Urodynamic insights: exploring the relationship between detrusor overactivity and pelvic organ prolapse in women with urge incontinence

PURPOSE

Pelvic organ prolapse (POP) and overactive bladder (OAB) commonly affect the aging female population. We aimed to investigate the possible relationship between the two, as reflected by urodynamic studies.

METHODS

A retrospective analysis was conducted on women who underwent urodynamic studies at a university-affiliated tertiary medical center from January 2018 to January 2021. Women presenting with urge incontinence and diagnosed with detrusor overactivity (DO) were included in the study. Based on the presence or absence of a modified POP-Q ≥ grade 2, these women were categorized into two groups. Data on general demographics, clinical symptoms, and urodynamic findings were extracted and compared using SPSS.

RESULTS

During the study period, 949 urodynamic evaluations were performed. Of these, 303 (31.92%) reported urge incontinence. Out of this subset, 151 (49.83%) were diagnosed with DO. Within this group, 18 (11.9%) had POP, while 134 (88.1%) did not. The POP group had a notably higher incidence of prior vaginal hysterectomy and anterior colporrhaphy (p = 0.02 and p = 0.01, respectively). While most urodynamic parameters were similar between groups, there was a significant increase in hesitancy in the POP group (13 s vs 8 s, p = 0.03). There was a trend indicating a reduced median Q max (12 ml/s vs. 18 ml/s, p = 0.06) and an increased flow time (55 s vs 40 s, p = 0.08) in the POP group.

CONCLUSION

The urodynamic profile of the POP group suggests an obstructive voiding pattern. Further longitudinal research is essential to fully understand the relationship between POP and OAB.

Maintaining the apex: a novel technique for vault suspension during vaginal hysterectomy

INTRODUCTION AND HYPOTHESIS

Post-hysterectomy vault prolapse poses significant challenges to patients and surgeons alike. Despite numerous surgical interventions during initial vaginal hysterectomy to counteract this, a comparative analysis of their efficacy is limited. This study introduces a pioneering technique intended to avert vault prolapse during vaginal hysterectomy by harmoniously merging level 1 and level 2 support.

METHODS

After obtaining informed consent, we recorded a variation of the McCall technique performed during vaginal hysterectomy and anterior repair. Patient follow-ups were conducted up to 6 months post-operation to evaluate anatomical outcomes and quality of life.

RESULTS

A total of 46 women underwent the surgery. Anatomical evaluations at the 6-month mark were commendable, with no recurrence instances. Quality-of-life assessments, using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12), showcased substantial improvement.

CONCLUSION

Our novel approach to vault suspension provides an uncomplicated, easily impartible, surgical procedure utilizing standard sutures. We believe that this approach is both enduring and safe.

A national survey of surgical training in gynaecology: 2014-2021

OBJECTIVES

Over the last decade barriers to surgical training have been identified, including reducing access to theatre lists, reducing numbers of major surgical procedures being performed, increasing numbers of trainees and reduction in working hours since the introduction of the European Work Time Directive (EWTD). We aimed to assess the impact of these challenges on training in gynaecology over time.

STUDY DESIGN

We designed a study which aimed to assess both trainers and trainees perception of gynaecological surgical training in Ireland. The purpose of this was to identify confidence levels and challenges and to highlight potential areas for future improvement of surgical training in gynaecology. A a cross-sectional survey was distributed to all trainees and trainers registered with the Royal College of Physicians of Ireland Obstetrics and Gynaecology higher specialist training programme in 2014, 2017 and again in 2021.

RESULTS

During the study period trainees' confidence that the training programme prepared them to perform gynaecological surgery fell significantly. This fall in confidence was most evident for trainees' ability to perform abdominal hysterectomy (40.9% vs 15.2%, χ2 = 4.61, p =.03) and vaginal hysterectomy (31.8% vs 12.1%, χ2 = 4.58, p =.03) when comparing 2014 with 2021. All trainees reporteded that gynaecology was not given adequate time in the training programme to prepare them to practice independently as consultants. Themes identified by participants to improve training included dedicated access to theatre time with a named trainer, increased simulation training and subspecialisation at later stages of training.

CONCLUSION

Our findings show an overall decrease in trainees' and trainers' confidence in the surgical training available in gynaecology over an eight-year period.. This is particularly true for major gynaecology procedures. Efforts must be made to ensure trainees have improved access to surgical training in gynaecology. Potential solutions include improving access to simulation and incorporation of subspecialist training into later stages of training.

M1 transcranial direct current stimulation augments laparoscopic surgical skill acquisition

The acquisition of basic surgical skills is a key component of medical education and trainees in laparoscopic surgery typically begin developing their skills using simulation box trainers. However, despite the advantages of simulation surgical training, access can be difficult for many trainees. One technique that has shown promise to enhance the deliberate practice of motor skills is transcranial electric stimulation (tES). The purpose of this study was to assess the impact of transcranial direct current stimulation (tDCS) on training induced improvements and retention of traditional time and kinematic based laparoscopic surgical skill metrics. Forty-nine medical students were randomly allocated to a neurostimulation or sham group and completed 5 training sessions of a bead transfer and threading laparoscopic task. Participants in both the sham and stimulation groups significantly improved their time and kinematic performance on both tasks following training. Although we did find that participants who received M1 tDCS saw greater performance benefits in response to training on a bead transfer task compared to those receiving sham stimulation no effect of neurostimulation was found for the threading task. This finding raises new questions regarding the effect that motor task complexity has on the efficacy of neurostimulation to augment training induced improvement and contributes to a growing body of research investigating the effects of neurostimulation on the sensory-motor performance of laparoscopic surgical skill.

The Inclusion of Practical Urology Skills in Intern Induction: A Pilot Programme

Introduction Intern is the first postgraduate year of training and gives interns the opportunity to practice skills in real-life settings. We aim to examine the undergraduate exposure to urology across all Irish Medical Schools and assess the impact of a mandatory urology training skills session delivered during induction on the preparedness of interns ahead of starting their intern year. Methods In July 2020 all interns mandated to attend the Dublin/Mid-Leinster (DML) network intern induction underwent a 120-minute urology teaching session. The session comprised of formal teaching, followed by practical training and an informal question and answer session. All interns were asked to complete a survey before and after the session that examined undergraduate urology exposure and confidence around practical skills. Results All interns (n=74) who attended induction completed the survey. Less than half [43% (n=32]) reported a compulsory urology placement in medical school and 57% (n=42) reported previous practical training sessions in urology. There was low level of confidence in the management of urological scenarios with only 45 % (n = 33) reporting confidence in the management of urosepsis and 26 % (n = 19) in the insertion of a male catheter. There was a significant increase in self-reported confidence following the teaching session with 78 % (n = 58) interns reporting confidence in the management of urosepsis and 81 % (n = 60) in the insertion of a male catheter. Conclusion To ensure best patient care interns need to be trained in the management of common urology presentations, but our results suggest the current undergraduate curriculum is not sufficient. A dedicated theory and practical urology teaching session during intern induction was able to improve self-reported confidence and better prepare interns. Therefore we support inclusion of practical urology skills session in network intern induction.

54 Patient Satisfaction During A Pandemic – Virtually Impossible?

Introduction

Throughout the COVID-19 pandemic we conducted virtual urology clinics for the first time at our institution. We aimed to assess patient satisfaction with the virtual clinic format.

Method

Patients who underwent virtual consultation were contacted by phone and surveyed about their appointment. Convenience, thoroughness, satisfaction, preference and reason for appointment were assessed via questionnaire

Results

77 randomly selected patients were contacted. 63 males (82%), 14 females (18%). Median age 61 years (range 16–86). 62 (80%) reviews, 12 (16%) new referrals, and 3 (4%) post-operative patients were surveyed. 55 (71%) were booked for repeat appointment, 13 (17%) for further investigations, 6 (8%) discharged, and 3 (4%) listed for surgery.

73 (95%) found it convenient, 3 (4%) were neutral and 1 (1%) found it inconvenient. 74 (96%) felt thoroughly assessed and 76 (99%) of patients had all their concerns addressed. 74 (96%) were satisfied with their review, 2 (3%) were neutral, and 1 (1%) was dissatisfied. Going forward, 50 (65%) would prefer virtual follow-up and 27 (35%) would prefer an in-person review.

Conclusions

Virtual clinic is preferable to the majority of patients in our urology service and is deemed convenient, thorough and satisfactory by them. It should be facilitated going forward in appropriately selected patients.

Iatrogenic Bowel Injury at Exchange of Supra-Pubic Catheter

Suprapubic catheter insertion and exchange is a common urological procedure, but it is not without risks and complications. While bowel perforation is a recognised complication at suprapubic catheter insertion, it is not commonly reported at suprapubic catheter exchange. We report our experience of recognition, diagnosis and subsequent successful management of the most important complication related to suprapubic catheters.

Patterns and outcomes of traumatic pancreatic injuries: A retrospective review from a large multi-institutional healthcare system

Introduction

Traumatic pancreatic injuries are rare, and morbidity and mortality information are often conflicting. To determine the frequency and outcomes of patients presenting with trauma to the pancreas, we reviewed data from a large multi-institutional healthcare system for mechanism of injury, intervention, subsequent complications, in-hospital morbidity rates, and mortality.

Methods

We performed a retrospective analysis of records of all pancreatic injury cases seen at four healthcare centers from 1990 to 2014. Descriptive measures are presented for continuous and categorical data. Mortality rates were obtained using the publicly accessible Social Security Death Master File.

Results

Of 69 patients with pancreatic injuries, median age was 24 years (range 1–88). Mechanisms of injury were blunt in 87% and penetrating in 11.8%. The median injury grade was 1. Most injuries involved the pancreatic head (24.6%). Median Injury Severity Score at presentation was 9. Thirty-seven (53.6%) patients required surgery. Twenty-five patients (36.2%) required total parenteral nutrition, 34 patients (49.3%) developed intra-abdominal fluid collections, 24 patients (34.8%) developed acute pancreatitis, and three (4.4%) developed endocrine insufficiency requiring insulin. Ten (14.5%) patients died. There were four (5.8%) readmissions and one re-operation (1.4%) within 30 days of discharge.

Conclusion

Traumatic pancreatic injuries occur most frequently in young healthy males with little or no comorbidities, and are generally associated with other acute injuries. Contrary to past reports, our results revealed a low mortality rate but significant morbidity, with the most common complications being intra-abdominal fluid collections, acute pancreatitis, and a need for total parenteral nutrition.

The Hidden Burden of Outpatient Repeat PSA Testing in a Prospective Cohort

PSA testing is widespread throughout Europe for diagnostic purposes and follow up. We performed a prospective outpatient cohort study of 250 men (2013-2015) in two hospital sites. Included were those men being followed up by urology with PSA blood testing. First appointments and those men in whom non-PSA tests were ordered by urology were excluded. The median age was 67.2yrs (46-88). Eighty-one point two percent of samples had a combination of 21 different serology tests at an added cost of >€18,000. Abnormal serology resulted in 53 referrals. Twenty-six-six percent of correspondence referenced abnormal serology other than PSA. Follow up of non-PSA test results poses a challenge in an outpatient setting with failure to appropriately follow-up on abnormal results, increased costs, and medico-legal implications. There is currently no Irish legislature in place to safeguard hospital physicians. This study quantifies the levels of expenditure, resources and risk associated with ambulant PSA testing.

Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study

Background

Traumatic pancreatic injuries are rare, and guidelines specifying management are controversial and difficult to apply in the acute clinical setting. Due to sparse data on these injuries, we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries. We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically.

Methods

We performed a retrospective review of data from four trauma centers in New York from 1990–2014, comparing patients who had blunt traumatic pancreatic injuries who were managed operatively to those managed non-operatively. We compared continuous variables using the Mann-Whitney U test and categorical variables using the chi-square and Fisher’s exact tests. Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups.

Results

Twenty nine patients were managed operatively and 32 non-operatively. There was a significant difference between the operative and non-operative groups in median age (37.0 vs. 16.2 years, P = 0.016), grade of pancreatic injury (grade I; 30.8 vs. 85.2%, P value for all comparisons <0.0001), median injury severity score (ISS) (16.0 vs. 4.0, P = 0.002), blood transfusion (55.2 vs. 15.6%, P = 0.0012), other abdominal injuries (79.3 vs. 38.7%, P = 0.0014), pelvic fractures (17.2 vs. 0.00%, P = 0.020), intensive care unit (ICU) admission (86.2 vs. 50.0%, P = 0.003), median length of stay (LOS) (16.0 vs. 4.0 days, P <0.0001), and mortality (27.6 vs. 3.1%, P = 0.010).

Conclusions

Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively. The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.

Paravaginal aggressive angiomyxoma

A 34-year-old nulliparous woman with a long-standing history of uterine fibroids and infertility had undergone prior open myomectomy, then uterine artery embolisation in treatment of an apparent large fibroid. Imaging on referral revealed an atypical 12×11×10 cm pelvic mass with the appearance of a fibroid. At laparotomy, the lesion was encapsulated but softer than a fibroid and located deep in the paravaginal space. The histopathological outcome was an aggressive angiomyxoma.

Carcinosarcoma of the penis

BACKGROUND

Carcinosarcoma of the penis is extremely rare and little is known about its biological behaviour.

AIMS

We report the second such case and discuss its histological categorisation and biological behaviour.

METHODS

A total penectomy with perineal urethrostomy was performed without lymphadenectomy in an 83-year old presenting with a fungating penile mass.

RESULTS

Microscopy of the gross specimen showed a biphasic tumour with both squamous and spindle cell elements. Immunohistochemical staining for epithelial markers showed positivity in the squamous cell elements but was uniformly negative in the spindle component. Immunohistochemistry of the spindle cell element demonstrated mesenchymal markers. The patient refused further treatment and follow up but presented at 26 months with inguinal lymphadenopathy. Biopsy confirmed squamous cell carcinoma metastasis consistent with penile origin. The patient refused further surgery and received pelvic irradiation. He died 6 months later.

CONCLUSIONS

This case illustrates the biological behaviour of this rare tumour.

Fractured penis: a clinical misnomer!

BACKGROUND

A 'fracture' of the penis refers to a tear in the deep layer of the tunica albuginea (Buck's fascia) and may be associated with a urethral injury.

AIM

To describe a classical case of a 'fractured' penis and discuss the management options.

METHOD

A case report of a 30-year-old man presented with a 'fractured' penis and who underwent surgical intervention.

CONCLUSION

This rare occurrence represents a urological emergency and necessitates imaging and repair of the cavernosal defect in order to prevent poor functional outcome.

Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP): a randomized trial design of the effect of a community pharmacist intervention program on serum cholesterol risk

OBJECTIVE

To determine the efficacy of a program of intervention by pharmacists on lipid risk management in patients at high risk for cardiovascular events.

METHODS

Randomized, multicenter (44 sites in Alberta and Saskatchewan) study of community pharmacist intervention versus usual care in 1000 patients. Patients are those at high risk of vascular events (existing atherosclerotic vascular disease, or diabetes with > or = 1 other risk factor). After obtaining consent, the pharmacist calls the Project Office to randomize. Patients allocated to intervention receive a brochure and education about cardiovascular risk factors. Pharmacists also complete a physician contact form, which lists the patient's risk factors, medications, and any recommendations. A point-of-care cholesterol test is performed, the result is discussed with the patient, and it is entered on the contact form. If appropriate, the patient is asked to see his or her primary care physician for further assessment and/or treatment, and the form is faxed to the physician. Patients are followed up at two, four, eight, 12, and 16 weeks. During follow-up visits, pharmacists provide educational reinforcement and check for primary end point occurrence. Patients allocated to usual care receive the brochure only, with minimal follow-up. The primary end point is a composite of measurement of a complete lipid panel by the physician, or addition or modification of lipid-lowering drug therapy. Substudies will evaluate economics (third-party payer and pharmacy manager perspective), patient satisfaction, and quality of life.

CONCLUSIONS

SCRIP (Study of Cardiovascular Risk Intervention by Pharmacists) is a unique ongoing trial that is evaluating a community pharmacist intervention designed to optimize cholesterol risk management in patients at high risk for cardiovascular events.

Efficacy of oral ondansetron, a selective antagonist of 5-HT3 receptors, in the treatment of nausea and vomiting associated with cyclophosphamide-based chemotherapies. Ondansetron Study Group

We evaluated the efficacy and safety of oral ondansetron, a selective antagonist of 5-HT3 receptors, for the treatment of nausea and vomiting associated with cyclophosphamide-based chemotherapy (> 500 mg/m2). In this trial 324 chemotherapy-naive cancer patients, mostly females with breast cancer, were randomized to receive either placebo or ondansetron 1 mg, 4 mg, or 8 mg three times per day for 3 days. There were no differences in the doses of cyclophosphamide, doxorubicin, and methotrexate between the study groups. All ondansetron dose groups were superior to the placebo control group (p < .001) for all measured efficacy parameters (complete response, number of emetic episodes, therapeutic failures, need of rescue antiemetics). No emetic episodes were reported by 9 (12%), 29 (37%), 48 (64%), and 47 (66%) of the placebo patients and the 1-mg, 4-mg, and 8-mg dose of ondansetron patients, respectively. Nausea was reduced and food intake was improved for all the ondansetron groups. A more severe emetic response was observed in patients receiving cyclophosphamide and doxorubicin combination chemotherapy. In this subgroup of patients, 66%, 38%, 25%, and 16% of the placebo group and 1-mg, 4-mg, and 8-mg ondansetron patients, respectively, required rescue antiemetics. No significant toxic effects were observed in this study. A higher incidence of headaches and gastrointestinal complaints (constipation, abdominal pain) were observed in the three ondansetron groups. In conclusion, oral ondansetron is an effective and well-tolerated antiemetic treatment in the management of cancer patients receiving ambulatory cyclophosphamide-based chemotherapy. These results support the view that serotonin and 5-HT3 receptors play an important role in cyclophosphamide-induced nausea and vomiting.

Efficacy of oral ondansetron in the prevention of emesis in outpatients receiving cyclophosphamide-based chemotherapy. The Ondansetron Study Group

OBJECTIVE

To evaluate the efficacy and safety of oral ondansetron (Zofran) as an antiemetic in patients receiving cyclophosphamide-based chemotherapy.

DESIGN

A multicenter, randomized, double-blind, stratified, placebo-controlled trial conducted between March 1989 and January 1990.

SETTING

Twenty-seven oncology centers including university hospitals, community cancer centers, and private medical oncology practices.

PATIENTS

A total of 349 chemotherapy-naive patients having their first cycle of cyclophosphamide (> or = 450 mg/m2)-based chemotherapy. Patients also received methotrexate (> or = 30 mg/m2) or doxorubicin (> or = 35 mg/m2). All patients were evaluated for safety and 318 (91%) were evaluated for efficacy.

INTERVENTIONS

Patients were randomly assigned to one of four treatment groups: placebo, 1 mg, 4 mg, or 8 mg of ondansetron. Assigned study medication was taken three times per day for 3 consecutive days.

MEASUREMENTS

Time and number of emetic episodes as well as degree of nausea were recorded by patients for each of the 3 study days.

RESULTS

Compared with placebo, all three doses of ondansetron were superior (P < 0.001) in preventing vomiting and controlling nausea. A complete response (no emetic episodes) was observed in 19%, 57%, 65%, and 66% of patients in the placebo, 1-mg, 4-mg, and 8-mg ondansetron groups, respectively. For patients who received higher-dose cyclophosphamide and doxorubicin, a dose-related trend in antiemetic efficacy of ondansetron was observed. Mild headache and constipation were the most frequently reported adverse events. No extrapyramidal reactions were observed.

CONCLUSION

Oral ondansetron is a safe and effective antiemetic that is more efficacious than placebo for patients receiving cyclophosphamide-based chemotherapy.

The influence of prostaglandin E1 on systemic and pulmonary haemodynamics after aortic surgery

The influence of a peroperative prostaglandin E1 (PGE1) infusion on systemic and pulmonary haemodynamics in a porcine model of aortic surgery was studied. Twenty-four pigs were randomised to PGE1 (100 ng/kg/min) or 0.9% Saline as placebo. Haemaccel was then infused to maintain a central venous pressure (CVP) of greater than 4 less than 6 mmHg and pulmonary artery wedge pressure (PAWP) of greater than 3 less than 5 mmHg. Standardised aortic surgery consisted of midline laparotomy, small bowel exteriorisation, 1.5 h aortic clamping and 1 h shock before resuscitation. Serial measurements of blood pressure (BP), cardiac output (CO), pulmonary vascular resistance (PVR), pulmonary shunt (A-V shunt), and arterial PO2 (PaO2) were recorded during and three days after surgery. Volume loading with Haemaccel prevented a significant fall in initial BP on PGE1 at 95.1 +/- 48 mmHg compared to 102 +/- 4.9 mmHg in control animals with similar CO in the two groups. Following release of the aortic clamp all animals became profoundly hypotensive with BP falling to 74.6 +/- 3.0 and 68.7 +/- 3.2 mmHg for PGE1 and placebo respectively, but CO was protected in those animals receiving PGE1 at 1.92 +/- 0.04 compared to 1.67 +/- 0.1 L/min/m2 on placebo and remained significantly higher following resuscitation and three days later (P less than 0.05). PGE1 also reduced the marked rise in pulmonary vascular resistance to 922 +/- 84 dynes-s/cm5/m2 during shock in control animals to only 555 +/- 30 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)