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Objective To examine and better understand expectations and facilitators of satisfaction amongst patients presenting to an ambulatory urology clinic at an academic medical center. Methods Patients completed an anonymous survey regarding expectations for their clinic visit. Patients were included in the investigation if they were aged 18-89 years and had the ability to complete informed consent. Chi-square analysis was then used to analyze the collected data. Results A total of five hundred patients were enrolled in the study. Patients were predominantly white males and were older than 60 years of age. Most patients had at least a college education and drew an annual household income between $40,000-$99,999. Most enrollees were return patients (74.8%). Most expected to be seen within 3-7 days of referral and expected 16-30 minutes with their provider. Patients noted they would not be equally satisfied seeing a physician versus advanced practice provider on their initial visit but would on a return visit. About half (52%) of the cohort stated they would be dissatisfied with their clinic experience if their expectations were not met. Significance was found between variables including age, race, gender and type of visit and their survey responses. Conclusion Patient satisfaction remains an important measure for the quality and safety of patient care. This investigation highlighted patient prioritization of time to be seen after referral and the provider that cares for them at both initial and follow-up visits. Future research is needed to enhance stakeholder understanding of precisely how expectations impact overall satisfaction.

This chapter summarizes the results of the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial, in which women without stress urinary incontinence undergoing prolapse surgery were randomized to a midurethral sling or no concomitant midurethral sling. The OPUS trial found that women randomized to undergo prophylactic concomitant midurethral sling at the time of transvaginal repair for pelvic organ prolapse had lower rates of urinary incontinence at 3 and 12 months but also experienced higher rates of adverse events such as bladder perforation, major bleeding, and urinary tract infections.

This chapter summarizes the results of the VALUE trial, in which women with stress urinary incontinence scheduled to undergo incontinence surgery were randomized to undergo preoperative urodynamic testing versus office evaluation alone. Treatment was considered successful in a similar, large proportion of women in both groups. A diagnosis of stress urinary incontinence was confirmed in most of the women who underwent urodynamic testing; changes were made to their surgical planning on the basis of the additional testing in very few of them. These findings suggested that urodynamic testing may not contribute to the overall success rate of surgery in healthy women with uncomplicated stress urinary incontinence.

This chapter summarizes the results of the Anticholinergic Versus Botulinum Toxin Comparison (ABC) trial, in which women with urgency urinary incontinence were randomized to receive daily oral anticholinergic therapy versus a one-time intradetrusor injection of 100 units of onabotulinumtoxin A (Botox). Women in both groups reported a similar reduction of about three in the mean number of incontinence episodes. Complete resolution of symptoms was more likely in the Botox group. Dry mouth was reported more frequently by women in the anticholinergic group; women in the Botox group had higher rates of urinary tract infections. This study demonstrated similar outcomes for both treatments with respect to symptoms of urinary incontinence but the two treatments had different side-effect profiles.

This chapter summarizes the results of the Stress Incontinence Surgical Treatment Efficacy (SISTEr) trial, which randomized women with stress urinary incontinence to an autologous sling procedure versus a Burch colposuspension. Overall treatment success favored the fascial sling over the Burch procedure group, as did the stress incontinence–specific success rate at 24 months. Postoperative voiding dysfunction and urge incontinence were more common in the sling group than the Burch group. These findings supported the historical shift toward slings (autologous and synthetic) versus Burch colposuspension procedures in clinical practice.

This chapter summarizes the results of the Trial of Mid Urethral Slings (TOMUS), in which women with stress urinary incontinence were randomized to a retropubic midurethral sling versus a transobturator sling. Bladder perforations and voiding dysfunction occurred only in the retropubic sling group; neurologic symptoms (weakness and numbness) were significantly more common in the transobturator group. Both objective and subjective measures of treatment success at 12 months were similar. Based on this and subsequent studies, retropubic and transobturator midurethral sling approaches appear to have similar outcomes at 12 months for the treatment of stress urinary incontinence. However, the approaches differ in their adverse-event profiles.

Spinal tumors and intervertebral disk prolapse are relatively uncommon causes of neurogenic bladder dysfunction. Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are compromised, resulting in disruption of motor and sensory function to the pelvic floor, bladder, and lower extremities. Primary tumors of the spinal cord, spinal nerve roots, and dura are relatively rare, while the bony spinal column is a common site of metastases in patients with visceral cancers. Spinal tumors are anatomically characterized into extradural, intradural but extramedullary, and intradural intramedullary. The association of intervertebral disk prolapse with voiding dysfunction has long been recognized and typically results from the impact of spinal nerve root compression causing axonal dysfunction, ischemia, inflammation, and biochemical sensitization by the protruding disk. CES is characterized by a constellation of symptoms including low back pain, unilateral or bilateral lower extremity pain and weakness, bowel disturbance, bladder and sexual dysfunction, and saddle or perineal paresthesia.

The purpose of this article is to review the available data regarding the application and therapeutic outcomes of laser therapy for the treatment of genitourinary syndrome of menopause (GSM). There have been several studies regarding the use of laser therapy for the treatment of GSM. Most of these studies show a trend toward safe and effective treatment in the short term (less than or equal to 12 weeks). However, these studies are lacking in randomization, blinding, placebo, and comparison groups. Although laser therapy for the treatment of the symptoms of GSM appears promising, there is currently a lack of high-level and long-term evidence regarding its safety and efficacy. There is also a lack of professional guidelines in the USA regarding this modality of treatment, specifically for GSM. Opportunities exist for future research in this area, specifically to determine safety and long-term outcomes of therapy.

Bladder dysfunction is common in neurologic disease and may be associated with significant secondary morbidity and mortality. Evaluation of neurogenic bladder patients is now taking place more frequently in an office setting. Flexible cystoscopy, videourodynamics, and office-based ultrasound imaging are commonly available in urologists’ offices. Emerging therapies, such as botulinum toxin injection, may reduce the need for surgical reconstruction and accelerate the shift of treatment of neurogenic bladder to the office setting. These complex patients, however, often have significant mobility issues that create barriers to care in the office setting. Optimal office design and setup as well as ancillary staff training are necessary to provide the most efficient and effective care of this patient population.

Neuromodulation offers a reversible and minimally invasive treatment for patients with urge incontinence, urinary urgency-frequency syndrome, and nonobstructive urinary retention that is refractory to conservative therapy. Despite many advances in the techniques of neuromodulation, the mechanism of neuromodulation of bladder function remains undefined. It seems to involve activation of peripheral afferent nerves and may influence bladder function in part through a supraspinal mechanism. Neuromodulation of bladder function is clinically available via US Food and Drug Administration-approved techniques of sacral nerve root stimulation and posterior tibial nerve stimulation. Sacral neuromodulation has emerged as the preferred treatment for symptoms that are refractory to conservative management. Few predictors of response to sacral neuromodulation have been identified. Alternative, more peripheral forms of neuromodulation for bladder dysfunction such as pudendal and dorsal genital nerve stimulation are being studied.

Background Transurethral radiofrequency collagen denaturation is a relatively novel, minimally invasive device-based intervention used to treat individuals with urinary incontinence (UI). No systematic review of the evidence supporting its use has been published to date. Objectives To evaluate the efficacy of transurethral radiofrequency collagen denaturation, compared with other interventions, in the treatment of women with UI. Review authors sought to compare the following. • Transurethral radiofrequency collagen denaturation versus no treatment/sham treatment. • Transurethral radiofrequency collagen denaturation versus conservative physical treatment. • Transurethral radiofrequency collagen denaturation versus mechanical devices (pessaries for UI). • Transurethral radiofrequency collagen denaturation versus drug treatment. • Transurethral radiofrequency collagen denaturation versus injectable treatment for UI. • Transurethral radiofrequency collagen denaturation versus other surgery for UI. Search methods We conducted a systematic search of the Cochrane Incontinence Group Specialised Register (searched 19 December 2014), EMBASE and EMBASE Classic (January 1947 to 2014 Week 50), Google Scholar and three trials registries in December 2014, along with reference checking. We sought to identify unpublished studies by handsearching abstracts of major gynaecology and urology meetings, and by contacting experts in the field and the device manufacturer. Selection criteria Randomised and quasi-randomised trials of transurethral radiofrequency collagen denaturation versus no treatment/sham treatment, conservative physical treatment, mechanical devices, drug treatment, injectable treatment for UI or other surgery for UI in women were eligible. Data collection and analysis We screened search results and selected eligible studies for inclusion. We assessed risk of bias and analysed dichotomous variables as risk ratios (RRs) with 95% confidence intervals (CIs) and continuous variables as mean differences (MDs) with 95% CIs. We rated the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Main results We included in the analysis one small sham-controlled randomised trial of 173 women performed in the United States. Participants enrolled in this study had been diagnosed with stress UI and were randomly assigned to transurethral radiofrequency collagen denaturation (treatment) or a sham surgery using a non-functioning catheter (no treatment). Mean age of participants in the 12-month multi-centre trial was 50 years (range 22 to 76 years). Of three patient-important primary outcomes selected for this systematic review, the number of women reporting UI symptoms after intervention was not reported. No serious adverse events were reported for the transurethral radiofrequency collagen denaturation arm or the sham treatment arm during the 12-month trial. Owing to high risk of bias and imprecision, we downgraded the quality of evidence for this outcome to low. The effect of transurethral radiofrequency collagen denaturation on the number of women with an incontinence quality of life (I-QOL) score improvement ≥ 10 points at 12 months was as follows: RR 1.11, 95% CI 0.77 to 1.62; participants = 142, but the confidence interval was wide. For this outcome, the quality of evidence was also low as the result of high risk of bias and imprecision. We found no evidence on the number of women undergoing repeat continence surgery. The risk of other adverse events (pain/dysuria (RR 5.73, 95% CI 0.75 to 43.70; participants = 173); new detrusor overactivity (RR 1.36, 95% CI 0.63 to 2.93; participants = 173); and urinary tract infection (RR 0.95, 95% CI 0.24 to 3.86; participants = 173) could not be established reliably as the trial was small. Evidence was insufficient for assessment of whether use of transurethral radiofrequency collagen denaturation was associated with an increased rate of urinary retention, haematuria and hesitancy compared with sham treatment in 173 participants. The GRADE quality of evidence for all other adverse events with available evidence was low as the result of high risk of bias and imprecision. We found no evidence to inform comparisons of transurethral radiofrequency collagen denaturation with conservative physical treatment, mechanical devices, drug treatment, injectable treatment for UI or other surgery for UI. Authors' conclusions It is not known whether transurethral radiofrequency collagen denaturation, as compared with sham treatment, improves patient-reported symptoms of UI. Evidence is insufficient to show whether the procedure improves disease-specific quality of life. Evidence is also insufficient to show whether the procedure causes serious adverse events or other adverse events in comparison with sham treatment, and no evidence was found for comparison with any other method of treatment for UI.

Neuromodulation is becoming a part of the clinical armamentarium for treatment of a variety of lower urinary tract conditions. Its increased usage stems from the needs of patients who have exhausted all other therapeutic options. Currently, neuromodulation may consist of the use of nerve stimulation and injectable therapies. This article concentrates on nerve stimulation.

Purpose of review Robotic surgery with its numerous advantages over conventional laparoscopy has assumed an ever-expanding role in pelvic and pelvic floor reconstructive surgery. Our goal is to review the literature regarding robotic use in urogynecologic surgery. Recent findings The current literature demonstrates the feasibility and safety of performing robotic urogynecologic procedures in a wide variety of cases. Robotic sacrocolpopexy and hysterectomy are most commonly described, but the use of robotics in the repair of complex pelvic fistulae has also been examined. The available studies mainly consist of case series with short-term follow-up, but early outcomes appear to be comparable to open surgery with decreased patient morbidity. Summary The role of robotics in urogynecologic surgery will continue to grow, as there is an increasing access to the robotic platform, and its use is being incorporated into residency training. More robust studies will be needed to validate the continued use of the robot, as there are concerns regarding cost, training, and credentialing.

A detailed working knowledge of normal and abnormal female pelvic anatomy is necessary for the proper evaluation of pelvic organ prolapse. However, even the most experienced gynecologist or urologist may have difficulty distinguishing among prolapsing organs competing for introital space. Accurate identification of all aspects of vaginal prolapse and pelvic floor relaxation are vital, not only to permit adequate surgical planning, but also to reduce the risk of recurrent prolapse. Radiographic evaluation of the woman with pelvic organ prolapse and pelvic floor relaxation should be viewed as a valuable extension of the physical examination. Urography, voiding cystography, dynamic colpocystodefecography, and MRI are each useful for the evaluation of pelvic prolapse and pelvic floor relaxation. Magnetic resonance imaging will continue to have an increasingly important role, because of its superior visualization of fluid-filled viscera and soft tissues, and the ability to simultaneously visualize all important pelvic organs without the need for patient preparation or instrumentation, or exposure to ionizing radiation.

Stress urinary incontinence is a prevalent condition that may have a significant negative impact on a woman's quality of life. With improved awareness and research, new nonsurgical and surgical managements are being developed; noninvasive measures should be considered before invasive treatments. Pelvic floor exercises, biofeedback, and electrical stimulation may be helpful depending on the individual. With the release of duloxetine, the first FDA-approved medication for stress urinary incontinence, pharmacologic therapy (which has not had a significant role in stress urinary incontinence) will gain more attention. Surgical treatments have become minimally invasive with good efficacy. Overall, as the understanding of the pathophysiology of stress urinary incontinence evolves, so will management of this disease state.

Adenocarcinoma of the prostate is the most common malignancy in men. The treatment options for prostate cancer are growing, but radical prostatectomy remains the treatment of choice for localized prostate cancer in age- and health-appropriate men. Although cancer control is the most important aspect of a radical prostatectomy, minimization of postoperative morbidity, especially urinary incontinence and erectile dysfunction, is becoming a greater concern.

We present a case of an ulcerated perforation of the bladder caused by a large pelvic hematoma without any direct injury to the bladder in a 71-year-old woman. She developed the hematoma after emergency percutaneous angioplasty and placement of an intra-aortic balloon pump that was complicated by retroperitoneal bleeding from an injured femoral artery. She presented several days later with gross hematuria and right hydroureteronephrosis. Cystoscopy and cystography revealed an extraperitoneal perforation at the right bladder neck. Although conservative management was attempted, the patient eventually required open repair. The perforation had transformed to an intraperitoneal perforation by making a communicating tract through the absorbed hematoma. After debridement and excision of the tract, the bladder perforation was repaired in two layers.