PubMed Health⌕ Search

Biomedical subjects

Jonathan S Starkman

Publications and source records attributed to Jonathan S Starkman.

10 recordsLinked to original sources
PubMed2007

Management of refractory urinary urge incontinence following urogynecological surgery with sacral neuromodulation.

AIMS: We sought to explore our patient outcomes utilizing sacral neuromodulation in the management of refractory urinary urge incontinence following urogynecological surgical procedures. METHODS: A total of 25 women with urinary urge incontinence following urogynecological surgery were selected for SNS therapy and retrospectively analyzed. All patients completed a comprehensive urological evaluation. Clinical data was recorded to determine outcomes and identify parameters that would be predictive of response to neuromodulation. Outcomes were determined via subjective patient questionnaire and graded as follows: significant response (> or =80% improvement), moderate response (> or =50% and <80% improvement), and poor response (<50% response). RESULTS: Nineteen patients had a previous pubovaginal sling (10 with concomitant pelvic prolapse repair), 3 a previous retropubic suspension, and 3 a transperitoneal vesicovaginal fistula repair. Urethrolysis was performed in 4 patients to alleviate bladder outlet obstruction prior to sacral neuromodulation. Mean patient age was 59.8 years and length of follow-up was 7.2 months. Twenty-two women (88%) had the IPG placed during a Stage 2 procedure. Twenty patients maintained at least a 50% improvement in clinical symptoms at last follow-up and 6 patients were continent. Overall, the number of pads/day improved from 4.2 to 1.1 (P < 0.001). There were no significant differences in response to neuromodulation based upon age, duration of symptoms, type of surgery, or urodynamic parameters. CONCLUSION: Sacral neuromodulation appears to be an effective therapy in patients with refractory urge incontinence following urogynecological surgery. Larger prospective studies with longer follow-up are needed to assess the durability of this therapeutic modality.

Adult↗
PubMed2006

Vesicovaginal fistula following a transobturator midurethral sling procedure.

Synthetic mid-urethral slings are currently the most common surgical procedure performed for the treatment of female stress urinary incontinence. The transobturator mid-urethral sling technique was originally described in 2001 and has since become widely accepted due to its high rate of success and low complication rate. Although complications remain infrequent, when they do occur, there is potential for significant patient morbidity. We report a case of a vesicovaginal fistula following a transobturator mid-urethral sling procedure and describe successful reconstruction with transvaginal sling excision, fistula closure, and placement of an autologous pubovaginal sling.

Female↗
PubMed2006

Methods and results of urethrolysis.

Although occurring with somewhat less frequency now than historically reported, outlet obstruction after incontinence surgery continues to be a source of postoperative patient dissatisfaction and therapeutic dilemma. Several techniques have been described that fall under the rubric of urethrolysis, including sling incision, sling lysis with explantation, and formal vaginal or retropubic urethrolysis (incision and disruption of bladder neck and urethral fibrosis). Surgical approaches have included vaginal, retropubic, or combined techniques with or without the use of adjunctive steps such as graft interposition. However, evidence emanating from reports of these varied techniques has been incomplete due to variability in outcomes presentation, lack of longevity of follow-up, or problematic study design. Nonetheless, the bulk of clinical evidence supports the efficacy of urethrolysis as an intervention for outlet obstruction after stress incontinence surgery. However, persistent irritative bladder symptoms remain bothersome for some women and, in addition, the recurrence of stress incontinence also may complicate the technique of urethrolysis. Management of these potential adverse outcomes also has been inconsistent, with some authorities routinely performing repeat incontinence surgery at the time of urethrolysis and others preferring to assess continence status after convalescence from urethrolysis. The differences among the types of urethrolysis and the results of each type are reviewed in this article in light of evolving definitions of outlet obstruction, diagnosis, and definition in women.

Female↗
PubMed2006

Emerging periurethral bulking agents for female stress urinary incontinence: is new necessarily better?

Bulking therapy for stress urinary incontinence in women continues to evolve from the standpoint of material science. Several new materials have recently been subjected to clinical trials with the aim of assessing efficacy and safety of these agents for possible device registration. These new additions run the gamut of biologic to synthetic materials, including re-engineered carbon-coated zirconium beads, ethylene vinyl copolymer, calcium hydroxylapatite, silicone, and hyaluronic acid. Trial design and results reporting for bulking agents has also evolved, with the addition of quality-of-life and patient approbation assessments now being included with outcomes for incontinence reduction and adverse events recording. The new agents and recent studies are reviewed within a context of the prior evidence that has supported the use of the bulking strategy for management of symptomatic stress incontinence. Several recent trials have also compared bulking agents with surgical interventions from effectiveness, approbation, and cost vantage points so as to better determine the reasonability of bulking agent use in an era of minimally invasive incontinence surgery.

Animals↗
PubMed2006

Voiding dysfunction following removal of eroded synthetic mid urethral slings.

PURPOSE: Voiding dysfunction following genitourinary erosion of synthetic mid urethral slings is not clearly reported. We investigated the incidence of voiding dysfunction in patients following sling excision due to vaginal, urethral or intravesical mesh erosion. MATERIALS AND METHODS: Retrospective review identified 19 patients with genitourinary erosion of polypropylene mesh slings. Comprehensive urological evaluation was performed in all patients, and perioperative and postoperative data were analyzed. Voiding dysfunction was defined as refractory storage symptoms, emptying symptoms and pelvic pain. All subsequent medical and surgical interventions were recorded. RESULTS: In 19 patients a total of 11 vaginal, 7 intravesical and 5 urethral erosions occurred. Mean patient age was 52 years (range 32 to 69) and average followup was 8.4 months (range 3 to 34). Average time from symptom onset to sling removal was 10.1 months (range 1.5 to 38). Of the 19 patients 14 (74%) presented with multiple symptoms. Symptoms varied, including refractory pain, recurrent infections and bladder storage/emptying dysfunction. Urodynamic studies were abnormal preoperatively and postoperatively in 9 of 13 (69%) and 4 of 6 patients (67%), respectively. Following surgery lower urinary tract symptoms resolved completely in only 4 of the 19 patients (21%). Stress incontinence recurred in 8 of the 19 patients (42%). Five patients underwent simultaneous pubovaginal sling, of whom none had recurrent stress urinary incontinence. Only 9 patients (47%) considered themselves dry with no pads following surgery. Four patients required further surgery for refractory voiding symptoms. CONCLUSIONS: Voiding dysfunction is not an uncommon finding after sling excision in the setting of genitourinary erosion. It may cause additional patient morbidity.

Adult↗
PubMed2006

Transdermal oxybutynin for overactive bladder.

Overactive bladder is commonly treated with oral anticholinergic drugs such as oxybutynin chloride. Although oral anticholinergic agents have been effective in controlling urinary urgency and frequency and in decreasing incontinence episodes, adverse events, particularly dry mouth, often cause patients to discontinue oral therapy and to endure incontinence. Oxybutynin can be delivered transcutaneously, maintaining the efficacy of oral oxybutynin while significantly minimizing the side effects (eg, dry mouth) that may complicate therapy. By avoiding hepatic and gastrointestinal metabolism of oxybutynin, less N-desethyloxybutynin is produced (this compound is deemed responsible for the anticholinergic side effects such as dry mouth). This novel oxybutynin formulation offers patients who have overactive bladder and urge urinary incontinence a well-tolerated option for managing the symptoms of overactive bladder.

Administration, Cutaneous↗
PubMed2006

Management of overactive bladder with transdermal oxybutynin.

In clinical trials, transdermal oxybutynin (OXY-TDS) has shown comparable efficacy and improved tolerability when compared with conventional pharmacotherapy. Systemic anticholinergic adverse effects are comparable to those with placebo, most likely owing to avoidance of first-pass hepatic metabolism and conversion of oxybutynin to N-desethyloxybutynin. OXY-TDS has predictable pharmacokinetic absorption and elimination parameters, as shown in both in vitro and in vivo studies. Consistent plasma concentrations of oxybutynin avoid labile peak and trough concentrations seen with immediate-release formulations, paralleling extended-release drug delivery. This novel drug delivery system has unique dermatologic skin application site reactions, including erythema and pruritus. Skin reactions are usually mild and can be minimized by varying the site of patch application. Most eczematous dermatologic reactions can be appropriately treated with a moderately potent topical corticosteroid cream. A small percentage of patients will discontinue therapy as a result of bothersome application site skin reactions.

Journal Article↗
PubMed2005

Comparison of bipolar transurethral resection of the prostate with standard transurethral prostatectomy: shorter stay, earlier catheter removal and fewer complications.

UNLABELLED: Authors from Detroit assess the use of the bipolar TURP against the monopolar technique; there were relatively few patients, reflecting the decreasing requirement for TURP in the USA. In addition, the amount of resected tissue was not particularly large, almost certainly a reflection of the decreasing size of resected prostatic tissue in that country. They found the bipolar TURP to have many advantages over standard monopolar TURP, and these are described. Acute urinary retention is a common urological emergency, and authors from London found that it had a measurable impact on the health-related quality of life of patients who develop this problem. They describe particularly how painful a condition it is, and that it had a significant economic burden. OBJECTIVE: To assess bipolar transurethral prostatectomy (TURP) using the Gyrus system (Gyrus Medical, Maple Grove, MD) compared with a standard monopolar TURP. PATIENTS AND METHODS: All 43 patients undergoing TURP from November 2000 to August 2002 were reviewed retrospectively; the 1.5-year observation period allowed for the detection of late complications. In all, 18 consecutive patients had standard and 25 had bipolar TURP. RESULTS: The resection was 18 g for standard and 15 g for the Gyrus TURP (part of the Gyrus chips are vaporized during resection). The Foley catheter was removed sooner (1.8 vs 3.2 days) and the hospital stay was less in the Gyrus group (1.2 vs 2.1 days). Acute complications occurred in a third of the standard group and four (16%) of the Gyrus group. Long-term complications were comparable, at two each in the standard and Gyrus groups. Four patients (15%) with small glands went home on the day of surgery, needing no bladder irrigation after Gyrus TURP. CONCLUSION: Few innovations in TURP technique have been described in the past few decades but comparing Gyrus to standard TURP showed that the former allows earlier removal of the urinary catheter and earlier discharge from hospital, while decreasing complications. The Gyrus system also has other benefits; it allows coagulation of tissue during resection, resulting in excellent intraoperative visualization, and normal saline is used as the irrigant fluid, reducing the potential for TUR syndrome. The shorter stay after Gyrus TURP can result in cost savings of up to $1200/patient/day at our institution.

Adult↗
PubMedDate not supplied

Transdermal drug delivery treatment for overactive bladder.

Overactive bladder is commonly treated with oral anticholinergic drugs such as oxybutynin chloride. Although oral anticholinergic agents have been effective in controlling urinary urgency and incontinence, adverse events, particularly dry mouth, often cause patients to discontinue oral therapy and to endure incontinence. Oxybutynin can be delivered transcutaneously, maintaining the efficacy of oral oxybutynin while significantly minimizing side effects (e.g., dry mouth) that may complicate therapy. By avoiding hepatic and gastrointestinal metabolism of oxybutynin, less N-desethyloxybutynin (N-DEO) is produced and this compound is deemed to be responsible for anticholinergic side effects such as dry mouth. This novel oxybutynin formulation offers patients with OAB and urge urinary incontinence a well-tolerated option for managing the symptoms of overactive bladder.

Administration, Cutaneous↗