with a devastated outlet. Surgical management for end-stage disease included cystectomy with conduit diversion, conduit diversion alone, and indwelling suprapubic catheter., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To analyze what factors contribute to a worse outcome after cystectomy and urinary diversion for benign disease as measured by the frequency of severe complications., Methods: A retrospective review was performed of consecutive patients who underwent a cystectomy for benign disease. The primary outcome was the type and severity of complications, according to Clavien-Dindo scale., Results: A total of 139 patients underwent cystectomy with diversion for benign diseases over the study period. The most common indications for surgery were spinal cord injury (32%) and radiation damage to the bladder (18%). The average preoperative age-adjusted Charlson comorbidity index was 4.6. Seventy-four patients (53%) underwent supratrigonal cystectomy. Mean surgery duration was 344±103 minutes, and the mean estimated blood loss was 476±379 mL. The most common complications were perioperative blood transfusion, prolonged ileus, and pyelonephritis. Seventy-nine patients (57%) had a complication grade≥II on the Clavien-Dindo scale. This did not differ based on indication for surgery, age, gender, body mass index, age-adjusted Charlson comorbidity index, estimated blood loss, or type of cystectomy. After adjustment, only duration of surgery in 10-minute increments (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P=.007) was associated with an increased incidence of serious complication., Conclusion: Most of the patients experience some complication after cystectomy and urinary diversion for benign indications. Duration of surgery is an important variable that can affect outcome., (Published by Elsevier Inc.)

Context: Nocturia is a common urologic symptom that has been covered in a variety of reported studies in the literature but is not specifically covered in current guidelines., Objective: To comprehensively review the literature pertaining to the definition, etiologies, and consequences of nocturia and assess the evidence supporting the use of conservative medical and interventional therapy., Evidence Acquisition: A literature search was conducted using the keyword nocturia, restricted to articles in the English language, after 2000 and before April 2012, in PubMed/Medline, Embase, Scopus, Web of Science, and Cochrane Library databases. Regarding treatment modalities, studies were included only if nocturia was a primary end point and if the studies were designed as randomized controlled trials without limit of date. When suitable, a meta-analysis was conducted. Papers covering treatment options for nocturia specifically related to nonurologic conditions were excluded., Evidence Synthesis: Nocturia is still defined as the symptom of wakening from sleep once or more often to void. The prevalence is high in both genders and increases with age. Frequency-volume charts, which are the pivotal tool of clinical assessment, detect 24-h polyuria, nocturnal polyuria (NP), or reduced nocturnal bladder capacity and help to target specific nonurologic etiologies. Nocturia is a morbid condition that significantly affects quality of life and increases mortality. Besides behavioral measures, validated treatment options include oral desmopressin, which is superior to placebo in treating NP. While the level of evidence for desmopressin is high, limited data support the use of α1-blockers and antimuscarinics; however, only rarely has nocturia been a primary end point when studying these drug classes, and studies have not consistently controlled for the effect of NP., Conclusions: Our knowledge of nocturia, its etiology, and its management has substantially improved in recent years. The evidence available on the management of nocturia remains limited; contributory factors include (1) the complexity of associated conditions, (2) the underuse of objective evaluation tools, and (3) the lack of specific focus on nocturia in clinical trials., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: To evaluate the impact of injectable agents on subsequent incontinence surgery outcomes to assess safety and efficacy of this treatment combination. Periurethral bulking agents are a minimally invasive treatment option for stress urinary incontinence (SUI), but often lack durability necessitating further surgical intervention., Methods: Retrospective review of 43 patients with SUI following bulking agent who underwent subsequent sling placement from November 2000 to September 2009 were evaluated for demographics, symptoms, urodynamics (UDS), bulking agent characteristics, concomitant procedures, pad requirements per day (PPD), subjective outcomes, and complications., Results: Mean patient age was 67 years, with mean follow-up of 37.3 months. All demonstrated SUI, and mixed urinary incontinence (MUI) was noted in 81.4%. Almost half (48.8%) had undergone a prior antiincontinence procedure. Mean number of injections was 3. After a bulking injection, 25 autologous fascia pubovaginal slings, 13 midurethral slings, and 5 biological pubovaginal slings were placed. Concomitant pelvic surgery was performed in 37.2%. Postoperatively, mean PPD decreased from 5.3 to 0.65, with a 60.5% subjective cure rate (no pads or leakage under any circumstances). No association was seen between number or type of injection, or type of sling with regards to patient outcomes. Results were significantly related to concomitant surgery (P = .007). SUI recurred in 8 patients (18.6%), which was not statistically associated with other parameters. Complications included urinary retention (8 patients) de novo urgency (1 patient), UTI (4 patients), abdominal wound infection (3 patients), and cystotomy (1 patient)., Conclusions: Prior treatment with bulking agents does not appear to negatively affect outcomes for future antiincontinence surgery in our patient population., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the efficacy and tolerability of flexible-dose fesoterodine vs placebo in subjects with overactive bladder (OAB)., Methods: In a 12-week double-blind trial, subjects were randomized to fesoterodine 4 mg or placebo once daily, taken within 4 hours of bedtime. At week 2, subjects could increase the fesoterodine dose to 8 mg (sham escalation for placebo). Subjects completed 3-day bladder diaries, Patient Perception of Bladder Condition, and Urgency Perception Scale at baseline and weeks 2, 6, and 12 as well as OAB Questionnaire at baseline and week 12., Results: Of 883 subjects, 63% and 73% of the fesoterodine (n = 438) and placebo (n = 445) groups, respectively, opted for dose escalation. Week 12 improvements from baseline in total micturitions, urgency episodes, urgency urinary incontinence episodes, frequency-urgency sum, and all OAB Questionnaire scales and domains, but not nocturnal micturitions or nocturnal urgency episodes, were significantly greater with fesoterodine than placebo (all P <.05). Treatment differences in micturitions and frequency-urgency sum were significant by week 2 and in urgency urinary incontinence and urgency episodes by week 6. Significantly greater percentages of subjects taking fesoterodine had improved Patient Perception of Bladder Condition and Urgency Perception Scale scores at weeks 2, 6, and 12 (P <.05). Dry mouth (fesoterodine, 26%; placebo, 8%) and constipation (fesoterodine, 11%; placebo, 6%) were the most common adverse events. In both groups, 87% of the subjects completed the trial; 8% and 5% of the fesoterodine and placebo groups, respectively, discontinued because of an adverse event., Conclusions: Flexible-dose fesoterodine was efficacious and generally well tolerated for treatment of OAB symptoms., (2010 Elsevier Inc. All rights reserved.)

Context: The focus of clinical understanding and management of male storage lower urinary tract symptoms (LUTS) has shifted from the prostate to the bladder. This is mirrored by an increasing body of experimental evidence suggesting that the bladder is the central organ in the pathogenesis of LUTS., Objective: A systematic review of the literature available on pathophysiologic aspects of storage LUTS., Evidence Acquisition: Medline was searched for the period ending December 2008 for studies on human and animal tissue exploring possible functional and structural alterations underlying bladder dysfunction. Further studies were chosen on the basis of manual searches of reference lists and review papers., Evidence Synthesis: Numerous recent publications on LUTS pathophysiology were identified. They were grouped into studies exploring abnormalities on urothelial/suburothelial, muscular, or central levels., Conclusions: Studies revealed both structural and functional alterations in bladders from patients with LUTS symptoms or animals with experimentally induced bladder dysfunction. In particular, the urothelium and the suburothelial space, containing afferent nerve fibres and interstitial cells, have been found to form a functional unit that is essential in the process of bladder function. Various imbalances within this suburothelial complex have been identified as significant contributors to the generation of storage LUTS, along with potential abnormalities of central function.

Context: The term "lower urinary tract symptoms" (LUTS) was introduced to dissociate male urinary symptoms from any implied site of symptom origin, such as the prostate., Objective: To consider a more expansive view of LUTS, moving beyond an organocentric focus., Evidence Acquisition: Review of the available literature by a consensus panel., Evidence Synthesis: A consensus group reviewed the literature and developed a conceptual framework to facilitate research and clinical practice in patients with LUTS, following steps outlined in the Delphi procedure. Committee discussion, with presentations and review of existing literature and knowledge at four separate occasions, and extensive review and discussion of draft documents encapsulating group views followed. Consensus group findings included evidence that LUTS increase with age and are prevalent in both male and female patients, with differences in the prevalence of individual storage, voiding, and postmicturition symptoms representing underlying pathophysiologic factors between the sexes. Additionally, it was recognised that patients often have underlying and overlapping pathophysiologic mechanisms that may be related to the expression of LUTS and that this global approach to LUTS reflects our contemporary recognition of the lower urinary tract as an integrated functional unit. To improve the current management of patients, education and awareness regarding LUTS, its causes, and associated comorbidities are needed. Major limitations of this work are the potential interpretive bias introduced by prior perceptions and the nature of the study populations drawn conventionally from secondary care., Conclusions: In conclusion, it is misleading to attribute individual symptoms to sex differences or to a specific underlying organ. LUTS are a non-sex-specific, non-organ-specific group of symptoms, which are sometimes age-related and progressive. A need exists to increase education and awareness regarding LUTS, its causes, and associated comorbidities, and to assess and treat men and women for all LUTS, not just selected symptoms.

Polypropylene midurethral slings have become the most common surgical procedure for the treatment of stress urinary incontinence. The efficacy has been well established through prospective and systematic evaluation. Transobturator midurethral slings have demonstrated comparable efficacy relative to the retropubic approach with the potential to minimize the morbidity associated with retropubic needle passage. We present a case of recalcitrant medial thigh pain after transobturator midurethral sling placement that ultimately required medial thigh/transobturator exploration and sling excision.

Objectives: Little is known about the host response to the various biologic and synthetic graft materials used as substitutes for autologous fascia. We investigated the host response to sling graft materials in humans., Methods: A total of 24 women undergoing sling revision had a portion of the graft material removed for comparative analysis. At exploration, the degree of graft preservation (integrity), encapsulation, infection, and fibrosis was quantified. A histopathologic analysis was performed by systematically examining each specimen for the inflammatory response, neovascularity, and host fibroblast infiltration., Results: A total of 24 grafts were explanted at 2-34 months after implantation. The indications for removal were a lack of sling efficacy in 2, urinary retention in 9, and sling obstruction in 13. The types of graft material were polypropylene mesh (PPM) in 10, autologous fascia in 5, porcine dermis in 4, cadaveric dermis in 3, and cadaveric fascia in 2. No graft degradation had occurred in PPM material. Autologous and cadaveric fascia had the most demonstrable graft degradation. No encapsulation had occurred with autologous fascia or PPM. The porcine dermis was the most encapsulated. No host infiltration had occurred with the encapsulated porcine grafts, and only peripheral infiltration of fibroblasts had occurred in the cadaveric grafts. The PPM grafts had the greatest number of fibroblasts throughout the entire graft. Neovascularity was the most prevalent in mesh and was also present in the autologous fascia. Giant cells were seen in two mesh and two porcine grafts., Conclusions: The results of our study have shown that porcine dermis has the potential to encapsulate. The degree of host tissue infiltration was greatest with PPM, and no degradation of the mesh material had occurred with time.

Objectives: A once-daily (QD) formulation of trospium chloride has been developed for the management of overactive bladder syndrome (OAB). This randomized controlled trial evaluated the efficacy and tolerability of this new extended-release formulation, trospium chloride 60 mg QD., Methods: Adults with OAB with urinary urgency, frequency, and urgency urinary incontinence (UUI) were eligible for inclusion. Subjects received trospium 60 mg QD or placebo for 12 weeks. Change in the mean number of toilet voids per day and UUI episodes per day were the primary outcome variables. Changes in urgency severity were also assessed and adverse events (AEs) were recorded., Results: Overall, 564 subjects participated in the study (trospium QD 280; placebo 284). Trospium QD demonstrated significant improvement in both primary outcome variables. The mean number of toilet voids per day was reduced from approximately 13 at baseline to 10.3 for trospium QD versus 11.1 for placebo (P <0.001) at week 12, whereas the number of UUI episodes per day was reduced from approximately 4 at baseline to 1.7 at week 12 with trospium QD versus 2.4 for placebo (P <0.001). Trospium QD also reduced urgency severity (P <0.001) and increased voided volume (P <0.01) compared with placebo. Benefits over placebo were apparent within the first week of treatment. Trospium QD was well tolerated; the most frequent AEs being dry mouth (trospium QD 12.9%; placebo 4.6%) and constipation (7.5% versus 1.8%, respectively). Central nervous system side effects were rarely observed and were comparable between groups., Conclusions: Trospium QD represents a convenient, effective, and well-tolerated treatment option for OAB.

Objectives: To evaluate the safety and effectiveness of soft-tissue augmentation of the urethral sphincter with calcium hydroxylapatite (CaHA; Coaptite) compared with glutaraldehyde cross-linked bovine collagen (Contigen) in female patients with stress urinary incontinence due to intrinsic sphincter deficiency and without associated urethral hypermobility., Methods: This 12-month prospective, randomized, comparative, multicenter, single-blind, parallel, clinical trial of CaHA and collagen for soft-tissue augmentation of the urethral sphincter in the treatment of stress urinary incontinence enrolled 296 women. Up to five injections were performed in the first 6 months of the trial. Twelve-month postinjection efficacy data were available for 231 patients., Results: The results indicated that CaHA and collagen were both well tolerated in this study. No systemic adverse events were observed with either product. We used the Stamey Urinary Incontinence Scale to grade the improvement, which was the primary endpoint of the study. At 12 months, 83 (63.4%) of 131 CaHA patients compared with 57 (57.0%) of 100 collagen patients showed improvement of one Stamey grade or more (P = 0.34). More CaHA patients required only one injection (n = 60; 38.0%) during the study compared with the Contigen patients (n = 36; 26.1%; P = 0.034). Also, the average total volume of material injected during the course of the study was less for CaHA than for collagen (4.0 mL versus 6.6 mL, respectively; P <0.0001)., Conclusions: The results of the study have demonstrated that Coaptite is an appropriate and well-tolerated treatment for patients with incontinence due to intrinsic sphincter deficiency. This new soft-tissue augmentation material has a good safety profile and appears to provide durable improvement.

Objectives: To compare the efficacy and safety of an oxybutynin transdermal delivery system (OXY-TDS) and oral, long-acting tolterodine (TOL-LA) with placebo in previously treated patients with urge or mixed urinary incontinence., Methods: After withdrawal of their current antimuscarinic therapy, 361 adult patients were randomized to 12 weeks of double-blind, double-dummy treatment with twice weekly OXY-TDS 3.9 mg/day, daily TOL-LA 4 mg, or placebo. Evaluations included change from baseline in patient urinary diary symptoms, incontinence-specific quality of life, and safety., Results: OXY-TDS 3.9 mg/day and TOL-LA 4 mg/day significantly reduced the number of daily incontinence episodes (median change -3 OXY-TDS and -3 TOL-LA versus -2 placebo; P <0.05), increased the average void volume (median change 24 and 29 mL versus 5.5 mL, P <0.01), and improved quality of life (incontinence impact questionnaire [IIQ] total score, P <0.05; Urogenital Distress Inventory Irritative Symptom subscale, P <0.05) compared with placebo. The most common adverse event for OXY-TDS was localized application site pruritus (14% versus 4% placebo) accompanied by a low incidence of systemic side effects (eg, dry mouth 4.1%). Anticholinergic adverse events occurred with greatest frequency during TOL-LA treatment (dry mouth 7.3% versus 1.7% placebo, P <0.05)., Conclusions: OXY-TDS and TOL-LA are effective and comparable treatments for patients with urge and mixed incontinence. OXY-TDS improves systemic safety with regard to anticholinergic side effects. Local skin irritation occurs in some OXY-TDS patients.

Lower urinary tract symptoms (LUTS) in men may arise from a variety of underlying causes, including benign prostatic hyperplasia. LUTS may have a significant component of storage symptoms (urgency, frequency, urge incontinence) at presentation; however, the absence of overactive bladder (OAB) symptoms does not necessarily imply pure outlet obstruction nor does their presence indicate the lack thereof. Symptomatic correlates to urodynamic findings are high when considering isolated OAB symptoms. However, mixed presentations or more overtly obstructive scenarios have less correlation with baseline symptom appraisal instruments. The ideal approach for diagnosis and management is predicated on a graded approach, with more invasive evaluation withheld for those men in whom presumptive therapy fails or who present with associated complex symptoms and in whom a higher level of intervention is being considered. The increasing incidence of LUTS with age implies a partial detrusor contribution, which must be considered in the overall management schema.

Clinicians and researchers agree that pharmacologic studies of the overactive bladder (OAB) require precise planning, strict adherence to study design, and meticulous attention to study conduct and statistical methods. In addition, there should be straightforward and highly directed formulation of the conclusions derived expressly from data that have been collected. The exact methods to achieve these ends, however, are often debated among statisticians and experts in study design and by physicians who interpret the clinical implications of the findings. For these reasons, the conclusions of clinical research in OAB are commonly criticized on the basis of study objectives, study design, statistical methods, or conclusions. However, a subtler, but possibly more critical problem exists: the method of defining the population and the methods for collecting the data for the efficacy outcome parameters, including frequency, urgency, and urge incontinence.

Objectives: To determine the perioperative morbidity of performing a concurrent pubovaginal sling with prolapse repair in women with occult (or potential) stress incontinence, particularly on voiding dysfunction and emptying., Methods: We reviewed the charts of 38 women with grade 3-4 pelvic prolapse and occult stress incontinence. All patients underwent video urodynamic testing with the prolapse unreduced and again with the prolapse reduced with a pessary or packing. The abdominal leak point pressure was determined. Appropriate surgical repair of all components of the prolapse was performed concurrently with pubovaginal sling placement. The outcomes were measured with respect to the time to spontaneous voiding, permanent urinary retention, development of stress incontinence or de novo urge incontinence, resolution of urge incontinence, and perioperative complications., Results: The mean age was 72 years, and the mean follow-up was 15 months (range 6 to 39). The mean time required before spontaneous voiding resumed without the need for catheterization was 11.8 days (range 2 to 46). No patient developed permanent urinary retention. Two (9.5%) of 21 women without preoperative urge incontinence developed de novo urge incontinence. However, existing urge incontinence resolved in 45%. One woman developed a suprapubic wound infection, which resolved with conservative management. Stress incontinence occurred in 2 women (7%) at 4 and 19 months postoperatively. Clinically significant prolapse (uterine) developed in 1 patient 2 years after surgery., Conclusions: Simultaneous pubovaginal sling placement for women with occult stress incontinence undergoing repair of a large pelvic prolapse is effective in preventing postoperative stress incontinence and has little negative effect on postoperative bladder emptying. It should be considered in all women with occult stress incontinence undergoing prolapse repair.

Objectives: To describe a simplified technique and results of pubovaginal sling lysis by incision of the sling in the midline by way of a transvaginal approach., Methods: We reviewed the charts of 19 women who underwent pubovaginal sling lysis for obstruction. Patients presenting with retention, incomplete emptying or storage, or voiding symptoms suggesting obstruction after pubovaginal sling placement were evaluated with videourodynamic studies and cystourethroscopy. The diagnosis of obstruction was made on the basis of a combination of clinical, urodynamic, and endoscopic findings. All patients underwent a midline incision of the sling by way of a transvaginal approach without formal urethrolysis., Results: The mean patient age was 57 years. Fifteen women (79%) had an autologous rectus fascial sling, 3 (16%) an allographic fascia lata sling, and 1 (5%) a polypropylene sling. Twelve women (63%) presented with urinary retention and required catheterization to empty. The other 7 women presented with obstructive and/or irritative symptoms without the need to catheterize. The mean time to sling lysis was 10.6 months from the initial surgery. The mean follow-up was 12 months (range 1 to 55). Overall, sling lysis was successful in 84% of the women. Stress incontinence recurred in 17%. No significant perioperative complications occurred., Conclusions: Pubovaginal sling lysis without formal urethrolysis appears to be a safe and effective method of relieving obstruction. The success and recurrent stress incontinence rates are comparable to those with formal urethrolysis.

Objectives: Improved understanding of pelvic neuroanatomy in women has led to modified surgical approaches and additional considerations in pelvic surgery. The innervation of the external urinary sphincter and urethra is not well defined in women, and, as such, the continence complex is not well understood., Methods: Fourteen pelvic sections from seven fresh female cadavers were dissected to investigate the neuroanatomy of the female continence complex., Results: Neuroanatomic dissections of the continence mechanism revealed that branches of the pelvic nerve travel beneath the fascia of the levator ani muscle and approach the urinary sphincter in near midline position, posterolateral to the rectum. This pelvic nerve branch passes laterally around the vagina and rectum to enter the sphincter musculature at the 5-o'clock and 7-o'clock positions. The pudendal nerve, traveling in the pudendal canal, gives an intrapelvic branch that courses to the urinary sphincter. At the level of the proximal urinary sphincter, it joins the pelvic nerve branch to the urinary sphincter., Conclusions: These neuroanatomic dissections provide a basis for surgical modifications that may address a variety of concerns regarding urinary continence in female surgical patients. With improved understanding of the female continence complex, we may now have a more precise anatomic explanation for the high failure rates associated with transvaginal urethral suspension procedures. Additionally, awareness and preservation of the continence nerves during cystectomy may allow for greater use of orthotopic bladder replacement in women.

Periurethral bulking agents have been used for decades. The only currently available agents (in the United States) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead technology. Initial subjective cure rates with collagen are acceptable, but with the majority of women requiring reinjection. The risk of allergic phenomena complicates collagen use. Autologous fat injection is initially effective in >50% of women, but resorption and fibrous replacement hamper the stability of the transplanted graft. Polytetrafluoroethylene and silicone are not currently approved by the US Food and Drug Administration because of particle migration. Materials in development include biologic agents such as allogeneic human collagen and autologous cartilage. Developmental synthetic agents include microballoon technology, hyaluronic acid with or without microsphere technology, hydroxylapatite, and a variety of polymeric technologies. Patient selection and material characteristics influence the optimal choice for injectable agent.

Continued developments in the understanding of lower urinary tract function have led to improvements in the pharmacologic manipulation of bladder dysfunction. Drug delivery changes have produced drugs that provide better efficacy and tolerability, thus improving patient compliance. Improvements in drug delivery systems have altered drug bioavailability and pharmacokinetics. Active current investigation in new agents and delivery systems for intravesical delivery has yielded intriguing early results that may substantially add to the armamentarium for the management of the overactive bladder (urgency, frequency, urge incontinence). New developments in the understanding of the neuropharmacology of the bladder, peripheral pelvic nerves, and sacral cord may provide agents with entirely new drug effects, either as primary agents or agents to be used in combination with currently available drugs. We herein review newer agents and drug delivery systems.

Objectives: To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury., Methods: A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury., Results: Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found (P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications (P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period., Conclusions: The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Objectives: The expected urodynamic findings of patients with suprasacral and sacral spinal cord injury have previously been reported. However, the associations between the radiographically determined level or levels of injury and urodynamic findings are ill defined. This study investigated these relationships, specifically the bladder behavior of patients with post-traumatic spinal cord injury with combined suprasacral and sacral injuries., Methods: A retrospective review of the patient records, spinal imaging studies, and video-urodynamic studies of 316 patients with post-traumatic spinal cord injury was performed. Of these patients, 243 had complete spinal computed tomography or magnetic resonance imaging studies and constitute the study population. Patients were categorized by the radiographically determined level or levels of injury, clinical neurologic level and completeness of injury, and urodynamic findings., Results: Of the 196 patients with suprasacral injuries, 186 (94.9%) demonstrated hyperreflexia and/or detrusor sphincter dyssynergia, 82 (41.8%) had low bladder compliance (less than 12.5 mL/cm H(2)O), and 79 (40.3%) had high detrusor leak point pressures (greater than 40 cm H(2)O). Of the 14 patients with sacral injuries, 12 (85.7%) manifested areflexia, 11 (78.6%) had low compliance, and 12 (85.7%) had high leak point pressures. Of the 33 patients with combined suprasacral and sacral injuries, urodynamic studies showed 23 with hyperreflexia and/or detrusor sphincter dyssynergia (67.7%), 9 with areflexia (27.3%), 19 (57.6%) with low compliance, and 20 (60.6%) with high leak point pressures., Conclusions: In patients with a single level of spinal cord injury, this study revealed a significant association between the level of injury and the type of voiding dysfunction. Patients with combined suprasacral and sacral injuries, as identified with precise spinal imaging techniques, had relatively unpredictable urodynamic findings. Management of the urinary tract in patients with spinal cord injury must be based on urodynamic findings rather than inferences from the neurologic evaluation.

Objectives: Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control., Methods: Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy., Results: At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o'clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o'clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92. 1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence., Conclusions: During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.

Objectives: The external striated urethral sphincter (rhabdosphincter) is a tubular muscle sleeve that extends from the prostato-membranous urethra and perineal membrane to the bladder neck. The male rhabdosphincter neuroanatomy remains unclear, and a better understanding of its innervation may provide insight into potential modifications of radical pelvic surgery to improve urinary continence., Methods: Fresh cadaveric dissections of 12 male hemipelves were undertaken to investigate the neuroanatomy of the urinary rhabdosphincter., Results: Neuroanatomic courses of the nerve supply to the rhabdosphincter revealed that, in the perineum, the perineal nerve (a terminal branch of the pudendal nerve) provided branches directly to the bulbospongiosus muscle and the urinary rhabdosphincter. In the pelvis, the course of the pelvic nerve was as follows: (1) arising from the inferior hypogastric plexus, it had a weblike course beneath the muscle fascia of the levator ani muscle; (2) traveling posterolateral to the rectum, it gave many branches that perforated into the lateral rectum; and (3) at the level of the prostatic apex, still beneath the levator ani muscle fascia (superior fascia), it sent multiple direct branches to the inferolateral aspect of urinary rhabdosphincter. The pudendal nerve traversed the pelvis in the pudendal canal, and, before leaving the pelvis to enter the perineum, it gave an intrapelvic branch that courses with the pelvic nerve to innervate the rhabdosphincter., Conclusions: Our understanding of the neuroanatomy of what may be the continence nerves has been improved by fresh cadaveric dissection. The rhabdosphincter receives nerve fibers from the pelvic nerve and dual innervation from an intrapelvic branch and a perineal branch of the pudendal nerve. Better understanding of these anatomic findings may have potential surgical significance with respect to improvement in postoperative urinary continence.

Objectives: Women undergoing four-corner bladder neck suspension were evaluated for subjective and objective results of the procedure. Patients were evaluated for continence, prolapse, and symptomatic status postoperatively., Methods: Forty-seven women underwent four-corner bladder neck suspension for moderate cystocele with (44) or without (3) stress urinary incontinence. Mean and median follow-up were 37 months (range 15 to 80). To assess results of the four-corner bladder neck suspension, two sets of outcome measures were used (subjective questionnaire, including patient satisfaction, and objective physical examination, with standing voiding cystourethrogram) to compare pre- and postoperative data., Results: At the time of follow-up, 25 patients (53%) reported no incontinence, 14 (30%) reported one incontinent episode per week, and 8 (17%) reported daily loss of urine. Twenty-seven (57%) had grade I or grade II cystoceles on follow-up examination and voiding cystourethrogram; however, only 12 (26%) experienced recurrent prolapse symptomatology. Overall patient acceptance of the procedure was high (70%)., Conclusions: The four-corner bladder neck suspension is an effective option in the management of moderate cystocele.