Optimizing practices to prevent urinary tract infection after cystoscopy and urodynamics in women: A quality improvement study.

OBJECTIVE: The objective of this study was to reduce the incidence of urinary tract infection (UTI) in women undergoing outpatient cystoscopy and/or urodynamic studies (UDS) at our centre by identifying and then altering modifiable risk factors through an analysis of incidence variability among physicians. METHODS: This was a quality improvement study involving adult women undergoing outpatient cystoscopy and/or UDS at an academic tertiary urogynecology practice. Prophylactic practices for cystoscopy/UDS were surveyed and division and physician-specific UTI rates following cystoscopy/UDS were established. In consultation with key stakeholders, this delineated change concepts based on associations between prophylactic practices and UTI incidence, which were then implemented while monitoring counterbalance measures. RESULTS: Two "Plan-Do-Study-Act-Cycles" were conducted whereby 212 and 210 women were recruited, respectively. Change concepts developed and implemented were: (1) to perform routine urine cultures at the time of these outpatient procedures, and (2) to withhold routine prophylactic antibiotics for outpatient cystoscopy/UDS, except in patients with signs of cystitis. There was no change in the incidence of early presenting UTI (9.0% vs. 9.2%, p = 0.680), but there were significantly fewer antibiotic-related adverse events reported (8.5% vs. 1.5%, p = 0.001). There was no significant change in the total incidence of UTI rates between cycles (7.8% vs. 5.6%, p = 0.649). CONCLUSIONS: No specific strategies to decrease the incidence of UTI following outpatient cystoscopy/UDS were identified, however, risk factor-specific antibiotic prophylaxis, as opposed to universal antibiotic prophylaxis, did not increase UTI incidence.

Comparing vitamin B2 versus 5% dextrose in water for optimal ureteric jet visualisation at the time of pelvic reconstructive surgery: A randomised controlled trial.

OBJECTIVE: To compare preoperative vitamin B2 versus intraoperative cystoscopy distension using 5% dextrose in water (D5W) for ureteric jet visualisation during pelvic reconstructive surgery. DESIGN: Double-blinded, randomised controlled trial. SETTING: Three tertiary hospitals in Toronto, Canada. POPULATION: Adult women undergoing pelvic reconstructive surgery. METHODS: Patients were randomised to receive 100 mg of vitamin B2 preoperatively versus bladder distension with D5W intraoperatively. MAIN OUTCOMES: The primary outcome was the rate of accurate detection of bilateral ureteric jets during cystoscopy. Secondary outcomes included the time elapsed until visualisation, use of intravenous furosemide or fluorescein to assist with visualisation, surgeon satisfaction, and positive urine culture 1 week after surgery. RESULTS: The intervention was completed by 236 patients (vitamin B2 n = 117, D5W n = 119). Preoperative characteristics were similar across groups. Accurate detection of both ureteric jets was high in both groups (vitamin B2 97.4% vs. D5W 90.8%, p = 0.051). The vitamin B2 group had significantly lower use of fluorescein rescue compared with the D5W group (3.4% vs. 11.8%, respectively, p = 0.025). Surgeon satisfaction while using vitamin B2 was significantly higher (p < 0.001). There were no significant differences in the time elapsed until visualisation, the use of furosemide, or the incidence of positive urine culture at 1 week after surgery. CONCLUSIONS: Both preoperative vitamin B2 and intraoperative cystoscopy distension with D5W are highly available and inexpensive methods to detect ureteric jets with high accuracy at the time of pelvic reconstructive surgery. Vitamin B2 was shown to have lower rates of fluorescein rescue for visualisation and higher rates of surgeon satisfaction.

Real-World Effectiveness of Pelvic Floor Muscle Training for Women With Urinary Tract Symptoms and/or Prolapse.

OBJECTIVES: To determine the real-world effectiveness of pelvic floor muscle therapy (PFMT) recommendations for patients. METHODS: We conducted a cross-sectional study of 70 women who were advised to undergo PFMT after their initial urogynaecology consultation for lower urinary tract symptoms and/or pelvic organ prolapse. About half (51%) of potential participants consented to answer our telephone survey. We calculated the proportion of patients who complied with the recommendation of PFMT, and we subjectively assessed whether these patients found PFMT to be helpful. We also collected demographic data and looked for reasons why patients did not attend PFMT. Chi-square, 2-tailed t, or Fisher exact tests were used to compare differences between patients who attended and those who did not. RESULTS: During the 6-month period after their initial consultation, only 28 of 70 women (40%) followed the recommendation to attend PFMT. Sixteen of the 28 women who attended PFMT (57%) reported that they found it helpful. Therefore, the "real-world effectiveness" of the entire study sample was 23%, with only 16 of 70 women benefiting from PFMT. Time constraints (27%) and cost (18%) were the top 2 reasons given for not attending. CONCLUSIONS: Despite evidence-based recommendations in favour of PFMT for various pelvic floor disorders, its real-world effectiveness is quite low. A public health commitment to providing access to PFMT would be of significant benefit.

Long-Term Experience with Modified McCall Culdoplasty in Women Undergoing Vaginal Hysterectomy for Pelvic Organ Prolapse.

OBJECTIVE: The incidence of post-hysterectomy vault prolapse following native tissue repair has been reported to be as high as 43%. The optimal way to maintain vault support is unknown. Our aim was to evaluate the long-term efficacy of modified McCall culdoplasty during vaginal hysterectomy for symptomatic uterine prolapse in preventing the recurrence of vaginal vault prolapse. METHODS: We conducted a retrospective chart review involving 490 patients who underwent vaginal hysterectomy with modified McCall culdoplasty, with or without a concomitant stress incontinence procedure, between January 2008 and December 2018 at Mount Sinai Hospital in Toronto. Data analyzed included patient demographics, preoperative prolapse staging, intraoperative and postoperative complications, and postoperative subjective and objective success rates. RESULTS: A total of 490 patients underwent vaginal hysterectomy with modified McCall culdoplasty. The mean follow-up period was 2.8 years. The objective success rate of vault support was 97.1%, and the subjective success rate was 94.1%. The total rate of reoperation for recurrence of vault prolapse was 1.0%. The objective cystocele recurrence rate was 8.6%, and 2.4% of these cases required reoperation. The objective rectocele recurrence rate was 4.7%, with 1.2% requiring reoperation. Unilateral ureteric kinking requiring intraoperative release of the McCall suture was recorded for 2.9% of patients. Overall, there was significant improvement in urinary, bowel, and prolapse symptoms post procedure. CONCLUSION: This cohort of patients who underwent modified McCall culdoplasty had low rates of vault prolapse recurrence and prolapse symptoms. The modified McCall culdoplasty technique practised at our institution is safe and effective in preventing post-hysterectomy vault prolapse.

The extended pessary interval for care (EPIC) study: a failed randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: To describe study design flaws and limited outcomes of a randomized trial that intended to compare satisfaction and complication rates between patients managing their pelvic organ prolapse with a pessary at different maintenance intervals. METHODS: A randomized clinical trial was conducted at two tertiary pessary clinics. After a successful fitting, patients were randomly allocated to follow-up at 3-month or 6-month intervals and followed for 12 months. Symptoms, complications, and pelvic examination characteristics were recorded at each visit. At 6 and 12 months, patient satisfaction with the pessary was also recorded. Sample size calculation was based on the minimal relevant difference in Pessary Satisfaction score (created for this study). With a power of 0.8 and an alpha of 0.05, the minimum number of patients required in each group was 28. RESULTS: We were unable to reach our sample size as most patients did not meet inclusion criteria. After 2 years we were only able to recruit 20/56 patients, with 9 patients in the 3-month group and 11 patients in the 6-month group. Additionally, seven patients dropped out of the study. Overall satisfaction was high and similar between groups at 6- and 12-month follow-up visits. Pessary complications were noted in both groups but in low numbers. CONCLUSIONS: Pessary use is associated with high patient satisfaction and low complication rates, regardless of the follow-up interval. The recruitment failure demonstrated that a randomized trial is not feasible for this research question. Optimally, pessary follow-up should be based on patient symptoms and scheduling preference.

A qualitative study of women's values and decision-making surrounding LeFort colpocleisis.

INTRODUCTION AND HYPOTHESIS: LeFort colpocleisis for uterovaginal prolapse can be appealing to elderly non-sexually active patients given the durability and low risk, particularly when the alternative procedure is more invasive and includes a hysterectomy. We used qualitative methods to explore women's decision-making and feelings after this procedure. METHODS: We interviewed ten women after a LeFort colpocleisis (with or without mid-urethral sling) for uterovaginal prolapse. We conducted semi-structured interviews that were recorded and transcribed and then analyzed using grounded theory. The main themes were: the process of decision-making about whether to have an obliterative procedure, adequacy of preoperative counseling, and comparison against an alternative, more invasive surgical procedure with a hysterectomy. We also used the Decision Regret Scale and the Satisfaction with Decision Scale for Pelvic Floor Disorders. RESULTS: Women made the decision to pursue LeFort colpocleisis mainly by themselves. They felt positive about the ability to control their body and their life through their own decision. None of the women regretted the procedure on the basis of the inability to have penetrative intercourse and did not feel it affected their sexual function in a negative way. Women felt adequately counseled regarding other options and the surgical procedure. Many patients wished they had pursued surgery earlier because they were very satisfied with the results. CONCLUSIONS: Women who underwent LeFort colpocleisis were very happy with their decision. They primarily made the decision to have surgery autonomously. None of them regretted having an obliterative procedure for pelvic organ prolapse for reasons of sexual function.

Is overactive bladder independently associated with anxiety?

INTRODUCTION AND HYPOTHESIS: Although some psychiatric anxiety questionnaires include overactive bladder (OAB) questions, there are few controlled data to confirm such an association. We tested the association between OAB and anxiety using a control group of women with non-OAB lower urinary tract symptoms (LUTS). METHODS: Patients referred to a urogynecology clinic for LUTS completed two questionnaires: the International Consultation on Incontinence Modular Questionnaire for Overactive Bladder (ICIQ-OAB), and the Generalized Anxiety Disorder 7-Item Scale (GAD-7). Based on ICIQ-OAB scores, patients were dichotomized as having OAB versus LUTS-other, and GAD-7 scores categorized patients as having anxiety. A 2-tailed Fisher's exact test was used to test the association between OAB and anxiety. Demographic variables were collected and significant confounders were included in a logistic regression analysis. Sample size calculation indicated a need for 100 subjects, but we recruited 105 subjects to account for incomplete questionnaires. RESULTS: One hundred and five subjects were enrolled (one excluded owing to incomplete questionnaires). Sixty-five patients had OAB and 39 had LUTS-other. Of the OAB patients, 17 out of 65 (26.2%) had anxiety, compared with 3 out of 39 (7.7%) of the LUTS-other group (p = 0.038 by Fisher's exact test, with a slight drop to p = 0.056 in the regression analysis). CONCLUSIONS: There appears to be an association between OAB and anxiety and it may be of clinical importance to assess for anxiety in patients that present with OAB symptoms. The drop in statistical significance from p = 0.038 to a borderline significance of p = 0.056 in the regression analysis may be a reflection of the sample size.

Does low-dose gapapentin reduce opioid use postoperatively?: A randomized controlled trial in women undergoing reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: Pre-emptive gabapentin has been shown to decrease postoperative pain in abdominal and vaginal hysterectomy. However, the effect of pre-emptive low-dose gabapentin has not been studied in vaginal hysterectomy combined with concomitant pelvic reconstruction. METHODS: A randomized double-blind placebo-controlled trial assessed all women seen for symptomatic prolapse requiring vaginal hysterectomy with concomitant pelvic reconstruction with or without midurethral sling. Gabapentin dosing was 600 mg (<65 years) or 300 mg (>65 years). The primary outcome was reduction in opioid consumption in the first 24 h after surgery. Secondary outcomes included sedation and prolongation of recovery room stay. Sample-size calculations indicated a need for 22 participants/group. Student's t test was used to compare differences in oral administration of morphine equivalents in the first 24 h postoperatively, time from end of surgery to leaving the recovery room, and length of recovery room stay. Mann-Whitney U test was used to compare visual analog scale (VAS) scores for anxiety, drowsiness/sedation, pain, and nausea. RESULTS: Twenty-one patients received gabapentin and 26 a placebo capsule. Groups were similar with respect to age, menopause status, parity, American Society of Anesthesiologist (ASA) class, and concomitant procedures. There were also no significant differences between groups in opioid requirements within the first 24 h after surgery, time from end of surgery to leaving the recovery room, length of time in recovery room, or VAS scores. CONCLUSIONS: Pre-emptive gabapentin at our institutional low doses did not significantly affect postoperative pain and opioid requirements in women undergoing vaginal hysterectomy with concomitant reconstruction. TRIAL REGISTRATION: www.clinicaltrials.gov , #NCT02999724.

No. 248-Guidelines for the Evaluation and Treatment of Recurrent Urinary Incontinence Following Pelvic Floor Surgery.

OBJECTIVE: To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery. OPTIONS: Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions. OUTCOMES: These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms. EVIDENCE: Published opinions of experts, and evidence from clinical trials where available. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table).

A Comparison of Health-Related Quality of Life of Women Awaiting Pelvic Organ Prolapse Surgery versus Hip or Knee Replacement.

OBJECTIVE: Pelvic organ prolapse (POP) can significantly decrease the health-related quality of life (HRQOL) of women. In 2005, provincial and territorial wait time benchmarks were set in areas such as hip and knee replacement, but such efforts were lagging for urogynaecological surgeries. This study aimed to compare wait times and HRQOL scores of females awaiting surgery for POP with those of women awaiting hip or knee replacement. METHODS: This was a prospectively planned study comparing women undergoing surgical repair of POP to women having a hip or knee replacement. All women completed a validated HRQOL questionnaire, the Short Form 36 Health Survey. The date of the decision to operate was recorded and patients were followed up prospectively to determine surgical wait time. RESULTS: Three of four physical health concepts were significantly worse for orthopedic patients compared with urogynaecology patients, including the physical component summary (29.2 vs. 41.5, respectively, P < 0.001). Urogynaecology and orthopedic patients had similar emotional and mental well-being, as demonstrated by similar mental component summaries (41.5 vs. 44.6, respectively, P = 0.09). The mean wait time at our institution for hip or knee replacement was 98 days, which was significantly shorter than the mean wait time of 210 days for POP surgery (P < 0.001). CONCLUSION: Despite less physical and pain impact, urogynaecology patients showed similar emotional distress and mental impact compared with orthopedic patients based on a validated HRQOL questionnaire. Because urogynaecology patients waited more than twice as long for their surgery, resources should be directed to prioritize and improve the surgical wait time for urogynaecology patients.

Short-term Uresta efficacy (SURE) study: a randomized controlled trial of the Uresta continence device.

INTRODUCTION AND HYPOTHESIS: An intravaginal device (Uresta) is currently available for the treatment of stress urinary incontinence (SUI). Case-series data on its effectiveness exist; however, controlled data are lacking. The objective of this study is to determine the short-term efficacy of the Uresta device using a randomized placebo controlled trial. The hypothesis is that the Uresta device might significantly reduce urinary loss. METHODS: A single blind randomized controlled trial was conducted among women with urodynamic SUI recruited from a single urogynecology unit. Participants were randomized to receive the Uresta device or a placebo vaginal silastic ring placed high in the vagina for the duration of a pad test. Pad tests were performed before and after device placement. The primary outcome was the achievement of a 50 % or greater reduction in pad weight after device placement, in a comparison of the two groups. Sample size calculation showed a need for 18 subjects per group. Fisher's exact test was used to analyze the primary outcome. Research Ethics Board approval was obtained. RESULTS: Eighteen subjects per group completed the study protocol. The percentage of patients who achieved the primary outcome was 66.7 % in the Uresta group and 22.2 % in the placebo group (p = 0.01). The baseline demographic data were similar in the two groups. There were no adverse events during the test period. CONCLUSIONS: The Uresta intravaginal continence device significantly reduces the short-term objective measures of urine loss due to SUI. Further study to assess subjective outcomes and long-term patient satisfaction is required.

A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse.

OBJECTIVE: To describe a streamlined laparoscopic sacrocolpopexy (LSCP) surgical technique in women with post-hysterectomy vault prolapse and to evaluate the functional outcomes, complication rates, and surgical morbidity within our centre. METHODS: We retrospectively reviewed the charts of 180 patients scheduled for LSCP between November 2002 and May 2013 in a tertiary care centre. Patients were followed-up at six weeks, six months, and yearly after surgery. We reviewed patient demographics, preoperative and postoperative symptoms, and perioperative variables. Objective success of the surgery was defined as having a less than stage 2 vault prolapse, and subjective success was defined as the absence of bulge or prolapse symptoms. Success and complication rates were calculated. RESULTS: Of the 180 patients who underwent surgery, 144 patients underwent the procedure as planned and had at least six months of follow-up. At the last follow-up visit, 133 of these 144 patients (92.4%) were free of prolapse symptoms. Several bladder and bowel symptoms showed significant improvement. Anatomical success of vault support was achieved in 140 of 144 patients (97.2%), and 119 patients (82.6%) had no prolapse beyond the hymen. Early complications (within the first 6 weeks) occurred in 8.3% of 162 patients with limited outcome data, and late complications (after 6 weeks) occurred in 11.5% of the 144 patients with long-term data. There were no cystotomies or mesh exposures. CONCLUSION: At an average of 32 months, this cohort of patients had low prolapse recurrence rates and no reports of cystotomy or mesh erosion. The abridged LSCP technique, as practised in our institution, is safe and effective in the surgical management of post-hysterectomy vault prolapse.

Prevalence of obstructive sleep apnea detected by the Berlin Questionnaire in patients with nocturia attending a urogynecology unit.

INTRODUCTION AND HYPOTHESIS: Nocturia has been associated with several chronic conditions including obstructive sleep apnea (OSA). The pathophysiological link between nocturia and OSA has been well delineated, but the prevalence of this condition in patients with nocturia is unknown. The aim of this study was to determine the prevalence of sleep apnea in patients with nocturia compared with patients without nocturia in a group of women referred to a urogynecology unit. METHODS: After ethics approval, a cross-sectional case control study including 81 cases and 79 controls was conducted. The sample size of 72 patients was required for each arm to detect a 23 % difference in the prevalence of OSA with a 95 % confident interval (CI) and statistical power of 80 %. All patients completed the Nocturia, Nocturia Enuresis and Sleep Interruption Questionnaire (NNES-Q) and the Berlin OSA Questionnaire. The NNES-Q was used to define cases and controls. The Berlin Questionnaire was used to classify patients as being at a high or a low risk of having OSA. Univariate analysis was first performed, followed by logistic regression to assess the association between nocturia and OSA, as well as other possible variables associated with nocturia. RESULTS: Fifty of the cases (61.7 %) were classified as being at a high risk of having OSA compared with only 19 (24.1 %) in the control group (OR 2.9, 95 % CI 1.29-6.52, p = 0.01). Other variables found to be statistically significant by logistic regression were high BMI, overactive bladder, and low bladder capacity (<300 cc). CONCLUSION: Patients with nocturia showed a significantly higher risk of having OSA. Patients with nocturia should be screened for OSA.

Outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape insertion, and transobturator tape insertion in women with recurrent stress urinary incontinence.

OBJECTIVE: Although the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures. METHODS: This retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications. RESULTS: Forty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction. CONCLUSION: The laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.

Objectif : Bien que la prise en charge chirurgicale de l'incontinence urinaire à l'effort primaire (IUE) ait été bien étudiée, la prise en charge optimale de l'IUE persistante ou récurrente constitue un défi considérable pour le chirurgien et les données publiées pertinentes sont limitées. Cette étude avait pour but de documenter les données quant aux issues de diverses techniques chirurgicales utilisées dans notre centre pour la prise en charge de l'IUE récurrente, ainsi que d'évaluer les complications immédiates et à long terme étant associées à ces interventions. Méthodes : Cette étude rétrospective a évalué l'issue de l'intervention laparoscopique de fronde à deux équipes, de l'insertion d'une bandelette vaginale sans tension (TVT) et de l'insertion d'une bandelette transobturatrice (TOT) dans la prise en charge de l'IUE récurrente chez des femmes. Parmi les données recueillies, on trouvait les caractéristiques démographiques des patientes, les données urodynamiques, la guérison postopératoire subjective et la guérison objective (test à la toux négatif), ainsi que les complications peropératoires et postopératoires. Résultats : Quarante-six femmes présentant une IUE récurrente ont été admises à l'étude : 24 d'entre elles ont subi une intervention laparoscopique de fronde à deux équipes, 15 ont subi une insertion de TVT et 7 ont subi une insertion de TOT. Les taux de guérison objective ont été de 91,7 %, de 73,3 % et de 85,7 %, respectivement, tandis que les taux de guérison subjective ont été de 79,2 %, de 60 % et de 57,1 %, respectivement. Au sein du groupe « intervention laparoscopique de fronde à deux équipes ¼, une des participantes en est venue à présenter un hématome infecté, tandis qu'une autre a nécessité une chirurgie en raison d'une occlusion de l'intestin grêle. Conclusion : L'intervention laparoscopique de fronde à deux équipes ou l'insertion d'une TVT ou d'une TOT peuvent être utilisées par des praticiens expérimentés pour assurer la prise en charge chirurgicale des patientes qui présentent une incontinence urinaire à l'effort récurrente. Nous n'avons constaté aucune différence significative sur le plan statistique en matière d'issues entre ces trois groupes, et ce, peut-être en raison de la faible envergure de l'échantillon. La tenue d'essais randomisés prospectifs comptant des échantillons de plus grande envergure et des suivis prolongés s'avère justifiée aux fins de l'identification de toute différence possible.

Efficacy and safety of tension-free vaginal tape compared with transobturator tape among obese women with stress urinary incontinence: a retrospective cohort study.

OBJECTIVE: To determine the efficacy and safety of tension-free vaginal tape (TVT) compared with transobturator tape (TOT) in obese women with stress urinary incontinence (SUI). METHODS: We performed a retrospective chart review of patients who underwent insertion of TVT or TOT for stress urinary incontinence between January 2003 and October 2009. Women were excluded if they had had previous surgery for SUI or had a diagnosis of intrinsic sphincter deficiency. RESULTS: One hundred eighty obese women (BMI > 30 kg/m²) with SUI and with follow-up for at least one year were identified (90 had TVT and 90 had TOT). The rates of success on the objective criteria were 91% for the TVT group and 88% for the TOT group (P = 0.46) and 87% versus 80% (P = 0.23) on subjective assessment. CONCLUSION: Our retrospective cohort study demonstrated similar rates of cure for obese women with SUI who underwent insertion of TVT and TOT.

Stress urinary incontinence six months post laparoscopic sacrocolpopexy.

OBJECTIVE: To determine the incidence of postoperative stress urinary incontinence (SUI) after laparoscopic sacrocolpopexy (LSCP) in women without preoperative symptoms or signs of SUI. METHODS: We conducted a retrospective chart review of all cases of LSCP over a five-year period in a major tertiary centre to identify cases of SUI at the six-month follow-up visit. Patients did not have demonstrable preoperative SUI with prolapse reduction techniques, and they did not have prior or concomitant SUI surgery. RESULTS: Of 31 women, only two had SUI at six months after LSCP, with one requiring surgery. CONCLUSION: We do not recommend concomitant prophylactic surgery for SUI at the time of LSCP in women who do not have objectively demonstrable SUI before surgery.

Randomized controlled trial of cystocele plication risks: a pilot study.

OBJECTIVE: We wished to determine the feasibility of a single-centre randomized controlled trial to investigate whether avoiding cystocele plication in women undergoing transvaginal repair of cystocele decreases the need for catheterization beyond the second postoperative day. METHODS: Patients undergoing transvaginal repair of cystocele were randomly assigned to either have or not have plication sutures during their procedure. We assessed the success of recruitment, physician acceptability, and adherence to protocol, and we also assessed the need for catheterization beyond the second postoperative day. RESULTS: Twenty-two women were randomized (a recruitment rate of 85%), and participating surgeons did not feel that one surgical technique was superior to the other. There were no protocol violations after randomization. No cases of postoperative voiding dysfunction were identified. CONCLUSION: A multicentre randomized controlled trial is required to determine the short-term and long-term risks and benefits of avoiding plication sutures in women undergoing transvaginal repair of cystocele. If patients and physicians support the study protocol, conducting such a trial is feasible.

Guidelines for the evaluation and treatment of recurrent urinary incontinence following pelvic floor surgery.

OBJECTIVE: To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery. OPTIONS: Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions. OUTCOMES: These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms. EVIDENCE: Published opinions of experts, and evidence from clinical trials where available. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). RECOMMENDATIONS: 1. Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to guide management. (II-3B) 2. Conservative management options should be used as the first line of therapy. (III-C) 3. Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral sling, pubovaginal sling). (II-2B) 4. Patients with evidence of intrinsic sphincter deficiency may be managed with a sling procedure (e.g., mid-urethral sling, pubovaginal sling). (II-3B) 5. In cases of surgical treatment of intrinsic sphincter deficiency, retropubic tension-free vaginal tape should be considered rather than transobturator tape. (I-B) 6. Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic sling procedure, use of an artificial sphincter, urinary diversion, or chronic catheterization. (III-C) 7. Overactive bladder should be treated using medical and/or behavioural therapy. (II-2B) 8. Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs to relax the urethral sphincter, timed toileting, and double voiding. Intermittent self-catheterization may also be used. (III-C) 9. Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or urethrolysis. (III-C) 10. Fistulae should be managed by an experienced physician. (III-C).

Overactive bladder: correlating symptoms with low cystometric capacity.

OBJECTIVES: : Overactive bladder (OAB) is a symptom complex that may be objectively assessed using urodynamic variables. The purpose of this study was to determine the correlation between OAB symptoms and low cystometric capacity (LCC). METHODS: : Between October and December 2005, 102 patients from the Urogynaecology Clinic at Mount Sinai Hospital participated in this prospectively planned, blinded, cross-sectional study. Participants underwent multichannel urodynamic testing and completed a symptom questionnaire focusing on urinary urgency, frequency, and urgency incontinence, in addition to recording fluid and caffeine intake. Answers were combined into symptom complexes and dichotomized into positive and negative responses. The diagnostic accuracy of OAB symptoms was assessed by calculating sensitivity, specificity, likelihood ratios, positive and negative predictive values, and Cohen's kappa, using urodynamic bladder capacity <350 mL as the reference. RESULTS: : Fifty-seven percent (58) of participants met our urodynamic diagnosis of LCC with a bladder capacity <350 mL. Of the patients, 49% (50) had a questionnaire result that was classified as positive for overactive bladder. The questionnaire had a specificity of 61%, a likelihood ratio of 1.47, a sensitivity of 57%, and a positive predictive value of 66%. With a Cohen's κ = 0.2, there was poor reliability. Reanalysis using an alternative method of dichotomizing, a bladder capacity cut-off of <300 mL, and the addition of information regarding fluid intake, did not improve accuracy measures. CONCLUSIONS: : Symptom history of OAB does not correlate with low cystometric capacity. We need further research to determine the accuracy of subjective and objective findings in patients with OAB, to provide the most accurate diagnosis in the least invasive manner.