SUFU WINTER 2020 NEWSLETTER

PRESIDENT’S MESSAGE By: Sandip Vasavada, MD

Dear SUFU members, speakers from many parts of the world. Dr. David Ginsberg and Dr. Stu Reynolds and the clinical committee have created I hope every one of you is doing well and a fantastic program that promises to still be as educational and staying healthy in this difficult time. I must say, thought provoking as ever. Both parts to the program will have this is not quite what I envisioned my SUFU several keynote speakers from around the world as well as Presidency would be like, but like so many of several “rooms” of virtual posters and podiums to enlighten us you, I have had to adapt to changes. One of the on the latest in FPMRS research and innovations. The clinical biggest paradigm shifts has been to replace portion of the program will be held on Friday, February 26 and our usual in-person annual meeting with a Saturday, February 27 from about 10:00 a.m. EST to 5:30 p.m. virtual option for this winter. Heather and the EST. Our meetings could not be held without the strong support WJ Weiser team did a great job in negotiating from so many of our industry partners. They will also be having with the hotel in Nashville and secured the commitment for several breakout symposia throughout the meeting that will be SUFU to be there now in 2023. Our 2022 meeting is slated to both engaging and interactive. be in San Diego. As always, please do not hesitate to reach out to us with any I know like many of you, I will miss the camaraderie and in- suggestions or to get more involved in SUFU. Stay safe and we person networking that has made SUFU so successful over the look forward to a fantastic, albeit virtual, meeting in February! last several years. The modified plan is that the basic science program, led by Dr. Larissa Rodriguez and Dr. MaryRose Sullivan, Sincerely, will be held on Thursday, February 25 and includes outstanding basic and translational science discussions with excellent Sandip Vasavada, MD

MESSAGE FROM THE BOARD By: David A. Ginsberg, MD

One of the fun jobs I have as SUFU Vice President is planning Saturday) and how long the sessions will go each day. We also the winter meeting. Little did I know planning would be double made a decision that if we were going virtual we were going the fun this year as we first organized an in-person meeting to take advantage of friends and colleagues around the world. which then evolved into planning the virtual meeting. However, This format will allow for participation of luminaries in our field before I speak to our upcoming meeting, I have to give a big that we all know but don’t necessarily attend our winter meeting shout of thanks to my planning committee (Stu Reynolds, with regularity. Because of these changes in speakers and the Doreen Chung, and Benji Dillon), the SUFU executive shortening of the program, many of you that were on the “in- committee, and both Heather and Michelle at Weiser who all person” program may not be part of the revised schedule. We contributed significantly to the entire process. look forward to getting your session back on for 2022.

As you would expect, the initial program contained the usual Thank you all for your patience as we worked out the various sessions that went from early in the morning to late in the changes to the program. Not only do I look forward to our afternoon. The virtual program is different. The meeting will be upcoming meeting I very much look forward to 2022 where we shorter in regard to both number of days (Thursday through can all (hopefully!) meet again in person in San Diego.

1 History of SUFU: Frank Hinman, Jr. By: Steven J. Weissbart, MD and Alan J. Wein, MD, PhD, FACS

One would imagine that when urologists hear the name, Frank emerging interest in neurogenic bladder, ureteral physiology, Hinman, Jr., they immediately think of his Atlas of Urologic and urinary tract infections, and several national symposia were Surgery, which nearly all of us have studied during training. held on these topics. In 1964, Frank Hinman, Jr. (along with Perhaps some urologists would connect the name Frank other soon to be founding members of the Urodynamics Society) Hinman, Jr. to his eponymous syndrome (Hinman’s Syndrome). attended an important symposium on pyelonephritis, and in Urologists and Society members may, however, be unaware that 1968, he organized a pivotal symposium on the hydrodynamics he was the 2nd President of our Society and was highly influential of micturition in Iowa City, Iowa. He was a core member of in its formative years. Thus, in this history column, we highlight numerous meetings on lower urinary tract function, and along the career of Frank Hinman, Jr., with a special emphasis on his with a core group of urologists and basic scientists, Frank contributions to our Society. Hinman, Jr. helped to form the Urodynamics Society, attending its first formal meeting in 1969. Urology may have been in Frank Hinman, Jr.’s DNA, having been born on October 2, 1915 to the first trained urologist in California: The Urodynamics Society did not attain formal structure until Frank Hinman, Sr. Frank Hinman, Jr. completed undergraduate 1973, when it decided to have both a scientific meeting and college at Stanford in 1937, graduating summa cum laude, and a business meeting as well as an election with three Society he attended Johns Hopkins Medical School, where he also officers: President, Vice President, and Secretary. Frank completed internship training in internal medicine. He then went Hinman, Jr. worked along Saul Boyarsky (our Society’s first to Cincinnati for two years for general surgery residency and President) to institute formal structure in the Society (Figure trained under Mont Reid. He subsequently served in WWII as a 1). Frank Hinman, Jr., as the Society’s first Vice President also surgeon on the aircraft carrier, Intrepid. After returning from the focused on introducing clinical topics to Society meetings as war, he completed urology residency at University of California. the meetings were previously more targeted to basic scientists His first job started in 1946 with his father in private practice. (Figure 2). Frank Hinman, Jr. became the second president of the Urodynamics Society and served his term from 1980-1982. While in practice, Frank Hinman, Jr. was involved in academics, serving as a clinical instructor at the University of California. While Frank Hinman, Jr. authored more than 250 research He was on staff at Franklin Hospital as well as Women’s and papers and books, his most well-known contributions include his Children’s Hospital. During this time, he treated children with 1973 paper on the occurrence of an uncoordinated detrusor and bladder exstrophy and published on adrenogenital syndrome. sphincter muscle (which earned the name Hinman Syndrome), It was in the setting of his treatment of children with urologic his 1983 textbook Benign Prostatic Hypertrophy, and his Atlas disease that he helped found the Society of Pediatric Urology of Urologic Surgery (first published in 1992). Frank Hinman, in 1951. Remarkably, this would not be the only subspecialty Jr. possessed a lifelong interest in painting, and so it does not society that Frank Hinman, Jr. helped to found. come as a surprise that he was able to capture urologic surgical anatomy so vividly in his atlas. And for all us who review his In 1958, he became chief of the Urology Service at San surgical atlas, it certainly reminds us of the old adage “a picture Francisco General Hospital. During this time, there was an is worth a thousand words.”

Figure 1: Correspondence between Frank Hinman Jr. and Saul Boyarsky regarding Society matters (from the Rubenstein Rare Book & Manuscript Library)

2 History of SUFU Continued By: Steven J. Weissbart, MD and Alan J. Wein, MD, PhD, FACS

Figure 2: Society Meeting Programs from the 1979 and 1980 meetings. Frank Hinman Jr. presided over these meetings and focused on clinical topics.

References: • Bloom DA, Kogan BA. Conversations with Frank Hinman, Jr. Urology. 2001 Apr 1;57(4):843-6. • Hinman F, editor. Hydrodynamics of micturition. Thomas; 1971. • Hinman F Jr (Ed): Benign Prostatic Hypertrophy. New York, Springer-Verlag, 1983. • Hinman F. Nonneurogenic neurogenic bladder (the Hinman syndrome)–15 years later. The Journal of urology. 1986 Oct;136(4):769-77. • Hinman F, Baumann FW. Vesical and ureteral damage from voiding dysfunction in boys without neurologic or obstructive disease. The Journal of urology. 1973 Apr;109(4):727-32. • Hinman F Jr: Atlas of Urologic Surgery, 1st ed. Philadelphia, WB Saunders, 1992.

3 SUFU Member Highlight: Steven J. Weissbart, MD - Part of the SUFU Young Members Committee a) Demographics so-called “Brindley event” occurred when Sir Giles Skey Brindley • Age: 37 years old injected himself with a vasoactive agent and walked around • Medical School: The George Washington University the room with his pants down to show urologists his erection. School of Medicine and Health Sciences (graduated This took place at the 1983 Urodynamic Society meeting in Las 2009) Vegas. When people think about SUFU, they probably think • Residency: Icahn School of Medicine at Mount Sinai more about lower urinary tract and pelvic floor dysfunction than (graduated 2014) ED. However, I learned that the Urodynamics Society was also • Fellowship: University of Pennsylvania – FPMRS initially interested in erectile dysfunction. Another surprising (graduated 2016) aspect of the Society was learning that it was formed by such a • Current employment: I am currently a faculty member small close-knit group of members. This was surprising to me as in the SUNY Stony Brook Department of Urology I’ve always known SUFU to have a membership volume in the • Any special positions at SUNY: I serve on the SUNY hundreds. Stony Brook IRB as well as the Medical School Admission Committee. d) What work do you have ongoing with regards to your • How many years have you been attending SUFU?: I history columns? started attending SUFU in 2012- my first meeting was the We have been excited to find a plethora of historical records that Winer meeting at the Roosevelt Hotel in New Orleans. were donated by our Society’s first president, Saul Boyarsky. We look forward to presenting the information contained in these b) You have been assisting our Society’s Historian. How did records’ future history columns. Additionally, as it has been you become interested in the Society’s history? announced, the 2021 SUFU winter meeting will be held virtually At the first SUFU meeting I attended in 2012, it was announced in the setting of the COVID pandemic. This will be a historical that our Society was changing names from the Society of first, and we will be paying special attention to capturing historical Urodynamics and Female Urology to the Society of Urodynamics, information about the society as it relates to the COVID crisis. Female Pelvic Medicine & Urogenital Reconstruction. I didn’t make much of it at the time, but years later after attending my e) Please give us a fun fact that others may not know about first SUFU meeting as an attending physician, I recalled the you. change in name. The idea popped up in my mind that SUFU’s My first concert was a combined performance by Elton John and newest members were likely unaware of this important historical Billy Joel as part of their face to face tour. As I was in college event. In addition, I realized that there likely was a lot of important at the time, we had seats in the nosebleed section. However, Society history that I was unaware of. This sparked my interested a concert producer approached us and gave us front row seats in learning more about the Society’s history and assisting our (we thought that the show possibly wanted really cool college Historian. Capturing our Society’s history not only serves to kids in the front for image?). So, there we were in the front row of acknowledge all of the contributions that members have made the MCI center in Washington DC. As Elton John and Billy Joel over the years, but it also educates newer members on how our ran across the stage, I remember high fiving them a couple of Society has developed over prior decades. times. It was a pretty cool experience. c) To date, what have been some of the most surprising f) What is you favorite FPRMS case to do? things you have found while digging through SUFU history? Definitely a robotic sacrocolpopexy. I love the anatomy and the By far and away, I was really surprised when I learned that the different surgical spaces that are entered, which are unique to “Brindley event” took place at one of our Society meetings. The the case.

NAU Update By: Roger Dmochowski, MD, MMHC, FACS

The journal continues to experience high volumes of submissions of descriptors for single use body worn absorbent incontinence for candidate articles. This year is no exception and likely will products details the complexities of describing and categorizing be the highest volume year for submissions to date. The journal these products. The second report provides the International has dramatically increased its process rapidity and now the Continence Society’s terminology group report for male urinary wait time to appearance in press is approximately one month incontinence interventions and appropriate descriptors thereof. after final acceptance. The Journal continues to have a robust Both are important documents and underscore the importance representation of a number of topics of interest to pelvic floor of the mutual efforts of the ICS and SUFU. medicine and continues its commitment to basic science publication as well as to breaking news in clinical science as The journal remains very interested in new reviewer’s and will well. soon be evaluating the editorial board for new membership. We welcome your interest and involvement, and we are happy In the eighth edition of the 39th volume, that which has most to hear your thoughts. Please don’t hesitate to contact me recently been published in press, two separate terminology papers personally or to send your thoughts and comment to the journal appeared. The ICS terminology report relates to standardization at [email protected]. 4 SUFU Podcast Update By: Rena D. Malik, MD, @RenaMalikMD

Did you miss the SUFU 2020 Winter Meeting? Not to worry we are releasing some of the amazing content from the meeting on our podcast starting December 8 EVERY WEEK until the SUFU 2021 SOCIETY OF URODYNAMICRODYNAMICSS, FEMALEEMALE PELVIC MEDICINE & Virtual Meeting. UROGENITAL RECONSTRUCTION

You can find our podcast on any iTunes, Stitcher, or wherever you consume your podcasts. Or check out wavve.link/SUFU SUFU PODCAST Scheduled releases include:

Date Podcast Title December 8, 2020 SUFU20: Point-Counterpoint: Neuromodulation: Where Should We Place the Lead? December 15, 2020 SUFU20: Enhanced Recovery After Surgery in FPMRS December 22, 2020 SUFU20: Panel: Urologic Issues in Pregnancy December 29, 2020 SUFU20: Enhancements to Office Based Female Pelvic Medicine/Reconstructive Practice January 5, 2021 SUFU20: Female Sexual Dysfunction January 12, 2021 SUFU20: When a Transgender Patient Walks into Your Office: Most Common Urologic Issues January 19, 2021 SUFU20: The Prolapsed in the Young Female: Should It Stay, or Should It Go? January 26, 2021 SUFU20: Distinguished Service Award Lecture - On Caring for Each Other by Roger Dmochowski, MD February 2, 2021 SUFU20: Meeting the Challenges of an Independent Urology Practice: What are the Future Options? February 9, 2021 SUFU20: Theoretical Basis for Neuromodulation February 16, 2021 SUFU20: Flap Use in Reconstructive Urology February 23, 2021 SUFU20: International Perspectives on the Use of Synthetic Mesh Slings

Basic Science Update By: Maryrose Sullivan, PhD, and Toby Chai, MD

As we readjust to an online conference, the Basic Science scientific advances in lower urinary tract dysfunction, our Committee is working hard to ensure that we provide a robust panelists will discuss critical aspects of this burgeoning research scientific program as part of the SUFU 2021 annual meeting, field, including bioinformatic approaches, multiomics analysis, notwithstanding an abridged schedule. We are excited that Dr. machine learning techniques and metagenomic applications. Martin Michel and Dr. Tony Yaksh have graciously accepted our invitation to serve as keynote speakers for our program. Dr. Michel, Finally, the Basic Science Program will culminate in a virtual Professor of Pharmacology at Johannes Gutenberg University, poster session that will highlight emerging trends in our field will update us on the therapeutic pipeline for bladder disorders, and showcase scientific contributions from our members and barriers to drug development and unmet research needs in the conference attendees. We hope to provide an interactive forum field of benign urology. Dr. Yaksh, Professor of Anesthesiology for this session that will promote the collaborative exchange and Pharmacology at the University of California, San Diego, will of ideas and dissemination of first-rate research discoveries. discuss the role of immune signaling in pain processing, and the Please join us online for this unique and informative Basic spinal pharmacology of opiates. Science Program. We look forward to your participation in these events and your engagement with fellow researchers. In addition to these renowned speakers, we have organized an outstanding panel of experts who will speak on the topic of Big Data as it relates to benign urologic disease. With the goal of understanding how Big Data can be exploited to accelerate

5 Health Policy Update The Federal Requirements for Patient Information Sharing: What should we know? By: Ayman Mahdy, MD, PhD

Introduction: How will that affect my way of patient chart documentation? Patient access to their EHI is not a new concept. Prior publications Knowing that patients are able to freely access their EHI, we have shown that patient access to their clinical notes and test (as providers) should follow best practices in writing our clinical results is associated with improvement in patient compliance. notes. We should use simple language and avoid medical jargon Research also showed patient access to EHI improves patients’ and acronyms in order for the patient to understand the content autonomy and provide them more control of their medical care. of the EHI notes. Supportive and encouraging statements in the notes can have positive impact on patient compliance. Providers The final rule of the 21st Century Cure Act implements certain should proofread their notes and use their EMR software features provisions of which regulations that limit information blocking are or “User Dictionary” that help with proper writing and spelling probably the most impactful on health care providers. Activities check. Details on how could we best formulate our clinical notes that do not constitute information blocking regulate the access, in the light of this new rule are detailed in an article by Klein et al exchange, and use of Electronic Health Information (EHI). (reference 6 below). Furthermore, and as part of the section 4006(a) of the Cures Act, the final rule supports patients’ access to their own medical Conclusion: records at no cost and in a convenient and easily accessible The implementation of the final rule information blocking provision manner. Under the final rule, patients will be able to access is around the corner. Under the final rule, patient access to their their own medical records using their smartphones by using EHI will be a federal requirement that applies to all the US health application programming interfaces (APIs). The final rule will care system. This will allow patients free and convenient access apply to all health care systems in the US. to their EHI simply using secure mobile apps. The final rule will be effective in 2022 and we as providers should be prepared to Exceptions to the final rule: tailor our approach to medical chart documentation accordingly. Under the “Preventing Harm Exception,” the provider is able to justify limiting patients’ access to their medical information. This References: exception is only determined by the patient provider and who is 1. Tom Delbanco , Jan Walker, Sigall K Bell, Jonathan D Darer, aware of the risks involved if the medical information is released Joann G Elmore, Nadine Farag, Henry J Feldman, Roanne to the patient. The provider justification for the “Preventing Harm Mejilla, Long Ngo, James D Ralston, Stephen E Ross, Neha Exception” has to be documented in the patient chart. There is Trivedi, Elisabeth Vodicka, Suzanne G Leveille Inviting also the “Privacy Exception” that can be invoked if there is a patients to read their doctors’ notes: a quasi-experimental federal law or statutes that dictate so. The “Privacy Exception” is study and a look ahead. Ann Intern Med. 2012 Oct 2; 157(7): also applicable if the patient requests their medical information 461-70. not to be released. This patient request has to be documented in 2. 21st Century Cures Act: Interoperability, Information Blocking, the patient chart as well. and the ONC Health IT Certification Program. https:// www.federalregister.gov/documents/2020/05/01/2020- Patient information privacy concerns and remedies: 07419/21st-century-cures-act-interoperability-information- Associated with the patient mobile app use, there arise the blocking-and-the-onc-health-it-certification privacy and security concerns related to the sensitive information 3. 21st Century Cures Act Final Rule: Key Health Data Privacy included in patients’ medical records. These concerns are Considerations. https://fpf.org/2020/11/02/21st-century- addressed through the CARIN Trust Framework and Code of cures-act-final-rule-key-health-data-privacy-considerations/ Conduct and Attestation (CARIN Code) and which enforces 4. HHS Extends Compliance Dates for Information Blocking and commitment for consenting, transparency, and security of the Health IT Certification Requirements in 21st Century Cures individual access. Furthermore, there are app developer privacy Act Final Rule. https://www.hhs.gov/about/news/2020/10/29/ policies, according to the Federal Trade Commission and State hhs-extends-compliance-dates-information-blocking-health- Attorneys General. Last but not least, the Office of the National it-certification-requirements-21st-century-cures-act-final- Coordinator for Health IT (ONC) provides recommendations rule.html to third-party app users and which pertain to privacy policies 5. CURES ACT FINAL RULE Changes and Clarifications from and procedures. The app users are required to follow these the Proposed Rule to the Final Rule. https://www.healthit. recommendations before they are able to use these apps to gov/sites/default/files/cures/2020-03/NPRMvsFinalRule.pdf. access EHI. 6. Jared W. Klein, Sara L. Jackson, Sigall K. Bell,Melissa K. Anselmo, Jan Walker,Tom Delbanco and Joann G. Elmore. When will this final rule be effective? Your Patient Is Now Reading Your Note: Opportunities, The final rule was released to the public march 2020 and Problems, and Prospects. The American Journal of Medicine. was effective June 30, 2020. In response to the COVID-19 October 2016; 129 (10): 1018-21. pandemic, the ONC has extended the compliance dates for this rule to November 2, 2020. The final rule has several different components, the one pertinent to information blocking provisions (45 CFR Part 171) has been delayed until April 2021 with the rest of the provisions to be fulfilled through December 31, 2022. 6 Education Committee Update By: Alexander Gomelsky, MD

Happy holidays to all! With the transition of the 2021 SUFU the forum will contain content only and the abstract presentations Winter Meeting to a virtual platform, the annual Fellows Forum will be canceled for this year. We anticipate a fun, interactive will follow suit. The virtual forum will take place on February 20, session and welcome all of the fellows to join in. the Saturday immediately preceding the Winter Meeting. The Committee is busy finalizing the final itinerary, but we expect that

SUFU Young Member Committee (YMC) Update

1. The SUFU UTI Tutor for women with frequent bladder 2. The SUFU Sacral Neuromodulation Education Endeavor infections. The SUFU Young Members committee has also created an The Young SUFU committee has created an online, online patient information sheet for what to expect during and interactive patient resource for women with frequent urinary after a sacral neuromodulation procedure. Like the recurrent tract infections. Frequent UTIs are a common problem urinary tract infection module above, we hope that this will that patients find distressing. We felt there was a need for be a useful resource for patients and SUFU members alike. a patient centered tool to help women understand some of the initial management options. We hope members will Vaginal Surgery Patient Guide recommend this website to patients and share this link with Sacral Neuromodulation Patient Guide women who are looking for practical advice to help manage this problem. We look forward to building on this tool in the 3. SUFU Shared EPIC Templates future based on the feedback from users. Finally, the SUFU Young Members committee has created SUFU Patient Resources an archive of EPIC templates (notes, procedures and post- visit instructions) that may be of use to members looking to increase visit efficiency.

SUFU EPIC Templates

Coding Corner By: Michael A. Ferragamo, MD, FACS

Coding Changes for 2021 1. Number and complexity of problem(s). 2. Amount and complexity of data to be reviewed and analyzed. On January 1, 2021 there will be new and major changes for CPT 3. Risk of complications, morbidity, and mortality of patient code 99201 to 99215, office and outpatient visits for both new and management. established patients. CPT code 99201 will be deleted for 2021 and for future years. The above visit codes will be reimbursed at Choice of coding a level of care using MDM will be determined an increased rate over payments of 2020. History and physical by the two highest levels of the three components with the final examination will no longer be utilized to effect documentation or level the lowest of the two highest components identified. fee selection. However, one must document an appropriate and necessary history and examination to be able to properly treat Note that with the exception of 99202 to 99215 all other E/M the patient and problem. The examining physician will determine codes will follow the 2020 intact rules and regulations both for the appropriateness of the examination but this will not contribute documenting the history, physical examination, and 2020 MDM in any way to code selection. There will be increased flexibility including the old risk table when documenting and billing a level for the physician in how visit levels are documented and chosen, of care. specifically one will have a choice to use either Time or a revised Medical Decision Making, MDM, table. See the 2021 CPT manual for the details for billing the new time schedule and the revised MDM table. There will be a new time schedule for each CPT E/M code including face-to-face and non-face-to-face time with ranges of time given for each level. Documentation of counseling and coordination of care will no longer be necessary when using time alone in billing for charges based on time. The new MDM table will be revised for 2021 and include three main components.

continued on following page 7 Coding Corner Continued By: Michael A. Ferragamo, MD, FACS

New and Deleted Codes for 2021 The following procedure codes have been deleted because of infrequent use: ICD-10-CM: there are no new diagnostic codes for October 1, 57112, radical with removal of para-vaginal tissue 2020. (bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling {biopsy}) CPT: there is a new add-on code: +57465, computer aided mapping of uteri during including optical 58293, vaginal for uterus>250 gm. with colpo- dynamic spectral imaging and algorithmic quantification of the urethropexy, (Marshall-Marchetti and Krantz type or Pereyra acetowhitening effect (list separately in addition to code for the type with or without endoscopic control). primary procedure.) All coding questions should be addressed to DR. Ferragamo at [email protected]

Interesting Case By: Fenwa Milhouse, MD

Presentation: After prolonged diversion with bilateral PCNs, the conduit was LR is a 69-year-old woman with history of vaginal cancer s/p revaluated. XRT and total , neovaginal formation (using biologic Alloderm graft), sigmoid colon conduit urinary diversion, 3/30/20: Looposcopy, loopogram, bilateral retrograde pyelogram, and end colostomy approximately four months ago. She presents left antegrade pyelogram revealed conduit-neovagina fistula, no to our institution with significant urine leakage from neovagina uretero-vaginal fistula and reduced output from her conduit. She was suspected to have a vaginal-urinary fistula from either her neovagina to conduit or neovagina to ureter. She also reported that her neovagina “falls out” at times. On physical exam, she was found to have a pool of fluid at the vaginal apex and complete vault prolapse with Valsalva.

Work up: She first underwent bilateral percutaneous nephrostomy placement. Vaginal leakage completely ceased after PCNs were placed.

2/14/20: Conduit loopogram

She also underwent cystoscopy of conduit/ looposcopy – conduit loop noted to be long and tortuous with a portion of the conduit appearing to go down towards the pelvis – likely near the apex of the neovagina.

Vaginoscopy and exam under anesthesia revealed vaginal apex with whitish tissue.

continued on following page 8 Interesting Case Continued By: Fenwa Milhouse, MD

Diagnosis: bowel for neovagina creation. Kim et al found a 17% prolapse Neovagina-conduit fistula, complete vault prolapse of neovagina rate after rectosigmoid vaginoplasty performed in 84 patients for various causes.9 The choice of prolapse repair depends on the Surgical Management: patient’s history, vaginoplasty method, and anatomy. 10 Mesh She underwent exploratory laparotomy, small bowel resection, prolapse repairs should be used with caution in neovaginas with repair of conduit-neovagina fistula, revision of colon conduit, impaired blood supply.11 Fascial harvests have been utilized as bilateral ureteroneocystotomy, and abdominal sacrocolpopexy a mesh-free sacrocolpopexy procedure in the prolapse repair with fascia lata harvest, perineorraphy. of native . Seth et al describes successfully using a 10- 18 cm x 2.5 cm autologous rectus fascia harvest, reconstructed It was a very difficult case given dense radiation changes and into a Y configuration, to treat 7 patients with uterine or vault her previous abdominal surgeries. A small bowel resection was prolapse.12 In our case, we harvested a 3 cm x 15 cm long required due to enterotomies inadvertently made during the take strip of fascia lata that was affixed to the anterior portion of the down of extensive bowel adhesions. The colon conduit was found neovagina on one end and the anterior longitudinal ligament on to be extremely long, with a significant portion of it adherent in the other end. This allowed us to achieve good apical suspension the pelvis and to the neovagina. The decision was made to of her prolapsed neovagina. reduce the conduit length in order to get it out of the pelvis and separate it from the fistula. Bilateral ureteral reimplantation was References: also necessary given the revision of the colon conduit. 1. Smith ZL, Johnson SC, Golan S, McGinnis JR, Steinberg GD, Smith ND. Fistulous Complications following Radical Cystectomy We were able to harvest a 3 cm x 15 cm fascia lata graft from for Bladder Cancer: Analysis of a Large Modern Cohort. J Urol. the left leg. We used multiple 2-0 PDS to suture the distal end of 2018;199(3):663-668. doi:10.1016/j.juro.2017.08.095 the fascia lata graft to the anterior portion of the neovagina. The 2. Gilbert SM, Lai J, Saigal CS, Gore JL. Downstream complications following urinary diversion. J Urol. 2013;190(3):916-922. proximal end of the fascia lata graft was sutured to the anterior doi:10.1016/j.juro.2013.03.026 longitudinal ligament on the sacrum using 2-0 Prolene sutures. 3. Rapp DE, O’Connor RC, Katz EE, Steinberg GD. Neobladder- A perineorraphy was done in the usual fashion to complete the vaginal fistula after cystectomy and orthotopic neobladder prolapse repair. construction. BJU Int. 2004;94(7):1092-1095. doi:10.1111/j.1464- 410X.2004.0339.x Discussion: 4. Carmel ME, Goldman HB, Moore CK, Rackley RR, Vasavada Fistula formation after radical pelvic surgery and urinary SP. Transvaginal neobladder vaginal fistula repair after radical diversion is a rare and therefore understudied complication. In a cystectomy with orthotopic urinary diversion in women. Neurourol large retrospective review of over 1000 patients who underwent Urodyn. 2016;35(1):90-94. doi:10.1002/nau.22687 radical cystectomy and urinary diversion at the University of 5. Rosenberg S, Miranda G, Ginsberg DA. Neobladder—Vaginal Chicago, a 3% fistula rate was reported.1 Gilbert et al reported fistula: The University of Southern California experience. Neurourol Urodyn. 2018;37(4):1380-1385. doi:10.1002/nau.23454 a 2.6% fistula rate with conduit urinary diversions in a review 6. Kaufman MR. Neobladder-Vaginal Fistula: Surgical Management of over 1500 patients using Medicare claims. The majority of Techniques. Curr Urol Rep. 2019;20(11). doi:10.1007/s11934-019- which occurred in the first two years following diversion.2 When 0934-0 fistulas occur following radical cystectomy and urinary diversion, 7. Tunuguntla HSGR, Manoharan M, Gousse AE. Management of most commonly they involve urinary diversion with the bowel. neobladder-vaginal fistula and stress incontinence following radical 1Previous radiation history and orthotopic neobladder diversion cystectomy in women: a review. World J Urol. 2005;23(4):231-235. have been found to be risks factors for fistula formation. 1 doi:10.1007/s00345-005-0013-7 8. Chowdhury ML, Shen A, Palmer C, Ghoniem G. Workup and There is scarcity of literature defining surgical approach and conservative management of ileal conduit-vaginal fistulas: review treatment of urinary diversion-vaginal fistulas. The overwhelming of literature. Int Urogynecol J. 2020;31(7):1377-1379. doi:10.1007/ majority of this literature involves the repair of neobladder- s00192-019-04143-0 9. Kim SK, Park JW, Lim KR, Lee KC. Is rectosigmoid vaginoplasty vaginal fistulas.3,4,5,6,7 Chowdhury et al reported a case of ileal still useful? Arch Plast Surg. 2017;44(1):48-52. doi:10.5999/ conduit-vaginal fistula following radiation and pelvic exenteration aps.2017.44.1.48 in a woman who was unfortunately a non-operative candidate.8 10. Neron M, Ferron G, Vieille P, Letouzey V, Fatton B, de Tayrac R. Unfortunately, these patients often already have significant Treatment of neovaginal prolapse: case report and systematic concomitant morbidities and complex surgical histories making review of the literature. Int Urogynecol J. 2017;28(1):41-47. operative correction exceptionally challenging. doi:10.1007/s00192-016-3009-5 11. Amies Oelschlager AM, Kirby A, Breech L. Evaluation In our case, the colon conduit was redundant and traveling and management of vaginoplasty complications. Curr inferiorly into the pelvis. The fistula was repaired by reducing the Opin Obstet Gynecol. 2017;29(5):316-321. doi:10.1097/ conduit from the redundant pelvic portion - essentially getting the GCO.0000000000000391 conduit out of the pelvis. This conduit revision provided adequate 12. Seth J, Toia B, Ecclestone H, et al. The autologous rectus fascia sheath sacrocolpopexy and sacrohysteropexy, a mesh separation from the neovagina. free alternative in patients with recurrent uterine and vault prolapse: A contemporary series and literature review. Urol Ann. Neovaginal prolapse is most commonly seen with the use of 2019;11(2):193-197. doi:10.4103/UA.UA_85_18

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SUFU 2021 Winter Meeting SUFU 2022 Winter Meeting February 25 - 27, 2021 February 22 - 26, 2022 Virtual Meeting Marriott Marquis San Diego Marina sufuorg.com/registration San Diego, CA All program times will be in Central Time.

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