Best of AUA 2013: Female Urology/Incontinence/Urodynamics

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Presented by Priya Padmanabhan, MD, MPH

University of Kansas, Kansas City

• A number of groups evaluated the results of the TOMUS (Trial of Mid-Urethral Slings) and SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) trials. In a comparison of the success of women from TOMUS who passed initial post-op voiding and those who did not, at 1-year follow-up, repeat voiders had an 85.8% success rate versus 75.3% among self-voiders. Another group looked at recurrent stress incontinence after SISTEr and TOMUS, reporting 5%-13% retreatment rates within 5 years and noting that injection therapy and autologous pre-vaginal slings were the most common secondary treatment. This group also examined women over age 65 years in the same cohort and found that the women had a lower Valsalva leak point pressure, a decrease in voiding pressures in Qmax, and an increase in voiding time, suggesting a more severe urethral intrinsic dysfunction.

• At 10-year follow-up, transobturator tape had a lower continence rate (60%) than tension-free vaginal tape (78.9%).

• In patients who underwent mesh sling removal, 44% needed subsequent surgery to treat their incontinence.

• A majority of patients undergoing mesh explantation experienced significant improvement or resolution of pain, yet almost 20% continued to suffer pain 1 year following explantation.

• A review of trends in pelvic organ prolapse procedures found that procedures appear to be increasing with the rise in mesh utilization.

• Younger age, less prominent prolapse, and concomitant hysterectomies are associated with a higher mesh-related complication rate.

• Advertisements related to transvaginal mesh lawsuits have high penetrance into the patient population but FDA communications regarding mesh do not. As such, patients are still willing to consider this type of surgery if advised by their physician.

• Overweight and obese patients have significantly higher open conversion and complication rates after undergoing robotic sacrocolpopexy.

• Long-term follow-up of patients undergoing non-radiated vesico-vaginal fistula repair found no difference in sexual and lower urinary tract symptoms between primary and recurrent repairs.

• Researchers reported a 100% success rate for vaginal neobladder fistula repair using four Martius flaps and one interpositional omental flap, although four of the five patients had severe stress incontinence due to their intrinsically short and incompetent urethras.

• Separate studies seem to indicate that simple questions regarding pad use, pad size, and degree of wetness could replace 24-hour pad test weights for evaluating post-prostatectomy incontinence.

• Use of minocycline and rifampin coating (InhibiZone, American Medical Systems) on artificial urinary sphincters (AUS) yielded no difference in infection rates compared with AUS that were not coated, and the coating added $1,300 in costs per AUS.

• Fesoterodine (Toviaz) significantly reduced urge incontinence episodes and was well tolerated. No baseline variables were associated with urge incontinence response. Impaired mobility, number of medications, and number of comorbidities were associated with some adverse affects.

• A pooled analysis of three randomized, double-blind, placebo-controlled, 12-week, phase III trials of the beta-3 adrenoceptor agonist mirabegron (Myrbetriq) demonstrated the agent’s efficacy in the treatment of overactive bladder, with statistically significant improvement in mean number of incontinence episodes.

• A combination therapy utilizing mirabegron and solifenacin (Vesicare) had greater efficacy on mean volume voided and micturition frequency than solifenacin alone.

• An interim analysis of a 3-year extension study on efficacy and safety of repeated onabotulinumtoxinA (Botox), 300 U, found sustained improvement in OAB symptoms, patient perception of improvement, and health-related quality of life, with consistent safety profile.

• Ten-year data on sacral neuromodulation found that 70% of patients maintained >50% improvement over a mean of 2 years. Forty percent required replacement, revision, or explantation for generator failure or lead migration. Women and non-diabetic patients were at increased risk of revision, and those with a history of back surgery, urge urinary incontinence, and no prior bladder outlet obstruction surgery history had a decreased risk of explantation.

• Sacral neuromodulation appears to have applications for milder indications of OAB, specifically for those who failed only one anticholinergic; researchers found improvement in all measures of quality of life through 12-month follow-up.

• In patients undergoing treatment with InterStim (Medtronic, Minneapolis), 27% showed positive bacterial cultures, with methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococcus the most common organisms.

• The severity of obstructive sleep apnea syndrome correlates with worsening nocturia. Nasal continuous positive airway pressure treatment reduced the number of awakenings up to 90%.

• A phase III study confirmed the efficacy of desmopressin, 25 mcg, for female nocturia without significant hyponatremia.

• In multiple sclerosis patients, urodynamics testing is essential, with over 70% of patients having management changes based on the results of testing.

• Serum creatinine alone is not reliable in monitoring renal function in spina bifida patients; glomerular filtration rate remains the gold standard.

• Myelomeningocele patients with neurogenic bladder should be screened for stone disease, upper tract changes, and need for revision surgery of the stoma or outlet.

• The use of onabotulinumtoxinA for neurogenic detrusor overactivity yielded consistent and persistent improvement in incontinence episodes and volume per void of patients with repeat treatment in two pivotal phase III studies.UT

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