Racial and Ethnic Disparities in Sacrocolpopexy Approach.

IMPORTANCE: Racial inequity elevates risk for certain diagnoses and health disparities. Current data show disparities for Black women when comparing open versus minimally invasive hysterectomy. It is unknown if a similar disparity exists in surgical management of pelvic organ prolapse. OBJECTIVE: The objective of this study was to determine whether racial or ethnic disparities exist for open abdominal versus minimally invasive sacrocolpopexy. STUDY DESIGN: Cross-sectional data of the Healthcare Cost and Utilization Project National Inpatient Sample and the Nationwide Ambulatory Surgery Sample for the year 2019 was used. Bivariate analysis identified demographic and perioperative differences between abdominal versus minimally invasive sacrocolpopexy, which were compared in a multivariable logistic regression. RESULTS: Forty-one thousand eight hundred thirty-seven patients underwent sacrocolpopexy: 35,820 (85.6%), minimally invasive sacrocolpopexy, and 6,016, (14.4%) abdominal sacrocolpopexy. In an unadjusted analysis, Black patients were more likely to undergo an abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 2.14, 95% CI 1.16-3.92, P <0.01). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 1.69, 95% CI 1.26-2.26, P <0.001). Other factors associated with abdominal sacrocolpopexy are zip code quartile, payer status, composite comorbidity score, hospital control, and hospital bed size. In the regression model, Black patients remained more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 2, 95% CI 1.26-3.16, P < 0.003). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 1.73, 95% CI 1.31-2.28, P < 0.001). CONCLUSION: Abdominal sacrocolpopexy was more likely to occur in patients who identified as Black or Hispanic.

Understanding the Pursuit of Third-Line Therapies for Overactive Bladder: A Mixed Methods Study.

IMPORTANCE: Overactive bladder (OAB) affects millions of women in the United States, with negative effects in multiple domains that have an impact on quality of life. Third-line therapies for OAB are as effective or superior to lifestyle/behavior modification and medical management, yet few women access these treatments and often spend more than 36 months to reach these treatments after starting medication. Factors associated with time to reach third-line therapy are not well studied, and little is known about how patients progress through care pathways for OAB. OBJECTIVES: The aim of the study was to determine factors associated with the time spent between second- and third-line therapy for OAB at an academic urogynecology and reconstructive pelvic surgery practice. We sought to identify demographic, treatment, clinical factors, and themes in barriers to receiving treatment for OAB. STUDY DESIGN: This was a mixed methods study consisting of a retrospective cohort study followed by qualitative key informant interviews. RESULTS: Eighty-five total participants were included in the analysis, and 42 (49.5%) spent more than 36 months between initiation of medical management and initial third-line therapy for OAB. No significant (P > 0.05) demographic, clinical, or treatment differences were found between groups. Facilitators and obstacles to receiving third-line therapy were identified among key informants, and a treatment decision framework was developed. CONCLUSIONS: Women often spend more than 36 months to pursue third-line therapy for OAB. Existing objective variables are poor predictors of pursuit of third-line treatment, and leveraging known facilitators and obstacles can be used to develop improved care pathways for OAB.

When to Remove the Indwelling Catheter After Minimally Invasive Sacrocolpopexy? CARESS (CAtheter REmoval after Sacrocolpopexy Surgery).

OBJECTIVE: The aim of the study was to determine the best practice guidelines regarding the use of indwelling catheters after minimally invasive sacrocolpopexy. METHODS: Multicenter (3 sites) randomized control trial comparing the standard overnight indwelling urethral catheterization (group 2) with removal of catheter immediately after surgery (group 1). Our primary outcome is the need for recatheterization. Secondary outcomes include the number of patients discharged with a catheter, length of hospital stay, number of urinary tract infections, patient satisfaction/pain scores, and whether patients would use the same treatment again. RESULTS: There were 32 patients (43.8%) in group 1 and 41 patients (56.2%) in group 2. On average, patients in group 1 required straight catheterization 0.8 (SD = 0.9) times versus 0.6 (SD = 0.9) times for group 2 (P = 0.239). The number of days with a catheter between the 2 groups was not statistically significant. There was no statistical significance between group 1 and group 2 in terms of operative time, times to leave the operating room, and hospital. Zero patients in group 1 and 2 patients in group 2 had a urinary tract infection. After dividing the groups based on whether or not they underwent a transvaginal tape procedure, the final results were similar. CONCLUSIONS: We did not observe a difference in the risk of recatheterization or discharge home with a urinary catheter between the 2 groups. Addition of transvaginal tape to sacrocolpopexy did not show a difference in the risk of recatheterization. One reason for the lack of difference between the 2 groups could be due to a lack of power in our study.

Anatomical Outcomes Based on Suturing Technique During Vaginal Mesh Attachment in Robotic Sacrocolpopexy.

OBJECTIVES: In this study, we assessed the difference in anatomical outcomes using the barbed, self-anchoring, delayed absorbable suture when compared with the traditional knot-tying interrupted suture technique during vaginal mesh attachment in robotic sacrocolpopexy. In addition, we compared the rates of mesh erosion with the 2 techniques. METHODS: This is a retrospective cohort study of 131 women who underwent minimally invasive robotic sacrocolpopexy at 2 sites. There were 65 subjects at site 1 (barbed, self-anchoring, delayed absorbable suture) and 66 from site 2 (traditional knot-tying technique). The primary outcome was anatomical success (measured by all Pelvic Organ Prolapse Quantification System points <0 postsurgery) in the barbed suture technique at site 1 compared with the traditional knot-tying technique at site 2. The secondary outcome was mesh erosion rates at these sites. RESULTS: In the barbed suture group, performed at site 1, 98% (n = 59/60) had postoperative success at the 3-month follow-up period compared with 62% (n = 40/65) in the traditional knot-tying group at site 2 during the 12-month postoperative follow-up (P < 0.0001). During this time period, 2% (n = 1) in the barbed suture group and 8% (n = 5) in the traditional knot-tying group experienced sacrocolpopexy mesh erosion (P = 0.208). CONCLUSIONS: Our results indicate that the barbed, self-anchoring, delayed absorbable suture is associated with less anatomical failures compared with traditional knot tying. The use of barbed suture is a safe technique and can be adopted in place of the traditional knot-tying technique. We also found less mesh erosion in the barbed suture group.

Comparing 3-Dimensional Ultrasound to 3-Dimensional Magnetic Resonance Imaging in the Detection of Levator Ani Defects.

OBJECTIVE: The aim of this study was to compare the detection of levator ani defects (LAD) between 3-dimensional (3D) ultrasound (US) and 3D magnetic resonance imaging (MRI). METHODS: This is a secondary analysis of the Pelvic Floor Nerve Injury Following Childbirth Study. Nulliparous women underwent a standardized protocol of pelvic floor evaluations between January 2008 and December 2013, prior to pregnancy (V1) and at 2 points postpartum: 6 weeks (V2) and 6 months (V3). Those women who underwent a high-resolution 3D MRI pelvic floor sequence were selected. Comparisons were made to concomitantly acquired 3D perineal US. Eight tomographic slices were examined in the axial plane, each side independently scored with 0 (no defect) or 1 (defect). A similar tomographic approach was applied to the MRI. For both MRI and US, the right and left sides were each scored. A total score of 0 to 8 was given to each side. A dichotomous variable "complete LAD" was defined. Cohen κ was used as a measurement of agreement of complete LAD between MRI and US. Kendall τ b was used to correlate total scores. RESULTS: On the right side, 80 (90%) of 89 pairs were in agreement (concordant in the diagnosis or not of a "defect"). On the left side, 72 (81%) of 89 pairs were in agreement. Correlations (Cohen κ) of complete LAD were 0.65 (P < 0.001) on the right and 0.37 (P < 0.001) on the left. Correlations of total scores were 0.47 (P < 0.001) on the right and 0.41 (P < 0.001) on the left. CONCLUSIONS: Moderate agreement was found between 3D US and 3D MRI LAD detection. More LADs and discordance were seen on the left.

Effect of sacrocolpopexy and retropubic sling on overactive bladder symptoms.

OBJECTIVE: In this study, we aimed to evaluate the effect of sacrocolpopexy and retropubic midurethral sling, or transvaginal tape (TVT) procedure, on overactive bladder (OAB) symptoms. Our null hypothesis was that concomitant sacrocolpopexy and TVT exacerbate OAB symptoms. MATERIAL AND METHODS: This is a prospective cohort study. All subjects had apical/anterior prolapse and underwent robotic-assisted sacrocolpopexy and TVT, with or without concomitant hysterectomy. All subjects completed a standardized one-year follow-up between 2009 and 2014. To assess for OAB symptoms, we used the Urogenital Distress Inventory subscale questions #15 and/or question #16. Reponses to these questions are based on a five-point 0 to 4 Likert scale (0 represents a negative response or no symptoms, and 4 represents the most problems). Any patient who answered 1 or higher on the Likert scale, either on the frequency or urge incontinence question, was defined as having OAB symptoms. RESULTS: Sixty-six subjects completed 12 months of visits. Preoperatively, 54 patients (83%) had OAB symptoms, and postoperatively 29 patients (45%) had OAB symptoms (p<0.001). Patients with postoperative OAB had a lower patient global impression of improvement (PGI-I) scores, PGI-I 5.8 with OAB, and PGI-I 6.6 without OAB (p<0.003). CONCLUSION: We found that sacrocolpopexy and concomitant retropubic midurethral sling does not contribute to additive OAB symptoms, and symptoms actually resolved in 38% of women in our cohort. The presence of postoperative OAB contributes to lower global impression of improvement.

Preoperative Prolapse Stage as Predictor of Failure of Sacrocolpopexy.

OBJECTIVES: Our aim was to determine if there was a correlation between the preoperative prolapse stage and postoperative recurrence of prolapse 1 year after sacrocolpopexy. Our null hypothesis is that the preoperative stage of prolapse does not increase the risk of recurrence. METHODS: This is a multicenter cohort study from 3 centers. We included subjects who underwent robotic-assisted sacrocolpopexy and completed a standardized 1-year follow-up from 2009-2014. All subjects underwent a complete preoperative evaluation and completed 12 months of follow-up with the pelvic organ prolapse quantification examination. We compared those subjects who met the definition of recurrence with those who did not, analyzing the following covariates: stage of prolapse using International Continence Society (ICS) definitions, individual pelvic organ prolapse quantification points, age, body mass index, race, exogenous estrogen use, menopause, smoking, vaginal parity, cesarean section, and performance of concomitant procedures. We defined recurrence as any prolapse beyond the hymen. RESULTS: We had 125 women from 3 centers who met our criteria, with 23.2% of them having recurrence at 1 year. We found that recurrence increased as the preoperative ICS stage of prolapse increased (P = <0.001 in the univariate model). In the multivariate model, using logistic regression, we found that the risk of recurrence of pelvic organ prolapse increased as the presurgery clinical stage increased with an odds ratio of 3.8 (95% confidence interval, 1.5-9) when controlling for age, menopausal status, and genital hiatus (P = 0.004). CONCLUSIONS: Much like a higher stage of disease in oncology, we found that increasing stage of prolapse preoperatively increased the risk of recurrence at 1 year after sacrocolpopexy.

Tension-Free Vaginal Tape Failure After Robotic Sacrocolpopexy and Tension-Free Vaginal Tape for Concomitant Prolapse and Stress Incontinence.

OBJECTIVE: Evidence of surgical cure with tension free vaginal tape (TVT) is robust for isolated stress urinary incontinence, but rigorous studies investigating combined prolapse and incontinence are lacking. Our study measured cure of stress incontinence in concomitant robotic sacrocolpopexy and retropubic sling (TVT). We hypothesized a higher rate of objective failure as measured by the cough stress test (CST) compared to failures reported in recent randomized trials of TVT in patients without prolapse (aggregate 8% failure). METHODS: Prospective cohort of patients with stress incontinence and prolapse, scheduled for robotic sacrocolpopexy and TVT. Outcomes assessed at 12 months: CST (primary aim), Patient Global Impression of Improvement (PGI-I), Pelvic Floor Distress Inventory, and the Sandvik questionnaire. RESULTS: Sixty-six of 77 subjects (86%) completed follow-up. Average age was 65 years, 96% were white, with mean body mass index of 28.1 kg/m2. Mean parity was 2.7, 50% had a previous hysterectomy. Mean leading edge of prolapse was +2.3 cm. All patients underwent the planned surgery; additionally, 50% underwent hysterectomy and 38% posterior colporrhaphy.The TVT failure (+CST) was 19.7% (95% confidence interval, 11.3%-31.7%; P < 0.001 compared to 8%). Neither preoperative disease severity, nor preoperative prolapse stage affected risk of failure of TVT. Eighty-three percent of the subjects were happy or very happy (PGI-I). However, those with a positive CST (failure) had significantly less satisfaction on PGI-I, UDI-6, and Pelvic Floor Distress Inventory-20. CONCLUSIONS: In this population with advanced prolapse, cure of stress urinary incontinence by TVT in setting of robotic sacrocolpopexy is lower compared to published trials where prolapse is absent. Women are less satisfied when the postoperative CST is positive.

Differences in recurrent prolapse at 1 year after total vs supracervical hysterectomy and robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Optimal management of the cervix at the time of hysterectomy and sacrocolpopexy for primary uterovaginal prolapse is unknown. Our hypothesis was that recurrent prolapse at 1 year would be more likely after a supracervical robotic hysterectomy (SRH) compared with a total robotic hysterectomy (TRH) at the time of robotic sacrocolpopexy (RSCP) for uterovaginal prolapse. METHODS: This was a retrospective cohort analysis of 83 women who underwent hysterectomy with RSCP over a 24-month period (40 with TRH and 43 with SRH). At 1 year post-procedure, subjects completed validated questionnaires regarding pelvic floor symptoms, sexual function, and global satisfaction, and underwent a pelvic examination to identify mesh exposure and evaluate pelvic floor support. RESULTS: Demographics of the two groups were similar, except for a higher mean body mass index in the TRH group (31.9 TRH vs 25.8 SRH kg/m(2), p < 0.001). The rate of recurrent prolapse ≥ stage II was higher for women who underwent SRH compared with TRH (41.9 % vs 20.0 %, p = 0.03; OR 2.8, 95 % CI, 1.07-7.7). However, when this was analyzed as recurrence ≥ hymen, there was no difference between groups (12.5 % TRH vs 18.6 % SRH, p = 0.45). Likewise, there was no difference between groups when a composite measure of success was used (30 out of 40 [75 %] TRH vs 29 out of 43 [67.4 %] SRH, p = 0.45). CONCLUSIONS: Women who underwent an SRH were 2.8 times more likely to have a recurrent prolapse, ≥ stage II, at 1 year, compared with those who underwent a TRH, but when composite assessment scores were used there was no difference between the groups.

Does fibromyalgia influence symptom bother from pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS: Determine if women with fibromyalgia report increased bother from pelvic organ prolapse compared with women without fibromyalgia. METHODS: We performed a cross-sectional study of women with symptomatic prolapse on consultation with a private urogynecology practice within a 46-month period. After matching for age, women with a diagnosis of fibromyalgia were compared with a reference group of women without fibromyalgia. Demographic, POPQ examination, medical history, and pelvic floor symptom data (PFDI, PFIQ, and PISQ-12) were collected. Our primary outcome was to compare the mean Pelvic Floor Distress Inventory (PFDI) scores of women with and without fibromyalgia. RESULTS: The prevalence of fibromyalgia in women evaluated for initial urogynecology consultation during the study period was 114 out of 1,113 (7%). Women with fibromyalgia reported significantly higher symptom bother scores related to pelvic organ prolapse, defecatory dysfunction, urinary symptoms, and sexual function: PFDI (p = 0.005), PFIQ (p=0.010), and PISQ (p=0.018). Women with fibromyalgia were found to have a higher BMI (p=0.008) and were more likely to report a history of sexual abuse, OR 3.1 (95 % CI 1.3, 7.9), and have levator myalgia on examination, OR 3.8 (95% CI 1.5, 9.1). In a linear regression analysis, levator myalgia was found to be the significant factor associated with pelvic floor symptom bother. CONCLUSIONS: In women with symptomatic prolapse, fibromyalgia is associated with an increased risk of levator myalgia and 50% more symptom bother from pelvic floor disorders.

Levator myalgia: why bother?

INTRODUCTION AND HYPOTHESIS: We report the prevalence of levator myalgia (LM) and describe symptom bother and comorbidities associated with this examination finding. METHODS: We performed a cross-sectional study of patients referred to urogynecology practices: a private practice (COMM) and a tertiary university-based practice (UNIV). We identified within our population a subset of patients with LM and a reference group without LM. The primary outcome was to report the prevalence of LM within a urogynecology referral population. Our secondary outcomes include mean Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) scores, medication use, medical co-morbidities, and presence of vulvodynia. RESULTS: The prevalence of LM was 24% at the UNIV detected on 5,618 examinations and 9% at the COMM based on 946 examinations. Women with LM were significantly younger: mean age 56.8 years vs 65.5 (p < 0.001). There was no difference in mean parity (2.3), BMI (28.2 kg/m(2)), and race (94% white). Patients with LM reported significantly higher mean symptom bother scores (PFDI, PFIQ; p = <0. 001) related to prolapse, defecatory dysfunction, and urinary symptoms. Women with LM were more likely to report a diagnosis of fibromyalgia (OR 4.4 [1.7, 11.0]), depression (OR 1.8 [1.2, 2.7]), a history of sexual abuse (OR 2.4 [1.3, 4.7]), and use narcotic pain medications (OR 2.5 [1.2, 5.2]). CONCLUSIONS: Levator myalgia is a prevalent condition in urogynecology practice, and is associated with approximately 50% greater bother in urinary, defecatory, and prolapse symptoms.

Blinded measure of Trendelenburg angle in pelvic robotic surgery.

STUDY OBJECTIVE: To estimate the Trendelenburg angle needed to perform robotic gynecologic surgical procedures. DESIGN: Cross-sectional study (Canadian Task Force classification III). SETTING: Community hospital. PATIENTS: All women undergoing gynecologic pelvic surgery using the da Vinci surgical robot at a single institution between December 2010 and April 2011. INTERVENTIONS: The primary surgeon determined the Trendelenburg angle needed for adequate visualization to perform surgery defined as small bowel and sigmoid colon displaced out of the surgical field. MEASUREMENTS AND MAIN RESULTS: The primary outcome, measured in blinded fashion, was the degree of Trendelenburg positioning needed to complete the surgical procedure robotically. Secondary data collected included body mass index, type of surgery performed, maximum end-tidal CO(2), and maximum peak inspiratory pressure. Sixteen surgeons performed a total of 104 robotic gynecologic pelvic surgeries during the study. Data were available for 86 cases. The mean Trendelenburg angle used was 28.0 degrees (95% confidence interval, 26.9-29.1). This was significantly less than the 40 degrees (p < .001) commonly recommended. The Trendelenburg angle used did not correlate with body mass index (r = -0.2; p = .13) or type of surgery performed (p = .41). Neither the maximum end-tidal CO(2) or maximum peak inspiratory pressure was influenced by the Trendelenburg angle used when adjusted for age and body mass index. CONCLUSIONS: A mean Trendelenburg angle of 28.0 degrees was adequate to complete most gynecologic robotic surgical procedures when compared with historical control angle of 40 degrees.

Robotic surgical staging for obese patients with endometrial cancer.

OBJECTIVE: To compare surgical outcomes for robotic vs laparotomy staging in obese endometrial cancer patients. STUDY DESIGN: This was a retrospective cohort study of patients with body mass index ≥30 kg/m(2) staged in a community gynecologic oncology practice. Patients undergoing robotic staging were compared with historic laparotomy controls. RESULTS: One hundred twenty-nine patients underwent robotic staging, compared with 110 laparotomy patients. The robotic cohort had fewer abdominal wound complications (13.9% vs 32.7%, P < .001), but more vaginal cuff complications (4.7% vs 0%, P = .032). Blood loss was lower in the robotic group (P < .001), as was length of stay (P < .001). Surgical times were longer in the robotic group (P < .001). There was no difference in terms of percentage of patients undergoing pelvic or paraaortic lymph node dissection. CONCLUSION: Robotic staging for endometrial cancer is feasible in obese women, with fewer abdominal wound complications, but more vaginal cuff complications.

Mesh erosion in robotic sacrocolpopexy.

OBJECTIVE: This study aimed to compare the incidence of mesh erosion after robotic sacrocolpopexy between women undergoing total and those undergoing supracervical hysterectomy (SH). METHODS: This is a retrospective cohort study of women who underwent sacrocolpopexy and concomitant hysterectomy using the DaVinci surgical robot between May 2007 and December 2010 at 2 sites. Baseline data were gathered before surgery. The primary outcome was mesh erosion identified during 3 months of follow-up. RESULTS: A total of 102 women underwent sacrocolpopexy, of whom 45 were with concomitant SH and 57 were with total hysterectomy (TH). Their mean age was 58 years, mean body mass index was 26.8 kg/m, 98% were white, 6% smoked, and 25% were on systemic hormone replacement therapy. Mean preoperative Ba = +1.4, C = -2.2. These were not different between the 2 groups or by site. Within 3 months of surgery, mesh erosion was diagnosed in 8 women, all of whom had TH. No mesh erosions occurred in the SH group (14% vs 0%). Total hysterectomy mesh erosion rate at site 1 was 37% compared with 3% [corrected] at site 2. Mesh type was the only identifiable difference between sites: self-cut polypropylene at site 1, precut polypropylene at site 2. Two women in the SH had abnormal uterine pathology: 1 endometrial adenocarcinoma and 1 focus of hyperplasia with atypia. CONCLUSIONS: No mesh erosions were associated with SH within the first 3 months. In TH, the graft material used may be a modifiable factor needing further investigation. Unexpected abnormal uterine pathologic diagnosis remains a possibility with SH. Longer-term follow-up and a randomized trial are warranted to answer these questions.