Valsalva Voiding Research Articles

Do urodynamics predict urinary retention after sling placement in the complex patient: the value of reproducing symptoms on urodynamics.

To examine urinary retention (UR) after female urethral sling placement in patients with or without detrusor underactivity (DU) or Valsalva voiding whose urodynamics (UDS) accurately reproduced voiding symptoms to determine whether the reproduction of voiding symptoms on UDS in those with DU is predictive of UR after sling placement. We performed a review of patients undergoing urethral sling procedures for stress urinary incontinence (SUI) looking specifically at the occurrence of short- and long-term urinary retention. Preoperative UDS data were obtained from a prospectively acquired UDS database in which patients were directly queried at the time of the UDS study about whether the filling and/or storage phase of the study reproduced their usual symptoms. Of the 141 women who had a urethral sling procedure, 124 (87.9%) had preoperative UDS. Of those who had UDS, 41 (33%) had de novo UR at some point postoperatively. Compared to those without DU, patients with DU and/or Valsalva voiding were more likely to have UR (75.6% vs. 56.6%, p = 0.04). There was no difference in association of UR in patients with DU/Valsalva voiding whose UDS reproduced voiding symptoms compared to those with DU/Valsalva voiding whose UDS did not reproduce symptoms (OR 1.01, CI 0.32-3.19, p 0.98). This study found that patients with DU/Valsalva voiding had an increased association with UR but did not find reproduction of symptoms on UDS to correlate with UR in either those with DU/Valsalva voiding or with normal bladder contractility.

882 - Risk of prolapse and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor using clean intermittent catheterization versus Valsalva voiding

882 - Risk of prolapse and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor using clean intermittent catheterization versus Valsalva voiding

Risk of prolapse and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor using clean intermittent catheterization versus Valsalva voiding.

To assess the relative risks of pelvic organ prolapse (POP) and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor voiding with Valsalva versus those using clean-intermittent catheterization (CIC). We conducted a retrospective analysis including all spina bifida patients with neurogenic acontractile detrusor with a minimum follow-up of 12 months. Patients were then divided in two groups according to their bladder management: voiding with Valsalva versus CIC. The primary endpoint was any de novo or worsened rectal and/or pelvic organ prolapse (POP) diagnosed during follow-up. The secondary outcome was urinary complications defined as febrile urinary tract infections (UTI) and/or urolithiasis and/or renal failure. Fifty-five patients (50.9% were males) met the inclusion/exclusion criteria: 28 voiding with Valsalva and 27 performing CIC. At baseline, the rates of vaginal prolapse (44.4% vs 50%; P = 0.99), and rectal prolapse/intussusception (25.9% vs 21.4%; P = 0.76) were similar in both groups. After a median follow-up of 80.6 and 65.6 months, respectively (P = 0.29), the rate of de novo or worsened rectal prolapse/intussusception was higher in the Valsalva voiding group than in the CIC group (32.1% vs 3.7%; P = 0.01). De novo or worsened vaginal prolapses were also more common in the Valsalva voiding group, but it did not reach statistical significance (33.3% vs 11.1%; P = 0.29). Valsalva voiding might be harmful in adult spina bifida patients with neurogenic acontractile detrusor as it may increase the risk of rectal prolapse/intussusception. Overall, the prevalence of POP and rectal prolapse was high in both groups.

Incidence of successful voiding and predictors of early voiding dysfunction after retropubic sling.

There is a paucity of literature on resumption of normal voiding predictors after synthetic retropubic sling insertion and lack of a standardized method of determination. Our goals were to determine the incidence of a successful voiding trial; whether clinical, operative, or urodynamic variables predict discharge with a catheter; and incidence of later retention in those who were initially successful. We performed an internal-review-board (IRB)-approved retrospective chart review of 229 consecutive patients who underwent retropubic sling (TVT, Boston Scientific, Natick, MA, USA)) from 2001 to 2010. Exclusions were concomitant surgery or cystotomy at the time of retropubic sling insertion. All participants underwent a voiding trial in recovery consisting of 300cc sterile-water retrograde fill and were discharged home without a catheter after single void of at least 200cc following catheter removal. Of 170 patients, 136 (80%) passed the voiding trial the same day, with 165 (97%) passing within 1day. Factors associated with delayed voiding were age ≥65years (p < 0.05), presence of Valsalva voiding (p < 0.01), lower body mass index (BMI) (p < 0.05), and higher gravidity (p < 0.05) and parity (p < 0.01). Age ≥65years [adjusted odds ratio (aOR) 3.72, 95% confidence interval (CI) 1.40-9.90, p < 0.01] and Valsalva voiding (aOR 3.89, 95% CI 1.56-9.69, p < 0.01) remained significant independent predictors in multivariate analysis. The majority of patients with retropubic sling can be safely discharged home the same day without a catheter after retrograde fill. Women >65years or Valsalva voiders had nearly four times the odds of being discharged with a catheter. Most patients resume normal voiding within 24h after retropubic sling insertion, but >65years and Valsalva voiding are risk factors for voiding inability at discharge.

Safety and Efficacy of Retropubic Mid-urethral Sling Placement in Women Who Void With Valsalva

To compare outcomes after retropubic sling (RPS) in women with and without Valsalva voiding. Women who underwent RPS for stress incontinence from 2010 to 2014 were identified and their baseline characteristics were examined. Valsalva voiding was defined as abdominal straining throughout voiding on preoperative urodynamics. Sub-analysis of those with Valsalva included a subset with detrusor underactivity on urodynamics. Follow-up was at 1, 3, 6, and 12 months. Primary outcomes were rates of subjective success, revisions, complications, and voiding dysfunction. Secondary measures were Urogenital Distress Inventory (UDI-6) score, Incontinence Impact Questionnaire (IIQ-7) score, post-void residual, and pad use. Subjects (n = 141) analyzed included 75 Valsalva voiders (VV) and 66 non-Valsalva voiders. At baseline, there were no differences in age, race, comorbidity, post-void residual, pad use, UDI-6, or capacity. Postoperatively, there were no differences in rates of passing initial void trial, need for clean intermittent catheterization, revisions, complications, or voiding dysfunction. No differences in pad use, UDI-6, or IIQ-7 were seen at 6 or 12 months. Within VV, no differences between patients with and without detrusor underactivity were seen for any primary or secondary outcomes (all P > .05). In patients who void with Valsalva, RPS appears to be safe and effective. Between VV and non-Valsalva voiders, there were no differences in rates of subjective success, revisions, or complications, even in patients with Valsalva voiding without appreciable detrusor contraction.

Urodynamics for incontinence after midurethral sling removal.

We reviewed the role of urodynamics (UDS) in the management of women with incontinence following mid-urethral sling removal (MUSR). Following IRB approval, women from a longitudinal database who had persistent or recurrent urinary incontinence (UI) after MUSR, desired further therapy, and subsequently underwent UDS were reviewed. Women with neurogenic bladder, obstructive symptoms without UI, urethra-vaginal fistula, anterior compartment prolapse >Stage 2, or those who had concomitant autologous sling surgery at the time of MUSR were excluded. Interval time between MUSR and UDS, UDS findings, and UI management after UDS were recorded. From 2006 to 2013, 71 of 246 women had UDS after MUSR for persistent or recurrent UI. For the 54 women in the final analysis, mean time between tape removal and UDS was 12.4 months (range: 4-65). UDS demonstrated incontinence in 78% of patients: stress urinary incontinence (SUI) in 19 (35%), detrusor overactivity incontinence (DOI) in 6 (11%), and mixed urinary incontinence (MUI) in 17 (32%). On pressure-flow studies, the following voiding patterns were demonstrated: normal voiding (39), valsalva voiding (6), obstruction (2), underactive detrusor (1), no voiding records (6). UDS storage and emptying data were used in subsequent symptom-based patient counseling for treatment planning. Urethral bulking agent was the most commonly chosen management (43%). Our current guidelines for UDS in women after incontinence procedures and MUSR are currently based on a low level of evidence. This study reinforces the role of UDS to guide therapy for UI after MUSR. Neurourol. Urodynam. 35:939-943, 2016. © 2015 Wiley Periodicals, Inc.

MP15-10 VALSALVA VOIDING DISTINGUISHES SLOW URINARY FLOW CAUSED BY ANTERIOR URETHRAL STRICTURES FROM PROSTATIC OBSTRUCTION

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) I1 Apr 2015MP15-10 VALSALVA VOIDING DISTINGUISHES SLOW URINARY FLOW CAUSED BY ANTERIOR URETHRAL STRICTURES FROM PROSTATIC OBSTRUCTION Rajveer Purohit, Matthew Benedon, Gabriel Mekel, James Weinberger, Johnson Tsui, and Jerry Blaivas Rajveer PurohitRajveer Purohit More articles by this author , Matthew BenedonMatthew Benedon More articles by this author , Gabriel MekelGabriel Mekel More articles by this author , James WeinbergerJames Weinberger More articles by this author , Johnson TsuiJohnson Tsui More articles by this author , and Jerry BlaivasJerry Blaivas More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.893AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It is difficult to distinguish decreased uroflow in patients who may have anterior urethral strictures (US) from prostatic obstruction (PO) such as older patients who may have undergone a urethroplasty. We hypothesize that in patients with US, Valsalva Voiding (VV) will significantly increase maximum urinary flow rate (Qmax) and will not do so in patients with PO. METHODS A prospective IRB-approved study of men seen at a tertiary care urology clinic was conducted. Subjects were divided into three groups based on clinical and cystoscopic information: group 1 (US), group 2 (PO), and a control group (group 3) with no obstruction. Each subject voided twice without intervention; once with NVV and once with VV. Qmax, voided volume, and PVR were recorded. Patients with voided volumes less than 150ml on either VV or NVV were excluded. In each patient, the difference in Qmax between VV and NVV was compared. In addition, the Siroky nomogram was used to compare normalized bladder volumes with a difference of greater than 1 standard deviation considered a significant increase in flow. A student T-test was used to assess statistical difference. RESULTS 113 individuals were evaluated. 26 were excluded due to voided volume < 150 ml. Mean age was 54 years (range 23–83). Table 1 depicts changes in Qmax between VV & NVV for each group. P values compare differences between VV and NVV. CONCLUSIONS These data suggest that change in Qmax with VV is a useful non-invasive test to distinguish PO from US. Patients with prostatic obstruction do not have any increase in Qmax with VV whereas those with US have slight increases and normal unobstructed individuals have large increases. Change in Qmax between Valsalva Voids and Non-Valsalva Voids Among Each Group Number of Patients Mean Change in Qmax Median Change in Qmax Standard Deviation P-value Urethral Stricture (Group 1) 23 5.04 5 6.75 0.03 Prostatic Obstruction (Group 2) 29 1.66 1 4.79 0.47 Unobstructed (Group 3) 35 7.69 9 8.51 0.01 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e162-e163 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rajveer Purohit More articles by this author Matthew Benedon More articles by this author Gabriel Mekel More articles by this author James Weinberger More articles by this author Johnson Tsui More articles by this author Jerry Blaivas More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

PI-05 IS RETROPUBIC MID-URETHRAL SLING SAFE AND EFFECTIVE FOR PATIENTS WITH VALSALVA VOIDING?

You have accessJournal of UrologyPlenary Session I - Best Abstracts1 Apr 2015PI-05 IS RETROPUBIC MID-URETHRAL SLING SAFE AND EFFECTIVE FOR PATIENTS WITH VALSALVA VOIDING? Blake Anderson, Joseph Pariser, Shane Pearce, Gregory Bales, and Doreen Chung Blake AndersonBlake Anderson More articles by this author , Joseph PariserJoseph Pariser More articles by this author , Shane PearceShane Pearce More articles by this author , Gregory BalesGregory Bales More articles by this author , and Doreen ChungDoreen Chung More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2933AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Due to the potential risk of voiding dysfunction after retropubic sling (RPS), there is concern regarding its use in women who void with Valsalva. The aim of this study was to compare outcomes after RPS in women with and without Valsalva voiding (VV). METHODS 141 women underwent RPS for stress incontinence from 2011-2014. Baseline demographics, urodynamics (UDS), operative and follow-up data were examined. VV was defined as abdominal straining throughout voiding on UDS. Analysis of those with VV included a subset with detrusor underactivity (DU) on UDS who had detrusor pressure <10 cm H2O or <20 sec contraction. Follow-up was at 1, 3, 6 and 12 months. Primary outcomes were subjective success rate (absence of stress incontinence with activity, coughing or sneezing), revision rate and complication (perioperative and 90-day) rate. Secondary measures were Urogenital Distress Inventory (UDI-6) score, Incontinence Impact Questionnaire (IIQ-7) score, post-void residual (PVR) and pad use. Tests of significance were Fisher's exact and t-tests. RESULTS Subjects included 75 Valsalva voiders (V) and 66 non-Valsalva voiders (N). At baseline, no differences were seen in age, race, comorbidity, PVR, pad use, UDI-6 or capacity. V had lower IIQ-7 (9.5 ± 6.6 vs. 12.6 ± 6.7, p=0.01) and more DU (23% vs. 5%, p<0.01) compared to N. No differences were seen in rates of passing initial void trial, clean intermittent catheterization, revisions, complications or voiding dysfunction. Revisions were for pain (1 V, 1 N), erosion (1 V, 4 N), voiding dysfunction (2 V, 3 N), sling migration (1 V) and sling failure (2 V, 1 N). Subjective success was similar out to 12 months (96% V vs. 92% N, p=0.6). At 6 and 12 months, there were no differences in pad use, UDI-6 or IIQ-7. For patients in V with and without DU, no differences were seen in rates of success, revisions, complications, voiding dysfunction or changes in UDI-6, IIQ-7, PVR or pad use. For V with DU, complications were 1 UTI, 1 asthma exacerbation, 1 voiding dysfunction and 1 pain. For V without DU, complications were 2 small cystotomies and 3 voiding dysfunctions. CONCLUSIONS In patients with VV, RPS appears to be safe and effective. Between V and N, no differences were seen in rates of subjective success, revisions, or complications, even for the subset of patients with VV and without appreciable detrusor contraction. Perioperative Outcomes, Complications and Revisions Parameter Non-Valsalva Voiders (N) Valsalva Voiders (V) p value Valsalva (-) DU Valsalva (+) DU p value n (%) 75 (53%) 66 (47%) 58 (77%) 17 (23%) Failed Initial Voiding Trial (%) 30 (45%) 29 (37%) 0.392 21 (36%) 7 (41%) 0.779 Catheter Time (days) 3.5 ± 3.1 2.9 ± 3.3 0.244 3.0 ± 3.4 2.4 ± 2.9 0.508 Clean Intermittent Catheterization Rate (%) 7 (11%) 7 (9%) ∼1.000 6 (10%) 1 (6%) ∼1.000 Revision Rate (%) 9 (14%) 7 (11%) 0.440 6 (12%) 1 (7%) ∼1.000 Complication Rate (%) 10 (15%) 9 (12%) 0.630 5 (9%) 4 (25%) 0.095 Clavien Grade (%) 0.062 0.074 1 4 (6%) 4 (5%) 3 (5%) 1 (6%) 2 1 (2%) 4 (5%) 1 (2%) 3 (18%) 3 5 (8%) 0 (0%) 0 (0%) 0 (0%) 4 0 (0%) 1 (1%) 1 (2%) 0 (0%) Voiding Dysfunction (%) 2 (3%) 4 (5%) 0.685 3 (5%) 1 (6%) ∼1.000 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e720 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Blake Anderson More articles by this author Joseph Pariser More articles by this author Shane Pearce More articles by this author Gregory Bales More articles by this author Doreen Chung More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Association of Urinary Nerve Growth Factor Levels With Bladder Outlet Obstruction in Women

Nerve growth factor (NGF) has been proposed as a urinary biomarker and previously shown to be elevated in male patients with bladder outlet obstruction (BOO) and other lower urinary tract symptoms. No published studies have examined NGF as a potential urinary biomarker in women with BOO. The aims of this prospective study were to evaluate NGF levels in urine from women with anatomic BOO resulting from pelvic organ prolapse (POP) and/or previous incontinence surgery and to measure the effect associated with surgical or conservative management. From January to September 2012, all female patients referred for evaluation and management of BOO from POP or previous incontinence surgery were screened for enrollment. Inclusion criteria included elevated postvoid residual, valsalva voiding on urodynamics, or urinary peak flow (Qmax) of 12 mL/s or less. A control group of 10 asymptomatic age-matched female volunteers was also recruited. In all subjects, urinary NGF and creatinine (Cr) levels were measured and normalized to the urinary Cr concentrations (NGF/Cr). Urinary NGF levels were measured at 1 month and 3 months after either surgical correction or initiation of clean intermittent catheterization. A total of 10 female patients with anatomic BOO (mean [SD] age of 66.2 [3.88] years) and 10 female control subjects (mean [SD] age of 62 [7] years) were recruited. Nine patients had POP. Six patients had undergone a previous anti-incontinence procedure. Five patients had both POP and undergone a previous anti-incontinence procedure. The urinary NGF/Cr levels in the study patients with BOO (mean [SE] 20.8 [4.31] pg/mg) were significantly higher (P = 0.0001) than the levels in the age-matched control group (5.6 [0.65] pg/mg). After treatment, the urinary NGF/Cr level significantly decreased to 6.50 (0.57) pg/mg (P = 0.01) CONCLUSIONS: In this study, female patients with anatomic BOO resulting from POP and/or previous incontinence surgery had significantly higher urinary NGF/Cr levels when compared with age-matched controls. After treatment, the urinary NGF/Cr levels significantly decreased.

The extent of changes in the membranous urethra angle is associated with the outcome of retrourethral transobturator sling procedure.

To evaluate the outcome of the retrourethral transobturator sling (RTS) by functional magnetic resonance imaging (MRI) and to identify parameters associated with sling failure. Of thirty recruited men with postprostatectomy stress urinary incontinence (SUI), 26 consecutively underwent functional MRI before sling procedure and 12 months thereafter in a prospective clinical cohort observational study. Periurethral/urethral fibrosis and sling visualization were evaluated on static sequences. The angle of the membranous urethra, position of the bladder neck and external urethral sphincter were assessed during Valsalva's maneuver and voiding. Sling success was defined as no or one dry "security" pad. The success and failure rates were 58 % (15/26 patients) and 42 % (11/26 patients), respectively. The sling leads to reduction in the membranous urethra angle during Valsalva's maneuver (39.55° vs. 36.82°, p = 0.025) and voiding (38.25° vs. 34.83°, p = 0.001) and elevation of the external urethral sphincter (2.9 vs. 4.8 mm, p = 0.017). Preoperative wider angle of the membranous urethra was significantly correlated with severe preoperative incontinence. Sling failure (p = 0.001) and severe preoperative incontinence (p = 0.001) were significantly related to only small changes of the membranous urethra angle. The interrater and intrarater reliability for membranous urethra angle was excellent (intraclass correlation coefficient ≥0.75). The RTS leads to reduction in the membranous urethra angle. The extent of the changes in the membranous urethra angle is associated with RTS outcome. Functional MRI is a reliable noninvasive visualization tool of interactions between the sling and pelvic floor for further research on the complex nature of postprostatectomy SUI.

MP33-18 A COMPARISON OF OUTCOMES AFTER RETROPUBIC MID-URETHRAL SLING, DOES VALSALVA VOIDING AFFECT SUCCESS RATE?

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence Therapy I1 Apr 2014MP33-18 A COMPARISON OF OUTCOMES AFTER RETROPUBIC MID-URETHRAL SLING, DOES VALSALVA VOIDING AFFECT SUCCESS RATE? Blake Anderson, David Hatcher, Rena Malik, Jessica Volsky, Gregory Bales, and Doreen Chung Blake AndersonBlake Anderson More articles by this author , David HatcherDavid Hatcher More articles by this author , Rena MalikRena Malik More articles by this author , Jessica VolskyJessica Volsky More articles by this author , Gregory BalesGregory Bales More articles by this author , and Doreen ChungDoreen Chung More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.969AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It is known that many women void via valsalva and that retropubic slings (RPS) may cause voiding dysfunction. The aim of this study was to compare outcomes after RPS in women with and without valsalva voiding. METHODS 95 women had RPS placed for stress urinary incontinence (SUI) from 2011 to 2013. Baseline demographics, urodynamic findings, operative parameters, and post-operative course were examined retrospectively. Valsalva voiding was defined as abdominal straining witnessed while voiding during urodynamics. Standardized follow-up was at 1, 3, 6, and 12 months. The primary outcome was subjective success rate (absence of SUI with physical activity, coughing, or sneezing). We also looked at Urogenital Distress Inventory (UDI-6) score, Incontinence Impact Questionnaire (IIQ-7) score, post-void residual (PVR), pad use, complications, and revision rate. Tests of significance were done using Fisher’s exact tests and Student’s t-tests. RESULTS Subjects included 45 (47%) valsalva voiders (VV) and 50 (53%) non-valsalva voiders (NV). No differences were seen between groups in mean age, PVR, or capacity. Abdominal leak point pressure without a catheter was significantly lower in VV (56 vs. 70 cm H2O, p=0.045), yet VV had less severe IIQ-7 at baseline compared to NV, (9 ± 6 vs. 13±7, p=0.01). Catheter time was significantly shorter in VV compared to NV (2.5 vs. 4.1 days, p=0.03). No differences were seen between groups in the rate of passing initial void trial (71% VV vs. 61% NV, p=0.1). In the perioperative period, 4.7% of VV and 11.9% of NV required clean intermittent catheterization (CIC) (p=0.16). No patients required CIC beyond 4 weeks. Complication rates (11.4% VV vs. 9.3% NV, p=0.3) and revision rates (7.1% VV vs. 9.5% NV, p=0.28) were similar. In total, 7 (7%) patients required revisions. Reasons were pain (1 VV, 2 NV), erosion (1 NV), voiding dysfunction (1VV, 1 NV), and sling failure (1 VV). Subjective success rates were similar with no significant differences at 1, 3, 6, and 12 months (91%, 94%, 100%, and 100 % for VV and 88%, 88%, 100%, and 93% for NV). At one month, VV had smaller change in postoperative pad use (-1.2 vs. -2.8, p=0.04), IIQ-7 (-5 vs. -12, p=0.0001), and UDI-6 (-4 vs. -8, p=0.01), but there were no significant differences in these parameters between VV and NV at 3, 6, and 12 months. CONCLUSIONS In women with valsalva voiding, RPS appear to be a safe and effective treatment for SUI. Between VV and NV, no differences were seen in success rate, postoperative voiding dysfunction, complication rate, or revision rate. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e345 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Blake Anderson More articles by this author David Hatcher More articles by this author Rena Malik More articles by this author Jessica Volsky More articles by this author Gregory Bales More articles by this author Doreen Chung More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impaired Detrusor Contractility and the Treatment of Female Stress Urinary Incontinence

Introduction and hypothesis: Little conclusive data exists regarding Urodynamic (UD) variables predictive of voiding dysfunction after synthetic Midurethral Sling (MUS) placement. This study aims to evaluate outcomes of MUS in female patients with Impaired Detrusor Contractility (IDC), Valsalva Voiding (VV), or both. We propose that there would be no direct relationship between these variables and urinary retention requiring Clean Intermittent Catheterization (CIC) or reoperation at 6 wk follow up. Methods: Retrospective chart review was performed for all MUS procedures at a single institution, 1/2010- present. Subjects with complete pre-operative UD records and 6 wk follow up were included. The primary outcome measure was urinary retention requiring CIC or re-operation at 6 wk follow up. Results: 187 women who underwent MUS from January 2010 to present had complete UD and ≥ 6 wk follow up data. Average age was 56.7 years. Pre-operative UD identified 64 (34.2%) IDC subjects. At 6-wk follow up, no new subjects in this group required CIC for obstruction or reoperation. No subjects without IDC required CIC or reoperation for urinary retention; however there were 2 reoperations in this group: persistent stress incontinence and vaginal extrusion. Pre-operative UD identified 50 (26.7%) VV subjects. One patient in this group required reoperation; however sling removal was for vaginal extrusion. In the group with both IDC and VV (n=23) no subjects required reoperation. Conclusions: Neither IDC nor VV appear to be risk factors for post-operative urinary retention or reoperation after MUS and have little predictive value for outcomes after MUS.

Treatment of Post-Prostatectomy Incontinence With Male Slings in Patients With Impaired Detrusor Contractility on Urodynamics and/or Who Perform Valsalva Voiding

Treatment of Post-Prostatectomy Incontinence With Male Slings in Patients With Impaired Detrusor Contractility on Urodynamics and/or Who Perform Valsalva Voiding

Treatment of Post-Prostatectomy Incontinence With Male Slings in Patients With Impaired Detrusor Contractility on Urodynamics and/or Who Perform Valsalva Voiding

Male slings have emerged as a popular and efficacious treatment for men with post-prostatectomy stress urinary incontinence. Traditionally slings have been used with caution or avoided in men with impaired detrusor contractility or Valsalva voiding because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with post-prostatectomy urinary incontinence who have impaired contractility and/or void with abdominal straining for urodynamics can be safely treated with slings. A retrospective review of patients with post-prostatectomy urinary incontinence who underwent an initial sling procedure between January 2004 and January 2010 was conducted at a single institution. Preoperative urodynamic characteristics, and postoperative Patient Global Impression of Improvement, post-void residual and noninvasive uroflow data were examined. Patients were grouped by poor bladder contractility or Valsalva voiding status. Exclusion criteria were lack of preoperative urodynamics and/or postoperative post-void residual. A total of 92 patients were analyzed. The variables were compared using the Student t test and the chi-square test. No statistically significant difference was shown in postoperative post-void residual (mean 4 months postoperatively) or urinary retention when comparing by bladder contractility or Valsalva voiding. In the subset of patients with available postoperative uroflow data, there were no differences in postoperative maximum flow rate or voided volume. Men with post-prostatectomy urinary incontinence with urodynamic findings suggesting impaired contractility or Valsalva voiding can be safely treated with sling surgery if they have normal preoperative emptying.

1015 TREATMENT OF POST-PROSTATECTOMY INCONTINENCE WITH MALE SLINGS IN MEN WITH IMPAIRED DETRUSOR CONTRACTILITY AND/OR VALSALVA VOIDING ON URODYNAMICS

INTRODUCTION AND OBJECTIVES: The use of male slings has emerged as a popular and efficacious treatment modality for men with post-prostatectomy incontinence (PPI). Traditionally, slings have been avoided in patients with impaired detrusor contractility because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with PPI who have impaired contractility and/or void with abdominal straining for urodynamics (UDS) can be safely treated with male slings. METHODS: A retrospective review of 123 consecutive patients with PPI who underwent a sling procedure between 1/04 and 1/10 was conducted at a single institution. Preoperative (preop) age, bladder capacity, post void residual (PVR), involuntary detrusor contractions (IDC), maximum flow rate (Qmax), detrusor pressure (Pdet), abdominal pressure (Pabd) and postoperative (postop) Patient Global Impression of Improvement (PGI-I), PVR and noninvasive uroflow were examined. Poor bladder contractility was defined as having bladder contractility index (BCI) 100. Valsalva voiding was defined as a change in Pabd at Qmax from baseline ( Pabd) 20. Exclusion criteria were lack of preop UDS and/or postop PVR or PGI-I. A total of 63 patients were analyzed. The variables were compared using Student’s t-test and chi-square test. RESULTS: No statistically significant difference was shown in postop PVR (mean 4 mos. postop) or urinary retention when comparing by BCI. Comparing by Pabd, a smaller PVR was seen with abdominal voiders, albeit likely clinically insignificant. Table 1 illustrates the preand postop outcomes compared by both BCI and Pabd. 31 patients (BCI 100, n 17 vs BCI 100, n 14) had postop uroflow available and there was no difference in postop Qmax (10.2 vs 13.1, p 0.22) or flow pattern. No patients excluded for incomplete data were treated for obstructive voiding or poor emptying. CONCLUSIONS: The results of this study indicate that men that may not have been traditionally offered a sling based on preop UDS findings can be safely treated with perineal sling. This may be a reflection of how contractility is measured in this population. Prospective studies comparing outcomes of men with impaired contractility that undergo various treatments may also be helpful. TABLE 1: Preand Postoperative Urodynamics Characterics of Male Sling Patients

13 Years of Experience With Artificial Urinary Sphincter Implantation at Baylor College of Medicine

We reviewed 13 years of experience with artificial urinary sphincter implantation (narrow backed cuff) at a single institution. Between 1992 and 2005, 270 patients underwent artificial urinary sphincter implantation, as performed by a single surgeon at Baylor College of Medicine, and followup data were available on 218 of them. Mean followup was 36.5 months (maximum 151.4). Of the 218 patients 60 underwent prostatectomy and pelvic radiation, 116 underwent prostatectomy without radiotherapy, 11 had neurogenic bladder and 31 underwent secondary artificial urinary sphincter implantation. The complication rate did not differ among the 4 treatment groups. Complication rates were infection in 5.5% of cases, erosion in 6.0%, urethral atrophy in 9.6%, mechanical failure in 6.0% and surgical removal or revision in 27.1%. Median time to complications was 3.7 months for infection, 19.8 months for erosion, 29.6 months for atrophy, 68.1 months for failure and 14.4 months for surgery. At 5 years 75% of patients were free from revision or removal. A history of failed injectable or male sling, or of Valsalva voiding did not adversely impact the outcome. The rate of bladder neck contracture was high in artificial urinary sphincter candidates, especially in irradiated patients (36% and 57%, respectively). Patients with prior pelvic radiation continued to be at higher risk for contracture recurrence after artificial urinary sphincter implantation (12%). Two-stage UroLume stent and artificial urinary sphincter placement offered long-term contracture and continence control in 8 of 11 patients with recurrent anastomotic contractures. An artificial urinary sphincter is durable treatment for sphincter deficiency even in patients with a history of complications, neurogenic bladder, pelvic radiation, bladder neck contracture, Valsalva voiding, or failed injectables or slings.

Foley versus intermittent self-catheterization after transvaginal sling surgery: which works best?

Objectives To determine whether the duration of catheter use differed between subjects using clean intermittent self-catheterization and those using continuous Foley catheterization after transvaginal sling surgery. Methods We performed a retrospective analysis of postoperative bladder drainage in 167 consecutive women undergoing transvaginal suburethral sling placement for stress urinary incontinence. The primary outcome measure was the duration of catheter use. Normal voiding was defined as a voided volume equal to twice the residual volume and a residual volume of less than 100 mL for 24 hours. The groups were compared for differences in demographic, preoperative, and postoperative variables using univariate and multivariate analyses. The potential confounding effects of age, concomitant procedures, sling material, preoperative Valsalva voiding, and voiding pressures were investigated using general linear models. Results A total of 122 subjects used clean intermittent self-catheterization and 45 had Foley catheter drainage. No differences were found between the groups in terms of concomitant procedures performed and preoperative diagnoses. The median duration of catheter use was 12 days (range 1 to 120) for women using clean intermittent self-catheterization versus 8 days (range 1 to 120) for those using Foley catheter drainage ( P = 0.026). This difference was not influenced by age, concomitant procedures, sling material, preoperative Valsalva voiding, or preoperative voiding pressures according to the multivariate analyses. Conclusions Although many advocate bladder retraining for postoperative bladder rehabilitation, continuous bladder drainage may result in quicker recovery of normal voiding after sling procedures.

Preoperative Urodynamic Evaluation May Predict Voiding Dysfunction in Women Undergoing Pubovaginal Sling

We determine which urodynamic parameters can best predict postoperative voiding dysfunction following pubovaginal sling surgery. The records of 98 consecutive women who had undergone pubovaginal sling surgery with allograft fascia lata between July 1998 and July 2000 were reviewed. Urodynamic and followup data were sufficient for evaluation for 73 patients. Urodynamic and clinical parameters were correlated with urinary retention, time to return of efficient voiding and development of postoperative urgency symptoms. Average time to return of efficient voiding was 3.92 days (median 3). Of 21 women who voided without a detrusor contraction urinary retention developed in 4 (23%) versus 0 of 48 who voided with detrusor contraction (p = 0.007). Urinary retention was defined as the need to perform even occasional self-catheterization. All 4 women with urinary retention had a detrusor pressure of less than 12 cm. H(2)O (0 in 3, 4 in 1). None of the women with a detrusor pressure of greater than 12 cm. H(2)O had urinary retention (p = 0.047). The presence of Valsalva voiding in women without a detrusor contraction did not affect the incidence of urinary retention (11.1%) compared to those who did not demonstrate Valsalva voiding (5.1%) (p = 0.603). Peak flow rate, detrusor instability on preoperative urodynamics and post-void residual urine volume were not associated with postoperative urinary retention. Finally, post-void residual urine volume predicted delayed return to normal voiding (p = 0.001). There were no other urodynamic parameters that were significantly associated with urinary retention, delayed return to normal voiding or postoperative urgency symptoms including peak flow rate, capacity or compliance. Women who void without or with a weak detrusor contraction are most likely to have urinary retention postoperatively. Therefore, we conclude that preoperative urodynamic evaluation may be used to counsel women regarding the risk of urinary retention following the pubovaginal sling procedure.