Success of Concomitant Versus Interval Slings for Prevention and Treatment of Bothersome de Novo Stress Urinary Incontinence.

BACKGROUND: Despite large trials designed to guide management on whether to perform a prophylactic continence procedure at the time of pelvic organ prolapse (POP) repair, it remains unclear if a staged or interval approach confers advantages in treatment of bothersome stress urinary incontinence (SUI) in women without bothersome SUI before their POP repair. OBJECTIVE: The objective of this study was to compare success of concomitant versus interval slings for the prevention/treatment of de novo bothersome SUI after POP repair. STUDY DESIGN: This multicenter retrospective cohort with prospective follow-up enrolled women with minimal or no SUI symptoms who underwent minimally invasive apical surgery for stage 2 or higher POP between 2011 and 2018 and had a concomitant sling placed at the time of POP surgery or an interval sling placed. Prospectively, all patients were administered the Urogenital Distress Inventory Short-Form 6, the Patient Global Impression of Improvement, and questions on reoperation/retreatment and complications. RESULTS: A total of 120 patients had concomitant slings, and 60 had interval slings. There were no differences in the proportion of patients who had intrinsic sphincter deficiency (22% vs 20%), although the concomitant sling group was more likely to have a positive cough stress test result (30% vs 8%, P = 0.006). The interval sling group was more likely to report "yes" to SUI symptoms on Urogenital Distress Inventory Short-Form 6 (3% vs 30%, P = 0.0006) and during their postoperative visit (0% vs 24%, P < 0.0001). There were no differences in surgical complications. CONCLUSIONS: Among women with minimal or no SUI symptoms undergoing prolapse repair, concomitant slings resulted in lower rates of bothersome SUI compared with similar women undergoing interval sling placement.

Route of Hysterectomy at the Time of Sacrocolpopexy: A Multicenter Retrospective Cohort Study.

OBJECTIVES: This study aimed to compare the incidence of mesh exposure based on route of hysterectomy at the time of minimally invasive sacrocolpopexy. Secondary outcomes included perioperative outcomes and prolapse recurrence. METHODS: This was a multicenter, retrospective cohort study. Patients who underwent sacrocolpopexy between 2007 and 2017 were stratified by hysterectomy approach: total vaginal hysterectomy (TVH), total laparoscopic or robotic hysterectomy (TLH), and laparoscopic or robotic supracervical hysterectomy (LSH). Total vaginal hysterectomy was subdivided into vaginal and laparoscopic mesh attachment to the cuff. Statistical analyses were performed, with P < 0.05 denoting statistical significance. RESULTS: Seven institutions participated, and 502 minimally invasive sacrocolpopexies with concomitant hysterectomy were performed by 23 surgeons: 263 TVH, 128 TLH, and 111 LSH. The median follow-up interval was 10 months, and this was significantly different between the groups (months): TVH, 11 (3-13); TLH, 2 (2-9); and LSH, 12 (5-24; P < 0.01). The overall incidence of vaginal mesh exposure was 4.0% (20/502). There were no significant differences in vaginal mesh exposure based on hysterectomy route: TVH, 5.7% (15/263); TLH, 1.6% (2/128); and LSH, 2.7% (3/111; P = 0.11). Within the TVH group, there was no significant difference in vaginal mesh exposure comparing vaginal and laparoscopic mesh attachment: 1.9% (1/52) versus 6.6% (14/211; P = 0.48). Laparoscopic supracervical hysterectomy demonstrated a significantly higher incidence of recurrence compared with TVH and TLH: 10.8% (12/111) versus 3.4% (9/263) and 2.3% (3/128; P < 0.01). CONCLUSIONS: The incidence of sacrocolpopexy mesh exposure was not significantly different based on route of hysterectomy or mode of mesh attachment to the vagina. There was a significant increase in prolapse recurrence with supracervical hysterectomy.

Characterization of symptom severity and impact on four fecal incontinence phenotypes in women presenting for evaluation.

AIM: To characterize symptom-specific distress and impact on quality of life (QOL) among women with urge, passive, and combined urge/passive fecal incontinence (FI) phenotypes. A secondary aim was to characterize FI symptom-specific distress and impact on women with a novel fourth phenotype, stress FI. METHODS: Women with at least monthly FI from 2003 to 2017 were included. Participants completed the Modified Manchester Health Questionnaire (MMHQ) including MHQ and Fecal Incontinence Severity Index (FISI). Anorectal manometry (ARM) and endoanal ultrasound (EAUS) testing was performed. Total MHQ and FISI scores were compared across FI subtypes controlling for pertinent baseline covariates. RESULTS: The cohort included 404 subjects, 220 meeting criteria for urge FI, 67 passive FI, and 117 combined urge/passive FI. On MHQ, women with combined urge/passive FI were most impacted (p < 0.01). FISI scores were significantly different from combined urge/passive FI having the greatest impact (38.1 ± 12.5) and urge FI (31.1 ± 11.3), p < 0.01 having the least. No differences were observed in ARM measurements or anal sphincter defects among the three groups (all p > 0.05). Twenty-nine subjects were identified with stress FI. There were no differences in overall MHQ or FISI scores or anal sphincter evaluation among the urge, passive, and stress FI groups (all p > 0.05). CONCLUSION: Women with combined urge/passive FI have higher symptom distress and impact on QOL than urge or passive FI alone. Further research is needed to determine the significance of stress FI as a subtype and response to treatment.

Assessing patients' preferences for gender, age, and experience of their urogynecologic provider.

INTRODUCTION AND HYPOTHESIS: Understanding patient preferences regarding provider characteristics is an under-explored area in urogynecology. This study aims to describe patient preferences for urogynecologic care, including provider gender, age, experience, and presence of medical trainees. METHODS: This was a multicenter, cross-sectional, survey-based study assessing patient preferences with a voluntary, self-administered, anonymous questionnaire prior to their first urogynecology consult. A 5-point Likert scale addressing provider gender, age, experience, and presence of trainees was used. Descriptive statistics summarized patient characteristics and provider preferences. Chi-squared (or Fisher's exact) test was used to test for associations. RESULTS: Six hundred fifteen women participated from eight sites including all geographic regions across the US; 70.8% identified as white with mean age of 58.5 ± 14.2 years. Urinary incontinence was the most commonly reported symptom (45.9%); 51.4% saw a female provider. The majority of patients saw a provider 45-60 years old (42.8%) with > 15 years' experience (60.9%). Sixty-five percent of patients preferred a female provider; 10% preferred a male provider. Sixteen percent preferred a provider < 45 years old, 36% preferred 45-60 years old, and 11% of patients preferred a provider > 60 years old. Most patients preferred a provider with 5-15 or > 15 years' experience (49% and 46%, respectively). Eleven percent preferred the presence of trainees while 24% preferred trainee absence. CONCLUSION: Patient preferences regarding urogynecologic providers included female gender and provider age 45-60 years old with > 5 years' experience. Further study is needed to identify qualitative components associated with these preferences.

Evidence-Based Review of Vaginal Native Tissue Hysteropexy for Uterovaginal Prolapse.

IMPORTANCE: As surgical techniques evolve in the treatment of pelvic organ prolapse and patient preferences are better understood, more studies are investigating uterine-sparing procedures for efficacy, safety, and potentially improved quality of life. Much of the literature reflects the use of mesh material in uterine-sparing procedures, and there is a paucity of data regarding the safety and efficacy of native tissue uterine-sparing procedures for the treatment of pelvic organ prolapse. OBJECTIVE: To summarize existing evidence regarding objective and subjective outcomes of uterine-preserving procedures including the Manchester procedure (MP) as well as native tissue uterovaginal hysteropexy with repairs, namely, uterosacral hysteropexy (USH) and sacrospinous hysteropexy (SSH), compared with outcomes of total vaginal hysterectomy (TVH) with repairs for the management of uterovaginal prolapse. EVIDENCE ACQUISITION: A review of the literature included MEDLINE, Cochrane, and clinicaltrials.gov databases. RESULTS: Few level 1 data exist comparing outcomes of native tissue hysteropexy to vaginal hysterectomy for management of uterovaginal prolapse. In general, outcomes of the MP for the management of uterovaginal prolapse revealed that compared with TVH it is associated with shorter operative times, lower estimated blood loss and risk of blood transfusion with no difference in hospital stay, and similar quality of life and sexual function outcomes. Retrospective data suggest no difference with respect to recurrent prolapse of any compartment between USH and TVH with repairs. Level 1 data reveal that SSH has been shown to have similar 1-year outcomes and safety compared with TVH with native tissue suspension. Women with stage 4 prolapse who undergo an SSH may be at higher risk of recurrence and may benefit from an alternative method of apical prolapse repair. CONCLUSIONS AND RELEVANCE: More level 1 data are needed in order to robustly understand long-term differences in outcomes between native tissue uterine-conserving versus vaginal hysterectomy surgical approaches in women with uterovaginal prolapse.

Surgical Outcomes of Paravaginal Repair After Robotic Sacrocolpopexy.

STUDY OBJECTIVE: To evaluate surgical outcomes of robotic sacrocolpopexy with and without paravaginal repair for pelvic organ prolapse (POP). DESIGN: A retrospective cohort study with a 3-month postoperative follow-up (Canadian Task Force classification II-3). SETTING: An academic-affiliated community hospital with a practice comprised of 3 surgeons board certified in female pelvic medicine and reconstructive surgery. PATIENTS: Patients undergoing robotic sacrocolpopexy for POP from April 2013 through November 2014. INTERVENTIONS: Robotic paravaginal repair (RPVR) after robotic sacrocolpopexy. The decision to perform a paravaginal repair was at the discretion of the surgeon. MEASUREMENTS AND MAIN RESULTS: One hundred fifty-six patients underwent a robotic sacrocolpopexy. Twenty-four patients were excluded because of a lack of a 3-month postoperative follow-up. Nine patients underwent concomitant vaginal paravaginal repair and were also excluded. Outcomes were defined by comparing preoperative characteristics with those at the 3-month follow-up. Of the 123 patients in this cohort, 21 patients underwent a concomitant RPVR, and 102 did not. All Pelvic Organ Prolapse Questionnaire (POP-Q) points improved within groups (p < .001) except for the total vaginal length (TVL) in the RPVR group (p = .940). The Patient Global Impression of Improvement (PGI-I) did not differ between groups (1.2 vs 1.5, p = .128). Subgroup analysis was performed on patients with preoperative anterior wall prolapse of stage 3 or greater. Baseline characteristics and perioperative data were not remarkably different from the main cohort. All POP-Q points improved within groups (p < .001) except for the TVL in the RPVR group (p = .572). The PGI-I did not differ between groups (1.2 vs 1.3, p = .378). CONCLUSION: In both groups, anatomic markers substantially improved within each group. There were significant differences in postoperative POP-Q findings, which may have been influenced by the fact that patients undergoing RPVR usually had worse baseline prolapse. This selection bias creates difficulty with interpretation. Although in this study RPVR did not change subjective outcomes, further study is necessary to control for the severity of prolapse.

Estimation of Uterine Size: How Accurate Are We?

OBJECTIVE: To evaluate the accuracy of gynecologic surgeons at estimating uterine dimensions and weight. METHODS: Six model uteri of various sizes were created to simulate the size and consistency of a uterus and displayed at 3 stations. The visual station (VS) comprised 2 specimens placed on an unmarked table. The laparoscopic station (LS) consisted of 2 model uteri, each placed in a separate simulated abdomen with a 0 degree laparoscope and 2 operative trocars with standard instruments. The blind weight station (BWS) consisted of blind palpation of 2 separately weighted models (heavy model [HM] and light model [LM]). Participants visually estimated the dimensions of each VS and LS models and blindly palpated the BWS models to estimate weight. RESULTS: Participants included 15 residents, 27 attendings, and 6 medical students. There was no difference in estimation accuracy regarding gender and age. For the VS and LS groups, participants underestimated all dimensions (VS variance = -15.0%; P < 0.001 and LS variance = -31.9%; P < 0.0001). Laparoscopic estimation was less accurate than direct vision (P < 0.0001). Attendings and residents equally underestimated the 3 dimensions visually (P = 0.46), but attendings were more accurate at estimating laparoscopic dimensions (-25.8% vs -41.1%; P = 0.0001). All groups overestimated model weights (HM variance, 92.5%; P < 0.001 and LM variance, 132.0%; P < 0.0001), with attendings more accurate than residents (39.7% vs 167.6%; P = 0.015 for HM and 52.0% vs 238.5%; P = 0.035 for LM). CONCLUSIONS: Gynecologic surgeons at all levels of training are inaccurate at estimating dimensions and weights. With surgical decisions often predicated on estimates, education is needed to improve estimation methods.

Hydrodistention of the bladder for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC).

AIMS: The purpose of this study is to determine whether a transvaginal trigonal block immediately preceding cystoscopy with hydrodistention yields an additional therapeutic benefit compared to cystoscopy with hydrodistention alone for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS: A retrospective chart review was performed at a single-center. Performance of a trigonal block prior to hydrodistention was at the discretion of the surgeon. A trigonal block consists of injecting 0.25% bupivacaine with 1.0% Xylocaine into the anterior vagina under the trigone under cystoscopic guidance. Procedures between January 1, 2008 and December 31, 2013 were included. The primary outcome compared change in pain score from the baseline to 1-month post-operative. RESULTS: One hundred and eighty-three patients underwent hydrodistention of the bladder. Seventy-seven were excluded and of the 106 patients remaining, 48 received a trigonal block and 58 did not. Both groups had a significant improvement in pain scores (P < 0.0001). There was no difference in change in pain score from baseline between both groups (-2.9 vs. -2.6; P = 0.694). Distention time was dichotomized into 2 and >5 min based on surgeon preference. There was no difference in change in pain score from baseline between both groups (-3.0 vs. -2.2; P = 0.061). CONCLUSIONS: Hydrodistention of the bladder decreased pain postoperatively regardless of trigonal block or time of distention. A randomized-controlled trial is necessary to determine the benefits of duration of hydrodistention or performance of a block. Neurourol. Urodynam. 36:784-786, 2017. © 2016 Wiley Periodicals, Inc.