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Insufficient data exist to conclude whether consumption of artificially sweetened beverages is associated with a higher risk of urinary tract cancers.We sought to investigate whether urinary tract cancer incidence differed among women who consumed various amounts of artificially sweetened beverages.This was a secondary analysis of data from the Women's Health Initiative Observational Study, a multicenter longitudinal prospective study of the health of 93 676 postmenopausal women with a mean follow-up time of 13.5 yr. Women were identified at 40 clinical centers across the USA and enrolled from 1993 to 1998. Women between the ages of 50 and 79 yr were enrolled. We included women who answered questions about artificially sweetened beverage consumption and reported no prior urinary tract cancer diagnoses. The frequency of artificially sweetened beverage consumption was categorized as follows: rare artificially sweetened beverage consumption (never to fewer than one serving per week), frequent consumption (one to six servings per week), and daily consumption (more than one servings per day).The incidence of urinary tract cancer reported during subsequent visits until February 28, 2020 was recorded. Demographic characteristics were compared between those with varying levels of artificially sweetened beverage consumption. Descriptive statistics were used to report the rates of urinary tract cancer diagnosis, and Cox regression models were constructed to determine hazard ratios and adjust for potential confounders.We identified 80 388 participants who met the inclusion criteria. Most participants (64%) were infrequent consumers of artificially sweetened beverages, with 13% (Frequent consumption of artificially sweetened beverages may be associated with a higher risk of kidney cancer among postmenopausal women.A secondary analysis of the Women's Health Initiative Observational Study showed that higher consumption of artificially sweetened beverages was associated with a higher risk of kidney cancer.

This clinical consensus statement on vaginal energy-based devices (EBDs) reflects an update by content experts from the American Urogynecologic Society's EBD writing group. In 2019, the American Urogynecologic Society's EBD writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 40 statements were assessed and divided into 5 categories: (1) patient criteria, (2) health care provider criteria, (3) efficacy, (4) safety, and (5) treatment considerations. Of the 40 statements that were assessed, 28 reached consensus and the remaining 12 did not. Lack of evidence was among the main reasons that vulvovaginal EBD treatment statements did not reach consensus. In March 2022, these statements were reassessed using the interim literature.

To create a hashtag ontology specific to menopause.This study analyzed tweets including the hashtag #menopause between November 2019 and November 2021. Tweets performed by international or national societies as well as expert social media influencers were included in the analysis. To analyze hashtag utilization amongst all Twitter users, hashtags from the "Top" tweets Twitter search function from October 2021 were also analyzed. Co-occurring hashtags were recorded as well as the type of user who performed the tweet during the "Top" tweets analysis. Social media influencers and experts reviewed and edited the hashtag list. The hashtags were then grouped by subject.We analyzed 382 tweets with #menopause. Of the users included in the "Top" tweets, 40% were patient advocates or advocacy groups; 38% were medical professionals, academics, societies, or journals; and 22% were general users. In total, 123 unique hashtags were identified. After social media influencer and expert review, 32 hashtags were included in the final ontology. The ontology was then grouped into the following categories based on subject matter: general, premature menopause, hormones, sexual function, and genital disorders.Social media is an important tool for medical professionals and patients. Our study is the first to develop a hashtag ontology specific to menopause. Adoption of a hashtag ontology with standardized terminology by medical professionals may facilitate easier communication with peers and patients.

The aim of this study is to report cognitive dysfunction with commonly used antimuscarinic overactive bladder medications in patients suffering from overactive bladder disorder with and without baseline neurologic conditions. We conducted an Ovid MEDLINE, Embase, and PsycINFO search from January 1998 to December 2018 using PRISMA guidelines. Eighteen studies met the inclusion criteria, including 5 randomized controlled trials and 13 observational studies. Cognitive decline was reported with oxybutynin use (5 of 8 studies) and tolterodine use (4 of 7 studies) among patients with and without baseline cognitive impairment. Oxybutynin use was linked to functional, mental, and behavioral decline among patients with Alzheimer’s disease (2 studies). No cognitive decline was detected among patients with and without baseline cognitive impairment taking trospium (6 studies), darifenacin (3 studies), imidafenacin (2 studies), and fesoterodine (1 study). Solifenacin was not associated with cognitive decline (2 studies) but was linked to an increased risk of dementia among patients with diabetes (1 study). In this review, cognitive decline was reported with oxybutynin and tolterodine use and should be used with caution in adults over 65 years of age. Solifenacin, fesoterodine, and imidafenacin showed mixed results related to central nervous system effect. Trospium and darifenacin were not associated with cognitive decline among patients with and without baseline cognitive impairment.

Objectives There is conflicting research on the effect of therapeutic suggestion in the perioperative period. This study systematically compared subjective and objective measures of postoperative pain, nausea and vomiting, urinary and bowel function, and global perception of symptomatic improvement between participants receiving perioperative therapeutic suggestion versus routine perioperative care during minimally invasive pelvic reconstructive surgery. Methods This was a single-blinded, randomized controlled trial of participants undergoing vaginal hysterectomy with minimally invasive sacrocolpopexy and concomitant prolapse repairs. The intervention group received perioperative therapeutic suggestion, whereas the control group did not. Primary outcomes included postoperative pain scores and analgesic use. Secondary outcomes included a postoperative nausea and vomiting scale, the Pelvic Floor Distress Inventory Questionnaire-Short Form 20, the Patient Global Impression of Improvement scale, and time to return of bowel and bladder function. Results Sixteen participants were randomized to each group. Final analysis included 15 intervention and 14 control participants. Overall measures of postoperative pain and analgesic use were low across all participants without a significant difference between intervention and control groups (opioid: 52.5; interquartile range [IQR], 25.5-58.9 vs 66 IQR, 7.3-125.8; morphine milligram equivalents; P = 0.64; acetaminophen: 2225 mg; IQR, 500-2600 mg vs 2800 mg; IQR, 650-4775 mg; P = 0.38). There were no statistically significant differences in secondary outcomes of urinary symptoms, bowel function, and subjective improvement of prolapse symptoms. Conclusions No differences in postoperative pain, analgesic use, return of bowel and bladder function, or pelvic organ prolapse symptoms were noted in participants receiving perioperative therapeutic suggestion versus routine perioperative care.

Data on the correlation between length of stay and postoperative complications following urogynecologic surgery are limited.The objective of this study was to use a nationwide database to examine the correlation between length of stay and 30-day postoperative complications following minimally invasive apical prolapse repair.This retrospective cohort study included women in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2018 who underwent laparoscopic/robotic sacrocolpopexy or uterosacral/sacrospinous repair and were discharged on postoperative day 0 (POD0) or 1 (POD1). The primary outcome was 30-day postoperative complication rate.Of the 28,269 women discharged home on POD0/1, 12,663 (45%) underwent laparoscopic/robotic sacrocolpopexy, and 15,606 (55%) underwent uterosacral/sacrospinous repair. Women discharged on POD0 were less likely to be White, less likely to have diabetes or hypertension, had lower mean body mass index, and were less likely to have undergone a hysterectomy ( P0.05 for all). Within 30 days of surgery, 7% had a postoperative complication, and 3% had a major complication. Women discharged on POD0 had a lower risk of any complication or any major complication. The most common complication, urinary tract infection, was lower in women discharged on POD0 (3% vs 4%, P0.01). Women discharged home on the same day had a higher risk of superficial surgical site infection after undergoing laparoscopic/robotic sacrocolpopexy (1.3% vs 0.5%, P0.01) and a higher risk of myocardial infarction/cardiac arrest after uterosacral/sacrospinous repair (0.2% vs 0%, P0.04).In women undergoing minimally invasive reconstructive apical repair, discharge on POD0 is correlated with similar or better (lower) 30-day postoperative complication rates compared with women discharged on POD1.

The objective was to determine the relationship between the preoperative D-point and apical outcomes at 24 months, using the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) dataset. This was a secondary analysis of the OPTIMAL trial, a randomized multi-centered study comparing outcomes of sacrospinous ligament fixation and transvaginal uterosacral ligament suspension (USLS). The 2-year dataset utilized included women undergoing USLS with concomitant hysterectomy. The primary outcome was the relationship between preoperative D-point and apical outcomes at 24 months. Secondary objectives were to determine the relationship between preoperative D-point and anatomical, composite and subjective outcomes, and to determine a D-point cut-off that could be used to predict success in each of these categories. Of the 186 women in the USLS arm, 120 were available for analysis of anatomical failure at 24 months. A higher preoperative D-point correlated with improved apical outcome (C-point) at 24 months (r = 0.34; p value = 0.0002). Using ROC curves, a moderate association was found between the preoperative D-point and apical and anatomical success, (AUC 0.689 and 0.662). There was no relationship between preoperative D-point and composite or subjective success (AUC 0.577 and 0.458). Based on the ROC curves, a “cut-off” D-point value of −4.25 cm (sensitivity = 0.58, specificity = 0.67) was determined to be a predictor of postoperative anatomical success at 2 years. Preoperative D-point correlates with postoperative anatomical and apical support, but is less successful at predicting subjective outcomes. The strongest predictive D-point cut-off for anatomical and apical success at 24 months was −4.25 cm.

Objective The objective of this study was to review and analyze the current social media status of urogynecology/female pelvic medicine and reconstructive surgery on Twitter and create a tag ontology. Methods A "tag ontology" is a standardized list of hashtags used to organize specific subject matter within a social media platform. We used an online social media analytics tool, Symplur to identify tweets and hashtags related to #urogynecology between January 2018 and July 2020. Hashtags identified using Symplur were verified manually via Twitter inquiries and reviewed by urogynecology social medial influencers for external validation. The hashtags were selected based on frequency of use, social media influencer opinion, and clinical relevance. Results We identified 6,847 tweets and 2,946 users. Our ontology includes 67 terms categorized into 5 groups (urinary, prolapse, anus/rectum, vulva, and other). Using "Symplur Rank," the 2 top influencers included @FPMRS and @FPMRSJournal. Conclusions Adaptation of a standardized hashtag ontology facilitates communication between providers and patients about pertinent health care issues. Our study has created a urogynecology-specific ontology based on 2018-2020 Twitter usage.

Study Objective To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. Design A multicenter prospective cohort study. Setting Ten institutions in the United States. Patients Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. Interventions Benign gynecologic surgery. Measurements and Main Results The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4–50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). Conclusion In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.

Objective The aim of the study was to compare 6-month efficacy and safety for treatment of vaginal dryness/genitourinary syndrome of menopause in women undergoing fractionated CO2 vaginal laser therapy to women using estrogen vaginal cream. Methods This multicenter, randomized trial compared fractionated CO2 laser to estrogen cream at 6 institutions. We included menopausal women with significant vaginal atrophy symptoms and we excluded women with prolapse below stage 2, recent pelvic surgery, prior mesh surgery, active genital infection, history of estrogen sensitive malignancy, and other autoimmune conditions. The primary outcome was the visual analog scale vaginal dryness score. Secondary outcomes included evaluation of vaginal atrophy, quality of life symptoms, assessment of sexual function, and urinary symptoms. Adverse events (AEs) and patient global impression of improvement (PGI-I) and satisfaction were also assessed. Results Sixty-nine women were enrolled in this trial before enrollment was closed due to the Federal Drug Administration requiring the sponsor to obtain and maintain an Investigational Device Exemption. Of the 69 participants enrolled, 62 completed the 6-month protocol; 30 women were randomized to the laser and 32 to estrogen cream from June 2016 to September 2017. Demographics did not differ between groups except the laser group was less parous (0 [range 0-4] vs 2 [0-6], P = 0.04). On patient global impression, 85.8% of laser participants rated their improvement as "better or much better" and 78.5% reported being either "satisfied or very satisfied" compared to 70% and 73.3% in the estrogen group; this was not statistically different between groups. On linear regression, mean difference in female sexual function index scores was no longer statistically significant; and, vaginal maturation index scores remained higher in the estrogen group (adj P value 0.02); although, baseline and 6-month follow-up vaginal maturation index data were only available for 34 participants (16 laser, 18 estrogen). Conclusions At 6 months, fractionated CO2 vaginal laser and vaginal estrogen treatment resulted in similar improvement in genitourinary syndrome of menopause symptoms as well as urinary and sexual function. Overall, 70% to 80% of participants were satisfied or very satisfied with either treatment and there were no serious adverse events. : Video Summary:http://links.lww.com/MENO/A470.

Background: Although sexual health can be considered a vital sign for overall health, several barriers prevent women from receiving proper medical counseling, support, and/or care for their sexual health needs and concerns. Methods: Experts in sexual health compiled research and experience on the impediments to women receiving adequate assessment and treatment for their sexual health. Specific solutions and a roadmap for overcoming such barriers and improving patient–clinician communication are presented. Results: Social stigma around female sexuality remains in Western culture and as a result, women often avoid and/or are embarrassed to discuss their sexual health with their health care professionals (HCPs). Moreover, midlife women are typically unaware or have misconceptions about conditions that may adversely impact their sexual life, such as genitourinary syndrome of menopause and hypoactive sexual desire disorder. Without understanding there may be underlying medical conditions, there is also a lack of awareness that safe and effective treatments are available. Lack of training, tools, time, and limited treatment options impede HCPs from providing women with necessary sexual health support. Educating women, training HCPs, and providing communication tools to HCPs can facilitate effective dialog between patients and HCPs. More specifically, HCPs can be trained to initiate and maintain a sexual health conversation in a manner that is comfortable for women to convey sexual health needs and concerns, and for HCPs to correctly identify, diagnose, and treat the sexual problems of their female patients. Conclusions: Solutions exist to address the barriers currently impeding patient–clinician interactions around sexual health.

Objectives The aim of this study was to report the prevalence of hydronephrosis associated with pelvic organ prolapse (POP). Methods We conducted a MEDLINE and PubMed search from 1996 to October 2016 using PRISMA guidelines. Eight studies met criteria for inclusion, including 3 prospective and 5 retrospective studies. Results The prevalence of hydronephrosis ranged from 3.5% to 30.6% in studies that included multiple stages of prolapse. Hydronephrosis correlated with prolapse severity in multiple studies, but serum creatinine did not consistently predict hydronephrosis. Two studies reported a significantly higher prevalence of hydronephrosis in patients with uterovaginal prolapse compared with vaginal vault prolapse. Complete resolution of hydronephrosis was described in 56% to 83% of patients after undergoing surgical treatment for advanced prolapse. Conclusions Hydronephrosis among patients with POP is not rare, and we suggest consideration of upper tract evaluation in patients presenting with POP, particularly in those with advanced uterovaginal prolapse electing to proceed with expectant or conservative management.

The objective of this study was to review and analyze the current social media status of urogynecology/female pelvic medicine and reconstructive surgery on Twitter and create a tag ontology.A "tag ontology" is a standardized list of hashtags used to organize specific subject matter within a social media platform. We used an online social media analytics tool, Symplur to identify tweets and hashtags related to #urogynecology between January 2018 and July 2020. Hashtags identified using Symplur were verified manually via Twitter inquiries and reviewed by urogynecology social medial influencers for external validation. The hashtags were selected based on frequency of use, social media influencer opinion, and clinical relevance.We identified 6,847 tweets and 2,946 users. Our ontology includes 67 terms categorized into 5 groups (urinary, prolapse, anus/rectum, vulva, and other). Using "Symplur Rank," the 2 top influencers included @FPMRS and @FPMRSJournal.Adaptation of a standardized hashtag ontology facilitates communication between providers and patients about pertinent health care issues. Our study has created a urogynecology-specific ontology based on 2018-2020 Twitter usage.

Study Objective The creation of an ontology may enable providers to more definitively engage the public in evidence-based and meaningful discussions about women's health. The goal of this study is to review and analyze the current social media status of minimally invasive gynecologic surgery (MIGS) on Twitter and create a tag ontology. Design Tag ontologies are lists of hashtags used to standardize searches within a social media platform. We examined trending terms and influencers on Twitter on the basis of the keyword “MIGS.” We then compiled a list of top hashtags on the basis of the number of tweets from January 2018 to August 2020. Terms were identified with manual Twitter queries and Symplur Signals and selected for inclusion in the ontology on the basis of frequency of use and clinical relevance. The ontology was then categorized by pelvic disease and intervention and reviewed/supplemented by key social media influencers for inclusivity. Setting N/A Patients N/A Interventions N/A Measurements and Main Results We identified 4550 tweets and 1836 users while searching #MIGS in August 2020. Twenty-nine terms were included in our ontology, which were then subcategorized into 6 groups (uterine pathology, adnexal pathology, menstruation, pelvic pathology, pelvic pain, and other). Conclusion Our study has created an ontology specific to the MIGS on the basis of Twitter usage over the last 2 years that may facilitate more effective social media communication.

Objective To compare 6-month safety and efficacy outcomes of fractionated CO2 laser (laser) with topical clobetasol propionate (steroid) for treatment of symptomatic vulvar lichen sclerosus. Methods We conducted a single-center randomized controlled trial that compared fractionated CO2 laser with steroid treatment for patients with biopsy-proven lichen sclerosus. Randomization was stratified by prior clobetasol propionate use. The primary outcome was mean change in Skindex-29 score at 6 months. A total sample size of 52 participants were recruited to detect a mean difference of 16 points on the Skindex-29 (SD±22) with 80% power, based on a one-sided two-sample t test with α=0.05, accounting for 10% attrition. Secondary outcomes included validated subjective and objective measures. Intention-to-treat, per protocol, and regression analysis based on prior steroid exposure were performed. Results From October 2015 to July 2018, 202 women were screened, 52 were randomized, and 51 completed a 6-month follow-up. No significant difference was found in baseline demographics, symptoms, and physician assessment scores. There was greater improvement in the Skindex-29 score in the laser arm at 6-months (10.9 point effect size, 95% CI 3.42-18.41; P=.007). Overall, 89% (23/27) of patients in the laser group rated symptoms as being "better or much better" compared with 62% (13/24) of patients in the steroid group, P=.07. More patients (81%, 21/27) were "satisfied or very satisfied" with laser treatment compared with steroid treatment (41%, 9/24); P=.01. After stratification for previous steroid use, the significant change of Skindex-29 score was only seen in the previously exposed group. There was one adverse event in each group: minor burning and blistering at the laser site and reactivation of genital herpes 1 week after starting steroid. Conclusion Fractionated CO2 laser treatment showed significant improvement in subjective symptoms and objective measures compared with clobetasol propionate, without serious safety or adverse events at 6 months. Clinical trial registration ClinicalTrials.gov, NCT02573883.

To compare 6-month safety and efficacy outcomes of fractionated CO2 laser (laser) with topical clobetasol propionate (steroid) for treatment of symptomatic vulvar lichen sclerosus.We conducted a single-center randomized controlled trial that compared fractionated CO2 laser with steroid treatment for patients with biopsy-proven lichen sclerosus. Randomization was stratified by prior clobetasol propionate use. The primary outcome was mean change in Skindex-29 score at 6 months. A total sample size of 52 participants were recruited to detect a mean difference of 16 points on the Skindex-29 (SD±22) with 80% power, based on a one-sided two-sample t test with α=0.05, accounting for 10% attrition. Secondary outcomes included validated subjective and objective measures. Intention-to-treat, per protocol, and regression analysis based on prior steroid exposure were performed.From October 2015 to July 2018, 202 women were screened, 52 were randomized, and 51 completed a 6-month follow-up. No significant difference was found in baseline demographics, symptoms, and physician assessment scores. There was greater improvement in the Skindex-29 score in the laser arm at 6-months (10.9 point effect size, 95% CI 3.42-18.41; P=.007). Overall, 89% (23/27) of patients in the laser group rated symptoms as being "better or much better" compared with 62% (13/24) of patients in the steroid group, P=.07. More patients (81%, 21/27) were "satisfied or very satisfied" with laser treatment compared with steroid treatment (41%, 9/24); P=.01. After stratification for previous steroid use, the significant change of Skindex-29 score was only seen in the previously exposed group. There was one adverse event in each group: minor burning and blistering at the laser site and reactivation of genital herpes 1 week after starting steroid.Fractionated CO2 laser treatment showed significant improvement in subjective symptoms and objective measures compared with clobetasol propionate, without serious safety or adverse events at 6 months.ClinicalTrials.gov, NCT02573883.

The objective was to determine the relationship between the preoperative D-point and apical outcomes at 24 months, using the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) dataset.This was a secondary analysis of the OPTIMAL trial, a randomized multi-centered study comparing outcomes of sacrospinous ligament fixation and transvaginal uterosacral ligament suspension (USLS). The 2-year dataset utilized included women undergoing USLS with concomitant hysterectomy. The primary outcome was the relationship between preoperative D-point and apical outcomes at 24 months. Secondary objectives were to determine the relationship between preoperative D-point and anatomical, composite and subjective outcomes, and to determine a D-point cut-off that could be used to predict success in each of these categories.Of the 186 women in the USLS arm, 120 were available for analysis of anatomical failure at 24 months. A higher preoperative D-point correlated with improved apical outcome (C-point) at 24 months (r = 0.34; p value = 0.0002). Using ROC curves, a moderate association was found between the preoperative D-point and apical and anatomical success, (AUC 0.689 and 0.662). There was no relationship between preoperative D-point and composite or subjective success (AUC 0.577 and 0.458). Based on the ROC curves, a "cut-off" D-point value of -4.25 cm (sensitivity = 0.58, specificity = 0.67) was determined to be a predictor of postoperative anatomical success at 2 years.Preoperative D-point correlates with postoperative anatomical and apical support, but is less successful at predicting subjective outcomes. The strongest predictive D-point cut-off for anatomical and apical success at 24 months was -4.25 cm.

This clinical consensus statement on vaginal energy-based devices (EBDs) reflects statements drafted by content experts from the American Urogynecologic Society's EBD writing group. The American Urogynecologic Society's EBD writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 40 statements were assessed and divided into 5 categories: (1) patient criteria, (2) health care provider criteria, (3) efficacy, (4) safety, and (5) treatment considerations. Of the 40 statements that were assessed, 28 reached consensus and the remaining 12 did not. Lack of evidence was among the main reasons that vulvovaginal EBD treatment statements did not reach consensus.

Female genital cosmetic surgery (FGCS) aims to alter the structure and appearance of female genitalia to attain the desired shape, size or look, or to decrease labial interference during intercourse, relieve pain and discomfort with clothing and exercise or decrease vaginal caliber and laxity. In the last 5 years, the number of labiaplasty surgeries performed in the United States rose by 53%. Despite the increasing popularity of FGCS, several divergent opinions regarding the ethics, safety, and efficacy of these procedures exist. Here we provide a brief overview of the terminology and techniques for FGCS and summarize current controversies.

While increasing attention has been given to the prevalence of work-related musculoskeletal disorders (WMDs) among surgeons in various medical specialties, there is no quantitative information about the potential work-related risk factors that contribute to WMDs among vaginal surgeons in the operating room (OR). This study aimed to quantify the frequency and duration of awkward postures, as well as musculoskeletal discomfort experienced by primary and assistant vaginal surgeons during surgery in order to provide a first step of informing ergonomics interventions that reduce postural loading during surgery. Thirteen primary and 14 assistant surgeons were evaluated during 13 surgical cases. Surgeon pre- and post-operative musculoskeletal discomfort ratings were collected with surveys. During surgery, real-time observations systematically characterized the frequency and duration of awkward neck, trunk and shoulder postures using tablet-based ergonomics software. Surgeons experienced postoperative increases in musculoskeletal discomfort of the neck, wrists, hands, back and feet. Assistant surgeons experienced greater right and left shoulder discomfort than primary surgeons (p Relevance to industry Surgeons provide a valuable healthcare service to the public, but surgeons are at high risk of musculoskeletal problems due to their work demands. This study provides new information about the physical requirements of vaginal surgeries to inform ergonomics interventions that prevent work-related musculoskeletal disorders among primary and assistant surgeons.

Objective Our objective was to estimate the prevalence of abdominal wall striae among women with and without pelvic organ prolapse (POP) in a population with pelvic floor disorders. Methods This cross-sectional study included nonpregnant women with urinary incontinence and POP presenting to a tertiary urogynecology practice between December 2012 and August 2013. Participants completed a nonvalidated questionnaire about striae, and the degree of abdominal wall striae was quantified on physical examination. Baseline demographics, clinical characteristics, and Pelvic Organ Prolapse Quantification (POP-Q) measurements were recorded. Results One hundred thirty-two women were approached for participation, of which 110 (83%) completed study questionnaires. Of these 110, 59 had POP defined at POP-Q stages 2-4, whereas 51 had normal pelvic support, POP-Q stages 0-1. The mean (SD) age was 55.5 (12) years, and most (78/110) were sexually active. Women with POP were more parous than women without POP (median 2 vs 1, respectively; P = 0.03). However, there was no difference in medical comorbidities, smoking status, or steroid use between groups (P > 0.05). More women with POP reported striae (42/59 [71%] vs 23/51 [45%], P = 0.006) and had quantifiable abdominal wall striae compared with women with normal support (39/59 [66%] vs 22/51 [44%], P = 0.02). On multivariate logistic regression, women with POP were 2.5 times more likely to have striae compared with women without POP after adjusting for skin type and smoking status (odds ratio, 2.5; 95% confidence interval, 1.03-6.06; P = 0.04). Conclusion Women with POP are more likely to have striae compared with women without POP.

Objective To assess whether there is any association between the implantation of synthetic polypropylene mesh slings for the treatment of stress urinary incontinence (SUI) and risk of cancer. Methods We performed a nationwide cohort study based on the general female population in Sweden. All women entered the observational period as unexposed on January 1, 1997, and contributed person-time as unexposed unless they underwent a midurethral sling procedure for SUI, after which they contributed person-time as exposed until first occurrence of any cancer, death, emigration, or end of the observational period (December 31, 2009). Occurrence of primary cancer was ascertained from the Cancer Register. Hazard ratios (HRs) with 95% CIs were calculated by Cox proportional hazards regression. Results The final study population included 5,385,186 women, including 20,905 exposed, encompassing a total of 44,012,936 person-years at risk. Other than an inverse association with rectal cancer (HR 0.5, 95% CI 0.3-0.8), there were no significant differences in risk between exposed and unexposed women for pelvic organ cancers including ovarian (HR 0.8, 95% CI 0.5-1.2), endometrial (HR 1.1, 95% CI 0.8-1.4), cervical (HR 0.4, 95% CI 0.2-1.0), bladder, and urethra (HR 0.7, 95% CI 0.4-1.2). No significant association was observed between exposed women and primary cancer in any organ system when compared with unexposed women. The relative risk for cancer after exposure showed little variation over time except for an inverse overall correlation within the first 4 years of surgery (HR 0.7, 95% CI 0.7-0.8). The incidence rates per 100,000 person-years (95% CIs) for exposed vs unexposed women were 20.5 (14.3-29.5) vs 21.0 (20.6-21.5) for rectal cancer, 25.5 (18.4-35.3) vs 19.8 (19.4-20.2) for ovarian cancer, 65.0 (53.0-79.8) vs 33.1 (32.6-33.7) for endometrial cancer, 5.7 (2.8-11.3) vs 11.9 (11.6-12.2) for cervical cancer, and 19.1 (13.1-27.8) vs 13.3 (13.0-13.7) for bladder and urethra cancer. Conclusion Our results suggest that midurethral polypropylene sling surgery for SUI is not associated with an increased cancer risk later in life.

Introduction Vaginal laxity (VL) is a sensation of vaginal looseness which may develop after pregnancy and vaginal delivery and may be affected by prior pelvic surgery, menopause and aging. Pelvic organ prolapse (POP) is a disorder in which pelvic organs descend from the normal position. VL has attracted recent attention due to the advent of energy-based treatments for this symptom. Aim To determine the correlation between VL symptoms and physical exam findings of POP, specifically the introital measurement of genital hiatus. Methods This was a multi-center cross-sectional study of sexually active women over 18 years of age with a parity of one or greater. Subjects completed the Vaginal Laxity Questionnaire (VLQ), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index (FSFI), and were asked if a sexual partner had commented on laxity. Subjects underwent pelvic exam, including the pelvic organ prolapse quantification (POP-Q). Main Outcomes Measures Correlation between VL symptoms as measured by the VLQ and POP as measured by elements of the POP-Q. Results A total of 95 subjects with an average age was 54.3 ± 13.18 years were included. Sixty-three percent of patients were postmenopausal. The average VLQ score was 4.2 ± 1.35 and the average FSFI score was 23.42 out of 36. There was no significant correlation between VLQ score and POP or mid-vaginal caliber. Sensation of vaginal tightness was significantly associated with age (P=0.03) and menopausal status (P=0.04). Only 28% of partners commented on laxity and the majority commented on the vagina being tight (21%) rather than loose (7%). Conclusion VL was not correlated with physical exam findings quantifying POP or sexual function. This study emphasizes the need to develop a more standardized definition of VL and a better assessment tool for VL symptoms.

Objectives Our primary aim was to define cervical elongation (CE) using the following methods: (1) measurement of pathology specimen, (2) physician perception, (3) intraoperative estimate of anterior cervical length, and (4) office Pelvic Organ Prolapse Quantification (POP-Q) points C and D. Our secondary aim was to determine whether these definitions correlate with perioperative outcomes. Methods Women undergoing vaginal hysterectomy and prolapse repair were enrolled. Office POP-Q measurements were collected. Estimates of cervical length were made based on points C minus D of the POP-Q and by manual exam using the surgeon's index and middle fingers. Cervical dimensions were measured from the pathology specimen at the end of the case. CE was defined as one standard deviation (SD) above the mean for each definition. Additional intraoperative data was collected to determine the surgeon perception of cervical anatomy. Results A total of 90 patients were enrolled during the study period. Our definitions for CE were as follows: (1) 5 cm (70 without and 20 with CE), (2) physician perception (67 without and 23 with CE), (3) 3.4 cm (79 without and 11 with CE), and (4) 8.3 cm (77 without and 13 with CE). After controlling for uterine weight and the presence of fibroids, the operative time was the only outcome measure that remained elevated for patients with CE using our first definition (42.4 ± 20.1 without vs. 53.8 ± 19.2 with CE, P = 0.03). Conclusions CE using our first definition was associated with a statistically significant increase in operative time in women undergoing hysterectomy at the time of prolapse repair.

Gynecologist and plastic surgeons pioneered the application of lasers in medicine and surgery almost 5 decades ago, initially used to treat cervical and vaginal pathologies. Ever since, energy-based devices have been deployed to treat pelvic pathologies and improve fertility. Recent technological developments triggered an unprecedented wave of publications, assessing the efficacy of fractional laser, and radiofrequency on the vaginal wall in reversing natural aging processes. Studies have shown that a certain degree of thermal energy deposited on the vaginal wall stimulates proliferation of the glycogen-enriched epithelium, neovascularization, and collagen formation in the lamina propria, and improves natural lubrication and control of urination. This review aimed to review such data and to guide future research. A unique assembly of experts from around the globe, compiled and edited this manuscript based on a thorough literature review and personal experience. Lasers Surg. Med. 49:137-159, 2017. © 2017 Wiley Periodicals, Inc.

OBJECTIVE To determine whether use of a new personalized risk calculator increases patient satisfaction with the decision whether or not to have a prophylactic midurethral sling (MUS) during pelvic organ prolapse (POP) surgery. METHODS We performed a randomized controlled trial involving English-speaking women without symptoms of stress urinary incontinence (SUI) with ≥ stage 2 POP who planned to undergo POP surgery with 1 of 4 fellowship-trained urogynecologists at a single academic center. Women with a history of prior POP or incontinence surgery, or who were pregnant, or unable to complete study forms were excluded. Participants were randomly assigned to standard preoperative counseling or preoperative counseling with the use of a validated, online risk calculator for de novo SUI after POP surgery. The primary outcome was patient satisfaction with the decision for prophylactic MUS placement during POP surgery at 3 months postoperative assessed using the Satisfaction with Decision Scale for Pelvic Floor Disorders. RESULTS Sixty-three women were approached for participation. Forty-two agreed to participate, 41 underwent randomization, and 33 had POP surgery and completed 3-month follow-up. Of these 33, 17 were randomized to the risk calculator and 16 to standard counseling. The mean age was 61.2 ± 9.1 years, and 41% (14/33) had a prophylactic MUS. At 3 months postoperative, there was no difference in Satisfaction with Decision Scale for Pelvic Floor Disorders scores between groups (4.67 ± 0.46 [intervention] vs 4.78 ± 0.34 [control]; P = 0.61). CONCLUSIONS Use of the de novo SUI risk calculator did not increase patient satisfaction with the decision regarding MUS placement during POP surgery.

The novel coronavirus (COVID-19) pandemic has had a major impact on how patients are evaluated and treated for diseases and conditions in normal patient care Due to lack of effective treatments for this virus or vaccines to prevent infection, focus is placed on infection prevention through use of social distancing, quarantine, and face masks To prevent COVID-19 infections in healthcare settings, the Centers for Disease Control and Prevention has recommended decreasing or eliminating nonurgent office visits Telehealth has emerged as an alternative way to deliver effective patient care, while reducing patient and physician exposure to the virus Telehealth is any remote healthcare process, including provider training or team meetings, whereas telemedicine refers to use of specific technology to connect a patient to a provider High quality of care can and must be provided by Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) as well as other specialists and health professionals using telemedicine Because of the health care emergency during the pandemic, the Centers for Medicare and Medicaid Services have broadened access to and reimbursement for telemedicine services Rapid advances in communications technology and widespread wireless access in many modern households have allowed the adoption and integration of telemedicine into urogynecology and other health practices There are no clear guidelines for the use of telemedicine in FPMRS The aim of this study was to conduct an expedited review of the evidence and to provide guidance for managing common outpatient FPRMS conditions during the COVID pandemic using telemedicine FPMRS conditions were grouped into those that likely to require different treatment with virtual management compared with in-person visits, and those that could use accepted behavioral counseling and not deviate from current management paradigms Rapid systematic review methodology was used to screen for articles related to 4 topics: (1) telemedicine in FPMRS, (2) pessary management, (3) urinary tract infections, and (4) urinary retention In addition, 4 other topics were addressed (based on past systematic reviews and national or international society guidelines): (1) urinary incontinence, (2) vaginal prolapse, (3) fecal incontinence, and (4) defecatory dysfunction Finally, clinical experience and expertise were pooled to reach consensus on 4 remaining areas: (1) FPMRS conditions amenable to virtual management, (2) urgent care scenarios requiring in-person visits, (3) symptoms that should alert providers to a possible COVID infection, and (4) special consideration for managing patients with known or suspected COVID-19 Overall, behavioral, medical, and conservative management provided in a virtual setting (via phone or Internet communication) will be valuable as first-line treatments Certain situations were identified that require different treatments in the virtual setting than in person, whereas others were shown to require an in-person visit despite risks of COVID-19 exposure and spread of infection This study presents guidance for treating FPMRS conditions via telemedicine in a format that can be actively referenced The strengths of the study include use of an expedited review method, extensive experience of the authors in conducting systematic reviews, as well as being seasoned FPMRS practitioners Main limitations include the rapid methodology, lack of data regarding many of the pertinent questions, and missed salient studies, because of the expedited evidence methods

OCCUPATIONAL APPLICATIONS Ergonomics postural assessment in real-time (ErgoPART) is a new job analysis tool designed to systematically characterize the postural demands of performing surgery. Tasks, equipment, and procedures that require ergonomic intervention can be identified. ErgoPART can also be used to quantify the benefits of ergonomic interventions that reduce the frequency and duration of non-neutral postures. Preliminary tests, conducted in the context of vaginal surgery, indicate that the tool is easy to learn and may allow broad categories of neck, shoulder, and trunk postures to be coded reliably. ErgoPART is freely available for use.TECHNICAL ABSTRACT Background: Little quantitative information exists regarding the postural demands placed on surgeons in the operating room. One reason for this is the lack of minimally invasive tools available to characterize the duration and frequency of non-neutral postures during surgery. Purpose: The objective of this study was to develop an ergonomics job ...

Surgical repair of pelvic organ prolapse often includes native tissue repair during which the patient’s own vaginal connective tissue is used to achieve pelvic support. This method, based on plication and suspension often yields suboptimal anatomical outcomes, possibly due to inadequate healing of the vaginal connective tissue. We hypothesized that age might have a negative effect on the time course and tissue biomechanics of vaginal wound healing in a rat model. Fifty young (12 weeks) and old (12 months) female 344BN Fischer rats were subjected to a posterior midline vaginal incision. The time course of repair was determined by measuring the size of the wound on days 1, 3, 7, and 14 post-injury. These findings correlated with the immune response to injury using a marker of impaired wound healing, the inflammatory cytokine macrophage migration inhibitory factor in the vaginal muscularis. Biomechanical properties of the healed vaginal tissue were tested 30 days post-injury. Wound healing was assessed on days 1, 3, 7, and 14 post-injury. On day 3 post-injury, the wounds in the young animals had all closed whereas the wounds in the old animals remained open. Furthermore, on day 7, the wound gap was still filled with granulation tissue in the old rats, whereas for the young rats, the wound area was almost indistinguishable from the non-injured area. Macrophage migration inhibitory factor was highly expressed in the vaginal epithelium and in the vaginal muscularis after injury. When compared with young animals, macrophage migration inhibitory factor levels of old rats began to rise more than 2 days later and the increased tissue expression persisted for 7 days longer. The breakpoint force of the healed vagina of old rats was almost 4-fold weaker than in young rats. At 30 days post-injury, the healed vagina in old rats regained less of the original (healthy) force at breakpoint than the young rats. In this rat model, age impaired vaginal wound healing, which was reflected in the altered inflammatory response to injury and reduced tissue strength.

Cystourethroscopy can be performed by obstetrician-gynecologists for diagnostic and occasional operative indications. Intraoperative use of cystourethroscopy to confirm urinary tract (urethral, bladder, and ureteral) integrity is one of the most important indications, because these findings can greatly affect patient care. This monograph provides an overview of appropriate instrumentation and technique for cystourethroscopy in women with normal anatomy. Also, it depicts benign and malignant lesions of the urethra and bladder and shows examples of intraoperative abnormalities, such as incidental bladder or urethral penetration, and nonpatent ureters, foreign body erosion, or fistula-related complications. Clinical vignettes outline differential diagnoses and management of common cystourethroscopic findings.

Study Objective To assess safety and durability of EnPlace (formerly, NeuGuide) for vaginal colpopexy to treat uterine prolapse. Design Prospective, observational, single arm, multi-center study with 12-month follow-up. Setting Academic centers and community hospitals. Patients or Participants Sixty-seven women > 35 years of age with symptomatic pelvic organ prolapse (POP) were enrolled from 13 (global) sites. Interventions EnPlace anchors were inserted bilaterally, transvaginally at the apex and deployed through the sacrospinous ligament under anesthesia. Two (pre-attached) sutures extend from the anchors and were tunneled behind the vagina and exited through a para-cervical incision. The bilateral suture tails were passed through cervical stroma and tied to reduce the cervix to a normal position and suspend the uterus. Measurements and Main Results All the women were post-menopausal (average age=69.4 ± 8.6 years), and all complained of vaginal bulging. Fifty patients completed 6-month follow-up, and 22 completed 12-month follow-up. Anterior and posterior average pre-op Ba, Bp and C POP-Q scores were +0.09 cm, -1.0 cm and +0.98 cm, respectively. At 6- and 12-month post-op, avg Bp and C point POP-Q scores were significantly more negative than baseline (p Conclusion The EnPlace System is feasible and safe as a minimally invasive procedure for the treatment of uterine prolapse. The preliminary results of this cohort of patients demonstrate that the procedure is effective for the treatment of uterine prolapse. There was no significant change in the C point between 6 and 12 months, suggesting that the EnPlace repair is durable, though further follow-up is necessary to establish long term durability.

Study Objective The purpose of this article is to provide an evidence based review of management options for patients with pelvic pain and an in situ Essure device. Design Literature review and qualitative analysis. Setting N/A Patients or Participants N/A Interventions N/A Measurements and Main Results The Essure device was voluntarily withdrawn from the market in 2018 by the manufacturer due in part to concerns about post placement adverse events and an FDA black box warning about uterine and fallopian tube perforation, suspected allergic or hypersensitivity reaction, and need for surgical removal for adverse events which were mostly related to pain. We performed a PubMed keyword literature search, as well as directed searches of Obstetrics & Gynecology, American Journal of Obstetrics and Gynecology, and Journal of Minimally Invasive Gynecology. A total of 43 publications were included, and consisted of 7 prospective studies, 15 retrospective studies, 18 case series, 2 review articles, and one summary article by the FDA. Conclusion A brief summary of recommendations and conclusions from this review: - Initial work up of pain in a patient with Essure devices should begin with placement confirmation via either transvaginal ultrasound or hysterosalpingogram/Xray. - In the event Essure microinserts are malpositioned, device removal is recommended. - In patients with a history and physical exam suggestive of possible endometriosis or adenomyosis, consider an attempt at hormonal management prior to surgical excision of the Essure device. - We recommend a laparoscopic resection of the fallopian tubes with or without partial coronuectomy for the management of pelvic pain of and no other identifiable source, even if Essure device is positioned appropriately. - We recommend an imaging modality be available in the OR during device removal to confirm an intact device and/or complete resection. - If hysterectomy is planned for in patients with the Essure device for indications other than pelvic pain, we recommend en block resection of the fallopian tubes and cornua.

PURPOSE OF REVIEW The purpose of this review is to describe new terminology for vulvovaginal atrophy and female sexual dysfunction and to highlight recent findings related to vaginal moisturizers, lubricants and prescription estrogen preparations. RECENT FINDINGS Sexual health is a marker for overall health. A minority (40%) of healthcare providers routinely ask about sexual problems and its impact on quality of life. New terminology by the American Psychiatric Association divides female sexual disorders into three categories: arousal/interest disorder, orgasmic disorder and genital pain and penetration disorder. First-line therapy for genitourinary syndrome of menopause includes over-the-counter vaginal lubricants and moisturizers, followed by topical estrogen formulations. Progesterones are generally not needed when topical low-dose estrogen is prescribed. A systemic selective estrogen receptor modulator, designed specifically for genitourinary menopausal symptoms, is an option for patients who do not tolerate local estrogen. SUMMARY Female sexual dysfunction is prevalent and causes distress, particularly among women at midlife. Although hypoactive sexual desire disorder may be the most prevalent dysfunction, dyspareunia and pain, particularly related to genitourinary and vulvovaginal atrophy, are also very common. Over-the-counter lubricants and prescription strength estrogen formulations are generally effective and well tolerated.

Objectives The aim of this study was to compare a Web app developed by the American Urogynecologic Society, called "BladderTrakHer," to the traditional paper voiding diary (PVD) for reliability and satisfaction. Methods Women presenting to our urogynecology practice with lower urinary tract symptom and access to an iPhone/iPad were randomized to a 3-day electronic voiding diary (EVD), using the BladderTrakHer Web app or PVD. Participants then completed a second voiding diary using the alternate format. Estimated fluid intake and output, number of voids, and episodes of incontinence were compared between formats. Patient and practitioner surveys assessed ease of use, ease of data interpretation, time to data entry, and overall satisfaction. Results Thirty-one of 122 patients completed both diary formats and the survey. The EVD and PVD showed good test-retest reliability. Patients recorded a higher number of entries for both voids and leaks while using the PVD (28.0 vs 25.5 [P = 0.03] and 4.5 vs 2.8 [P = 0.02], respectively). There was no significant difference in time to data entry among diary formats; 51.6% of patients preferred the EVD, and 78% of patients would prefer an electronic format if the app were improved. Four of 6 practitioners found the PVD easier to interpret, but all stated a preference for an EVD if the data were presented in a more organized fashion. Conclusions The use of an EVD is acceptable and reliable in our population of adult female patients with lower urinary tract symptom. Electronic voiding diary and PVD have good test-retest reliability, although the number of voids and leaks entered is slightly lower for the EVD.

The best predictors for postoperative anatomic apical success after transvaginal uterosacral ligament suspension remain unknown. The aim of this study was to determine if there is a correlation between the preoperative D point and anatomic outcomes for apical prolapse after 1 year.This retrospective cohort study included subjects undergoing transvaginal uterosacral ligament suspension from 2008 through 2013 who had at least 1 year follow-up. Demographic information, preoperative and postoperative Pelvic Organ Prolapse Quantification (POPQ) examination measurements, need for retreatment or repeat surgery, and assessment of pelvic floor symptoms were reviewed. Postoperative apical success was defined as C point descent no more than one third into the vaginal canal.One hundred twenty-five women met inclusion criteria and had follow-up at 1 year or more. Concomitant procedures included anterior/posterior repair and midurethral sling. Mean follow-up time was 22.8 months (range, 12-63 months). At last follow-up, 96% met criteria for apical success. A more negative preoperative D point was significantly related to improved postoperative apical support, with each 1-cm descent in preoperative D point resulting in a postoperative C point that was 0.21 cm lower (P = 0.0005). Based on the receiver operating characteristic curve, a "cutoff" D point value of -4.25 (sensitivity, 0.8; specificity, 0.65) was determined to be a predictor of postoperative apical success at 1 year or more.The preoperative D point correlates with postoperative apical support, and a clinically meaningful relationship exists between the preoperative D point and anatomic apical success.

Informed consent is the process in which a patient makes a decision about a surgical procedure or medical intervention after adequate information is relayed by the physician and understood by the patient. This process is critical for reconstructive pelvic surgeries, particularly with the advent of vaginal mesh procedures. In this article, we review the principles of informed consent, the pros and cons of different approaches in reconstructive pelvic surgery, the current legal issues surrounding mesh use for vaginal surgery, and tips on how to incorporate this information when consenting patients for pelvic floor surgery.

The process for introducing new surgical devices differs from drug evaluations. The US Food and Drug Administration (FDA) often clears medical devices through the 510(k) process, which evaluates safety by substantial equivalence to another device. New drug evaluations, however, assess both premarket efficacy and safety. Transvaginal mesh kits for pelvic organ prolapse were initially cleared in 2004 based on predicate synthetic suburethral slings and hernia mesh. Reported serious complications associated with transvaginal mesh use led to a 2008 FDA public health notification and 2011 safety communication. Subsequently, the FDA issued 522 orders for post-market surveillance data to all manufacturers of transvaginal mesh kits. Some companies ceased transvaginal mesh manufacturing, while others invested millions in research to satisfy these orders. Recently, the American Urogynecologic Society (AUGS) partnered with the FDA, other major medical societies, manufacturers, and representatives from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), to develop the Pelvic Floor Disorders Registry (PFDR), which launched the initial 522 studies. In addition, AUGS and the American College of Obstetricians and Gynecologists (ACOG) published and reaffirmed a committee document on vaginal placement of mesh in 2011 and 2015. In 2012, AUGS published guidelines for credentialing surgeons on transvaginal mesh use. Finally, in 2016, the FDA reclassified vaginal mesh devices from class II to class III, requiring manufacturers to provide premarket data. Careful patient selection, better surgeon training, advances in mesh design, and increased post-market surveillance of transvaginal mesh devices will lead to improved safety, decreased complications, and better long-term outcomes for women.