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Este mes en... Female Pelvic Medicine & Reconstructive Surgery:

American Urogynecologic Society Best Practice Statement: Evaluation and Counseling of Patients With Pelvic Organ Prolapse Abstract: Women with prolapse should have an examination to quantify the loss of anatomic support and should be evaluated for associated bladder, bowel, and prolapse symptoms as well as associated bother. Treatment options should be tailored to meet the patient's medical health and personal functional goals. In most cases, women should be informed of the range of treatment options including observation as well as nonsurgical and surgical management. Evaluating the Impact of Intraoperative Surgical Team Handoffs on Patient Outcomes Objective: The aim of the study was to assess the impact of intraoperative personnel handoffs on clinical outcomes in patients undergoing minimally invasive sacrocolpopexy (SCP). Methods: We retrospectively reviewed SCPs performed at an academic center between 2009 and 2014. We analyzed the number of staff handoffs, defined as any instance a scrub technician (tech) or circulating nurse handed off responsibility for a break or shift change. Outcomes included operative (OR) time and composite variables for major complications (conversion to an open procedure, bladder injury, bowel injury, blood transfusion, infection, ileus, bowel obstruction, readmission, or mesh complication) and prolapse recurrence (prolapse at or beyond the hymen or retreatment). Postoperative complications were defined as being within 6 weeks of surgery. Mesh complications and prolapse recurrence were recorded for the entire 68-month study period. Results: Of 814 patients, 97.4% were white, 85.3% postmenopausal, mean (SD) age 59.7 (8.8) years, and mean (SD) body mass index 27.5 (4.5) kg/m2. Most had stage 3 prolapse (n = 563, 69.9%). There were 478 (58.7%) laparoscopic and 336 (41.3%) robotic SCPs. The median scrub tech and nurse handoff per case was 1.0 (interquartile range [IQR], 0.0–1.0) and 1.0 (IQR, 1.0–2.0), respectively. Mean (SD) OR time was 204.8 (69.0) minutes. One hundred twenty-nine patients (15.8%) had a major complication and 45 (7.5%) experienced prolapse recurrence over a median follow-up interval of 41.0 weeks (IQR, 12.0–101.0). On multivariable linear regression, each tech and nurse handoff was associated with an increased OR time of 13.6 (P < 0.001) and 9.4 minutes (P < 0.001), respectively. Thus, the median of 1 tech and 1 nurse handoff per case will increase OR time by 23.0 minutes (11.2%). On multivariable logistic regression, staff handoffs were not associated with major complications or prolapse recurrence. Conclusions: Intraoperative scrub technician and circulating nurse handoffs increased OR time for minimally invasive SCP procedures. The Role of the Surgeon on Outcomes of Vaginal Prolapse Surgery With Mesh Introduction: Adverse outcomes after surgery for pelvic organ prolapse (POP) with mesh are often attributed to the mesh material with little attention paid to the influence of surgeon factors. We used a national data set to determine whether surgeon case volume and specialty influenced vaginal prolapse surgery outcomes with mesh. Materials and Methods: Public Use File data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with a diagnosis of POP who underwent surgery with mesh between 2007 and 2008 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology, 4th Edition procedure codes. Outcomes were compared by surgeon case volume and specialty. Results: From 2007 to 2008, 1657 surgeries for POP were performed with mesh. Low-, intermediate-, and high-volume surgeons performed 881 (53%), 408 (25%), and 368 (22%) of the cases with mesh, respectively. The cumulative reoperation rates for low-, intermediate-, and high-volume providers were 6%, 2%, and 3%, respectively. The difference in reoperation rates between low and intermediate and low- and high-volume surgeons was statistically significant (P = 0.007 and 0.003, respectively). There was no significant difference in reoperation rates between gynecologists and urologists when vaginal mesh was implanted for POP surgery. Conclusions: Low-volume surgeons performed most of the vaginal prolapse repairs with mesh and had significantly higher reoperation rates. Surgeon experience must be a consideration when reporting mesh-related complications of POP surgery. Symptom Relief and Retreatment After Vaginal, Open, or Robotic Surgery for Apical Vaginal Prolapse Objectives: The aim of this work was to determine the degree of symptom relief and survival free of retreatment after Mayo-McCall culdoplasty (MMC), open abdominal sacrocolpopexy (ASC), and robotic sacrocolpopexy (RSC) for posthysterectomy vaginal vault prolapse. Methods: We retrospectively studied patients who had undergone surgery for posthysterectomy apical vaginal prolapse from January 1, 2000, through June 30, 2012, at our institution. Baseline characteristics and perioperative outcomes were abstracted from electronic health records. Cross-sectional data for current pelvic floor symptoms were collected by using validated questionnaires. Survival free of retreatment was estimated with the Kaplan-Meier method. To account for selection bias, adjusted analyses using inverse probability weighting (IPW) were performed to compare outcomes for MMC versus ASC, MMC versus RSC, and ASC versus RSC. Results: Of 512 patients, 337 completed at least a validated or abbreviated questionnaire. Among MMC, ASC, and RSC groups, overall Pelvic Floor Distress Inventory 20, Pelvic Floor Impact Questionnaire Short Form 7, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 summary scores were not significantly different. There was no significant difference in 5-year survival free of retreatment for MMC (94.0%) versus RSC (95.5%) and ASC (94.8%) versus RSC (92.1%). However, patients who had MMC were more likely to have retreatment than patients who had ASC during the first 10 years (10-year survival free of retreatment: 81.1% vs 95.4%; hazard ratio, 3.68 [95% confidence interval, 1.51–8.98]); the 10-year data were not available for RSC comparisons, given the later initiation of RSC. Conclusions: Symptom relief was comparable after MMC, ASC, and RSC. Among all groups, most patients were free of retreatment for prolapse at 5 years. Between the MMC and ASC groups, survival free of retreatment (%) within 10 years was still favorable, but ASC had greater durability, particularly after accounting for selection bias. The Relationship of Anterior Vaginal and Apical Position to Postvoid Residual Urine Objective: The aim of the study was to investigate the association between severity of anterior vaginal or apical prolapse and postvoid residual volume (PVR). Methods: The charts of all women who presented to Urogynecology Clinic at Olive View-UCLA Medical Center for a 2-year period were reviewed. Demographic data, the degree of prolapse pelvic organ prolapse quantification points Aa, Ba, and C, and PVR were recorded. Patients with incomplete pelvic organ prolapse quantification assessment or improperly measured PVR were excluded. Results: Three hundred fifty-two patients were included. Median age was 54 years (range, 26–80). Mean gravidity and parity were 4.4 and 3.7, respectively. Mean body mass index was 29.9 kg/m2. One hundred forty-nine women had previous pelvic surgery. Median PVR was 25 mL, and 40 patients (11.4%) had a PVR of 100 mL or greater. Considering 15 potential PVR predictors, we found that the position of apex/cervix (point C) significantly correlated with an increase in PVR and also after controlling for the other significant covariates (rate of change b = 4.7% increase in PVR/cm, P = 0.0007). The other significant (P < 0.05) covariates were gravidity (5.7% per pregnancy), postmenopausal status (32.4%), and vaginal surgical history (61.4%). This was not true, however, for the anterior vaginal position (points Aa, Ba; P > 0.15). There was no difference in mean PVR in patients with versus without a hysterectomy (P = 0.236). Conclusions: Elevated PVR values have long been linked with prolapse of the anterior vaginal wall. We found that there is a linear association between PVR and the anatomic position of the apex. There was no association of PVR with the position of the anterior vaginal wall. Standing Vs Supine; Does it Matter in Cough Stress Testing? Objectives: The aim of this study was to compare the sensitivity of cough stress test in the standing versus supine position in the evaluation of incontinent females. Methods: We performed a prospective observational study of women with the chief complaint of urinary incontinence (UI) undergoing a provocative cough stress test (CST). Subjects underwent both a standing and a supine CST. Testing order was randomized via block randomization. Cough stress test was performed in a standard method via backfill of 200 mL or until the subject described strong urge. The subjects were asked to cough, and the physician documented urine leakage by direct observation. The gold standard for stress UI diagnosis was a positive CST in either position. Results: Sixty subjects were enrolled, 38 (63%) tested positive on any CST, with 38 (63%) positive on standing compared with 29 (28%) positive on supine testing. Nine women (15%) had positive standing and negative supine testing. No subjects had negative standing with positive supine testing. There were no significant differences in positive tests between the 2 randomized groups (standing first and supine second vs. supine first and standing second). When compared with the gold standard of any positive provocative stress test, the supine CST has a sensitivity of 76%, whereas the standing CST has a sensitivity of 100%. Conclusions: The standing CST is more sensitive than the supine CST and should be performed in any patient with a complaint of UI and negative supine CST. The order of testing either supine or standing first does not affect the results. Transurethral Polyacrylamide Hydrogel Injection Therapy in Women Not Eligible for Midurethral Sling Surgery Objectives: This study aims to determine the effects of transurethral polyacrylamide hydrogel injection in patients considered ineligible for midurethral sling surgery. Methods: In this prospective observational study, 81 patients received treatment with transurethral polyacrylamide hydrogel injection. Patients were considered ineligible for placement of a midurethral sling based on significant comorbidity (48%), 1 or more previously failed invasive treatments (16%), mixed urinary incontinence (27%), continuous incontinence (5%), or previous pelvic radiation therapy (4%). Longitudinal assessment of subjective treatment outcomes was performed using the validated Urinary Distress Inventory (UDI) and the Pelvic Floor Impact Questionnaire at baseline, 2, and 6 months. To deal with repeated measurements, mixed linear models were used to assess changes in the outcomes over time. Results: There was a significant improvement in the overall UDI score from baseline to month 2 follow-up (FU) (P<0.001). No major differences between the month 2 and 6 FUs were observed. The largest difference in effect was observed for the irritative and stress subscales. Twenty-five patients (33%) requested a second injection at the month 2 FU visit. At month 6 FU, the UDI scores for patients having had only 1 injection were largely unchanged, whereas all UDI domains worsened further for patients having had a second injection at the month 2 visit. After the injection, there were 3 minor adverse events (3.7%) and no serious adverse events. Conclusions: In patients considered ineligible for midurethral sling surgery, transurethral injection with polyacrylamide hydrogel may alleviate urinary incontinence symptoms. Repeat injections did not improve outcomes in this complicated group of patients. Knowledge, Perceptions, and Attitudes Toward Pelvic Organ Prolapse and Urinary Incontinence in Spanish-Speaking Latinas Objectives: The aim of the study was to explore individual views and perceptions of Spanish-speaking Latinas living on the US/Mexico border toward pelvic organ prolapse (POP) and urinary incontinence (UI), including awareness of conditions, implications of diagnoses, knowledge, and attitudes toward available treatment options. Methods: Spanish-speaking Latina women were recruited from clinics at Texas Tech University Health Sciences Center El Paso. Focus group discussions were conducted, addressing topics including female pelvic anatomy, perceived etiology and course of POP and UI, and attitudes toward treatment options. Discussions were transcribed and qualitative analysis performed to identify common themes and concepts. Results: Twenty-four women participated in 5 focus groups as follows: 2 groups of women diagnosed with POP/UI, 2 groups of women with POP/UI symptoms, and 1 group of asymptomatic women. Mean age of participants was 52 years. Participants had a good basic understanding of pelvic organs and function. The following 3 common themes were derived from our analysis: culture, barriers, and misconceptions. Concepts identified from common themes included views of POP/UI as “abnormal” conditions; perceptions that providers may downplay or ignore symptoms of POP/UI; fear of doctor; views of cancer as a common POP complication; embarrassment; views of “massage” therapy as an effective treatment for POP; and willingness to consider all available treatment options for POP and UI, including pessary. Conclusions: Findings suggest need for patient reassurance about the prevalence and benign course of POP and UI upon initial assessment, with continued reinforcement of basic concepts after diagnosis, and need for increased awareness and information resources for healthcare providers and Spanish-speaking Latina women regarding these common pelvic floor disorders. Histologic Anatomy of the Anterior Vagina and Urethra Background: Vaginal and urethral histology is important to understanding the pathophysiology of the pelvic floor. Methods: En bloc removal of 4 female cadaveric pelvises was performed, with 18 to 25 serial sections obtained from each. The vaginal and urethral lengths were divided into distal and proximal sections; urethra was divided into anterior and posterior segments as well. Innervation and vasculature were qualified as small and large and quantified per high-power field. Results: The mean vaginal length was 7.45 cm, and the mean urethral length was 3.38 cm. A distinct vaginal fibromuscular layer was noted, without evidence of a dense sheet of continuous collagen. An epithelial, lamina propria, and muscular layer surrounded the urethral lumen. Adipose and loose fibroconnective tissue separated the urethra from the anterior vagina in 41% of slides. Nerves and vasculature were concentrated in the lamina propria. More small nerves and vessels were grossly seen compared with larger counterparts in both the vagina and urethra. No significant differences in layer thickness, innervation, or vasculature were observed along the vaginal length. The posterior urethra had greater innervation than did the anterior (P = 0.012). The distal posterior urethra had more large vessels than did the proximal posterior urethra (P = 0.03). No other differences were noted in urethral sections. Conclusions: A vaginal fibromuscular layer was confirmed, refuting a true fascia. Innervation and vasculature were quantitatively the same along the anterior vagina. However, the posterior urethra had greater innervation than did anterior and is most innervated proximally. Nerve and vascular histology may relate to pelvic floor disorder etiology. Decreased Urethral Volume Is Comparable to Funneling as a Predictor of Intrinsic Sphincter Deficiency Objectives: The aims of this study were to determine the association between x-ray funneling and ultrasound urethral sphincter complex measurements and to compare the reliability of funneling versus urethral volume measurement in the detection of intrinsic sphincter deficiency (ISD). Methods: This was a retrospective analysis, which included 54 stress incontinent women dichotomized into those with (1) ISD and (2) no ISD. The presence of bladder neck funneling was diagnosed by fluoroscopic images obtained at the time of video-urodynamics testing. Measurements of the urethral sphincter complex were obtained from ultrasound volumes. Reliability measures were obtained for both funneling and urethral volume measurements. Results: Rhabdomyosphincter length and area were found to be smaller in patients with funneling compared with those with no funneling (P = 0.0161, P = 0.0359). The urethral volume was significantly smaller in the ISD versus no-ISD group (P = 0.0002). For those who had funneling, the ISD group had smaller urethral volume compared with the no-ISD group (P = 0.0019). For those who did not have funneling, the ISD group still had a smaller urethral volume compared with the no-ISD group (P = 0.0054). An ultrasound urethral volume of less than 3.5 cm3 had a sensitivity of 81% and a specificity of 64% for the presence of ISD, whereas x-ray funneling had a sensitivity of 76% and a specificity of 73%. Conclusions: Smaller rhabdomyosphincter length and area on ultrasound are associated with x-ray funneling. Ultrasound urethral volume of 3.5 cm3 as a cutoff provides the same reliability as x-ray funneling for the diagnosis of ISD. Ultrasonographic Features of Female Urethral Diverticula: A Retrospective Study of 25 Patients Objectives: This article summarizes the ultrasonographic features of female urethral diverticula on biplane transrectal ultrasound (B-TRUS). Methods: A retrospective study was performed with 25 consecutive women who were diagnosed and treated as having urethral diverticulum (UD) between January 2012 and March 2016. All the patients were preoperatively evaluated using B-TRUS. The number, location, configuration, size, and type of the UD on B-TRUS were assessed. Results: Twenty-eight diverticula were found on B-TRUS. Twenty-two patients had single diverticulum, whereas the other 3 had double diverticula. The locations included proximal (14%), mid (46%), and distal (40%) urethra. In transverse section, the configuration presented as round or oval (46%), and horseshoe-like or circumferential (54%). The maximal diameter of the 28 diverticula ranged from 3 to 48 mm. The types contained simple UD (36%) and complex UD (64%). Color blood flow signal could be detected in the septa, cystic wall, and solid mass, whereas negative in other areas inside the UD. Conclusions: Various sonographic characters of female UD could be observed during the evaluation, including single or multiple diverticula, different sites, diverse shapes, and septa, calculi, or neoplasm inside diverticulum, all of which could be clearly displayed on B-TRUS. Pessary Education for Residents No abstract available