Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT

The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue.

OBJECTIVE

To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data.

EVIDENCE ACQUISITION

PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed.

EVIDENCE SYNTHESIS

Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE).

CONCLUSIONS

Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence.

PATIENT SUMMARY

In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

Is a Course of Intermittent Self-dilatation with Topical Corticosteroids Superior at Stabilising Urethral Stricture Disease in Men and Improving Functional Outcomes over a Course of Intermittent Self-dilatation Alone? A Systematic Review and Meta-analysis

Context

Intermittent self-dilatation (ISD) is a therapeutic strategy used to stabilise a urethral stricture and postpone or avoid further treatment. Adding corticosteroids to this mode of management might further enhance its outcomes by downregulation of collagen deposition and excessive scar tissue formation.

Objective

To explore whether a course of ISD with topical corticosteroids is superior at stabilising urethral stricture disease in men and improving functional outcomes over a course of ISD alone.

Evidence acquisition

This systematic review and meta-analysis was undertaken by the European Association of Urology Urethral Strictures Guideline Panel according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (CRD42021256744). The primary benefit outcome was successful stabilisation of the urethral stricture. Treatment-related complications were the primary harm outcome.

Evidence synthesis

In total, 978 records were screened for eligibility, ultimately leading to five included studies, all randomised controlled trials, comprising 250 patients, of whom 124 underwent a course of ISD with corticosteroids and 126 underwent a course of ISD alone, all after direct vision internal urethrotomy (DVIU). Successful stabilisation of the stricture was achieved in 77% and 64% of patients in the group with and without corticosteroids, respectively (p = 0.04). No extra complications related to the addition of corticosteroids to the ISD regimen were reported. The risk of bias of the included studies was generally unclear to high.

Conclusions

Based on the currently available data, a course of ISD with topical corticosteroids appears to be safe and superior at stabilising a urethral stricture after DVIU in the short term to a course of ISD alone. However, given the unclear to high risk of bias in the included studies, further high-quality studies are needed to fully underpin this.

Patient summary

This study shows that addition of topical corticosteroids to intermittent self-dilatation after direct vision internal urethrotomy can better stabilise the stricture in the short term.

European Association of Urology Guidelines on Urethral Stricture Disease Part 3: Management of Strictures in Females and Transgender Patients

CONTEXT

Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice.

OBJECTIVE

To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of urethral strictures in females and transgender patients.

EVIDENCE ACQUISITION

The panel performed a literature review on these topics covering a time frame between 2008 and 2018 and used predefined inclusion and exclusion criteria for study selection. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on the review of the available literature and after panel discussion.

EVIDENCE SYNTHESIS

Management of urethral strictures in females and transgender patients has been described in a few case series in the literature. Endoluminal treatments can be used for short, nonobliterative strictures in the first line. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.

CONCLUSIONS

Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.

PATIENT SUMMARY

Although different techniques are available to manage narrowing of the urethra (called a stricture), not every technique is appropriate for every type of stricture. These guidelines, developed on the basis of an extensive literature review, aim to guide physicians in selecting the appropriate technique(s) to treat a specific type of urethral stricture in females and transgender patients. TAKE HOME  MESSAGE: Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.

Botulinum toxin A injection to the external urethral sphincter for voiding dysfunction in females: A tertiary center experience

AIM

The aim of this study is to examine the functional outcomes of ona-botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for female patients with nonneurogenic nonrelaxing sphincter as the underlying cause of voiding dysfunction (VD).

METHOD

A retrospective analysis was performed for all the patients with the urodynamic findings of higher than expected maximum urethral closure pressure (MUCP) who received their first injection during the study period. All patients were evaluated with preoperative videourodynamic study and urethral pressure profilometry and received 100 U of EUS BTX-A. Patients aged less than 18 years and those with neurogenic bladder were excluded. All patients were followed up with the free flow, postvoid residuals (PVR), and patient global impression of improvement (PGI-I) scale at 6 weeks and then at 3 monthly intervals.

RESULT

We identified 35 female patients with a mean age of 37.5 ± 15 years (range 18-72 years) with a mean follow-up of 20 months. More than 50% of patients had a history of prior surgical intervention and 28 (80%) patients were catheter dependent, a suprapubic catheterization, or clean intermittent self-catheterization. Mean MUCP was 97.1 ± 22 cm of water. After treatment with BTX-A, 21 (60%) patients were able to void per urethral (p = 0.02). The mean maximum flow rate (Qmax) improved from 8.8 to 11 mls/s and the mean PVR decreased from 200 to 149 mls (p < 0.05). On multivariate analysis, we identified high preoperative PVR, high preoperative actual MUCP, and previous surgical intervention (urethral dilatation, sacral neuromodulation, and pelvic surgery) as predictors of successful voiding restoration. The mean duration of response was 4.7 months, 46% of patients requested repeat injection, and 29% were established on maintenance injections. On the 5-point PGI-I score, 13 (37%), 12 (34%), and 10 (29%) patients reported good, some, and no improvement, respectively. Quality of life was also improved in 60% of patients. Two patients had transient stress urinary incontinence (for <6 weeks) and there were no significant long-lasting adverse events.

CONCLUSION

EUS BTX-A is a valid treatment option for VD considering therapeutic options are limited. The patient must be made aware of the need for repeat treatments.

Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment

BACKGROUND

Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI.

METHODS

A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions.

DISCUSSION

There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

Does response to percutaneous tibial nerve stimulation predict similar outcome to sacral nerve stimulation?

AIMS

Percutaneous tibial nerve stimulation (PTNS) is a simple neuromodulation technique to treat an overactive bladder. It is unclear whether the response to PTNS would suggest a similar response to sacral nerve stimulation (SNS), and whether PTNS could be utilized as an alternative test phase for an SNS implant. This study assessed whether PTNS response was a reliable indicator for subsequent SNS trials.

METHODS

We performed a retrospective review of the hospital databases to collect all patients who had PTNS and who subsequently had an SNS trial in two tertiary hospitals from 2014 to 2020. Response to both interventions was assessed. A 50% reduction in overactive symptoms (frequency-volume charts) was considered a positive response. McNemar's tests using exact binomial probability calculations were used. The statistical significance level was set to 0.05.

RESULTS

Twenty-three patients who had PTNS subsequently went on to a trial of SNS. All patients except one had previously poor response to PTNS treatment. Eight of them also failed the SNS trial. However, 15 patients (including the PTNS responder) had a successful SNS trial and proceeded with the second-stage battery implantation. The difference in response rates between the PTNS and SNS trial was statistically significant (p < 0.001).

CONCLUSIONS

Poor response to PTNS does not seem to predict the likelihood of patients responding to SNS. A negative PTNS trial should not preclude a trial of a sacral nerve implant. The predictive factors for good and poor responses will be the subject of a larger study.

285 ‘Smart Phrase’ Ward Rounds: Do They Improve Documentation and Efficiency?

Aim

Accurate ward round documentation plays a crucial role in patient management. In the last two years, UCLH has introduced EPIC software. This gives opportunity to create templates for repetitive processes (‘smart phrases’). The aim of this project was to assess if the introduction of ‘smart phrase’ templates can improve the quality of ward round documentation.

Method

Following consultation, 5 fundamental domains were agreed to be included in the template, namely: Procedure and postoperative day, current clinical issues, physical examination, objective assessment (including vital signs, fluid balance/drains, blood tests, DVT prophylaxis, antibiotic status), and 24h treatment plan. A baseline audit was performed, then the new template was introduced. Two PDSA cycles were performed, for 3 weeks after introduction, and repeated two months later. Chi-square tests was used to assess statistical significance of change (p&lt;0.05).

Results

A statistically significant improvement in documentation for all domains - apart from ‘current clinical issues’ and ‘24h planning', which were well documented to start - was observed after the introduction of smart phrases; with an average improvement of 34.8% (range 0–65.6%). The improvement was maintained at 2 months (improvement from baseline 35.1%, range 0–59%). A small decrement in documentation occurred between introduction and the 2-month PDSA assessments in some domains (mean change 0.7%, range -12.3 to 23%), although this was not statistically significant.

Conclusions

The introduction of smart phrases significantly improved ward round documentation of important parameters. Evolution of additional smart phrase is expected to further improve the accuracy leading to more efficient decisions and safer clinical practice.

What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review

PURPOSE

The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given.

MATERIALS AND METHODS

To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed.

RESULTS

Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL.

CONCLUSIONS

The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

European Association of Urology Guidelines on Urethral Stricture Disease (Part 2): Diagnosis, Perioperative Management, and Follow-up in Males

CONTEXT

Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice.

OBJECTIVE

To present a summary of the 2021 European Association of Urology (EAU) guidelines on diagnosis, classification, perioperative management, and follow-up of male urethral stricture disease.

EVIDENCE ACQUISITION

The panel performed a literature review on the topics covering a time frame between 2008 and 2018, and using predefined inclusion and exclusion criteria for the literature. Key papers beyond this time period could be included if panel consensus was reached. A strength rating for each recommendation was added based on a review of the available literature after panel discussion.

EVIDENCE SYNTHESIS

Routine diagnostic evaluation encompasses history, patient-reported outcome measures, examination, uroflowmetry, postvoid residual measurement, endoscopy, and urethrography. Ancillary techniques that provide a three-dimensional assessment and may demonstrate associated abnormalities include sonourethrography and magnetic resonance urethrogram, although these are not utilised routinely. The classification of strictures should include stricture location and calibre. Urethral rest after urethral manipulations is advised prior to offering urethroplasty. An assessment for urinary extravasation after urethroplasty is beneficial before catheter removal. The optimal time of catheterisation after urethrotomy is <72 h, but is unclear following urethroplasty and depends on various factors. Patients undergoing urethroplasty should be followed up for at least 1 yr. Objective and subjective outcomes should be assessed after urethral surgeries, including patient satisfaction and sexual function.

CONCLUSIONS

Accurate diagnosis and categorisation is important in determining management. Adequate perioperative care and follow-up is essential for achieving successful outcomes. The EAU guidelines provide relevant evidence-based recommendations to optimise patient work-up and follow-up.

PATIENT SUMMARY

Urethral strictures have to be assessed adequately before planning treatment. Before surgery, urethral rest and infection prevention are advised. After urethral surgery, x-ray dye tests are advised before removing catheters to ensure that healing has occurred. Routine follow-up is required, including patient-reported outcomes. These guidelines aim to guide doctors in the diagnosis, care, and follow-up of patients with urethral stricture.

European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease

OBJECTIVE

To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease.

EVIDENCE ACQUISITION

The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion.

EVIDENCE SYNTHESIS

Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques, and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.

CONCLUSIONS

Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations.

PATIENT SUMMARY

Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.

Prevalence of chronic pain following suburethral mesh sling implantation for post-prostatectomy incontinence

PURPOSE

To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation.

MATERIALS AND METHODS

A multi-center retrospective medical notes review of patients implanted for bothersome post-prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation.

RESULTS

One-hundred and twenty-seven men were reviewed over an 8-year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty-nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0-10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations.

CONCLUSION

Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year.

Can radiation-induced lower urinary tract disease be ameliorated in patients treated for pelvic organ cancer: ICI-RS 2019?

Aims

This article reviews the clinical outcomes and basic science related to negative effects of radiotherapy (RT) on the lower urinary tract (LUT) when used to treat pelvic malignancies.

Methods

The topic was discussed at the 2019 meeting of the International Consultation on Incontinence―Research Society during a “think tank” session and is summarized in the present article.

Results

RT is associated with adverse effects on the LUT, which may occur during treatment or which can develop over decades posttreatment. Here, we summarize the incidence and extent of clinical symptoms associated with several modes of delivery of RT. RT impact on normal tissues including urethra, bladder, and ureters is discussed, and the underlying biology is examined. We discuss innovative in vivo methodologies to mimic RT in the laboratory and their potential use in the elucidation of mechanisms underlying radiation‐associated pathophysiology. Finally, emerging questions that need to be addressed through further research are proposed.

Conclusions

We conclude that RT‐induced negative effects on the LUT represent a significant clinical problem. Although this has been reduced with improved methods of delivery to spare normal tissue, we need to (a) discover better approaches to protect normal tissue and (b) develop effective treatments to reverse radiation damage.

Treating Women with Recurrent Stress Urinary Incontinence: A Hornet's Nest Still Needing Proper Clinical Evidence

Evidence is lacking on the best treatment for women presenting with recurrent stress urinary incontinence. PURSUIT is a randomised trial of urethral bulking agent injection versus surgical intervention. It will provide high-quality evidence to aid counselling and inform choice.

Current Use of the Artificial Urinary Sphincter in Adult Females

PURPOSE OF REVIEW

The aim of the present report was to review the recent evidences regarding the use of artificial urinary sphincter (AUS) in adult females.

RECENT FINDINGS

While the excellent functional outcomes of AUS in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) have been reported for decades, its use has remained confidential in most countries likely due to its challenging implantation and inherent morbidity. Over the past few years, laparoscopic and, more recently, robotic techniques of AUS implantation in female patients have been described with promising perioperative outcomes. As a result, the use of AUS has increased in several countries. The indications are mostly recurrent or persistent SUI after previous anti-incontinence procedures and neurogenic SUI. Owing to its unique potential to restore continence while maintaining low outlet resistance during the voiding phase, AUS may be of special interest in female patients with detrusor underactivity. High level of evidence data from trials which are underway, along with developments in robotic surgery and technological refinements of the device, may well, almost 50 years after its introduction, give to the AUS its momentum as a major contributor in the female SUI armamentarium. While the use of AUS in female patients has been restricted to some countries and a few high-volume centers, it has started spreading again over the past few years, thanks to the rise of minimally invasive approaches which facilitate its implantation, and this is yielding promising outcomes.

Management of recurrent urinary tract infections in women

Urinary tract infections are highly prevalent and result in significant patient morbidity as well as large financial costs to healthcare systems. Recurrent urinary tract infections can be challenging for many healthcare professionals, and the repeated use of antibiotics in this patient cohort inevitably contributes to the growing issue of antimicrobial resistance and superbugs. It is essential that these patients are appropriately diagnosed and managed to ensure rapid resolution of symptoms and the prevention of chronic or recurrent urinary tract infections. There are several antibiotic-based options available for the prophylaxis of recurrent urinary tract infections however, in the current era of rising antimicrobial resistance, an awareness of antibiotic stewardship and the use of non-antibiotic alternatives for the treatment and prevention of urinary tract infections is of critical importance. We present a case-based multidisciplinary team discussion to highlight how women with recurrent urinary tract infections should be managed, encouraging the use of non-antibiotic prophylactic measures when suitable.

Level of evidence:

Level 5

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

How can we improve investigation, prevention and treatment for recurrent urinary tract infections - ICI-RS 2018

BACKGROUND

Recurrent urinary tract infection (rUTI) is a chronic condition and has a significant impact on health-related quality of life. The commonly used definition for rUTI is greater than three episodes in a year or more than two in 6 months. Current diagnostic methods have been used worldwide for over five decades, despite well evidenced criticism. Enhanced culture techniques demonstrate that the microbiome of the bladder is far more complex than previously thought and begs a reappraisal of our current testing. Treatment of rUTI is based on a small number of antibiotic trials with some evidence showing a reduction in the number of positive cultures, but one must be cautious in interpreting the results and weigh against the risk of generation of antimicrobial resistance (AMR).

AIM

The International Consultation on Incontinence-Research Society think tank reviewed the literature with a view to improving investigation, prevention and treatment of rUTI.

METHODS

A multidisciplinary team of experts were invited to present evidence regarding the current diagnostic methods, recent advances related to bladder biome mapping and current treatment strategies, including antibiotic and nonantibiotic options. Current guidelines regarding antibiotic stewardship and concerns regarding AMR were discussed.

DISCUSSION

Outcome of the think tank discussions are summarised with a set of recommendations to inform future research. Particular consideration is given to bacterial survival in the bladder after treatment as well as defects in urothelial barrier function which may play a significant part in the failure to eradicate UTI.

Treatment validation of the Solomon-Greenwell nomogram for female bladder outlet obstruction

AIM

Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention.

METHODS

The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up.

RESULTS

The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH₂ O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred.

CONCLUSIONS

All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.

Do we have adequate data to construct a valid algorithm for management of synthetic midurethral sling complications? ICI-RS 2019

BACKGROUND

Synthetic midurethral sling (MUS) procedures, purported for the last two decades as the gold standard surgical treatment for stress urinary incontinence, have been in creasingly scrutinized in recent years with regard to the rate and severity of complications.

METHODS

During the International Consultation on Incontinence Research Society meeting held in Bristol, UK, in 2019, a multidisciplinary panel held a think tank and discussed the contemporary evidence pertaining to the classification, investigation, and treatment of MUS complications.

RESULTS

The current classification system of mesh-related complications was discussed, and shortcomings were identified. The lack of a standardized clinical pathway was noted, and the value of clinical investigations and surgical treatments was difficult to fully evaluate. The paucity of high-level evidence was a common factor in all discussions, and the difficulties with setting up relevant randomized-controlled trials were highlighted.

CONCLUSIONS

The outcome of the think-tank discussions is summarized with a set of recommendations designed to stimulate future research.

Surgical outcomes of vesicovaginal fistulae in patients with previous pelvic radiotherapy

INTRODUCTION AND HYPOTHESIS

Vesicovaginal fistulae (VVF) repair success rates for simple surgical fistulae are high, but constitute a significantly greater challenge when occurring in a radiotherapy field. We aim to evaluate the causes, assessment, closure rates and functional outcomes of VVF surgery in patients with previous radiotherapy.

METHODS

Data on all VVF repairs were collected prospectively. A retrospective review of outcomes in those with VVF performed between 2009 and 2018 was carried out. Details including time from radiotherapy, pre-operative assessments, approach to surgery and functional outcome were analysed.

RESULTS

Twenty women with VVFs were identified. The mean age was 59 (range 25-88) years. Primary malignancy was cervical in 16 women, with the remaining 4 women having ovarian, urethral, endometrial and rectal cancer respectively. All women had external beam radiotherapy with 6 (30%) undergoing boosted brachytherapy. Mean interval between radiotherapy and fistula repair was 19 (range 0-40) years. Fistulae arose spontaneously in 14 patients, whereas 6 occurred following a further surgical intervention.Closure was attempted vaginally in 7 women and abdominally in 1, whereas 12 had a primary diversion owing to significant bladder contracture and ureteric involvement. The closure rate in those attempted was 62.5%, 40% in those with spontaneous fistulae compared with 100% for post-surgical fistulae, but only 20% for the total cohort.

CONCLUSIONS

Closure of VVF is a significant challenge, with an initial success rate of 20% and an overall success rate of only 25%. Seventy percent required primary or secondary urinary diversion. Vaginal surgery was utilised in the majority to try to avoid a hostile pelvis, but the surgical approach should be tailored to individual circumstances.

Can multicentre urodynamic studies provide high quality evidence for the clinical effectiveness of urodynamics? ICI-RS 2019

Aims

Lower urinary tract (LUT) function can be investigated by urodynamic studies (UDS) to establish underlying functional abnormalities in the LUT. A multicentre registry could present an opportunity to improve the scientific evidence base for UDS. During the International Consultation on Incontinence Research Society (ICI‐RS) meeting in Bristol, United Kingdom 2019, an expert panel discussed the potential of a multicentre urodynamic registry to improve the quality of urodynamic output.

Methods

the potential importance of a multicentre urodynamic registry, parameter inclusion, quality control, and pitfalls during a registry roll‐out were reviewed and discussed.

Results and Conclusions

The clinical utility, evaluation, and effectiveness of UDS remain poorly defined due to a lack of high quality evidence and large study populations. Therefore, the ICI‐RS proposes formation of a urodynamic panel for future roll‐out of a registry. The inclusion of basic parameters was discussed and the essential parameters were defined as well as the potential pitfalls of a registry roll‐out. The discussion and recommendations in this paper form the base for future urodynamic registry development.

Bulking for stress urinary incontinence in men: A systematic review

AIMS

An updated literature review on outcomes in men treated with currently commercially available bulking agents was performed to determine whether this is a reasonable option in selected patients.

METHODS

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework of systematic reviews. A comprehensive search of PubMed, Medline, and Embase was undertaken. Abstracts were independently screened by two investigators to include men with stress urinary incontinence treated with a peri-urethral injection of bulking agents currently available in the market.

RESULTS

Only eight original articles met the inclusion criteria. The bulking agents used were Macroplastique in five studies (total 123 patients), Opsys, Durasphere, and Urolastic in one study each (10, 7, and 2 patients, respectively). Only one study was randomized; Macroplastique vs AUS in men with mild or total incontinence. The included populations were heterogeneous and encompassed endoscopic, perineal, abdominal and laparoscopic prostate surgery as well as spinal cord injuries and urethral sphincter insufficiency. Significant dissimilarity was evident for the duration of incontinence (9-108 months), mean volume of bulking agent used (2.3-13.5 mL), number of cushions (1-5), depth and position of the cushions. The outcomes varied significantly, with reported dry rates between 0% and 83%. Outcomes were limited by relatively short follow-up in most studies.

CONCLUSION

Following initial enthusiasm and then dismay with collagen-based compounds, sparse and heterogeneous literature data were produced on newer non-migrating and nonabsorbable bulking agents. Some studies have suggested encouraging, if short term outcomes, however, future studies are needed in this field to support recommendations for widespread use.

The cost effectiveness of vaginal versus abdominal repair of vesicovaginal fistulae

Introduction and hypothesis

The objective was to assess the comparative provider costs of vaginal and open abdominal repair of vesicovaginal fistula (VVF) and to determine the most cost-effective means of managing VVF.

Methods

A prospectively acquired database of all women undergoing VVF repair by a single surgeon between 2007 and 2015 was retrospectively reviewed to determine operating time, perioperative complications, inpatient stay and 30-day readmissions. The success and cost of the VVF repair were identified. Statistical analysis was by unpaired t test, Chi-squared test and Mann–Whitney U test.

Results

Forty-seven consecutive women of mean age 51 years (range 21–88) undergoing a first attempt at VVF repair at our institution were included; 32(68%) had vaginal repair with Martius fat pad interposition and 15 (32%) had open abdominal repair with omental interposition. There were no perioperative complications or 30-day readmissions in either group. Mean operative time was longer for open abdominal (223.4 min) than vaginal repair (196.9 min). Median inpatient stay was longer for an open abdominal (8 days) than for a vaginal approach (4 days). Successful anatomical closure was achieved in 91% of vaginal and 86% of open abdominal repairs at first attempt, and in 100% after second repair, where required. Mean/median costs for an abdominal repair were significantly higher, at £4,608.69/£4,169.20 than for vaginal repair at £3,381.50/£3,009.24 (P<0.05).

Conclusions

Vesicovaginal fistulae were successfully repaired in 89% of cases at first attempt. The success rate did not differ between approaches. Vaginal repair is significantly more cost-effective than abdominal repair owing to the shorter operative time and length of stay.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center

OBJECTIVES

To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula.

METHODS

We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted.

RESULTS

Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion.

CONCLUSIONS

Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

Diagnosis and surgical outcomes of ectopic ureters in adults: A case series and literature review

OBJECTIVES

To evaluate functional outcomes of surgery in patients with ectopic ureters diagnosed in adulthood; to review the world literature.

PATIENTS AND METHODS

Patients were referred over 10 years. Data including surgical history, presenting symptoms, diagnostic modalities, interventions and functional outcomes were collected; and the world literature reviewed.

RESULTS

9 women and 1 man had a mean age of 37 (range 20-58). All women were referred with lifelong leakage. The man was referred with storage LUTS. Three women had heminephrectomy/nephrectomy with the distal ureter left in-situ prior to referral. MRI was the predominant diagnostic tool but often took senior review to confirm the diagnosis. Excision of the ectopic ureter was performed with bladder neck reconstruction in 6 women, with concomitant rectus fascial sling in one patient. 4 of 6 (67%) women were cured of their stress incontinence with the bladder neck reconstruction alone, whilst two required further intervention. Three women had nephroureterectomy alone as primary treatment of which two were cured. The single male had heminephrectomy and excision of seminal vesicle.

CONCLUSIONS

Ectopic ureter is a rare diagnosis in adults but should be considered in patients who describe lifelong incontinence. Fine slice MRI is the imaging of choice. Excision of the ureter with bladder neck reconstruction alone was successful in two-thirds of patients, whilst further stress urinary incontinence surgery was required in one-third. Malignancy in ureteric remnants is described in 8% of the world literature. Patients should be counselled of this risk if the ureter is left in-situ.

The autologous rectus fascia sheath sacrocolpopexy and sacrohysteropexy, a mesh free alternative in patients with recurrent uterine and vault prolapse: A contemporary series and literature review

Introduction:

About 40% of women suffer pelvic organ prolapse (POP) in a lifetime. The current standard intervention for vault prolapse is a mesh sacrocolpopexy or sacrohysteropexy. However, patients and surgeons are increasingly hesitant to use mesh given recent the UK and Food and Drug Administration warnings and litigation. A possible alternative is to use autologous tissue to support the vault, as a mesh-free solution. We report the outcomes from an initial series of autologous rectus fascia sheath (RFS) sacrocolpopexy and sacrohysteropexy in patients with complex pelvic floor dysfunction.

Patients and Methods:

All patients had previous, multiple urological/gynecological surgery and declined standard mesh repairs. All had preoperative videourodynamics and defecating magnetic resonance imaging evaluation. The autologous POP repair was performed using 10–18 cm of rectus sheath with a similar technique to that employing mesh to support the anterior-posterior vaginal walls or encircle the cervix and secured to the sacral promontory.

Results:

Seven patients with a mean age of 52 (33–64) years underwent autologous RFS POP repair between 2014 and 2017. Mean follow-up is 16 (range 2–33) months. All patients have durable result at last follow-up. No significant complications are reported.

Conclusions:

This is the first report of patients with complex pelvic floor dysfunction and apical POP being managed with autologous RFS sacrocolpopexy/sacrohysteropexy, and only the second report of a free graft being utilized with success. Autologous RFS sacrocolpopexy/sacrohysteropexy avoids the 10%–15% risks of mesh-related complications. Further studies of long-term durability are needed.

Penile urethral stricture disease

Patients affected by a urethral stricture account for a considerable cost to all healthcare systems. The estimated prevalence of all urethral stricture in the UK is 10/100,000 men during youth, increasing to about 40/100,000 by age 65 years and to more than 100/100,000 thereafter. A penile urethral stricture is a narrowing of the lumen of the urethra due to ischaemic fibrosis of the urethral epithelium and/or spongiofibrosis of the corpus spongiosum occurring within the penile urethra. Its aetiology is largely idiopathic but other important causes are failed hypospadias repair and lichen sclerosus, which account for 60% of all cases. Strictures of the anterior urethra account for 92% of cases: bulbar strictures are more frequent (46.9%), followed by penile (30.5%) and combined bulbar/penile (9.9%), that is, 40.4% of all men presenting with stricture will have a penile urethral stricture alone or in combination with a bulbar urethral stricture. There are several options for the treatment of penile urethral strictures ranging from less invasive treatments, including urethral dilatation and direct vision internal urethrotomy, to more complex augmentation graft and flap urethroplasty. The aim of the present review is to describe the aetiology and epidemiology of anterior urethral strictures and the available options reported in literature for their treatment.

Level of evidence: 1a

The anatomy and an illustrated description of a technique for combined laparoscopic and vaginal total removal of an obturator mid urethral tape

To date complete excision of a mid-urethral obturator tape has required vaginal and groin exploration—a morbid procedure. We detail the theoretical anatomy and describe the operative technique for the first ever combined laparoscopic and vaginal complete excision of mid-urethral obturator tape. This procedure was successfully performed in a 65-year-old female along with simultaneous laparoscopic redo colposuspension with complete removal of mid-urethral obturator tape and successful resolution of all symptoms including stress urinary incontinence. It is possible for an experienced laparoscopic and vaginal surgeon working in tandem to completely remove a mid-urethral obturator tape without the need for groin dissection. This is the first description of this technique.

Results of the British Association of Urological Surgeons female stress urinary incontinence procedures outcomes audit 2014-2017

OBJECTIVES

To analyse the results of the stress urinary incontinence (SUI) audit conducted by the British Association of Urological Surgeons (BAUS), and to present UK urologists' contemporary management of SUI.

PATIENTS AND METHODS

The BAUS audit tool is an online resource, to which all UK urologists performing procedures for SUI are invited to submit data. The data entries for procedures performed during 2014-2016 were collated and analysed.

RESULTS

Over the 3-year period analysed, 2917 procedures were reported by 109 surgeons, with a median of 20 procedures reported per surgeon. A total of 2 366 procedures (81.1%) were recorded as a primary surgery, with 548 procedures (18.8%) performed for recurrent SUI. Within the time period analysed, changes were noted in the frequency of all procedures performed, with a trend towards a reduction in the use of synthetic mid-urethral tapes, and a commensurate increase in the use of urethral bulking agents and autologous fascial slings. A total of 107 (3.9% of patients) peri-operative complications were recorded, with no association identified with patient age, BMI or surgeon volume. Follow-up data were available on 1832 patients (62.8%) at a median of 100 days postoperatively. Reduced pad use was reported in 1311 of patients (84.5%) with follow-up data available and 86.3% reported a pad use of one or less per day. In all, 375 patients (85%) reported being satisfied or very satisfied with the outcome of their procedure at follow-up, although data entry for this domain was poor. De novo overactive bladder (OAB) symptoms were reported by 15.2% of patients (263/1727), and this was the most commonly reported postoperative complication. For those reporting pre-existing OAB prior to their SUI surgery, 28.7% (307/1069) of patients reported they got better after their procedure, whilst 61.9% (662/1069) of patients reported no change and 9.4% of patients (100/1 069) got worse.

CONCLUSIONS

This review identified that, despite urological surgeons undertaking a relatively low volume of procedures per year, SUI surgery by UK urologists is associated with excellent short-term surgeon- and patient-reported outcomes and low numbers of low grade complications. Complications do not appear to be associated with surgeon volume, nor do they appear higher in those undergoing mesh surgery. Shortfalls in data collection have been identified, and a longer follow-up period is required to comment adequately on long-term complications, such as chronic pain and tape extrusion/erosion rates.

Vesico-vaginal fistulae in the resource-limited setting: current status and the challenges that lie ahead, all you need to know for those practicing in a well-resourced setting

In this review we examine the incidence, aetiology, pathology and classification of vesico vaginal fistulae (VVF) in the resource poor setting. We compare the diagnosis, management and outcomes of VVF repair in resource-poor countries to current practice in the well-resourced setting, finally looking ahead to the future and the changes we need to make on a global scale in order to prevent this debilitating condition.

There is a clear need for more accurate data collection and classification systems appropriate to the setting. Lack of facilities such as radiology limit diagnostic capabilities and options for repair, however outcome data from resource poor countries is promising. Most importantly, a holistic approach, which examines not just the physical aspects of the condition but the social and cultural factors predisposing women to VVF, needs to be adopted when considering prevention and management of this injury.

Level of evidence: Not applicable as this is a review article.

Does videourodynamic classification depend on patient positioning in patients with stress urinary incontinence?

INTRODUCTION AND AIMS

Videocystometrogram (VCMG) is used to assess patients with SUI. A common classification system of SUI is the Blaivas and Olsson classification. The position this grading is performed in has never been established.

MATERIALS AND METHODS

One hundred twenty-one women complaining of SUI refractory to conservative measures had video-urodynamic assessment prior to operative intervention. Grading of stored video SUI image traces was assessed as per Blaivas and Olsson criteria by two independent investigators whilst women were both lying and standing with bladder at maximum cystometric capacity.

RESULTS

Seventy-two (56.7%) patients' grading remained the same in both lying and standing positions. 49(40.5%) patients' grading altered on standing. twenty had non-demonstrable incontinence converted to demonstrable incontinence and 29 had demonstrable incontinence on lying that changed grading on standing; 22 of these by one grade and seven by two grades (from I to IIb). A Fisher's exact test demonstrated a statistically significant difference in the distribution of SUI grading between supine and standing positions (P < 0.01).

CONCLUSION

40.5% of women have a changed Blaivas and Olsson grade of SUI when assessed standing as opposed to lying. This has implications for surgical treatment options and patient counselling. While the Blaivas and Olsson grading system for SUI is simple and reproducible there is little standardisation as to which position this grading is to be performed. We recommend that an international consensus is agreed upon in order for results to be comparable and to help with future outcome studies.

Urethral diverticulum carcinoma in females-a case series and review of the English and Japanese literature

The aims of our study were to describe our case series of three urethral diverticulum carcinomas (UDC) in women and to review the literature on UDC in females to determine patient characteristics, presenting symptoms and outcomes along with optimal investigations and treatment modalities. A literature search was performed utilizing Medline, EMBASE and the Cochrane library for all papers including case reports on UDC in women published to date. The results along with those of our three cases are detailed. A total of 126 cases of UDC in women have been reported; 75% adenocarcinoma (Adenoca), 15% transitional cell carcinoma (TCC) and 10% squamous cell carcinoma (SCC). Median age at presentation was 53 years (range, 14-81 years). The commonest presenting symptoms were bleeding and retention. Cystoscopy, MRI and trans-urethral biopsy were the commonest methods of diagnosis. Treatment was radiotherapy +/- chemotherapy alone in 21%, local excision +/- radiotherapy in 44%, urethrectomy in 3% and anterior exenteration +/- radiotherapy in 32%. At last follow-up 63% were alive and well, 10% were alive with recurrent cancer and 25% had died from their disease. UDC is rare in women. It is predominantly adenocarcinoma. There is no established treatment and survival is at best moderate. An international registry and consensus on management is needed if this is to be improved.

Predicting a successful outcome in sacral neuromodulation testing: Are urodynamic parameters prognostic?

AIMS

To assess whether the urodynamic parameters of mean voided volume, peak detrusor overactivity (DO) pressure, bladder compliance, capacity, and volume at first detrusor overactivity during filling cystometry can predict a successful outcome at first stage tined lead placement (FSTLP).

METHODS

Ninty-nine consecutive patients with urodynamically proven idiopathic detrusor overactivity (IDO) refractory to medical treatment and opting for Sacral Nerve Stimulation (SNS), were assessed pre and post FSTLP. Data from 3-day frequency-volume charts, and patient reported (subjective) outcomes were used to assess success or failure after FSTLP. Success was defined as improvement in symptoms >50%. Binary logistic regression analysis was used to ascertain whether key parameters at filling cystometrogram were predictors for success prior to FSTLP.

RESULTS

Binary logistic regression analysis did not demonstrate any significant relationship between the five parameters at urodynamics and outcome at FSTLP (B < 0.01, P > 0.16) for all parameters.

CONCLUSIONS

The results from this prospective analysis on patients with IDO refractive to medical therapy referred for SNS would suggest that aside from proving DO at urodynamics as a pre-requisite for intervention as per NICE and EAU guidelines, no parameter is predictive for a successful outcome at FSTLP.

How and why to take a Martius labial interposition flap in female urology

The Martius modified labial fat pad flap at nearly 90 years old is still very much part of the modern vaginal surgeon’s armamentarium. Here we describe this straightforward and adaptable technique, the avoidance of pitfalls, its advantages and uses in vaginal surgery, and outcomes both short and long term. Specifically patient reported outcomes related to scar perception and sexual function are explored.