International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction. METHODS: An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed. RESULTS: The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP. CONCLUSIONS: The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Colpocleisis Techniques: An Open-and-shut Case for Advanced Pelvic Organ Prolapse.

OBJECTIVE: To highlight several advanced surgical techniques for all types of colpocleisis. Pelvic organ prolapse is a common condition that affects up to 40% of the postmenopausal female population.1,2 Particularly for women with advanced pelvic organ prolapse who no longer desire penetrative vaginal intercourse and with multiple medical comorbidities, the obliterative approach is preferred due to decreased anesthetic needs, operative time, and perioperative morbidity.3 Additionally, colpocleisis is associated with a greater than 95% long-term efficacy with low patient regret, high satisfaction, and improved body image.4,5 MATERIALS AND METHODS: The umbrella term of "colpocleisis" encompasses a uterine-sparing procedure, the LeFort colpocleisis, colpocleisis with hysterectomy, and posthysterectomy vaginal vault colpocleisis. We demonstrate the surgical steps of performing each type of colpocleisis as well as levator myorrhaphy and perineorrhaphy, which are typically included to reinforce the repair. RESULTS: To streamline the LeFort colpocleisis procedure, we demonstrate use of electrosurgery to mark out the epithelium and methods to create the lateral tunnels with LeFort colpocleisis with and without the use of a urinary catheter. We also present techniques that can be utilized across all types of colpocleisis including the push-spread technique for dissection, tissue retraction with Allis clamps and rubber bands on hemostat clamps to improve visualization, and approximation of the anterior and posterior vaginal muscularis to close existing space. Attention must be paid not to proceed past the level of the urethrovesical junction to avoid angulation of the urethra. We use an anatomic model to demonstrate appropriate suture placement during levator myorrhaphy to facilitate an adequate purchase of the levator ani muscles in order to adequately narrow the vaginal opening. Ultimately the goal of the colpocleisis procedure is a well-approximated, obliterated vagina, approximately 3 cm in depth and 1 cm in width. CONCLUSION: The skills demonstrated enable the surgeon to maximize efficiency and surgical outcomes for an effective obliterative procedure for advanced stage pelvic organ prolapse.

Does symptom severity predict response to low-dose onabotulinumtoxinA for the treatment of urgency urinary incontinence?

OBJECTIVE: Intradetrusor onabotulinumtoxinA is a third-line treatment for urgency urinary incontinence (UUI) which is customarily reserved for severe disease. We sought to determine if symptom severity predicts the proportional response to onabotulinumtoxinA and whether low-dose injection may be an appropriate treatment for mild-moderate symptoms. STUDY DESIGN: This prospective cohort study compared patients with urgency urinary incontinence who were recruited from the Urogynecology Clinic with mild-moderate (2-9 episodes/3-day diary) and severe UUI (>9 episodes/3-day diary) symptoms. Twenty-eight subjects were treated (11 mild-moderate, 17 severe) with 50 units of intradetrusor onabotulinumtoxinA. Voiding diaries and validated questionnaires (UDI-6 and IIQ-7) were collected at baseline and one, six, and twelve months post-treatment. The primary outcome was the difference in percent reduction in UUI episodes per 3-day diary at one month. Secondary outcomes included differences in absolute reduction of UUI events, treatment success rate (defined as greater than 50% reduction in UUI episodes), changes in UDI-6 and IIQ-7 questionnaire scores, and rates of urinary retention, self-catheterization, and urinary tract infection. Normally distributed data are presented as means with standard deviations (SD) and groups were compared using the two sample t-test. Data that were not normally distributed are presented as medians with the interquartile range (IQR) and were compared using the Wilcoxon rank sum test. RESULTS: The mild-moderate group showed median improvement; 100% (IQR: 100%, 100%) and severe group; 81% (IQR: 35%, 100%), p < 0.019. Both had significant improvement in UUI episodes; the mild-moderate group decreased by four and the severe group by 15. No differences were noted in percent reduction between groups. There was no association between baseline severity and percent reduction in UUI episodes (rs = 0.127, p = 0.544); however, absolute reduction was highly correlated (rs = -0.821, p < 0.001). Treatment success was 90% in mild-moderate and 73% in the severe group (p = 0.615). Complications included urinary tract infections (25%) and intermittent catheterization (3.6%). CONCLUSIONS: Patients with both mild-moderate and severe symptoms showed a statistically significant improvement in UUI events from baseline to one month, but no difference between the groups in proportional improvement or treatment success.

Pelvic Organ Prolapse in a Fighter Pilot with Alpha-1 Antitrypsin Deficiency.

BACKGROUND: Few researchers have studied symptomatic younger to middle-aged women with pelvic organ prolapse. The association between highly strenuous activity and prolapse symptoms is largely theoretical. It is also known that a genetic component likely contributes to early-onset pelvic organ prolapse, but prevention and treatment with respect to this has not been explored. Service restrictions differ for active duty women who are diagnosed with symptomatic pelvic organ prolapse. CASE REPORT: We present a case of a 33-yr-old Gravida 1 Para 1 fighter pilot who developed symptomatic pelvic organ prolapse after a vaginal delivery. Her prolapse symptoms initially prevented her from flying due to exacerbation of pain and pressure. Her exam demonstrated Stage III pelvic organ prolapse. She was treated with a course of physical therapy and ring with support pessary which allowed the patient to return to flight status after 5 mo. After completing the course of physical therapy, her physical exam improved to Stage II pelvic organ prolapse. A few months later, the patient reported that distracting vaginal pain recurred with the highest G forces. Coincidently, the patient was also diagnosed with pulmonary sequela of alpha-1 antitrypsin deficiency and disqualified from flight status. DISCUSSION: This case illustrates the capability of decreasing pelvic organ prolapse with conservative measures, even in extreme environments, but it also identifies a possible association between an elastase activity defect and susceptibility to pelvic organ prolapse.Buckley K, Gann J, Barbier H, Greer J. Pelvic organ prolapse in a fighter pilot with alpha-1 antitrypsin deficiency. Aerosp Med Hum Perform. 2018; 89(1):66-69.

Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort.

OBJECTIVES: The aim of this study was to evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). METHODS: This is a retrospective cohort study comparing all women who underwent laparoscopic and vaginal USLSs at 2 institutions (part of a single training program with procedures performed by 11 fellowship-trained Female Pelvic Medicine and Reconstructive Surgery gynecologic surgeons) between January 2008 and June 2013. RESULTS: A total of 208 patients in the study underwent a USLS, 148 in the laparoscopic group and 60 in the vaginal group. At baseline, there were statistically significant differences between the groups in mean age (50.4 vs 55.3 years, P = 0.008), parity (2.44 vs 2.77, P = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively; P = 0.042).There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.0% vs 10.0%, respectively; P < 0.001). In an analysis evaluating only those ureteral compromises requiring stent placement, the higher rate of ureteral compromise in the vaginal group persisted despite exclusion of those cases requiring only suture removal and replacement (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; P = 0.023).There was a lower median blood loss in the laparoscopic group (137.5 vs 200.0 mL, respectively; P = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; P = 0.025). There were no other significant differences in postoperative complications between the 2 groups. CONCLUSIONS: We found a lower rate of ureteral compromise in the laparoscopic approach to USLS compared with the traditional vaginal approach.

Laparoscopic colpotomy using monopolar electrocautery: does power really matter?

OBJECTIVE: The purpose of this study was to assess the extent and rate of vaginal tissue injury associated with the utilization of various monopolar electrosurgical power settings when laparoscopically transecting vaginal tissue. METHODS: This is an Institutional Animal Care and Use Committee-approved prospective, paired, single-blinded study. Externalized porcine vagina was transected using monopolar energy at 30, 50, and 80 W in the cut mode with laparoscopic Endo Shears. The slides were prepared and stained with both hematoxylin-eosin and Masson trichrome and were examined by board-certified veterinary pathologists blinded to the study. RESULTS: There were 18 swine; each animal was tested on all 3 power settings (n = 54). Tissue injury was measured to a mean (SD) of 767 (519) µm at 30 W, 690 (600) µm at 50 W, and 556 (470) µm at 80 W. When comparing the monopolar settings, the results were as follows: 30 versus 50 W (P = 0.33), 30 versus 80 W (P = 0.067), and 50 versus 80 W (P = 0.17). The mean (SD) time for complete transection was measured at each power setting (n = 18), with 35.8 (5.4) seconds for 30 W, 13.5 (5.5) seconds for 50 W, and 8.4 (5.1) seconds for 80 W (P < 0.001). There was a statistically significant difference in the mean (SD) rates of injury, with 20.8 (8.8) µm/s at 30 W, 39.8 (11.8) µm/s at 50 W, and 50.1 (19.2) µm/s at 80 W (P = 0.01). CONCLUSIONS: Using various power settings of monopolar energy may not make a significant difference in swine vaginal tissue damage at the time of colpotomy. However, there was a significant difference in the times and rates at which tissue was transected when using higher powers. We recommend using the 50- or 80-W setting, as this will likely decrease surgical times without altering vaginal tissue damage.

Magnification effects on distance estimation during robotic suturing.

We aimed to understand the impact of magnification on distance estimation during robotic suturing. Twenty subjects estimated the lengths of various sutures externally, in plain sight, to validate their ability to measure distances. They then robotically repaired a 3-cm cystotomy, suturing 10 mm above and below the incision and 10 mm on either side of the incision. The bladder was removed and distances measured. A total of 20 surgeons were analyzed: 7 residents, 8 fellows, and 5 staff. Specialties comprised four urologists, eight general gynecologists, two urogynecologists, three gynecologic oncologists, and three reproductive endocrinologists. The mean estimation for external suture length was not significant at 10 mm: mean = 9.6 (±3.2) mm (p = 0.59). When comparing these data sets, the externally visualized 10-mm suture versus the suture-to-suture and the suture-to-incision distances were both significantly different (p = 0.002 and p < 0.001, respectively). The mean distance between each suture was 6.5 (±1.8) mm, which was significantly different from the 10-mm goal (p < 0.001, 95 % confidence interval (CI) [-4.4,-2.6]). The mean distance from the suture to the incision was 4.1 (±1.0) mm, which was also statistically significantly different from the goal (p < 0.001, 95 % CI [-6.3,-5.4]). Surgical experience was negatively associated with suture-to-incision distance (r s = -0.53, p = 0.016). Inter-suture distance was also negatively associated with experience (r s = -0.30, p = 0.22), though not statistically significant. In vivo distances are significantly underestimated during robotic suture placement. Interestingly, the most experienced surgeons had the worst distance estimation from the incision to the suture.