Innovation for Pelvic Health

When most clinicians first see the term near infrared spectroscopy (NIRS), they do not recognize that this is an application of physics to medicine that they do in fact have some experience using. Transillumination of a scrotal mass employs the basic physics of light transmission through tissue, and oximetry is able to provide measurement of oxygen saturation (SaO2) because of application of spectroscopic principles. Oximeters use wavelengths that optimize light penetration into tissue and allow measurement of changes in the concentration of hemoglobin because light absorption by this molecule varies depending on the wavelengths used and whether or not it is carrying oxygen. The net result, derived with the aid of signal averaging and software algorithms, is a value of such importance that it is now widely regarded as “the fifth vital sign.”

The International Continence Society (ICS) defines urinary incontinence as the complaint of any involuntary leakage.1 The prevalence of urinary incontinence in community-dwelling women ranges from 10% to 40%; wider ranges can be found in elderly women.2 In studies that differentiate any urinary incontinence from severe or daily disease, the prevalence was 29% (range 11%–72%) and 7% (3%–17%), respectively.3 About a quarter of urinary incontinence is regarded as severe.4 Prevalence has always been higher in institutionalized subjects. Several recent studies from around the world suggest a prevalence of ≥ 50%.2 Approximately half of all incontinent women are classified as stress incontinent, making this group the largest among urge, mixed, and stress types.3

Physicians and their patients have been well served by the recent innovations that have revolutionized the treatment of urinary incontinence and pelvic surgery; however, few developments have dramatically improved post-operative (post-op) urinary management since the introduction of the Foley catheter in 1935.1 There is scarcely better support for this position than the prevalence of cases in which the patients’ predominant concerns are directed toward post-op care rather than the comparative risks inherent to surgical intervention.

Ironically, apprehension regarding postsurgical catheters and urine bags typically overshadows what would logically be far more serious mortality and morbidity concerns associated with general anesthesia, significant blood loss, or other surgical complications.2,3

To many involved with the routine assessment of voiding and storage dysfunction, urodynamics involves the measurement of long-established parameters of bladder pressures and uroflow rates. Initially, voiding assessment was simply “eyeball” urodynamics. From those simple observations to the use of the hydrostatic water column, urodynamics moved from qualitative measurements to something more quantitative.

Incontinence following prostatectomy can be a devastating complication significantly impacting quality of life. The prevalence of post-prostatectomy urinary incontinence (PPI) varies from 2.5%–87%, with 2%–10% reported in more recent series.1,2 Incontinence can also occur in 1% of patients undergoing surgical treatment for benign prostatic hypertrophy. 1

Due to its efficacy, safety, and relative simplicity, the synthetic mid-urethral sling procedure has emerged as one of the mainstays
of surgical therapy for female stress urinary incontinence. The transobturator approach to placing mid-urethral slings has recently been marketed as safer than the retropubic approach due to avoidance of entry into the retropubic space. However, accumulated experience has demonstrated that significant complications are possible with both techniques. The purpose of this review is to summarize the rates, etiology, and management of the most common complications encountered with synthetic mid-urethral slings and to compare, based on recent evidence, complication rates of the retropubic and transobturator approaches to sling placement.

It is well known that patients suffer from urinary symptoms and incontinence in positions that differ from the somewhat artificial conditions created by conventional urodynamic studies. This poses a problem in analysis of the data, particularly when we consider that one of the main goals of such studies is to reproduce the patient’s state when experiencing symptoms or abnormal bladder dynamics, allowing the healthcare provider to gain insight into the pathophysiology of the underlying problem and to devise sound treatment options.

Every year, whether the subject is healthcare,  industry,  or personal lifestyle, you hear the famous phrase Do more with less. How is it possible to gain more out of something with fewer resources? In our everyday lives everything is becoming more expensive, and we see how we are getting less for the same money. When someone asks you to turn the tide and do more with less, you have got to think this request is completely unreasonable! Doing anything impacts the time, people, and efficiency that relate to productivity. Certainly we can try to improve patient processing to improve efficiency, but is it enough to demand more work to be done in less time or at less cost? Processes in patient care and management can do only so much, and once they are optimized, what is left to consider?

Pelvic prolapse is a common condition affecting adult women of all ages, with an estimated 11% of all women undergoing surgical intervention by age 80 for this condition. ¹ Anterior wall defects, or cystoceles, are very common in women and result from a weakness in the anterior vaginal wall support, a continuous connective tissue support from each pelvic sidewall laterally and from the anterior pubic symphysis to the sacrum posteriorly. There are two main defects responsible for cystoceles: central  and lateral. Central defects are caused by a weakness in the perivesical or pubocervical fascia in the midline. Lateral defects stem from a detachment of the vesicopelvic fascia from the arcus tendineus fascia pelvis. The weakened vesicopelvic fascia allows the bladder and urethra to slide down as a unit. The etiology of cystoceles is multifactorial and includes genetic factors that determine tissue strength, parity, hormonal status, age, and previous pelvic surgery. Many cystoceles are asymptomatic; however, they can become symptomatic if the bladder descends to the level of or outside the introitus. Patients may present with a vaginal bulge or pressure while standing that may resolve when they are supine. Many women with symptomatic cystoceles also have concomitant lower urinary tract symptoms including stress incontinence, urgency with or without urge incontinence, and a sensation of incomplete bladder emptying; they may even need to manually reduce the prolapse in order to void to completion.

Urinary incontinence is the involuntary loss of urine. In the United States it may affect 13 million people, with an economic cost of more than 20 billion dollars. ¹ With the aging population, the number of people and funds spent on managing incontinence will likely continue to grow.

The U.S. federal government takes managing patient records for any element of healthcare very seriously. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is the foundation of patient-information control, particularly—but not exclusively—when such information becomes as portable as it does in electronic form. Since the act was passed by Congress, several revisions and clarifications have been approved. Most important is the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule, in short), the final rule of which was issued by the Department of Health and Human Services, and was put into effect on October 15, 2002.*

The goal of urodynamics testing is to provide objective confi rmation of the signs and symptoms of incontinence and voiding dysfunction. While diagnosis and optimal treatment of lower urinary tract dysfunction require a careful history and objective evaluation, it has been demonstrated that urinary symptoms alone are not specifi c in predicting the type of dysfunction (15%–40% of diagnoses will be wrong without urodynamics testing, and 25%–30% of patients will have multiple diagnoses).

About 5% of the population suffers from urinary incontinence, and the proportion is much higher among the elderly. This means that in a city region of 2 million people there are about 100,000 people with this problem— probably about 100 new cases every week (figure 1,).  Most of these people receive no help because it is not offered and they do not ask for it, although half of them would like it.

Incontinence in a child can be a diffi cult problem for child, parent, and physician. A comprehensive history and physical examination will often narrow down the cause of the problem and lead to the development of a treatment plan; however, sometimes more extensive testing is needed because incontinence  may be multi-factorial. Often the treatment strategy needs to be similarly multi-modal.

Many of us have heard of jumping on the bandwagon, an expression used to describe someone following a trend or movement.

At LABORIE, when we think about our quality goals or our customer-service initiatives, we want everyone in our company on the bandwagon, thinking along the same path or philosophy. When it comes to product technology, however, the technology plane instead of the bandwagon is much more appropriate.  After all, when you think of bandwagons, we conjure images of horse-drawn carriages and endless circling when under threat.  This is not at all what we at Laborie want to project.  The airplane is much more sophisticated and of course, it is the modern way to travel.