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The objective was to examine the effect of the surgical removal of vaginally placed prolapse and incontinence mesh on sexual function. We hypothesize that patients with painful complications of mesh will experience improvement in dyspareunia and sexual function after mesh removal. The eligible cohort consisted of 133 women who presented with a new onset of pain attributed to mesh-augmented incontinence or prolapse surgery and who elected to undergo mesh removal between 1 August 2012 and 1 July 2013. Sexual function symptoms were assessed before and after mesh removal surgery using the Pelvic Organ Prolapse and Urinary Incontinence Sexual Function Questionnaire short form (PISQ-12). Multivariate analysis was performed to identify predictors of improvement in dyspareunia. Ninety-four patients undergoing mesh removal completed a pre-operative questionnaire, 63 of whom also completed a post-operative questionnaire. After mesh removal, there was a nearly 50% reduction in the proportion of women reporting always experiencing post-operative pain with intercourse among those experiencing pre-operative pain. There was a statistically significant quantitative improvement in pain with intercourse after mesh removal based on mean change score of PISQ-12 question 5 “How often do you experience pain with intercourse?”. In multivariate analysis, only history of vaginal delivery was associated with symptom improvement. Removal of transvaginal prolapse mesh is associated with improvement in self-reported dyspareunia based on a standardized question on a validated instrument in a small cohort of women. Although larger studies are needed to confirm the relationship between mesh-augmented surgeries and post-procedural dyspareunia, these data suggest that consideration of mesh removal is a reasonable step for patients with painful intercourse attributed to mesh-augmented prolapse and incontinence surgeries.

Background: Mesh-related complications resulting from pelvic organ prolapse (POP) reconstruction operations may be a devastating experience leading to multiple and complex interventions. Objectives: The aim of the study was to describe the experience and time frame of management of mesh-related complications in women treated for POP or stress urinary incontinence in a tertiary center. Methods: 1,530 cases of mesh-related complications were accessed regarding their clinical presentation, number of surgeries, and timeline of surgical treatments to treat multiple clinical complaints until the ultimate operation where all the meshes were removed in a single tertiary center. Results: The studied population revealed to be a highly referred one with only 10.2% of the cases implanted at our center. Clinical presentation varied widely with 48.7% referring pain as the chief complaint, while 31.3% complained of voiding dysfunctions, 2.5% reported genital prolapses, 2.2% complained of vaginal problems, and 1.2% noted intestinal problems as the main clinical complaint. Only 4.8% of the cases presented mesh erosion at examination; 57.8% of the cases required more than 1 operation to address the mesh-related problems. Sixty-eight cases had more than 10 operations up to complete removal. Three clusters of patients could be identified: (i)–those from whom the mesh was promptly removed after clinical problems emerged, (ii) those with slowly evolving problems, and (iii) those with escalating problems despite treatment attempts. Conclusions: Mesh-related complications after pelvic floor reconstruction are an evolving disease with diverse clinical presentation. The identified time-related problems and the multiple failed attempts to treat their complications warrant attention with continuous monitoring of these patients and aggressive removal of the mesh if the clinical complaint cannot be swiftly managed.

To assess preoperative and perioperative characteristics associated with increased length of stay and major complications after mid-urethral sling mesh removal.We performed an IRB-approved retrospective analysis of patients who underwent mid-urethral sling mesh removal. Demographic data and baseline surgical characteristics were collected. Operative reports and hospital/clinic notes were reviewed for complications which were categorized using the Clavien-Dindo Classification scheme. Length of stay was deemed abnormal if greater than 1 day. Complications were assessed using multivariate regression analysis.A total of 468 patients were identified as having undergone mid-urethral sling mesh removal. Mean age was 56 (± 11.1). 431 patients had either retropubic or transobturator slings. 241 patients underwent retropubic or groin exploration as a part of their mesh removal. A prolonged length of stay was noted in 73 patients (15.6%) and 13 patients (2.8%) experienced a Clavien Grade 3 complication. Pre-operative narcotic/benzodiazepine use, concomitant surgical procedure, bladder injury, increased ASA class, and major complications had an increased odds of a prolonged length of stay. Patients who experienced a bladder injury, groin/suprapubic incision, and estimated blood loss of over 400 mL had an increased odds of Clavien Grade 3 complications.Patient characteristics and perioperative factors are associated with increased length of stay and major complications after mid-urethral sling mesh removal.

Pelvic reconstructive surgery is increasingly being performed with autologous grafts to avoid complications of synthetic mesh and improve the durability of a native tissue repair. Autologous fascia lata (AFL) provides a reliable source of robust connective tissue to improve surgical outcomes. We present our technique and initial experience with performing robotic sacrocolpopexy (RSC) augmented with AFL. A retrospective review was conducted of patients who underwent RSC with AFL between January 2015 and November 2017. Outcomes evaluated include recurrence of prolapse on physical examination, prolapse symptoms, urinary incontinence, patient satisfaction based on the Patient Global Impression of Improvement (PGI-I) and complications. Twelve patients were identified with a median age of 68 years (range, 46–77 years) at the time of RSC with AFL. Eleven patients had a history of prior sling and/or vaginal mesh. The median operative time was 225 min (177–302 min). There were no intra- or postoperative complications. After a median follow-up of 14.7 months (5.7 to 39 months), the median PGI-I response was 2 (range, 1–3, very much to a little better). No recurrent or persistent apical prolapse was observed. Three patients (25%) reported recurrence of sensation of a vaginal bulge, which were all due to anterior vaginal wall prolapse. RSC can be performed with AFL and should be considered in patients with a history of mesh complications. Overall patient satisfaction was high. While these short-term outcomes are encouraging, further studies are needed to assess long-term durability of anatomic results.

Acute, uncomplicated cystitis is one of the most common bacterial infections seen in clinical practice. Quality improvement and antibiotic stewardship efforts to optimize cystitis management rely on clinicians managing patients in a manner recommended by experts and guidelines. However, it is unclear if recent recommendations for cystitis from experts and guidelines from US medical societies that provide recommendations are well aligned. We examined recommendations and guidelines for acute, symptomatic cystitis in women published in US medical societies’ journals from January 1, 2008, to December 31, 2016, within the fields of family medicine, obstetrics and gynecology, internal medicine, female pelvic medicine and reconstructive surgery, and infectious diseases. All recommendations endorsed the use of symptoms and urine dipstick to diagnose cystitis. Some societies did not recommend urine dipstick in patients with recurrent urinary tract infection (UTI), classic UTI symptoms, or a lack of underlying conditions or competing diagnoses. All endorsed nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as first-line agents. Some guidelines classified fluoroquinolones as second- or third-line, while others considered them first-line treatment for UTI. Avoiding use of amoxicillin and ampicillin, antibiotic agents with high prevalence of resistance in the US, was recommended by some societies. US recommendations differed in their approach to the treatment of acute, uncomplicated cystitis. Lack of uniformity likely contributes to clinical management variance for patients with UTI and hampers quality improvement and antibiotic stewardship efforts aimed at promoting optimal management. Our findings emphasize the need for more consistent recommendations for cystitis management.

Caudal duplication syndrome is an exceedingly rare condition that manifests as duplicative anomalies of the gastrointestinal and genitourinary systems. We present a case of an adult patient born with multiple congenital anomalies including duplicated reproductive and urinary systems. She presented to our center for initial evaluation 11 years ago largely experiencing right-sided pelvic organ prolapse and bilateral urinary tract voiding dysfunction. She underwent successful surgical management and presented several years later for recurrent symptoms. We describe her presentation and our surgical experience, including complications and outcomes, for this case. We also review caudal duplication syndrome-its etiology, clinical presentation, diagnostic workup, surgical intervention (if any), and recommendations.

Objective We sought to examine the risk of recurrent stress urinary incontinence (SUI) after suburethral sling mesh removal or excision. Materials and Methods We conducted a retrospective cohort study of patients who were continent before removal or excision of synthetic midurethral slings; this cohort of 278 subjects was much larger than seen in previous such studies. Patients with preoperative incontinence, additional vaginal mesh placements, prior mesh revision/excision, existing SUI, and prior pelvic radiation or fistula were excluded. Only patients with follow-up detailing continence status within 1 year of mesh removal were examined. Results Of 278 patients, 117 (70 retropubic and 47 transobturator) midurethral sling removals met inclusion criteria. Demographic data were comparable between groups. Presenting symptoms were also similar, with similar extrusion rates. Chronic pain was the reason for mesh removal in 80% of cases. In 1 year of follow-up, 38.6% (27/70) retropubic and 34.0% (16/47) transobturator sling removals had SUI requiring an anti-incontinence procedure. Total sling mesh removal was performed in 51.4% of retropubic vaginal mesh and 51.1% of transobturator mesh cases. Conclusion In this continent population with sling complications, approximately 1/3 developed significant SUI within 1 year of mesh removal requiring anti-incontinence surgery, regardless of the amount or type of mesh removed. Total mesh removal did not increase SUI risk.

Objective To evaluate the safety and short-term efficacy of complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy. Methods A retrospective cohort study of patients undergoing complete sacrocolpopexy mesh excision and concomitant autologous fascia sacrocolpopexy from March 2013 to September 2016 was conducted. The primary objective was assessment of perioperative outcomes including complications within 60 days of surgery. The secondary outcome measure was surgical success defined as no need for retreatment by either surgery for apical prolapse or pessary. Results Nineteen patients were identified. Median patient age was 56 years old (range 35-78). Median time from mesh placement to surgical excision was 4.5 years (0-13). Indications for mesh excision included refractory pelvic pain in 18 patients (95%), symptomatic mesh exposure in 8 patients (42%), and bilateral ureteral obstruction with ureterovaginal fistula in 1 patient (5%). Median operative time, estimated blood loss, and length of hospital stay were 228 minutes (133-362), 200 mL (50-1000), and 5 days (2-9), respectively. The rate of minor and major complications within 60 days was 36.8% and 5.3%, respectively. There were no cases of bladder or bowel injury. At a median follow-up of 9.9 months (2.4-39) no patient required secondary surgery for apical vaginal prolapse or retreatment with pessary. Conclusion Complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy can be accomplished safely with a low rate of major complications. These are short-term findings and longer follow-up of anatomic and functional outcomes is needed.

AIMS To present our technique of suprameatal urethrolysis with Martius flap (SMUM) and outcomes of this procedure for refractory female bladder outflow obstruction (BOO). METHODS A retrospective chart review was performed to identify female patients who underwent SMUM between January 2010 and August 2016 after failed transvaginal urethrolysis (TVU) for BOO due to prior stress urinary incontinence (SUI) surgery. The primary outcome measure was surgical success defined as patient ability to void volitionally without need for catheterization or additional surgery for BOO. Secondary outcomes assessed included perioperative outcomes, intraoperative and 30-day complications, change in post-void residual volume (PVR), resolution of urge urinary incontinence (UUI), incidence of recurrent SUI, and treatment for any urinary incontinence. RESULTS Eleven patients were identified. After a median follow-up of 10.8 months (range 3.1-20.1), the procedure was successful in nine patients (82%). Postoperative median PVR was 29 cc (range 0-425) and median change in PVR was a 280 cc (range 29-1050) decrease (P

There is currently a national shortage of indigo carmine. In efforts to identify the most efficient aid for visualizing ureteral efflux intraoperatively we investigated the time to excretion of phenazopyridine vs a newly identified alternative, sodium fluorescein.We analyzed prospectively collected data on a cohort of women who underwent pelvic reconstructive surgery in 2015. Per provider preference patterns a number of patients were administered 200 mg phenazopyridine orally with a sip of water 1 hour prior to the start of operative time. Other patients were given 0.5 ml 10% sodium fluorescein intravenously in the operating room. In all cases time was measured between the administration of the agent and the visualization of color changes consistent with agent efflux in an indwelling catheter, which was placed at the start of the operation. Differences in excretion times between the groups were compared with the Wilcoxon rank sum test.Seven women received phenazopyridine and 5 received sodium fluorescein. Mean excretion time was significantly longer in the phenazopyridine group compared to the sodium fluorescein group (81.9 vs 5.1 minutes, p = 0.0057). Median excretion time for phenazopyridine was 70 minutes (range 59 to 127) and for sodium fluorescein it was 5 minutes (range 3 to 9).Sodium fluorescein is excreted significantly faster in the operating room compared to phenazopyridine. Depending on the cost of these agents at an institution, in addition to the desire to decrease operative time, this may impact practice patterns and agent selection.

Objectives Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). Methods Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. Results One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. Conclusions In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

Sling erosion is a significant complication of midurethral sling (mesh) placement for stress urinary incontinence, a common pelvic floor disorder. The goal of this retrospective case-control pilot study was to evaluate the performance of translabial ultrasound (TLUS) and magnetic resonance imaging in diagnosing mesh erosion. Therefore, women who underwent surgery in the setting of prior failed midurethral sling for stress urinary incontinence were identified from the hospital database. The case subcohort comprised all women with intraoperatively documented erosion, and the control subcohort comprised an equal number of randomly selected patients without erosion. The data consisted of selected clinical parameters, the presence of erosion at surgery (reference standard) and at cystourethroscopy, and dual-reader preoperative TLUS consensus interpretation for mesh location (intraluminal, mural, and extramural) and erosion (defined as intraluminal or mural mesh location). Odds ratios were calculated for the selected clinical parameters. Of the 198 women identified, 15 (8%) had mesh erosion at surgery into the lower urinary tract. The sensitivity, specificity, and accuracy of TLUS and cystourethroscopy in detecting erosion in the combined group of cases and controls (30 women) were 93%, 88%, and 90%, as well as 67%, 100%, and 83%, respectively (TLUS Cohen κ = 0.85). Thus, TLUS may be a good diagnostic tool in diagnosing mesh erosion. Only 7 of 30 women had pelvic magnetic resonance examination, and mesh fragments were not visualized. Case-control comparison of the selected clinical parameters was not statistically significant.

BACKGROUND Uterine power morcellation, where the uterus is shred into smaller pieces, is a widely used technique for removal of uterine specimens in patients undergoing minimally invasive abdominal hysterectomy or myomectomy. Complications related to power morcellation of uterine specimens led to US Food and Drug Administration (FDA) communications in 2014 ultimately recommending against the use of power morcellation for women undergoing minimally invasive hysterectomy. Subsequently, practitioners drastically decreased the use of morcellation. OBJECTIVE We aimed to determine the effect of increased patient awareness on the decrease in use of the morcellator. Google Trends is a public tool that provides data on temporal patterns of search terms, and we correlated this data with the timing of the FDA communication. METHODS Weekly relative search volume (RSV) was obtained from Google Trends using the term “morcellation.” Higher RSV corresponds to increases in weekly search volume. Search volumes were divided into 3 groups: the 2 years prior to the FDA communication, a 1-year period following, and thereafter, with the distribution of the weekly RSV over the 3 periods tested using 1-way analysis of variance. Additionally, we analyzed the total number of websites containing the term “morcellation” over this time. RESULTS The mean RSV prior to the FDA communication was 12.0 (SD 15.8), with the RSV being 60.3 (SD 24.7) in the 1-year after and 19.3 (SD 5.2) thereafter (P CONCLUSIONS Google search activity about morcellation of uterine specimens increased significantly after the FDA communications. This trend indicates an increased public awareness regarding morcellation and its complications. More extensive preoperative counseling and alteration of surgical technique and clinician practice may be necessary.

Background: Uterine power morcellation, where the uterus is shred into smaller pieces, is a widely used technique for removal of uterine specimens in patients undergoing minimally invasive abdominal hysterectomy or myomectomy. Complications related to power morcellation of uterine specimens led to US Food and Drug Administration (FDA) communications in 2014 ultimately recommending against the use of power morcellation for women undergoing minimally invasive hysterectomy. Subsequently, practitioners drastically decreased the use of morcellation. Objective: We aimed to determine the effect of increased patient awareness on the decrease in use of the morcellator. Google Trends is a public tool that provides data on temporal patterns of search terms, and we correlated this data with the timing of the FDA communication. Methods: Weekly relative search volume (RSV) was obtained from Google Trends using the term “morcellation.” Higher RSV corresponds to increases in weekly search volume. Search volumes were divided into 3 groups: the 2 years prior to the FDA communication, a 1-year period following, and thereafter, with the distribution of the weekly RSV over the 3 periods tested using 1-way analysis of variance. Additionally, we analyzed the total number of websites containing the term “morcellation” over this time. Results: The mean RSV prior to the FDA communication was 12.0 (SD 15.8), with the RSV being 60.3 (SD 24.7) in the 1-year after and 19.3 (SD 5.2) thereafter (P

OBJECTIVES We report our experience with removal of synthetic and biologic implants used in pelvic reconstruction in a tertiary referral center from 2005 to 2012. METHODS We performed a retrospective cohort study of all consecutive patients who underwent surgical implant removal for treatment of implant-related complications. Symptoms were determined by patient self-assessment including validated questionnaires. One hundred seventy-nine patients completed follow-up. RESULTS Three hundred six patients underwent removal for exposure or erosion (57%), pain (46%), and urinary symptoms or incontinence (54%). Ninety patients (29%) had previous revision. Eleven percent had pelvic organ prolapse (POP) implants, 48% had sling implants, and 41% had both implants. Mean time from removal to follow-up was 2 years (median, 2 years; range

Our study aims to enhance the accuracy of the clinical diagnosis in patients with vaginal mesh extrusion following transvaginal mesh placement for pelvic organ prolapse using significant clinical parameters and risk factors. All patients who underwent vaginal mesh removal were retrospectively reviewed from January 2000 to May 2014. Eligible patients were divided into two groups according to the presence of vaginal mesh extrusion. A total of 862 patients, 798 were included. 357 (44.7%) had evidence of vaginal mesh extrusion, and 441 (55.3%) had no evidence of vaginal mesh extrusion. The mean age of the vaginal mesh extrusion group was slightly higher than in the group without vaginal mesh extrusion (58.7 ± 11.2 vs. 56.4 ± 11.5, respectively; p = 0.002). From multivariate analysis, the significant clinical correlations for vaginal mesh extrusion were vaginal bleeding [60 (16.9) vs. 14 (3.2%), p

In the setting of an emerging patient population suffering from recurrent pelvic floor symptoms after mesh removal, the principles and practices of native tissue repair have taken on a new, ever-important position in vaginal reconstructive surgery. This chapter provides a case-study of a patient who undergoes complex mesh removal, with improvement in her constellation of presenting symptoms. Although she improves significantly, she goes on to develop recurrent prolapse in the setting of persistent stress urinary incontinence (SUI). Description of her management details techniques for surgical intervention that we have used successfully after mesh removal to treat deficient, attenuated, atrophied, and scarred pelvic floor tissues.

Introduction : We report on one surgeon’s clinical experience with the 2 and 4 corner Raz bladder suspension performed for the treatment of stress urinary incontinence (alone or associated with cystocoele repair) in a consecutive patient cohort between 2003 and 2012 reporting short and longer term results. Materials and Methods : We performed a retrospective study of consecutive patients who underwent a 2 or 4 corner Raz bladder suspension by one surgeon (EHA ) to treat stress urinary incontinence over a period of time from Jan 1 2003 -Sept 2012. 3 month and longer term outcomes was determined by patient self assessment including validated questionnaires. Results : 98.7% of 82 patients reported no stress incontinence at 3 months Longer term follow-up was available on 48 (65%) patients. Of those lost to follow up, 8 were deceased. Mean age was 66.1 years. Mean follow up was 48.2 months (range 4-111months). 21 of the 48 (44%)patients were beyond 48 months. 41 of 48 (85%) patients were either delighted, pleased or mostly satisfied. 42 of 48 patients (87.5 %) had 50 % or more improvement. Pad use of 2.6 decreased to 0.9 pads with P value less than 0.0001. Conclusion : The Raz bladder suspension has good short and longer term results in relieving stress incontinence in addition to low morbidity and lower costs without the use of any mesh product.

Neurogenic voiding dysfunction refers to disease pathways impacting the function of the afferent and efferent nerve fibers of the somatic and autonomic nervous systems, which innervate the lower genitourinary tract. The term “obstructive voiding” may in and of itself be misleading, as a neurogenic bladder may be unable to empty, not only because of functional obstruction but because of hypocontractility as well. Thus, perhaps a more comprehensive conceptual framework is to think of this as neurogenic urinary retention. When evaluating patients with possible neurogenic bladder, although urodynamic tracings can be completed without a video component, fluoroscopy during these studies offers a rich collection of information, including description of a possible functional obstruction (if it exists and where it is in the tract, i.e., bladder neck, urethra), the state of the bladder (severely trabeculated or smooth), and if there is evidence of high pressures contributing to upper tract deterioration (i.e., vesicoureteral reflux, dilated ureters). This chapter presents three case studies of patients with neurogenic bladders and voiding dysfunction, consistent with neurogenic retention; it demonstrates the utility of fluoroscopic images taken during the urodynamic studies, allowing the provider a window into the upper tracts and providing an opportunity to assess where a point of obstruction may be.

We report on the long-term outcomes of the distal urethral polypropylene sling for stress urinary incontinence in a patient cohort that was closely followed and whose outcomes were reported at 1 and 5 years after surgery.We performed a prospective study of all consecutive patients who underwent a distal urethral polypropylene sling procedure between November 1999 and April 2000. The 1 and 5-year outcomes for this particular patient cohort were previously reported. At the minimum 11-year followup, outcome was determined by patient self-assessment including validated questionnaires.A total of 69 patients were followed prospectively and followup was obtained for 30. Of those lost to followup 10 were deceased and 5 were cognitively impaired. Mean patient age at followup was 73 years (range 40 to 97). More than 11 years after surgery 48% of patients reported no stress urinary incontinence symptoms and 63% were never bothered by stress urinary incontinence. Patients reported a mean overall symptom improvement of 64% compared to 81% at 5 years. Overall 82% of patients met the criteria for treatment success by symptom scores and 80% met the criteria by bother scores.The distal urethral polypropylene sling procedure has excellent long-term durability in the treatment of stress urinary incontinence, in addition to low morbidity and low cost as previously described. Eleven years after the procedure the majority of patients report symptom improvement. Nevertheless, many older patients are unable to participate in followup. When choosing an anti-incontinence procedure, durability should be considered in light of patient age given that the theoretical advantages of long-term durability are limited by cognitive decline and mortality.

Pelvic organ prolapse is a common medical condition that affects the quality of life of many women. Approximately 50% of parous women have pelvic organ prolapse and the lifetime risk for surgical intervention is 6.7% at the age of 80 years. In the USA, the number of women at risk for symptomatic prolapse is increasing, which is consistent with the recent increase in the overall number of prolapse and incontinence procedures being performed. Although prolapse is usually multicompartmental and isolated defects are rare, the apical compartment deserves special attention because apical support is integral to a durable prolapse repair. Since many women may initially present to their primary care physicians, all members of the medical community should have a basic understanding of the diagnosis and treatment for apical prolapse.

Aims Research has focused on treatment of overactive bladder (OAB) symptoms in women with the goal of cure. The objective of this study was to assess women's perceptions of their OAB symptoms, treatment experience, and outcomes by conducting patient focus groups. Methods Women seen in our academic center female urology referral clinics were identified by ICD-9 codes for OAB symptoms and recruited to participate in one of five focus groups, totaling 33 patients. Non-clinician moderators conducted the focus group sessions incorporating topics related to patients' perceptions of OAB symptoms, treatments, and outcomes. Data analysis was performed using grounded theory methodology. Results Qualitative analysis yielded several preliminary themes: impact of OAB on quality of life, strategies to control wetness, medications and side effects, and triggers. The majority of focus group participants reported only a partial response to medication and other physician-recommended treatments for OAB. Therefore, they developed self-reliant personalized strategies to improve their quality of life. These strategies included fluid restriction, preventive toileting, and, most importantly, the use of incontinence pads. Conclusions The majority of the women who participated in the focus groups reported only a partial response to medical and other treatments for OAB. As a result, they developed personalized self-management strategies to improve their quality of life. Although most studies addressing the treatment of OAB aim at curing the condition, such a strategy may be unrealistic. Applying a chronic care model that uses a patient-centered symptom-management approach to OAB may optimize patient outcomes and improve quality of life. Neurourol. Urodynam. 30:1295–1299, 2011. © 2011 Wiley-Liss, Inc.

Objectives To better understand aging women's experience with overactive bladder (OAB) symptoms and the care they receive, with the ultimate goal of improving the quality of care provided to aging women with overactive bladder. Methods Women seen in outpatient female urology clinics were identified by ICD-9 codes for OAB and recruited. Patients with painful bladder syndrome, mixed stress and urge incontinence, prolapse, or recent pelvic surgery were excluded. Patient focus groups were conducted by trained nonclinician moderators incorporating topics related to patients' perceptions of OAB physiology, symptoms, diagnostic evaluation, treatments, and outcomes. Qualitative data analysis was performed using grounded theory methodology. Results Five focus groups totaling 33 women with OAB were conducted. Average patient age was 67 years (range, 39-91). Older women with OAB lacked knowledge about the physiology of their disease and had poor understanding regarding the rationale for many diagnostic tests, including urodynamics and cystoscopy. The results of diagnostic studies often were not understood by older patients. Many women were dissatisfied with the care they had received. This lack of knowledge and understanding was more apparent among the elderly women in the group. Conclusions Findings demonstrated a poor understanding of the physiology of overactive bladder and the rationale for various diagnostic modalities and treatments. This was associated with dissatisfaction with care. There is a need for better communication with older women experiencing OAB symptoms about the physiology of the condition.

The objective of this review is to discuss emerging concepts in pelvic organ prolapse, in particular, “What is cure?” In a post-trial data analysis of the CARE (Colpopexy and Urinary Reduction Efforts) trial, treatment success varied tremendously depending on the definition used (19.2%–97.2%). Definitions that included the absence of vaginal bulge symptoms had the strongest relationships with the patients’ assessment of overall improvement and treatment success. As demonstrated by this study, there are several challenges in defining cure in prolapse surgery. Additionally, the symptoms of prolapse are variable. The degree of prolapse does not correlate directly with symptoms. There are many surgical approaches to pelvic organ prolapse. Multiple ways to quantify prolapse are used. There is a lack of standardized definition of cure. The data on prolapse surgery outcomes are heterogeneous. The goal of surgical repair is to return the pelvic organs to their original anatomic positions. Ideally, we have four main goals: no anatomic prolapse, no functional symptoms, patient satisfaction, and the avoidance of complications. The impact of transvaginal mesh requires thoughtful investigation. The driving force should be patient symptoms in defining cure of prolapse.

Urinary fistulas are well-recognized, iatrogenic complications in developed countries that require timely diagnosis and tailored management. Vesicovaginal fistula (VVF) is the most common type of urinary fistula. Depending on the size, mechanism of injury, time of discovery, evidence of active inflammation, and experience of the surgeon, a wide range of treatment options exist for VVF. Most fistulas can be promptly repaired transvaginally, with high success rates at the time of diagnosis unless there are ongoing inflammatory processes. Tissue interposition and surgical approach should be guided by individual case. The role of novel techniques for urinary fistula repair—such as laparoscopic-assisted approach, endoscopic fulguration, and use of fibrin glue—is still being defined and currently has limited application. This article reviews the current literature and establishes guidelines for the evaluation and management of VVF.

Pelvic floor dysfunction (PFD) is a hidden women's health epidemic in the United States, with over 10% of women having a lifetime risk for undergoing a surgical repair for this problem. Given the paucity of understanding of PFD pathophysiology and the high rate of recurrence and repeat surgery, imaging plays a major role in its clinical management, especially for the preoperative assessment of patients with multicompartment defects and failed surgical repairs. The recent development of fast magnetic resonance (MR) imaging sequences allows noninvasive, radiation-free, rapid, high-resolution evaluation of the entire pelvis in one examination. The H line, M line, organ prolapse (HMO) classification system, which is applied to dynamic MR images, allows consistent standardization and grading of various forms of PFD. In addition, the HMO system clearly defines and differentiates between the two main components of PFD: pelvic floor relaxation and pelvic organ prolapse. In addition to serving as an objective diagnostic tool in patients with surgical PFD, MR imaging has tremendous potential to be used as a research tool in trying to understand the pathophysiology of these complex disorders.

Pelvic organ prolapse (POP) will continue to become more prevalent as the female population ages and life expectancy increases. POP repair poses a challenging dilemma that is difficult to manage. Current research on various techniques of posterior compartment repair favors a transvaginal approach. Randomized trials have demonstrated its superiority when compared to transanal repair. Fascial defect reconstruction is superior to levator ani plication, although outcomes are comparable. However, site-specific fascial repairs are inferior to midline fascial plication. No randomized trials compare the transabdominal to transvaginal repair, although the laparoscopic approach has proven superior to transanal repair. The use of graft in posterior compartment repair enhances functional and surgical outcomes; however, mesh erosion, infection, and rejection may influence its use.

Despite multiple variations in cystocele repair techniques, success rates have been historically low. In this review we summarize strategies to optimize long-term results of vaginally approached cystocele repair for the high-grade defect. Our proposed strategies include addressing prolapse of the vaginal apex (the uterus or the vaginal cuff), using the obturator fascia as an anchor for lateral cystocele defect repair, augmenting the repair with loosely woven polypropylene mesh, and placing a midurethral sling.