Shifts in Vaginal Bacterial Community Composition Are Associated With Vaginal Mesh Exposure.

OBJECTIVE: The objective of this study was to evaluate the relationship between vaginal mesh exposure and vaginal bacterial community composition. METHODS: Vaginal swab samples were collected from 13 women undergoing excision of vaginal mesh with vaginal mesh exposure. Samples were collected at the midvagina, site of exposure, and underneath the vaginal epithelium at the exposure. Control samples were collected vaginally during 15 new patient examinations. For all samples, we extracted genomic DNA and polymerase chain reaction amplified and sequenced the 16S rRNA gene V4 region. We tested for differences in the microbiota among control and exposure samples with PERMANOVA tests of beta diversity measures (Morisita-Horn dissimilarity) and Wilcoxon rank sum tests of Lactobacillus distribution. RESULTS: Vaginal bacterial communities in both control and case groups were divided into 2 primary community types, one characterized by Lactobacillus dominance (>50% of community) and the other by low Lactobacillus and a high diversity of vaginal anaerobes. In 10 of 13 case women, bacterial communities were highly similar between the 3 vaginal sites (adonis R2 = 0.86, P = 0.0099). In the 3 women with community divergence, all 3 were characterized by decreased Lactobacillus abundance at the exposure site. Overall, Lactobacillus abundance was lower at the site of mesh exposure and under the epithelium than in the experimental control (W = 137, P = 0.072, r = 0.41; W = 146, P = 0.025, r = 0.50). Common putative pathogenic mesh colonizing bacteria were common (in 51 of 54 samples), but generally not abundant (median relative abundance = 0.014%). CONCLUSIONS: In vaginal mesh exposure cases, a woman is more likely to have a diverse, non-Lactobacillus-dominant community.

The Accuracy of Portable Ultrasound Bladder Scanner Measurements of Postvoid Residual Volume in Women With Pelvic Organ Prolapse.

OBJECTIVES: The purpose of this study was to evaluate the accuracy of portable bladder scanner postvoid residual (PVR) volume measurements in patients with pelvic organ prolapse. A secondary goal was to determine whether covariates such as bladder volume and stage of prolapse affect bladder scanner accuracy. STUDY DESIGN: Complex urodynamic studies were performed on 70 patients with stage II or greater prolapse. Complex urodynamic studies included measurement of maximum bladder capacity (MBC) as well as measurement of PVR by urethral catheterization before, and following, complex filling cystometry. For each catheterized PVR, a corresponding bladder scanner measurement was obtained; the primary outcome was the difference between these measurements. In addition, bladder scanner measurements of MBC were compared with MBC by urodynamic pump. Measurements were compared by paired t test. Linear regression was used to assess association between covariates and bladder scanner error. RESULTS: There was no significant difference between catheter and bladder scanner PVR at the initial (mean difference, 5.94 mL; 95% confidence interval [CI], -3.8 to 15.7) or final (mean difference, 1.37 mL; 95% CI, -10.9 to 13.6) measurements. Maximum bladder capacity measurements by bladder scanner were significantly smaller than catheterized measurements (mean difference, -21.3 mL; 95% CI, -40.3 to -2.3). Stage III/IV prolapse was associated with increased bladder scanner error (P = 0.03). CONCLUSIONS: The portable bladder scanner accurately measures PVR in patients with pelvic organ prolapse and could be considered as an alternative to catheterized assessment. However, stage III/IV prolapse is associated with increased bladder scanner error, which should be considered when determining appropriate candidates for bladder scanner PVR assessment.

The Effect of Lithotomy Position on Nerve Stretch: A Cadaveric Study.

OBJECTIVE: The objective of our study was to design a method to measure nerve stretch in cadaveric subjects and then use the method to assess femoral nerve stretch in the lithotomy position with varying degrees of flexion and extension. METHODS: A university-based, cadaveric observational study of femoral nerve stretch was conducted. In 6 cadaveric subjects, femoral nerve near the inguinal ligament was dissected in each cadaveric subject. The nerve was marked, and digital images of the nerve were obtained in the supine position and lithotomy position in both flexion and extension. Distances were calculated using the ratio of pixels to millimeter specific for each image. The average distance for each set of images was then used to calculate the percent change from supine for each position. RESULTS: We were able to assess nerve stretch using photo-editing software. For extended position, all nerves showed some degree of stretch with the mean percent change in nerve length being 10.35%. For all other positions, most showed a decrease of nerve length. There was not a significant relation between degree of extension and stretch (Pearson r, P < 0.05). CONCLUSIONS: Hip extension between 10 and 20 degrees consistently stretches the femoral nerve greater than 5%. The potential for femoral nerve stretch and avoiding hip extension should be considered when positioning a patient in lithotomy for surgical procedures.

Anatomical Relationships of Burch Colposuspension Sutures.

OBJECTIVES: The prevalent use of minimally invasive midurethral slings for the treatment of stress urinary incontinence in the last several decades has resulted in fewer Burch procedures being performed and diminished surgical experience in performing the Burch colposuspension. However, recent antimesh media has resulted in more patients requesting nonmesh anti-incontinence procedures and a subsequent need for surgeons to refamiliarize themselves with the Burch procedure and its relevant anatomy. The objective of this study was to evaluate the relationships of Burch sutures to surrounding neurovascular anatomic structures in the human cadaver. METHODS: The retropubic space of 11 unembalmed female cadavers was dissected, and a Burch procedure performed. The distance from the Burch sutures' location through both Cooper's ligament and the vagina to the obturator neurovascular bundle and external iliac vessels was measured. RESULTS: The mean distance from the most lateral stitch in Cooper's ligament to the obturator bundle was 25.9 ± 7.6 mm and to the external iliac vessels was 28.9 ± 9.3 mm, and in some instances, these structures were less than 1.5 cm away. CONCLUSIONS: The obturator bundle and external iliac lie, on average, within 3 cm of sutures placed during a Burch colposuspension. Knowledge of these anatomical relationships is valuable when dissecting the space of Retzius and placing sutures for a Burch to avoid injury.

Morphologic Evaluation of Post-implanted Monofilament Polypropylene Mesh Utilizing a Novel Technique with Scanning Electron Microscopy Quantification.

Polypropylene mesh has been shown to shrink up to 50%; however, little is known about other changes that may occur while it is implanted. It is unclear whether such changes have clinical impact; nonetheless, knowledge of such can ultimately affect the technique of implantation and may affect outcomes. The objective of this study was to evaluate surgically explanted mesh after two years implantation for evidence of change in morphology using scanning electron microscopy (SEM). Secondly, we describe a novel technique for quantifying such changes with intentions for future validation. SEM imaging was conducted and mesh changes were visualized. SEM images revealed deep surface cracks both transverse and longitudinal, flaking and peeling of fibers, as well as fibrosis. Microstructural quantification of cracks was also completed. The fraction of transverse cracked area to whole surface area was 24.2%. Average crack length range was 0.58 to 71.46 µm and average crack thickness range was 0.99 to 25.46 µm. Polypropylene mesh is subject to structural changes after surgical implantation. It is important to investigate how these processes impact clinical outcomes. Validated techniques of quantifying such changes can prove useful in future research and aid in development of the ideal graft.

Correlation of patient age with CT-measured aorta-sacral promontory distance.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders are becoming more prevalent in the elderly population. Since more patients are seeking definitive management for their prolapse, the number of elderly patients undergoing sacral colpopexies will likely increase. During sacral colpopexies, the surgeon must carefully dissect in the presacral space and avoid vital structures. In elderly patients the aorta potentially elongates and the vertebral body height decreases. Consequently, there is a potential for anatomical change of distance from the bifurcation of the aorta to the sacral promontory. This study aimed to correlate the aorta-sacral promontory distance with age. METHODS: From 1 January 2013 to 31 January 2014 computed tomography (CT) images of 241 patients were reviewed in this retrospective study. Radiologists measured the aorta-sacral promontory distance on sagittal acquisition. The corresponding demographic information of age, body mass index, and comorbidities was evaluated using univariate analysis and univariate linear regression. RESULTS: The mean age was 56.6 years, and BMI was 27.6. The mean aorta-sacral promontory measurement based on the CT scan was 63.11 mm. Univariate analysis using a t test and ANOVA demonstrated an inverse correlation with age (p < 0.0001) and hypertension (p = 0.0034) and a positive correlation with BMI categories (p < 0.0017) Under univariate linear regression, the weight of the patient in kilograms demonstrated positive correlation (p = 0.0413). CONCLUSIONS: Based on CT measurements, the aorta-sacral promontory distance is decreased in elderly and hypertensive patients. Heavier patients have an increased aorta-sacral promontory distance. These potential anatomical variants should be considered before operating in the presacral space.

Surface and boney landmarks for sacral neuromodulation: a cadaveric study.

INTRODUCTION AND HYPOTHESIS: Standard external landmarks have been suggested as a guide for in-office percutaneous nerve evaluation (PNE), but validity of these landmarks has not been assessed. Our objective was to determine whether the standard 9 cm from the tip of the coccyx indicates the position of the S3 sacral foramen and whether other boney landmarks and measurements improved positioning. METHODS: Measurements and distances between external boney landmarks were obtained in 22 embalmed cadavers. Spinal needles were placed 9 cm superior to the coccyx and 2 cm lateral to midline bilaterally. After dissection, internal measurements relating to sacral length, position of S3, and location of the needle in relation to S3 were recorded. Correlations among measured variables were assessed using descriptive statistics. RESULTS: Mean distance from the tip of coccyx to S3 was 9.26 cm (±0.84), from S3 to midline 2.30 cm (±0.2); from needle to S3 1.25 cm, and needle placement was as likely to be placed above or below S3; and S2-S3 and S3-S4 interforamenal distance 1.48 cm (±0.30) and 1.48 cm (±0.24), respectively. Mean distance from S3 to sacroiliac joint (SIJ) was shorter than S2 to SIJ. All associations between external measurements and length from tip of coccyx to S3 were not significant. CONCLUSION: A distance 9 cm from the tip of the coccyx is a reasonable starting landmark for in-office blind PNE. However, given the variability in coccyx length, caution should be taken; also, sensory-motor response is necessary to confirm proper placement.

Robotic Burch colposuspension: a surgical case and instructional video.

INTRODUCTION AND HYPOTHESIS: The Burch colposuspension is a well-studied and proven surgical treatment for stress urinary incontinence without intrinsic sphincter deficiency. The advent of the minimally invasive mid-urethral sling has given rise to diminished surgical experience in performing the Burch. Recent anti-mesh media and FDA notifications have caused patients to demand mesh-free surgery, resulting in an opportunity for the resurgence of the Burch procedure. The objective of this video is to demonstrate surgical technique and instruction for a robotic Burch colposuspension as well as recommendations for successful completion of the procedure. Additionally, the video reviews and illustrates pertinent surgical anatomy regardless of approach. METHODS: The patient is a 53-year-old woman who presented with symptoms of vaginal pressure, urinary incontinence, and constipation. She had symptoms and urodynamics consistent with mixed urinary incontinence without intrinsic sphincter deficiency and had been treated with antimuscarinics for overactive bladder. On examination she was found to have stage II prolapse. She desired surgical management of both her prolapse and stress incontinence. CONCLUSION: Robotic Burch colposuspension can be completed in a safe and effective manner and should be considered as an option for patients in whom an anti-incontinence procedure is indicated and who are already undergoing robotic surgery.

Impact of sperm morphology on the likelihood of pregnancy after intrauterine insemination.

OBJECTIVE: To determine whether there is a difference in ongoing pregnancy rates (PRs) between patients undergoing IUI with strict sperm morphology ≤4% compared with >4% on initial semen analysis. DESIGN: Retrospective chart review with multivariate analysis. SETTING: Academic outpatient reproductive center. PATIENT(S): A total of 408 couples with male and/or female factor infertility and known strict sperm morphology (SSM). INTERVENTION(S): A total of 856 IUIs with partner's sperm (IUI-P). MAIN OUTCOME MEASURE(S): Ongoing PRs based on ultrasound documentation of intrauterine pregnancy with fetal heart tones. RESULT(S): There is no statistically significant difference in per cycle PRs when comparing patients with a strict sperm morphology of ≤4% versus >4% who undergo IUI-P (17.3% vs. 16.7%; odds ratio 0.954, 95% confidence interval 0.66-1.37). Multiple potential confounding factors were assessed using multivariate analysis. CONCLUSION(S): Strict sperm morphology ≤4% is not associated with lower PRs in couples undergoing IUI-P, and thus should not be the sole reason for advancing to IVF.

Evaluation of surgical instrument handling on polypropylene mesh using scanning electron microscopy.

INTRODUCTION AND HYPOTHESIS: To evaluate the effect of surgical instruments handling on polypropylene mesh using scanning electron microscopy (SEM). METHODS: We applied different surgical instruments, including a few robotic ones, to pieces of polypropylene mesh. SEM was used to evaluate the morphological changes with this intervention. RESULTS: Straight hemostat, laparoscopic atraumatic grasper, laparoscopic needle driver, and robotic instruments (Bipolar forceps, Cadiere forceps, PK dissecting forceps and SutureCut) were applied to the mesh. SEM images of tool-affected mesh regions in specimens handled by different instruments along with the images of intact mesh were obtained. Average mesh fiber diameters, as well as the average parameters characterizing instrument-affected regions, were measured. There was substantial widening of the fibers in specimens handled by hemostat or a needle holder. An elliptical but much longer and narrower tool marking with more surface roughness was observed in mesh handled by a grasper. A ∼25-µm-wide and ∼200-µm-long strap was split on one side from the core of the fiber caused by Cadiere. CONCLUSIONS: There are morphological changes to polypropylene mesh caused by instrument handling. These changes are different depending on the instrument used. These alterations vary from changes in the surface creating roughness of the fiber, compression of the mesh with narrowing of the fiber in at least one direction or actual splitting or pitting of the fiber. Since there are no data regarding the effect of these morphological changes to the ultimate functioning of the mesh, surgeons should minimize mesh handling by instruments.