Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To explore how permanent compared with absorbable suture affects anatomic success in native tissue vaginal suspension (uterosacral ligament suspension and sacrospinous ligament suspension) and sacrocolpopexy with mesh. DATA SOURCES: MEDLINE, EMBASE, and ClinicalTrials.gov were searched through March 29, 2022. METHODS OF STUDY SELECTION: Our population included women undergoing apical prolapse surgery (uterosacral ligament suspension and sacrospinous ligament suspension and abdominal sacrocolpopexy). Our intervention was permanent suture for apical prolapse surgery, and our comparator was absorbable suture. We determined a single anatomic success proportion per study. Adverse events collected included suture and mesh exposure, surgery for suture and mesh complication, dyspareunia, and granulation tissue. Abstracts were doubly screened, full-text articles were doubly screened, and accepted articles were doubly extracted. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. In single-arm studies using either permanent or absorbable suture, random effects meta-analyses of pooled proportions were used to assess anatomic success. In comparative studies investigating both suture types, random effects meta-analyses of pooled risk ratios were used. TABULATION, INTEGRATION, AND RESULTS: Of 4,658 abstracts screened, 398 full-text articles were assessed and 63 studies were included (24 vaginal suspension [13 uterosacral ligament suspension and 11 sacrospinous ligament suspension] and 39 sacrocolpopexy). At 2-year follow-up, there was no difference in permanent compared with absorbable suture in uterosacral ligament suspension and sacrospinous ligament suspension (proportional anatomic success rate 88% [95% CI 0.81-0.93] vs 88% [95% CI 0.82-0.92]). Similarly, at 18-month follow-up, there was no difference in permanent compared with absorbable suture in sacrocolpopexy (proportional anatomic success rate 92% [95% CI 0.88-0.95] vs 96% [95% CI 0.92-0.99]). On meta-analysis, there was no difference in relative risk (RR) of success for permanent compared with absorbable suture for uterosacral ligament suspension and sacrospinous ligament suspension (RR 1.11, 95% CI 0.93-1.33) or sacrocolpopexy (RR 1.00, 95% CI0.98-1.03). CONCLUSION: Success rates were similarly high for absorbable and permanent suture after uterosacral ligament suspension, sacrospinous ligament suspension, and sacrocolpopexy, with medium-term follow-up. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021265848.

Assessment of Level of Fear in Adult Patients Undergoing Elective Urogynecologic and Gynecologic Procedures and Surgeries During the COVID-19 Pandemic Using the Validated Surgical Fear Questionnaire.

OBJECTIVE: This study aimed to assess and trend fears surrounding elective surgery and office procedures in benign gynecologic and urogynecologic patients during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This was a multicenter, prospective, observational study. Recruitment occurred from June 23, 2020, to March 23, 2021. Females 18 years or older presenting for elective benign gynecologic or urogynecologic surgery or office procedures were eligible. Patients were excluded if non-English speaking or undergoing an emergent procedure or surgery. Fear was assessed by the Surgical Fear Questionnaire (SFQ), which was also modified to include 2-4 additional questions pertaining to COVID-19 (modified version of the Surgical Fear Questionnaire [mSFQ]). Total SFQ scores and short- and long-term fear scores were compared between procedures and surgery and to historic data. RESULTS: A total of 209 patients undergoing 107 procedures or 102 surgical procedures completed the questionnaire. Participants were separated into subgroups determined by the timing of questionnaire completion related to phases of the pandemic. The most common procedure was urodynamics (n = 59 [55%]). The most common elective surgical procedure was hysterectomy (n = 59 [57.8%]). Furthermore, 72.5% of surgical procedures were for urogynecologic indications.Fear levels were low and not different in patients undergoing procedures versus surgery (12.38 ± 12.44 vs 12.03 ± 16.01, P = 0.958). There was no difference between procedures versus surgery for short- (6.21 ± 8.38 vs 6.81 ± 8.44, P = 0.726) or long-term fear (6.18 ± 8.89 vs 5.22 ± 8.20, P = 0.683). Compared with historic data, our hysterectomy patients had less surgical fear. The mSFQ demonstrated higher fear scores for both procedures and surgery (mSFQ, 20.57 ± 20.55 for procedures; 28.78 ± 28.51 for surgery). There were no significant fluctuations in SFQ score in relation to critical COVID-19 events. CONCLUSIONS: Fear of surgery and office procedures was low and consistent throughout the COVID-19 pandemic and lower than historic data.

The Effect of Symptomatic Stress Urinary Incontinence on Catheterization Rates After Intradetrusor OnabotulinumtoxinA Injections.

OBJECTIVES: To determine whether catheterization rates after intradetrusor onabotulinumtoxinA injection for nonneurogenic overactive bladder and urgency incontinence differ between women with urgency urinary incontinence only and women with urgency-predominant mixed urinary incontinence. METHODS: This was a retrospective cohort study of patients that underwent intradetrusor onabotulinumtoxinA injection of 100 U for nonneurogenic urgency urinary incontinence. The primary outcome was the difference in catheterization rates between women with urgency urinary incontinence alone compared with women with urgency-predominant mixed urinary incontinence. Descriptive statistics and multivariate logistic regression analysis were performed. RESULTS: Of the 177 women included in the final analysis, 105 had urgency urinary incontinence and 72 had urgency-predominant mixed urinary incontinence. The overall catheterization rate after onabotulinumtoxinA injection was 11.3%, with significantly fewer women with mixed urinary incontinence requiring catheterization when compared with women with urgency urinary incontinence alone (4.2% vs 16.2%; P = 0.03), despite an older population (P = 0.02). Patient-reported improvement (P = 0.37) and decision to continue onabotulinumtoxinA treatments (P = 0.89) were similar between groups. Multivariate logistic regression analysis revealed that women with mixed urinary incontinence had significantly lower odds of requiring catheterization after onabotulinumtoxinA injections than women with urgency urinary incontinence alone (odds ratio, 0.16; 95% confidence interval, 0.04-0.67; P = 0.01). CONCLUSIONS: Findings suggest that the presence of symptomatic stress urinary incontinence is associated with lower rates of catheterization after intradetrusor onabotulinumtoxinA, but does not compromise efficacy of treatment for urgency-predominant mixed urinary incontinence.

Estimation of Urinary Frequency: Does Question Phrasing Matter?

PURPOSE: To evaluate if question phrasing and patient numeracy impact estimation of urinary frequency. MATERIALS AND METHODS: We conducted a prospective study looking at reliability of a patient interview in assessing urinary frequency. Prior to completing a voiding diary, patients estimated daytime, and nighttime frequency in 3 ways: (1) how many times they urinated (2) how many hours they waited in between urinations (3) how many times they urinated over the course of 4 hours. Numeracy was assessed using the Lipkus Numeracy Scale. RESULTS: Seventy-one patients completed the study. Correlation of estimates from questions 1, 2, and 3 to the diary were not statistically different. Prediction of nighttime frequency was better than daytime for all questions (correlation coefficients 0.751, 0.754, and 0.670 vs 0.596, 0.575, and 0.460). When compared to the diary, Question 1 underestimated (8.5 vs 9.7, P = .014) while Question 2 overestimated (11.8 vs 9.7, P = .027) recorded voids on a diary. All questions overpredicted nighttime frequency with 2.6, 2.9, and 3.9 predicted versus 1.6 recorded voids (P < .001). Although not statistically significant, for each question, the predicted frequency of numerate patients was more correlated to the diary than those of innumerate patients. CONCLUSION: When compared to a voiding diary for daytime urinary frequency, asking patients how many times they urinated underestimated, and asking patients how many hours they waited between urinations overestimated the number recorded voids. Regardless of phrasing, patients overestimated nighttime urination. Patients in our functional urology population have limited numeracy, which may impact accuracy of urinary frequency estimation.

Persistence in Percutaneous Tibial Nerve Stimulation Treatment for Overactive Bladder Syndrome is Best Predicted by Patient Global Impression of Improvement Rather Than Symptom-Specific Improvement.

OBJECTIVES: To evaluate whether progression to maintenance percutaneous tibial nerve stimulation (PTNS) was related to perceived global impression of improvement (PGII) rather than symptom-specific improvement in patient with overactive bladder (OAB). We hypothesize that PGII will predict continuation of PTNS long-term. METHODS: This prospective observational study included 90 patients with OAB that initiated PTNS. The PGII and OAB short-form questionnaires (OABq-SF) were used to assess bladder symptom severity and improvement. Those that completed the 12-week induction phase were offered to continue PTNS monthly maintenance or pursue other options. The primary outcome was difference in PGII score between those pursuing maintenance therapy versus other options. Descriptive statistics and mixed effect modeling analysis were employed. RESULTS: Seventy patients (78%) completed 12 weeks of PTNS. The majority of completers pursued monthly maintenance (P< .01) and had significantly lower median PGII scores compared with those who sought alternatives (P < .01), while OABq-SF scores did not differ significantly (P = .65). Patients that pursued monthly PTNS maintenance had lower body mass index than those who chose alternative therapies (P < .01). Only 19% continued PTNS therapy for at least 1 year. CONCLUSION: More patients pursued PTNS monthly maintenance over any other therapy, and this was significantly associated with lower PGII scores. Global improvement, and not symptom-specific response, predicts long-term PTNS maintenance. No symptom-specific predictors were identified in those who pursued maintenance over other options. One-year continuation rates are low.

The impact of concomitant mid-urethral sling surgery on patients undergoing vaginal prolapse repair.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess whether mid-urethral sling (MUS) placement at the time of vaginal prolapse repair compared to vaginal prolapse repair alone is associated with an increase in 30-day postoperative complications. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Database, Current Procedural Terminology codes were used to identify cases of vaginal prolapse repair with and without concomitant MUS from 2012 to 2017. Student's t-test and chi-square test were used to compare differences between the groups. RESULTS: A total of 1469 cases of vaginal prolapse repair with sling were compared to 4566 cases without sling. There was no difference between prolapse repair with sling compared to without sling in mean hospital length of stay (LOS) (1.42 versus 1.32 days, p = 0.65), postoperative urinary tract infection (UTI) (6.1% versus 5.8%, p = 0.670), perioperative blood transfusion (1.1% versus 1.2%, p = 0.673), readmission (2.7% versus 2.6%, p = 0.884) and postoperative wound infection (0.5% versus 0.7%, p = 0.51). There was a higher rate of reoperation (2.2% versus 1.5%, p = 0.049) and venous thromboembolism (VTE) (0.4% versus 0.1%, p = 0.030) in patients undergoing concomitant MUS compared to those undergoing prolapse repair alone. CONCLUSIONS: Compared to prolapse repair alone, the addition of a sling did not increase hospital LOS, UTI, perioperative blood transfusions, readmission or postoperative wound infections. However, concomitant sling was found to be associated with a higher risk of reoperation and VTE.

Venous thromboembolism prophylaxis in vaginal surgery for pelvic organ prolapse: Predictors of high risk in a low-risk population.

AIM: Venous thromboembolism (VTE) rates in vaginal pelvic organ prolapse (POP) repair are low. Our aim is to evaluate specific risk factors for VTE in patients undergoing vaginal POP repair. METHODS: This is a cross-sectional study using the American College of Surgeons NSQIP database. Using CPT codes, cases of vaginal POP repair between 2014 and 2017 were identified. Patient and operative characteristics were collected. VTE was defined as pulmonary embolism (PE) or deep vein thrombosis (DVT) within 30 days from surgery. Univariate analyses were performed using the Student t test for continuous and χ2  tests for categorical variables. Multivariate logistic regression was performed to identify factors independently associated with VTE. RESULTS: Of 44 207 women who underwent vaginal POP repair, there were 69 cases of VTE (0.16%). VTE rates for obliterative (0.15%) and functional (0.16%) vaginal POP repair, as well as for repairs with hysterectomy (0.17%) and without hysterectomy (0.12%) were not significantly different (p = .616 and .216, respectively). Multivariate analysis demonstrated predictors for postoperative VTE to be ASA physical status classification ≥ 3 (aOR, 1.99; p = .014), length of stay >75th percentile (aOR, 2.01; p = .007), operative time >3 h (aOR, 2.24; p = .007), and dyspnea (aOR, 3.26, p = .004). CONCLUSION: Despite the low incidence of VTE after vaginal POP repair, patients with ASA physical status classification ≥ 3, length of stay >75th percentile, operative time >3 h, and dyspnea were at higher risk for VTE. Vaginal POP repair may have independent VTE risk factors not captured in standard risk assessment tools.

Mirabegron Versus Solifenacin in Multiple Sclerosis Patients With Overactive Bladder Symptoms: A Prospective Comparative Nonrandomized Study.

OBJECTIVE: To determine the patient-perceived effectiveness and tolerability of mirabegron compared to solifenacin in a multiple sclerosis (MS) population with overactive bladder (OAB) symptoms. MATERIALS AND METHODS: MS patients with OAB symptoms who were not on medication for their urinary symptoms at enrollment were prospectively recruited. Patients enrolled in years 1-2 were prescribed mirabegron, whereas patients enrolled in years 3-4 were prescribed solifenacin. At enrollment and 6-week follow-up, patients completed several patient reported outcome measures. The primary outcome was change in OAB Questionnaire Short Form (OAB-q SF) symptom severity and minimal clinically important difference (MCID) achievement. The Patient Assessment of Constipation Symptoms (PAC-SYM) was used to assess bowel function over the treatment period. RESULTS: Sixty-one patients were enrolled. The majority of the mirabegron (70%) and the solifenacin (69%) group achieved the OAB-q SF symptom severity MCID. The solifenacin group had a statistically significant greater decrease in its end of study OAB-q SF score (Δ = -37.87 vs -20.43, P = .02). Constipation improved in the mirabegron group and worsened in the solifenacin group (ΔPAC-SYM = -0.38 vs +0.22; P = .02), with 30% of patients prescribed solifenacin experiencing worsening above the MCID threshold. CONCLUSION: Among MS patients, we demonstrated similar response rates to mirabegron and solifenacin, with approximately 50%-70% achieving each patient reported outcome measure's MCID. Though this small study showed some short-term evidence that improvement in urinary symptom severity was greater with solifenacin, this potential benefit must be weighed against the observed risk of worsening constipation. Further studies are needed to confirm these findings.

Prolapse repair in the elderly patient: contemporary trends and 30-day perioperative complications.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse is common and increases with age. Although conservative options exist for management, surgery remains a mainstay of treatment. Understanding how surgical repair affects the elderly is increasingly important as the population ages. We set out to describe current treatment patterns for prolapse repair in the elderly. Our main goal was to compare perioperative morbidity and mortality for elderly patients who undergo surgical repair of pelvic organ prolapse with colpocleisis, vaginal repair or sacrocolpopexy. METHODS: Women 75 years and older who underwent prolapse repair from 2014 to 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using Current Procedural Terminology (CPT) codes for colpocleisis, vaginal prolapse repair, and abdominal sacrocolpopexy. Variables including demographics, comorbidities, concomitant hysterectomy or stress urinary incontinence procedure, hospital length of stay, morbidity, and mortality were evaluated. A regression model was used to analyze risk factors for perioperative complications. RESULTS: We identified 764 women who underwent prolapse repair. The largest proportion of patients (334, 43.7%) underwent transvaginal repair, closely followed by colpocleisis (323, 42.3%), and the remainder (107, 14%) sacrocolpopexy. Older age and higher ASA class were significantly associated with colpocleisis (p < 0.001, p = 0.03). No difference was observed in complications across the three approaches, but length of stay was shorter (1.2 days vs 1.7 days, p = 0.03) for colpocleisis. CONCLUSIONS: In current practice, patients undergoing colpocleisis compared with transvaginal repair or sacrocolpopexy are older with more comorbidities. Despite this, length of stay remains shorter for these patients and complications rates equivalent.

Gel-Infused Translabial Ultrasound in the Evaluation of Female Urethral Stricture.

OBJECTIVES: The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques. METHODS: Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison. RESULTS: Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis. CONCLUSIONS: Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.

Rectus Fascia Versus Fascia Lata for Autologous Fascial Pubovaginal Sling: A Single-Center Comparison of Perioperative and Functional Outcomes.

OBJECTIVE: To compare perioperative and functional outcomes of autologous fascia lata versus rectus fascia pubovaginal sling in female patients with stress urinary incontinence (SUI). METHODS: The charts of all patients undergoing pubovaginal sling for SUI from 2012 to 2017 at a single center were retrospectively reviewed. Patients were divided into 2 groups: those with the sling harvested from the fascia lata (FL group) and those with the sling harvested from the rectus fascia (RF group). RESULTS: Between 2012 and 2017, 105 women underwent pubovaginal slings: 21 using FL and 84 using RF. Operative time did not differ significantly between the FL and RF groups (84 vs 81.9 minutes; P=0.68). Estimated blood loss was lower in the FL group (91.7 vs 141.6 mL; P=0.04). There were more wound complications in the RF group, although this was not statistically significant (0% vs 14.3%; P=0.12). Overall complications were comparable between FL and RF groups (52.4% vs 48.9%; P=0.81), but the proportion of Clavien grade 2 or greater were higher in the RF group (4.8% vs 20.2%; P=0.11). Overall, wound complications accounted for 29.3% of postoperative complications in the RF group (12/41). Functional outcomes were comparable between FL and RF groups, with similar rates of patients without SUI symptoms after 1 month (82.4% vs 76.4%; P=0.74), 1 year (55.6% vs 63.8%; P=0.76), and at the latest follow-up (66.7% vs 65.8%; P=0.87). CONCLUSIONS: When compared with rectus fascia for pubovaginal sling, fascia lata may decrease perioperative morbidity, especially wound complications, without compromising functional outcomes.

Radiation exposure during videourodynamic testing: Is dose reduction possible using a standardized protocol?

AIMS: To evaluate the impact of a protocol for standardized image capture during video urodynamics (VUD) on radiation exposure. Secondly, to categorize radiation exposure by condition warranting VUD and to identify clinical variables that correlate with increased radiation exposure. METHODS: One hundred fifty patients underwent VUD using our standardized protocol. All images were taken using low dose and pulsed settings. Four images are captured: one scout image, one filling image, one voiding image, and one post-void image. If the patient is unable to void with the catheter in place, the catheter is removed and a second image is taken during an attempt at unintubated flow. If vesicoureteral reflux (VUR) is identified, an alternate protocol is entered to document parameters. The mean radiation exposure measured in dose area product (DAP), fluoroscopy time, and number of images were noted and compared with previously published fluoroscopy data collected at our institution before protocol implementation. RESULTS: The mean fluoroscopy exposure after the implementation of our protocol was 273.5 mGy/cm2 taking 5.2 images in 4.5 seconds. Protocol implementation leads to a 51.2% reduction in radiation exposure calculated by mean DAP (P < .0001) and a 96.5% reduction in fluoroscopy time (P < .0001). The presence of VUR, fluoroscopy time, and body mass index (BMI) > 25 were associated with higher radiation exposure (P < .0001). CONCLUSION: Implementation and adherence to a standardized protocol for fluoroscopy led to a reduction in radiation exposure fluoroscopy time. The presence of VUR, fluoroscopy time, and BMI > 25 were associated with higher radiation exposure.

Nocturia in female patients: Current clinical features, treatment patterns and outcomes at a tertiary referral centre.

Objective: To report the current clinical features, treatment patterns and outcomes of female patients who were seen at a tertiary referral centre with a primary diagnosis of nocturia, and to assess the predictive factors of therapeutic management failure. Patients and methods: A retrospective chart review of all new female patients seen in a single-centre functional urology practice with the diagnosis of nocturia was performed. Up to three visits within a 12-month period from the time of presenting were reviewed. The primary endpoint was patient-reported improvement assessed at each follow-up visit and the change in the number of nocturia episodes. Results: In all, 239 female patients were included for analysis. The prevalence of nocturnal polyuria, reduced bladder capacity, and global polyuria were 75%, 40.2%, and 18.1%, respectively. Within the first two visits, 72.7% of patients had started a treatment beyond behavioural therapies. Anticholinergics were the most commonly initiated treatment (47.2% of patients). At the latest considered visit, 80 patients reported improvement in nocturia (45.5%) and there was a mean - 0.8 decrease in the number of nocturia episodes from 4 to 3.2, which was statistically significant (P < 0.001). There was no statistically significant association between any of the bladder diary findings and treatment outcomes. A smaller number of nocturia episodes was the only predictive factor of therapeutic management failure in multivariate analysis (odds ratio 0.10; P = 0.01). Conclusions: Whilst the prevalence of nocturnal polyuria in women with nocturia is high, the therapeutic management until 2016 seemed to rely mostly upon overactive bladder medications with a relatively low success rate. Abbreviations: BD: bladder diary; BPS: bladder pain syndrome; ICD(-9)-(10): International Classifications of Disease (ninth revision) (10th revision); NPI: Nocturnal Polyuria Index; OAB: overactive bladder; OR: odd ratio; POP: pelvic organ prolapse.