Percutaneous tibial nerve stimulation maintenance therapy for overactive bladder in women: long-term success rates and adherence.

PURPOSE: Our objectives are to (1) identify predictors of treatment success in women with overactive bladder (OAB) after 1 year of percutaneous tibial nerve stimulation (PTNS) maintenance therapy, (2) identify trends in success rates during that 1 year, and (3) assess maintenance treatment adherence. MATERIALS AND METHODS: A retrospective study of 141 women with OAB was performed with the definition of success based on a Patient Global Impression-Improvement (PGI-I) score of 1 ("very much better") or 2 ("much better") or a PGI-I score of 1, 2, or 3 ("a little better"). Multivariable logistic regression was performed to identify factors associated with treatment response and the Cochrane-Armitage trend test to identify changes in the scores over time. RESULTS: After completing 12 weekly treatments, 141 women initiated maintenance therapy with a mean treatment interval of 29 days. At 1 year, 75/141 (53.2%) had discontinued treatment. Those adherent with treatment had a sustained treatment response, with 66.2% of women reporting a PGI-I score of 1, 2 and 92.3% reporting a PGI-I score of 1, 2, or 3 at 1 year. Considering those women who discontinued maintenance therapy as treatment failures, the success rate of 1 year of maintenance therapy ranged from 30.7%-42.9%. No clinical factors were found to be predictive of maintenance treatment success or failure. CONCLUSIONS: Although an effective treatment for those adherent, discontinuation rates of PTNS maintenance therapy at 1 year are high. Given the low numbers of women referred to maintenance therapy, and the high discontinuation rates, long-term PTNS treatment may be feasible for only a minority of women with OAB.

8 versus 12 weeks of percutaneous tibial nerve stimulation and response predictors for overactive bladder.

INTRODUCTION AND HYPOTHESIS: The primary objective is to compare weekly success rates after 8 vs 12 weekly percutaneous tibial nerve stimulation (PTNS) sessions for treatment of overactive bladder (OAB) in women and the secondary objective is to identify treatment response predictors. METHODS: A retrospective study of 470 women was performed with the primary definition of success a Patient Global Impression-Improvement (PGI-I) score of 1 ("very much better") or 2 ("much better") and a ≥ 10-point improvement in both subscales of the Overactive Bladder Questionnaire-Short Form (OABq-SF). Additional analyses were performed to include a success definition of a PGI-I score of 3 ("a little better"). Categorical variables were compared using the Chi-squared test. Multivariate logistic regression was performed to identify factors associated with response. RESULTS: One hundred and thirty-six out of 470 (29%) discontinued treatment before 12 weeks. One hundred out of 334 (29.9%) were successes at 8 weeks vs 138 out of 334 (41.3%) at 12 weeks (p = 0.002). Including a PGI-I score of 3 as an indicator of success, 181 out of 334 (54.2%) at 8 weeks and 202 out of 334 (60.5%) at 12 weeks were successes (p = 0.10). Factors associated with treatment response were neurological disorder (OR 4.32 [1.10-16.04]), prolapse surgery history (OR 3.89 [1.12-14.49]), and vaginal estrogen use (OR 1.76 [1.01-3.08]). Recurrent UTI was associated with failure (OR 0.42 [0.21-0.86]). CONCLUSIONS: The PTNS treatment success rate for OAB in women is greater at 12 weeks than at 8 weeks based on two validated questionnaires, the PGI-I and the OABq-SF. However, the success rates were equivalent if women who are "a little better" are also considered successes; with this definition, clinicians may consider shortening treatment duration to 8 weeks. Four clinical factors were significantly associated with response and may help to guide patient selection.

Measuring the impact of a posterior compartment procedure on symptoms of obstructed defecation and posterior vaginal compartment anatomy.

INTRODUCTION AND HYPOTHESIS: We hypothesized that there would be a significant difference in changes in obstructed defecation symptoms and posterior compartment prolapse between women who underwent posterior vaginal wall prolapse repair (PR) and those who did not. METHODS: This was a two-site prospective cohort study of women undergoing prolapse or incontinence surgery in which a PR was, or was not, performed at the discretion of the surgeon. Women were assessed using validated obstructed defecation questionnaires and standardized examination measures (including POP-Q, measurement of transverse gh, and assessment for a rectovaginal pocket and laxity) prior to pelvic surgery and 12 weeks after surgery. RESULTS: Of 68 women who underwent surgery, 43 had PR. The PR group had higher obstructed defecation symptoms and greater posterior compartment prolapse at baseline. At 12 weeks, obstructed defecation symptoms had improved significantly more in the PR group than in the no PR group (all p < 0.03). Anatomic outcomes showed greater improvement in point Bp in the PR group (-3.4 vs. -0.7 no PR, p < 0.001) and resolution of the rectovaginal pocket (86 % vs. 42 %, p = 0.002). There were no significant changes in obstructed defecation symptoms or anatomic outcomes from baseline in the no PR group, while the PR group showed significantly improved obstructed defecation symptoms and anatomic outcomes after repair (p < 0.001 for both). CONCLUSIONS: Significant improvements in obstructed defecation symptoms and posterior compartment prolapse were seen after PR, but not in women who did not receive PR. Obstructed defecation symptoms, Bp and rectovaginal pocket were the measures best able to demonstrate improvement after PR. We recommend the use of these measures to assess the impact of surgery in the posterior compartment.

Trends in urodynamics study utilization in a Southern California managed care population.

OBJECTIVE: We examined trends in overall and preoperative urodynamics utilization among women with stress urinary incontinence (SUI) to determine if practice patterns changed following publication of a 2012 randomized trial questioning the value of preoperative urodynamics in patients with uncomplicated SUI. STUDY DESIGN: We collected electronic medical record data on the number of female patient visits to Kaiser Permanente Southern California urology and urogynecology clinics with stress or mixed incontinence, urodynamic studies (UDS) performed, surgeries performed for stress incontinence, and the demographic and clinical characteristics of these patients during 2 discrete time periods before and after a potentially practice-changing publication. We used χ(2) tests and t tests as appropriate. A multivariate logistic regression model was used to estimate the odds of urodynamics performed during January 2013 through June 2014 (study period 2) compared to urodynamics performed during July 2010 through December 2011 (study period 1) after adjustment for demographic and clinical characteristics. RESULTS: In all, 33,775 women were diagnosed as having SUI or mixed urinary incontinence during study period 1 and 37,238 women were diagnosed with these conditions during study period 2. Among these women 12.8% underwent UDS in study period 1 compared to 8.4% in study period 2 (P < .01). The rate of UDS per patient visit decreased 27.0% between the 2 time periods (P < .01). In women undergoing surgery for stress incontinence, urodynamics were performed 56.5% of the time in study period 1 and 46.5% of the time in study period 2. After controlling for demographic, pelvic organ prolapse, and other bladder diagnoses, the odds of urodynamics performed in study period 2 was 0.54 times the odds of urodynamics performed in study period 1 (95% confidence interval, 0.52-0.57). Among women with only the diagnosis of stress incontinence, 1.78% underwent urodynamics in study period 1 compared with 0.84% in study period 2 (P < .01). Preoperative urodynamics decreased from 39% in study period 1 to 20% in study period 2 (P < .01). CONCLUSION: Significantly fewer UDS are being performed overall and prior to stress incontinence surgery in this population. This change may be due to recent studies suggesting low utility of urodynamics in patients with uncomplicated, stress-dominant incontinence.

Tools for the direct observation and assessment of psychomotor skills in medical trainees: a systematic review.

CONTEXT: The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties. METHODS: An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system. RESULTS: A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence. CONCLUSIONS: Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited.

Surgical management of pain and infertility secondary to endometriosis.

The management of pain and infertility secondary to endometriosis remains a challenge. Surgical management of early-stage endometriosis-associated infertility has only a mild effect with a number needed to treat of at least 12 to achieve one pregnancy. Excision of endometriomas provides the best outcome for fertility and pain; however, there is a potential to reduce the ovarian reserve. Pain relief is seen in most patients undergoing surgical management but with a high recurrence rate over time. Long-term postoperative medical suppressive therapy with oral contraceptives may have some benefit in reducing recurrence of symptoms. Hysterectomy is effective in the long-term management of chronic pain associated with endometriosis.

Measuring surgical trainee perceptions to assess the operating room educational environment.

OBJECTIVE: To determine measurable differences in the perception of learning between junior and senior residents in the operating rooms of an obstetrics and gynecology (OBGYN) residency program. DESIGN, SETTING, AND PARTICIPANTS: Using a cross-sectional design, the Operating Room Educational Environment Measure (OREEM), a 40-item educational environment inventory, was administered to 28 OBGYN residents from 1 training program, who train at 3 hospital sites. The OREEM measures a trainee's perceptions of the teaching surgeon, learning opportunities, operating room atmosphere, and workload. The primary outcome was total OREEM scores and secondary outcomes were OREEM subscale scores, global impression of education, and internal consistency and validity of the OREEM scale. Group sample sizes of 10 and 10 achieved 80% power to detect a 10% difference between group mean OREEM scores +/- 10% with a significance level of 0.05. RESULTS: Twenty-four residents including 11 junior (postgraduate years 1 and 2) and 13 senior (postgraduate years 3 and 4) residents were included in the analysis. Total OREEM scores, learning opportunities, and workload/support subscale scores were significantly lower for junior residents compared with senior residents across all sites. Perceptions of learning at a multispecialty tertiary referral hospital were lower than the community and regional hospitals. This was secondary to complexity of cases, subspecialty fellows, and decreased opportunities to first-assist in the operating room. The OREEM demonstrated acceptable reliability and construct validity. CONCLUSIONS: There are measurable differences in perception of the operating room educational environment between junior and senior OBGYN residents using the reliable and valid Operating Room Educational Environment Measure.

Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy.

We report on the transabdominal resection of infected lumbosacral bone, synthetic mesh, and sinus tract following sacral colpopexy. A 45-year-old nulliparous patient who had undergone transvaginal mesh followed by robot-assisted sacral colpopexy presented with increasing back pain and foul-smelling vaginal drainage. An epidural abscess required surgical intervention, including diskectomy, sacral debridement, and mesh removal to drain the abscess and vaginal sinus tract. Recognized complications of open prolapse procedures also manifest following minimally invasive approaches. Osteomyelitis of the sacral promontory following sacral colpopexy may require gynecologic and neurosurgical management.

Assessing vaginal surgical skills using video motion analysis.

OBJECTIVE: To demonstrate the feasibility of using video motion analysis to quantitate a key step of vaginal hysterectomy and define measurable differences between novice and experienced surgical trainees during vaginal hysterectomy. METHODS: Analyses focused on clamping, transecting, and suturing the left uterosacral ligament. Using a cutoff of 25, trainees were grouped as experienced (n=14) and novice (n=9) based on the total number of vaginal hysterectomies performed by each trainee. Contrasting-groups analysis was used to determine cutoff values that separated novices from experts. RESULTS: Novice trainees took longer (112 seconds compared with 84 seconds) and had greater cumulative translational motion (92 cm compared with 49 cm, P=.05) while performing the task. Experienced trainees placed the Heaney clamp closer to a right angle to the vertical axis (experienced 96 degrees compared with novice 109 degrees , P=.03) while passing the needle through the uterosacral ligament. Trainees move from novice to experts when the steps occur in 112 or fewer seconds, cumulative translational motion is at or less than 75 cm, and the angle between the clamp to bladder retractor is at or below 105 degrees . CONCLUSION: Video motion analysis is a feasible technique to quantify and compare surgical skills objectively during vaginal surgery. There are measurable differences between novice and more experienced surgical trainees performing vaginal hysterectomy that can be quantified using motion analysis. LEVEL OF EVIDENCE: III.

Vulvar mammary-type myofibroblastoma: a case report.

BACKGROUND: Mammary-type myofibroblastomas have been reported at extramammary sites, especially along the mammary midline, but not previously in the vulva. CASE: A 56-year-old woman presented with complaints of a left vulvar mass, pelvic organ prolapse and urinary incontinence. Examination revealed a 3-cm,firm vulvar mass, located in close proximity to the Bartholin's gland. CONCLUSION: Although myofibroblastomas have been reported at extramammary sites, this is this first reported case in the vulva. These masses are densely adherent to surrounding tissue, which can lead to a difficult dissection. Therefore they should be removed in the operating room with appropriate equipment and sedation.

Complication and reoperation rates after apical vaginal prolapse surgical repair: a systematic review.

OBJECTIVE: To compare postoperative complication and reoperation rates for surgical procedures correcting apical vaginal prolapse. DATA SOURCES: Eligible studies were selected through an electronic literature search covering January 1985 to January 2008 using PubMed, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews and Effects. METHODS OF STUDY SELECTION: Only clinical trials and observational studies addressing apical prolapse repair and recurrence or complication rates were included. The search was restricted to original articles published in English with 50 or more participants and a follow-up period of 3 months or longer. Oral platform and poster presentations from the American Urogynecological Society, the Society for Gynecologic Surgeons, the International Urogynecological Association, and the International Continence Society from January 2005 to December 2007 were hand searched to determine whether they were eligible for inclusion. TABULATION, INTEGRATION, AND RESULTS: Procedures were separated into three groups: traditional vaginal surgery, sacral colpopexy, and vaginal mesh kits. Complications were classified using the Dindo grading system. Weighted averages were calculated for each Dindo grade, complication, and reoperation. Dindo grade IIIa (433/3,425 women) and IIIb (245/3,425) rates were highest in the mesh kit group owing to higher rates of mesh erosion (198/3,425) and fistulae (8/3,425). Reoperation rates for prolapse recurrence were highest in the traditional vaginal surgery group (308/7,827). The total reoperation rate was greatest in the mesh kit group (291/3, 425, 8.5%). CONCLUSION: The rate of complications requiring reoperation and the total reoperation rate was highest for vaginal mesh kits despite a lower reoperation rate for prolapse recurrence and shorter overall follow-up.

Incidence and risk factors for surgical intervention after uterine artery embolization.

OBJECTIVE: To determine the incidence and risk factors for surgical intervention after uterine artery embolization for symptomatic uterine fibroids. STUDY DESIGN: Electronic medical records of all patients who underwent uterine artery embolization for symptomatic uterine leiomyomata were reviewed. Logistic regression was used to identify independent risk factors for any surgical intervention and for hysterectomy alone after uterine artery embolization. RESULTS: Uterine artery embolization was performed in 454 patients during the study period, with a median follow-up time (range) of 14 (0-128) months. Overall, 99 patients (22%) underwent any surgical intervention after uterine artery embolization in the operating room. Risk factors for any surgical intervention included younger age (P < .003), bleeding as an indication for uterine artery embolization (P < .01), presence of significant collateral ovarian vessel contribution to the uterus (P < .01), or use of 355-500 mum particles (P < .008). CONCLUSION: Patients undergoing uterine artery embolization have a 22% risk for requiring additional surgical intervention, but overall uterine artery embolization is an effective minimally invasive option.

An update on the laparoscopic approach to urogynecology and pelvic reconstructive procedures.

PURPOSE OF REVIEW: To review the evidence behind laparoscopic pelvic organ prolapse and urinary incontinence repair. RECENT FINDINGS: A review of the recent literature continues to support the use of laparoscopy for colposuspension and sacral colpopexy as a viable alternative for open surgery. Polypropylene mid-urethral slings are comparable, if not better than laparoscopic Burch, though most data are short-term. The literature regarding other laparoscopic prolapse procedures, such as uterosacral ligament suspension, paravaginal defect repair, and rectocele repair is sparse. SUMMARY: Short-term studies support the use of laparoscopy in urogynecology and reconstructive pelvic surgery. However, longer term studies are needed to confirm these findings.

An extrahepatic biliary anomaly.

Several variations in intrahepatic and extrahepatic accessory biliary ducts have been reported in the past. An accessory extrahepatic biliary duct connecting the lateral segment of the left lobe to the medial segment of the left lobe is described. A review of the literature reveals that this anomaly has rarely been reported in the past. Knowledge of such anomalies is critical in the prevention of iatrogenic injuries during surgery.