Retention of a Foreign Body in the Vagina of an Adult for 13 Years: A Case Report.

Cases in which foreign bodies have been inserted into the vagina predominately occur in the pediatric population. This report presents the case of an adult woman with a retained foreign body for 13 years. A duplicated ureter suggestive of a Mullerian anomaly was incidentally identified on intraoperative cystoscopy. Mullerian anomalies may be associated with complex patient presentations and are associated with reproductive implications that should be discussed based on patient-specific characteristics.

COVID-19: changing the care process for women's health-the patient's perspective.

OBJECTIVE: Assess women's perceptions of the impact of COVID-19 on their health care and well-being, access to and satisfaction with medical care due to the changes in delivery of care triggered by the pandemic. METHODS: An online survey of women having health care appointments in the outpatient facilities across all divisions of a Department of Obstetrics and Gynecology at a tertiary care referral center in North Central Florida. Patients had outpatient appointments that were scheduled, canceled or rescheduled, in person or by telemedicine, between 11 March 2020 and 11 May 2020, a time during which a COVID-19 stay-at-home order was enacted across our state. A total of 6,697 visits were planned. Patients with multiple visits were unified, leaving 6,044 unique patients to whom the survey was emailed between 20 July 2020 and 31 July 2020. The survey was closed on 21 August 2020. Analyses were focused on simple descriptive statistics to assess frequency of responses. Analyses of variance and chi-square analyses were conducted to compare outcomes when all cells were ≥ 10, based on sub-specialty and insurance status; otherwise, frequencies were examined for the entire sample only. Missing data were excluded listwise. RESULTS: A total of 6044 patients were contacted. Completed surveys numbered 1,083 yielding a response rate of 17.9%. The most common sub-specialty visit was gynecology (56.7%) followed by obstetrics (31.5%,), pelvic floor disorders (4.8%), gynecological oncology (2.9%,), and reproductive endocrinology (0.5%). A substantial percentage of women had visits canceled (19.2%), rescheduled (32.8%) or changed (42.1%) to telemedicine. In our patient population, 32.6% were worried about visiting the clinic and 48.1% were worried about visiting the hospital. COVID-19 triggered changes were perceived to have a negative impact by 26.1% of respondents. Refusal of future telemedicine visits was by 17.2%, however, 75.2% would prefer to use both in-person and telemedicine visits. CONCLUSION: During the initial COVID-19 surge with lockdown, the majority of survey respondents were following public health precautions. However, there were significant concerns amongst women related to obstetric and gynecologic medical appointments scheduled during that period. During pandemics, natural disasters and similar extreme circumstances, digital communication and telemedicine have the potential to play a critical role in providing reassurance and care. Nevertheless, given the concerns expressed by survey respondents, communication and messaging tools are needed to increase comfort and ensure equity with the rapidly changing methods of care delivery.

Female pelvic medicine & reconstructive surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 7: can fibroids worsen incontinence?

This case presents the work-up and management of a patient with a fibroid uterus and urinary incontinence. Five international experts also provide their evaluation and approach to this case. According to the literature, there is uncertainty surrounding the relationship between fibroids and urinary incontinence. The experts emphasize patient counseling and a staged approach.

A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence.

INTRODUCTION AND HYPOTHESIS: The COVID-19 pandemic and the desire to "flatten the curve" of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic. METHODS: We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19. RESULTS: Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission. CONCLUSIONS: We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and obstetrics.

The coronavirus disease 2019 pandemic warrants an unprecedented global healthcare response requiring maintenance of existing hospital-based services while simultaneously preparing for high-acuity care for infected and sick individuals. Hospitals must protect patients and the diverse healthcare workforce by conserving personal protective equipment and redeployment of facility resources. While each hospital or health system must evaluate their own capabilities and surge capacity, we present principles of management of surgical services during a health emergency and provide specific guidance to help with decision making. We review the limited evidence from past hospital and community responses to various health emergencies and focus on systematic methods for adjusting surgical services to create capacity, addressing the specific risks of coronavirus disease 2019. Successful strategies for tiered reduction of surgical cases involve multidisciplinary engagement of the entire healthcare system and use of a structured risk-assessment categorization scheme that can be applied across the institution. Our institution developed and operationalized this approach over 3 working days, indicating that immediate implementation is feasible in response to an unforeseen healthcare emergency.

American Urogynecologic Society Systematic Review: The Impact of Weight Loss Intervention on Lower Urinary Tract Symptoms and Urinary Incontinence in Overweight and Obese Women.

OBJECTIVE: Obesity can contribute to urinary symptoms such as urgency, frequency, and incontinence. In addition to classic treatments, weight loss interventions offer a unique clinical opportunity to improve these symptoms. STUDY DESIGN: The American Urogynecologic Society Systematic Review Group conducted a review of articles on the impact of surgical and behavioral weight loss (BWL) interventions on urinary symptoms in overweight and obese women. The certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: The review group identified 43 publications from 39 studies, including 10 reports that used data from 5 randomized trials. Overall, there is high-certainty evidence that BWL, such as diet and exercise, decreases the prevalence of stress urinary incontinence 15% to 18% and overall urinary incontinence (UI) by 12% to 17% at 1 to 2.9 years. The certainty of evidence on the long-term impact of these interventions was lower. The certainty of the evidence was moderate to low regarding the benefit of BWL on urgency UI and overactive bladder symptoms. No randomized trials evaluated the impact of surgical weight loss on urinary symptoms, and the certainty of evidence of other study types was very low. CONCLUSIONS: There is high-certainty evidence that BWL results in modest improvements in stress and overall UI in overweight and obese women at 1 to 2.9 years after the intervention. Robust studies with low risk of bias are needed to assess whether these benefits are maintained over the long term and are associated with adverse events and to assess the impact of surgical weight loss interventions on urinary outcomes in overweight and obese women.

Patients' Knowledge of and Attitude Toward Robotic Surgery for Pelvic Organ Prolapse.

OBJECTIVES: Robotic sacrocolpopexy for pelvic organ prolapse (POP) has increased, along with marketing and media coverage. It is unknown whether this exposure influences patients' opinions on POP repair. This study describes the preference for and knowledge of robotic surgery in women with POP. METHODS: We performed a cross-sectional survey of new patients presenting with POP at 7 academic sites. Subjects had no prior surgical counseling. A self-administered questionnaire was designed to investigate robotic surgery knowledge, preference, and exposure. Subjects expressed their preferred route of POP repair (robotic, vaginal, abdominal, laparoscopic, or no preference). Knowledge was determined by the number of correctly answered questions (range, 0-7). Perception of robotic surgery was compared with other surgical routes. RESULTS: One hundred seventy-six subjects were included. Most had no surgical preference (66.3%), whereas 27.3% preferred nonrobotic and 6.4% preferred robotic routes. The mean knowledge score was 2.3 (SD, 1.7). Women preferring robotic surgery were more likely to view it as faster than laparoscopic surgery (P < 0.001). These same subjects did not perceive any advantages for robotic surgery related to blood loss, pain, and organ injury (P > 0.05). Most reported no prior exposure to robotic surgery information (56.2%) or advertisements (65.2%). Those with prior exposure most frequently obtained information via the Internet and encountered hospital advertisements. CONCLUSIONS: The majority of women with POP reported no preference for robotic approach to POP surgery. Knowledge about robotic surgery was low, even among subjects who expressed preference. Comprehensive counseling may help patients make informed decisions even when surgical preferences exist.

Design and Early Experience With a Real-World Surgical Registry.

OBJECTIVES: We describe the rationale, design, and methods and 6-year experience with a real-world surgical registry for female pelvic reconstructive and incontinence procedures and postoperative outcomes. METHODS: The primary goal of creating this registry was to establish the feasibility of prospective data capture for all urogynecologic procedures. Data captured included baseline demographics, surgical procedures, perioperative complications, and subjective and objective findings up to 36 months after surgery. RESULTS: The Pelvic Reconstruction and Incontinence Surgery ± Mesh Registry was developed over 3 years to include 194 unique variables for prospective data capture. The registry was implemented in December 2010, and data from 924 separate case events from a single surgeon were recorded, comprising 100% surgical case capture. Cases included a variety of procedures representing a comprehensive urogynecology practice on 804 unique patients. Patients who were asked to participate in long-term follow-up (n = 299) returned with attendance of 96% at 6 weeks, 64% at 6 months, 51% at 12 months, 39% at 24 months, and 22% at 36 months. CONCLUSIONS: The Pelvic Reconstruction and Incontinence Surgery ± Mesh Registry effectively captured all urogynecologic procedures for the purpose of quality improvement. This real-world tool demonstrates that 100% case capture is feasible and provides valuable information for the highly motivated surgeon, although adequate long-term follow-up is limited. Additional research is needed to better understand the role of surgical registries for quality improvement and development of patient-centered strategies to increase long-term follow-up.

Hydronephrosis Presenting 6 Months After Sacral Colpopexy: Case Report and Literature Review.

OBJECTIVES: The aim of this study was to describe a case of uterovaginal prolapse managed with robotic-assisted sacral colpopexy complicated by severe right-sided hydronephrosis despite normal intraoperative cystoscopy. METHODS: A 68-year-old woman presented with a worsening vaginal bulge over the past 2 years. Tricompartment stage 2 uterovaginal prolapse, with dominant cystocele and skin erosion at the posterior fourchette from prolapse friction, was identified on physical examination, and the patient underwent pelvic reconstructive surgery, including sacral colpopexy. RESULTS: The patient was discharged on postoperative day 4 after being treated for a urinary tract infection. At her 6-week postoperative visit, the patient demonstrated normal vaginal support. She presented 6 months postoperatively with right-sided hydronephrosis with an almost imperceptible stricture where the right iliac vessels cross the pelvic brim, demonstrating a delayed manifestation of ureteral injury. She underwent open ureteroscopy, ureteroneocystostomy with vesicopsoas hitch, and ureteral stent placement. Ureteroscopy demonstrated a very mild narrowed caliber of the ureter just above the sacroiliac joint without overt obstruction. Follow-up intravenous pyelogram demonstrated no evidence of damage or obstruction. At nearly 1-year follow-up, the patient remained asymptomatic and had normal renal function. CONCLUSION: This case demonstrates the challenges of an uncommon, but highly morbid, complication of pelvic reconstructive surgery. Even when adequate visualization of the ureters and delicate ureteral dissection is achieved throughout surgery, occult injuries can still occur. Surgeons should maintain a high index of suspicion of ureteral injury when evaluating patients for late presentations of postoperative complications.

Identifying Gaps and Inconsistencies in Urogynecologic Surgical Training of Obstetrics and Gynecology Residents.

OBJECTIVE: This study aims to determine the expectations of Obstetrics and Gynecology (ObGyn) residency and Female Pelvic Medicine & Reconstructive Surgery (FPMRS) fellowship program directors (FPDs) for the independent performance of urogynecologic procedures during residency and to compare these expectations with the Council on Resident Education in Obstetrics and Gynecology (CREOG) educational objectives. MATERIALS AND METHODS: Two parallel, anonymous surveys were distributed simultaneously to all directors of accredited ObGyn residency and FPMRS fellowship programs in the United States. Respondents provided their own professional and program demographic information and indicated whether they expected their residents to independently perform 27 selected urogynecologic procedures. RESULTS: Among residency program directors (RPDs) and FPDs, the online survey response rate was 24.8% (n = 59) and 51.9% (n = 27), respectively. More RPDs expected residents to perform prolapse procedures with mesh, including laparoscopic sacrocolpopexy, all apical suspensions, mesh excisions, and cystotomy repairs, than FPDs. In addition, RPDs expected mastery of most urogynecologic procedures by the Post Graduate Year 3 level, whereas most FPDs did not expect independent performance of these procedures during residency at all. There were notable differences between RPDs' expectations and CREOG objectives regarding several surgical procedures. Whereas CREOG recommends independent performance of anterior and posterior repair, vaginal suspension, vaginal hysterectomy, and transobturator slings, a significant number of RPDs did not report expecting mastery of these procedures during residency. Approximately 30% of RPDs expected residents to perform open sacrocolpopexy and vesicovaginal fistula repair, whereas CREOG recommends only the understanding of these, without procedural mastery. CONCLUSIONS: Although community needs vary by region and setting, CREOG objectives serve as the standard for resident surgical education. This study highlights the discordance between these objectives and ObGyn RDPs' reported expectations for resident performance as well as those held by FPMRS FPDs, the outcome of which reflects a misalignment in graduate medical education between RPDs and FPDs, thus hindering a clear standard for resident surgical competencies.

Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions.

OBJECTIVE: The aim of this study was to compare perioperative complications by route of hysterectomy before and after the introduction of robotic surgery. METHODS: This is an ancillary analysis of a multicenter, retrospective cohort study with historical controls through the Fellows' Pelvic Research Network. Hysterectomies performed for benign conditions were collected prior to introduction of the robot (prerobot) and the year after introduction of the robot (postrobot) at each institution. To obtain a representative annual case distribution for each institution, a maximum of 20 cases per month were selected using stratified random sampling. Patient demographics and intraoperative and postoperative complication data were collected. RESULTS: One thousand four hundred forty cases were included in this study, 732 in the prerobot and 708 in the postrobot period. Intraoperative complications in the prerobot group were highest in the abdominal group (7.4%) followed by vaginal (3.9%) and laparoscopic (3.7%) groups. Postoperative complications were higher in the vaginal (8.3%) and abdominal (7.4%) groups compared with laparoscopic (1.8%) groups (P = 0.03), because of a higher proportion of infections. In the postrobot period, intraoperative complications were lower in the vaginal (2.8%), robotic (3%), and laparoscopic (4.6%) groups compared with abdominal (10.8%) (P = 0.04). Postoperative complications were lowest in the vaginal (5.1%), laparoscopic (3.6%), and robotic (3%) approaches compared with the abdominal (13.9%) approach (P = 0.003). CONCLUSIONS: Vaginal hysterectomy has comparable rates of perioperative complications when compared with robotic and laparoscopic approaches and should be considered as a primary surgical approach in the growing armamentarium of minimally invasive approaches for hysterectomy for benign conditions.

The Pelvic Floor Disorders Registry: Purpose and Development.

Pelvic organ prolapse (POP) is a common problem that negatively impacts women's quality of life. A variety of surgeries exist for POP treatment, including procedures performed with and without mesh augmentation. The growing use of mesh in prolapse surgeries in the 2000s was associated with increasing reports of complications, resulting in Food and Drug Administration (FDA) Safety Notifications, and in 2012, the FDA ordered transvaginal mesh manufacturers to conduct prospective studies to evaluate longer-term outcomes. These requirements provided incentives and an environment conducive to collaboration. American Urogynecologic Society leaders collaborated with device manufacturers, the FDA, and other professional organizations to establish the Pelvic Floor Disorders Registry (PFDR), a collection of interrelated registries, which could meet manufacturers' needs but also allow surgeons to track individual and aggregate outcomes for quality improvement. The PFDR was developed and launched by American Urogynecologic Society with objectives of (1) collecting, storing, and analyzing clinical data related to POP treatment; (2) establishing common data elements and quality metrics; and (3) providing a framework for external stakeholders to conduct POP research. The PFDR includes industry-sponsored studies, as well as 2 options for volunteer registry participation, the PFDR-Quality Improvement and PFDR-Research. The PFDR promotes quality improvement and national benchmarking and will provide real-world comparative safety and effectiveness data for prolapse surgeries. The PFDR can serve as a model for collaboration between medical practitioners, researchers, industry, and federal agencies and may allow progress toward our similar goal of high-quality surgical care of women with prolapse.

Registries as Tools for Clinical Excellence and the Development of the Pelvic Floor Disorders Registry.

Surgical device innovation has been less regulated than drug development, allowing integration of unproven techniques and materials into standard practice. Successful device registries gather information on patient outcomes and can provide postmarket surveillance of new technologies and allow comparison with currently established treatments or devices. The Pelvic Floor Disorders Registry was developed in collaboration with the Food and Drug Administration, device manufacturers, and other stakeholders to serve as a platform for industry-sponsored postmarket device surveillance, investigator-initiated research, and quality and effectiveness benchmarking, all designed to improve the care of women with pelvic floor disorders.

Pelvic Floor Disorders Registry: Study Design and Outcome Measures.

Pelvic floor disorders affect up to 24% of adult women in the United States, and many patients with pelvic organ prolapse (POP) choose to undergo surgical repair to improve their quality of life. While a variety of surgical repair approaches and techniques are utilized, including mesh augmentation, there is limited comparative effectiveness and safety outcome data guiding best practice. In conjunction with device manufacturers, federal regulatory organizations, and professional societies, the American Urogynecologic Society developed the Pelvic Floor Disorders Registry (PFDR) designed to improve the quality of POP surgery by facilitating quality improvement and research on POP treatments. The PFDR will serve as a resource for surgeons interested in benchmarking and outcomes data and as a data repository for Food and Drug Administration-mandated POP surgical device studies. Provider-reported clinical data and patient-reported outcomes will be collected prospectively at baseline and for up to 3 years after treatment. All data elements including measures of success, adverse events, and surgeon characteristics were identified and defined within the context of the anticipated multifunctionality of the registry, and with collaboration from multiple stakeholders. The PFDR will provide a platform to collect high-quality, standardized patient-level data from a variety of nonsurgical (pessary) and surgical treatments of POP and other pelvic floor disorders. Data from this registry may be used to evaluate short- and longer-term treatment outcomes, patient-reported outcomes, and complications, as well as to identify factors associated with treatment success and failure with the overall goal of improving the quality of care for women with these conditions.

Long-term efficacy of the pubovaginal Mersilene mesh sling.

OBJECTIVE: The objective of the study was to determine the efficacy of the pubovaginal Mersilene mesh sling (PVMMS) for complicated urodynamic stress incontinence (USI). STUDY DESIGN: Between 1990 and 2008, patients with USI plus an at-risk diagnosis underwent a PVMMS by a single surgeon. They were followed up with urodynamics (UDE) and Pelvic Floor Distress Inventory-short form 20 (PFDI-20). Stratification was in an at-risk hierarchy: intrinsic sphincter deficiency (ISD) greater than recurrent USI (RUSI) greater than USI with chronically increased intraabdominal pressure (CI-IAP). A cough stress test determined objective cure. PFDI question 17 assessed subjective cure. RESULTS: Three hundred six patients with ISD (43.5%), RUSI (26.8%), and CI-IAP (29.7%) had objective cure rates of 89.2% in the short term, 86.7% in the intermediate term, and 91.2% in the long term. A group of 48 patients with both short- and long-term UDEs showed cures of 100% and 91.7%. Long-term objective cure rates were: ISD, 90.5% (n = 21); RUSI, 84.2%, (n = 19); CI-IAP, 100% (n = 17). The mean score of postoperative PFDI question 17 was 0.57 (n = 119). Mean symptom improvement was -2.98 (n = 52; P < .0001). CONCLUSION: We demonstrated PVMMS to be subjectively and objectively effective in long-term treatment of complicated forms of USI.

Anatomic outcomes of vaginal mesh procedure (Prolift) compared with uterosacral ligament suspension and abdominal sacrocolpopexy for pelvic organ prolapse: a Fellows' Pelvic Research Network study.

OBJECTIVE: The objective of the study was to compare apical support anatomic outcomes following vaginal mesh procedure (VMP) (Prolift) to uterosacral ligament suspension (USLS) and abdominal sacrocolpopexy (ASC). STUDY DESIGN: This multicenter, retrospective chart review compared apical anatomic success (stage 0 or 1 based on point C or D of the Pelvic Organ Prolapse Quantification), level of vaginal apex (point C or D) 3-6 months after prolapse repair at 10 US centers between 2004 and 2007. RESULTS: VMP, USLS, and ASC were performed for 206, 231, and 305 subjects respectively. There was no difference in apical success after VMP (98.8%) compared with USLS (99.1%) or ASC (99.3%) (both P = 1.00) 3-6 months after surgery. The average elevation of the vaginal apex was lower after VMP (-6.9 cm) than USLS (-8.05 cm) and ASC (-8.5 cm) (both P < .001) CONCLUSION: Patients undergoing VMP have similar apical success compared with USLS and ASC despite lower vaginal apex 3-6 month after surgery.

Can we use a catheter to do the q-tip test?

OBJECTIVE: To compare two commonly used modifications to the standard Q-tip test for urethral hypermobility: catheter alone and catheter with Q-tip. METHODS: All women referred for the evaluation of urinary incontinence or pelvic organ prolapse were included in the study. A postvoid residual urine was collected on each patient and the angle of the urethra with the horizontal plane was measured at rest and with Valsalva with the Q-tip, catheter alone, and catheter with Q-tip. The test was considered positive if the angle of excursion was 30 degrees or more. RESULTS: In this group of 100 consecutive women with urinary incontinence or pelvic organ prolapse, the mean change in the angle was significantly different from the standard Q-tip test (51 degrees) when catheter alone (35 degrees, P<.001) or catheter with Q-tip modifications were used (44 degrees, P<.001). This difference was due to a significant reduction in the resting and Valsalva maneuver angles with the catheter alone, and a significant decrease only in the Valsalva maneuver angle with the catheter with Q-tip method (P<.001). The percentage of positive tests for the standard Q-tip test (92%) was significantly different from the catheter only method (63%, P<.001), and from the catheter with Q-tip technique (83%, P=.021). The "best match" values of 10 degrees for the catheter alone, and 15 degrees for the catheter with Q-tip methods produce the best equivalent results at this time. CONCLUSION: The use of a catheter, instead of a Q-tip, in the evaluation of urethral hypermobility resulted in reduced angles of excursion from resting to Valsalva maneuver. LEVEL OF EVIDENCE: III.