Publications by authors named "Alana Murphy"

37 Publications

Evaluation and management of female urinary incontinence.

Can J Urol 2021 Aug;28(S2):27-32

Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

INTRODUCTION Urinary incontinence (UI) is a common condition in all demographics of women and consists of stress UI (SUI), Urgency UI (UUI), and mixed UI (MUI). Treatment includes lifestyle modifications, medical treatment, and surgery depending on the type of UI and severity of symptoms. This review is an update on the evaluation and management of UI in women.

Materials And Methods: This review article covers the evaluation and management options for UI in women and includes the most recent guidelines from the American Urological Association (AUA) as well as recently published literature on the management of UI.

Results: Any evaluation of UI should include a thorough targeted history and physical, and counseling for treatment should consider patient goals and desired outcomes. For both SUI and UUI, behavioral therapy and lifestyle modifications are effective first line treatments. Patients with UUI can benefit from medical therapy which includes anticholinergics and ß3-agonist medications, as well as neuromodulation in treatment refractory patients. SUI patients may further benefit from mechanical inserts which prevent leaks, urethral bulking agents, and surgical treatments such as the mid urethral sling and autologous fascial pubovaginal sling.

Conclusions: Treatment of UI in women requires a graded approach that considers patient goals and symptom severity, beginning with lifestyle and behavioral modifications before progressing to more aggressive interventions.
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August 2021

Surgical management of vaginal prolapse: current surgical concepts.

Can J Urol 2021 Aug;28(S2):22-26

Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

INTRODUCTION Pelvic organ prolapse (POP) is a condition defined by a loss of structural integrity within the vagina and often results in symptoms which greatly interfere with quality of life in women. POP is expected to increase in prevalence over the coming years, and the number of patients undergoing surgery for POP is expected to increase by up to 13%. Two categories of surgery for POP include obliterative and reconstructive surgery. Patient health status, goals, and desired outcomes must be carefully considered when selecting a surgical approach, as obliterative surgeries result in an inability to have sexual intercourse postoperatively.

Materials And Methods: This review article covers the role of traditional native tissue repairs, surgical options and techniques for vaginal and abdominal reconstruction for POP and the associated complications, and considerations for prevention and management of post-cystectomy vaginal prolapse.

Results: Studies comparing native and augmented anterior repairs demonstrate better anatomic outcomes in patients with mesh at the cost of more surgical complications, while different procedures for posterior repair result in similar improvements in symptoms and quality of life. In the management of apical prolapse, vaginal obliterative repair, namely colpocleisis, results in very low risk of recurrence at the cost of the impossibility of having sexual intercourse postoperatively. Reconstructive procedures preserve vaginal length along with the ability to have intercourse, but show higher failure rates over time. They can be divided into vaginal approaches which include sacrospinous ligament fixation (SSLF) and uterosacral vaginal vault suspension (USVS), and the abdominal approach which primarily includes abdominal sacrocolpopexy (ASC). There is evidence that ASC confers a distinct advantage over vaginal approaches with respect to symptom recurrence, sexual function, and quality of life. Patients who have had radical cystectomy for bladder cancer are at an increased risk of POP, and may benefit from preventative measures and prophylactic repair during surgery. Importantly, the success rates of POP surgery vary depending on whether anatomic or clinical definitions of success are used, with success rates improving when metrics such as the presence of symptoms are incorporated.

Conclusions: The surgical management of POP should greatly take into account the postoperative goals of every patient, as different approaches result in different sexual and quality of life outcomes. It is important to consider clinical metrics in the evaluation of success for POP surgery as opposed to using exclusively anatomic criteria. Preoperative counseling is critical in managing expectations and increasing patient satisfaction postoperatively.
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August 2021

Future Pharmacists' Opinions on the Facilitation of Self-Care with Over-the-Counter Products and Whether This Should Remain a Core Role.

Pharmacy (Basel) 2021 Jul 31;9(3). Epub 2021 Jul 31.

Medical Biology Centre, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.

Background: The aim was to investigate pharmacy students' views on the role of the pharmacist in facilitating self-care with over-the-counter (OTC) medicines, particularly in light of new roles, and establish personal practice.

Methods: Final year pharmacy students at Queen's University Belfast were invited to participate. Data were collected via a pre-piloted questionnaire, distributed at a compulsory class (only non-identifiable data were requested). Descriptive statistics were performed, and non-parametric tests were employed for inferential statistical analysis (responses by gender).

Results: The response rate was 87.6% (78/89); 34.6% (27/78) males and 65.4% (51/78) females. Over a third [34.6% (27/78)] reported using OTC medicines about once a month. All appreciated the importance of an evidence-based approach to optimize patient care. Most [(96.2% (75/78)] deemed OTC consultations should remain a fundamental responsibility of pharmacists and 69.2% (54/78) thought OTC consultations have the potential to be as complex as independent pharmacist prescribing. Females felt more confident recommending OTC emergency contraception than males ( = 0.002 for levonorgestrel and = 0.011 for ulipristal acetate). Many [61.5% (48/78)] considered more medicines should not be deregulated from prescription-only status.

Conclusions: Data from this single institution suggests that enabling self-medication is an important part of practice but there were confidence issues around deregulations.
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http://dx.doi.org/10.3390/pharmacy9030132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8396246PMC
July 2021

How I Do It: PureWick female external catheter: a non-invasive urine management system for incontinent women.

Can J Urol 2021 Jun;28(3):10669-10672

Department of Urology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Catheter associated urinary tract infections (CAUTIs) are common hospital-acquired infections and remain a significant medical and financial challenge to the healthcare system. Despite this risk, incontinent women may require prolonged catheterization to accurately monitor urine output and prevent skin breakdown. The PureWick Female External Urinary Catheter is a promising non-invasive urine collection system for use in incontinent women that may help reduce CAUTI rates, maintain skin integrity, accurately quantify urine output, and avoid extra healthcare costs.
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June 2021

Faculty Development: How Do We Encourage Faculty to Become Better Teachers and Mentors?

Curr Urol Rep 2020 Aug 18;21(10):40. Epub 2020 Aug 18.

Department of Urology, Sidney Kimmel Medical College of Thomas Jefferson University, 1025 Walnut Street, suite 1100, Philadelphia, PA, 19107, USA.

Purpose Of Review: A healthy mentor relationship is a mutually beneficial experience and a necessary part of the natural progression of a career in academic medicine. We sought to explore the advantages of and challenges to becoming a mentor in current academic urology.

Recent Findings: Mentorship can promote self-confidence in the ability to choose a career, drive academic productivity, and even inspire a career in academic medicine. It is necessary to help promote advancement in diverse socioeconomic groups within medical trainees. Strong mentors can serve as role models to the next generation of doctors. However, the ability to be an effective mentor is being challenged in today's world of academic medicine. By staying current with the issues surrounding mentorship, an individual can be fulfilled and successful in training and guiding doctors into the new era of medicine.
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http://dx.doi.org/10.1007/s11934-020-00994-zDOI Listing
August 2020

Vesicoureteral Reflux in Adults with Urinary Tract Infections: Is There a Role for Treatment?

Curr Urol Rep 2020 Aug 12;21(10):35. Epub 2020 Aug 12.

Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA.

Purpose Of Review: Urinary tract infections (UTI) place a significant burden on individual patients and the healthcare system as a whole. Vesicoureteral reflux (VUR) is a risk factor for UTIs and is the focus of much research in the pediatric field due to the opportunity for early intervention and prevention of long-term sequelae. However, VUR in the adult population is not well studied and can present different treatment challenges. The goal of this review article is to discuss the role VUR plays in UTIs in the adult population with a specific focus on complications and treatment.

Recent Findings: The true prevalence of VUR in the adult population remains unknown, and urologists need to maintain an index of suspicion for VUR when evaluating adult patients with recurrent pyelonephritis or complicated UTIs. A number of case series and smaller retrospective studies have documented successful endoscopic treatment of adult VUR patients with recurrent pyelonephritis. Ureteral reimplantation remains an option for adult patients who are refractory to endoscopic treatment of VUR. The current treatments and recommendations for VUR in adults have been extrapolated from the pediatric population due to the scarcity of research. VUR is uncommon in the adult population and requires a high index of suspicion by the clinician. Accurate diagnosis and treatment of VUR can relieve patients from recurrent infections, repetitive antibiotic use, and the risk of hospitalization.
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http://dx.doi.org/10.1007/s11934-020-00990-3DOI Listing
August 2020

Female Representation at High-profile Urology Conferences, 2014-2019: A Leadership Metric.

Urology 2021 Apr 5;150:72-76. Epub 2020 Jun 5.

Department of Urology, Thomas Jefferson University, Philadelphia, PA.

Objective: To measure female leadership through speakership at urology conferences and compare involvement to the overall representation of women in the urologic workforce.

Methods: A cross-sectional analysis was conducted to identify the gender of conference speakers from 2014 to 2019. Six high-profile urology conferences were selected: AUA; SUFU; SPU; SUO; GURS; WCE. Using programming published by each society, the number of invited female speakers at each conference was recorded. Comparisons were made to the proportion of practicing female urologists based on AUA census data.

Results: A total of 34 conferences were reviewed. From 2014 to 2019, the percentage of female representation increased from 13.7% to 19.3% (P < .05). The proportion of female speakers at all conferences ranged from 0% to 35.6%. The average absolute increase was 1.3% each year. Female representation at urology conferences in 2019 was significantly greater than female representation in the field (19.3% vs 9.9%, P < .05).

Conclusion: There is a slight trend of increasing proportion of invited female speakers at academic urology conferences from 2014 to 2019. Although the proportion of women in urology remains low, the trend indicates that the mean proportion of female speakers is higher than the proportion of women in the field. Inclusion of female conference speakers presents an opportunity for increased gender parity within urology leadership.
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http://dx.doi.org/10.1016/j.urology.2020.05.049DOI Listing
April 2021

Industry payments to female pelvic medicine and reconstructive surgeons: an analysis of Sunshine Act open payments from 2014-2017.

Int Urogynecol J 2020 04 31;31(4):799-807. Epub 2019 Oct 31.

Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, 1025 Walnut Street, Suite 1100, Philadelphia, PA, 19107, USA.

Introduction And Hypothesis: We aim to examine the financial relationship between industry and female pelvic medicine and reconstructive surgeons (FPMRS) during the first four full calendar years since the implementation of the Sunshine Act.

Methods: All board-certified FPMRS specialists were identified using the American Board of Medical Specialties directory. Program directors (PDs) were identified using an Accreditation Council for Graduate Medical Education (ACGME) database. All identified physicians were categorized by gender, specialty, and American Urological Association (AUA) region. Payment data for each individual from 2014 to 2017 were accessed using the Centers for Medicare and Medicaid Services (CMS) Open Payments website. Statistical analyses were performed to elucidate payment trends.

Results: Of the 1,307 FPMRS physicians identified, 25.1% (n = 328) are urology-trained and 74.9% (n = 979) are obstetrics/gynecology (OB/GYN)-trained. Of all physicians analyzed, 6.8% had no reported payments over the 4-year period. 90.1%, 86.5%, 85.3%, and 84.4% received some sort of payment in 2014 to 2017 respectively. Median total payments for all physicians decreased yearly, whereas mean payments decreased from 2014 to 2015 before increasing in all subsequent years. Median general payments were higher for men versus women, urology-trained versus OB/GYN-trained, and PDs versus non-PDs in all years analyzed. The largest contributor to overall payments was the "others" compensation category, which includes gifts, royalties, honoraria, and non-continuing medical education speaking engagements.

Conclusions: Since institution of the Sunshine Act, the percentage of physicians receiving payments has decreased each year. Additionally, there has been a decrease in median total payments and an increase in yearly research payments in all years analyzed.
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http://dx.doi.org/10.1007/s00192-019-04098-2DOI Listing
April 2020

Medical evaluation and management of male and female voiding dysfunction: a review.

Rom J Intern Med 2019 Sep;57(3):220-232

Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.
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http://dx.doi.org/10.2478/rjim-2019-0009DOI Listing
September 2019

Knowledge Gaps in Urologic Care of Female Spinal Cord Injury Patients.

Curr Urol Rep 2019 Mar 23;20(5):21. Epub 2019 Mar 23.

Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Ste 1100, Philadelphia, PA, 19107, USA.

Purpose Of Review: We highlight the substantial gaps in knowledge on urologic care of female spinal cord injury (SCI) patients.

Recent Findings: Males account for approximately 80% of people living with SCI in developed nations. Although there is a robust body of literature in some aspects of urologic care of individuals with SCI, such as treatments for neurogenic detrusor overactivity, there are relatively few studies focusing specifically on females. There are also few studies focusing on other aspects of urologic care of women with SCI such as sexual dysfunction, pelvic organ prolapse, and bladder cancer. Established guidelines for bladder management exist, generally recommending intermittent catheterization, but the fact remains that a substantial number of women with SCI utilize indwelling catheters for bladder management. There remains a paucity of literature using patient-reported measures regarding both outcomes and experiences of urologic management in the SCI population. Bladder management is challenging for many women with SCI. There are few studies on other urologic concerns in women with SCI.
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http://dx.doi.org/10.1007/s11934-019-0884-6DOI Listing
March 2019

Thigh exploration for excision of a transobturator sling.

Int Urogynecol J 2017 May 17;28(5):793-794. Epub 2017 Feb 17.

Section of Female Pelvic Medicine and Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Cleveland, OH, USA.

Introduction And Hypothesis: Groin pain is a known complication of transobturator mesh placement. The objective of this instructional video is to present the surgical technique used to excise the thigh portion of a sling in a patient with persistent thigh pain after placement of a transobturator sling.

Methods: The featured patient is a 49-year-old woman with a history of bilateral groin pain since undergoing placement of a type one polypropylene transobturator sling. Because of persistent pain after removal of the vaginal portion of the sling, she elected to undergo a bilateral thigh dissection to remove the remaining transobturator mesh arms 14 months after her initial surgery.

Results: A bilateral thigh exploration was completed with successful excision of all remaining mesh.

Conclusion: Thigh exploration performed in a systematic fashion is a feasible option for transobturator mesh excision even when the vaginal component of the sling has been previously excised.
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http://dx.doi.org/10.1007/s00192-017-3276-9DOI Listing
May 2017

Assessment of voiding after sling: a randomized trial of 2 methods of postoperative catheter management after midurethral sling surgery for stress urinary incontinence in women.

Am J Obstet Gynecol 2015 May 27;212(5):597.e1-9. Epub 2014 Nov 27.

Women's Health Institute, and Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Cleveland Clinic, Cleveland, OH.

Objective: The objective of this study was to compare the backfill standard voiding trial (SVT) that relies on the assessment of voided volume to subjective patients' evaluation of their voiding based on the assessment of the force of stream (FOS) after an outpatient midurethral sling surgery.

Study Design: This double-blinded randomized trial included patients undergoing an outpatient midurethral sling surgery without any other concomitant surgery. Participants were randomized to either the SVT group or to the FOS group. The primary outcome was the rate of catheterization any time up to 6 weeks after surgery. Both groups underwent the same backfill voiding trial protocol postoperatively. Measurements of the voided amount, postvoid residual, and the response to the FOS visual analog scale were collected. The criteria for passing the voiding trial in the SVT group was voiding at least two-thirds of the instilled amount; while the criteria for passing the trial in the FOS group was assessment of FOS at least 50% of the baseline, regardless of the voided volume. Participants were interviewed preoperatively and 2-4 days, 7-9 days, and 6 weeks postoperatively. All postoperative interviews included assessments of pain, tolerance of physical activity, urinary FOS, as well as satisfaction with the surgery. Validated questionnaires (Incontinence Severity Index and Urinary Distress Inventory, short form) before the surgery and 6 weeks after were used to evaluate urinary symptoms.

Results: A total of 108 patients were enrolled and randomized, and 6-week follow-up data were available for 102 participants (FOS 50, SVT 52). The 2 groups were similar with respect to demographic characteristics and urinary symptoms. The incidence of catheterization was also similar between the groups (FOS 13 [26%], SVT 13 [25.5%]; P=.95). Amount voided had a moderate correlation with FOS assessment (Spearman rho 0.5; P<.001). There was no significant difference in mean catheter days, pain scores, Incontinence Severity Index, and Urinary Distress Inventory, short form scores between the 2 groups. Of the patients who were discharged home without a catheter in either group none required catheter reinsertion within 6 weeks after the surgery.

Conclusion: Patient's subjective assessment of the urinary FOS correlated well with the measured voided amount and no difference in catheterization days was noted between the subjective and objective assessment of voiding. Thus subjective evaluation of the FOS is a reliable and safe method to use after outpatient midurethral surgery.
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http://dx.doi.org/10.1016/j.ajog.2014.11.033DOI Listing
May 2015

Development and validation of a ureteral anastomosis simulation model for surgical training.

Female Pelvic Med Reconstr Surg 2013 Nov-Dec;19(6):346-51

From the *Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, and †Glickman Urologic Institute, Cleveland Clinic, Cleveland, OH.

Objective: To develop and validate a new ureteral anastomosis simulation model.

Methods: We designed a training model to simulate the task of ureteral anastomosis required for ureteroneocystostomy that is suitable for robotic and laparoscopic approaches. Face validity was measured using questions related to surgical authenticity and educational value of the model. Construct validity was measured by comparing scores using Global Operative Assessment of Laparoscopic Skills Scale (GOALS) scale between "procedure experts," "robotic experts," and "trainees" groups. One-way analysis of variance was used to compare differences in the scores and operating times between the 3 groups. Associations between previous surgical experience and performance scores were measured using the Spearman rho correlation coefficient.

Results: Four urologists experienced with robotically assisted ureteroneocystostomies were included in the procedure experts group. The robotic experts group consisted of 5 gynecologists experienced in robotic surgery. The trainees group consisted of 12 urology and gynecology upper-level residents and fellows. All experts agreed or strongly agreed that the model was authentic to the live procedure and a useful training tool. Mean (SD) total GOALS scores were significantly better for the procedure experts group compared to the robotic experts group and to the trainees group (P=0.02 vs P=0.004, respectively). The robotic experts group's GOALS scores were also significantly higher than that of the trainees group (P=0.05). There were no differences in mean times required to complete the procedure. Surgical experience moderately correlated with scores on all 3 assessment scales.

Conclusions: Superior performance on the model by more experienced surgeons demonstrates evidence of construct validity. This authentic and useful model allows surgeons to learn and practice the ureteral anastomosis portion of the ureteral reimplantation surgeries before operating on a live patient.
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http://dx.doi.org/10.1097/SPV.0b013e3182a331bfDOI Listing
December 2013

Utility of postoperative laboratory studies after female pelvic reconstructive surgery.

Am J Obstet Gynecol 2013 Oct 13;209(4):363.e1-5. Epub 2013 Jun 13.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

Objective: We sought to determine the frequency of laboratory studies after female pelvic reconstructive surgery and the rate of intervention based on the results of these laboratory values at a single institution.

Study Design: We conducted a retrospective review of all patients undergoing female pelvic reconstructive surgery for pelvic organ prolapse by 5 fellowship-trained pelvic reconstructive surgeons at a single institution from Jan. 1, 2010, through Dec. 31, 2010. Exclusion criteria were outpatient procedures, isolated hysterectomy, and a combined surgery with another surgical team performing a separate procedure. Interventions based on the number of laboratory studies were classified as minor (electrolyte repletion, repeat laboratory tests, initiation of antibiotics) or major (transfusion, delayed discharge).

Results: A total of 356 patients were included in the final dataset and 100% of patients had routine postoperative laboratory studies. A total of 8771 laboratory values were obtained with a mean of 25 ± 18 laboratory values (0-133) per patient. One-third of postoperative patients (n = 120) underwent a total of 207 interventions based on abnormal laboratory results. The majority of interventions were minor (96%). Of the 120 patients who had a minor intervention, electrolyte repletion was the most common (78%), followed by repeat blood collection (40%) and initiation of antibiotics (4%). The major intervention rate was 4% (n = 8) and all underwent transfusion. Of the 8 transfused patients, 7 demonstrated clinical instability before transfusion and 1 was transfused based on laboratory values and a significant cardiac history.

Conclusion: Routine postoperative laboratory studies are not necessary for all patients after female pelvic reconstructive surgery and more judicious use based on clinical findings may limit unnecessary minor interventions.
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http://dx.doi.org/10.1016/j.ajog.2013.06.008DOI Listing
October 2013

Transvaginal sacrospinous hysteropexy.

Int Urogynecol J 2013 Apr 8;24(4):529-30. Epub 2012 Dec 8.

Section of Female Pelvic Medicine and Reconstructive Surgery, Glickman Urological Institute, 9500 Euclid Ave Q10, Cleveland Clinic, Cleveland, OH 44195, USA.

Introduction And Hypothesis: Sacrospinous hysteropexy provides a transvaginal technique for pelvic organ prolapse (POP) repair with uterine preservation. The objective of the video is to provide an instructional guide for sacrospinous hysteropexy.

Methods: The featured patient is a 73-year-old woman with anterior predominant stage 3 POP. The video outlines the steps and surgical principles necessary to achieve a successful sacrospinous hysteropexy.

Results: Sacrospinous hysteropexy provides a transvaginal approach to POP repair that minimizes operative times and reduces blood loss and risk of lower genitourinary tract injury.

Conclusion: Sacrospinous hysteropexy is a timely technique in an era of increasing interest in uterine preservation and should be considered by surgeons well versed in transvaginal surgery.
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http://dx.doi.org/10.1007/s00192-012-1977-7DOI Listing
April 2013

Prevalence of stress urinary incontinence in women with multiple sclerosis.

Int Neurourol J 2012 Jun 30;16(2):86-90. Epub 2012 Jun 30.

Cleveland Clinic Glickman Urological Institute, Cleveland, OH, USA.

Purpose: The purpose of this study was to determine the prevalence of stress urinary incontinence (SUI) in women with multiple sclerosis (MS) and to what degree these women are bothered by their SUI, since there is a paucity of literature regarding the nature of SUI in this unique population of women.

Methods: We conducted a prospective Institutional Review Board approved study. Women scheduled for outpatient follow-up appointments at a dedicated MS center were asked to complete a questionnaire regarding urinary incontinence. Urgency urinary incontinence (UUI) and SUI were defined as an answer of slightly, moderately or greatly to the Urogenital Distress Inventory (UDI-6) question #2 and question #3, respectively. Impact of SUI on physical activity was determined by Incontinence Impact Questionnaire (IIQ-7) question #2.

Results: A total of 55.9% (80/143) women had SUI, 70.6% (101/143) women had UUI, and 44.8% (64/143) women had mixed urinary incontinence. The mean age was 45.8 years old (range, 20 to 72 years). Women with SUI were significantly older (mean, 47.2 vs. 41.9; P=0.023) and there was a trend towards a greater body mass index (mean, 29.3 vs. 26.5; P=0.057). Women with SUI had significantly higher IIQ-7 scores compared to women without SUI (P<0.001). Impact of urinary incontinence on physical activity was also found to be significantly greater in women with SUI (mean IIQ-7 question #2, 0.96 vs. 0.35; P<0.001).

Conclusions: The prevalence of SUI in women with MS is 55.9% and the presence of SUI has a significant impact on their quality of life. A comprehensive urologic evaluation of a woman with MS should include assessment of SUI.
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http://dx.doi.org/10.5213/inj.2012.16.2.86DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395804PMC
June 2012

Treatment of overactive bladder: what is on the horizon?

Int Urogynecol J 2013 Jan 3;24(1):5-13. Epub 2012 Jul 3.

Glickman Urological & Kidney Institute, Cleveland Clinic, Lerner College of Medicine, Cleveland, OH, USA.

There is still a need to develop additional effective and well-tolerated therapies for the treatment of overactive bladder (OAB). The purpose of this review is to discuss alternative therapies for idiopathic OAB that employ a unique mechanism of action or offer a novel application of an existing therapy. We performed a comprehensive literature review to identify alternative therapies and potential future treatments for idiopathic OAB. The use of botulinumtoxin for idiopathic OAB is on the rise and FDA approval will likely be granted in the future. New innovations in neuromodulation hold the promise of less invasive and more patient-controlled therapies. A number of novel medications, such as β-adrenoreceptor agonists, or medications with alternative indications, such as phosphodiesterase inhibitors, have been identified as potential therapies for OAB. In addition, novel drug delivery systems, such as vaginal inserts, are also in development and may provide an attractive mechanism to deliver medications with proven efficacy. While conservative measures such as behavioral modification and pelvic floor exercises remain first-line therapy for OAB, anti-muscarinics are the mainstay of medical treatment. For patients with idiopathic OAB refractory to traditional first-line therapies, a number of promising new treatments are on the horizon.
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http://dx.doi.org/10.1007/s00192-012-1860-6DOI Listing
January 2013

Pro: the contemporary use of transvaginal mesh in surgery for pelvic organ prolapse.

Curr Opin Urol 2012 Jul;22(4):282-6

Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.

Purpose Of Review: This review will focus on the strengths of transvaginal mesh-augmented repairs over traditional native tissue repairs with an emphasis on the more recent literature.

Recent Findings: Recent attention from the Food and Drug Administration has prompted a re-evaluation of the use of commercial mesh kits in pelvic organ prolapse (POP) repair. Mesh kits for POP repair were recently reclassified from Class 2 medical devices to Class 3 medical devices, a policy change that will prompt additional trials for POP repair in the future. The statements published by the FDA and the reclassification of mesh kits have generated a debate regarding the use of mesh in POP repairs.

Summary: Higher complication rates involving mesh exposures have been documented in the past leading to the recent controversy; however, current mesh studies with longer term follow-up show lower and acceptable exposures with improved objective and subjective outcomes.
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http://dx.doi.org/10.1097/MOU.0b013e32835459a7DOI Listing
July 2012

Transobturator tape removal: a cautionary tale.

Female Pelvic Med Reconstr Surg 2011 Jul;17(4):198

Center for Female Pelvic Medicine and, Reconstructive Surgery, Glickman Urologic Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.

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http://dx.doi.org/10.1097/SPV.0b013e318224ddd1DOI Listing
July 2011

Mid-urethral slings in female incontinence: Current status.

Indian J Urol 2011 Jul;27(3):320-5

Cleveland Clinic, Glickman Urological and Kidney Institute, Section of Female Pelvic Medicine and Reconstructive Surgery Cleveland, OH, USA.

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring one's choice of MUS to the individual patient and her unique clinical parameters remains the best option.
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http://dx.doi.org/10.4103/0970-1591.85424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193730PMC
July 2011

A comparison of the outcomes of neoadjuvant and adjuvant chemotherapy for clinical T2-T4aN0-N2M0 bladder cancer.

Cancer 2012 Jan 29;118(2):358-64. Epub 2011 Jun 29.

Department of Urology, Columbia University Medical Center, New York, New York, USA.

Background: Despite evidence supporting perioperative chemotherapy, few randomized studies compare neoadjuvant and adjuvant chemotherapy for bladder cancer. Consequently, the standard of care regarding the timing of chemotherapy for locally advanced bladder cancer remains controversial. We compared patient outcomes following neoadjuvant or adjuvant systemic chemotherapy for cT2-T4aN0-N2M0 bladder cancer.

Methods: In a retrospective review of a single institutional database from 1988 through 2009, we identified patients receiving neoadjuvant or adjuvant multiagent platinum-based systemic chemotherapy for locally advanced bladder cancer. Survival analysis was performed comparing disease-specific survival (DSS) and overall survival (OS).

Results: A total of 146 patients received systemic perioperative chemotherapy (73 neoadjuvant, 73 adjuvant). Of these, 84% (122/146) received cisplatin-based chemotherapy compared with carboplatin-based chemotherapy (24/146, 16.4%). Most patients receiving cisplatin-based chemotherapy were treated with methotrexate/vinblastine/adriamycin/cisplatin (79/122, 64.8%), whereas the remaining patients received gemcitabine/cisplatin (GC) (43/122, 35.2%). In multivariable analysis, there was no significant difference in DSS (P = .46) or OS (P = .76) between neoadjuvant or adjuvant chemotherapy groups. There was statistically significant improvement in DSS when patients received neoadjuvant GC rather than adjuvant GC (P = .049, hazard ratio, 10.6; 95% confidence interval, 1.01-112.2).

Conclusion: In this study, there was no statistically significant difference in OS and DSS between patients receiving neoadjuvant versus adjuvant systemic platinum-based chemotherapy for locally advanced bladder cancer. In addition, there was no significant difference between neoadjuvant and adjuvant cisplatin- or carboplatin-based chemotherapy. Chemotherapy sequence relative to surgery appeared less important than whether or not a patient actually received perioperative chemotherapy.
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http://dx.doi.org/10.1002/cncr.26278DOI Listing
January 2012

Clinical trials report: low-dose oral desmopressin for nocturia.

Curr Urol Rep 2011 Oct;12(5):313-5

Center for Female Pelvic Medicine and Reconstructive Surgery, Glickman Urologic and Kidney Institute, The Cleveland Clinic, Euclid Avenue/Q10, Cleveland, OH 44195, USA.

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http://dx.doi.org/10.1007/s11934-011-0195-zDOI Listing
October 2011

Endoscopic management of vesicoureteral reflux in adult women.

BJU Int 2011 Jul 11;108(2):252-4. Epub 2010 Nov 11.

Columbia University Medical Center, Department of Urology, New York, NY, USA.

Objective: • To describe our endoscopic management of adult women with vesicoureteral reflux (VUR) and associated outcomes.

Patients And Methods: • We retrospectively identified 19 adult women who presented for the endoscopic treatment of VUR from November 2001 to January 2008. • Each patient was diagnosed with VUR by voiding cystourethrogram or nuclear cystourethrogram after an episode of pyelonephritis or recurrent urinary tract infections with renal scarring on ultrasound. • A dimercaptosuccinic acid renal scan was performed prior to treatment. All patients underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux). Patients with bilateral VUR received bilateral injections during the same procedure. • Follow-up imaging was obtained and success was strictly defined as no degree of VUR. Patients with residual VUR received repeat endoscopic treatment.

Results: • Nineteen patients with a mean age of 22 years old (range 18-33 years old) underwent endoscopic treatment for VUR. A total of 79% (15/19) had pre-existing risk factors for VUR, including prior open anti-reflux surgery (26%), family history of VUR (26%) and childhood diagnosis of VUR (26%). • Imaging revealed that 47% (9/19) had renal scarring and 26% (5/19) had bilateral VUR. The success rate was 79% (19/24) after one treatment, 92% (22/24) after 5 patients received a second treatment, and 96% (23/24) after 2 patients received a third treatment. There were no perioperative complications.

Conclusion: • Endoscopic management of VUR is both safe and effective in adult women.
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http://dx.doi.org/10.1111/j.1464-410X.2010.09824.xDOI Listing
July 2011

Overnight urethral stenting after tubularized incised plate urethroplasty for distal hypospadias.

Pediatr Surg Int 2010 Jun 24;26(6):639-42. Epub 2010 Apr 24.

Division of Pediatric Urology, Department of Urology, Morgan Stanley Children's Hospital of New York, Presbyterian, Columbia University College of Physician and Surgeons, 3959 Broadway, New York, NY 10032, USA.

Objectives: The duration of urethral stenting after tubularized incised plate (TIP) urethroplasty for hypospadias varies among surgeons. Typically the catheter is left for up to 7 days with the goal of minimizing post-operative complications. We describe our experience with overnight stenting for distal TIP hypospadias repair.

Materials And Methods: A retrospective chart review was performed on patients who underwent TIP hypospadias repair from 2003 to 2008. Patients who had their urethral catheter overnight were included in this analysis. Outcomes analyzed were the rates of: urethrocutaneous fistula, meatal stenosis, urethral stricture and urinary tract infections.

Results: A total of 64 patients underwent outpatient TIP hypospadias repair. Forty-nine patients had overnight urethral stenting with at least 12 months follow-up and were included in the analysis. Five of the 49 patients (10.2%) developed urethrocutaneous fistula. Of these five patients, two had undergone re-do hypospadias repair. The fistula rate in primary repairs was 3/45 (6.7%). There were no incidences of meatal stenosis, urinary tract infections or urethral strictures.

Conclusion: In our experience, overnight urethral stenting for TIP hypospadias repair does not significantly affect the rates of urethrocutaneous fistula, meatal stenosis and urinary tract infections. Patients who have had a primary TIP hypospadias repair may have their urethral catheter removed safely on post-operative day one.
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http://dx.doi.org/10.1007/s00383-010-2605-6DOI Listing
June 2010

Long-term clinical outcomes of a phase I trial of intravesical docetaxel in the management of non-muscle-invasive bladder cancer refractory to standard intravesical therapy.

Urology 2010 Jan 13;75(1):134-7. Epub 2009 Nov 13.

Department of Urology, Columbia University Medical Center, New York, New York, USA.

Objectives: To report the long-term clinical outcomes and durability of response after treatment with induction intravesical docetaxel. Most novel agents used to treat bacillus Calmette-Guerin refractory high-grade non-muscle-invasive (NMI) bladder cancer are evaluated only after short follow-up periods. Our previously published phase I trial demonstrated that docetaxel is a safe agent for intravesical therapy with minimal toxicity and no detectable systemic absorption. We sought to determine long-term clinical outcomes after treatment with intravesical docetaxel.

Methods: Eighteen patients with recurrent Ta (n = 7), T1 (n = 5), and Tis (n = 6) transitional cell carcinoma who experienced treatment failure with at least 1 prior intravesical therapy completed the phase I trial. Docetaxel was administered as 6 weekly intravesical instillations using a dose-escalation model terminated at 0.75 mg/mL. Efficacy was evaluated by interval cystoscopy with biopsies when indicated, cytology, and computed tomography imaging. Follow-up consisted of quarterly cystoscopy, cytology, computed tomography, and biopsy when indicated.

Results: With a median follow-up of 48.3 months, 4 patients (22%) have demonstrated a complete durable response and currently remain disease-free without further treatment. Three patients (17%) had a partial response, defined as a single NMI recurrence with no further therapy for bladder cancer. Eleven patients (61%) failed treatment, and required another intervention. One patient developed stage progression. No delayed toxicities were noted. The median disease-free survival time was 13.3 months.

Conclusions: After 4 years of follow-up without maintenance therapy, intravesical docetaxel has demonstrated the ability to prevent recurrence in a select number of patients with refractory NMI bladder cancer and warrants further investigation.
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http://dx.doi.org/10.1016/j.urology.2009.06.112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508734PMC
January 2010

Reoperative retroperitoneal lymph-node dissection for testicular germ cell tumor.

World J Urol 2009 Aug 28;27(4):501-6. Epub 2009 Jul 28.

Department of Urology, Columbia University Medical Center, New York, NY 10032, USA.

Purpose: We sought to discuss the indications for reoperative retroperitoneal surgery, preoperative evaluation of patients, distribution of retroperitoneal recurrences and technical considerations for reoperative procedures. In addition, the histologic findings, clinical outcomes and perioperative complications were reviewed.

Methods: A PubMED and Medline search was performed to identify reoperative retroperitoneal surgery series for patients with nonseminomatous germ cell tumor.

Results: A reliance on cisplatin-based chemotherapy to treat residual disease after RPLND is inadequate for most patients. If retroperitoneal failure does occur, reoperative RPLND should be considered as the recurrence can harbor viable GCT or teratoma, which both necessitate surgical excision. The left para-aortic and left renal hilar regions are the most common sites of retroperitoneal failure. Reoperative retroperitoneal surgery can be performed with an acceptable morbidity as long as surgeons are equipped to handle significant intraoperative complications. Clinical outcomes after reoperative RPLND are influenced by serum tumor markers, histologic findings and completeness of surgical resection.

Conclusions: Overall survival rates in men requiring redo RPLND appear significantly lower than similar patients who are successfully treated with their initial RPLND. Given the potential complexity of this operation and its impact on a patient's prognosis, reoperative RPLND surgery should be limited to specialized quaternary care centers.
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http://dx.doi.org/10.1007/s00345-009-0457-2DOI Listing
August 2009

The number of negative pelvic lymph nodes removed does not affect the risk of biochemical failure after radical prostatectomy.

BJU Int 2010 Jan 22;105(2):176-9. Epub 2009 Jun 22.

Department of Urology, Columbia University Medical Center, New York, NY 10032, USA.

Objectives: To assess patients who had radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for pT2-4 N0M0 prostate cancer, to determine if LN yield affects the risk of biochemical failure (BCF), as the extent of PLND at the time of RP has become increasingly uncertain with the decreasing trend in tumour stage.

Patients And Methods: We reviewed the Columbia University Urologic Oncology Database for patients with pT2-4 N0M0 prostate cancer treated with RP from 1990 to 2005. Exclusion criteria included <12 months of follow-up, incomplete clinical and pathological data, and neoadjuvant androgen-deprivation therapy (ADT) or immediate adjuvant ADT or external beam radiotherapy. Unadjusted and adjusted models were used to determine the ability of clinical and pathological variables to predict BCF.

Results: The final dataset included 964 patients, with a mean age of 60.5 years and median preoperative prostate-specific antigen (PSA) level of 6.2 ng/mL. The median (range) LN yield was 7 (1-42) and the median follow-up 59 (12-190) months. In the unadjusted and adjusted models, preoperative PSA, pathological Gleason score, pathological stage, surgical margin status and year of surgery were significant predictors of BCF. The LN group was not a significant predictor of BCF in both the unadjusted and adjusted model (P = 0.759 and 0.408, respectively). When patients were stratified into high- and low-risk groups, LN yield remained an insignificant predictor of BCF.

Conclusion: A higher LN yield at the time of RP does not increase the chance of cure for patients with pT2-4N0M0 prostate cancer. This lack of a survival advantage holds true for patients with high-risk disease.
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http://dx.doi.org/10.1111/j.1464-410X.2009.08707.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508720PMC
January 2010

Increasing detection rate of benign renal tumors: evaluation of factors predicting for benign tumor histologic features during past two decades.

Urology 2009 Jun 15;73(6):1293-7. Epub 2009 Apr 15.

Department of Urology, Columbia University, Medical Center, New York, New York 10032, USA.

Objectives: To determine whether the detection of benign renal tumors is increasing and to identity the predictors of benign histologic features. The detection of renal cortical tumors has increased with the increased use of abdominal imaging. Current imaging and biopsy techniques cannot predict the renal tumor histologic features with complete accuracy, and many patients undergo surgery for benign lesions.

Methods: The Columbia Urologic Oncology Database was reviewed, and 1244 patients who had undergone partial or radical nephrectomy from 1988 to 2007 were identified. A cohort of 775 patients with a tumor diameter of
Results: The proportion of renal surgery for benign tumors of .05).

Conclusions: Even when controlling for tumor diameter and sex, the incidence of benign tumors detected at renal surgery at our institution has increased significantly in the past 2 decades.
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http://dx.doi.org/10.1016/j.urology.2008.12.072DOI Listing
June 2009

Gender discrepancies in the diagnosis of renal cortical tumors.

World J Urol 2007 Mar;25(1):81-5

Department of Urology, Columbia University Medical Center, New York, NY 10032, USA.

Renal cell carcinoma (RCC) is more common in men than women although the relationship between sex and histologic sub-type of RCC is unknown. The Columbia University Urologic Oncology Database of 1,105 patients who underwent nephrectomy from 1990-2005 was reviewed. 1,018 patients were included who underwent renal surgery with complete demographic data and post-operative pathologic information; 49 with incomplete information and 36 with "granular" histology were excluded. Differences in histology, size and volume of primary tumor, laterality, chief complaint, age, pathologic stage and status were evaluated by sex using ANOVA techniques. The cohort included 671 (66.1%) men and 344 (33.8%) women. There were no differences in age (61.0 vs. 60.7 years, P = 0.36), size (6.22 vs. 5.53 cm, P = 0.08) or volume (305 vs. 129cc, P = 0.07) of primary tumor. Men were more likely to have bilateral tumors (9.6 vs. 3.5%, P = 0.003). A greater percentage of men had malignant pathologic histology at nephrectomy (90.9 vs. 84.0%, P = 0.002). The rate of malignancy for women increased from 44.5% for tumors < 1 cm to 92.7% for tumors greater than 10 cm; there was no trend noted in men. Women had a greater percentage of conventional RCC (77.2 vs. 70.5%, P = 0.04). When analyzed by histologic sub-type, men were more likely to have papillary histology than women (17.4 vs. 4.5%), women were more likely to have chromophobe histology (11.2 vs. 5.0%; P = 0.006). Differences in demographics, pathologic parameters and histologic sub-typing are observed between men and women treated for renal masses.
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http://dx.doi.org/10.1007/s00345-006-0124-9DOI Listing
March 2007
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