What Pelvic Floor Muscle Training Load is Optimal in Minimizing Urine Loss in Women with Stress Urinary Incontinence? A Systematic Review and Meta-Analysis

Pelvic floor muscle training is commonly used for urine loss. However, research studies have not determined which training load is the most effective for women with stress urinary incontinence (SUI). Moreover, none of the previous reviews or studies have described the total effectiveness of pelvic floor muscle training (PFMT) with an objective test such as the pad test. The objectives were to analyze the effectiveness of pelvic floor muscle training in women with SUI and to determine which training load produces the greatest adaptations for decreasing urine loss. The search was conducted in three databases (PubMed, Web of Science and Cochrane), for randomized controlled trials (RCTs) that evaluated the effects of PFMT. Studies were included if they met the following criteria: participants were women; were older than 18; had SUI; were treated with PFMT; and the assessments of the effects were measured with a pad test. Finally, 10 articles (293 women) analyzed the pad test in women with SUI who performed PFMT. The meta-analysis showed that PFMT, independent of the protocol used in the study, resulted in decreased urine loss in women suffering from SUI. However, for large effects, the program should last 6-12 weeks, with >3 sessions/week and a length of session <45 min.

Strong correlation between standing cough test and 24-hour pad weights in the evaluation of male stress urinary incontinence

AIMS

We sought to compare in-office physical exam findings via standing cough test (SCT) versus 24-hour pad weights among men seeking treatment for postprostatectomy stress urinary incontinence (SUI).

METHODS

A retrospective review of a single surgeon database of incontinence procedures was performed. Documentation of SUI severity (grades 0-4) was completed by SCT preoperatively utilizing the Male Stress Incontinence Grading Scale (MSIGS). All patients had pads per day (PPD) and 24-hour pad weights obtained. We determined the Spearman's correlation coefficient between these variables.

RESULTS

We identified 104 men who underwent anti-incontinence surgery (AdVance Sling or artificial urinary sphincter [AUS]). In the sling group (65 patients), nearly all (97%) had minimal incontinence with SCT (MSIGS = 0-2). In the AUS group (39 patients), most patients (69%) had an MSIGS 3 or 4 with SCT. Spearman's coefficient between quantification of SCT and pad weight for the overall group was ρ = .68 (P < .0001) demonstrating a strong positive correlation. PPD was also strongly correlated with pad weight (ρ = .55, P < .0001). As seen previously, SCT and PPD were correlated (ρ = .47, P < .0001). In a multivariable model predicting pad weight, the effect of SCT was greater than PPD (β = 83 [54-111], P < .0001 vs 45 [2169], P = .0004).

CONCLUSIONS

SCT findings strongly correlate to 24-hour pad weights in the evaluation of male SUI. The SCT shows promise as a rapid, reliable, noninvasive measure of SUI severity before anti-incontinence surgery.

Surgical results in women with detrusor underactivity and stress urinary incontinence undergoing suburethral sling procedure-Predictive factors for successful outcome

OBJECTIVES

To elucidate the treatment results and predictors for successful outcome in women with detrusor underactivity (DU) and stress urinary incontinence (SUI) undergoing suburethral sling procedure.

METHODS

Medical records of women with coexistent SUI and DU treated with a suburethral sling were retrospectively reviewed and we analyzed the association between treatment outcome and baseline demographics including etiology of DU and urodynamic variables. Patients who were dry and could urinate spontaneously were considered successful. Treatment failure was considered in those who were dry but needing clean intermittent catheterization (CIC) and patients who were still wet. Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) scores were used to assess the impact of surgery on the quality of life.

RESULTS

Among 71 patients, a successful outcome was noted in 39 (55%), failed outcome with CIC in 15 (21%), and totally treatment failure in 17 (24%). Treatment outcome did not differ among the etiology subgroups. Overall, UDI-6 and IIQ-7 scores significantly improved after surgery. Multivariable logistic regression analysis revealed that the IIQ-7 and maximum flow rate (Qmax) were two independent predictors for improvement after surgery. An IIQ-7 score ≤6, and Qmax ≥6 mL/s can predict improvement by receiver operating characteristic analysis. Qmax ≤6 mL/s can predict needing CIC after surgery.

CONCLUSIONS

For women with SUI and coexistent DU who underwent suburethral sling procedure, low IIQ-7 (≤6) scores and higher Qmax (≥6 mL/s) are predictors for improvement of surgical outcome. A Qmax of <6 mL/s was the only predictor for CIC after surgery.

Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis

Background:

The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP).

Methods:

This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included.

Results:

Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies.

Conclusions:

Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

Photodynamic Therapy for the Treatment of Complex Anal Fistula

BACKGROUND AND OBJECTIVES

To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula.

STUDY DESIGN/MATERIALS AND METHODS

This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J).

RESULTS

In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively.

CONCLUSION

i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

An animal experimental study on pubourethral ligament restoration with platelet rich plasma for the treatment of stress urinary incontinence

Introduction

Minimally invasive methods for injured ligament and tendon restoration have been developed and gained popularity in recent years. Injury and relaxation of the pubourethral ligament (PUL) can lead to stress urinary incontinence (SUI). The aim of this study was to investigate the impact of injecting platelet rich plasma (PRP) into the PUL following its surgical transection resulting in SUI, confirmed by leak point pressure (LPP) measurements pre- and post-intervention in an experimental animal model.

Material and methods

Twenty female adult Sprague-Dawley rats were assigned in 2 groups: 1) treatment group with transection of the PUL and application of PRP at the time of transection and at one month follow-up and 2) a control group, with transection of the PUL only. Leak point pressures (LPPs) were measured prior to transection, immediately following the transection and at 1 and 2 months in both groups.

Results

The median LPPs for the control group were: LPP – preT: 35.6 (29.8–44.8) cmH₂O, LPP – postT: 14.6 (5.8–19.0) cmH₂O, LPP – 1 month: 27.3 (19.2–33.8) cmH₂O, LPP – 2 months: 29.0 (27.0–34.0) cmH₂O, whereas for the PRP group were: LPP-preT: 40.5 (33.2–46.3) cmH₂O, LPP – postT: 15.7 (3.0–24.0) cmH₂O, LPP – 1month: 31.6 (24.8–37.4) cmH₂O, LPP – 2 months: 36.8 (32.5–45.4) cmH₂O. PRP injections on transected PULs significantly increased LPPs at one month follow-up [31.6 cmH₂O vs. 27.3 cmH₂O, p = .043]. This effect was confirmed at two months [36.8 cmH₂O vs. 29.0 cmH₂O, p <.001].

Conclusions

Injection of PRP into transected PULs significantly improved LPPs at one and two months' follow-up. However, further experimental and clinical research is needed to evaluate the safety and efficacy of this treatment, in clinical practice.

Coping with a Disruptive Life Caused by Obstetric Fistula: Perspectives from Malawian Women

Background: The main symptom of obstetric fistula is urinary and or fecal incontinence. Incontinence, regardless of the type is debilitating, socially isolating, and psychologically depressing. The objective of this study was to explore the strategies that women with obstetric fistula in Malawi use to manage it and its complications. Methods: A subset of data from a study on experiences of living with obstetric fistula in Malawi was used to thematically analyze the strategies used by women to cope with their fistula and its complications. The data were collected using semi-structured interviews. Nvivo 10 was used to manage data. Results: Participants used two forms of coping strategies: (1) problem-based coping strategies: restricting fluid intake, avoiding sexual intercourse, using homemade pads, sand, corn flour, a cloth wreathe and herbs, and (2) emotional-based coping strategies: support from their families, children, and through their faith in God. Conclusion: Women living with incontinence due to obstetric fistula employ different strategies of coping, some of which conflict with the advice of good bladder management. Therefore, these women need more information on how best they can self-manage their condition to ensure physical and emotional comfort.

Incontinence in Phelan-McDermid Syndrome

OBJECTIVE

The aim of the study was to evaluate gastrointestinal symptoms and continence in the context of Phelan-McDermid Syndrome (PMS).

METHODS

A prospective evaluation of children with PMS (n = 17) at the National Institutes of Health.

RESULTS

Parent-reported history of symptoms were common: constipation (65%), reflux (59%), choking/gagging (41%), and more than half received gastrointestinal specialty care. No aspiration was noted in 11/11 participants who completed modified barium swallows. Four participants met criteria for functional constipation, 2 of whom had abnormal colonic transit studies. Stool incontinence was highly prevalent (13/17) with nonretentive features present in 12/17. Participants who were continent had significantly smaller genetic deletions (P = 0.01) and higher nonverbal mental age (P = 0.03) compared with incontinent participants.

CONCLUSIONS

Incontinence is common in PMS and associated with intellectual functioning and gene deletion size. Management strategies may differ based on the presence of nonretentive fecal incontinence, functional constipation, and degree of intellectual disability for children with PMS.

The Distribution of Post-Void Residual Volumes in People Seeking Care in the Symptoms of Lower Urinary Tract Dysfunction Network Observational Cohort Study With Comparison to Asymptomatic Populations

OBJECTIVE

To describe the distribution of post-void residual (PVR) volumes across patients with and without lower urinary tract symptoms (LUTS) and examine relationships between self-reported voiding symptoms, storage symptoms, and PVR.

METHODS

PVR and demographic data were obtained from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) observational cohort study. Self-reported symptoms were collected using the American Urological Association Symptom Index and the LUTS Tool. PVR values were obtained from 2 other cohorts: living kidney donors with unknown LUTS from the Renal and Lung Living Donors Evaluation Study (RELIVE), and continent women in the Establishing the Prevalence of Incontinence (EPI) study, a population-based study of racial differences in urinary incontinence prevalence.

RESULTS

Across the 3 studies, median PVRs were similar: 26 mL in LURN (n = 880, range 0-932 mL), 20 mL in EPI (n = 166, range 0-400 mL), and 14 mL in RELIVE (n = 191, range 0-352 mL). In LURN, males had 3.6 times higher odds of having PVR > 200 mL (95% CI = 1.72-7.48). In RELIVE, median PVR was significantly higher for males (20 mL vs 0 mL, P= .004). Among women, only the intermittency severity rating was associated with a probability of an elevated PVR. Among men, incomplete emptying and burning severity rating were associated with a higher odds of elevated PVR, but urgency severity ratings were associated with lower odds of elevated PVR.

CONCLUSION

Care-seeking patients have PVRs similar to those in people with unknown history of LUTS (RELIVE) and without self-reported LUTS (EPI). Although PVR was correlated with voiding symptoms, the mean differences only explain ∼2% of the variance.

One-year results with selective bladder denervation in women with refractory overactive bladder

AIMS

To report 1-year results with selective bladder denervation (SBD) of the trigone in women with refractory overactive bladder (OAB).

METHODS

In this prospective, international, multicenter case series, women with refractory OAB underwent a single SBD treatment of the bladder subtrigone region using temperature-controlled radiofrequency. Patients were followed for 1 year and evaluated for changes in OAB symptoms and adverse events.

RESULTS

Among 35 women, 29 (83%) returned for 1-year follow up. Median symptom reductions based on 3-day bladder diaries were 68% for urgency urinary incontinence ( P < .001), 67% for urinary incontinence ( P < .001), 43% for urgency episodes ( P < .001), 5% for urinary frequency ( P = .19), and 33% for the total urgency and frequency score ( P < .001), with the majority of treatment benefit realized in the first month. Treatment benefit was reported in 72% of patients, the clinical success rate (≥50% reduction in urgency urinary incontinence) was 69%, and the dry rate was 10%. Statistically significant improvements occurred on Symptom Bother and Health-related Quality of Life scales on the Overactive Bladder questionnaire, and on 6 of 9 King's Health Questionnaire domains. Patients with less severe baseline symptoms had similar quality of life improvements as those with more severe baseline symptoms. Device- or procedure-related adverse events were reported in 6 (17%) patients.

CONCLUSIONS

A single treatment with selective bladder denervation is durable for 1-year in a significant proportion of women with refractory overactive bladder.

Tissue response to applied loading using different designs of penile compression clamps

Background: Penile compression devices (PCD) or clamps are applied to compress the urethra and prevent urinary incontinence (UI). PCDs are more secure and less likely to leak than pads, allowing men the opportunity to participate in short-term, vigorous activities. However, they are uncomfortable, can cause pressure ulcers (PU) and affect penile blood flow. No objective assessment of tissue health has been undertaken to assess and compare different PCD designs and to provide guidance on safe use.

Objective: This study was designed to evaluate existing PCDs in terms of their physiological response and potential for pressure-induced injury.

Design, setting and participants: Six men with post-prostatectomy UI tested four selected PCDs at effective pressures, in a random order, in a controlled laboratory setting.

Outcome measurements and statistical analysis: Using objective methods for assessing skin injury, PCDs were measured in situ for their effects on circulatory impedance, interface pressures and inflammatory response.

Results and limitations: There was evidence for PCD-induced circulatory impedance in most test conditions. Interface pressures varied considerably between both PCDs and participants, with a mean value of 137.4±69.7 mmHg. In some cases, penile skin was noted to be sensitive to loading with elevated concentration of the cytokine IL-1α after 10 mins wear, indicating an inflammatory response. IL-1α levels were restored to baseline 40 mins following PCD removal.

Conclusion: Skin health measures indicated tissue and blood flow compromise during the 50 mins of testing using all PCDs. Although there was an elevation in pro-inflammatory cytokines, PCDs did not cause sustained irritation and skin health measures recovered 40 mins after PCD removal. This research indicates that application of a clamp for one hour with an equal clamp free time before reapplication is likely to be safe. Longer periods are often recommended by manufacturers but have yet to be tested.

Renal failure caused by severe pelvic organ prolapse

Pelvic organ prolapse (POP), the transvaginal descent of pelvic organs, can cause mild hydronephrosis but rarely leads to a deterioration in kidney function. We present a case of severe uterovaginal prolapse that caused bilateral ureteral obstruction and led to renal failure and urinary tract infection. During outpatient follow-up, kidney function had already been deteriorating, but POP was not recognised as a causal factor. A longer duration of ureteral obstruction can lead to irreversible kidney damage, and therefore, timely recognition and intervention is of essence. Even in complex cases with various causative factors for kidney injury, the presence of severe POP and kidney injury should prompt the clinician to exclude this cause.

The role of urodynamics in females with lower urinary tract symptoms

Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used.

Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: ‘female urology’, ‘lower urinary tract symptoms’, ‘urodynamic’, ‘incontinence’, ‘overactive bladder’, ‘bladder outlet obstruction’. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society.

Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS.

Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity.

Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence

Toileting difficulties in older people with and without dementia receiving formal in-home care-A longitudinal study

AIM

To estimate the prevalence of toileting difficulties over time among older people (≥70 years) with and without dementia receiving formal in-home care at baseline and to explore whether dementia at baseline was associated with toileting difficulties at the last assessment when adjusting for relevant covariates. We hypothesize that those with dementia have a higher prevalence and that baseline dementia is associated with toileting difficulties at last follow-up.

DESIGN

A longitudinal observational study with three assessments over 36 months. Older people (≥70 years) from 19 Norwegian municipalities with in-home care needs were included. The participants and their next of kin were interviewed.

METHOD

In total, 1,001 (68% women) persons with a mean (SD) age 83.4 (5.7) years participated at baseline. Toileting difficulties were assessed using Lawton and Brody's Physical Self-Maintenance Scale and Individual Nursing and Care Statistics. Information on physical comorbidity, number of prescribed drugs, cognitive function and formal care given was included. Dementia was diagnosed based on all information gathered.

RESULTS

At all time points, toileting difficulties were more prevalent in people with than without dementia. In adjusted analyses, dementia at baseline was associated with toileting difficulties at the last assessment. Nursing home admission was associated with increased odds for toileting difficulties.

Considering Low Health Literacy: How Do the Pelvic Floor Distress Inventory-Short Form 20 and Pelvic Floor Impact Questionnaire-Short Form 7 Measure Up?

OBJECTIVE

The objective of this study was to evaluate the readability and understandability of 2 commonly used pelvic floor disorder questionnaires, Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and Pelvic Floor Impact Questionnaire-Short Form 7 (PFIQ-7), in a low health literacy patient population.

METHODS

Flesh-Kincaid, SMOG, Fry, and FORCAST readability assessment tools were used to assign US grade levels to each questionnaire (PFDI-20, PFIQ-7). Two health literacy experts used PEMAT and ELF-Q tools to determine understandability, organization, content, and quality of each form. A focus group of women with low health literacy used Stop Light Coding and a facilitator-prompted discussion to further evaluate understandability and critique the forms.

RESULTS

The PFIQ-7 required higher reading ability compared with PFDI-20 (ninth to 11th vs sixth to eighth mean grade level equivalents). Expert and focus group reviews identified concerns regarding purpose, formatting, and word choice in both forms. Focus group participants recommended assistance with questionnaire completion from clinical staff and gave mean overall ratings of 5.4 (0-10/worst to best) for PFDI-20 and 8.0 for PFIQ-7.

CONCLUSIONS

Knowledge of potential barriers to understanding and completion may improve utilization of and accuracy of patient responses to PFDI-20 and PFIQ-7 in women with low health literacy.

Recent advances in pelvic floor repair

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are conditions which result in significant physical, mental and social consequences for women worldwide. The high rates of recurrence reported with primary repair for POP led to the use of synthetic mesh to augment repairs in both primary and secondary cases following failed previous POP repair. The widely reported, unacceptably high rates of complications associated with the use of synthetic, transvaginal mesh in pelvic floor repair have severely limited the treatment options that surgeons can offer. This article summarises the recent advances in pelvic floor repair, such as improved quantification and modelling of the biomechanics of the pelvic floor and the developing technology within the field of tissue engineering for treatment of SUI/POP, including biomaterials and cell-based therapies. Finally, we will discuss the issues surrounding the commercial introduction of synthetic mesh for use within the pelvic floor and what lessons can be learned for the future as well as the current guidance surrounding treatment for SUI/POP.

The Spectrum of Bladder Health: The Relationship Between Lower Urinary Tract Symptoms and Interference with Activities

Background: Little research to date has focused on lower urinary tract symptom (LUTS) prevention and bladder health promotion in women. To address this gap, the Prevention of LUTS Research Consortium developed the following working bladder health definition: "A complete state of physical, mental, and social well-being related to bladder function [that] permits daily activities [and] allows optimal well-being." To begin to inform and quantify this definition, we used data from the Boston Area Community Health Survey, drawing upon its rare collection of information on LUTS and LUTS-specific interference with activities. Methods: At baseline, participants reported their frequency of 15 LUTS and interference with 7 activities. Prevalence ratios (PRs) were calculated by generalized linear models with robust variance estimation, adjusting for LUTS risk factors and individual LUTS. Results: Of the 3169 eligible participants, 17.5% reported no LUTS or interference, whereas the remaining 82.5% reported some frequency of LUTS/interference: 15.1% rarely; 21.7% a few times; 22.6% fairly often/usually; and 22.9% almost always. LUTS independently associated with interference were urgency incontinence, any incontinence, urgency, nocturia, perceived frequency, and urinating again after <2 hours (PRs = 1.2-1.5, all p < 0.05). Conclusions: Our findings suggest that bladder health exists on a continuum, with approximately one in five women considered to have optimal bladder health (no LUTS/interference), the majority to have intermediate health (LUTS/interference rarely to usually), and a further one in five to have worse or poor health (LUTS/interference almost always). These findings underscore the need for LUTS prevention and bladder health promotion.

Evaluating the impact of radiation therapy on patient quality of life following primary artificial urinary sphincter placement

Background

The impact of prior radiation therapy on patient satisfaction following primary artificial urinary sphincter (AUS) placement is not well described, therefore our aim was to evaluate the effect of radiation on patient satisfaction among men undergoing primary AUS with and without a history of prior radiation.

Methods

From 1983-2011, 1,082 men underwent primary AUS placement at our institution. Of these, 467 were alive, with an intact primary AUS and invited to participate in a mailed survey assessing AUS status, patient satisfaction, and urinary control. Clinical subjective outcomes were assessed via reported change in urinary control from pre-operative to post-AUS placement.

Results

In total, 229/467 (49%) of men with an intact primary AUS completed the survey, with a median follow-up of 8.4 years [interquartile range (IQR) 5.8-11.4]. Of these, 64 men (28%) had a prior history of radiation therapy. Both men with and without history of radiation, reported a high likelihood of electing to have AUS surgery again, 87% vs. 91% respectively (P=0.87), and of recommending AUS surgery to a family member, 86% vs. 93% respectively (P=0.18). There were no significant differences between those with and without prior radiation with regard to rates of reported: substantial improvement in urinary control following surgery (72% vs. 78%, P=0.30), minimal bothersome leakage (57.1% vs. 66%, P=0.31), and pad use ≤1 pad/day (49% vs. 59%, P=0.06).

Conclusions

In a large cohort of primary AUS implants with and without prior radiation therapy we noted a high-level of satisfaction and though many patients still utilized 1 or more pads/day with long-term follow-up. Importantly, there was no significant difference in quality of life (QoL) outcomes compared between those with and without prior radiation therapy.

First-in-human implantation of a mid-field powered neurostimulator at the sacral nerve: Results from an acute study

INTRODUCTION

Commercially approved implantable systems for sacral neuromodulation require the implantation of a multipolar lead subcutaneously connected to an implantable pulse generator (IPG). Eliminating the need for an IPG would eliminate the need for tunneling of the lead, reduce procedure time, infection risk, and the need for IPG replacement. The objective was to demonstrate the feasibility of implanting the AHLeveeS System in the S3 Foramen to stimulate the S3 sacral nerve.

MATERIALS AND METHODS

A first-in-human, prospective, single center, nonrandomized, acute feasibility clinical investigation at the Maastricht University Medical Center+. Patients with refractory overactive bladder underwent acute implantation of the AHLeveeS neurostimulator before the InterStim procedure. Outcome measurements included motor responses, procedural time and a scoring of the difficulty of the implant and explant procedure. Retrospectively, qualitative responses to the stimulation protocol were assessed by video motion analyses. Only descriptive statistics were used.

RESULTS

During the stimulation a motor response to stimulation was seen in four of the five subjects. In all implantations the AHLeveeS was correctly placed. The median time for complete procedure was 24 minutes. The implant and explant procedures were successfully performed and no device or procedure related adverse events occurred.

CONCLUSIONS

The results from this acute first-in-human study demonstrate the feasibility of implantation and acute stimulation of the sacral nerve with this mid-field powered system. Future clinical studies will focus on safety and efficacy of a chronically implanted device.

Sciatic Nerve to Pudendal Nerve Transfer: Anatomical Feasibility for a New Proposed Technique

Aim Restoration of bladder and bowel continence after pudendal nerve anastomosis has been shown successfully in animal models and may be applicable in humans. Aim of this cadaveric study was to assess feasibility of pudendal nerve neurotization using motor fascicles from sciatic nerve.

Methods Pudendal and sciatic nerves were exposed via gluteal approach in 5 human cadavers (10 sites). Size of pudendal and sciatic nerves and the distance between two nerves was measured.

Results There were four male and one female cadavers. Mean age was 62 (range, 50–70) years. Mean pudendal nerve diameter was 2.94 mm (right side) and 2.82 mm (left side). Mean sciatic nerve diameter was 11.2 mm (right side) and 14.2 mm (left side). The distance between two nerves was 23.4 mm on both sides.

Conclusion Transfer of the motor fascicles from sciatic nerve to pudendal nerve to restore the bladder and bowel continence is feasible.

Effect of artificial urinary sphincter implantation on erectile function and sexual satisfaction

Artificial urinary sphincter (AUS) implantation is the gold standard treatment in total stress urinary incontinence (SIU). Our aim is to evaluate the effect of AUS implantation on erectile function and sexual satisfaction (SS). Fourteen patients aged 58-73 years (mean: 66.92 ± 4.51 years) who underwent AUS implantation by a perineal approach between May 2015 and April 2018 were included in our study. Patients with neurogenic disease or very low or no erectile function and those who underwent non-nerve-sparing radical prostatectomy were excluded. Erectile function and intercourse satisfaction were evaluated pre-operatively and post-operatively at 6-month follow-up using international index of erectile function (IIEF) questionnaires. After AUS implantation; eight patients were totally dry, four achieved social continence (less than one pad/day), and two still had SUI (two or more pads/day). Mean pre- and post-operative IIEF values of the patients were 16.14 ± 3.18 and 17.42 ± 4.43 respectively. Mean pre- and post-operative SS values were 8.57 ± 1.78 and 8.71 ± 2.19 respectively. There was no statistically significant difference between pre- and post-operative IIEF-5 and intercourse satisfaction scores (p > 0.05). Although we did not see a significant effect of AUS implantation in our study, in SIU patients, coital incontinence or unpleasant odour during intercourse can lead to sexual avoidance and reduced SS, and AUS implantation may improve SS.

Patient-reported outcomes and urodynamic findings in men with persistent lower urinary tract symptoms following robot-assisted radical prostatectomy

AIMS

To evaluate the patient-reported outcome measures (PROMs) and urodynamic findings in men seeking intervention for lower urinary tract symptoms (LUTS) after robotic-assisted radical prostatectomy (RARP) in a regional referral center for continence surgery.

METHODS

Consecutive men with post-RARP LUTS, who were referred for specialist evaluation and urodynamics between December 2012 and October 2017, were evaluated. Men were invited to complete the International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms Long Form (ICIQ-MLUTS) pre-operatively and at 6, 12 and 18 months post-RARP.

RESULTS

In total 64/860 (7.4%) men post-RARP were referred for specialist evaluation. There was a significant increase in total ICIQ-MLUTS and bother scores at 6, 12 and 18 months compared with the baseline in these men (P < 0.001 and P < 0.05, respectively). Urodynamics identified 41/64 (64%) had urodynamic stress incontinence (USI) only, 2/64 (3%) had detrusor overactivity (DO) only and 11/64 (17%) had a combination of USI and DO. Of those referred to a continence specialist 29/64 (45%) underwent a continence procedure.

CONCLUSIONS

Patients with bothersome LUTS post-RARP have higher baseline ICIQ-MLUTs scores and significant worsening of total scores at all time points compared with the baseline. Routine use of PROMs may identify patients at risk of bothersome symptoms after RARP and prompt earlier referral for further management of their LUTS. Urodynamic evaluation revealed that the most common finding was pure stress incontinence but the range of urodynamic diagnoses highlights the need to perform urodynamics before making treatment decisions for men with LUTS post-RARP.

Cross-Cultural Adaptation and Quantitative Evaluation of Dysfunctional Voiding and Incontinence Scoring System in Pediatric Serbian Population

Background and objective: Dysfunctional voiding (DV) presents relatively frequent problem in pediatric urologist practice. The necessity for implementation of DV evaluation in the pediatric population is of particular importance, since there is no clear consensus on the clinical assessment of such condition. The aims of our study were to evaluate the test/retest reliability and reproducibility of dysfunctional voiding and incontinence scoring system: Serbian version (DVISS_SR) in patients with voiding and incontinence dysfunctions without structural deformities, and to estimate cut-off value for DVISS_SR. Methods: The cross-sectional study included 57 children with voiding and incontinence dysfunctions and 30 healthy pediatric controls. For the evaluation of voiding and incontinence dysfunction we used DVISS. The forward–backward method was applied for translation of the DVISS questionnaire from English into Serbian language. Reproducibility was analyzed by Interclass Correlation Coefficient (ICC). Sensitivity and specificity of DVISS_SR scores was done by receiver operating curve (ROC) curve. Results: There was a significant difference in DVISS_SR score between patients and controls (p < 0.001). For reliability and reproducibility of the questionnaire, there was no significant difference between repeated measurements (p = 0.141), and strong reliability (ICC = 0.957; p < 0.001). Conclusion: We have demonstrated successful translation and validation of the DVISS_SR score. Moreover, a reliable scoring system of children with voiding dysfunctions should include evaluations of symptom scoring systems at the multicentric level.

Primary malignant melanoma of the urethra in a patient with rheumatoid arthritis treated with methotrexate

We report a case of a 79-year-old woman with urinary incontinence who presented at a urogynaecology appointment. Her medical history included rheumatoid arthritis (RA) treated with methotrexate (MXT) for 22 years. A polypoidal lesion was protruding from the meatus urethrae. The histoimmunocytology confirmed a primary superficial spreading malignant melanoma. The tumour was extensively excised, but 8 months later, due to a lymphatic nodal swelling, a positron emission tomography/CT was performed showing a process suspicious of malignant melanoma and multiple distant metastasis. The subsequent treatment was palliative and 1 year later, the patient died. The aetiology of malignant melanomas in the urethra is poorly understood. There is consistent evidence that RA is associated with a number of cancers, but it remains controversial whether this risk is increased with MXT. This case emphasises the importance of gynaecological examination even in patients with only weak symptoms from the pelvic region, especially in patients undergoing immunosuppressive treatment.