Search

OBJECTIVE: We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. STUDY DESIGN: Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. RESULTS: At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. CONCLUSION: Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved. [ABSTRACT FROM AUTHOR]

The volume and time required to manage a nurse telephone triage line in an urogynecology practice can be a concern for staffing, time management, and office patient flow. Therefore, telephone triage logs were retrospectively reviewed for a 12-month period to investigate whether call volume differed on days of the five-day office work week. Results showed Monday to be the busiest telephone triage day, with an average of 32.26 calls per day, and Friday as the second busiest day, with 28.52 calls per day. Based on this review, staffing patterns may need to be adjusted to accommodate the higher call volumes on Mondays and Fridays. [ABSTRACT FROM AUTHOR]

Importance: The impact of preoperative pain on outcomes can guide counseling., Objective: The objective of this study was to compare outcomes after vaginal reconstructive surgery and pelvic muscle training between women with and without preoperative pain., Study Design: This is a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial, which randomized patients to a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (pelvic floor muscle training vs usual care). Preoperative pain was defined as a response of "5" or greater on the pain scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question "Do you usually experience pain in the lower abdomen or genital area?", Results: The OPTIMAL trial included 109 women with preoperative pain and 259 without pain. Although women with pain had worse pain scores and pelvic floor symptoms at baseline and postoperatively, they had greater improvement on pain scores (-2.3 ± 2.4 vs -0.2 ± 1.4, P < 0.001), as well as Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores. Among women with pain who underwent a sacrospinous ligament fixation, those who received pelvic floor muscle training had a greater reduction in pain compared with those in the usual care group (-3.0 ± 2.3 vs -1.3 ± 2.1, P = 0.008). Persistent or worsening pain was present at 24 months in 5 (16%) women with preoperative pain., Conclusions: Women with preoperative pain experience significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery. Pelvic floor muscle training perioperatively may be beneficial for select patients., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2023 American Urogynecologic Society. All rights reserved.)

Background: Vaginal epithelial abnormalities (VEA) are a common complication associated with pessary use. The objective of this study was to determine if there is a host pro-inflammatory response associated with pessary use and VEA., Methods: Patients wearing pessaries for at least two weeks for the management of pelvic organ prolapse and/or urinary incontinence were screened for eligibility. Vaginal swabs were collected from women with VEA (cases) and without VEA (controls). Cases were matched to controls in a 1:3 ratio. Cytokine analysis of the collected samples was performed using multiplex analysis to determine the concentrations of interleukin (IL)6, interferon alpha 2 (IFNα2), tumor necrosis factor alpha (TNFα) and IL1β. A cross-sectional analysis was performed, comparing vaginal cytokine concentrations in women with and without VEA., Results: We enrolled 211 patients in this analysis: 50 cases and 161 controls. The median concentrations (pg/mL) of the four cytokines for cases and controls respectively were; IL6: 6.7 (IQR <2.9 [the lower limit of detection, LLD]-14.2) and < 2.9 (LLD) (IQR <2.9 [LLD]-5.5), IFNα2: 8.2 (IQR 6.1-13.9) and 7.9 (IQR 3.9-13.6), TNFα: 15.2 (IQR 6.1-30.4) and 4.68 (IQR <2.3 [LLD]-16.3), IL1β 195.7 (IQR 54.5-388.6) and 38.5 (IQR 6.7-154.9). The differences in median cytokine levels were statistically higher in cases for IL6, TNFα, and IL1β (all p < 0.001) compared to controls. Older age (OR: 1.062, 95% CI, 1.015-1.112), lower BMI (OR: 0.910, 95% CI, 0.839-0.986) and presence of VEA at last check (OR: 5.377, 95% CI, 2.049-14.108) were associated with higher odds of having VEA on multivariate analysis., Conclusion: Pro-inflammatory cytokines, specifically IL6, TNFα, and IL1β, are elevated in pessary-wearing patients who have VEA. Additional prospective studies are needed to assess baseline vaginal inflammatory profiles before and after pessary placement to understand VEA formation in pessary patients., (© 2021. The International Urogynecological Association.)

Background: Pelvic pain is a debilitating condition that is common among women with pelvic floor disorders. Limited information is known about the impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery., Objective: This study aimed to compare the outcomes after vaginal reconstructive surgery between women with and without preoperative pelvic pain., Study Design: Baseline and postoperative data were analyzed from the "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial." The multicenter trial involved women with anterior prolapse without symptoms of stress incontinence randomized to receive either a midurethral sling or sham incisions during a vaginal reconstructive surgery. Participants completed the visual analog scale adapted for suprapubic pain and Pelvic Floor Distress Inventory at baseline, 3 months, and 12 months. Preoperative pelvic pain was defined as a response of "5" or greater on pain on the visual analog scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question, "Do you usually experience pain in the lower abdomen or genital area?" Outcomes and complication rates were compared between women with and without pelvic pain., Results: The "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial" participants included 112 women with pelvic pain (58 had a midurethral sling and 54 had sham incisions) and 212 women without pelvic pain (105 had a midurethral sling and 107 had sham incisions). Women who had a midurethral sling and pelvic pain were younger than women without pelvic pain (60.3±12.1 vs 65.1±8.6; P=.004). Women who had sham incisions and pelvic pain were more likely of Hispanic ethnicity than women without pelvic pain (27.8% vs 9.4%; P=.002). Patient improvement based on the Patient Global Impression of Improvement scale did not differ between arms. Women with pelvic pain had greater improvement on the visual analog scale pain scores after a surgical procedure at 3 months (-3.1±2.9 vs -0.4±1.6; P<.001) and at 12 months (-3.4±3.0 vs -0.6±1.6; P<.001) than women without pain, although their pain scores remained higher than those without preoperative pelvic pain at all time points (P<.001 for all). Similar improvements were found on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. The differences observed were not affected by whether women were in the midurethral sling or sham arm of the trial. Postoperative urinary tract infection and incomplete bladder emptying did not differ between the groups., Conclusion: Women with preoperative pelvic pain experienced significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery and had similar subjective improvement postoperatively compared with women without preoperative pelvic pain. Reassuringly, the performance of a midurethral sling did not have an impact on the results., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Risk factors can be used to determine what patients will develop delayed postoperative urinary retention after female pelvic reconstructive surgery., Methods: A case-control study was performed including all female pelvic reconstructive surgeries necessitating a voiding trial. All patients passed their previous voiding trial. Cases had an acute encounter for urinary retention. Controls did not have acute postoperative urinary retention. Cases and controls were stratified based on procedure. Demographics, medical/surgical histories, voiding symptoms, urodynamic testing, and intraoperative data were collected. Cases were matched to controls in a 1:3 ratio. Mann-Whitney U and chi-square tests were used for univariate analyses; logistic regression was used to determine predictors of delayed postoperative urinary retention (DPOUR)., Results: A total of 1219 patients underwent pelvic reconstructive surgery that met eligibility; 51 cases of DPOUR (4.3%) were identified and matched with 153 controls without postoperative urinary retention. Of the procedures performed, 41.2% had prolapse surgery, 10.3% had incontinence surgery, and 48.5% had both prolapse and incontinence surgery. There were no differences between cases and controls in age, race, prior surgery, medical comorbidities, prolapse stage ≥ 3, voiding symptoms, and surgical characteristics. Cases had a lower BMI than controls (p < 0.001). There was no difference in preoperative urodynamic variables. Cases had lower percent voided volume on their last voiding trial than controls (90.2% ± 28.6% vs. 110.7% ± 39.5%, respectively; p = 0.001); however, clinically we consider a voided volume of two-thirds or greater of the instilled volume to be a normal result., Conclusions: DPOUR is an uncommon postoperative event. Demographic and clinical factors and urodynamic findings were unable to predict DPOUR. Percent voided volume on voiding trial was greater in controls.

Objective: To determine the relationship between age at first delivery and subsequent risk of pelvic organ prolapse., Study Design: We performed a retrospective cross-sectional study using the National Health and Nutrition Examination Survey data from 2005 to 2012. Our primary outcome was self-reported prolapse. Survival analyses and Cox proportional hazard models were used to estimate parous women's risks of reporting prolapse in terms of time since first delivery, adjusting for parity, body mass index, prior hysterectomy, ethnicity, and education. We performed subgroup analyses on women with at least 1 vaginal delivery and those with only cesarean deliveries., Results: The survey-weighted prevalence of prolapse was 2.82%. A total of 6203 women, 79% of all parous women surveyed, reported age at first delivery. Kaplan-Meier curves were different for women based on age at first delivery (P = 0.034). For each year increase in age at first delivery, there was a 6% increase in the rate of developing prolapse (adjusted hazard ratio, 1.06; 95% confidence interval, 1.01-1.11; P = 0.011). Compared with a woman who was 20 years at her first delivery, someone who was 30 years had 1.79 times the risk, while at 40 years the risk was 3.21 times. Among women with at least 1 vaginal delivery, the same relationship was found (adjusted hazard ratio, 1.06; 95% confidence interval, 1.01-1.12; P = 0.019). However, this was not significant for women with only cesarean deliveries (P = 0.367)., Conclusions: Older age at the time of first delivery was associated with a higher risk of subsequent prolapse. These results should be interpreted with caution given the limitations of cross-sectional survey data., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objective: The aim of the study was to compare perioperative morbidity of stress urinary incontinence surgery using data from a nationwide cohort., Methods: This is a retrospective cohort study of the American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2016. Stress urinary incontinence surgery was defined using current procedural terminology (CPT) for abdominal retropubic colposuspension (CPT 51840, 51841), laparoscopic retropubic colposuspension (CPT 51990, 51992), and suburethral sling (CPT 57288). Patients were excluded if they underwent any concomitant surgery except for cystoscopy (CPT 52000). Surgical approach and perioperative morbidity were examined using suburethral sling as the referent population. Patient characteristics, operative data, and 30-day postoperative events were collected., Results: Overall, 19,093 women underwent a stress urinary incontinence surgery: 317 abdominal retropubic colposuspension, 357 laparoscopic retropubic colposuspension, and 18,419 suburethral sling. Patients undergoing abdominal retropubic suspension had more inpatient procedures compared with suburethral sling and laparoscopic retropubic colposuspension (65% vs 10.4% and 17.6%, P < 0.001) and longer length of stay (1.6 ± 2.9 vs 0.3 ± 2.7 and 0.3 ± 0.6, respectively, P < 0.001). Abdominal retropubic colposuspension had the longest odds ratio time compared with suburethral sling (72.0 ± 64.6 vs 38.1 ± 34.2 minutes, P < 0.001). Composite morbidity was significantly higher for abdominal retropubic colposuspension compared with suburethral sling and laparoscopic retropubic colposuspension (7.9% vs 3.4% and 2.0%, P < 0.001). After adjusting for comorbidities, composite morbidity was higher for abdominal retropubic suspension (P = 0.007) compared with suburethral sling., Conclusions: Compared with suburethral sling, laparoscopic retropubic colposuspension had the lowest 30-day comorbidity and abdominal retropubic colposuspension had the highest 30-day comorbidity., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objective: To evaluate the influence of pessary visit intervals on development of vaginal epithelial abnormalities., Methods: We conducted a randomized, noninferiority trial of office-based pessary care. Eligible participants were adult women wearing a ring, Gellhorn, or incontinence dish pessary to treat pelvic organ prolapse or incontinence or both. Patients were randomized 1:1 to routine pessary care (office visits every 12 weeks, "routine" arm) or to extended pessary care (office visits every 24 weeks, "extended" arm). The primary study outcome was rate of vaginal epithelial abnormalities (epithelial break or erosion) at the final study visit (48 weeks). The predetermined noninferiority margin was 7.5%., Results: From January 2015 through June 2017, inclusive, 448 patients were screened and 130 were randomized, 64 to the routine arm and 66 to the extended arm. Baseline characteristics of the study arms were similar with the exception of pessary type, with ring pessary more common in the routine arm and Gellhorn pessary more common in the extended arm (P=.02). The rate of epithelial abnormalities at the final study visit (48 weeks) was 7.4% in the routine arm and 1.7% in the extended arm (difference, -5.7 percentage points; 95% CI -7.4 to -4), which met the criterion for noninferiority. Rates of all types of epithelial abnormalities did not differ between arms at any time point. Increasing duration of pessary use (P=.003) and history of prior epithelial abnormalities were associated with development of epithelial abnormalities (P=.01). Other than epithelial abnormalities, no adverse events related to pessary use occurred in either arm., Conclusion: In women who receive office-based pessary care and are using a ring, Gellhorn, or incontinence dish pessary, routine follow-up every 24 weeks is noninferior to every 12 weeks based on incidence of vaginal epithelial abnormalities., Clinical Trial Registration: ClinicalTrials.gov, NCT02371083.

Introduction and Hypothesis: Hospital readmission is increasingly used as a measure of quality care. Our objective was to evaluate the rate of readmission and associated factors in women undergoing suburethral sling placement in the USA., Methods: This is a cohort study of suburethral sling procedures performed in the USA from 2012 to 2014 using the American College of Surgeons' National Surgical Quality Improvement Program database. The database was queried for suburethral sling procedures. Records were excluded if concomitant surgery had been performed. Patient and surgical characteristics were evaluated for association with readmission using Chi-squared test for categorical variables and Student's t test for continuous variables. All results yielding p < 0.05 were deemed statistically significant., Results: A total of 7,117 suburethral sling procedures were identified. There were 83 (1.16%) hospital readmissions. Those who were readmitted tended to be older (p = 0.011), non-Hispanic (p = 0.04), smokers (p < 0.001), and have an American Society of Anesthesiologists Physical Status Classification System score of 3 or 4 (p = 0.001). A history of bleeding disorder (p < 0.001), congestive heart failure (p < 0.001), or chronic obstructive pulmonary disease (p < 0.001) was associated with readmission. Fifty-four (0.75%) patients underwent reoperation within 30 days of suburethral sling placement. The most common reoperation procedure was sling excision (20 patients). The most common complication was urinary tract infection, which occurred in 189 patients (2.7%)., Conclusions: Suburethral sling placement is a safe procedure with a low rate of readmissions, reoperations, and complications. Consistent with other types of surgery, infection is the most common post-operative complication.

Objective: To evaluate the relationship between perioperative use of transdermal scopolamine and the rate of urinary retention after stress urinary incontinence and pelvic organ prolapse procedures in women., Methods: This is a retrospective, cohort study; the primary outcome is the rate of acute postoperative urinary retention. Study candidates were adult female patients who underwent pelvic reconstructive surgery at a tertiary care center. Subjects were excluded if preoperative postvoid residual urine volume was greater than 150 mL, preoperative urodynamic testing was not performed, or if a postoperative trial of void was not performed. Subjects were grouped based on preoperative use of transdermal scopolamine. Patients were selected consecutively until 138 subjects per group was reached. Differences in rates of acute postoperative urinary retention were evaluated using a chi-square test. Group demographics were evaluated using t tests and χ tests., Results: Two hundred seventy-six subjects were included in the analysis, 138 received a transdermal scopolamine patch in the perioperative period and 138 did not. The overall rate of acute postoperative urinary retention was 25.3%. There was no significant difference in the rate of acute postoperative urinary retention between the study groups (scopolamine, 26.8%; no scopolamine, 23.9%; P = 0.580). Demographics of the 2 groups were compared; patients who received scopolamine patch were younger (P = 0.001), received a greater amount of intravenous fluids (P = 0.007), and underwent a greater percentage of incontinence procedures (P = 0.048). Otherwise, there were no differences between the groups., Conclusions: Transdermal scopolamine is not a risk factor for acute postoperative urinary retention after pelvic reconstructive procedures.

Objective: The purpose of this study was to evaluate the pressure placed on the shoulders as a function of varying degrees of head-down tilt (the Trendelenburg position) and to compare these pressures among 3 different patient-positioning systems., Study Design: Participants were placed in the dorsal-lithotomy position with arms tucked and tilted at 5, 10, 15, 20, 25, and 30 degrees of head-down tilt. Using a manometer, we measured the pressure (centimeters of water) on the shoulders at each angle for 3 support devices: the Skytron shoulder support (Skytron, Grand Rapids, MI), the Allen shoulder support (Allen Medical Systems, Acton, MA), and the Allen Hug-u-Vac., Results: Among 23 participants, body mass index (mean ± SD) was 24.5 ± 4.3 kg/m(2). As the tilt angle increased, so did the shoulder pressure for all support systems. At a 30-degree Trendelenburg position, the Allen Hug-u-Vac transmitted less pressure to the shoulders than the Skytron (right and left, P < .001) and the Allen shoulder supports system (right, P < .001; left, P = .434). Each participant was asked, "Which system was most comfortable?" Seventy-four percent of the participants reported that they preferred the Hug-u-Vac (P < .001)., Conclusion: Shoulder pressure increases as tilt angle increases. Of the 3 support systems that were tested, the Allen Hug-u-Vac transmitted less pressure to the shoulders at a 30-degree Trendelenburg position than the Skytron and the Allen shoulder support systems., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To evaluate whether patients with advanced pelvic-organ prolapse (POP) were less likely than controls to obtain screening Papanicolaou (Pap) test, mammography, and colonoscopy., Study Design: Records were reviewed from 7/2/2010 through 4/22/2011. We identified patients with advanced POP, defined as prolapse > or = 4 cm beyond the hymenal ring, and made age- and parity-matched controls from patients whose prolapse was <4 cm. Compliance for screening of cervical, breast and colon cancers was compared between the two groups., Results: Of 933 records, we identified 51 patients with advanced POP and 51 controls. Neither Pap test nor colonoscopy screening differed between the groups (McNemar chi2, P=1.00; McNemar chi2, P=1.00). Mammogram screening did not differ statistically; however, there was a trend towards neglecting screening in the advanced POP group (McNemar chi2, P=0.057)., Conclusion: Patients with POP > or = 4 cm beyond the hymenal ring were equally as likely to obtain routine health screening as age- and parity-matched controls whose POP measured <4 cm.

Objective: We sought to evaluate the prevalence of pelvic organ prolapse (POP) among a diverse group of women and to determine if race/ethnicity and/or socioeconomic status (SES) are factors in treatment-seeking behavior., Study Design: All data were collected from the National Institutes of Health-supported Boston Area Community Health Survey. SES was calculated by a 2-factor index that combined household income with years of education. Inferential statistics comprised 1-way analysis of variance, with a post hoc Scheffé test performed to evaluate whether there were differences between individual groups. A χ(2) test was used to evaluate whether distributions were equal among the various questions by race/ethnicity and SES category., Results: A total of 3205 women were included in the analysis. Hispanic ethnicity and younger age were associated with POP (P < .002 and P < .001, respectively) as well as with seeking treatment for prolapse (P = .007 and P < .001, respectively). These factors were also associated with subsequent surgical repair (P = .027 and P = .019, respectively). A regression model showed that women were 4.9% more likely to seek treatment for every year younger they were, across the range of age. Although women of a higher SES were more likely to have POP, SES was neither associated with a higher likelihood of seeking treatment nor with the surgical management of prolapse., Conclusion: Hispanic ethnicity and younger age were associated with seeking treatment for POP. Hispanics were more likely than whites or blacks to proceed with surgical management. There was no correlation of SES with any of the above factors., (Copyright © 2013 Mosby, Inc. All rights reserved.)

One proposed advantage of robotic surgery is improved ergonomics and decreased surgeon fatigue. The objective of this study is to quantify and compare the physical activity of surgeons during robotic and abdominal surgery using accelerometers. Eight gynecologic surgeons who perform both abdominal and robotic surgery were the subjects of this study. Each wore an accelerometer on the hip during one procedure performed abdominally and during a similar procedure performed robotically. Activity parameters analyzed were average activity counts (AAC) and percentage of time spent in sedentary, light, moderate, and vigorous activity. The paired t-test was used to evaluate differences between robotic and abdominal procedures. AAC was similar between the robotic and abdominal approaches (mean ± SD: 83.9 ± 50.9 versus 79.1 ± 37.8 counts/min, respectively, P = 0.820). The majority of activity spent in robotic and abdominal surgery was sedentary (79.0% ± 5.9% versus 80.9% ± 8.6%, respectively; P = 0.625) followed by light activity (14.7% ± 3.9% versus 12.8% ± 6.1%, respectively; P = 0.541) and then by moderate activity (6.3% ± 3.4% versus 6.3% ± 2.8%, respectively; P = 0.981). None of the activity for either surgical approach qualified as vigorous. There were no differences in activity parameters by surgical approach. Accelerometer data demonstrate that surgeon activity expenditure is similar in robotic and abdominal surgery. Future studies comparing measures of physical activity and strain between surgical approaches are needed to determine whether the robot's improved ergonomics translates to improved surgeon experience.

Background: Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period., Case: A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh., Conclusion: Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

Permanent suture material and synthetic grafts can be used as part of pelvic organ prolapse surgery. These materials are often attached to the sacrospinous ligament or passed in retroperitoneal spaces. There is a risk for erosion and granulation tissue formation with any of these materials. Typically, this is managed through a transvaginal incision.We present a case of a postmenopausal woman with persistent granulation tissue and a sinus tract from a braided polyester (Ethibond) suture placed in the right sacrospinous ligament fixation. After failing several attempts at treating this granulation tissue through a vaginal incision, we managed this via an abdominal retroperitoneal approach.

Introduction/hypothesis: To identify factors that influence nulliparous women to choose cesarean delivery on maternal request (CDMR)., Methods: Nulliparous women at > or = 34 weeks completed a 76-item survey about concerns during labor, delivery and postpartum., Results: Mean age of the 294 respondents was 28.4 years (+/- 6.13 years SD) and mean gestational age was 35.4 weeks (+/- 2.8 weeks). Sixteen patients (5.4%) would request CDMR if offered. Women who would request CDMR were more likely to plan breastfeeding (OR 5.1, P=0.02), have a mother who delivered by C-section (OR 5.1, P= 0.01), and be concerned about the number of family members present (OR 1.75, P=0.002). Pelvic muscle damage, urinary incontinence, fecal incontinence, or need for prolapse surgery were notcited by any patient as her top concern., Conclusions: Few women in our sample desire CDMR. Concern for pelvic-floor problems was low.

Introduction and Hypothesis: This study aims to compare the post-operative rates of stress urinary incontinence (SUI) after abdominal sacral colpopexy (ASC) with either Burch or mid-urethral sling, tension-free vaginal tape (TVT), or no anti-incontinence procedure. The null hypothesis was there would be no difference in SUI among groups., Methods: A cohort of women who had undergone ASC (n = 150) either alone or with an anti-continence procedure were analyzed to determine the rates of post-operative SUI. Statistically significant differences were evaluated with a Student's t-test., Results: A total of 150 subjects were evaluated, with 115 having SUI preoperatively. Post-operatively, 10% (15/150) of all subjects had SUI. Subjects with preoperative SUI who had a Burch were more likely to have post-operative SUI than those who had a TVT (10 versus 0, p = 0.007)., Conclusions: Burch and TVT procedures improve SUI symptoms in patients undergoing ASC. Mid-urethral slings performed with ASC have lower rates of post-operative SUI.

Introduction: We evaluated whether women with urge urinary incontinence (UUI) have lower quality of life (QOL) than women with other forms of urinary incontinence., Methods: Patients completed three validated questionnaires when presenting for evaluation at a urogynecology practice and were divided into four groups based on their responses: those with symptoms of stress urinary incontinence (SUI), UUI, both SUI and UUI (mixed UI), and neither SUI nor UUI (controls)., Results: A total of 465 women were included: 53 women with UUI (11.4%), 101 with SUI (21.7%), 200 with mixed UI (43%), and 111 controls (23.9%). Overall, there was a significant difference (p < 0.001) in PFIQ bladder scale scores as a function of UI group, with individual mean PFIQ scores of 17.1 for controls, 22.3 for SUI, 32.7 for UUI, and 36.8 for mixed UI. Individually, all seven questions in the PFIQ bladder domain were significantly different by group (p

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy.

Aims: The relationship of detrusor overactivity (DO) to neuromuscular causes is well established, but a connection to kidney function has not yet been studied. We sought to evaluate whether patients with DO have differences in estimated glomerular filtration rate (eGFR)., Methods: After Institutional Review Board approval, we collected data from all patients who underwent urodynamic testing in our office from September 1, 2006 to February 28, 2007 and calculated eGFR using the equation derived from the Modification of Diet in Renal Disease (MDRD) study., Results: Data were collected on 359 patients, who had a mean eGFR for all patients of 82.99 ml/min/1.73 m(2) (+/-22.2). The patients were divided into groups by the presence or absence of DO on filling cystometry. There was no significant difference in eGFR between the patients with and without DO (80.9 ml/min/1.73 m(2) vs. 84.4, P = 0.290)., Conclusions: Kidney function does not differ between patients with or without DO.

The purpose of this study was to evaluate whether community-dwelling women can reliably identify infected urine samples. A convenience sample of 25 women judged six urine samples. Of these, two were normal, two contained culture-proven infections, and two were intentionally abnormal because of ingestion of asparagus or vitamins. The women decided if each sample was infected based on its color, clarity, and odor. For the two normal samples, 56 and 96% women correctly identified them. Of the two samples positive for infection, women were correct 80 and 100% of the time. Of the two samples designed to be abnormal, women were correct in 92 and 64% of their evaluations. Using the 150 total evaluations of urine samples, the sensitivity was 90%, and the specificity was 77%. Based on this small sample, community-dwelling women can detect infected samples of urine. However, women should still be screened for factors that might have distorted normal urine.

We investigated whether women with and without anterior vaginal wall prolapse have voiding differences. Women (n=109) who presented to a urogynecology practice were categorized into two groups based on anterior vaginal wall prolapse: stages 0 and 1 and stages 2, 3, and 4. Women with prolapse were older than the women without prolapse but the groups were otherwise similar demographically. There was a higher rate of activity-related urine loss and use of wetness protection amongst women without prolapse. There was no significant difference for urgency symptoms or urge incontinence. Urodynamic testing found no significant differences for maximal flow rate or maximal urethral closing pressures. Postvoid residual volume and detrusor overactivity were not different but approached significance. Anterior vaginal wall prolapse of stage 2 or greater was not associated with urge incontinence or voiding function in this population. Women without prolapse were more likely to report stress incontinence.

Background and Objectives: Fistulas inaccessible from the vagina may require abdominal repair; we sought to evaluate the robotic-assisted laparoscopic approach for this procedure., Methods: A 41-year-old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy, and office evaluation identified a vesicovaginal fistula. After discussion with the patient regarding the surgical options, the robotic approach was chosen to facilitate precise dissection, fine visualization, and suturing. A stent was placed from the bladder into the vagina, and no intentional cystotomy was made. The bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 hours, and robotic time was about 2.5 hours., Results: At 3 months after surgery, the patient had no recurrent symptoms., Conclusions: The robotic-assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated.

Objective: To determine if there is a significant difference in outcomes of clinical trials funded by industry or not of antimuscarinic medications used to treat overactive bladder (OAB) symptoms and detrusor overactivity (DOA)., Methods: A Medline search was conducted from January 1966 to June 2003 to identify human clinical trials of oxybutynin and tolterodine published in English. Randomized controlled trials on subjects aged > or = 16 years who were being treated with oxybutynin or tolterodine for OAB symptoms or DOA; 24 studies were identified. The endpoints assessed were OAB symptoms or changes in uninhibited detrusor contractions on cystometrography. The outcome variables were dichotomized as 'improvement' or 'no improvement'. Odds ratios and 95% confidence intervals were calculated for each study based on data derived or extracted from tables and figures., Results: Meta-analysis showed no significant difference in the outcomes trails funded by industry or not. Trials were then reviewed to determine their adherence to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for randomized trials., Conclusions: Clinical trials are important for clinicians when selecting medical therapies. In this analysis we found no difference in outcomes when comparing studies funded by industry or not for tolterodine and oxybutynin. The quality of all trials would be improved by close adherence to the CONSORT guidelines for randomized clinical trials.

Anterior enterocele is an uncommon finding in patients with pelvic organ prolapse. We reviewed 490 consecutive operations for pelvic organ prolapse . Three anterior enteroceles were identified in a series of 193 enterocele repairs (1.6%). The presentation and treatment of each of these patients is reviewed.

Objective: To describe the proximity of the major vessels in the retropubic space and anterior abdominal wall to the tension-free vaginal tape needle., Methods: Tension-free vaginal tape needles were inserted bilaterally in ten cadavers. Dissection of the superficial epigastric, inferior epigastric, external iliac, and obturator vessels was performed. Measurements from the lateral aspect of the needle to the medial edge of the vessels were recorded. In an additional cadaver, three planes were created by placing a string from the midlabia to the shoulder, mid-biceps brachii muscle, and 6 cm lateral to the mid-biceps brachii muscle of the cadaver's extended, ipsilateral arm. An operator, blinded to the retropubic space anatomy, passed the needle in these planes bilaterally. The distances from the needle to the external iliac and obturator vessels were measured., Results: All vessels measured were lateral to the tension-free vaginal tape needle. The mean distance from the tension-free vaginal tape needle to the obturator vessels was the closest: 3.2 cm (range 1.6-4.3 cm). The mean distance from the tension-free vaginal tape needle to the superficial epigastric vessels was 3.9 cm (range 0.9-6.7); to the inferior epigastric vessels, 3.9 cm (range 1.9-6.6 cm); and to the external iliac vessels, 4.9 cm (range 2.9-6.2 cm). When the needle was directed 6 cm lateral to the mid-biceps brachii muscle, the external iliac vein was punctured., Conclusion: The major vessels in the retropubic space and anterior abdominal wall lie 0.9-6.7 cm lateral to the tension-free vaginal tape needles. If the tension-free vaginal tape needle is laterally aimed or rotated, major vascular injury can occur.

Study Objective: To assess the safety of laparoscopic treatment of adnexal masses in the second trimester of pregnancy., Design: Retrospective chart review (Canadian Task Force classification II-3., Setting: Large tertiary care medical center., Patients: Eleven women., Intervention: Laparoscopic surgery., Measurements and Main Results: All masses were identified by ultrasound. The average gestational age at the time of surgery was 17 weeks, 4 days. In seven women the primary cannula was inserted in the left upper quadrant of the abdomen. Procedures were eight ovarian cystectomies, two oophorectomies, and one exploratory laparoscopy. Average operating time was 135 minutes (range 95-195 min). Average time exposed to carbon dioxide was 78 minutes (range 59-135 min). None of the masses was malignant. There were no fetal complications or malformations. No patients had preterm labor and all delivered at term., Conclusions: The increasing number of reported cases and our experience suggest that laparoscopic treatment of adnexal masses in the second trimester is safe and effective, but the surgeon must be skilled in advanced techniques of laparoscopic surgery.

Objective: To determine the safety and efficacy of primary left upper quadrant laparoscopic cannula insertion., Design: Retrospective review., Setting: Tertiary care medical center., Patient(s): Women undergoing laparoscopic surgery for gynecologic indications., Intervention(s): Left upper quadrant cannula insertion., Main Outcome Measure(s): Intraoperative complications., Result(s): Primary left upper quadrant cannula insertion was performed 58 times. There were no intraoperative complications. In one woman there was more pain at the LUQ site than at her other incisions. In 12 women (21%) adhesiolysis was performed before insertion of the umbilical cannula., Conclusion(s): Primary left upper quadrant cannula insertion is a safe and effective alternative to primary umbilical cannula insertion.

Background: Tension-free vaginal tape procedure is a popular surgical treatment of genuine stress urinary incontinence., Cases: Two cases of retropubic hematoma after tension-free vaginal tape procedure are reported. One woman with an 8 x 10 cm hematoma localized to the retropubic space required transfusion of two units of packed red blood cells for symptomatic relief. Neither case required reoperation, and both patients' hematomas resolved over 6 months without treatment. Both patients were continent 9-12 months after surgery., Conclusion: Although the tension-free vaginal tape procedure is a minimally invasive operation for stress urinary incontinence and appears to be effective, significant vascular complications can result.

Objective: To compare laparoscopic, gross, and fluorescent assessment of laparoscopic pelvic injuries., Design: Experimental prospective study., Setting: Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio., Animal(s): Nonpregnant adult female pigs., Intervention(s): Pelvic organs injured with laparoscopic energy sources were assessed laparoscopically, grossly, and with a fluorescent indicator and Wood's lamp., Main Outcome Measure(s): Three different measurements of each laparoscopic injury., Result(s): Assessment of injuries by laparoscopy did not differ significantly from gross assessment of injuries. In the segments of bowel and bladder that were injured with monopolar cautery, the Wood's lamp assessment of the injuries was significantly longer than the laparoscopic assessment of the injuries., Conclusion(s): Laparoscopic assessment of injured ureters, bowel, and bladder appear to be similar to gross assessment of these tissues. In tissue where the serosal surface is intact, the use of a fluorescent dye and a Wood's lamp provides a clear margin of the injured tissue.

Objective: To examine the histology of the vaginal wall in women with an enterocele confirmed by physical examination, cystoproctography, and intraoperative exploration., Methods: Thirteen women with posthysterectomy apical and posterior wall prolapse were evaluated with a detailed physical examination, cystoproctography, and intraoperative exploration. All women had enterocele repair. A specimen of full thickness vaginal wall from the leading edge of the enterocele was excised and examined histologically. The histology of these patients was compared with the histology of two comparison groups, five women undergoing hysterectomy without prolapse and 13 women undergoing radical hysterectomy., Results: One woman with an enterocele repaired intraoperatively did not have an enterocele by cystoproctography. One woman with an enterocele repaired intraoperatively did not have an enterocele detected by physical examination. All women with an enterocele repaired had an intact vaginal wall muscularis. No woman had vaginal wall epithelium in direct contact with the peritoneum. The average vaginal wall muscularis thickness in women with enteroceles was 3.5 +/- 1.4 mm, in women with no prolapse 3.2 +/- 0.8 mm, and in women undergoing radical hysterectomy 2.8 +/- 0.9 mm., Conclusion: Women with enteroceles have a well-defined vaginal muscularis between the peritoneum and vaginal epithelium.

Objective: To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair., Methods: Fifty-four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms., Results: Fifty-four women had enterocele repairs as part of their surgery. Mean follow-up time was 16 months (range 6-29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty-three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow-up., Conclusion: Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.

Study Objective: To assess the outcome of laparoscopic repair of pelvic ureter injuries., Design: Retrospective case series (Canadian Task Force classification II-2)., Setting: Large urban tertiary care medical center., Patients: Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures., Intervention: Laparoscopic ureteroureterostomy., Measurements and Main Results: All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury., Conclusion: Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure.

Objective: To compare the gross and histologic effects of bipolar and monopolar cautery, ultrasonic scalpel, and CO(2) laser on porcine ureter, bladder, and rectum., Design: Experimental prospective study., Setting: Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio., Animal(s): Nonpregnant adult female pigs., Intervention(s): The rectum, bladder, and ureters of 12 female pigs were injured with four different laparoscopic energy sources., Main Outcome Measure(s): Gross measurements of injured tissue and histologic analysis of the depth of the tissue injury., Result(s): Gross assessment results were that monopolar injuries of the bowel and bladder were significantly longer than ultrasonic injuries (P<0.01). Injuries were generally manifest as coagulative denaturation of collagen bundles. This resulted in an eosinophilic homogenization of tissue. Nuclei were retained in the injured tissue, although in most cases they had a pyknotic, streamed appearance. The CO(2) laser caused no deep-tissue injury., Conclusion(s): Laparoscopic energy sources injure tissue differently. Monopolar cautery appears to have the most lateral spread of thermal energy. The CO(2) laser appears to cause the least deep-tissue injury.

Injury to the ureter is a possible complication of laparoscopic surgery. Traditionally, it is repaired by laparotomy. During laparoscopic surgery for bilateral ovarian remnants in a 29-year-old woman, the left ureter was transected. The ureter was repaired by primary end-to-end anastomosis by laparoscopy. The patient recovered uneventfully, and postoperative intravenous puelogram confirmed the repair to be intact.

Objective: To determine the frequency of lower urinary tract injury detected by routine intraoperative cystoscopy after anti-incontinence surgery., Methods: We reviewed charts from women who had anti-incontinence surgery and routine intraoperative cystoscopy done by a single surgeon from June 1, 1995, to June 1, 1998, and assessed preoperative and intraoperative variables., Results: We reviewed 351 patient records. Four records were incomplete and there were nine injuries in the other 347 cases (2.6%, 95% confidence interval [CI] 1.2, 4.9). Four cystotomies occurred during laparoscopic Burch procedures and were detected before cystoscopy. Five injuries were detected at cystoscopy, a rate of 1.5% (95% CI 0. 5, 3.4). Four injuries occurred during 161 pubovaginal sling procedures (2.5%, 95% CI 0.7, 6.2). One woman had sutures in her bladder from a prior procedure detected at cystoscopy. In 186 Burch procedures (48 laparoscopic, 138 open), there were no previously unrecognized injuries detected by cystoscopy. All injuries were repaired during original surgery. It was not possible to assess preoperative and intraoperative risk factors because of the low rate of injury., Conclusion: The rate of injury to the lower urinary tract during anti-incontinence surgery in this series was 2.6% (95% CI 1.2, 4.9). Injuries during Burch procedures were all detected before cystoscopy.

Study Objective: To determine the anatomy of the left upper quadrant (LUQ) of the abdomen in women with different body mass indexes., Design: Review of computed tomographic (CT) scans and medical records (Canadian Task Force classification II-2)., Setting: Large tertiary care medical center., Patients: Sixty-three women over age 18 years who had scans performed for any indication. Nine women were excluded because of contraindication to LUQ laparoscopic cannula insertion and five because of incomplete records. Intervention. None., Measurements and Main Results: The closest organs to the LUQ insertion site were the liver and stomach. There was significantly more subcutaneous fat at the umbilicus than at the insertion site. A positive correlation was found between body mass index and distance between structures and the site., Conclusion: Cannulas should not be inserted in the LUQ in women with hepatomegaly or splenomegaly. Because the stomach is so close to the insertion site, gastric drainage should be performed before cannula insertion. The site is likely safe in obese women whose abdominal organs are far away from it, and who have less subcutaneous fat there than at the umbilicus.