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Purpose/objective: To measure the impact of the placement of a midurethral sling (MUS) on development of urinary tract infections (UTI) in women with stress urinary incontinence., Methods: This is an analysis of a large managed care organization MUS database from 2005 to 2016. The database was queried to identify UTI and diagnosis of recurrent UTI. The primary outcome was the UTI rate after MUS. Secondary outcomes included the recurrent UTI rate and rates of UTI over time., Results: Over the study period, 13,404 MUS were performed. In the 12 postoperative months, 23% of patients developed a UTI, while 4% developed a de novo recurrent UTI diagnosis. UTIs were most frequently diagnosed in the 1st month, with the 7th postoperative day the most common. Predictors of UTI development included increased age (OR 3.69 [95% CI 2.58-5.26]), being diabetic (OR 1.43 [95% CI 1.28-1.60]), and having urinary retention requiring prolonged catheterization (OR 2.45 [95% CI 2.11-2.85]). UTIs were less likely to be diagnosed in those with transobturator MUS (OR 0.85 [95% CI 0.78-0.94]). Patients who developed a UTI were more likely to have a reoperation (p = 0.0147), including a reoperation for mesh revision/removal (p = 0.0287), and recurrent SUI (p = 0.0394). Patients who developed a UTI were more likely to develop postoperative de novo urgency urinary incontinence (UUI) (p < 0.0001)., Conclusion: Patients are at risk of UTI and rUTI after MUS. Risk of developing UTIs decreases with time. Predictors of developing UTI can help surgeons in the care of patients after MUS., (© 2021. The International Urogynecological Association.)

Introduction and Hypothesis: We sought to examine the change in utilization of the midurethral sling (MUS) for the treatment of stress urinary incontinence (SUI) after the 2011 US FDA communication regarding transvaginal mesh., Methods: This is a retrospective cohort study evaluating surgical utilization of MUS at a managed care organization of 4.5 million patients from 2008 to 2016. The primary outcome was the change in utilization of synthetic mesh MUS before and after the July 2011 FDA communication. Secondary outcomes were the changes in surgeon level MUS utilization., Results: MUS procedures decreased from 131 to 116 per 100,000 adult women with a decrease of 11.5% from 2010 to 2012. Year over year utilization of MUS was rapidly increasing (p < 0.01) prior the FDA communication from 116 (in 2008) to 131 (in 2010) per 100,000 women and then significantly declined (p < 0.01) after its release from 135 (in 2011) to 75 (in 2016) per 100,000 women (13% increase vs 44% decrease). The number of surgeons performing MUS increased (p < 0.01) from 172/year to 186/year from 2008 to 2010 (Table 1). This decreased (p < 0.01) from 183/year to 121/year from 2011 to 2016., Conclusions: MUS for SUI drastically declined after the FDA communication. Despite the 2011 FDA communication concerning only transvaginal mesh for pelvic organ prolapse, there was a significant decrease in MUS with synthetic mesh utilization. Our findings support the importance of continued long-term outcome data regarding the safety and efficacy of MUS and highlight the impact of the FDA warning on MUS utilization., (© 2020. The International Urogynecological Association.)

Introduction and Hypothesis: We hypothesized that there would be a significant difference in changes in obstructed defecation symptoms and posterior compartment prolapse between women who underwent posterior vaginal wall prolapse repair (PR) and those who did not., Methods: This was a two-site prospective cohort study of women undergoing prolapse or incontinence surgery in which a PR was, or was not, performed at the discretion of the surgeon. Women were assessed using validated obstructed defecation questionnaires and standardized examination measures (including POP-Q, measurement of transverse gh, and assessment for a rectovaginal pocket and laxity) prior to pelvic surgery and 12 weeks after surgery., Results: Of 68 women who underwent surgery, 43 had PR. The PR group had higher obstructed defecation symptoms and greater posterior compartment prolapse at baseline. At 12 weeks, obstructed defecation symptoms had improved significantly more in the PR group than in the no PR group (all p < 0.03). Anatomic outcomes showed greater improvement in point Bp in the PR group (-3.4 vs. -0.7 no PR, p < 0.001) and resolution of the rectovaginal pocket (86 % vs. 42 %, p = 0.002). There were no significant changes in obstructed defecation symptoms or anatomic outcomes from baseline in the no PR group, while the PR group showed significantly improved obstructed defecation symptoms and anatomic outcomes after repair (p < 0.001 for both)., Conclusions: Significant improvements in obstructed defecation symptoms and posterior compartment prolapse were seen after PR, but not in women who did not receive PR. Obstructed defecation symptoms, Bp and rectovaginal pocket were the measures best able to demonstrate improvement after PR. We recommend the use of these measures to assess the impact of surgery in the posterior compartment.

Introduction and Hypothesis: The premise of midurethral sling (MUS) surgery is to apply a tension-free vaginal tape in the midurethra that does not constrict the urethra at rest but stabilizes the urethra and prevents downward descent and opening of the urethra during stress maneuvers, but current technology has limitations in measuring urethral pressures during dynamic conditions. Our objective was to describe the change in maximum urethral closure pressures (MUCPs) after MUS surgery using an 8F high-resolution manometry (HRM) system that can measure urethral pressures during cough and strain maneuvers (ManoScan® ESO; Covidien) without migration or withdrawal limitations., Methods: We measured rest, cough, and strain MUCPs in 26 women before and after retropubic or transobturator MUS for stress urinary incontinence using the HRM system., Results: The objective success rate after MUS was 92.3 % based on postoperative cough stress testing. Mean resting MUCPs measured by HRM did not change after surgery (59.3 before vs. 59.7 cm H2O after surgery; p = 1.0). Mean cough MUCPs measured by HRM increased from 36.9 to 100.7 cm H2O (p < 0.001), and strain MUCPs increased from 35.0 to 92.7 cm H2O (p < 0.001)., Conclusions: Advanced HRM technology to measure MUCPs under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism after tension-free MUS: MUCPs do not change at rest but do increase significantly during cough and strain maneuvers.

Introduction and Hypothesis: We investigated the efficiency and efficacy of vaginal mesh attachment using interrupted, non-barbed, delayed absorbable sutures in comparison with a running, barbed, delayed absorbable suture during laparoscopic sacrocolpopexy (LSC) and robotic sacrocolpopexy (RSC)., Methods: Women undergoing LSC or RSC were recruited. Participants were randomized to at least six 0 PDS non-barbed interrupted sutures or at least six passes of a 1 PDS barbed suture (Quill™) on each anterior and posterior polypropylene mesh leaflet. The primary outcome was the time to attach the mesh to the vagina. The LSC and RSC groups were block randomized by suture type. Secondary outcomes included: (1) intraoperative surgeon assessment of satisfaction as measured using a 10-cm visual analog scale (VAS), (2) postoperative POP-Q evaluation for anatomic failure, and (3) overall appearance of vaginal walls measured using a VAS., Results: Of the 64 included subjects who were randomized, 32 had mesh attachment with the barbed suture (16 LSC, 16 RSC) and 32 had attachment with non-barbed sutures (16 LSC, 16 RSC). Among all the subjects (LSC and RSC), the non-barbed suture group had significantly longer mesh attachment times than the barbed suture group (42 vs. 29 min, p < 0.001). The non-barbed suture group had significantly better scores for intraoperative ease of suture placement, surgeon satisfaction with mesh appearance, and global satisfaction. At 12 months, there were no significant differences in anatomic failure between the suture groups or overall appearance of the vaginal walls (p > 0.05)., Conclusions: The barbed suture technique was 11 - 16 min faster for attaching mesh to the vagina than the non-barbed suture technique. Anatomic outcomes at 12 months were comparable between the suture groups. It is reasonable to use a running, barbed suture in minimally invasive sacrocolpopexy.

Introduction and Hypothesis: This video introduces a 3D high-resolution manometry (HRM) system to the field of urogynecology. We demonstrate how to obtain and interpret dynamic urethral pressures with this measurement system and use it to evaluate pre- and postoperative women., Methods: The 3D HRM catheter is ∼12 F; 11 cm of its length has pressure sensors with eight circumferentially distributed pressure-sensitive segments that collect and transmit individual pressure measurements to construct a 3D pressure map. In this video, we demonstrate the output display of the 3D HRM measurement system., Results: Pressure output maps are shown for one woman with stress urinary incontinence (SUI) and one with a history of SUI who underwent successful midurethral sling insertion. We also show a summary of 3D pressure-measurement patterns of 44 women who underwent pressure measurements to evaluate qualitatively the 3D pressure profile of the urethra in an effort to better understand pelvic floor and urethral sphincter physiology., Conclusions: Advanced HRM technology to measure urethral pressures under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism in continent and incontinent women and after continence surgeries.

Introduction and Hypothesis: Optimal measures for assessing anatomy and defecatory symptoms related to posterior compartment prolapse are unknown. Our objectives were: (1) to test the inter- and intrarater reliability of commonly used or reported anatomic measures of posterior compartment prolapse performed in the clinic setting and under anesthesia; and (2) to examine the correlation between posterior compartment anatomy and defecatory symptoms prior to surgical intervention., Methods: A prospective cohort of women with pelvic floor disorders was assessed using a variety of validated questionnaires and standardized examination measures at baseline, at a preoperative visit, and intraoperatively. Inter- and intrarater reliability for anatomic measures were assessed by two separate examiners at the initial visit and repeated by one of the original examiners at a preoperative visit. Reliability was measured using kappa or intraclass correlations according to data type. Symptom and anatomic measure correlations were analyzed using Spearman rank tests., Results: Mean age of the 120 women recruited was 57 ± 15 years, 49 (41 %) had a point Bp ≥ 0; 59 % reported at least moderate bother from at least one obstructed defecation symptom on the Pelvic Floor Distress Inventory (PFDI). At baseline, most anatomic measures showed at least moderate to good inter/intrarater reliability (> 0.5). There were no moderate or better correlations between any symptom and anatomic measure (all r <  0.27)., Conclusions: Most anatomic measures of posterior compartment prolapse are reliable and reproducible; however, they do not correlate well with defecatory symptoms.

Introduction and Hypothesis: We aimed to compare the outcomes of native tissue vs. biological graft-augmented repair in the posterior compartment. We hypothesized that the addition of graft would result in superior anatomic and functional outcomes., Methods: A retrospective review of posterior repairs between 2001 and 2008 was performed to compare the anatomic and functional outcomes between native tissue and graft-augmented techniques. Mann-Whitney and chi-square tests were used. Power calculation determined that 32 subjects were needed in each group., Results: One hundred twenty-four native tissue and 69 graft-augmented repairs were performed with a median follow-up of 35.8 months (range, 6 to 157 months). Anatomic success was similar for native tissue vs. graft (Bp < -1, 86% vs. 80% and Bp ≤ 0, 97% vs. 97%; all p > 0.05). Postoperative splinting and incomplete evacuation was greater in the graft group (splinting, 85% vs. 68%; p = 0.04 and incomplete evacuation, 85% vs. 64%; p = 0.03)., Conclusion: Long-term success of posterior repair is high. Graft augmentation does not appear to improve anatomic or functional outcomes.

Introduction and Hypothesis: The purpose of this study is to identify risk factors for mesh erosion in women undergoing minimally invasive sacrocolpopexy (MISC). We hypothesize that erosion is higher in subjects undergoing concomitant hysterectomy., Methods: This is a retrospective cohort study of women who underwent MISC between November 2004 and January 2009. Demographics, operative techniques, and outcomes were abstracted from medical records. Multivariable regression identified odds of erosion., Results: Of 188 MISC procedures 19(10%) had erosions. Erosion was higher in those with total vaginal hysterectomy (TVH) compared to both post-hysterectomy (23% vs. 5%, p = 0.003) and supracervical hysterectomy (SCH) (23% vs. 5%, p = 0.109) groups. In multivariable regression, the odds of erosion for TVH was 5.67 (95% CI: 1.88-17.10) compared to post-hysterectomy. Smoking, the use of collagen-coated mesh, transvaginal dissection, and mesh attachment transvaginally were no longer significant in the multivariable regression model., Conclusion: Based on this study, surgeons should consider supracervical hysterectomy over total vaginal hysterectomy as the procedure of choice in association with MISC unless removal of the cervix is otherwise indicated.

Introduction and Hypothesis: This study seeks to evaluate axial variation, comparisons with current technology, performance during dynamic conditions, and patient tolerability of the urethral sleeve sensor (USS) for maximal urethral closure pressure (MUCP) measurements., Methods: Eighteen continent and seven stress incontinent women underwent assessments with USS and urethral pressure profilometry (UPP) in random order. Intravesical (p (ves)) and urethral (p (ura)) pressure signals were collected and urethral closure pressure (p (clo)) was calculated. A visual analog scale (VAS) was used to evaluate subject discomfort., Results: The correlation coefficient between MUCP obtained by UPP and USS techniques was 0.86 (p < 0.001). Higher USS pressures were obtained with catheter oriented to 12 o'clock. Continent subjects demonstrated higher values of p (clo). MUCP became <0 cm H(2)O in subjects with clinical leakage during Valsalva, but not in continent subjects. Subjects tolerated the USS technique better than the UPP technique on VAS (p < 0.001)., Conclusions: USS technology can be used to evaluate the urethra in both static and dynamic conditions and is better tolerated than withdrawal techniques.