TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
1315
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.047 available at http://jurology.com/ Editorial Comment: Pelvic organ prolapse is among the most common genitourinary conditions in elderly women. Incidence and prevalence increase with advancing age, and multiple risk factors have been identified, including prior pregnancy and vaginal delivery, obesity and decreases in tissue quality of pelvic floor support structures. Treatment includes surgical repair with either open or minimally invasive surgery using laparoscopy or robotic technology, or nonsurgical therapy with pessaries. Apical prolapse may involve more extensive surgery with sacral colpopexy or other fixation methods. This retrospective analysis compared outcomes of laparoscopic and robotic sacral colpopexies in elderly (65 years or older) and younger women. Major complications occurred in 27.4% of elderly and 17.0% of younger women (p ¼ 0.04). Examples included conversion to open laparotomy, bowel or bladder injuries, hospital readmission, infections, ileus and small bowel obstruction. No patients in either group required blood transfusion. The statistical difference in complications between older and younger patients persisted even after controlling for body mass index, route of surgery, estimated blood loss and length of surgery. These findings are in contrast to the majority of geriatric surgical studies showing that chronological age is not an independent risk factor for outcomes. There were important baseline differences in the groups, with older women having higher rates of prior hysterectomy and more severe (grade III or higher) prolapse. However, these data may help guide counseling recommendations in elderly women being considered for this type of reconstructive surgery. Tomas L. Griebling, MD, MPH
Suggested Reading Gerten KA, Markland AD, Lloyd LK et al: Prolapse and incontinence surgery in older women. J Urol 2008; 179: 2111.
Trauma, and Genital and Urethral Reconstruction Re: The Virtue SlingdA New Quadratic Sling for Postprostatectomy IncontinencedResults of a Multinational Clinical Trial C. V. Comiter, E. Y. Rhee, L. M. Tu, S. Herschorn and V. W. Nitti Departments of Urology, Stanford University Medical School, Stanford and Kaiser Permanente Medical Group, San Diego, California, New York University Langone Medical Center, New York, New York, and Universite´ de Sherbrooke, Sherbrooke, Quebec and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Urology 2014; 84: 433e438.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.009 available at http://jurology.com/ Editorial Comment: The VirtueÒ sling is a new 4-arm mesh sling for male stress urinary incontinence. The authors evaluate a new fixation technique with tunneling of the transobtuator arms toward the pubis and document an improved “cure” rate from 15% to 46% compared to the original method. These results are comparable to the 53% cure rate reported by Rehder et al with the retroluminal AdVanceÔ male sling system.1 Allen F. Morey, MD
1. Rehder P, Haab F, Cornu JN et al: Treatment of postprostatectomy male urinary incontinence with the transobturator retroluminal repositioning sling suspension: 3-year follow-up. Eur Urol 2012; 62: 140.
1316
BENIGN PROSTATIC HYPERPLASIA
Re: A Valsalva Leak-Point Pressure of > 100 cmH2O is Associated with Greater Success in AdVanceTM Sling Placement for the Treatment of Post-Prostatectomy Urinary Incontinence J. Barnard, S. van Rij and A. M. Westenberg Department of Urology, Auckland Hospital, Auckland, New Zealand BJU Int, suppl., 2014; 114: 34e37.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.010 available at http://jurology.com/ Editorial Comment: What is the best way to determine sling candidates from artificial urinary sphincter candidates? Patient history regarding the number of pads required during a 24-hour period is the most commonly used measure of stress urinary incontinence (SUI) severity. But pad usage is subjective and does not account for level of activity or fastidiousness of the patient. Pad weights are similarly imperfect and more unwieldly. This report from New Zealand examines Valsalva leak point pressure (VLPP) as an indicator of success of sling surgery. Most men had either mild (1 to 2 pads) or moderate (3 to 5) SUI. VLPP is an objective measure that is urodynamically derived. The authors found a greater than 90% success rate with the AdVanceÔ sling in men with VLPPs greater than 100 cm H2O. They do not advocate VLPP assessment in all individuals with SUI, but suggest considering it for men with moderate SUI as an adjunctive test. Allen F. Morey, MD
Benign Prostatic Hyperplasia Re: Early Results from a United States Trial of Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia S. Bagla, C. P. Martin, A. van Breda, M. J. Sheridan, K. M. Sterling, D. Papadouris, K. S. Rholl, J. B. Smirniotopoulos and A. van Breda Cardiovascular and Interventional Radiology Department, Inova Alexandria Hospital, Alexandria, Inova Research Center, Falls Church and Inova Health System, Springfield, Virginia, and Georgetown University School of Medicine, Washington, D.C. J Vasc Interv Radiol 2014; 25: 47e52.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.027 available at http://jurology.com/ Editorial Comment: Those of us who have been involved in investigative trials for new therapeutic interventions for benign prostatic hyperplasia have become a bit skeptical regarding the long-term viability of these new, miraculous cures. Too often initial data in a few select patients have not translated to more widespread efficacy and safety. A relatively new player has been prostatic artery embolization (PAE). It is noteworthy that the authors are interventional radiologists, which suggests that urologists will not be the driving force behind this technology, although, ironically, we are the major source of patient referrals. In this preliminary analysis a number of items stand out. First, only 20 of 72 men screened underwent the procedure, with exclusions ranging from, “I just do not want to do this” to opting for watchful waiting. However, the results demonstrate the disconnect between reduction in prostate volume and lower urinary tract symptoms. At 3 months there was a significant decrease in prostate volume (from 82.7 to 56.7 cm3). There was also a symptom score decrease of about 12 points. However, at 3 months most men still had moderate or significant symptoms and would have been eligible for entry into a clinical trial for benign prostatic hyperplasia. As the authors note, this was a small cohort with limited followup. If this technology continues to evolve, it will be interesting to see how clinical trials will be developed. To gain approval, one suspects
1315
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.047 available at http://jurology.com/ Editorial Comment: Pelvic organ prolapse is among the most common genitourinary conditions in elderly women. Incidence and prevalence increase with advancing age, and multiple risk factors have been identified, including prior pregnancy and vaginal delivery, obesity and decreases in tissue quality of pelvic floor support structures. Treatment includes surgical repair with either open or minimally invasive surgery using laparoscopy or robotic technology, or nonsurgical therapy with pessaries. Apical prolapse may involve more extensive surgery with sacral colpopexy or other fixation methods. This retrospective analysis compared outcomes of laparoscopic and robotic sacral colpopexies in elderly (65 years or older) and younger women. Major complications occurred in 27.4% of elderly and 17.0% of younger women (p ¼ 0.04). Examples included conversion to open laparotomy, bowel or bladder injuries, hospital readmission, infections, ileus and small bowel obstruction. No patients in either group required blood transfusion. The statistical difference in complications between older and younger patients persisted even after controlling for body mass index, route of surgery, estimated blood loss and length of surgery. These findings are in contrast to the majority of geriatric surgical studies showing that chronological age is not an independent risk factor for outcomes. There were important baseline differences in the groups, with older women having higher rates of prior hysterectomy and more severe (grade III or higher) prolapse. However, these data may help guide counseling recommendations in elderly women being considered for this type of reconstructive surgery. Tomas L. Griebling, MD, MPH
Suggested Reading Gerten KA, Markland AD, Lloyd LK et al: Prolapse and incontinence surgery in older women. J Urol 2008; 179: 2111.
Trauma, and Genital and Urethral Reconstruction Re: The Virtue SlingdA New Quadratic Sling for Postprostatectomy IncontinencedResults of a Multinational Clinical Trial C. V. Comiter, E. Y. Rhee, L. M. Tu, S. Herschorn and V. W. Nitti Departments of Urology, Stanford University Medical School, Stanford and Kaiser Permanente Medical Group, San Diego, California, New York University Langone Medical Center, New York, New York, and Universite´ de Sherbrooke, Sherbrooke, Quebec and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Urology 2014; 84: 433e438.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.009 available at http://jurology.com/ Editorial Comment: The VirtueÒ sling is a new 4-arm mesh sling for male stress urinary incontinence. The authors evaluate a new fixation technique with tunneling of the transobtuator arms toward the pubis and document an improved “cure” rate from 15% to 46% compared to the original method. These results are comparable to the 53% cure rate reported by Rehder et al with the retroluminal AdVanceÔ male sling system.1 Allen F. Morey, MD
1. Rehder P, Haab F, Cornu JN et al: Treatment of postprostatectomy male urinary incontinence with the transobturator retroluminal repositioning sling suspension: 3-year follow-up. Eur Urol 2012; 62: 140.
1316
BENIGN PROSTATIC HYPERPLASIA
Re: A Valsalva Leak-Point Pressure of > 100 cmH2O is Associated with Greater Success in AdVanceTM Sling Placement for the Treatment of Post-Prostatectomy Urinary Incontinence J. Barnard, S. van Rij and A. M. Westenberg Department of Urology, Auckland Hospital, Auckland, New Zealand BJU Int, suppl., 2014; 114: 34e37.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.010 available at http://jurology.com/ Editorial Comment: What is the best way to determine sling candidates from artificial urinary sphincter candidates? Patient history regarding the number of pads required during a 24-hour period is the most commonly used measure of stress urinary incontinence (SUI) severity. But pad usage is subjective and does not account for level of activity or fastidiousness of the patient. Pad weights are similarly imperfect and more unwieldly. This report from New Zealand examines Valsalva leak point pressure (VLPP) as an indicator of success of sling surgery. Most men had either mild (1 to 2 pads) or moderate (3 to 5) SUI. VLPP is an objective measure that is urodynamically derived. The authors found a greater than 90% success rate with the AdVanceÔ sling in men with VLPPs greater than 100 cm H2O. They do not advocate VLPP assessment in all individuals with SUI, but suggest considering it for men with moderate SUI as an adjunctive test. Allen F. Morey, MD
Benign Prostatic Hyperplasia Re: Early Results from a United States Trial of Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia S. Bagla, C. P. Martin, A. van Breda, M. J. Sheridan, K. M. Sterling, D. Papadouris, K. S. Rholl, J. B. Smirniotopoulos and A. van Breda Cardiovascular and Interventional Radiology Department, Inova Alexandria Hospital, Alexandria, Inova Research Center, Falls Church and Inova Health System, Springfield, Virginia, and Georgetown University School of Medicine, Washington, D.C. J Vasc Interv Radiol 2014; 25: 47e52.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.027 available at http://jurology.com/ Editorial Comment: Those of us who have been involved in investigative trials for new therapeutic interventions for benign prostatic hyperplasia have become a bit skeptical regarding the long-term viability of these new, miraculous cures. Too often initial data in a few select patients have not translated to more widespread efficacy and safety. A relatively new player has been prostatic artery embolization (PAE). It is noteworthy that the authors are interventional radiologists, which suggests that urologists will not be the driving force behind this technology, although, ironically, we are the major source of patient referrals. In this preliminary analysis a number of items stand out. First, only 20 of 72 men screened underwent the procedure, with exclusions ranging from, “I just do not want to do this” to opting for watchful waiting. However, the results demonstrate the disconnect between reduction in prostate volume and lower urinary tract symptoms. At 3 months there was a significant decrease in prostate volume (from 82.7 to 56.7 cm3). There was also a symptom score decrease of about 12 points. However, at 3 months most men still had moderate or significant symptoms and would have been eligible for entry into a clinical trial for benign prostatic hyperplasia. As the authors note, this was a small cohort with limited followup. If this technology continues to evolve, it will be interesting to see how clinical trials will be developed. To gain approval, one suspects
