Arcus-anchored acellular dermal graft compared to anterior colporrhaphy for stage II cystoceles and beyond.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to compare acellular dermal matrix to standard colporrhaphy for cystocele repair. METHODS: One hundred two patients with greater than or equal to stage II anterior prolapse (Aa or Ba 0) who underwent anterior colporrhaphy with acellular dermal implant attached to the arcus between October 2003 and February 2007 were compared to 89 controls who received standard anterior colporrhaphy. Objective recurrence was defined as greater than or equal to stage II (Aa or Ba -1). RESULTS: The dermal graft and colporrhaphy groups were comparable in age, parity, body mass index, and concomitant surgeries except hysteropexy and hysterectomy. Regression was performed for possible confounders. Postoperatively, 14 (19%) recurrences were identified in the dermal graft group vs. 26 (43%) in the colporrhaphy group (p = 0.004). Two patients underwent reoperations for cystocele recurrence in the study group vs. four in the control group. Time to normal voiding, subjective stress urinary incontinence, estimated blood loss, and length of hospital stay did not differ between groups. CONCLUSION: Dermal acellular matrix provides benefit over standard colporrhaphy.

Predictors of persistent detrusor overactivity after transvaginal sling procedures.

OBJECTIVE: Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence STUDY DESIGN: Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models. RESULTS: Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001). CONCLUSION: When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.

Impact of hysterectomy on stress urinary incontinence: an identical twin study.

OBJECTIVE: This study uses the unique properties of twin research design to evaluate whether hysterectomy impacts stress urinary incontinence (SUI). STUDY DESIGN: As part of the Evanston Twins Sister Study, we performed bivariate and multivariate analyses on 83 identical twin pairs discordant for hysterectomy. RESULTS: In bivariate analysis, SUI was less common in women who had prior hysterectomy (P =0.028). Multivariate analysis suggested that SUI was significantly less common after hysterectomy (odds ratio [OR], 0.55, confidence interval [CI], 0.30 to 1.00). Exclusion of twin pairs with a history of pelvic floor defect surgery eliminated the statistical relationship between hysterectomy and SUI (OR, 0.79, CI, 0.4 to 1.40). CONCLUSION: Hysterectomy, when analyzed with all cases, was associated with reduced SUI. When concurrent pelvic floor defect surgeries were excluded from the analysis, we found no relationship between hysterectomy and the risk of SUI afterward.

Overactive bladder syndrome presentations at the 31st International Urogynecological Association Annual Meeting.

There were 586 abstracts presented at the 31st Annual Meeting of the International Urogynecological Association in Athens, Greece, in September 2006. Many of these abstracts focused on the common condition of overactive bladder syndrome. The results of large multicenter industry-sponsored trials such as MATRIX, STAR, and SUNRISE were presented. Smaller trials of new treatments, including pudendal nerve stimulation and botulinum toxin A injection, were presented. A pair of studies addressed the importance of anatomic correction of pelvic organ prolapse in the treatment of overactive bladder syndrome. Nineteen abstracts are reviewed here.

Histologic characterization of vaginal vs. abdominal surgical wound healing in a rabbit model.

We aimed to compare the histologic characteristics of vaginal vs. abdominal surgical wound healing in the rabbit. Bilateral 6 mm full-thickness circular segments were excised from the vagina and abdominal skin in 34 New Zealand white female rabbits. Animals were euthanized on the day of and 4, 7, 10, 14, 21, 28, and 35 days after wounding, and their wounds were evaluated using a modified scoring system. The inter- and intraobserver agreements of the scoring system were good (weighted kappa 0.63 and 0.71, respectively). A transient fibrinous crust was evident in 75% of the abdominal and in none of the vaginal wound specimens on days 4-7 after wounding (p=0.01). Acute inflammation peaked at day 4 in both the vaginal and abdominal wounds, while chronic inflammation peaked at days 4-7 and 14-21 in the abdomen and vagina, respectively. Both neovascularization and the amount of granulation tissue peaked at days 4 and 7 in the vagina and abdomen, respectively. Maturation of granulation tissue and collagen deposition increased persistently in both tissues until postwounding day 35. Reepithelialization increased after wounding, and was completed by day 14 in both tissues. The surgical wound-healing process in both the vagina and abdomen includes transient acute and chronic inflammation, fibroblast proliferation, and neovascularization, as well as progressive maturation of granulation tissue, reepithelialization, and collagen deposition. A transient fibrinous crust forms in the abdomen but not in the vagina 4-7 days after wounding. The modified histologic scoring system described here was found to be reliable and reproducible.

Detrusor overactivity and urge urinary incontinence following trans obturator versus midurethral slings.

AIMS: To compare the rates of resolution of detrusor overactivity (DO) and subjective urge urinary incontinence (UUI) as well as de novo DO and UUI between the Monarc, TVT, and SPARC midurethral sling procedures. METHODS: Two hundred and seventy-six subjects with urodynamic stress or mixed urinary incontinence underwent retropubic midurethral slings (TVT, N = 99; SPARC, N = 52) or transobturator slings (Monarc, N = 125). All evaluable subjects had a routine office evaluation, subjective assessment of UUI, and multichannel urodynamic testing pre- and 3 months postoperatively. Comparisons were made using Student's t-test, ANOVA, McNemar's test, and Chi-Square test where appropriate. Multivariate logistic regression was performed to detect possible confounding factors such as sling type, and differences in concomitant surgical procedures. RESULTS: De novo subjective UUI differed significantly between the Monarc and the other two slings (33% TVT vs. 8% Monarc vs. 17% SPARC, P = 0.04). Fourteen to Sixteen percents of patients with preoperative UUI who underwent TVT or SPARC had worsening of their UUI symptoms while only 6% of the Monarc group did (P = 0.02). There was no difference in rates of resolution of DO among the three groups (40% vs. 48% vs. 32%, P = 0.39) or de novo DO (32% vs. 22% vs. 22%, P = 0.64) at 3 months. CONCLUSIONS: Patients who undergo transobturator procedures have significantly lower rates of de novo UUI than those who undergo midurethral sling procedures. Rates of resolution of DO, UUI, and de novo DO do not differ between groups.

Is transobturator tape as effective as tension-free vaginal tape in patients with borderline maximum urethral closure pressure?

INTRODUCTION: The purpose of this study was to compare transobturator tape (MONARC) with tension-free vaginal tape in patients with borderline low maximum urethral closure pressure. STUDY DESIGN: Historical cohort analysis of 3-month outcomes in 145 subjects (MONARC = 85; tension-free vaginal tape = 60). A cut-off point of 42 cm H2O for preoperative maximum urethral closure pressure was identified as predictor of success in the entire cohort. The cohort was stratified by sling type and analyzed. Outcome variables included urodynamic stress incontinence, urethral pressure profiles, subjective stress incontinence symptoms, and complications. RESULTS: The relative risk of postoperative urodynamic stress incontinence 3 months after surgery in patients with a preoperative maximum urethral closure pressure of 42 cm or less H2O was 5.89 (1.02 to 33.90, 95% confidence interval) when we compared MONARC with tension-free vaginal tape. Subjects in the MONARC and tension-free vaginal tape groups did not differ significantly in baseline characteristics. We defined subjects as failures if they demonstrated postoperative objective stress incontinence on multichannel urodynamic testing. CONCLUSION: In subjects with maximum urethral closure pressure of 42 cm or less H2O, the MONARC was nearly 6 times more likely to fail than tension-free vaginal tape at 3 months after surgery. Long-term follow-up and randomized controlled trials are needed.

Biomechanical characterization of vaginal versus abdominal surgical wound healing in the rabbit.

OBJECTIVE: The objective of the study was to compare biomechanical properties of vaginal versus abdominal surgical wound healing in the rabbit. STUDY DESIGN: Bilateral 6-mm full-thickness circular segments were excised from the vagina and abdominal skin in 38 New Zealand White female rabbits. Animals were killed 0, 4, 7, 10, 14, 21, 28, and 35 days after wounding, and the wounds were assessed for surface area and tensile properties. RESULTS: Wound closure and scar contraction were significantly faster in the vagina than the abdomen (P = .001). Baseline tensile strength (P = .05), modulus (P = .001), and tensile energy to break (P = .18) were higher in the abdomen, whereas maximal tissue elongation was higher in the vagina (P = .13). After wounding, a drop in tensile strength, modulus, and tensile energy to break was observed in both tissues through postwounding day 4, followed by a progressive recovery of these properties. A progressive loss of elasticity was noted in both tissues after wounding. CONCLUSION: The surgical wound closes and contracts faster in the rabbit vagina than in its abdomen. Although these tissues have different biomechanical properties at baseline, they regenerate their tensile strength and lose their elasticity at a similar rate.

Effect of parity on sexual function: an identical twin study.

OBJECTIVE: To assess the impact of childbirth on female sexual function by using an identical twin study design. METHODS: A survey including the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was administered to 542 twin sisters, and PISQ-12 scores of 29 twin pairs discordant for parity were compared. Multiple linear regression models were used to evaluate impact on total PISQ-12 scores in 276 identical, sexually active twins. Three models were used 1) to evaluate the effect of parity and general risk factors, 2) to examine the impact of birth mode, and 3) to examine the role of episiotomy and operative delivery. RESULTS: Mean PISQ-12 scores were significantly higher for discordant nulliparous twins than for parous twins (102.5 versus 93.5, P < .001). The mean (standard deviation) PISQ-12 score was 99.3 (11.7). Age of 50 years or older (difference in mean scores -5.4, P = .019), stress urinary incontinence (-3.3, P = .02), urge urinary incontinence (-5.9, P < .001), parity (-6.5, P < .001), and fecal incontinence (-5.7, P = .048) were associated with decreased mean PISQ scores in the univariable analysis. Parity (-4.9, P < .001) and urge urinary incontinence (-4.3, P = .009) were the only factors remaining independently predictive of diminished sexual function in the multivariable analysis. Mode of delivery did not significantly affect mean PISQ scores (P = .763). Among women who had vaginal deliveries only, neither episiotomy nor operative delivery was associated with change in PISQ scores (P = .553). CONCLUSION: Nulliparous women reported superior sexual satisfaction scores compared with parous women, regardless of age and mode of delivery. Childbirth appears to have a lasting impact on sexual function, due to psychological more than physical factors, well beyond the postpartum period. LEVEL OF EVIDENCE: II-2.

Detrusor overactivity and urge urinary incontinence [corrected] following midurethral versus bladder sling procedures.

OBJECTIVE: The objective of the study was to compare detrusor overactivity and urge urinary incontinence rates after midurethral slings versus bladder neck slings. STUDY DESIGN: Three hundred forty subjects underwent midurethral slings or bladder neck slings. Comparisons were made using Student's t test and chi2 test. Multivariate analysis was performed to detect confounding factors. RESULTS: More patients in the midurethral sling group resolved detrusor overactivity than in the bladder neck sling group (38% versus 15%, P < .001). In addition, subjects in the midurethral sling group had significantly lower rates of de novo detrusor overactivity than subjects in the bladder neck sling group (29% versus 62%, P = .002). The only significant predictors of postoperative detrusor overactivity were preoperative detrusor overactivity (P < .001) and sling type (P < .001). After adjusting for preoperative detrusor overactivity, bladder neck slings significantly increased the risk for persistent detrusor overactivity (odds ratio 3.9). CONCLUSION: Midurethral slings have increased rates of resolution of detrusor overactivity and lower rates of de novo detrusor overactivity than transvaginal bladder neck sling procedures.

Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston-Northwestern Twin Sisters Study.

OBJECTIVE: We studied a large cohort of identical twin sisters, utilizing the unique properties of a twin research design to explore the relationship between obstetrical delivery mode and stress urinary incontinence. STUDY DESIGN: An anonymous 67-item survey was completed by 271 identical twin pairs (n = 542) at the world's largest annual gathering of twins. Logistic regression for repeated binary measures was used to evaluate risk factors and accounting for shared genetics within pairs. RESULTS: The twins had a mean age of 47.1 years (range 15 to 85 years), and stress urinary incontinence was reported by 51.8%. Stress urinary incontinence was associated with age (P = .001), parity (P = .001), obesity (P = .002), and birth mode, with vaginal delivery conferring a considerable increase in stress urinary incontinence risk relative to cesarean section (odds ratio 2.28, 95% confidence interval 1.14 to 4.55, P = .019). CONCLUSION: Vaginal delivery mode represents a potent determinant of stress urinary incontinence, carrying more than twice the risk of cesarean section. This study of identical twins provides new insight into the epidemiology of female incontinence.

Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study.

OBJECTIVE: To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance. METHODS: A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately. RESULTS: Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21-6.0; flatal: OR 1.90, 95% CI 1.11-3.24), menopause (fecal: OR 2.10, 95% CI 1.15-3.8; flatal: OR 2.11, 95% CI 1.43-3.13), increasing parity (parity > or = 2; fecal: OR 3.09, 95% CI 1.25-7.65; flatal: OR 2.72, 95% CI 1.65-4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12-3.98; flatal: OR 1.72, 95% CI 1.14-2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries. CONCLUSION: Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence.

The effect of preemptive pudendal nerve blockade on pain after transvaginal pelvic reconstructive surgery.

OBJECTIVE: To assess the effect of preemptive pudendal nerve blockade on pain and consumption of narcotic analgesia following transvaginal pelvic reconstructive surgery. METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients undergoing transvaginal pelvic reconstructive surgery under general anesthesia were randomized to receive pudendal block with either bupivacaine 0.25% or placebo (normal saline 0.9%) immediately before surgery. All patients received postoperative intravenous hydromorphone patient-controlled analgesia. Patients were asked to report on their pain intensity 1, 3, 5, 7, 18, and 24 hours postoperatively, using a validated visual analog pain scale from 0-10. Main outcome measures included postoperative pain intensity and hydromorphone consumption. RESULTS: One hundred ten patients enrolled in the study, of whom 106 underwent randomization, and 102 received pudendal nerve blockade, 51 with bupivacaine and 51 with saline. Demographic and baseline clinical characteristics were not significantly different between the 2 patients groups. There were no significant differences in postoperative pain intensity (median scores: 1 hour, 4.0 versus 5.0; 3 hours, 3.0 versus 4.0; 7 hours, 2.0 versus 3.0; 18 hours, 3.0 versus 4.0), the consumption of hydromorphone (0-3 hours, 1.84 mg versus 1.77 mg; 4-7 hours, 1.19 mg versus 1.20 mg; 8-18 hours, 2.89 mg versus 2.35 mg), or mean hospital stay (39.6 versus 37.3 hours) between the bupivacaine and saline groups. CONCLUSION: Preemptive pudendal nerve blockade does not affect postoperative pain intensity or the consumption of narcotic analgesia after transvaginal pelvic reconstructive surgery.