Publications by authors named "Brian J Linder"

90 Publications

A comparison of artificial urinary sphincter outcomes after primary implantation and first revision surgery.

Asian J Urol 2021 Jul 13;8(3):298-302. Epub 2021 Mar 13.

Department of Urology, Mayo Clinic, Rochester, MN, USA.

Objective: The artificial urinary sphincter (AUS) is the gold standard for severe male stress urinary incontinence, though evaluations of specific predictors for device outcomes are sparse. We sought to compare outcomes between primary and revision AUS surgery for non-infectious failures.

Methods: We identified 2045 consecutive AUS surgeries at Mayo Clinic (Rochester, MN, USA) from 1983 to 2013. Of these, 1079 were primary AUS implantations and 281 were initial revision surgeries, which comprised our study group. Device survival rates, including overall and specific rates for device infection/erosion, urethral atrophy and mechanical failure, were compared between primary AUS placements versus revision surgeries. Patient follow-up was obtained through office examination, written correspondence, or telephone correspondence.

Results: During the study period, 1079 (79.3%) patients had a primary AUS placement and 281 (20.7%) patients underwent a first revision surgery for mechanical failure or urethral atrophy. Patients undergoing revision surgery were found to have adverse 1- and 5-year AUS device survival on Kaplan-Meier analysis, 90% 85% and 74% 61%, respectively (<0.001). Specifically, revision surgery was associated with a significantly increased cumulative incidence of explantation for device infection/urethral erosion (4.2% 7.5% at 1 year; =0.02), with similar rates of repeat surgery for mechanical failure (=0.43) and urethral atrophy (=0.77).

Conclusions: Our findings suggest a significantly higher rate of overall device failure following revision AUS surgery, which is likely secondary to an increased rate of infection/urethral erosion events.
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http://dx.doi.org/10.1016/j.ajur.2021.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356035PMC
July 2021

Assessing the Impact of Hospital Dismissal Summary Readability on Patient Outcomes Following Prostatectomy.

Urology 2021 Jul 22. Epub 2021 Jul 22.

Department of Urology, Mayo Clinic, Rochester, MN. Electronic address:

Purpose: To assess the impact of decreasing the reading level of hospital dismissal summary information on the number of unplanned patient contacts with providers following robot-assisted radical prostatectomy.

Methods: A multidisciplinary team revised the hospital dismissal summary given to patients following prostatectomy to decrease the reading level from a 13 grade to seventh grade level. We conducted a retrospective cohort study comparing 30-day outcome measures including: patient-initiated telephone calls and online messages, unplanned clinic visits, readmission rates, and emergency department visits pre- and post-intervention. Other perioperative practices remained unchanged between the cohorts.

Results: A total of 110 patients were included in the study (pre-intervention n=60, post-intervention n=50). Patient age (P =.72), race (P =.59), marital status (P =.39), and education level (P = 1.0) were similar between the groups. Pre-intervention, 11.7% of patients had a self-reported education lever lower than the 13 grade, compared to 2% of patients post-intervention with an education level at or below the seventh grade. Following revision of the dismissal information, the number of patient-initiated messages (per patient) significantly decreased (mean 2.3 vs 1.4; P =.02). Patients who received the new dismissal information were significantly less likely to have an emergency department visit (20% vs 4%;P = .02). There were no differences in 30-day unplanned office visits (P =.75) or readmissions (P = 1.0).

Conclusion: Reducing grade level readability of hospital dismissal information was associated with significantly lower rates of patient-initiated messages and emergency department visits. This intervention represents a valuable opportunity for improving the quality of patient care and decreasing postoperative care burden on the healthcare system.
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http://dx.doi.org/10.1016/j.urology.2021.06.040DOI Listing
July 2021

Urinary Symptoms and Bladder Voiding Dysfunction Are Common in Young Men with Defecatory Disorders: A Retrospective Evaluation.

Dig Dis Sci 2021 Jul 22. Epub 2021 Jul 22.

Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

Background And Aims: Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS.

Methods: We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction.

Results: A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]).

Conclusions: Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.
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http://dx.doi.org/10.1007/s10620-021-07167-zDOI Listing
July 2021

An Unusual Complication of Retropubic Midurethral Sling Placement: Obturator Neuralgia.

Urology 2021 Jul 3. Epub 2021 Jul 3.

Department of Urology, Mayo Clinic, Rochester, MN. Electronic address:

Midurethral sling placement is a common treatment for female stress urinary incontinence. We report a case of a woman with a 9-month history of significant pelvic and right lower extremity pain following synthetic retropubic sling placement at an outside facility. On evaluation, she had unilateral obturator neuropathy and underwent combined vaginal, and robotic excision of the right arm of the sling. During surgery, the sling was adherent to the obturator nerve and passed laterally through the obturator fossa. Following removal, her pain completely resolved. This case highlights strategies for preventing, diagnosing, and managing an unusual complication of retropubic sling placement, obturator neuralgia.
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http://dx.doi.org/10.1016/j.urology.2021.06.020DOI Listing
July 2021

Universal Cystoscopy at the Time of Hysterectomy: Why Not?

J Minim Invasive Gynecol 2021 Aug 16;28(8):1450-1451. Epub 2021 Jun 16.

Departments of Obstetrics and Gynecology (Drs. Linder, Cohen Rassier, Burnett, and Gebhart), Mayo Clinic, Rochester, Minnesota. Electronic address:

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http://dx.doi.org/10.1016/j.jmig.2021.06.003DOI Listing
August 2021

Perioperative Outcomes of Rectovaginal Fistula Repair Based on Surgical Approach: A National Contemporary Analysis.

Female Pelvic Med Reconstr Surg 2021 02;27(2):e342-e347

From the Department of Obstetrics and Gynecology.

Objective: To compare the perioperative outcomes of transvaginal/perineal and abdominal approaches to rectovaginal fistula (RVF) repair using a national multicenter cohort.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify women undergoing RVF repair from 2005 to 2016. Emergent cases and those with concomitant bowel diversion were excluded. Baseline patient demographics, procedure characteristics, 30-day postoperative complications, return to the operating room, and readmission were evaluated. Baseline characteristics were compared across surgical approach. Multivariable logistic regression models identified preoperative characteristics independently associated with postoperative complications.

Results: A total of 2288 women underwent RVF repair: 1560 (68.2%) via transvaginal/perineal approach and 728 (31.8%) via abdominal approach. Patients undergoing transvaginal/perineal repair were significantly younger (median age, 46 years vs 63 years), with lower American Society for Anesthesiologist (ASA) scores, and less frequency of diabetes mellitus, dyspnea, severe chronic obstructive pulmonary disease, hypertension, disseminated cancer, and bleeding disorders (all P < 0.01). Those undergoing abdominal repair had higher rates of major complications (25.8% vs 8.7%), minor complications (13.5% vs 6.3%), and readmission (13.2% vs 7.8%). On multivariable analyses, ASA Class 3/4, disseminated cancer, and hematocrit <30% (P < 0.01) were associated with major complications in both groups.

Conclusions: Patients undergoing RVF repair via abdominal approach were older with more comorbidities and had higher postoperative complications rates, likely secondary to underlying differences in the treated populations. Irrespective of surgical approach, ASA class, disseminated cancer, and preoperative anemia were associated with higher postoperative morbidity. This may enhance preoperative counseling and allow for careful patient selection.
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http://dx.doi.org/10.1097/SPV.0000000000000924DOI Listing
February 2021

Management of Vaginal Mesh Exposures Following Female Pelvic Reconstructive Surgery.

Curr Urol Rep 2020 Oct 30;21(12):57. Epub 2020 Oct 30.

Division of Urogynecology, Mayo Clinic Department of OB/Gyn, Rochester, MN, USA.

Purpose Of Review: To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery.

Recent Findings: Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on the patient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.
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http://dx.doi.org/10.1007/s11934-020-01002-0DOI Listing
October 2020

Malpractice Litigation in Iatrogenic Ureteral Injury: a Legal Database Review.

Urology 2020 Dec 9;146:19-24. Epub 2020 Sep 9.

Department of Urology, Mayo Clinic Rochester, MN. Electronic address:

Objective: To examine the factors associated with iatrogenic ureteral injury litigation and outcomes.

Methods: The Westlaw legal database was queried for all iatrogenic ureteral injury cases. Variables extracted included available clinical factors, method of settlement, and litigation outcomes. Linear regression analysis was conducted to examine factors associated with award amount.

Results: A total of 522 cases from 1961 to 2019 were included in the study. The most common specialty named was gynecology (353/512, 68.9%), followed by urology (89/512, 17.4%). The most common claim was intraoperative negligence (474/522 cases, 90.8%). Fifty two cases were settled or arbitrated and 470 went to trial. Settlement or arbitration was more likely in cases involving institution-only defendant (15.4% vs 7.3%, P< .01), academic institution (19.7% vs 7.1%, P < .01), and patient death (42.9% vs 10.7%; P < .001). Of cases that went to trial, the verdict favored the defendant in 339/470 cases (72.1%). The median award was $552,822.96 (interquartile range 187,007-1,063,603). Duration of temporary drainage ($5050/day, P = .02), delayed repair (P = .03), claim of inadequate workup (P = .03), and claim of failure to supervise trainee (P < .001) were significantly associated with increasing award amount.

Conclusion: The majority of ureteral injury litigation ruled in favor of the defendant. However, when awarded, the amount was substantial and correlated with drainage duration, delayed repair, claim of inadequate workup, and failure to supervise trainee. These findings highlight factors perceived to be associated with significant distress and reflect trends in medicolegal decision-making.
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http://dx.doi.org/10.1016/j.urology.2020.08.049DOI Listing
December 2020

Surgical management of stress urinary incontinence following traumatic pelvic injury.

Int Urogynecol J 2021 01 12;32(1):215-217. Epub 2020 Aug 12.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.

Introduction And Hypothesis: The objective was to discuss the evaluation and management of stress urinary incontinence (SUI) following traumatic pelvic injury by use of a video case.

Methods: We present a patient with severe SUI following pelvic trauma and our surgical approach to her case. Her injuries included two sacral compression fractures and four un-united bilateral pubic rami fractures, with her right-upper pubic rami impinging on the bladder.

Results: Preoperative assessment included detailed review of her pelvic imaging, multichannel urodynamic testing, cystoscopy, and examination of periurethral and bony pelvis anatomy. We proceeded with a synthetic retropubic mid-urethral sling, which required medial deviation of the trocar passage owing to her distorted anatomy. Rigid cystoscopy provided an inadequate bladder survey following sling placement, thus flexible cystoscopy was used to confirm the absence of bladder perforation. Postoperatively, our patient experienced resolution of SUI.

Conclusions: In patients who sustain pelvic fractures, imaging to evaluate bony trauma and genitourinary tract injury is essential. Urodynamic testing provides clarity of the nature and severity of incontinence symptoms. Rigid and/or flexible cystoscopy should be performed for diagnostic purposes pre-operatively and after operative intervention. Typical anti-incontinence procedures can be offered to these patients, but since bony anatomy can be unreliable, an individualized approach to their specific injury should be utilized.
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http://dx.doi.org/10.1007/s00192-020-04449-4DOI Listing
January 2021

McIndoe neovagina creation for the management of vaginal agenesis.

Int Urogynecol J 2021 02 15;32(2):453-455. Epub 2020 Jul 15.

Department of Urology (BJL) and Obstetrics and Gynecology (BJL, JBG), 200 First Street SW, Rochester, MN, 55905, USA.

This video reviews technical considerations for performing a modified McIndoe vaginoplasty with skin graft. A 24-year-old female was referred for management of vaginal agenesis. She had unsuccessfully tried vaginal dilation and was interested in vaginal canal creation. A 10 × 20-cm split-thickness skin graft was harvested from the buttock and secured to a condom-covered rubber-sponge mold. The vaginal dissection was initially performed with electrocautery and sharp dissection to enter the plane between the bladder anteriorly and the rectum posteriorly. Then, blunt dissection using a finger, surgical sponges, and retractors was performed to open the space to the level of the peritoneal reflection. With the dissection completed, the graft-covered mold was inserted and secured with labial stay sutures. During the second stage of the procedure, roughly 14 days later, the mold was removed, the graft assessed, and the distal edges secured. A polyethylene mold was then used as the wound continued to heal. The patient had an uncomplicated perioperative course. She had excellent take of her skin graft, with 10 cm vaginal length and adequate vaginal caliber. Vaginoplasty with a split-thickness skin graft is an excellent surgical option for vaginal canal creation in patients with vaginal agenesis.
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http://dx.doi.org/10.1007/s00192-020-04425-yDOI Listing
February 2021

The impact of prior external beam radiation therapy on device outcomes following artificial urinary sphincter revision surgery.

Transl Androl Urol 2020 Feb;9(1):67-72

Department of Urology, Mayo Clinic, Rochester, MN, USA.

Background: Previous reports on the effect of radiation therapy on primary artificial urinary sphincter (AUS) device survival have met with conflicting results, and data evaluating this after revision surgery is sparse. Thus, we evaluated AUS device outcomes after revision surgery, and compared them among individuals who did versus did not undergo prior radiation therapy.

Methods: A database of patients who underwent AUS revision surgery at our institution was used to perform a retrospective review. Device survival endpoints, including overall survival, infection/erosion, urethral atrophy, and device malfunction were evaluated. Overall device survival (i.e., any repeat surgery) was compared between groups, stratified by external beam radiation status, via Kaplan-Meier method. Proportional hazard regression and competing risk analysis were used to evaluate association between prior radiation therapy and device outcomes.

Results: From 1983 to 2016, a total of 527 patients underwent AUS revision surgery. Of these, 173 (33%) patients had undergone prior radiation therapy. Patients with prior radiation therapy were more likely to have diabetes mellitus (22% . 14%; P=0.05), hypertension (71% . 56%; P<0.01), previous vesicourethral anastomotic stenosis (41% . 19%; P<0.0001), as well as prior androgen deprivation therapy (26% . 6%; P<0.0001). Overall, there was not enough evidence to support the existence of a significant difference in device survival among patients with or without a history of radiotherapy, with 1- and 5-year-overall survival of 84% . 85% and 51% . 64%, respectively (P=0.07). On competing risk analysis, a history of pelvic radiation therapy was not enough evidence to support a significant association with the risk of device infection/erosion, mechanical failure, or urethral atrophy.

Conclusions: There was not enough evidence of a difference in the rate of device erosion or infection, cuff atrophy, malfunction, or overall device survival following AUS revision surgery between patients with and without a history of pelvic radiation. These findings may be helpful when counseling patients regarding outcomes after AUS revision.
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http://dx.doi.org/10.21037/tau.2019.09.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995922PMC
February 2020

Long-term device survival and quality of life outcomes following artificial urinary sphincter placement.

Transl Androl Urol 2020 Feb;9(1):56-61

Department of Urology, Mayo Clinic, Rochester, MN, USA.

Background: Artificial urinary sphincter (AUS) placement is the standard for treatment of severe male stress urinary incontinence (SUI). While there is evidence to suggest satisfactory device survival, there is a paucity of data addressing long-term quality of life outcomes.

Methods: We identified patients who underwent primary AUS placement from 1983 to 2016. We assessed rates of secondary surgery (overall, device infection/erosion, urethral atrophy, malfunction) and factors associated with these endpoints. Quality of life was evaluated by pad usage and Patient Global Impression of Improvement (PGI-I) at various time points from primary surgery. Follow-up was obtained in clinic or by phoned/mailed correspondence.

Results: During the study time frame, 1,154 patients were eligible and included in the analysis. Patients had a median age of 70 years (IQR, 65-75 years) and median follow up of 5.4 years (IQR, 1.6-10.5 years). Overall device survival was 72% at 5 years, 56% at 10 years, 41% at 15 years, and 33% at 20 years. On univariate analysis, variables associated with need for secondary surgery were prior cryotherapy (HR 2.7; 95% CI, 1.6-4.6; P<0.01) or radiation therapy (HR 1.4; 95% CI, 1.1-1.7; P=0.01). On multivariable analysis, only cryotherapy remained significantly associated with this endpoint (HR 2.4; 95% CI, 1.3-4.2; P<0.01). While 36% and 23% of patients 5-10 years out from surgery and >10 years out from surgery, respectively, reported using a security pad or less per day, 78% and 81% of those patients, respectively, reported their PGI-I as at least "much better".

Conclusions: AUS placement has excellent long-term outcomes, and is associated with sustained improvement in patient quality of life.
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http://dx.doi.org/10.21037/tau.2019.08.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995928PMC
February 2020

Evaluation and Treatment of Overactive Bladder in Women.

Mayo Clin Proc 2020 02;95(2):370-377

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Urology, Mayo Clinic, Rochester, MN. Electronic address:

Overactive bladder (OAB) is a symptom complex that includes urinary urgency, frequency, urgency incontinence, and nocturia. It is highly prevalent, affecting up to 12% of the adult population, and can significantly impact quality of life. The diagnosis of OAB is made by history, physical examination, and a urinalysis to rule out underlying infection or other concerning potential etiologies. The need for additional testing is based on the initial evaluation findings, and is recommended in cases of underlying urinary tract infection, microscopic hematuria, obstructive voiding symptoms, and symptoms refractory to previous treatments. Initial management includes behavioral modification with attention to total daily fluid intake, avoidance of bladder irritants, treatment of constipation, weight loss, timed voiding, urge-suppression techniques, and pelvic floor physical therapy. Options for oral medications include antimuscarinic agents and β adrenergic agents, and can be used following or in conjunction with behavioral treatment. For patients refractory to behavioral therapy and oral medications, consideration should be given to referral to a specialist (eg, a urologist or urogynecologist) for discussion of more advanced therapies such as sacral neuromodulation, percutaneous tibial nerve stimulation, and intradetrusor injection of onabotulinumtoxinA. These more advanced treatments have favorable efficacy compared with oral agents in randomized trials, although each has a unique risk/benefit profile and shared decision-making with the individual patient is crucial. Here, we review pertinent considerations in the clinical evaluation and management of OAB in women.
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http://dx.doi.org/10.1016/j.mayocp.2019.11.024DOI Listing
February 2020

Techniques for optimizing lead placement during sacral neuromodulation.

Int Urogynecol J 2020 05 24;31(5):1049-1051. Epub 2019 Dec 24.

From the Department of Urology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

We present a video describing technical considerations for optimizing lead placement for sacral neuromodulation. A 56-year-old female presented with urinary urgency incontinence refractory to behavioral modification, physical therapy, and oral pharmacotherapy. An Interstim device had been placed 3 years prior by another provider, but the patient did not find it beneficial and had uncomfortable stimulation despite reprogramming. After counseling, she opted for device revision. The S3 foramen is identified using fluoroscopy in anterior-posterior and lateral views; a needle is advanced through the cephalad and medial aspect of the foramen and tested for bellows and toe responses. After the directional guide is placed, the introducer is advanced until it is midway through the bony table. The lead, with a curved stylet, is advanced for repeat testing prior to deployment. It should have a cephalad-to-caudad appearance and curve laterally. Motor responses are tested and optimally should be < 2 V with all electrodes. The lead is then advanced fully, deployed, and retested. The patient's daytime frequency improved to 6 per day from 11 per day at baseline; her urgency incontinence and the uncomfortable stimulation resolved. Optimization of lead placement for sacral neuromodulation is crucial for improving clinical results.
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http://dx.doi.org/10.1007/s00192-019-04208-0DOI Listing
May 2020

LeFort partial colpocleisis: tips and technique.

Int Urogynecol J 2020 08 18;31(8):1697-1699. Epub 2019 Dec 18.

Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Introduction And Hypothesis: We present a video describing the technical considerations for performing a LeFort colpocleisis.

Methods: A 79-year-old woman presented with a symptomatic vaginal bulge. She was not sexually active, and had no desire to maintain the vaginal canal. Her history was significant for aortic valve replacement, chronic anticoagulation, and a cardiac pacemaker. She had uterine procidentia, with occult stress urinary incontinence. After discussing options, she elected to undergo LeFort colpocleisis. Following sharp endometrial curettage, hydro-dissection was performed with lidocaine and epinephrine. Rectangular patches of vaginal epithelium were excised anteriorly and posteriorly, and the proximal margins were re-approximated, inverting the cervix. Following this, the lateral margins were re-approximated to create lateral channels. The anterior and posterior rectangles were then plicated, reducing the prolapse. The vaginal incision was closed transversely. A retropubic, synthetic, mid-urethral sling was placed, and an aggressive posterior colpoperineorrhaphy was performed.

Results: Her postoperative course was uncomplicated. At her 6-week follow-up she had no recurrent prolapse, denied stress incontinence, and was voiding without difficulty.

Conclusions: Important tips for LeFort colpocleisis include ruling out underlying malignancy, using lidocaine with epinephrine for hydrodissection, creating adequate lateral channels, closure in multiple layers with excellent hemostasis, and an aggressive posterior repair.
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http://dx.doi.org/10.1007/s00192-019-04194-3DOI Listing
August 2020

Reoperation for Urinary Incontinence After Retropubic and Transobturator Sling Procedures.

Obstet Gynecol 2019 08;134(2):333-342

Division of Urogynecology, the Division of Biomedical Statistics and Informatics, and the Department of Urology, Mayo Clinic, Rochester, Minnesota; the Clinical Pharmacology Division, Vanderbilt University, Vanderbilt, Tennessee; and the Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio.

Objective: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures.

Methods: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure.

Results: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups.

Conclusion: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.
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http://dx.doi.org/10.1097/AOG.0000000000003356DOI Listing
August 2019

Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery.

Am J Obstet Gynecol 2019 11 18;221(5):515.e1-515.e8. Epub 2019 Jun 18.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.

Background: Nationally, there is increasing concern regarding the volume of opioid medications prescribed postoperatively and the rate of prescription opioid-related adverse events. In evaluation of this, several reports have identified significant variability in postoperative opioid-prescribing patterns, including quantities exceeding patient's needs, especially after minor surgical procedures. However, data regarding patient's postoperative opioids needs following surgery for pelvic organ prolapse are sparse.

Objective: To design procedure-specific opioid-prescribing recommendations for pelvic organ prolapse surgeries and evaluate their impact on opioid stewardship.

Study Design: We prospectively evaluated opioid-prescribing patterns, patient use, medication refills, and patient satisfaction in women undergoing prolapse surgery (ie, vaginal, abdominal, or robotic) during an 8-month time period. Two cohorts of women, stratified by whether they had surgery before or after implementation of procedure-specific opioid-prescribing recommendations, were evaluated. Postoperative opioid usage (assessed via pill count), medication refills, and satisfaction with pain management after hospital dismissal were evaluated by telephone call 2 weeks after surgery. Postoperative opioid prescribing and use were recorded after conversion to oral morphine equivalents.

Results: Overall, 96 women were included, 57 in the initial baseline cohort, and 39 following implementation of the prescribing recommendations. In the initial cohort, 32.8% of the prescribed oral morphine equivalents (3607/11,007 mg) were consumed. Following implementation of the prescribing recommendations, median oral morphine equivalents prescribed decreased from 200 mg oral morphine equivalents (interquartile range 150, 225) to 112.5 mg oral morphine equivalents (interquartile range 22.5, 112.5; P<.0001). The total oral morphine equivalents prescribed decreased by 45% when compared with the volume that would have been prescribed before implementing the recommendations. The amount of leftover opioids per patient significantly decreased as well (P<.0001). Pain medication refills increased after the intervention (18% vs 3.5%; P=.03), whereas satisfaction scores were similar in both cohorts (P=.87).

Conclusions: By using procedure-specific opioid prescribing recommendations, we decreased the number of opioids prescribed at hospital dismissal by roughly one half. Decreased opioid prescribing did not adversely impact patient satisfaction.
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http://dx.doi.org/10.1016/j.ajog.2019.06.023DOI Listing
November 2019

National Patterns of Filled Prescriptions and Third-Line Treatment Utilization for Privately Insured Women With Overactive Bladder.

Female Pelvic Med Reconstr Surg 2021 02;27(2):e261-e266

Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.

Objective: The aim of this study was to evaluate national patterns of care for women with overactive bladder (OAB) in an administrative data set and identify potential areas for improvement.

Methods: We performed an analysis using the OptumLabs Data Warehouse, which contains deidentified administrative claims data from a large national US health insurance plan. The study included women, older than 18 years, with a new OAB diagnosis from January 1, 2007, to June 30, 2017. We excluded those with an underlying neurologic etiology, with interstitial cystitis/painful bladder syndrome, were pregnant, or did not have continuous enrollment for 12 months before and after OAB diagnosis. Trends in management were assessed via the Cochran-Armitage test. Time to discontinuation among medications was compared using t test.

Results: Of 1.4 million women in the database during the study time frame, 60,246 (4%) were included in the study. Median age was 61 years [interquartile range (IQR), 50-73], and median follow-up was 2.6 years (IQR, 1.6-4.2). Overall, 37% were treated with anticholinergics, 5% with beta-3 agonists, 7% with topical estrogen, and 2% with pelvic floor physical therapy; 26% saw a specialist; and 2% underwent third-line therapy. Median time to cessation of prescription filling was longer for beta-3 agonists versus anticholinergics [median, 4.1 months (IQR, 1-15) vs 3.6 months (IQR, 1-10); P < 0.0001]. Use of third-line therapies significantly increased over the study time frame, from 1.1% to 2.2% (P < 0.0001).

Conclusions: Most of the patients do not continue filling prescriptions for OAB medications, and a minority of patients were referred for specialty evaluation. Although third-line therapy use is increasing, it is used in a small proportion of women with OAB. Given these patterns, there may be underutilization of specialist referral and other OAB therapies.
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http://dx.doi.org/10.1097/SPV.0000000000000744DOI Listing
February 2021

Evaluating the impact of radiation therapy on patient quality of life following primary artificial urinary sphincter placement.

Transl Androl Urol 2019 Mar;8(Suppl 1):S31-S37

Department of Urology, Section of Pelvic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.

Background: The impact of prior radiation therapy on patient satisfaction following primary artificial urinary sphincter (AUS) placement is not well described, therefore our aim was to evaluate the effect of radiation on patient satisfaction among men undergoing primary AUS with and without a history of prior radiation.

Methods: From 1983-2011, 1,082 men underwent primary AUS placement at our institution. Of these, 467 were alive, with an intact primary AUS and invited to participate in a mailed survey assessing AUS status, patient satisfaction, and urinary control. Clinical subjective outcomes were assessed via reported change in urinary control from pre-operative to post-AUS placement.

Results: In total, 229/467 (49%) of men with an intact primary AUS completed the survey, with a median follow-up of 8.4 years [interquartile range (IQR) 5.8-11.4]. Of these, 64 men (28%) had a prior history of radiation therapy. Both men with and without history of radiation, reported a high likelihood of electing to have AUS surgery again, 87% 91% respectively (P=0.87), and of recommending AUS surgery to a family member, 86% 93% respectively (P=0.18). There were no significant differences between those with and without prior radiation with regard to rates of reported: substantial improvement in urinary control following surgery (72% 78%, P=0.30), minimal bothersome leakage (57.1% 66%, P=0.31), and pad use ≤1 pad/day (49% 59%, P=0.06).

Conclusions: In a large cohort of primary AUS implants with and without prior radiation therapy we noted a high-level of satisfaction and though many patients still utilized 1 or more pads/day with long-term follow-up. Importantly, there was no significant difference in quality of life (QoL) outcomes compared between those with and without prior radiation therapy.
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http://dx.doi.org/10.21037/tau.2018.11.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511699PMC
March 2019

Perioperative Complications in Minimally Invasive Sacrocolpopexy Versus Transvaginal Mesh in the Management of Pelvic Organ Prolapse: Analysis of a National Multi-institutional Dataset.

Female Pelvic Med Reconstr Surg 2021 02;27(2):72-77

Surgical Outcomes Program, Mayo Clinic Kern Center for the Science of Health Care Delivery.

Objectives: The objective of this study was to evaluate perioperative complications in women who underwent minimally invasive sacrocolpopexy (MISC) versus mesh-augmented vaginal repair (vaginal mesh) for pelvic organ prolapse.

Methods: We identified patients undergoing MISC and vaginal mesh via Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2016. Those undergoing concomitant hysterectomy were excluded. Univariate analyses were performed to compare baseline characteristics and 30-day complications. Multivariable logistic regression models were constructed to assess the association between surgical approach and complications, prolonged hospitalization, reoperation, and blood transfusion. A multivariable Cox proportional hazard model was used to evaluate hospital readmission.

Results: A total of 5722 patients were identified (2573 MISC [45%], 3149 vaginal mesh [55%]). Those undergoing MISC repairs had a significantly lower rate of urinary tract infection (3.1 vs 4.2%; P = 0.03) and blood transfusion (0.5 vs 1.4%; P < 0.001). There was no difference in reoperation rate (1.3 vs 1.6%; P = 0.35). Multivariable analysis showed no significant association of MISC with overall (odds ratio [OR], 0.91; P = 0.44), major (OR, 1.30; P = 0.31), or minor complication (OR, 0.85; P = 0.26). There were lower odds of receiving a blood transfusion (OR, 0.44; P = 0.02) and higher odds of prolonged hospitalization (>2 days; OR, 1.47; P = 0.003) for the MISC group. There was no difference in reoperation (OR, 0.79; P = 0.38) or hospital readmissions (hazard ratio, 1.25, P = 0.32).

Conclusions: Minimally invasive sacrocolpopexy was associated with a lower rate of blood transfusion than transvaginal mesh placement. There was no significant difference in 30-day complication rates, reoperation, or readmission between these prolapse procedures when performed without concomitant hysterectomy.
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http://dx.doi.org/10.1097/SPV.0000000000000738DOI Listing
February 2021

Bacterial Cultures at the Time of Artificial Urinary Sphincter Revision Surgery in Clinically Uninfected Devices: A Contemporary Series.

J Urol 2019 06;201(6):1152-1157

Department of Urology, Section of Female Pelvic and Reconstructive Surgery, Mayo Clinic , Rochester , Minnesota.

Purpose: We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies.

Materials And Methods: We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization.

Results: Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%.

Conclusions: Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.
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http://dx.doi.org/10.1097/JU.0000000000000102DOI Listing
June 2019

A National Contemporary Analysis of Perioperative Outcomes for Vaginal Vault Prolapse: Minimally Invasive Sacrocolpopexy Versus Nonmesh Vaginal Surgery.

Female Pelvic Med Reconstr Surg 2019 Sep/Oct;25(5):342-346

Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.

Objective: The aim of this study was to compare the perioperative morbidity of minimally invasive sacrocolpopexy (MISC) and nonmesh apical vaginal surgeries for repair of vaginal vault prolapse using data from a contemporary nationwide cohort.

Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify women who underwent apical prolapse surgery via vaginal approach or MISC from 2010 to 2016. Those undergoing concomitant hysterectomy or transvaginal mesh placement were excluded. Associations of surgical approach with 30-day complications, prolonged hospitalization, and reoperation were evaluated using logistic regression. Readmission within 30 days was calculated using the person-years method and Cox proportional hazards models.

Results: Overall, 6390 women underwent surgery, including 3852 (60%) via vaginal approach and 2538 (40%) via MISC. Patients undergoing MISC were younger (P < 0.0001) and less likely to have hypertension (P = 0.04) or chronic obstructive pulmonary disease (P = 0.008), with lower American Society of Anesthesiologists scores (P < 0.0001) and higher preoperative hematocrit (P = 0.009). The MISC cohort had a lower unadjusted rates of minor complications (3.9% vs 5.6%; P = 0.004), urinary tract infection (3.3% vs 4.8%; P = 0.004), and prolonged hospitalization (5.2% vs 7.9%; P < 0.0001), with a higher rate of nephrologic (P = 0.01) complications. On multivariable analysis, there were no significant associations of MISC with the risk of 30-day complications (odds ratio [OR], 1.51; 95% confidence interval [CI], 0.92-2.51; P = 0.11), prolonged hospitalization (OR, 0.96; 95% CI, 0.76-1.21; P = 0.72), readmission (HR 1.03; 95% CI, 0.71-1.49;P = 0.88), or reoperation (OR, 0.95; 95% CI, 0.57-1.60; P = 0.86).

Conclusions: Minimally invasive sacrocolpopexy is associated with similar rates of 30-day complications, prolonged hospitalization, readmission, and reoperation compared with nonmesh vaginal surgeries for apical prolapse.
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http://dx.doi.org/10.1097/SPV.0000000000000678DOI Listing
March 2020

Robot-assisted vesicovaginal fistula repair via a transvesical approach.

Int Urogynecol J 2019 02 18;30(2):327-329. Epub 2018 Dec 18.

Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Objective: The objective of this video is to demonstrate a technique for robot-assisted vesicovaginal fistula (VVF) repair utilizing a mini cystotomy with a transvesical approach.

Methods: A 53-year-old female developed a VVF after she underwent an abdominal hysterectomy for uterine fibroids at an outside facility. She was referred to us following two failed VVF repairs (one vaginal, one abdominal with bladder bivalving and omental flap). After discussing options, she underwent a robotic VVF repair via a transvesical approach. Following port placement, the space of Retzius was mobilized. An intentional cystotomy was made and the camera and working arms advanced into the bladder. The fistula was identified and circumferentially mobilized. The fistula was closed in three layers using absorbable sutures, and care was taken to avoid the ureters.

Results: The patient's postoperative recovery was uncomplicated. Follow-up imaging was performed via cystogram at 4 weeks and showed resolution of the fistula.

Conclusions: A robot-assisted transvesical approach using a mini cystotomy to VVF repair is a useful technique especially when previous surgical planes have been used in prior repairs and failed. It maintains a minimally invasive approach and may avoid complications associated with an open abdominal approach.
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http://dx.doi.org/10.1007/s00192-018-3843-8DOI Listing
February 2019

Risk factors for subsequent urethral atrophy in patients undergoing artificial urinary sphincter placement.

Turk J Urol 2019 03 26;45(2):124-128. Epub 2018 Nov 26.

Department of Urology, Mayo Clinic, Rochester, MN, United States.

Objective: Artificial urinary sphincter (AUS) device failure or revision can be due to multiple etiologies including erosion, infection, mechanical malfunction, and urethral atrophy. However, few studies have evaluated factors that predispose patients to urethral atrophy. Here, we sought to identify preoperative and perioperative risk factors associated with urethral atrophy in men undergoing primary artificial urinary sphincter (AUS) placement for stress urinary incontinence.

Material And Methods: From 1987 to 2013, 1829 AUS procedures were performed at our institution. A total of 1068 patients underwent primary AUS placement and were the focus of our study. Multiple clinical and surgical variables were evaluated for a potential association with revision for atrophy. Those found to be associated with atrophy and relevant competing risks were further evaluated on multivariable analysis.

Results: With a median follow-up of 4.2 years (IQR 1.3-8.1), 89 men (8.3%) had urethral atrophy requiring reoperation. Median time to revision was 4.5 years (IQR 1.9-7.6). On univariable analysis, only smaller cuff size (4.0-cm versus 4.5-cm; HR 3.1, p=0.04) was associated with an increased rate of urethral atrophy. Notably, patient age at the time of surgery (p=0.62), body mass index (0.22), and smoking status (p=1.00) were not associated with a risk of atrophy. On multivariable analysis smaller urethral cuff size remained significant (HR 2.8, 95% CI 1.1-7.1; p=0.01).

Conclusion: Revision surgery for urethral atrophy was performed in approximately 8% of men undergoing primary AUS placement. Utilization of a smaller AUS cuff size appears to be an independent factor associated with increased rate of urethral atrophy.
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http://dx.doi.org/10.5152/tud.2018.82781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368031PMC
March 2019

Artificial urinary sphincter revision with Quick Connects versus suture-tie connectors: does technique make a difference?

Turk J Urol 2019 07 26;45(4):284-288. Epub 2018 Nov 26.

Department of Urology, Mayo Clinic, Rochester, MN, USA.

Objective: To evaluate characteristics of artificial urinary sphincter (AUS) mechanical failures and compare outcomes based on the use of either suture-tied connections or Quick-Connects (QC) for single-component revisions.

Material And Methods: A total of 46 patients underwent single-component AUS revisions following primary AUS placement from January 1983 to January 2011 at our institute. Prior to 1996 all revision cases were performed with suture-tie connections and after that time we used QC for revisions. Device success was evaluated for a potential association with revision surgery including the type of connector used.

Results: Forty-six patients underwent single-component revision surgery for primary device malfunction. In these cases, the tubing connections were performed using suture-tie connectors in 34 (74%), and QC in 12 (26%) cases. The median age was 68.8 years for suture-tie vs 70.6 years for QC (p=0.52). The median follow-up period after revision surgery was 24 months (IQR 7.2, 55.2). There was no statistically significant difference in 5-year device survival rates between suture-tie and QC (36% vs. 61%; p=0.85) techniques. There were no cases of device infection or repeat mechanical failure at the connector among cases of revision performed using QC, as compared to five device infections and four repeat mechanical failures among the suture-tie cohort.

Conclusion: The use of QC for single-component AUS revision for mechanical failures appears to be safe, efficient and reliable. There is not enough evidence supporting the presence of an association between connector type with the risk of overall device failure.
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http://dx.doi.org/10.5152/tud.2018.33733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6619845PMC
July 2019

Synthetic Midurethral Slings: Roles, Outcomes, and Complications.

Urol Clin North Am 2019 Feb;46(1):17-30

Department of Urology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. Electronic address:

Synthetic midurethral sling placement is the most studied anti-incontinence procedure available. Multiple randomized trials demonstrate its safety and efficacy, with results out to 5 years. With long-term follow-up, it seems there may be some benefit in efficacy to retropubic sling placement compared with the transobturator approach. Single-incision slings are a newer modification to multi-incision sling placement, and the data regarding safety and efficacy are not as mature as other forms of sling placement. Complications may occur with mesh midurethral sling placement and surgeons performing these procedures should be comfortable with the diagnosis and management of these issues.
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http://dx.doi.org/10.1016/j.ucl.2018.08.013DOI Listing
February 2019

Cystoscopic ureteral stent placement: techniques and tips.

Int Urogynecol J 2019 Jan 15;30(1):163-165. Epub 2018 Sep 15.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.

Introduction And Hypothesis: We present a video demonstrating technical considerations and tips for cystoscopic placement of external, lighted, and internal ureteral stents.

Methods: Cystoscopic ureteral stent placement is useful in cases where difficult pelvic periureter dissection is expected or encountered. In this video, we review cystoscopy basics, our approach to various types of retrograde stent placement, and performing retrograde pyelograms. Traditional external ureteral stent and lighted stent placement for prophylactic purposes are discussed, with attention to understanding stent markings, appropriate resistance, and steps for externalization. Internal, double-J ureteral stent placement with the use of fluoroscopy is initiated with placement of a guidewire. An open-ended ureteral catheter is advanced over the wire in the pelvic portion of the ureter, and a retrograde pyelogram is performed. The wire is reintroduced and the stent advanced to the renal pelvis under fluoroscopy. The proximal curl is confirmed to be in the appropriate position with fluoroscopy. The string attached to the stent is then cut and removed, the guidewire is removed, and the stent is deployed with the distal curl in the bladder.

Conclusions: This video reviews key steps for cystoscopic ureteral stent placement in a prophylactic setting, cases of challenging anatomy, or ureteral injury.
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http://dx.doi.org/10.1007/s00192-018-3762-8DOI Listing
January 2019

"Occult" pelvic abscess following previous robotic sacrocolpopexy.

Int Urogynecol J 2018 Dec 16;29(12):1849-1850. Epub 2018 Aug 16.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1007/s00192-018-3742-zDOI Listing
December 2018

Autologous rectus fascia sling placement in the management of female stress urinary incontinence.

Int Urogynecol J 2018 09 11;29(9):1403-1405. Epub 2018 Apr 11.

Department of Urology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Introduction And Hypothesis: Autologous pubovaginal sling placement remains a treatment option in index patients, given high, long-term success rates. This video reviews the technical considerations for performing an autologous rectus fascia sling.

Methods: The patient is a 47-year-old woman with stress urinary incontinence (SUI) refractory to conservative management. First, a 10-cm rectus fascial segment is harvested and prepped with placement of nonabsorbable stay sutures for later sling passage. Then, an inverted U-shaped incision is made in the anterior vaginal wall based on the bladder neck, and perforation of the endopelvic fascia is performed. Following passage of the sling in the retropubic space, it is secured to periurethral tissue. Cystoscopy is then used to evaluate for bladder perforation and to confirm sling tensioning.

Results: The patient was discharged on the same day of surgery with a suprapubic tube in place, which was removed on postoperative day 7 after passing a capping trial. At 6 weeks' follow-up, the patient had complete resolution of SUI, with no de novo urgency symptoms, and could empty her bladder to completion.

Conclusion: Autologous pubovaginal sling placement remains an effective treatment option for the management of female SUI. This video highlights important technical considerations for this procedure.
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http://dx.doi.org/10.1007/s00192-018-3643-1DOI Listing
September 2018

Entry into the anterior cul-de-sac during vaginal hysterectomy.

Int Urogynecol J 2018 08 11;29(8):1223-1225. Epub 2018 Apr 11.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.

Introduction And Hypothesis: We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vaginal hysterectomy, including tips for troubleshooting difficult cases such as: uterine procidentia, cervical elongation, and multiple prior cesarean sections.

Methods: Anterior cul-de-sac entry is a critical step in performing a vaginal hysterectomy. In this video, we review our approach to anterior entry in patients with normal anatomy, followed by a discussion of techniques that may be useful in cases with challenging anatomy. To start, we drain the bladder, set up exposure with Deaver retractors, and make a circumferential incision at the cervicovaginal junction. In cases with normal anatomy, using sharp, followed by broad blunt finger dissection, the vesicocervical space is opened, and the peritoneal reflection is identified and sharply entered. If this is not possible, additional techniques such cystoscopic bladder illumination, posterior entry first, securing pedicles with extraperitoneal ties, or additional sharp dissection may be utilized. With all techniques, proper intraperitoneal entry should be verified by the visualization of small bowel or fat.

Conclusion: This video reviews technical considerations for anterior cul-de-sac entry during vaginal hysterectomy in patients with normal anatomy and provides tips for troubleshooting challenging cases.
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http://dx.doi.org/10.1007/s00192-018-3646-yDOI Listing
August 2018
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