A urogenital fistula is an abnormal communication between two structures which causes urine to leak into a space other than through the urethral meatus. Vesicovaginal fistulae represent the most common type of fistula encountered by pelvic surgeons today. In developed countries, the more common etiologies include pelvic surgeries for hysterectomy, incontinence, or pelvic reconstructive procedures [1]. In developing countries, pregnancy-related complications from obstructed labor result in ischemic injury to the bladder and vagina and can lead to very large fistulae that can be difficult to treat [2] (Table 14.1).

Achieving 100% closure and continence rate in the management of vesicovaginal fistulas remains a challenge. There is still debate about several aspects of the care including the following:•How successful is conservative treatment with catheter drainage, and can it be improved with newer techniques?•When is the best time to operate?•What is the best surgical approach?•Are interpositional flaps helpful?•Is there any way to reduce the risk of future stress incontinence during the initial surgery?•How long does the bladder need to be drained after surgery?•What is the best way to manage radiation-induced fistulas?•Where and by whom should the patient be operated?

BACKGROUND:Women with stress urinary incontinence and concomitant obstructive (voiding) lower urinary tract symptoms (LUTS) represent a challenging patient population. Furthermore, their diagnosis and management remain incompletely studied and controversial. We evaluated the outcomes of midurethral sling procedures in women with severe obstructive LUTS.METHODS:We performed a post hoc analysis of women who were part of an institutional review board-approved study of midurethral sling surgery. Preoperatively and at 4-6 weeks postoperatively, patients completed the American Urological Association Symptom Score (AUASS) questionnaire. A postvoid residual urine test was obtained preoperatively, at the time of the voiding trial, and 4-6 weeks postoperatively. Three groups of patients with severe LUTS were then defined: Group A (AUASS ≥20), Group B (voiding subscale ≥12), and Group C (urodynamic obstruction). Patients could be included in more than one group. AUASS was again obtained at a medium-term follow-up of 31.6 months.RESULTS:Of 106 women completing follow-up, 30, 23, and 11 subjects met the criteria for groups A, B, and C, respectively. All had statistically significant improvements in storage and voiding subscales, as well as their stress urinary incontinence. No subject presented with retention or voiding dysfunction at follow-up. These improvements continued at medium-term follow-up with the exception of Group C that failed to demonstrate persistence of statistical improvement in AUASS subscales.CONCLUSION:Patients with stress urinary incontinence and severe voiding LUTS can be treated safely with midurethral sling procedures. In both the short and medium term, these symptoms improve dramatically in the majority of patients.

Purpose: We assessed how a group shared appointment influenced patient preparedness for sacral nerve stimulation for refractory overactive bladder and/or urge urinary incontinence. We also evaluated subjective and objective outcomes.Materials and Methods: Patients considering sacral nerve stimulation were prospectively enrolled and invited to attend a group shared appointment. This 75-minute presentation included a question and answer period with an implanting surgeon and an implanted patient. Control patients received standard office counseling. A patient preparedness questionnaire was completed after the group shared appointment or office counseling. Response to treatment was determined using the postoperative satisfaction questionnaire, Patient Global Impression of Improvement (PGI-I) and voiding diaries.Results: In our study 36 women with a mean +/- SD age of 61 +/- 15 years underwent sacral nerve stimulation. There was no significant difference in patient demographics between the 19 women who attended the group shared appointment and the 17 controls. Overall preparedness was greater in the shared appointment group (p = 0.043) with better understanding of the purpose of (p = 0.003) and alternatives to (p = 0.043) sacral nerve stimulation. Significantly more women in the shared appointment group than controls felt completely prepared (78.9% vs 29.4%, p = 0.003) and completely satisfied (78.9% vs 35.3%, p = 0.003) with sacral nerve stimulation as well as very much better (68.4% vs 17.6%, p = 0.002) according to the PGI-I. There was no difference between the groups in the number of women with a 50% or greater symptom reduction on voiding diary.Conclusions: Participating in a group shared appointment before sacral nerve stimulation improved patient preparedness and perceived outcomes of treatment, although there was no difference in objective outcomes based on voiding diary.

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence, Evaluation & Therapy (II)1 Apr 20131048 GROUP SHARED APPOINTMENTS IMPROVE PATIENT PREPAREDNESS FOR SACRAL NEUROMODULATION AND PATIENT-REPORTED OUTCOMES BUT DO NOT IMPACT OBJECTIVE MEASURES OF SUCCESS Farzeen Firoozi, Bradley Gill, Michael Ingber, Courtenay Moore, Howard Goldman, Raymond Rackley, and Sandip Vasavada Farzeen FirooziFarzeen Firoozi New York, NY More articles by this author , Bradley GillBradley Gill Cleveland, OH More articles by this author , Michael IngberMichael Ingber Whippany, NJ More articles by this author , Courtenay MooreCourtenay Moore Cleveland, OH More articles by this author , Howard GoldmanHoward Goldman Cleveland, OH More articles by this author , Raymond RackleyRaymond Rackley Cleveland, OH More articles by this author , and Sandip VasavadaSandip Vasavada Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.634AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Discrepancies between subjective (patient-determined) and objective (physician-determined) outcomes in treating quality of life issues can exist. Studies have noted higher subjective success rates with increased patient preparedness, which consists of more realistic outcome expectations and/or better comprehension of informed consent components. This study investigated how a group shared appointment (GSA) impacted patient preparedness for, as well as both subjective and objective outcomes of, sacral neuromodulation (SN) for refractory overactive bladder and/or urge urinary incontinence. METHODS Patients considering SN for the indications above were prospectively enrolled and invited to a GSA, which was a 30-minute presentation and 45-minute question-and-answer session hosted by an implanting surgeon with an implanted patient volunteer sharing his or her experience. Control patients declined GSA attendance and received standard office counseling. The validated patient preparedness questionnaire (PPQ) was answered after the GSA or office counseling. The Patient Global Impression of Severity (PGI-S) and Patient Global Impression of Improvement (PGI-I), as well as voiding diaries assessed response to treatment. RESULTS A total of 36 women received SN during the study and had a mean(SD) age of 61(15) years and body mass index of 31(6) kg/m2 with no significant differences in these or the prevalence of diabetes, smoking, or prior pelvic surgery between the GSA (N=19) and non-GSA (N=17) groups. Overall preparedness (p=0.043) was higher in the GSA group, with improved understanding of the purpose (p=0.003) and alternatives (p=0.043) to SN as well as the perception of spending more time with physicians (p=0.006), but no differences in comprehension of the benefits, risks, or complications of SN existed between groups. More women in the GSA than non-GSA group felt “completely prepared” (78.9% vs 29.4%, p=0.003) and “completely satisfied” (78.9% vs 35.3%, p=0.003) with SN as well as “very much better” (68.4% vs 17.6%, p=0.002) via PGI-I response. There were no differences between groups in the number of women with a 50% or greater symptom reduction on voiding diary or number of surgical complications. CONCLUSIONS Participating in a GSA prior to SN improved patient preparedness and perceived outcomes of the treatment despite not impacting objective outcomes assessed by voiding diary. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e430 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Farzeen Firoozi New York, NY More articles by this author Bradley Gill Cleveland, OH More articles by this author Michael Ingber Whippany, NJ More articles by this author Courtenay Moore Cleveland, OH More articles by this author Howard Goldman Cleveland, OH More articles by this author Raymond Rackley Cleveland, OH More articles by this author Sandip Vasavada Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE To quantify the frequency of genitourinary (GU) physical examinations obtained by the emergency department or primary hospital team before obtaining a urologic consultation and evaluate the role of the different demographic and clinical factors.MATERIALS AND METHODS For 6 weeks, from July to August 2010, 420 consecutive patients evaluated by the urology consultation service had their medical charts reviewed retrospectively, with the frequency of GU physical examination performed by the emergency department or primary hospital team recorded.RESULTS Of 357 patients requiring a urologic consultation, 88 of 324 (27%) had a GU physical examination performed by the emergency department and 98 of 319 (31%) had a GU physical examination performed by the primary hospital team before the urologic consultation. The emergency department was 6 times more likely to perform a GU physical examination on a male patient than a female patient, and the primary team was twice as likely to perform a GU physical examination on a male patient than a female patient. The likelihood of examination by either team decreased as patients became older. Race was not significantly associated with the likelihood of examination.CONCLUSION The results of our study indicate that examinations are performed less than one-third of the time before obtaining a urologic consultation, with the frequency related to age and sex. The low rate of preconsultation examination creates concern for quality of care, the correctness of billing, and unnecessary urologic consultations. UROLOGY 80: 1243-1246, 2012. (C) 2012 Elsevier Inc.

Purpose: Commercial prolapse mesh kits are increasingly used in the management of pelvic organ prolapse. We present our experience with the transvaginal/perineal management of synthetic mesh related complications from prolapse kits. In addition, we used the new ICS/IUGA (International Continence Society/International Urogynecological Association) prostheses/grafts complication classification system to report on our contemporary series.Materials and Methods: A retrospective chart review of all patients who underwent surgical removal of transvaginal mesh for mesh related complications after prolapse kit use from November 2006 to April 2010 at 1 institution was performed. We report our contemporary series of mesh complications using the new ICS/IUGA prostheses/grafts complication classification system. Postoperative pain, degree of improvement and presence of continued symptoms were reported by patients at last followup.Results: A total of 23 patients underwent transvaginal removal of mesh during the study period. Mean patient age was 61 years. Median period of latency to mesh related complication was 10 months (range 1 to 27). Indications for mesh removal included vaginal/pelvic pain (39%), dyspareunia (39%), vaginal mesh extrusion/exposure (26%), urinary incontinence (35%), recurrent pelvic organ prolapse (22%), bladder mesh perforation with recurrent urinary tract infection (22%), rectal mesh perforation (4%), ureteral perforation injury (4%), retained foreign body (surgical sponge) in the bladder (4%) and vesicovaginal fistula (9%), with most patients citing more than 1 reason.Conclusions: Although technically difficult in some cases, purely transvaginal mesh excision appears to be safe with resolution of almost all presenting symptoms. Although slightly cumbersome, the new ICS/IUGA prostheses/graft complication classification system can be used to report and more accurately characterize mesh complications.

We appreciate the comments provided by the reader. Deciding on which statistical analysis to perform can be challenging, especially when the positive outcome group (urinary tract infection) was rather small, as in our study. The reader comments that in the text the postvoid residual urine volume (PVR) was described using the mean and standard deviation and in Figure 1, it was described using the median and interquartile range. Although box plots do display quartiles, we chose to use these in Figure 1 to provide the reader with a visual display of the difference between the 2 groups. We believe this was appropriate, regardless of whether the data were normally or non-normally distributed. Re: Ingeber et al.: Incidence of Perioperative Urinary Tract Infection After Single Dose Antibiotic Therapy for Midurethral Slings (Urology 2010;76:830-834)UrologyVol. 77Issue 4PreviewThe study by Ingeber et al was a prospective study evaluating the urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing midurethral sling placement who had received single-dose antibiotic therapy. Univariate analysis was used to compare the different variables between the subjects with and without UTI. Full-Text PDF

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring one's choice of MUS to the individual patient and her unique clinical parameters remains the best option.

Uterine prolapse is one of the common reasons for hysterectomy throughout the world. However, recent data has shown that uterine-sparing techniques appear to be equivocal to that of hysterectomy. Older reports of intra-abdominal uterine suspension describe open approaches and more recent descriptions involve robotic and laparoscopic approaches utilizing mesh. We describe the first reported laparoendoscopic single-site (LESS) sacral hysteropexy utilizing a strip of polypropylene mesh placed posteriorly on the uterus and attached to the sacral promontory. A 45-year-old female with grade 3 uterine prolapse, cystocele, and rectocele underwent the procedure. The procedure involved access utilizing a single-port system placed transumbilically, and dissection using articulating laparoscopic instruments. The hysteropexy was completed by placing a 3-cm wide strip of polypropylene mesh along the posterior vaginal wall and cervicouterine junction, and suturing the proximal end to the anterior longitudinal ligament overlying the sacral promontory. The patient was discharged home within 18 h of the procedure. At 6 month follow-up, the patient has excellent anatomic support, with no evidence for recurrence of prolapse. LESS hysteropexy appears to be a safe, effective procedure for uterine prolapse and provides patients with excellent outcome with no visible scar. Additional studies will determine whether the LESS approach provides any benefit when compared with robotic or traditional laparoscopic approaches with respect to blood loss, pain, and time of full recovery.

OBJECTIVES To present the largest reported cohort of women with urethral diverticula and to evaluate the surgical outcomes and long-term voiding symptoms after urethral diverticulectomy. Studies evaluating the outcomes after urethral diverticulectomy have been limited by small patient numbers and short-term follow-up.METHODS Women who had undergone diverticulectomy at our institution from 1996 to 2008 were mailed surveys. Urinary bother was assessed using the Urogenital Distress Inventory 6-item questionnaire, and patients were asked to report subsequent urethral or vaginal surgery and the number of urinary tract infections within the previous year. To determine the rate of surgical recurrence, the charts of women not responding to the survey were reviewed.RESULTS A total of 122 women were identified as having undergone urethral diverticulectomy during the study period. Of these, 13 (10.7%) had an eventual recurrence that required repeat surgical excision. Patients with a proximal diverticulum, multiple diverticula, or previous pelvic or vaginal surgery (excluding previous diverticulectomy) were more likely to develop recurrence (P = .01, P = .03, and P < .001, respectively). For the 61 women (50%) responding to our survey, the mean follow-up was 50.4 months. Of these 61 women, 24 (39.3%) had had a urinary tract infection within the previous year, with 14 (23%) women having had >= 3 within the previous year. Also, 16 (26.2%) had persistent pain or discomfort with urination. The mean +/- SD total Urogenital Distress Inventory-6 score was 31.1 +/- 25.5 for the survey responders.CONCLUSIONS To our knowledge, our study represents the largest study with the longest follow-up after urethral diverticulectomy. Patients with proximal or multiple diverticula and those with previous pelvic surgery should be counseled appropriately regarding the risks of recurrence and persistent voiding dysfunction. UROLOGY 77: 65-69, 2011. (C) 2011 Elsevier Inc.

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Basic Research1 Apr 2011911 SCREENING FOR HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) IN THE UROLOGY OFFICE SETTING Michael Ingber, Tianming Gao, and Howard B. Goldman Michael IngberMichael Ingber Denville, NJ More articles by this author , Tianming GaoTianming Gao Cleveland, OH More articles by this author , and Howard B. GoldmanHoward B. Goldman Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.802AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES HSDD is the most common sexual desire disorder found in women. Multiple comorbidities may contribute to low sexual desire, specifically those found in women seeking care from a urologist. Our objective was to determine the prevalence of low sexual desire in women presenting to the urology office for a variety of reasons. A secondary objective was to determine factors that may contribute to having low desire. METHODS This was a prospective study of female patients presenting to the urology office for any reason (stones, hematuria, prolapse, incontinence, etc.). Female subjects over the age of 18 were offered the Decreased Sexual Desire Screener (DSDS). Patients answering “yes” to the first 4 questions on the DSDS represented the cohort qualifying for a diagnosis of HSDD, pending physician evaluation to see if any other factors (listed in item 5 on the DSDS) can impact low desire. Demographic factors as well as diagnosis codes were recorded and analyzed. Descriptive statistics, univariate and multivariate logistic regression were used in order to determine any predictors of low desire. RESULTS Overall 339 women completed the DSDS. 273 (81%) had a decrease in sexual desire, with 95 (28%) qualifying for a possible diagnosis of HSDD by answering “yes” to items 1 through 4 on the DSDS. Women between the age of 41 and 52 were most likely to qualify for a diagnosis of HSDD with 37% of this age group qualifying. Factors such as marital status, employment status, race and BMI did not contribute to low desire, nor did diagnosis code. The presence of low sexual desire was common among women presenting with stones, incontinence, prolapse, infection, retention, pain, voiding dysfunction and malignancy. No one diagnosis code was predictive of women having low sexual desire or HSDD. CONCLUSIONS The presence of low sexual desire is common in all women presenting to the urology office. Specifically, women between the ages of 41 and 52 are at an increased likelihood of having a diagnosis of HSDD. Because many women are hesitant to bring up these complaints, urologists should be aware of sexual desire issues and question their patients on sexual function. Descriptive Statistics by HSDD status Mean (SD) or n (%) Non-HSDD n=244 HSDD n=95 p-value Age 52.2(14.1) 48.2(12.4) 0.02 Married 160(67.8%) 62(68.1%) 0.95 Employed 138(58.5%) 53(58.2%) 0.97 Caucasian 193(85.8%) 75(88.2%) 0.57 Weight (kg) 77.2(20.4) 77.5(23.1) 0.91 BMI 29.2(8.0) 29.6(10.0) 0.81 © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e365 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Ingber Denville, NJ More articles by this author Tianming Gao Cleveland, OH More articles by this author Howard B. Goldman Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The study by Ingeber et al was a prospective study evaluating the urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing midurethral sling placement who had received single-dose antibiotic therapy. Univariate analysis was used to compare the different variables between the subjects with and without UTI. Incidence of Perioperative Urinary Tract Infection After Single-dose Antibiotic Therapy for Midurethal SlingsUrologyVol. 76Issue 4PreviewA recent Best Practice Statement published by the American Urological Association (AUA) recommends that antibiotic therapy in patients undergoing midurethral synthetic slings (MUS) should be 24 hours or less. Subjects at our institution are routinely administered a single dose of intravenous antibiotics before MUS surgery. We prospectively evaluated urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing MUS who receive single-dose antibiotic therapy. Full-Text PDF Reply by the AuthorsUrologyVol. 77Issue 4PreviewWe appreciate the comments provided by the reader. Deciding on which statistical analysis to perform can be challenging, especially when the positive outcome group (urinary tract infection) was rather small, as in our study. The reader comments that in the text the postvoid residual urine volume (PVR) was described using the mean and standard deviation and in Figure 1, it was described using the median and interquartile range. Although box plots do display quartiles, we chose to use these in Figure 1 to provide the reader with a visual display of the difference between the 2 groups. Full-Text PDF