The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training.

IMPORTANCE: The impact of preoperative pain on outcomes can guide counseling. OBJECTIVE: The objective of this study was to compare outcomes after vaginal reconstructive surgery and pelvic muscle training between women with and without preoperative pain. STUDY DESIGN: This is a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial, which randomized patients to a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (pelvic floor muscle training vs usual care). Preoperative pain was defined as a response of "5" or greater on the pain scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question "Do you usually experience pain in the lower abdomen or genital area?" RESULTS: The OPTIMAL trial included 109 women with preoperative pain and 259 without pain. Although women with pain had worse pain scores and pelvic floor symptoms at baseline and postoperatively, they had greater improvement on pain scores (-2.3 ± 2.4 vs -0.2 ± 1.4, P < 0.001), as well as Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores. Among women with pain who underwent a sacrospinous ligament fixation, those who received pelvic floor muscle training had a greater reduction in pain compared with those in the usual care group (-3.0 ± 2.3 vs -1.3 ± 2.1, P = 0.008). Persistent or worsening pain was present at 24 months in 5 (16%) women with preoperative pain. CONCLUSIONS: Women with preoperative pain experience significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery. Pelvic floor muscle training perioperatively may be beneficial for select patients.

Host inflammatory response in women with vaginal epithelial abnormalities after pessary use.

BACKGROUND: Vaginal epithelial abnormalities (VEA) are a common complication associated with pessary use. The objective of this study was to determine if there is a host pro-inflammatory response associated with pessary use and VEA. METHODS: Patients wearing pessaries for at least two weeks for the management of pelvic organ prolapse and/or urinary incontinence were screened for eligibility. Vaginal swabs were collected from women with VEA (cases) and without VEA (controls). Cases were matched to controls in a 1:3 ratio. Cytokine analysis of the collected samples was performed using multiplex analysis to determine the concentrations of interleukin (IL)6, interferon alpha 2 (IFNα2), tumor necrosis factor alpha (TNFα) and IL1ß. A cross-sectional analysis was performed, comparing vaginal cytokine concentrations in women with and without VEA. RESULTS: We enrolled 211 patients in this analysis: 50 cases and 161 controls. The median concentrations (pg/mL) of the four cytokines for cases and controls respectively were; IL6: 6.7 (IQR <2.9 [the lower limit of detection, LLD]-14.2) and < 2.9 (LLD) (IQR <2.9 [LLD]-5.5), IFNα2: 8.2 (IQR 6.1-13.9) and 7.9 (IQR 3.9-13.6), TNFα: 15.2 (IQR 6.1-30.4) and 4.68 (IQR <2.3 [LLD]-16.3), IL1ß 195.7 (IQR 54.5-388.6) and 38.5 (IQR 6.7-154.9). The differences in median cytokine levels were statistically higher in cases for IL6, TNFα, and IL1ß (all p < 0.001) compared to controls. Older age (OR: 1.062, 95% CI, 1.015-1.112), lower BMI (OR: 0.910, 95% CI, 0.839-0.986) and presence of VEA at last check (OR: 5.377, 95% CI, 2.049-14.108) were associated with higher odds of having VEA on multivariate analysis. CONCLUSION: Pro-inflammatory cytokines, specifically IL6, TNFα, and IL1ß, are elevated in pessary-wearing patients who have VEA. Additional prospective studies are needed to assess baseline vaginal inflammatory profiles before and after pessary placement to understand VEA formation in pessary patients.

The impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery.

BACKGROUND: Pelvic pain is a debilitating condition that is common among women with pelvic floor disorders. Limited information is known about the impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery. OBJECTIVE: This study aimed to compare the outcomes after vaginal reconstructive surgery between women with and without preoperative pelvic pain. STUDY DESIGN: Baseline and postoperative data were analyzed from the "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial." The multicenter trial involved women with anterior prolapse without symptoms of stress incontinence randomized to receive either a midurethral sling or sham incisions during a vaginal reconstructive surgery. Participants completed the visual analog scale adapted for suprapubic pain and Pelvic Floor Distress Inventory at baseline, 3 months, and 12 months. Preoperative pelvic pain was defined as a response of "5" or greater on pain on the visual analog scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question, "Do you usually experience pain in the lower abdomen or genital area?" Outcomes and complication rates were compared between women with and without pelvic pain. RESULTS: The "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial" participants included 112 women with pelvic pain (58 had a midurethral sling and 54 had sham incisions) and 212 women without pelvic pain (105 had a midurethral sling and 107 had sham incisions). Women who had a midurethral sling and pelvic pain were younger than women without pelvic pain (60.3±12.1 vs 65.1±8.6; P=.004). Women who had sham incisions and pelvic pain were more likely of Hispanic ethnicity than women without pelvic pain (27.8% vs 9.4%; P=.002). Patient improvement based on the Patient Global Impression of Improvement scale did not differ between arms. Women with pelvic pain had greater improvement on the visual analog scale pain scores after a surgical procedure at 3 months (-3.1±2.9 vs -0.4±1.6; P<.001) and at 12 months (-3.4±3.0 vs -0.6±1.6; P<.001) than women without pain, although their pain scores remained higher than those without preoperative pelvic pain at all time points (P<.001 for all). Similar improvements were found on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. The differences observed were not affected by whether women were in the midurethral sling or sham arm of the trial. Postoperative urinary tract infection and incomplete bladder emptying did not differ between the groups. CONCLUSION: Women with preoperative pelvic pain experienced significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery and had similar subjective improvement postoperatively compared with women without preoperative pelvic pain. Reassuringly, the performance of a midurethral sling did not have an impact on the results.

Perioperative Adverse Events for Stress Urinary Incontinence Surgery: A National Analysis.

OBJECTIVE: The aim of the study was to compare perioperative morbidity of stress urinary incontinence surgery using data from a nationwide cohort. METHODS: This is a retrospective cohort study of the American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2016. Stress urinary incontinence surgery was defined using current procedural terminology (CPT) for abdominal retropubic colposuspension (CPT 51840, 51841), laparoscopic retropubic colposuspension (CPT 51990, 51992), and suburethral sling (CPT 57288). Patients were excluded if they underwent any concomitant surgery except for cystoscopy (CPT 52000). Surgical approach and perioperative morbidity were examined using suburethral sling as the referent population. Patient characteristics, operative data, and 30-day postoperative events were collected. RESULTS: Overall, 19,093 women underwent a stress urinary incontinence surgery: 317 abdominal retropubic colposuspension, 357 laparoscopic retropubic colposuspension, and 18,419 suburethral sling. Patients undergoing abdominal retropubic suspension had more inpatient procedures compared with suburethral sling and laparoscopic retropubic colposuspension (65% vs 10.4% and 17.6%, P < 0.001) and longer length of stay (1.6 ± 2.9 vs 0.3 ± 2.7 and 0.3 ± 0.6, respectively, P < 0.001). Abdominal retropubic colposuspension had the longest odds ratio time compared with suburethral sling (72.0 ± 64.6 vs 38.1 ± 34.2 minutes, P < 0.001). Composite morbidity was significantly higher for abdominal retropubic colposuspension compared with suburethral sling and laparoscopic retropubic colposuspension (7.9% vs 3.4% and 2.0%, P < 0.001). After adjusting for comorbidities, composite morbidity was higher for abdominal retropubic suspension (P = 0.007) compared with suburethral sling. CONCLUSIONS: Compared with suburethral sling, laparoscopic retropubic colposuspension had the lowest 30-day comorbidity and abdominal retropubic colposuspension had the highest 30-day comorbidity.

Predictors of delayed postoperative urinary retention after female pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Risk factors can be used to determine what patients will develop delayed postoperative urinary retention after female pelvic reconstructive surgery. METHODS: A case-control study was performed including all female pelvic reconstructive surgeries necessitating a voiding trial. All patients passed their previous voiding trial. Cases had an acute encounter for urinary retention. Controls did not have acute postoperative urinary retention. Cases and controls were stratified based on procedure. Demographics, medical/surgical histories, voiding symptoms, urodynamic testing, and intraoperative data were collected. Cases were matched to controls in a 1:3 ratio. Mann-Whitney U and chi-square tests were used for univariate analyses; logistic regression was used to determine predictors of delayed postoperative urinary retention (DPOUR). RESULTS: A total of 1219 patients underwent pelvic reconstructive surgery that met eligibility; 51 cases of DPOUR (4.3%) were identified and matched with 153 controls without postoperative urinary retention. Of the procedures performed, 41.2% had prolapse surgery, 10.3% had incontinence surgery, and 48.5% had both prolapse and incontinence surgery. There were no differences between cases and controls in age, race, prior surgery, medical comorbidities, prolapse stage ≥ 3, voiding symptoms, and surgical characteristics. Cases had a lower BMI than controls (p < 0.001). There was no difference in preoperative urodynamic variables. Cases had lower percent voided volume on their last voiding trial than controls (90.2% ± 28.6% vs. 110.7% ± 39.5%, respectively; p = 0.001); however, clinically we consider a voided volume of two-thirds or greater of the instilled volume to be a normal result. CONCLUSIONS: DPOUR is an uncommon postoperative event. Demographic and clinical factors and urodynamic findings were unable to predict DPOUR. Percent voided volume on voiding trial was greater in controls.

Relationship Between Maternal Age at First Delivery and Subsequent Pelvic Organ Prolapse.

OBJECTIVE: To determine the relationship between age at first delivery and subsequent risk of pelvic organ prolapse. STUDY DESIGN: We performed a retrospective cross-sectional study using the National Health and Nutrition Examination Survey data from 2005 to 2012. Our primary outcome was self-reported prolapse. Survival analyses and Cox proportional hazard models were used to estimate parous women's risks of reporting prolapse in terms of time since first delivery, adjusting for parity, body mass index, prior hysterectomy, ethnicity, and education. We performed subgroup analyses on women with at least 1 vaginal delivery and those with only cesarean deliveries. RESULTS: The survey-weighted prevalence of prolapse was 2.82%. A total of 6203 women, 79% of all parous women surveyed, reported age at first delivery. Kaplan-Meier curves were different for women based on age at first delivery (P = 0.034). For each year increase in age at first delivery, there was a 6% increase in the rate of developing prolapse (adjusted hazard ratio, 1.06; 95% confidence interval, 1.01-1.11; P = 0.011). Compared with a woman who was 20 years at her first delivery, someone who was 30 years had 1.79 times the risk, while at 40 years the risk was 3.21 times. Among women with at least 1 vaginal delivery, the same relationship was found (adjusted hazard ratio, 1.06; 95% confidence interval, 1.01-1.12; P = 0.019). However, this was not significant for women with only cesarean deliveries (P = 0.367). CONCLUSIONS: Older age at the time of first delivery was associated with a higher risk of subsequent prolapse. These results should be interpreted with caution given the limitations of cross-sectional survey data.

Timing of Office-Based Pessary Care: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the influence of pessary visit intervals on development of vaginal epithelial abnormalities. METHODS: We conducted a randomized, noninferiority trial of office-based pessary care. Eligible participants were adult women wearing a ring, Gellhorn, or incontinence dish pessary to treat pelvic organ prolapse or incontinence or both. Patients were randomized 1:1 to routine pessary care (office visits every 12 weeks, "routine" arm) or to extended pessary care (office visits every 24 weeks, "extended" arm). The primary study outcome was rate of vaginal epithelial abnormalities (epithelial break or erosion) at the final study visit (48 weeks). The predetermined noninferiority margin was 7.5%. RESULTS: From January 2015 through June 2017, inclusive, 448 patients were screened and 130 were randomized, 64 to the routine arm and 66 to the extended arm. Baseline characteristics of the study arms were similar with the exception of pessary type, with ring pessary more common in the routine arm and Gellhorn pessary more common in the extended arm (P=.02). The rate of epithelial abnormalities at the final study visit (48 weeks) was 7.4% in the routine arm and 1.7% in the extended arm (difference, -5.7 percentage points; 95% CI -7.4 to -4), which met the criterion for noninferiority. Rates of all types of epithelial abnormalities did not differ between arms at any time point. Increasing duration of pessary use (P=.003) and history of prior epithelial abnormalities were associated with development of epithelial abnormalities (P=.01). Other than epithelial abnormalities, no adverse events related to pessary use occurred in either arm. CONCLUSION: In women who receive office-based pessary care and are using a ring, Gellhorn, or incontinence dish pessary, routine follow-up every 24 weeks is noninferior to every 12 weeks based on incidence of vaginal epithelial abnormalities. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02371083.

Suburethral sling procedures in the United States: complications, readmission, and reoperation.

INTRODUCTION AND HYPOTHESIS: Hospital readmission is increasingly used as a measure of quality care. Our objective was to evaluate the rate of readmission and associated factors in women undergoing suburethral sling placement in the USA. METHODS: This is a cohort study of suburethral sling procedures performed in the USA from 2012 to 2014 using the American College of Surgeons' National Surgical Quality Improvement Program database. The database was queried for suburethral sling procedures. Records were excluded if concomitant surgery had been performed. Patient and surgical characteristics were evaluated for association with readmission using Chi-squared test for categorical variables and Student's t test for continuous variables. All results yielding p < 0.05 were deemed statistically significant. RESULTS: A total of 7,117 suburethral sling procedures were identified. There were 83 (1.16%) hospital readmissions. Those who were readmitted tended to be older (p = 0.011), non-Hispanic (p = 0.04), smokers (p < 0.001), and have an American Society of Anesthesiologists Physical Status Classification System score of 3 or 4 (p = 0.001). A history of bleeding disorder (p < 0.001), congestive heart failure (p < 0.001), or chronic obstructive pulmonary disease (p < 0.001) was associated with readmission. Fifty-four (0.75%) patients underwent reoperation within 30 days of suburethral sling placement. The most common reoperation procedure was sling excision (20 patients). The most common complication was urinary tract infection, which occurred in 189 patients (2.7%). CONCLUSIONS: Suburethral sling placement is a safe procedure with a low rate of readmissions, reoperations, and complications. Consistent with other types of surgery, infection is the most common post-operative complication.

Transdermal Scopolamine and Acute Postoperative Urinary Retention in Pelvic Reconstructive Surgery.

OBJECTIVE: To evaluate the relationship between perioperative use of transdermal scopolamine and the rate of urinary retention after stress urinary incontinence and pelvic organ prolapse procedures in women. METHODS: This is a retrospective, cohort study; the primary outcome is the rate of acute postoperative urinary retention. Study candidates were adult female patients who underwent pelvic reconstructive surgery at a tertiary care center. Subjects were excluded if preoperative postvoid residual urine volume was greater than 150 mL, preoperative urodynamic testing was not performed, or if a postoperative trial of void was not performed. Subjects were grouped based on preoperative use of transdermal scopolamine. Patients were selected consecutively until 138 subjects per group was reached. Differences in rates of acute postoperative urinary retention were evaluated using a chi-square test. Group demographics were evaluated using t tests and χ tests. RESULTS: Two hundred seventy-six subjects were included in the analysis, 138 received a transdermal scopolamine patch in the perioperative period and 138 did not. The overall rate of acute postoperative urinary retention was 25.3%. There was no significant difference in the rate of acute postoperative urinary retention between the study groups (scopolamine, 26.8%; no scopolamine, 23.9%; P = 0.580). Demographics of the 2 groups were compared; patients who received scopolamine patch were younger (P = 0.001), received a greater amount of intravenous fluids (P = 0.007), and underwent a greater percentage of incontinence procedures (P = 0.048). Otherwise, there were no differences between the groups. CONCLUSIONS: Transdermal scopolamine is not a risk factor for acute postoperative urinary retention after pelvic reconstructive procedures.

Advanced pelvic organ prolapse and routine health screening.

OBJECTIVE: To evaluate whether patients with advanced pelvic-organ prolapse (POP) were less likely than controls to obtain screening Papanicolaou (Pap) test, mammography, and colonoscopy. STUDY DESIGN: Records were reviewed from 7/2/2010 through 4/22/2011. We identified patients with advanced POP, defined as prolapse > or = 4 cm beyond the hymenal ring, and made age- and parity-matched controls from patients whose prolapse was <4 cm. Compliance for screening of cervical, breast and colon cancers was compared between the two groups. RESULTS: Of 933 records, we identified 51 patients with advanced POP and 51 controls. Neither Pap test nor colonoscopy screening differed between the groups (McNemar chi2, P=1.00; McNemar chi2, P=1.00). Mammogram screening did not differ statistically; however, there was a trend towards neglecting screening in the advanced POP group (McNemar chi2, P=0.057). CONCLUSION: Patients with POP > or = 4 cm beyond the hymenal ring were equally as likely to obtain routine health screening as age- and parity-matched controls whose POP measured <4 cm.

Socioeconomic status and race as predictors of treatment-seeking behavior for pelvic organ prolapse.

OBJECTIVE: We sought to evaluate the prevalence of pelvic organ prolapse (POP) among a diverse group of women and to determine if race/ethnicity and/or socioeconomic status (SES) are factors in treatment-seeking behavior. STUDY DESIGN: All data were collected from the National Institutes of Health-supported Boston Area Community Health Survey. SES was calculated by a 2-factor index that combined household income with years of education. Inferential statistics comprised 1-way analysis of variance, with a post hoc Scheffé test performed to evaluate whether there were differences between individual groups. A χ(2) test was used to evaluate whether distributions were equal among the various questions by race/ethnicity and SES category. RESULTS: A total of 3205 women were included in the analysis. Hispanic ethnicity and younger age were associated with POP (P < .002 and P < .001, respectively) as well as with seeking treatment for prolapse (P = .007 and P < .001, respectively). These factors were also associated with subsequent surgical repair (P = .027 and P = .019, respectively). A regression model showed that women were 4.9% more likely to seek treatment for every year younger they were, across the range of age. Although women of a higher SES were more likely to have POP, SES was neither associated with a higher likelihood of seeking treatment nor with the surgical management of prolapse. CONCLUSION: Hispanic ethnicity and younger age were associated with seeking treatment for POP. Hispanics were more likely than whites or blacks to proceed with surgical management. There was no correlation of SES with any of the above factors.

A comparison of shoulder pressure among different patient stabilization techniques.

OBJECTIVE: The purpose of this study was to evaluate the pressure placed on the shoulders as a function of varying degrees of head-down tilt (the Trendelenburg position) and to compare these pressures among 3 different patient-positioning systems. STUDY DESIGN: Participants were placed in the dorsal-lithotomy position with arms tucked and tilted at 5, 10, 15, 20, 25, and 30 degrees of head-down tilt. Using a manometer, we measured the pressure (centimeters of water) on the shoulders at each angle for 3 support devices: the Skytron shoulder support (Skytron, Grand Rapids, MI), the Allen shoulder support (Allen Medical Systems, Acton, MA), and the Allen Hug-u-Vac. RESULTS: Among 23 participants, body mass index (mean ± SD) was 24.5 ± 4.3 kg/m(2). As the tilt angle increased, so did the shoulder pressure for all support systems. At a 30-degree Trendelenburg position, the Allen Hug-u-Vac transmitted less pressure to the shoulders than the Skytron (right and left, P < .001) and the Allen shoulder supports system (right, P < .001; left, P = .434). Each participant was asked, "Which system was most comfortable?" Seventy-four percent of the participants reported that they preferred the Hug-u-Vac (P < .001). CONCLUSION: Shoulder pressure increases as tilt angle increases. Of the 3 support systems that were tested, the Allen Hug-u-Vac transmitted less pressure to the shoulders at a 30-degree Trendelenburg position than the Skytron and the Allen shoulder support systems.

Effect of surgical approach on physical activity and pain control after sacral colpopexy.

OBJECTIVE: We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. STUDY DESIGN: Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. RESULTS: At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. CONCLUSION: Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved.

Surgeon activity in robotic versus abdominal gynecologic surgery.

One proposed advantage of robotic surgery is improved ergonomics and decreased surgeon fatigue. The objective of this study is to quantify and compare the physical activity of surgeons during robotic and abdominal surgery using accelerometers. Eight gynecologic surgeons who perform both abdominal and robotic surgery were the subjects of this study. Each wore an accelerometer on the hip during one procedure performed abdominally and during a similar procedure performed robotically. Activity parameters analyzed were average activity counts (AAC) and percentage of time spent in sedentary, light, moderate, and vigorous activity. The paired t-test was used to evaluate differences between robotic and abdominal procedures. AAC was similar between the robotic and abdominal approaches (mean ± SD: 83.9 ± 50.9 versus 79.1 ± 37.8 counts/min, respectively, P = 0.820). The majority of activity spent in robotic and abdominal surgery was sedentary (79.0% ± 5.9% versus 80.9% ± 8.6%, respectively; P = 0.625) followed by light activity (14.7% ± 3.9% versus 12.8% ± 6.1%, respectively; P = 0.541) and then by moderate activity (6.3% ± 3.4% versus 6.3% ± 2.8%, respectively; P = 0.981). None of the activity for either surgical approach qualified as vigorous. There were no differences in activity parameters by surgical approach. Accelerometer data demonstrate that surgeon activity expenditure is similar in robotic and abdominal surgery. Future studies comparing measures of physical activity and strain between surgical approaches are needed to determine whether the robot's improved ergonomics translates to improved surgeon experience.

Complex sacral abscess 8 years after abdominal sacral colpopexy.

BACKGROUND: Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period. CASE: A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh. CONCLUSION: Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

Characteristics of nulliparous women who would consider cesarean delivery on maternal request.

INTRODUCTION/HYPOTHESIS: To identify factors that influence nulliparous women to choose cesarean delivery on maternal request (CDMR). METHODS: Nulliparous women at > or = 34 weeks completed a 76-item survey about concerns during labor, delivery and postpartum. RESULTS: Mean age of the 294 respondents was 28.4 years (+/- 6.13 years SD) and mean gestational age was 35.4 weeks (+/- 2.8 weeks). Sixteen patients (5.4%) would request CDMR if offered. Women who would request CDMR were more likely to plan breastfeeding (OR 5.1, P=0.02), have a mother who delivered by C-section (OR 5.1, P= 0.01), and be concerned about the number of family members present (OR 1.75, P=0.002). Pelvic muscle damage, urinary incontinence, fecal incontinence, or need for prolapse surgery were notcited by any patient as her top concern. CONCLUSIONS: Few women in our sample desire CDMR. Concern for pelvic-floor problems was low.

Abdominal extraperitoneal excision of a foreign body in the pararectal space.

Permanent suture material and synthetic grafts can be used as part of pelvic organ prolapse surgery. These materials are often attached to the sacrospinous ligament or passed in retroperitoneal spaces. There is a risk for erosion and granulation tissue formation with any of these materials. Typically, this is managed through a transvaginal incision.We present a case of a postmenopausal woman with persistent granulation tissue and a sinus tract from a braided polyester (Ethibond) suture placed in the right sacrospinous ligament fixation. After failing several attempts at treating this granulation tissue through a vaginal incision, we managed this via an abdominal retroperitoneal approach.

Difference in quality of life in women with urge urinary incontinence compared to women with stress urinary incontinence.

INTRODUCTION: We evaluated whether women with urge urinary incontinence (UUI) have lower quality of life (QOL) than women with other forms of urinary incontinence. METHODS: Patients completed three validated questionnaires when presenting for evaluation at a urogynecology practice and were divided into four groups based on their responses: those with symptoms of stress urinary incontinence (SUI), UUI, both SUI and UUI (mixed UI), and neither SUI nor UUI (controls). RESULTS: A total of 465 women were included: 53 women with UUI (11.4%), 101 with SUI (21.7%), 200 with mixed UI (43%), and 111 controls (23.9%). Overall, there was a significant difference (p < 0.001) in PFIQ bladder scale scores as a function of UI group, with individual mean PFIQ scores of 17.1 for controls, 22.3 for SUI, 32.7 for UUI, and 36.8 for mixed UI. Individually, all seven questions in the PFIQ bladder domain were significantly different by group (p

Is Burch or mid-urethral sling better with abdominal sacral colpopexy?

INTRODUCTION AND HYPOTHESIS: This study aims to compare the post-operative rates of stress urinary incontinence (SUI) after abdominal sacral colpopexy (ASC) with either Burch or mid-urethral sling, tension-free vaginal tape (TVT), or no anti-incontinence procedure. The null hypothesis was there would be no difference in SUI among groups. METHODS: A cohort of women who had undergone ASC (n = 150) either alone or with an anti-continence procedure were analyzed to determine the rates of post-operative SUI. Statistically significant differences were evaluated with a Student's t-test. RESULTS: A total of 150 subjects were evaluated, with 115 having SUI preoperatively. Post-operatively, 10% (15/150) of all subjects had SUI. Subjects with preoperative SUI who had a Burch were more likely to have post-operative SUI than those who had a TVT (10 versus 0, p = 0.007). CONCLUSIONS: Burch and TVT procedures improve SUI symptoms in patients undergoing ASC. Mid-urethral slings performed with ASC have lower rates of post-operative SUI.

A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy.

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy.