Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery.

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

A Comparison of Sacrospinous Hysteropexy Augmented With Polypropylene Mesh Versus Human Dermis at 12-Month Follow-up: An Ambidirectional Study.

BACKGROUND: Suture-based hysteropexy is performed for pelvic organ prolapse with varying results. Graft augmentation may improve outcomes. OBJECTIVE: The aim of this study was to determine whether vaginal hysteropexy with mesh reduces recurrence at 1-year postoperative examination compared with hysteropexy with allograft. METHODS: Data were collected for patients who underwent vaginal hysteropexy with either mesh "Uphold" (referred to as "mesh") or a cadaveric allograft "Axis or Repliform" (referred to as "dermal"). The primary outcome was anatomic success defined as no prolapse Pelvic Organ Prolapse Quantification System stage II or less at 12 months postoperative. The secondary outcomes were recurrence to the hymen and a composite score (any positive response to the 20-item Pelvic Floor Distress Inventory question 3 and cervix ≥ -1/2 total vaginal length at rest or as reference point 3 cm proximal to or above the hymenal ring anteriorly [Ba] ≥0) measured at 12 months. RESULTS: Two hundred seventy-four patients returned for their 1-year postoperative examination: 93.5% of the mesh group (231/247 subjects) and 95.5% of the dermal group (43/45 subjects). The mesh group had fewer recurrences to or beyond Pelvic Organ Prolapse Quantification System stage II (mesh 18% vs dermal 29%, P = 0.03), to the hymen (2.6% vs 9.3%, P = 0.007), or based on composite score (19 vs 33%, P = 0.007). Questionnaire data improved more in the mesh group (P < 0.0001). The exposure rate was 5.75% (13/247) in the mesh group. Reoperation rate was greater in the dermal group (mesh 4.3%vs dermal 7.3%, P = 02). CONCLUSIONS: Hysteropexy augmented with mesh reduced the recurrence at 1 year compared with hysteropexy with allograft. Fewer patients in the mesh group felt a bulge at 1 year (4.5% vs 20.9%, P < 0.0001). These findings need to be weighed against the mesh exposure rate of 5.75%.

Subjective and objective responses to PTNS and predictors for success: a retrospective cohort study of percutaneous tibial nerve stimulation for overactive bladder.

INTRODUCTION AND HYPOTHESIS: We investigated the objective improvements in overactive bladder (OAB) symptoms in patients undergoing percutaneous tibial nerve stimulation (PTNS) and predictive factors of patient satisfaction. METHODS: In this single-center retrospective cohort study at a tertiary urogynecology center, we identified all female patients who underwent PTNS therapy from 1 October 2007 - 1 January 2016 and followed them from their initial visit through medication therapy and PTNS treatments. Patients who tried at least one medication prior to starting PTNS therapy and completed at least one PTNS visit were included. Baseline demographic data, urinary data, and details of medication and PTNS therapy sessions were collected from records through chart review. Paired or two-sample t-tests were used to compare changes over time or groups. Bivariate and multivariable logistic regression were performed. RESULTS: Two hundred thirteen patients underwent PTNS therapy and 183 patients met the criteria. Overall patients were able to decrease voiding frequency by 1 h, decrease nocturia episodes by 0.8, and decrease urge incontinence episodes with PTNS therapy by ten episodes per week (p = 0.02). Patients who continued OAB medications did not have additional improvements compared with patients who did not continue OAB medications during PTNS. Overall, 25.4% (43/169) patients reported ≥ 75% improvement during PTNS therapy, and 61.5% (104/169) reported ≥ 50% improvement. When evaluating predictive factors of ≥ 50% overall improvement, the number of PTNS sessions increased odds of subjective success (OR = 1.8, p = 0.004). Other factors were not significant predictors of subjective PTNS success. CONCLUSIONS: PTNS can provide both objective and subjective improvements for patients who do not respond to OAB medication therapy.

Is There a Relationship Between Patient-Reported Satisfaction and Persistence on Overactive Bladder Syndrome Pharmacotherapy?

OBJECTIVES: This study aimed to determine the relationship between patient satisfaction with overactive bladder syndrome (OAB) pharmacotherapy and persistence rates. We compared persistence rates between satisfied and dissatisfied patients at designated study intervals. METHODS: This was a retrospective cohort study of new patients who initiated OAB medication. Patients were classified as either satisfied or dissatisfied on the basis of a single-item treatment satisfaction question. Persistence was defined as continuous days on therapy. The measured rate of persistence was determined as the ratio of patients who persisted on medication at 4, 12, and 24 weeks. Data collection included demographic and prescription information; urinary symptom parameters, symptom and quality-of-life scales, and patient-reported outcomes. Two-sample t test or Wilcoxon rank sum test was used to compare continuous outcomes between both groups (satisfied vs not satisfied). χ Test or Fisher exact test was used to compare categorical outcomes between groups. RESULTS: We analyzed the first 116 charts that met our inclusion criteria. Satisfied and dissatisfied patients did not differ in demographic variables. Satisfied patients had a median of 461 vs 254 persistent days (P = 0.0001). Satisfied patients (12.5% vs 40%) were less likely to discontinue medication (P = 0.0068). The discontinuation-free distribution was significantly different between satisfied and dissatisfied cohorts, favoring those who reported satisfaction with OAB medication at all time points (P < 0.0001). Patients who totally discontinued pharmacotherapy were 7 times more likely to be dissatisfied (odds ratio, 7.0; P = 0.002). CONCLUSIONS: Our study helps clarify the relationship between persistence on OAB medication and treatment satisfaction. We found that persistence could serve as a surrogate marker for patient satisfaction because those who reported being satisfied were more likely to persist on therapy at all study intervals.

Transvaginal mesh: a historical review and update of the current state of affairs in the United States.

INTRODUCTION: Transvaginal mesh usage has been at the forefront of popular media and academic debate for the past 10 years. Several US Food and Drug Administration (FDA) communications, society statements, and research articles have been written in an attempt to define and articulate the classification system, safety data, and efficacy of this approach to transvaginal surgery. In this review, we explore the history of transvaginal mesh surgery for pelvic organ prolapse (POP), review FDA and society statements, and research current practice in the United States. METHODS: We searched the English language literature using PubMed for articles related to safety and monitoring of transvaginal mesh and reviewed all FDA publication and notices and gynecology and urogynecology society statements on its use in the United States. We then reviewed 22 articles and grouped them into several sections. RESULTS: Mesh used to augment transvaginal repair of POP was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several FDA notifications and warnings. The type of mesh used, reporting and classifications systems, and provider usage has varied widely over time. CONCLUSION: We present a historical review of transvaginal mesh use for pelvic organ prolapse in the United States from 2005 to 2016. There continues to be heated debate among practitioners about balancing the efficacy of mesh use to decrease recurrent prolapse and complications. Research into safety and efficacy, along with tighter FDA regulations, is ongoing.

Does physician specialty affect persistence to pharmacotherapy among patients with overactive bladder syndrome?

INTRODUCTION AND HYPOTHESIS: We compared persistence on overactive bladder (OAB) pharmacotherapy in patients treated in the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) department compared with patients treated in the Internal Medicine (IM) and General Urology (GU) departments within an integrated health-care system. We hypothesized that persistence would be higher among FPMRS patients. METHODS: This was a retrospective cohort study. Patients with at least one prescription for OAB between January 2003 and July 2014 were identified. Demographic, prescription and treatment specialty data and data on the use of third-line therapies were collected. The primary outcome was persistence, defined as days on continuous pharmacotherapy. Discontinuation was defined as a treatment gap of ≥45 days. Discontinuation-free probabilities were calculated using the Kaplan-Meier method and compared among the specialties. Predictors of persistence were estimated using logistic regression with adjustment for covariates. Pearson correlation coefficients were calculated to identify risk associations. RESULTS: A total of 252 subjects were identified. At 12 weeks, 6 months and 1 year, FPMRS patients had the highest persistence rates of 93 %, 87 % and 79 % in contrast to 72 %, 68 % and 50 % in GU patients, and 83 %, 71 % and 63 % in IM patients (p = 0.006, p = 0.007, p = 0.001, respectively). The median persistence in FPMRS patients was 738 days, in GU patients 313 days and in IM patients 486 days (p = 0.006). Of the FPMRS patients, 61 % switched to at least a second medication, as compared to 27 % of IM patients and 14 % of GU patients (p < 0.0001). CONCLUSIONS: Persistence on OAB pharmacotherapy was higher among FPMRS patients than among GU and IM patients in this community setting. These results suggest that persistence is higher under subspecialist supervision.

Predictive modeling and threshold scores for care seeking among women with urinary incontinence: The short forms of the Pelvic Floor Distress Inventory and Urogenital Distress Inventory.

AIMS: To further the interpretability of the Pelvic Floor Distress Inventory (PFDI-20) and Urogenital Distress Inventory (UDI-6) by (i) evaluating the ability of these measures to distinguish between women with urinary incontinence who do and do not seek care, (ii) defining PFDI-20 and UDI-6 threshold scores above which women with urinary incontinence seek care, and (iii) developing a predictive model for incontinence care seeking. METHODS: An observational study was conducted with two groups of women with urinary incontinence: 256 who had not sought care and 90 seeking initial care at a tertiary center. Sample sizes were based upon the prevalence of care seeking for urinary incontinence and the number of potential predictors for care seeking. Wilcoxon rank-sum tests, receiver operating characteristics, and multivariable logistic regression were use to achieve the study aims. RESULTS: Women with urinary incontinence who sought care had higher median PFDI-20 and UDI-6 scores compared to non-care seekers (73.96 vs. 16.67, P < 0.0001, and 41.67 vs. 8.33, P < 0.0001). A PFDI-20 score of 33.33 (83.33% sensitivity and 79.30% specificity) had very good discriminatory accuracy in distinguishing care and non-care seekers (AUC 0.886 ± 0.019 [95%CI 0.8518, 0.9254] P < 0.0001). A UDI-6 score of 25.00 (83.33% sensitivity and 83.59% specificity) had excellent discriminatory accuracy in distinguishing care and non-care seekers (AUC 0.9025 ± 0.0190 [95%CI 0.8653, 0.9398] P < 0.0001). A multivariable predictive model accurately identified 82.4% of care and non-care seekers. CONCLUSIONS: A PFDI-20 score of 33.33 and UDI-6 score of 25.00 provide meaningful benchmarks for care seeking among women with urinary incontinence. Neurourol. Urodynam. 35:949-954, 2016. © 2015 Wiley Periodicals, Inc.

Measuring the success of combined intravesical dimethyl sulfoxide and triamcinolone for treatment of bladder pain syndrome/interstitial cystitis.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to investigate change in bladder capacity as a measure of response to combined intravesical dimethyl sulfoxide (DMSO) and triamcinolone instillations for the treatment of newly diagnosed bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS: 141 newly diagnosed women were identified retrospectively. 79 were treated with weekly DMSO/triamcinolone instillations. Change in bladder capacity with bladder retrofill, daytime urinary frequency, nocturia episodes per night, and Likert scale symptom scores were reviewed. Wilcoxon signed-rank tests, Wilcoxon rank-sum tests, Spearman's rank correlations, COX regression analysis, and a Kaplan-Meier survival curve were performed. RESULTS: Significant changes (median (25(th)-percentile to 75(th)-percentile) were noted for bladder capacity (75 mL (25 to 130 mL), p < 0.0001), inter-void interval (0 hrs (0 to 1 hour), p < 0.0001), nocturia episodes per night (-1 (-2 to 0), p < 0.0001), and aggregate Likert symptom scores (-2 points (-5 to 0), p < 0.0001). Percent change in bladder capacity correlated positively with percent change in inter-void interval (p = 0.03) and negatively with percent changes in nocturia (p = 0.17) and symptom scores (p = 0.01). Women without detrusor overactivity (DO) had greater percent changes in capacity than women with DO (62.5 % vs. 16.5 %, p = 0.02). 61.3 % of patients were retreated with a 36 weeks median time to retreatment and no difference in time to retreatment based upon DO. Greater capacity was protective against retreatment (hazard ratio = 0.997 [95 % CI 0.994,0.999], p = 0.02). CONCLUSIONS: Percent change in bladder capacity is a useful objective measure of response to intravesical DMSO/triamcinolone for newly diagnosed BPS/IC. Clinical outcomes do not differ based upon presence of DO.

Transforming growth factor ß 1 gene expression during vaginal vs cutaneous surgical woundexpression during vaginal vs cutaneous surgical wound healing in the rabbit.

INTRODUCTION AND HYPOTHESIS: Reconstructive pelvic surgery outcome is closely related to the vaginal and pelvic wound healing processes. Transforming growth factor beta 1 (TGF-ß1) is a principal mediator of wound repair in dermal tissue. We sought to assess this factor's expression in vaginal and dermal surgical wound repair in the rabbit. METHODS: We excised bilateral 6-mm full-thickness circular segments from the abdominal skin and vagina in 36 New Zealand White (NZW) nulliparous female rabbits. Animals were sacrificed before, on the day of, and 4, 7, 10, 14, 21, 28, and 35 days after tissue wounding, and their wounds were assessed for surface area and TGF-ß1 gene transcription by real-time polymerase chain reaction (PCR). RESULTS: In both the abdominal skin and vagina, TGF-ß1 gene transcription increased immediately after tissue injury, reaching maximal levels on days 4-7, and decreased shortly thereafter, attaining minimal values on day 35. A significant correlation between TGF-ß1 expression and the wound's closure rate was found in both tissues. CONCLUSIONS: TGF-ß1 gene transcription significantly correlates with the surgical vaginal and dermal wound closure rate, implying that this factor is involved in the process of wound repair in both tissues.

Enhanced interpretability of the PFDI-20 with establishment of reference scores among women in the general population.

AIMS: To enhance the interpretability of the PFDI-20 by establishing a score distribution for women in the general population and to determine whether scores correspond with urinary and anal incontinence (UI and AI). METHODS: Subjects recruited during Twins Day Festivals from 2004 to 2009 completed a survey assessing for stress and urgency urinary incontinence (SUI and UUI) and AI of flatus and stool. Score distributions for the PFDI-20 and each of its subscales were determined for all subjects and for women with isolated forms of incontinence. Scores were compared between continent and incontinent women and between incontinent subtypes by Wilcoxon rank-sum tests. RESULTS: One thousand three hundred seventy-six women completed the survey with PFDI-20 (Median = 8.9, IQR 31.3), POPDI-6 (Median = 0, IQR = 8.3), CRADI-8 (Median = 0, IQR = 10.7), and UDI-6 (Median = 0, IQR = 16.7). PFDI-20, POPDI-6, CRADI-8, and UDI-6 scores were significantly greater among women reporting isolated SUI (P < 0.0001, P = 0.04, P < 0.0001, P < 0.0001, respectively), UUI (P < 0.0001, P = 0.02, P < 0.0001, P < 0.0001, respectively), mixed UI (P < 0.0001 each), AI flatus (P < 0.0001 each), and AI stool (P < 0.0001 each) compared to those denying incontinence. Women with mixed UI had significantly greater PFDI-20 and UDI-6 scores compare to those with SUI (P < 0.0001) or UUI (P < 0.0001). Subjects with AI stool had significantly greater PFDI-20 and CRADI-8 scores compared to those with AI flatus (P = 0.01). CONCLUSIONS: PFDI-20 scores from a sample of the general population correspond with the presence or absence of UI and AI. These normative and symptom-specific score distributions for the PFDI-20 provide reference points to gauge the effect of disease and intervention on quality of life for women with incontinence.

Expression of platelet-derived growth factor-B mRNA during vaginal vs. dermal incisional wound healing in the rabbit.

OBJECTIVE: The outcome of pelvic reconstructive surgery is largely dependent on the vaginal wound healing process, but this process has not yet been fully elucidated. Platelet-derived growth factor (PDGF) is an important mediator of the wound healing process in cutaneous tissue. We sought to compare PDGF-B mRNA expression in vaginal versus cutaneous incisional wound healing in a rabbit model. STUDY DESIGN: Bilateral 6 mm full-thickness circular segments were excised from the vagina and abdominal skin in 36 New Zealand-White female rabbits. Animals were euthanized sequentially before, on the day of and 4, 7, 10, 14, 21, 28 and 35 days after wounding. Their wounds were evaluated for surface area and PDGF-B mRNA expression using real time PCR. RESULTS: In both tissues PDGF-B mRNA expression increased constantly after wounding, reaching peak levels on day 10, and declined immediately thereafter, reaching minimal values on day 21. In both tissues, the expression of PDGF-B mRNA significantly correlated with the wound closure rate. CONCLUSION: PDGF-B mRNA expression significantly correlates with incisional vaginal and cutaneous wound closure, suggesting that this factor plays an important role in the wound healing process of both tissues.

Two unusual presentations of bladder diverticula.

BACKGROUND: Bladder diverticula are protrusions of the mucosal and submucosal layers of the bladder through the muscular wall of the bladder. We discuss the identification and management of two unusual presentations of bladder diverticula. CASE: In two cases of bladder diverticula, one presented as pelvic organ prolapse and the other largely replaced the anterior cervix and was incidentally encountered during a loop electrosurgical excision procedure. Both were discovered intraoperatively and repaired surgically. CONCLUSION: Alternatives to pelvic organ prolapse must be in the differential diagnosis when evaluating a patient with complaints of vaginal bulging.

Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is a coexistence of stress (SUI) and urgency urinary incontinence (UUI). There is conflicting evidence on the effectiveness of midurethral slings (MUS) in this condition. The objective of this study is to evaluate the effectiveness of MUS in women with MUI by systematic review of the literature. METHODS: Systematic literature search was carried (June 2010) using relevant search terms in Medline, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis was performed with random effects model using STATA 8. RESULTS: There were six randomised trials and seven prospective studies with average to good quality included in this systematic review. There was heterogeneity in outcomes reported. The overall subjective cure from seven prospective nonrandomised studies that included patients with symptomatic ± urodynamically proven MUI was found to be 56.4% (95% confidence interval 45.7-69.6%) at 34.9 ± 22.9 months follow-up. The overall cure of urgency and UUI component was 30-85% at a follow-up of few months up to 5 years. Most of the studies described that this cure does not persist over the time. The cure rate of SUI following MUS varies from 85% to 97%. On meta-analysis of five RCTs which included women with MUI symptoms, the odds of overall subjective cure with TVT versus transobturator tapes are similar at 6-33 months follow-up (OR, 0.9; 95% CI, 0.63-1.27). This was true when a subgroup analysis was performed on women with MUI who were negative for DO on UDS (OR, 1.21; 95% CI, 0.7-2.08) CONCLUSIONS: There is evidence of persistent and good cure of stress component following MUS in women with MUI. The cure of the urge component is variable but less than stress component. Methodologically sound RCTs of retropubic and transobturator tapes with long-term follow-up are needed specifically for women with urodynamically proven and symptomatic mixed incontinence.

Nongenetic factors associated with stress urinary incontinence.

OBJECTIVE: To explore the role of hereditary and environmental factors on the development of stress urinary incontinence in a large cohort of identical and nonidentical twins. METHODS: This is a large, population-based, classic twin study of twin sisters recruited to complete a health survey at the world's largest annual twins festival during 2003-2008. Concordance rates were calculated and structural equation models were used to estimate the contribution of genetic effects compared with environmental factors toward the development of stress urinary incontinence. RESULTS: Eight hundred eighty-two twin sister pairs (n=1,764), including 765 identical and 117 nonidentical twin sister pairs, completed the questionnaires. Sequential structural equation modeling revealed that common environmental factors contributed 77.6% (95% confidence interval [CI], 41.4-83.8; P<.001) of the variance and unique environmental factors contributed 20.9% (95% CI, 15.8-26.7; P<.001) of the variance. The effect of genetics was not statistically significant at 1.49% (95% CI, 0.0-38.8; P=.46). CONCLUSION: Female stress urinary incontinence is more a consequence of environmental risk factors than heredity. This epidemiologic insight should be considered in preventive health efforts. LEVEL OF EVIDENCE: II.

Effect of bilateral oophorectomy on wound healing of the rabbit vagina.

We aimed to assess the effect of bilateral oophorectomy on vaginal wound healing in three groups of New Zealand White rabbits (24 rabbits each). Group 1 underwent bilateral oophorectomy, group 2 underwent a sham surgery, and group 3 served as control. Standardized vaginal tissue specimens were harvested and assessed for wound and scar surface area and tensiometric analysis before wounding, and sequentially thereafter, showing that vaginal wound closure, scar contraction, and recovery of biomechanical properties are significantly slower in oophorectomized rabbits.

Urge incontinence: estimating environmental and obstetrical risk factors using an identical twin study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to determine risk factors for urge urinary incontinence (UUI). METHODS: A multi-item survey was administered to a community sample of identical twin sisters from 2002-2008. Generalized estimating equations accounting for co-twin correlation were used to perform three different regression models on the outcome: UUI (yes vs. no). RESULTS: Mean age, median parity, and BMI were 41.4 +/- 16.4 (18-85), 1.0, and 26.0 +/- 6.5 (13.5-55.8), respectively. Thirty-five percent of women were post-menopausal, and 27.5% had UUI. Urge urinary incontinence was reported in 40.1% of parous versus 14.1% among nulliparous women (p < .0001). The rate of UUI was 40.6% after vaginal delivery, 36.7% after cesarean delivery, and 14.1% in nulliparous women (p < .0001). Obesity, age >40, and chronic constipation were also identified as risk factors for urge urinary incontinence. CONCLUSION: Risk factors for UUI include parity, age, obesity, and chronic constipation. There was a 2.5-fold increased risk of UUI after one or more births, regardless of type of delivery.

A Valid Form of the PISQ-12, the PISQ-9, for Use in Comparative Studies of Women With and Without Pelvic Organ Prolapse and/or Urinary Incontinence.

OBJECTIVES: : To test the validity and reliability of a modified short-form Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-9) in a general female population. METHODS: : A cross-sectional survey of 364 sexually active women attending annual gatherings in 2005-06 was conducted. Validated questionnaires were completed, including PISQ-12, Index of Female Sexual Function (IFSF), Pelvic Floor Distress Inventory-20 (PFDI-20), Beck Depression Inventory Second Edition (BDI-II) and Pelvic Pain Urgency/Frequency (PUF) scale. PISQ-12/PISQ-9 scores, for construct validity, were compared with the validated questionnaires, and reliability was assessed with Cronbach's alpha statistic. RESULTS: : PISQ-12/PISQ-9 scores correlated significantly with IFSF scores (Spearman-coefficient, 0.65 and 0.66, respectively, P < 0.0001). Mean PISQ-12/PISQ-9 scores in asymptomatic women were significantly better than those in symptomatic women (PISQ-12: 40.0 ± 4.3 versus 37.1 ± 5.2, P < 0.0001; effect size = 0.65, PISQ-9: 28.1 ± 4.1 versus 25.8 ± 4.8, P < 0.0001, effect size = 0.56). PISQ-12/PISQ-9 scores were worse in women with depressive/bladder-pain symptoms compared with those women without these symptoms. Cronbach's alpha values were 0.73 and 0.72 for PISQ-12 and PISQ-9 scores, respectively. CONCLUSIONS: : PISQ-9 scores strongly correlate with PISQ-12 scores as well as scores of a general sexual-function questionnaire and Cronbach's alpha statistics are acceptable. The PISQ-9 can be reliably used in comparative studies assessing pelvic floor function in women with and without prolapse or incontinence.

Arcus-anchored acellular dermal graft compared to anterior colporrhaphy for stage II cystoceles and beyond.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to compare acellular dermal matrix to standard colporrhaphy for cystocele repair. METHODS: One hundred two patients with greater than or equal to stage II anterior prolapse (Aa or Ba 0) who underwent anterior colporrhaphy with acellular dermal implant attached to the arcus between October 2003 and February 2007 were compared to 89 controls who received standard anterior colporrhaphy. Objective recurrence was defined as greater than or equal to stage II (Aa or Ba -1). RESULTS: The dermal graft and colporrhaphy groups were comparable in age, parity, body mass index, and concomitant surgeries except hysteropexy and hysterectomy. Regression was performed for possible confounders. Postoperatively, 14 (19%) recurrences were identified in the dermal graft group vs. 26 (43%) in the colporrhaphy group (p = 0.004). Two patients underwent reoperations for cystocele recurrence in the study group vs. four in the control group. Time to normal voiding, subjective stress urinary incontinence, estimated blood loss, and length of hospital stay did not differ between groups. CONCLUSION: Dermal acellular matrix provides benefit over standard colporrhaphy.

Predictors of persistent detrusor overactivity after transvaginal sling procedures.

OBJECTIVE: Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence STUDY DESIGN: Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models. RESULTS: Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001). CONCLUSION: When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.