INTRODUCTION AND HYPOTHESIS:Intradetrusor onabotulinumtoxinA (BTX-A) is a third-line therapy for overactive bladder (OAB), however several gaps exist in periprocedural care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. The primary aim of this study was to evaluate patient-reported temporal improvement in symptoms, with secondary aim to evaluate medication resumption rates, following initial BTX-A injection.METHODS:A prospective, single-arm cohort study of patients with non-neurogenic urgency incontinence undergoing initial BTX-A injection was performed. Intradetrusor 100 units BTX-A was administered in standard 20-site template. Patients discontinued OAB medication(s) at BTX-A injection and completed a daily Patient Global Impression of Improvement (PGI-I) diary for 3 weeks. Data were collected at 1 month, including final satisfaction score, medication resumption rates, and adverse outcomes.RESULTS:Fifty-one patients were included, with 25 patients (49%) actively taking an OAB medication. Median time to first improvement was 3 days, at least "much better" (PGI-I <2) was 5 days, and maximal improvement was 7 days. Twenty of 25 patients (80%) opted to remain off OAB medications at 1 month based on symptomatic improvement following injection. Adverse outcomes included urinary tract infection in three patients (6%) and symptomatic incomplete emptying requiring temporary intermittent catheterization in two patients (4%).CONCLUSIONS:Median time to first and maximal improvement was 3 and 7 days, respectively, following initial 100 units BTX-A. Eighty percent of patients on medications opted to remain off at 1 month. These data may help further counsel patient expectations following initial BTX-A therapy.

INTRODUCTION AND OBJECTIVE:Synthetic midurethral sling placement (MUS) is a common surgical treatment of female stress urinary incontinence (SUI). Mesh perforation involving the urethra is an uncom...

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy II (MP52)1 Sep 2021MP52-11 PATIENT-REPORTED ONSET OF SYMPTOM IMPROVEMENT FOLLOWING INITIAL INTRADETRUSOR ONABOTULINUMTOXINA INJECTIONS FOR OVERACTIVE BLADDER Neil J. Kocher, Jacqueline Zillioux, Sarah Martin, Raymond R. Rackley, Sandip P. Vasavada, and Howard B. Goldman Neil J. KocherNeil J. Kocher More articles by this author , Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Sarah MartinSarah Martin More articles by this author , Raymond R. RackleyRaymond R. Rackley More articles by this author , Sandip P. VasavadaSandip P. Vasavada More articles by this author , and Howard B. GoldmanHoward B. Goldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002082.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intradetrusor onabotulinumtoxinA (BTX-A) is a common third-line therapy for treatment of refractory overactive bladder (OAB), however several gaps exist in pre- and post-procedural standard of care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. We performed a prospective study evaluating several factors involved in the BTX-A patient care pathway. The primary aim of this abstract was to determine patient-reported temporal improvement in symptoms following initial BTX-A therapy. METHODS: A prospective, non-randomized study of patients with non-neurogenic, refractory urgency-frequency syndrome and urgency urinary incontinence undergoing first-time BTX-A injection under local anesthesia was performed. Intradetrusor injection of 100 units BTX-A was performed by one of 3 FPMRS-trained providers using a standard 20-site template. Patients were required to discontinue their OAB medication(s) at the time of BTX-A injection for 3 weeks and complete a daily Patient Global Impression of Improvement (PGI-I) diary during this time. Data were collected at 1 month, including final satisfaction score and adverse outcomes. Descriptive analysis was performed in R programming. RESULTS: 25 patients were included (24 female, 1 male). Median age was 75 years and BMI was 34.3. Figure 1 shows a jitter plot with loess smoothed fit of patient-reported PGI-I over time following BTX-A injection. 24 patients (96%) reported symptom improvement (PGI <4) by 3 weeks, with 19 patients (76%) documenting at least “much better” (PGI >2). Median time to first improvement (PGI <4) was 1 day, at least “much better” was 4 days, and median time to maximum patient improvement was 6 days. Median final satisfaction score was PGI 2 (“much better”). Adverse outcomes included UTI in 2 patients (8%) and incomplete emptying requiring transient intermittent catheterization in 1 patient (4%). CONCLUSIONS: Patients with refractory OAB undergoing first-time 100 units BTX-A injection reported median time to first improvement (PGI <4) at 1 day, at least “much better” at 4 days, and median time to maximum patient improvement at 6 days. These data may help further counsel patient expectations following initial BTX-A therapy. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e934-e934 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Neil J. Kocher More articles by this author Jacqueline Zillioux More articles by this author Sarah Martin More articles by this author Raymond R. Rackley More articles by this author Sandip P. Vasavada More articles by this author Howard B. Goldman More articles by this author Expand All Advertisement Loading ...

INTRODUCTIONTo assess whether patients with a large renal mass, treated by radical nephrectomy (RN), could have benefited from preoperative renal mass biopsy (RMB). The decision to perform partial nephrectomy (PN) for an organ-confined > 4 cm renal mass can be complex. Albeit often feasible, oncologic safety of PN in this cohort is debated. Yet, a significant portion of large renal masses that undergo RN prove benign or indolent, indicating a potential role for RMB to guide nephron preservation.MATERIALS AND METHODSWe queried prospectively maintained databases from three institutions to identify patients who underwent RN for localized > 4 cm renal mass. We excluded patients with nodal or distant metastases. Multivariable analysis assessed how clinicopathologic variables, mass anatomic complexity, and patient comorbidities related to the likelihood of harboring an indolent neoplasm.RESULTSA total of 702 patients underwent RN for localized > 4 cm renal mass (median tumor size 7.0 cm (IQR 5.5-9.2); 12.8% (n = 90) of patients were diagnosed with oncocytoma/oncocytic neoplasm (n = 27, 3.8%) or chromophobe RCC (n = 63, 9.0%). When stratified by tumor size, indolent tumors comprised 10.1% of 4-7 cm masses, 15.6% of ≥ 7-10 cm masses, and 17.3% of ≥ 10 cm tumors. Upon multivariate analysis, younger age was associated with indolent tumors (p = 0.04, OR 0.97, 95% CI 0.94-0.99).CONCLUSIONSApproximately 1 in 8 patients with a renal mass > 4 cm harbored benign or low risk indolent potential lesions and were associated with younger age. As such, patients with large renal masses for whom risk trade-offs between PN and RN are unclear, present a unique opportunity for greater utilization of RMB.

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder I (MP25)1 Sep 2021MP25-16 IMPACT OF DURATION OF ANTIBIOTIC PROPHYLAXIS ON UTI RATE AFTER ONABOTULINUMTOXINA INJECTION Sarah Martin, Jacqueline Zillioux, Neil Kocher, Raymond Rackley, Sandip Vasavada, Howard Goldman, Katie Propst, Eiftu Haile, and Emily Slopnick Sarah MartinSarah Martin More articles by this author , Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Neil KocherNeil Kocher More articles by this author , Raymond RackleyRaymond Rackley More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , Howard GoldmanHoward Goldman More articles by this author , Katie PropstKatie Propst More articles by this author , Eiftu HaileEiftu Haile More articles by this author , and Emily SlopnickEmily Slopnick More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002022.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There are currently no specific guidelines on antibiotic prophylaxis for intravesical OnabotulinumtoxinA (BTX) injection, despite high risk of post-procedural urinary tract infection (UTI). Our objective was to assess the impact of duration of antibiotic prophylaxis on rate of UTI within 30 days of BTX injection. METHODS: A retrospective chart review was performed of patients who received office BTX injection from 2014-2020 with FPMRS providers at a single academic institution. UTI rates within 30 days of BTX were compared between three prophylaxis regimens: no antibiotic, a single dose, or a multiple day course of any antibiotic. UTI was defined as new lower urinary tract symptoms treated either empirically or associated with a positive urine culture. Patients on daily antibiotic prophylaxis for recurrent UTI were excluded. Association of UTI with units of BTX, BMI, history of diabetes, immunosuppresion, neurogenic bladder or recurrent UTI and incidence of new post-procedure urinary retention were also investigated. Statistical analysis was performed with univariate and subsequent multivariable logistic regression analysis to assess for possible confounding factors. RESULTS: A total of 180 patients and 560 cycles of BTX injections were included: 173 (96%) were women with mean age 62.9 years (range 20-95; SD 12.6). The majority received 100U (65%) for a non-neurogenic diagnosis (67%). Overall rates of UTI and urinary retention within 30 days were 11% and 6%, respectively. No antibiotic prophylaxis was given to 79 (14%) patients, 343 (61%) received a single dose, and 138 (25%) received a multiple day regimen (3-7 days). On univariate analysis, UTI incidence was lower with administration of any antibiotic prophylaxis as compared to none: single dose 7.6% vs. 25.3% (OR 0.24, p<0.001), multiple dose 11.0% vs. 25.3% (OR 0.36, p=0.007). There was no difference in UTI rates between single and multiple dose antibiotic regimens (p=0.233). On multivariable logistic regression, use of any antibiotic prophylaxis was associated with a lower incidence of UTI (single OR 0.32, p=0.002; multiple OR 0.42, p=0.042), with no difference between single and multiple dose regimens (p=0.068). History of recurrent UTI (OR 2.3, p=0.024) and de novo post-procedure retention (OR 3.9, p=0.002) were predictors of UTI. CONCLUSIONS: Use of antibiotic prophylaxis for office intravesical BTX injection is associated with a significantly lower incidence of UTI compared to no antibiotic. Importantly, a multiple day regimen was not more effective than a single dose of antibiotics in preventing UTI. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e459-e460 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah Martin More articles by this author Jacqueline Zillioux More articles by this author Neil Kocher More articles by this author Raymond Rackley More articles by this author Sandip Vasavada More articles by this author Howard Goldman More articles by this author Katie Propst More articles by this author Eiftu Haile More articles by this author Emily Slopnick More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neurogenic Voiding Dysfunction (PD36)1 Sep 2021PD36-09 SACRAL NEUROMODULATION IN PARKINSON'S DISEASE: AN EFFECTIVE AVENUE OF TREATMENT Sarah Martin, Jacqueline Zillioux, Neil Kocher, Raymond Rackley, Sandip Vasavada, and Howard Goldman Sarah MartinSarah Martin More articles by this author , Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Neil KocherNeil Kocher More articles by this author , Raymond RackleyRaymond Rackley More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , and Howard GoldmanHoward Goldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002040.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Parkinson’s disease (PD) is the second-most common degenerative neurologic disease worldwide. Overactive bladder (OAB) is prevalent in this population but can be challenging to treat due to risks associated with polypharmacy (anticholinergics) and difficulty with self-catheterization in cases of retention (Onabotulinumtoxin-A). Sacral neuromodulation (SNM) is an attractive treatment option, especially with the recent introduction of MRI conditional technology, but remains understudied in PD. We have utilized SNM in PD patients for some time and herein describe our outcomes. METHODS: We performed a retrospective chart review of PD patients who underwent peripheral nerve evaluation (PNE) or Stage 1 SNM from 2000-2020. Primary outcome was progression to permanent implant with ≥50% improvement of urinary symptoms. The impact of PD stage and pre-procedural urodynamic (UDS) parameters on test-phase outcome was assessed with Fisher’s exact and Wilcoxin rank sum tests. Long term efficacy was assessed using Wilcoxon matched-pairs test looking at change in urinary symptoms (frequency, nocturia, incontinence episodes, pad use) documented at available follow-up visits and further need for treatment. RESULTS: 34 patients underwent test phase SNM (7 PNE, 27 Stage 1). Mean age was 72 (STD 7) years with median follow-up of 11 [IQR 5.8, 29.8] months. Indications included refractory OAB (30/34) and non-obstructive urinary retention (4/34). Overall, 82% (28/34) of patients proceeded to permanent implant. 71% (5/7) of PNEs were successful. Test-phase success did not differ based on PD disease severity or UDS parameters. In patients with OAB/UUI who progressed to permanent implant, 83% (24/28) experienced subjective improvement in their urgency and there was a statistically significant improvement in their urinary symptoms from baseline (Figure I). Most (68%) patients were able to discontinue OAB medications post-implant, and 62.5% did not require further treatment. Overall lead revision rate was 14% (4/28) and 3 devices required removal. CONCLUSIONS: SNM is an efficacious treatment option for PD patients with a high percentage of patients having improvement in their urinary symptoms. No UDS parameters were found to predict which patients would progress to permanent implantation. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e598-e599 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah Martin More articles by this author Jacqueline Zillioux More articles by this author Neil Kocher More articles by this author Raymond Rackley More articles by this author Sandip Vasavada More articles by this author Howard Goldman More articles by this author Expand All Advertisement Loading ...

Background Complications can occur following radical nephroureterectomy (RNU) in 20–40% of patients. The Comprehensive Complication Index (CCI) is an alternative grading system to the Clavien-Dindo (CD) grading system that aggregates all complications experienced by a patient on a continuous (as opposed to categorical) scale. We investigate whether the cumulative nature of CCI renders it superior to CD in predicting perioperative course after RNU. Methods The records of 596 patents who underwent RNU at 7 academic medical centers from 2005 to 2015 were reviewed. Complications occurring within 30 days of RNU were annotated using both the CD and CCI classification systems. Logistic regression was used to determine associations between CD and CCI with perioperative covariates as well as measures of convalescence [hospital length of stay (LOS) and readmission]. Results A total of 377 men and 219 women with a median age of 71, BMI of 27, and Charlson comorbidity score of 4 were included. Over half underwent a minimally invasive RNU. Median LOS following RNU was 6.0 days (range, 1–37 days) and readmission within 30-days occurred in 45 (8%) patients. Overall, 136 patients (23%) experienced a post-operative complication with 91 having a single complication and 45 with multiple (range, 2–6); 44 (7%) patients had Clavien III or greater complications, and the median CCI for those patients experiencing a complication was 20.9 (range, 8.7–100). Both the upper quartile of CCI (≥75th %) and major CD complications were associated with higher baseline Charlson score, ECOG ≥2, and CKD stage ≥ III (all P<0.05). However, only the upper quartile of CCI was associated with LOS (8.9 vs. 5.4 days, P<0.01) and hospital readmission (OR 3.2, 95% CI: 1.9–5.6, P=0.02) after RNU. Conclusions The CD and CCI classification systems both are associated with similar baseline and perioperative characteristics for RNU patients. However, the cumulative nature of the CCI allows for superior prediction of postoperative course after RNU including LOS and readmission.

INTRODUCTION AND OBJECTIVE: Impedance changes over time, or “impedance drift”, in neuromodulation can influence the need for device reprogramming, lead revision, and battery replacement. Abnormal electrical impedance (AEI) has been understudied with respect to impact on sacral neuromodulation (SNM). This study assessed SNM longevity in individuals with and without AEI and its impact on revisions. METHODS: Patients with one or more SNM interrogations in the office were identified. Those implanted from 2003 to present were included. Follow-up within the first 10 years of device implantation was analyzed. Patients with AEI were identified as cases and the remaining patients who underwent device interrogation were controls. Time intervals collected included: implant to device interrogation encounter, device interrogation to revision, and original implant to revision. Revision included surgical interventions for the lead and/or pulse generator. Device longevity, or time from original implant to revision, was analyzed by Kaplan-Meier analysis. RESULTS: Of 710 patients with device interrogations, 132 (18.6%) were ‘cases’ and had an AEI within the first 10 years of follow-up (Figure 1A). Of these, 11 (1.5%) were short circuits (<50Ω) and 121 (17%) were open circuits (>4,000Ω). The remaining 578 patients were ‘controls’ and had normal impedances. Amongst patients with AEI, 41% (N=50/121) underwent revision, 58% (N=70/121) received device reprogramming, and 0.8% (N=1/121) pursued removal. Operative intervention was avoided in 54% (N=38/70) of the patients undergoing reprogramming. A 21% (N=121/578) revision rate was noted in the control group. Device longevity did not differ between cases and controls with regard to time from implant to revision (p=0.24, Figure 1 B). Interval from implant to device interrogation (AEI: 27.6 vs control: 23.3 months, p=0.16) nor interval from SNM interrogation to revision (AEI: 7.6 vs control: 9.8 months, p=0.24) differed between cases and controls. Cases with AEI that underwent reprogramming achieved a mean additional 17.3 months of device longevity prior to revision. CONCLUSIONS: The prevalence of AEI in SNM increases with duration of follow-up, however device reprogramming can avoid surgical revision in many cases.Source of Funding: None

Retropubic midurethral sling (RMUS) procedures have become a gold standard for primary stress urinary incontinence (SUI) with more than 3 million synthetic midurethral slings placed since 1995. 1 Giusto LL Zahner PM Goldman HB Management of the exposed or perforated midurethral sling. Urol Clin North Am. 2019; 46: 31-40 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Owing to its minimally invasive approach, there is risk of injury to adjacent structures including the bladder, urethra, major vessels, or bowel. Bowel perforation is a rare complication that often presents in the immediate postoperative period. We report a case of incidentally noted sling mesh in the cecum on screening colonoscopy in an asymptomatic patient 4 years following RMUS surgery, with no progressive symptoms on close follow-up and no change on colonoscopy 6 years postoperatively.

You have accessJournal of UrologyFemale Pelvic Surgery (V13)1 Apr 2020V13-10 DISTAL LEVATOR PLICATION: AN ADJUNCT FOR ANTERIOR PREDOMINANT PELVIC ORGAN PROLAPSE REPAIR Jessica Rueb*, Michele Fascelli, Neil Kocher, Samir Derisavifard, and Howard Goldman Jessica Rueb*Jessica Rueb* More articles by this author , Michele FascelliMichele Fascelli More articles by this author , Neil KocherNeil Kocher More articles by this author , Samir DerisavifardSamir Derisavifard More articles by this author , and Howard GoldmanHoward Goldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000970.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Levator myorrhaphy was first described as a constricting technique in 1961 with wide levator ani midline plication to which the vaginal cuff was affixed. This was considered for patients who did not intend to be sexually active and reported low morbidity. Our technique of distal levator plication (DLP) is a reconstruction of the levator ani complex proximal to and at the vaginal introitus. This approach is preferred for minimal posterior prolapse wherein traditional colpocleisis would be difficult. We seek to describe out technique. METHODS: Here we describe DLP in an 85-year-old female status post total abdominal hysterectomy who presented with symptomatic pelvic organ prolapse. Exam demonstrated a stage 3 cystocele and the vaginal cuff was within two centimeters of the hymen. She no longer was interested in sexual activity. After anterior colporrhaphy and apical suspension, DLP is performed. A rectangular area of posterior vaginal epithelium is excised to expose the fibromuscular layer, extending from the hymenal ring to 2-3 cm proximal. The levator ani are plicated with 0-PDS to create a muscular ridge overlying the distal portion of rectum and perineum prior to recreating the perineal body. RESULTS: All compartments are well supported and the end result is a narrowed genital hiatus, accommodating approximately one to two finger breadths. Post-operatively, vaginal packing is removed in the recovery unit, the patient is discharged home on post-operative day (POD) 0, and outpatient voiding trial is performed on POD two. CONCLUSIONS: In our experience, DLP combined with anterior and apical repairs results in a greater than 95% symptomatic resolution. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1213-e1213 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Rueb* More articles by this author Michele Fascelli More articles by this author Neil Kocher More articles by this author Samir Derisavifard More articles by this author Howard Goldman More articles by this author Expand All Advertisement PDF downloadLoading ...

Introduction: Additional preoperative safety checklist requirements at Penn State Health were recently implemented on the morning of surgery. We evaluate whether this added safety policy impacted reported adverse patient safety events and institutional operating room performance indicators. Methods: Key operating room performance indicators from fiscal years 2016 through 2019 quarter 2 were reviewed. Additional attestation requirements by the attending surgeon were implemented at start of fiscal year 2018 (July 1, 2017). All reported perioperative patient safety events during this time were reviewed with events classified into one of 8 select categories. Results: Total operative case volume was 49,894 cases in fiscal years 2016 and 2017, and 36,533 in fiscal years 2018 and 2019 through quarter 2 (p<0.10). Mean operating room use was 81% in both groups (p<0.46). First case on time start rates decreased from 79.5% to 58%, respectively (p<0.0001). Mean turnover time between cases also increased from 35 minutes to 40 minutes, respectively (p<0.0001). There were 252 patient events (0.51%) in fiscal years 2016 and 2017 compared to 94 (0.26%) events in fiscal years 2018 and 2019 through quarter 2 following implementation of the surgical safety checklist (p < 0.0001). The number of incomplete preoperative checklists (39 vs 14, p=0.008) and missing/incomplete patient identification bands (15 vs 2, p=0.004) were also decreased between fiscal years 2016 and 2017, and fiscal years 2018 and 2019 through quarter 2, respectively. Conclusions: A day-of-surgery safety checklist decreased the number of reported patient safety events but with a negative impact on standard metrics of operating room productivity for 18 months following implementation. Further study is necessary to determine if these effects persist over time.

PURPOSE OF REVIEW:This manuscript reviews recent technological advances in ambulatory urodynamics.RECENT FINDINGS:Ambulatory urodynamics is currently recommended by the International Continence Society as a second-line diagnostic tool in patients with nondiagnostic traditional urodynamics. Novel techniques involving telemetric monitoring are in development, which utilize catheter-free wireless systems to address several recognized shortcomings of inoffice urodynamic studies. Current research in catheter-free bladder pressure measurements involves either an intravesical, intradetrusor, or transdetrusor approach. Real-time bladder volume estimation may be performed using ultrasonography, near-infrared spectroscopy, or bladder volume conductance measurement. Ambulatory urodynamics can measure bladder function in the "real world" setting, capturing physiological bladder filling and emptying and allowing patients to reproduce the activities that may trigger their symptoms. Telemetric devices being developed represent further advances in this field and focus upon improving diagnostic capabilities, evaluating patient response to treatment, and facilitating closed-loop bladder control with neuroprosthetic integration.

Background: Rectovesical fistulae (RVF) are uncommon complications of pelvic surgeries and are a potential cause of significant morbidity. RVF are not typically closed endoscopically but rather require reoperative surgery of the lower pelvis with closure of tract, interposition of fat or omentum, and possible permanent bowel diversion. We present a unique case of a rectovesical fistula developing after robotic prostatectomy that was managed by multimodal multistage endoscopic therapy as an alternative to conventional operative repair. Case Presentation: A healthy 78-year-old Caucasian man underwent a robot-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection for high-risk adenocarcinoma of the prostate. The patient's postoperative course was complicated by an unrecognized rectal injury culminating in emergent exploration, abdominal washout, creation of a diverting loop transverse colostomy, and resultant development of a large rectovesical fistula. Given the patient's hostile abdomen and desire for conservative management the fistula was managed through a combined cystoscopic and endoscopic procedure that utilized suturing and clipping to close the fistula. This novel technique was followed by a series of three subsequent endoscopic procedures that enabled us to gradually downsize the fistula over time and ultimately achieve complete closure. The patient's colostomy was eventually reversed with return of bowel continuity. Conclusion: Although uncommon, RVF are significant complications of pelvic surgery. The presence of abdominal/pelvic adhesions from previous surgeries or patient comorbidities can make open surgical repair extremely challenging or impracticable. Therefore, it is important to recognize and consider the use of endoscopic techniques as potential options for closure of rectovesical fistula in certain situations.

INTRODUCTION AND OBJECTIVE:The female stress urinary incontinence (SUI) American Urological Association (AUA) guidelines state physicians should communicate with patients in the early postop period...

Peripheral nerve evaluation (PNE) permits a trial of sacral neuromodulation to determine candidates for single stage implant. Before routine fluoroscopy, PNE success rates were 40%–50% compared to approximately 77% with staged procedures. There are limited data on PNE success rates with the use of fluoroscopy and improved techniques. We evaluated a contemporary series of PNE patients to determine predictors of PNE success and persistent functional response following permanent implantation.