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BackgroundThe purpose of this research was review the epidemiology of the association of obesity and urinary incontinence, and to summarize the published data on the effect of weight loss on urinary incontinence.MethodsA literature review of the association between urinary incontinence and overweight/obesity in women was performed. Case series and clinical trials reporting the effect of surgical, behavioral, and/or pharmacological weight loss on urinary incontinence are summarized.ResultsEpidemiological studies demonstrate that obesity is a strong and independent risk factor for prevalent and incident urinary incontinence. There is a clear dose-response effect of weight on urinary incontinence, with each 5-unit increase in body mass index associated with a 20%-70% increase in risk of urinary incontinence. The maximum effect of weight on urinary incontinence has an odds ratio of 4-5. The odds of incident urinary incontinence over 5-10 years increase by approximately 30%-60% for each 5-unit increase in body mass index. There appears to be a stronger association between increasing weight and prevalent and incident stress incontinence (including mixed incontinence) than for urge incontinence. Weight loss studies indicate that both surgical and nonsurgical weight loss leads to significant improvements in prevalence, frequency, and/or symptoms of urinary incontinence.ConclusionEpidemiological studies document overweight and obesity as important risk factors for urinary incontinence. Weight loss by both surgical and more conservative approaches is effective in reducing urinary incontinence symptoms and should be strongly considered as a first line treatment for overweight and obese women with urinary incontinence.

Natural orifice translumenal endoscopic surgery (NOTES) has the potential to decrease the burden of an operation on a patient. Limitations of the endoscopic platform require innovative solutions to provide retraction and create an operation comparable with the gold standard, laparoscopic cholecystectomy.Four patients underwent transvaginal cholecystectomy. All procedures were performed under laparoscopic vision to ensure safety. The endoscope and a long articulating RealHand instrument were placed via a 15-mm vaginal trocar. A magnetic retraction system was used to retract the gallbladder safely. Laparoscopic clips were used to ligate the cystic duct and artery. All four gallbladders were successfully removed. No complications occurred. The mean operating time was 102 min.All four procedures were completed without complications. The four patients all were discharged shortly after surgery and reported normal sexual activity without pain.Transvaginal cholecystectomy can be completed safely using current technology. Further studies are needed to determine the safety of the procedure and to determine whether it confers any benefits other than cosmesis.

Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques.A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min.The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics.The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach.

Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience.Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance.Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred.The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.

Introduction and hypothesis: We evaluated whether the use of estrogen vaginally prior to synthetic midurethral sling insertion mediates the risk of mesh exposure. A secondary aim was to evaluate other factors that may be associated with mesh exposure. Methods: We performed a retrospective cohort study of patients undergoing midurethral sling insertion from January to December 2010 within the Southern California Permanente Medical Group. Women who used estrogen vaginally prior to surgery were classified as those who filled a prescription between 1 and 45 days before surgery or whose medical records indicated its use at the time of preoperative evaluation. Logistic regression analysis was used to calculate odds ratios (OR) and 95 % confidence intervals (CI) for factors associated with mesh exposure while controlling for confounding variables. Results: A total of 1544 patients met inclusion criteria, of whom 248 (16.1 %) used estrogen vaginally prior to surgery. Mean age was 53.7 years (range 27-89). Thirty-seven (2.4 %) women were diagnosed with mesh exposure, of whom 19 underwent surgical reoperation. In multivariate logistic regression analysis, preoperative use of estrogen vaginally was not associated with the risk of mesh exposure (OR 0.79, CI 0.26-2.38, p = 0.67). Age, body mass index, menopausal status, use of hormone replacement therapy, smoking status, and diabetes were not associated with risk of mesh exposure. Conclusions: Preoperative use of estrogen vaginally did not appear to mediate the risk of mesh exposure following midurethral sling placement in this cohort. [ABSTRACT FROM AUTHOR]