Pregnancy and Outcomes After Prolapse Surgery: A Case Series.

IMPORTANCE: There are limited data on whether pelvic organ prolapse (POP) surgery is durable after subsequent delivery. OBJECTIVES: The aims of this study were to evaluate the safety and durability of POP surgery after delivery and to describe the medical decision-making and clinical outcomes of patients who gave birth after POP surgery. STUDY DESIGN: This study is a retrospective case series of patients who underwent surgery for symptomatic POP between 2007 and 2017, and subsequently had a live birth. RESULTS: Twenty patients were identified. Seventeen patients underwent posterior colporrhaphy, 10 anterior colporrhaphy, and 5 apical suspensions. The mean interval between POP surgery and the first delivery was 28.6 months. One patient endorsed recurrent POP symptoms before pregnancy, and none of the remaining 19 patients reported recurrent POP symptoms before or during pregnancy. There were no pregnancy complications related to the POP surgery. Nine patients underwent cesarean delivery (CD). Four patients were counseled to have a CD due to their prior POP surgery, 3 patients had an elective primary CD due to the POP surgery, 1 patient chose an elective repeat CD, and 1 patient had a CD due to obstructed labor. Urogynecologists were consulted for delivery recommendations for 6 patients and recommended CD for 3 of them. Eleven patients had spontaneous vaginal delivery. Three patients reported recurrent POP symptoms after delivery. CONCLUSIONS: Our findings corroborate previous case series demonstrating the safety and durability of POP surgery during and after pregnancy. More than 75% of patients gave birth by CD, which was due to physician or patient concerns regarding the prior POP surgery.

Rectocele: Correlation Between Defecography and Physical Examination.

IMPORTANCE: There is a lack of consensus regarding the clinical applicability of fluoroscopic defecography in evaluation of pelvic organ prolapse. OBJECTIVES: The aim was to evaluate the association between rectocele on defecography and posterior vaginal wall prolapse (PVWP) on physical examination. The secondary objective was to describe radiologic and clinical predictors of surgical intervention and outcomes. STUDY DESIGN: This was a retrospective review of patients enrolled in a large health maintenance organization who underwent defecography and were examined by a urogynecologist within 12 months. The electronic medical record was reviewed for demographic and clinical variables, including pelvic organ prolapse and defecatory symptoms, physical examination, and surgical intervention through 12 months after initial urogynecologic examination or 12 months after surgery if applicable. RESULTS: One hundred eighty-six patients met inclusion criteria. Of those, 168 (90.3%) had a rectocele on defecography and 31 (16.6%) had PVWP at or beyond the hymen. Rectocele size on defecography was poorly correlated with PVWP stage (spearman ρ = 0.18). Forty patients underwent surgical intervention. Symptoms of splinting, digitation, and stool trapping were associated with surgical intervention (odds ratio, 4.24; 95% confidence interval, 1.59-11.34; P < 0.01) as was advanced PVWP stage ( P < 0.01), while rectocele presence and size on defecography were not. Large rectocele size on defecography was correlated with persistent postoperative defecatory symptoms ( P = 0.02). CONCLUSIONS: We demonstrated a poor correlation between rectocele size on defecography and PVWP stage. Defecatory symptoms (splinting, digitation, stool trapping) and higher PVWP stage were associated with surgical intervention, while rectocele on defecography was not.

A Randomized Controlled Trial Assessing the Impact of Opioid-Specific Patient Counseling on Opioid Consumption and Disposal After Reconstructive Pelvic Surgery.

OBJECTIVES: This study aims to determine the effect of opioid-specific counseling on postdischarge opioid consumption and opioid storage/disposal patterns after reconstructive pelvic surgery. METHODS: In this multicenter randomized-controlled trial, participants were randomized to standard generalized counseling or opioid-specific perioperative counseling. Opioid-specific counseling was provided at the preoperative and 2-week postoperative visits with educational handouts about the risks of opioids and U.S. Food and Drug Administration recommendations for appropriate opioid storage and disposal. The primary outcome was morphine milligram equivalent (MME) consumption between hospital discharge and 2 weeks postoperatively. Secondary outcomes included opioid storage 2 weeks postoperatively, opioid disposal 6 weeks postoperatively, and rate of opioid refills. RESULTS: Among 70 opioid-specific and 65 standard counseling participants, there were no significant differences in demographic characteristics, type of surgery, concomitant hysterectomy, or perioperative complications. For the primary outcome, there was no significant difference in median opioid consumption between the 2 arms. Median (interquartile range) postdischarge MME consumption for all participants was 15 mg (0-75). Forty percent of participants denied postdischarge MME consumption. For secondary outcomes, there were no significant differences in appropriate opioid storage between groups. The appropriate disposal rate of unused opioid tablets 6 weeks after surgery was higher among participants who received opioid-specific counseling. The rate of opioid refill was 7.4%. CONCLUSIONS: Opioid-specific counseling did not affect postdischarge consumption but increased the disposal rate of unused opioid tablets 6 weeks postoperatively. Opioid-specific counseling could minimize the potential for opioid misuse by reducing the number of unused opioid tablets in patients' possession after surgery.

Extraction of a large vaginal calculus utilizing an ear, nose, throat mallet and osteotomes.

BACKGROUND: Previous case reports on vaginal calculi extraction have described the removal of small calculi facilitated via episiotomy or transabdominal incision. This surgical video demonstrates a novel technique of transvaginal extraction of a large calculus utilizing an ear, nose, and throat (ENT) mallet and osteotomes. CASE: An 86-year-old female with urgency incontinence and limited mobility presented with obstipation and was found to have an 8.8 cm vaginal calculus. She had a history of prior vaginal mesh exposure after a mid-urethral sling that was managed expectantly without surgical resection. Cystourethroscopy and anoscopy excluded fistula. The calculus was extracted utilizing an ENT mallet and osteotomes in < 90 min, and no recurrent vaginal mesh exposure was identified. CONCLUSION: An ENT mallet and osteotomes can be safely utilized to expedite extraction of a vaginal calculus.

Vaginal Hysterectomy in a Large Health Maintenance Organization: Retrospective Application of a Clinical Algorithm.

STUDY OBJECTIVE: The primary objective was to describe practice patterns of benign hysterectomy within a large community health maintenance organization (HMO) and evaluate clinical and surgeon characteristics associated with the performance of vaginal hysterectomy (VH). Secondary objectives were to retrospectively apply a VH algorithm to determine how our practice patterns conform, and compare rates of perioperative complications among patients who did and did not meet the algorithm. Patient and surgeon characteristics, and perioperative complications, were compared between patients who underwent VH and did or did not meet the VH algorithm. DESIGN: Retrospective cohort study. SETTING: Large community HMO. PATIENTS: Women undergoing benign hysterectomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Route of hysterectomy, patient and surgeon characteristics, perioperative complications. One hundred and thirty-one of 984 (13.3%) benign hysterectomies from January 1, 2013 to June 30, 2015 were vaginal. Patients who were vaginally parous, Hispanic, had normal preoperative uterine size and documentation of uterine descent were more likely to have VH (all p <.05). High-volume surgeons performed 18.8% of their hysterectomies vaginally, as compared to low-volume surgeons who performed 11.4% of their hysterectomies vaginally (p <.01). VH were more likely to be performed by surgeons with longer practice durations than non-vaginal hysterectomies (16.3 vs 12.2 years, p <.01). Seventy-five percent of patients who met the VH algorithm underwent non-vaginal hysterectomy and they had longer operative durations and higher rates of postoperative complications compared to patients who underwent VH. Conversely, patients who underwent VH despite not meeting the VH algorithm did not have significantly different rates of perioperative complications or blood loss than patients who met the VH algorithm. CONCLUSION: Seventy-five percent of patients deemed appropriate for VH by our algorithm underwent non-vaginal hysterectomy and had more postoperative complications and longer operative durations. Our data suggest that surgeon characteristics, including surgical volume and duration of practice, may explain some of this performance gap. These findings contribute additional insight into current practice patterns and describe clinical factors that should be included in VH algorithms.

Mechanical inserts for the treatment of faecal incontinence: A systematic review.

Objective: To perform a systematic review of the literature to examine original research on the role of mechanical inserts, both vaginal and anal, for the treatment of faecal incontinence (FI). Materials and methods: We searched the PubMed, Cochrane Library, and ClinicalTrials.gov databases for any peer-reviewed original research in English on the role of mechanical inserts for the treatment of FI. Results: We identified 35 unique citations. After title review and exclusion of articles not reporting original research, eight publications were included in the final review: two focused on vaginal inserts and six focused on anal inserts. Limited evidence indicates that both vaginal and anal inserts can be an effective and safe therapeutic option for patients with FI. Conclusions: Data regarding vaginal and anal mechanical inserts for the treatment of FI, albeit limited, suggest that inserts can be included in a discussion of therapeutic options for a patient with FI. Further studies are needed to elucidate long-term usability, efficacy, and safety. Abbreviations: FI: faecal incontinence; (m)ITT: (modified) intention-to-treat.

Evaluation of Opioid Prescriptions After Urogynecologic Surgery Within a Large Health Care Organization: How Much Are We Prescribing?

OBJECTIVES: Data regarding postoperative opioid prescriptions for patients undergoing urogynecologic surgery are sparse. Our objective was to quantify surgeon prescribing patterns for patients undergoing surgery for pelvic organ prolapse or stress urinary incontinence. METHODS: Patients who underwent surgery for pelvic organ prolapse or SUI within a large health care maintenance organization were identified by procedural codes within the electronic medical record. Medical records were reviewed for demographic and clinical data. Our primary objective was to describe initial postoperative morphine milligram equivalent (MME) dosages for patients undergoing various urogynecologic surgeries. Secondary objectives were to evaluate rates of postoperative non-opioid analgesic prescriptions, presence of additional postoperative opioid prescriptions within 90 days of surgery, and to characterize prescribing patterns of surgeons from different specialties. RESULTS: We evaluated 855 patients undergoing 7 urogynecologic surgeries. There was wide variation in the quantity of MME prescribed to patients undergoing different urogynecologic surgeries, and the mean MME ranged from 137.6 mg after a colpocleisis to 214.1 mg after a laparoscopic uterosacral ligament suspension. Less than two thirds of patients received a postoperative nonsteroidal anti-inflammatory drug (NSAID) prescription, and rates of NSAID prescriptions varied widely between surgeons from different specialties. Thirty-nine (4.6%) patients received an additional postoperative opioid prescription specifically for the indication of persistent postoperative pain. CONCLUSIONS: There is wide variation in the range of MME prescribed postoperatively to patients undergoing common urogynecologic surgeries. Less than two thirds of patients received a postoperative NSAID prescription, which was found to be independently associated with a higher postoperative opioid prescription dose.

Sacral Nerve Stimulation as a Therapy for Patients With Refractory Voiding and Bowel Dysfunction.

Sacral nerve stimulation delivers nonpainful electrical pulses to the sacral nerves that modulate the reflexes that control the bladder, bowels, and pelvic floor musculature. This relatively simple procedure was generated to improve and restore function in patients with a variety of pelvic floor disorders. Currently this therapy is approved for use in patients with urgency urinary incontinence, urinary urgency-frequency, nonobstructive urinary retention, and fecal incontinence. This review includes the history of this treatment modality, explains the mechanism of action, and describes the procedure for implantation of this device. Additionally, advancements in this treatment over the past two decades and landmark literature to date regarding sacral nerve stimulation are reviewed. Current literature regarding off-label uses of this treatment modality for a variety of pelvic floor disorders is also discussed.

A Large Retrospective Series of Pregnancy and Delivery After Midurethral Sling for Stress Urinary Incontinence.

OBJECTIVES: The aim of this study was to review the complete medical course, including safety, efficacy, and medical decision making, of patients who delivered a pregnancy after the placement of midurethral sling (MUS) within a large health maintenance organization. METHODS: We conducted a retrospective case series of patients within the Northern and Southern California Permanente Medical Group who were identified based on procedural codes for placement of MUS for stress urinary incontinence. Electronic medical records with MUS code were referenced against records of live births within the health care system. Demographic and clinical data were abstracted through extensive, standardized physician review of the electronic medical records of all identified patients. RESULTS: Twenty-six patients were identified and included in analysis. Sixteen patients had a retropubic MUS, and 10 had a transobturator MUS. Twenty-one of 26 patients reported subjective resolution of urinary incontinence after MUS. Fourteen of the 25 first deliveries after MUS were cesarean section (CS). Of these, 5 CS were elective primary for the indication of previous MUS, 5 were elective repeat CS, and the remaining 4 were for fetal indications. Eleven patients had spontaneous vaginal deliveries. There were no MUS-related pregnancy complications. One patient developed recurrent stress urinary incontinence postpartum, for which she underwent repeat MUS within a year resulting in cure of incontinence. CONCLUSIONS: This case series corroborates previous series demonstrating the safety and durability of MUS after subsequent pregnancy.

A validation study of electrical cardiometry in pregnant patients using transthoracic echocardiography as the reference standard.

To validate electrical cardiometry (EC) in pregnant patients using transthoracic echocardiography (TTE) as the reference standard. To improve EC accuracy via a one-time, measurement of left ventricular outflow tract (LVOT) diameter. 44 non-laboring, resting women with singleton, viable pregnancies underwent simultaneous EC and TTE measurements. Data were analyzed using Bland-Altman analysis. Entry multiple regression with stepwise elimination was used to develop a model for improved prediction of stroke volume by TTE (SVTTE) using EC. Bootstrapping and an 11-fold cross validation were used to test the model. Heart rate by TTE and EC had a mean bias of 3.3 beats/min and mean percentage error of 10.7 %. Envelope time and left ventricular ejection time had a mean bias of -4.9 ms and mean percentage error 12.7 %. Stroke volumes by the two techniques had a mean bias of 15.6 mL and mean percentage error of 43.7 %. A model, SVEC_Modified, predicting SVTTE was developed using LVOT area, stroke volume by electrical cardiometry and weight. SVTTE and SVEC_Modified had a mean bias of -0.83 mL and mean percentage error of 22 %. EC accurately measures heart rate and duration of systole when compared with TTE. Stroke volume measurements correlate but have a high bias and percentage error. Knowledge of LVOT area, by a one-time, measurement with TTE, could improve prediction of stroke volume by EC.