An evaluation of pelvic floor disorders in a public and private healthcare setting.

INTRODUCTION AND HYPOTHESIS: The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans. METHODS: A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type. RESULTS: A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size. CONCLUSIONS: Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.

Barriers to Care Affecting Presentation to Urogynecologists in a Community Setting.

OBJECTIVE: To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings. METHODS: Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care. RESULTS: One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01). CONCLUSION: This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care.

Vaginal intraperitoneal versus extraperitoneal uterosacral ligament vault suspensions: a comparison of a standard and novel approach.

INTRODUCTION AND HYPOTHESIS: Uterosacral ligament suspension surgery is commonly utilized to correct post-hysterectomy vaginal vault prolapse (VVP). Vaginal intraperitoneal uterosacral vault suspension (IUSVS) is a viable option, but intraperitoneal access can be challenging. An alternative approach is an extraperitoneal uterosacral vault suspension (EUSVS). The aim of our study was to compare surgical outcomes of IUSVS and EUSVS in patients with post-hysterectomy VVP. METHODS: Retrospective cohort study of women who underwent treatment of post-hysterectomy VVP with an IUSVS and EUSVS from May 2016 to January 2019 at our institution. The primary outcome was surgical success that was assessed by a composite outcome for surgical failure, defined as ANY of the following: (1) apical descent > 1/3 of the TVL or anterior or posterior vaginal wall beyond the hymen, (2) retreatment of prolapse, or (3) bothersome vaginal bulge symptoms with a positive response to either of two questions on the PFDI questionnaire. Secondary outcomes included EBL, operative time, duration of hospitalization, and perioperative complications. Two-sample t-tests and chi-square tests were used for the bivariate analysis. RESULTS: Eighty patients were included (36 IUSVS and 44 EUSVS) with a mean follow-up of 7 months. For our primary outcome, there was no difference in surgical success (IUSVS group 72.22% vs. EUSVS group 81.82%, p = 0.307). Operative time, duration of hospitalization, and EBL were significantly less in the EUSVS group than in the IUSVS group. CONCLUSIONS: EUSVS demonstrated similar short-term success compared to IUSVS for post-hysterectomy VVP, with shorter operative time, EBL, and length of stay.

Overactive Bladder Symptoms After Pelvic Organ Prolapse Repair.

OBJECTIVES: This study aimed to identify the characteristics associated with overactive bladder (OAB) symptoms perioperatively in patients undergoing pelvic organ prolapse (POP) surgery with and without slings and to determine the rate of OAB symptom resolution postoperatively. METHODS: This retrospective, single-institution study involved women undergoing prolapse surgery with and without concomitant midurethral sling from 2011 to 2016. A validated questionnaire was used to determine OAB symptoms preoperatively and postoperatively. The primary outcome was rate of resolution in OAB symptoms after POP surgery with and without midurethral sling. Baseline characteristics and surgery type were presented, and univariate and multivariate logistic regression models were applied to evaluate characteristics associated with OAB symptoms at the first postoperative visit. RESULTS: The analysis included 203 patients. Among those with baseline OAB symptoms, 103 (61%) had symptom resolution, whereas 66 (39.1%) reported persistent symptoms. Among 34 patients without baseline OAB symptoms, 6% developed de novo symptoms. Older age was found to be a significant risk factor for persistence of symptoms postoperatively both on univariate (odds ratio, 0.97; 95% confidence interval, 0.94-1; P = 0.038) and multivariate logistic regression (odds ratio, 0.96, 95% confidence interval, 0.92-1; P = 0.049). The rate of medication discontinuation postoperatively was 25%. CONCLUSIONS: Approximately 61% of patients undergoing POP surgery had resolution of OAB symptoms postoperatively whether or not an incontinence procedure was performed. Older age was significantly related to persistent OAB symptoms in both univariate (P = 0.038) and multivariate (P = 0.049) models. The rate of de novo OAB symptoms was 6%.

Does body mass index impact passing voiding trial after midurethral sling procedures for stress urinary incontinence?

OBJECTIVE: : To test the hypothesis that body mass index (BMI) is a factor associated with passing a voiding trial after midurethral sling procedures for stress urinary incontinence (SUI). STUDY DESIGN: : The medical records of 136 consecutive patients who underwent placement of either tension-free vaginal tape (TVT) or transobturator tape (TOT) for SUI during a 1-year period (September 1, 2007 to August 31, 2008) were retrospectively reviewed. Variables assessed were BMI, age, and passing or failing a postoperative urinary voiding trial. Patients with concomitant pelvic organ prolapse surgeries were not included in this analysis. RESULTS: : Sixty-seven patients underwent TVT, whereas 69 had TOT procedures. In the TVT group, 30 patients (42%) were unable to void immediately postoperatively compared with 11 patients (16%) in the TOT group (P = 0.0003). The mean (SD) age and BMI of patients who failed or passed voiding trials was 58.6 (12.0) years and 28.0 (4.9) kg/m or 53.5 (12.3) years and 29.8 (5.7) kg/m, respectively. Of 38 patients who did not pass a voiding trial on the day of the procedure, 31 (82%) passed on postoperative day 1, and all patients had passed a voiding trial by postoperative day 11. The mean (SD) BMI for 7 patients who did not pass voiding trial by postoperative day 1 was 28.3 (5.2) kg/m. CONCLUSIONS: : Women with higher BMIs were more likely to pass voiding trials after midurethral sling procedures. Patients who had TOT placement had greater success passing a postprocedure voiding trial than did patients who had TVT placement.

Hemorrhagic complication during placement of tension-free vaginal tape.

A 66-year-old para III with a 20-year history of stress urinary incontinence underwent placement of tension-free vaginal tape. Intraoperative arterial bleeding occurred. An expanding hematoma was palpated postoperatively. Interventional radiology performed a pelvic arteriogram with selective bilateral internal iliac arteriograms, a supraselective anterior division and obturator arteriogram, a left external iliac arteriogram, coil embolization of a branch of the left obturator artery, and gel foam embolization of the anterior division of the left internal iliac artery.

Effect of estrogen replacement on the histologic response to polypropylene mesh implanted in the rabbit vagina model.

OBJECTIVE: The aim of this study was to determine the effect of estrogen replacement after ovariectomy on the histologic response to polypropylene mesh implanted in rabbit vagina. STUDY DESIGN: Thirty rabbits were assigned to 5 groups: sham laparotomy, ovariectomy, ovariectomy-preoperative estrogen, ovariectomy-postoperative estrogen, or ovariectomy-preoperative and postoperative estrogen. Rabbits underwent sham surgery or ovariectomy and were infused with vehicle or 17beta-estradiol (200 microg/d) for 4 weeks ("preoperative" estrogen). Polypropylene mesh was implanted in the posterior vaginal wall, and rabbits were infused with vehicle or "postoperative" estrogen for an additional 8 weeks. Grafts were harvested and underwent histologic evaluation. RESULTS: Vaginal atrophy in ovariectomized rabbits was reversed by estrogen replacement. Scores for inflammation (P = .33) and neovascularization (P = .23) at the graft site were not different among estrogen replacement groups, but estrogen administration was associated with increased collagen deposition (P = .005). CONCLUSION: Estrogen replacement administered for 8 weeks postoperatively increases collagen deposition into polypropylene mesh.

Biomechanical properties of synthetic and biologic graft materials following long-term implantation in the rabbit abdomen and vagina.

OBJECTIVE: We sought to evaluate the effects of anatomic location and ovariectomy on biomechanical properties of synthetic and biologic graft materials after long-term implantation. STUDY DESIGN: A total of 35 rabbits underwent ovariectomy or sham laparotomy and were implanted with polypropylene (PP) mesh (n = 17) or cross-linked porcine dermis (PS) (n = 18) in the vagina and abdomen. Grafts were harvested 9 months later and underwent mechanical properties testing. RESULTS: After implantation, PS was similar in strength (P = .52) but was twice as stiff as PP (P = .04) and had a maximal elongation only half that of PP (P < .001). Degradation of PS was associated with decreased ultimate tensile strength (P = .03) and elastic modulus (P = .046). Vaginal PP grafts shrunk more (P < .001) and were less stiff than abdominal PP grafts (P = .049) but were not different in strength (P = .19). Ovariectomy had no effect (P > .05). CONCLUSION: Cross-linked PS undergoes long-term degradation resulting in compromised biomechanical properties and thus is likely inferior to lightweight PP meshes for pelvic organ prolapse and incontinence procedures.

Long-term histologic response to synthetic and biologic graft materials implanted in the vagina and abdomen of a rabbit model.

OBJECTIVE: We sought to evaluate the effects of graft type, site of implantation, and ovariectomy on the long-term histologic response to graft materials used in pelvic reconstructive surgery. STUDY DESIGN: In all, 45 rabbits underwent ovariectomy or sham laparotomy and were implanted with polypropylene (PP) mesh (n = 23) or cross-linked porcine dermis (PS) (n = 22) in the vagina and abdomen. Grafts were harvested 9 months later and were processed for histology to evaluate the host inflammatory response and degree of tissue incorporation within the grafts. RESULTS: Polypropylene induced a milder (P < .007), more uniform response than PS, whereas PS elicited a more variable response and degraded by 9 months. Vaginal grafts had higher scores for inflammation (P = .005) and neovascularization (P < .001), and had lower scores for fibroblastic proliferation (P < .001) than abdominal grafts. Ovariectomy had no effect (P > .05). CONCLUSION: Synthetic and biologic grafts evoke different foreign body responses, which may have implications for surgical outcomes in women.

Transverse cystocele repair with uterine preservation using native tissue.

The goals of this study were to describe the surgical procedure of the transverse cystocele repair with uterine preservation using native tissue and to examine the surgical complications and short-term anatomical outcomes of this operation. Patients who underwent transverse cystocele repair with uterine preservation at our institution were identified by retrospective chart review for the interval from January 2001 to September 2006. Sixty-nine patients were identified. Median point for first postoperative visit was 6.1 weeks (range 3-101 weeks). Average age was 66.6 +/- 13.1 years (range 33-89). Patients undergoing this procedure had no intraoperative complications and high frequency of initial anatomic success (defined as Baden-Walker halfway system grade 0 or 1 for anterior compartment) during a relatively short follow-up interval. Preoperatively, bladder grade averaged 2.6 with postoperative grade averaging 0.02. Based on our initial anatomical findings, we conclude that this surgical approach has merit for a subset of patients with adequate uterine support.

Histologic response of porcine collagen-coated and uncoated polypropylene grafts in a rabbit vagina model.

OBJECTIVE: The purpose of this study was to determine whether the host tissue response in the rabbit vagina differs for 2 synthetic graft materials that are used in pelvic reconstructive surgery. STUDY DESIGN: One strip of porcine collagen-coated or uncoated polypropylene mesh was implanted adjacent to a sham operative site into the posterior vagina of 10 New Zealand white rabbits and harvested 12 weeks later. Rabbits were assigned randomly to group 1 (coated; n = 5), group 2 (uncoated; n = 5), or group 3 (unoperated; n = 4). Full-thickness sagittal sections of posterior vaginal wall and rectum were scored for inflammation, neovascularization, and fibroblastic proliferation. RESULTS: Erosion of grafts did not occur in any animal. Coated and uncoated meshes induced a mild inflammatory response with minimal fibrosis and good host tissue incorporation within the grafts. Few apoptotic and proliferating cells were seen for both graft types. CONCLUSION: Both coated and uncoated polypropylene meshes elicit a mild foreign body reaction and minimal fibrotic response without evidence of vaginal epithelial erosion.

Rectocele repair: a randomized trial of three surgical techniques including graft augmentation.

OBJECTIVE: This study was undertaken to compare outcomes of 3 different rectocele repair techniques. STUDY DESIGN: One hundred six women with stage II or greater posterior vaginal wall prolapse were randomly assigned to either posterior colporrhaphy (n = 37), site-specific rectocele repair (n = 37), or site-specific rectocele repair augmented with a porcine small intestinal submucosa graft (Fortagen, Organogenesis, Inc, Canton, MA; n = 32). Subjects underwent a physical examination and completed 3 validated pelvic floor instruments at baseline and 6 months, 1 year, and 2 years after surgery. Anatomic failure was defined as pelvic organ prolapse quantitation system (POPQ) point Bp > or = -2 at 1 year. RESULTS: Of 106 subjects who enrolled, 105 underwent surgery and of those 105, 98 subjects returned (93%) with a mean follow-up of 17.5 +/- 7 months. After 1 year, those subjects who received graft augmentation had a significantly greater anatomic failure rate (12/26; 46%) than those who received site-specific repair alone (6/27; 22%) or posterior colporraphy (4/28; 14%), P = .02. There was a significant improvement in prolapse and colorectal scales and overall summary scores of the Pelvic Floor Distress Inventory short form 20 (PFDI-20), the Pelvic Floor Impact Questionnaire short form 7 (PFIQ-7) after surgery in all groups (P < .001 for each) with no differences between groups. The proportion of subjects with functional failures was 15% overall, and not significantly different between groups. There was no significant change in the rate of dyspareunia 1 year after surgery and there were no differences between groups. Overall sexual function as measured by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) improved significantly in all groups postoperatively (P < . 001), with no differences between groups. CONCLUSION: Posterior colporraphy and site-specific rectocele repair result in similar anatomic and functional outcomes. The addition of a porcine-derived graft does not improve anatomic outcomes. All 3 methods of rectocele repair result in significant improvements in symptoms, quality of life, and sexual function.

Recurrent pelvic organ prolapse in a woman with bladder exstrophy: a case report of surgical management and review of the literature.

Management of gynecologic issues in women with bladder exstrophy is challenging. Congenital pelvic organ prolapse and prolapse-associated pregnancy and delivery are common. The management of prolapse is complicated by the anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina. A case of recurrent pelvic organ prolapse successfully managed with a sacral colpopexy and a review of the literature are presented.

Surgical management of vaginal vault prolapse in a woman with a neovagina and pelvic kidneys.

BACKGROUND: Women with Mayer-Rokitansky-Kuster-Hauser syndrome have congenital absence of the uterus and upper two-thirds of the vagina, which is frequently accompanied by skeletal and renal anomalies. Mechanical dilation or surgical creation of a vagina allows for function but does not provide endopelvic fascial support of the vagina. Vaginal prolapse may occur. CASE: A 32-year-old woman presented with pelvic kidneys and a 5-year history of prolapse of her mechanically created neovagina. She underwent a sacrospinous ligament suspension with a cadaveric fascia lata bridge. The apex of the neovagina was 5 cm above the hymen 30 months postoperatively. CONCLUSION: An allograft colpopexy to the sacrospinous ligament is an effective method of surgical treatment of women with a prolapsed shortened vagina and an inaccessible presacral space.

The relationship of tension-free vaginal tape insertion and the vascular anatomy.

OBJECTIVE: To describe the proximity of the major vessels in the retropubic space and anterior abdominal wall to the tension-free vaginal tape needle. METHODS: Tension-free vaginal tape needles were inserted bilaterally in ten cadavers. Dissection of the superficial epigastric, inferior epigastric, external iliac, and obturator vessels was performed. Measurements from the lateral aspect of the needle to the medial edge of the vessels were recorded. In an additional cadaver, three planes were created by placing a string from the midlabia to the shoulder, mid-biceps brachii muscle, and 6 cm lateral to the mid-biceps brachii muscle of the cadaver's extended, ipsilateral arm. An operator, blinded to the retropubic space anatomy, passed the needle in these planes bilaterally. The distances from the needle to the external iliac and obturator vessels were measured. RESULTS: All vessels measured were lateral to the tension-free vaginal tape needle. The mean distance from the tension-free vaginal tape needle to the obturator vessels was the closest: 3.2 cm (range 1.6-4.3 cm). The mean distance from the tension-free vaginal tape needle to the superficial epigastric vessels was 3.9 cm (range 0.9-6.7); to the inferior epigastric vessels, 3.9 cm (range 1.9-6.6 cm); and to the external iliac vessels, 4.9 cm (range 2.9-6.2 cm). When the needle was directed 6 cm lateral to the mid-biceps brachii muscle, the external iliac vein was punctured. CONCLUSION: The major vessels in the retropubic space and anterior abdominal wall lie 0.9-6.7 cm lateral to the tension-free vaginal tape needles. If the tension-free vaginal tape needle is laterally aimed or rotated, major vascular injury can occur.

Adoption of the pelvic organ prolapse quantification system in peer-reviewed literature.

OBJECTIVE: The purpose of this study was to examine the method of describing pelvic organ prolapse in the peer-reviewed literature since the introduction of the Pelvic Organ Prolapse Quantification System (POPQ). STUDY DESIGN: Representative US and international gynecology and urology journals were selected for review. All prolapse or urinary incontinence articles published in these journals from January to December of 1999 (period 1) and July 2001 to June 2002 (period 2) were hand searched by two independent reviewers. Systems for grading the severity of pelvic organ prolapse were separated into the following categories: POPQ, Baden-Walker system, Beecham system, grade without reference, or nonstandardized system. Chi-square and Fisher exact tests were used for statistical analysis. RESULTS: A prolapse staging system was not referenced, or a nonstandardized staging system was used in 54.8% of studies. Overall, the POPQ system was the most common system used (22.6%), followed by the Baden-Walker system (19.8%). There was a statistically significant increase in the use of POPQ from period 1 (13.3%) to period 2 (28%) (P=.03). Articles published in gynecology journals were more likely to use the POPQ system than those published in urology journals (29% vs. 14%, P=.009). CONCLUSION: POPQ was the most common system used; however, the staging system was not cited or a nonstandardized staging system was used in more than half of studies.