Percutaneous Tibial Nerve Stimulation in Diabetic and Nondiabetic Women With Overactive Bladder Syndrome: A Retrospective Cohort Study.

OBJECTIVES: The primary objective of this study was to compare optimal response ("very much better" or "much better" on the Patient Global Impression of Improvement [PGI-I] index) to posterior tibial nerve stimulation (PTNS) for overactive bladder (OAB) in patients with and without diabetes mellitus. Secondary outcomes included longitudinal data regarding PTNS use in patients with diabetes and controls. METHODS: We performed a retrospective cohort analysis of women in our tertiary care center who completed at least 10 weekly and 1 maintenance PTNS treatments for OAB, excluding patients who were treated with PTNS for a non-OAB primary diagnosis. Participants were grouped into those with diabetes mellitus and those without. Previous research demonstrated a 20% difference in subjective response to anticholinergics in persons with diabetes versus persons without diabetes with OAB. To demonstrate a 20% difference in optimal PGI-I with 80% power, our analysis required 92 patients in each group. RESULTS: We identified 356 patients: 96 with diabetes mellitus, and 260 controls. There was no statistically significant difference in the primary outcome, with 43 (44.8%) of 96 persons with diabetes versus 115 (44.2%) of 260 controls demonstrating optimal PGI-I response (P = 0.92). Among patients with diabetes, no baseline variables were found to predict treatment response, including hemoglobin A1c greater than 7%, diabetes with sequelae, or higher Charlson Comorbidity Index. CONCLUSIONS: In women undergoing PTNS for OAB, the optimal PGI-I response rate is similar in patients with and without diabetes.

Use of pelvic model-based simulation for sacrospinous ligament fixation education in novice learners: a single-blinded randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: We hypothesize that there will be improvement in a novice learners' confidence and skill level with sacrospinous ligament fixation (SSLF) following a pelvic model-based simulation. METHODS: We performed a single-blinded randomized controlled trial with obstetrics and gynecology residents who were novices at SSLF. The residents were randomly assigned to two groups. The control group received a lecture on the SSLF procedure and anatomy, whereas the intervention group received the same lecture in addition to a pelvic model-based simulation session taught by urogynecologists. The residents' knowledge of SSLF anatomy and confidence level with the procedure were measured via assessments administered before and after the educational interventions. Their technical skills were objectively assessed by one of two fellowship-trained urogynecologists who were blinded to their group allocation. RESULTS: A total of 28 residents were recruited with 14 residents in each group and equal distribution of junior and senior trainees. None of the residents had previously performed the SSLF procedure. There was no difference in anatomical knowledge between the two groups. The intervention group showed a greater increase in their average confidence score compared with the control group: 4.0 ± 1.4 (95% CI 3.1-4.8) versus 2.6 ± 1.6 (95% CI 1.7-3.4) respectively, with p = 0.02. The intervention group also showed better objective scores in specific technical skills, such as instrument handling (p < 0.001), instrument movement/motion (p < 0.001), and speed (p = 0.01). CONCLUSION: Our results demonstrate that inclusion of a pelvic model simulation significantly improves confidence and certain technical skills of novice trainees in performing SSLF.

The Anatomical Distribution of the Pudendal Nerve Block Injection: A Cadaveric Study.

OBJECTIVE: The objective of this study was to assess the accuracy of commonly used injection locations of the pudendal nerve block by examining the proximity of the injected dye to the pudendal nerve in a cadaveric model. METHODS: Pudendal block injections at 4 sites were placed transvaginally on 5 cadaveric pelvises. These sites were 1 cm proximal to the ischial spine (black dye), at the ischial spine (red dye), 1 cm distal to the ischial spine (blue dye), and 2 cm lateral and 2 cm distal to the ischial spine (green dye). The cadavers were dissected via a posterior approach. RESULTS: We measured the shortest distance from the center of the dye-stained tissue to the pudendal nerve. As expected, the injections at the ischial spine (red) resulted in a distribution of dye closest to the pudendal nerve, averaging 3.0 ± 0.95 mm. Dyes at other sites were close to the nerve: 3.1 ± 1.00 mm (black), 3.6 ± 1.14 mm (blue), and 4.05 ± 1.28 mm (green). CONCLUSIONS: Regardless of the injection site, all dyes were close the pudendal nerve, indicating accuracy. We observed wide variation in the dye distribution even though all injections were performed by the same provider, implicating lack of precision. Based on our findings, we propose that the most effective injection location is at the ischial spine because it is the closest to the pudendal nerve; however, all injections were within 4 mm of the pudendal nerve, suggesting that only 1 to 2 injections may be sufficient.

A Systematic Review of Frailty Assessments in Women With Pelvic Floor Disorders: Are We Following the American College of Surgeons National Surgical Quality Improvement Program/American Geriatric Society Guidelines?

INTRODUCTION: Associations between frailty and women with pelvic floor disorders (PFDs) are not well understood. This study seeks to describe studies among women with PFD and the associated frailty assessments as recommended in the American College of Surgeons National Surgical Quality Improvement Program/American Geriatric Society (ACS NSQIP/AGS) guidelines. METHODS: This systematic review was registered with PROSPERO using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) criteria are applied to assess study quality. Data synthesis is descriptive. Outcomes of interest include the ratio of studies adhering to the ACS NSQIP/AGS guidelines and evidence for frailty assessments versus usual care for women with PFDs. RESULTS: Twenty studies regarding frailty and PFDs were included for systematic review. Studies were categorized as relating to (1) epidemiology, (2) frailty and incontinence, (3) postoperative morbidity, and (4) surgical choice. Most studies (5/20) did not define frailty or failed to follow the ACS NSQIP/AGS guidelines. All studies were of very low to low quality. Collectively, each category generated very low GRADE quality evidence of frailty and the relationship to PFDs. CONCLUSIONS: Most studies regarding frailty among women with PFDs did not define frailty as recommended in the ACS NSQIP/AGS guidelines. The evidence regarding PFDs and frailty is of very low quality. This is the first systematic review regarding frailty assessments specifically among women with PFDs. Paucity of data regarding frailty in women with PFDs, particularly with regard to surgical choice and surgical counseling, highlights the need for further study in this area.