Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures.

INTRODUCTION AND HYPOTHESIS: Urethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement. METHODS: This was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n 13) or based on their last follow-up appointment. RESULTS OBTAINED: Nineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n 1), incontinence (onabotulinum toxin injection n 1, rectus fascia autologous sling n 1), prolapse (colpopexy n 1), and pain (trigger-point injection n 1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better. CONCLUSIONS: The management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

Factors Associated With Hemostatic Agent Use During Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To evaluate factors associated with the use of hemostatic agents during traditional laparoscopic or robotic hysterectomy. DESIGN: A retrospective cohort trial (Canadian Task Force classification III). SETTING: A single medical center in Cincinnati, OH, from August 1, 2013, to July 31, 2014. PATIENTS: Women undergoing traditional laparoscopic or robotic hysterectomies with and without the use of hemostatic agents. INTERVENTION: The use of a hemostatic agent at the time of hysterectomy. MEASUREMENTS: Patient characteristics and pre- and postoperative metrics were recorded for each subject. Associations between categoric variables were analyzed using chi-square testing, whereas continuous variables were analyzed using analysis of variance. Modeling of study variables to predict hemostatic agent use was performed using chi-square-assisted interaction detection methods. MAIN RESULTS: The study sample included 176 cases performed by 30 surgeons. In our sample, 42% of minimally invasive hysterectomies were performed with the surgical robot (robotic-assisted laparoscopic hysterectomy); the remainder of minimally invasive hysterectomies by approach was as follows: total laparoscopic hysterectomy, 27%; laparoscopic-assisted vaginal hysterectomy, 16%; and laparoscopic supracervical hysterectomy, 15%. Forty-six percent (81/176) of cases recorded the use of a fibrin hemostat, 26% (46/176) involved an alternative hemostat, and 28% (49/176) of cases did not use any hemostat. By surgical approach, no hemostatic agent use was noted most often among laparoscopic-assisted hysterectomy; alternative hemostats were most often used during total laparoscopic hysterectomy. Robotic-assisted laparoscopic hysterectomy and laparoscopic supracervical hysterectomy were most often associated with fibrin-based hemostats. The use of any hemostatic agent did not result in clinical significant blood loss relative to cases in whino product was used. The study variable identified most predictive of hemostat use by the chi-square-assisted interaction detection regression tree model was surgeon identity. CONCLUSION: Hemostatic agent use during traditional laparoscopic and robotic hysterectomy does not appear to be associated with operative bleeding but is related to surgeon identity.

Quality of information on pelvic organ prolapse on the Internet.

INTRODUCTION AND HYPOTHESIS: This study aimed to determine the quality of available patient-centered information for pelvic organ prolapse (POP) on the Internet using a modified validated scale. METHODS: Two independent investigators using three search engines (Google, Yahoo, Bing) searched and reviewed the top 30 unique sites for four terms: bladder prolapse; dropped bladder; uterine prolapse; dropped uterus. A total of 219 websites were reviewed by both reviewers excluding redundancies. A two-stage, 6-point rating scale with score range per question of 0-5 was developed from the DISCERN instrument. Also recorded was whether a site had Health On the Net (HON) Foundation certification. The 400 sites were (as stated) a separate search where in the the domain suffix for the top 100 sites per serach term was recorded. RESULTS: The summary of 400 sites reviewed across the four search terms identified 64 % .com, 19 % .org, 8 % .edu, 6 % other and 3 % .gov; .gov yielded the highest quality information. Only 23 (9.5 %) sites were HON certified, yet these sites possessed higher DISCERN scores (p < 0.0001). For the three questions referencing conservative treatments (i.e., pessary, physical therapy, watchful waiting), 115 (52 %) sites indicated a summed mean score of ≤3, indicating less complete information regarding these treatments. CONCLUSIONS: Web-based information available to women regarding treatment for POP based on the modified DISCERN instrument is incomplete and biased toward surgical treatments. Government-sponsored websites (.gov) appear to provide the best quality information regarding this condition.