Recurrent Incontinence After Transvaginal Partial Sling Excision in Patients with Prior Mid-Urethral Sling.

INTRODUCTION: Patients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision. OBJECTIVE: The primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients. METHODS: From 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant. RESULTS: About 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate >16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009). CONCLUSION: In conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of >16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.

Safety and Efficacy of a Disposable Vaginal Device for Stress Urinary Incontinence.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of an over-the-counter device for the treatment of stress urinary incontinence (SUI) in females. METHODS: A multicenter, interventional, single-arm study involving 5 different sites was conducted including women diagnosed with symptomatic SUI using a self-inserted pessary device. A 1-week baseline period was followed by a 2-week period of wearing the device. The main outcome of our study was to determine if the device was able to reduce at least 50% the number of leakage events and pad weight. RESULTS: Across all study sites, 73 subjects were enrolled and 51 completed the study. Efficacy analyses were conducted on the modified intent-to-treat population (n = 48), whereas the safety analysis was conducted on all consented participants. The average pad weight gain was 0.9 g/h at baseline and 0.5 g/h during the treatment phase. The number of leakage episodes per day decreased from 2 at baseline to 0.9 during the treatment phase (P < 0.0001). Seventy-one percent of the study population experienced a more than 50% reduction in leakage volume, leakage episodes, or both. The quality of life scores improved from baseline to posttreatment phase by 4.35 points on average (P < 0.0001). A total of 40 adverse events were recorded, and only 4 subjects withdrew due to adverse events. CONCLUSIONS: The self-deployable pessary device evaluated in this study is an alternative option for women seeking an over-the-counter method to manage symptoms of SUI. Further studies are required to determine the long-term effects and compliance using the device.

Urethral Diverticulum following Polypropylene Mesh Midurethral Slings: A Literature Review.

AIMS: It is currently unknown whether an association exists between polypropylene mesh and urethral diverticulum formation following placement of polypropylene midurethral slings (MUS) for the treatment of stress urinary incontinence (SUI). We aimed to examine the literature associating MUS with the occurrence of urethral diverticula. METHODS: Multiple online research databases, including PubMed, Google Scholar, EBSCOhost, and the Cochrane Library, were searched, from January 2019 to February 2019, for evidence related to the occurrence of urethral diverticula following polypropylene MUS procedures. RESULTS: Four case reports were published demonstrating the occurrence of urethral diverticula following the use of polypropylene mesh for surgical treatment of SUI. Subjects of these cases were menopausal and had an elevated body mass index (BMI), recurrent urinary tract infections (UTIs), autoimmune conditions, or prior pelvic floor surgeries. A thorough urologic workup, including imaging prior to sling placement, was not always performed. CONCLUSION: No clear association exists between polypropylene MUS placement and subsequent urethral diverticulum formation. Factors that diminish polypropylene mesh biocompatibility include elevated BMI, menopause, recurrent UTIs, prior pelvic surgeries, and preexisting medical conditions. Symptoms associated with urethral diverticula should prompt a complete urologic workup prior to MUS placement.

Recurrent Anterior Vaginal Wall Hernia after a Radical Cystectomy.

True pelvic floor areas are uncommon conditions, but they can occur after extensive pelvic surgery including radical cystectomies or pelvic exenteration. We present the case of a patient with a persistent hernia that failed a native tissue repair and required a prosthetic mesh implant as definitive surgical treatment.

Accuracy of Bladder Scanner for the Assessment of Postvoid Residual Volumes in Women With Pelvic Organ Prolapse.

OBJECTIVES: The aim of the study was to evaluate the accuracy of the bladder scanner in assessing postvoid residual (PVR) volumes in patients with pelvic organ prolapse (POP). METHODS: We performed a prospective parallel cohort study evaluating the accuracy of the BVI 3000 bladder scanner in patients with POP. Patients with POP to the hymen were offered inclusion. Primary outcome was the absolute difference between bladder scanner and catheterization PVR. We also investigated the effect of prolapse stage on bladder scanner accuracy. A prevoid bladder volume was obtained by bladder scan. Subjects voided volume was then collected. A PVR was obtained by bladder scan, followed by a PVR by catheterization. Descriptive statistics, Wilcoxon signed-rank test, linear regression analysis, and sensitivity/specificity analysis were performed. RESULTS: We enrolled 87 subjects. There was a statistically significant difference between catheter and bladder scan PVR, with an absolute median difference of 20 mL (SD = 37.7), P < 0.001. Linear regression analysis showed a difference between mild and advanced prolapse groups. The regression coefficients of the mild prolapse group and advanced prolapse were 0.91 (confidence interval = 0.75-1.06) and 0.66 (confidence interval = 0.54-0. 78), P = 0.015, respectively, indicating a deterioration of accuracy of the bladder scanner for advanced prolapse. The sensitivity of the bladder scanner identifying catheterized PVR volumes less than 100 mL was 93.7%. For catheter PVRs greater than 100 mL, the specificity of the bladder scanner was 72.7%. CONCLUSIONS: Bladder scanner PVRs are less accurate in advanced prolapse, and PVRs of greater than 100 mL should be confirmed by catheterization.

The Effect of Toileting Position in Uroflow Curves in Young Healthy Nulliparous Women.

The objective of our study was to determine the effect of voiding positions on uroflow parameters in young, healthy nulliparous women with no pelvic floor disorders. Material and Methods. From December 2017 to February 2018, we performed a single-institution cross-sectional study with 30 healthy volunteers comparing uroflow curves in sitting and hovering positions. 49 participants were initially prescreened with a validated tool questionnaire for pelvic floor disorders and 30 participants who had absent symptoms were included for the final analysis. From the selected participants, demographics were collected and comparisons between the sitting and hovering position groups regarding the maximum flow rate (Qmax), average flow rate (Qave), voided volume (VV), and time to peak flow (TQmax) were conducted using either the paired t-test or the Wilcoxon rank sum test. In addition, linear regression analysis was performed to determine whether height, BMI, and age have significant impact on the log-transformed average of the pre- and postvalues of either Qmax, Qave, VV, or TQmax, as the average of these values are not normally distributed. Results. There were no statistical differences between the hovering and sitting position groups on the maximum flow rate (p=0.93), average flow rate (p=0.82), voided volume (p=0.53), and time to peak flow (p=0.82). BMI had borderline significant impact on Qave with p value = 0.0531. Conclusion. Different voiding toileting habits do not affect the most commonly used uroflow parameters in young healthy nulliparous patients. Results need to be corroborated by a larger scale study considering the small sample size of our study.

The Effect of Oral Phenazopyridine on Perioperative Voiding After Midurethral Slings (EPIPhANy Study).

OBJECTIVE: To determine the effect of preoperative oral phenazopyridine on postoperative voiding dysfunction in women undergoing a retropubic midurethral sling. METHODS: A single-institution randomized clinical trial was performed from September 2015 to March 2017, comparing 200 mg of oral phenazopyridine versus no phenazopyridine in patients undergoing a retropubic midurethral sling under general anesthesia with no concomitant procedures. A power calculation indicated that we required at least 40 subjects per arm. Preoperative demographics, intraoperative medications, blood loss, and complications were recorded. A standardized voiding trial was performed before discharge. Voiding dysfunction was determined by the proportion of subjects who failed a postoperative voiding trial. Pain scores were obtained before and 2 to 3 hours after the surgical procedure. Patient characteristics and surgical data were compared using χ, Fisher exact test, or Wilcoxon rank sum test. RESULTS: Ninety-two subjects were enrolled in the study. Three patients cancelled their surgery and 1 had an intraoperative urethral injury, leaving 88 patients for the final analysis (44 per arm). Patient demographics showed no differences between groups. Phenazopyridine did not reduce the proportion of patients who failed the voiding trial (27%) compared with subjects who did not receive the medication (21%) (P = 0.453). Postoperative visual analog pain scores were higher in those not receiving phenazopyridine (1.76 vs 1.21, P = 0.046), but after adjusting for the difference in preoperative and postoperative pain scores, the groups showed no difference (P = 0.087). CONCLUSIONS: Our prospective trial shows that phenazopyridine has no effect on short-term postoperative voiding dysfunction. This condition appears to be multifactorial, and further research is needed.

The Effect of Preoperative Phenazopyridine on Urinary Retention Following Midurethral Sling.

OBJECTIVE: The aim of this study was to determine the effect of preoperative oral phenazopyridine on short-term voiding dysfunction in patients undergoing a retropubic midurethral sling. METHODS: We conducted a retrospective cohort study in subjects undergoing a retropubic midurethral sling comparing those who received preoperative oral phenazopyridine with those who did not. We included all women who underwent a retropubic midurethral sling without concomitant procedures under general anesthesia at our institution. Slings were placed by either suprapubic or transvaginal approach, per surgeon's preference. Demographics and intraoperative data on preoperative dose of phenazopyridine and medications linked to voiding dysfunction were captured. RESULTS: One hundred seventy-four subjects were identified. Twenty-five subjects failed to meet inclusion and exclusion criteria and were excluded, and 149 subjects comprised the final groups. Eighty-two subjects (55.03%) received phenazopyridine, and 67 (44.97%) did not. Most subjects received a 200-mg dose (97.6%). Except for surgical approach, both groups receiving and not receiving phenazopyridine had similar demographic characteristics. Eighty-eight percent of the subjects who received phenazopyridine passed the voiding trial versus 73.1% (odds ratio, 2.98; 95% confidence interval, 1.23-7.17). After adjusting for medications, estimated blood loss, number of trocar passages, or bladder perforation, the patients receiving phenazopyridine were still more likely to pass the postoperative voiding trials compared with those who did not (odds ratio, 2.97; 95% confidence interval, 1.10-7.98). CONCLUSIONS: Our findings suggest that the preoperative administration of phenazopyridine may improve postoperative voiding function after a retropubic midurethral sling. Additional prospective trials are needed to confirm this finding.

Voiding Function After Midurethral Slings With and Without Local Anesthetic: Randomized Controlled Trial.

OBJECTIVES: This study aimed to compare the effect of periurethral infiltration of bupivacaine versus normal saline on postoperative voiding function and pain in patients undergoing retropubic midurethral sling METHODS: A randomized double-blind placebo-controlled study was performed at the University of Massachusetts from March 2012 to June 2015. Ninety patients were randomized to receive 0.5% bupivacaine with epinephrine or normal saline with epinephrine solution for periurethral hydrodissection. Postoperative pain was assessed at 2 to 3 and 6 to 7 hours using a visual analog scale. Voiding function was determined by the proportion of subjects passing or failing a voiding trial. Descriptive statistics and percentages were used to compare the rate of voiding dysfunction. A logistic regression analysis was performed adjusting for possible covariates. RESULTS: Ninety subjects enrolled and 45 were randomized to each group. Thirty-nine subjects received the normal saline and 41 received bupivacaine. The remaining 10 withdrew before the procedure. Pain scores at 2 to 3 hours did not differ between the groups (P = 0.837), but at 6 to 7 hours, patients who received bupivacaine had less pain (P = 0.028). There was no difference in voiding dysfunction between the study and placebo groups (17.9% and 24.4%, respectively; P = 0.481). Because of the unavailability of indigo carmine midway through the study, 36 of 80 subjects received preoperative phenazopyridine for the assessment of ureteral patency. Three (8%) of these subjects failed their voiding trial compared with 19 (30%) of the patients who did not receive phenazopyridine (P = 0.010). CONCLUSIONS: The use of bupivacaine did not affect postoperative voiding function but had lower pain scores at 6 to 7 hours postoperatively. Preoperative phenazopyridine may reduce postoperative urinary retention.

Pharmacological Agents to Decrease New Episodes of Recurrent Lower Urinary Tract Infections in Postmenopausal Women. A Systematic Review.

OBJECTIVES: The purpose of this systematic review was to evaluate and summarize pharmacological interventions evaluated in randomized clinical trials designed to prevent recurrent episodes of urinary tract infections (UTIs) in postmenopausal women. METHODS: Excerpta Medica dataBASE, Pubmed, Medline, and Cochrane Library were accessed to search for nonexperimental drugs evaluated in randomized clinical trials published in peer reviewed journals from January 1, 1970, to August 1, 2015, to reduce the number of recurrent UTIs in postmenopausal women. RESULTS: A systematic search yielded 9 articles that met eligibility criteria. Five articles involved the use of systemic or vaginal estrogen therapy and the remainder used oral antibiotics, lactobacilli, or a combination of interventions. Antibiotics were the most efficacious therapy but with a higher incidence of systemic side effects. Oral lactobacillus was noninferior to sulfamethoxazole with trimethoprim with a safer profile in 1 small study. Vaginal estrogen appeared to be inferior to continuous oral antibiotic suppression; however, use of multiple formulations of both treatment options precludes meta-analysis. Oral estrogen use did not decrease UTI recurrence and resulted in local and systemic side effects in up to nearly 30% of the patients. CONCLUSIONS: This review supports the use of antibiotic suppression, vaginal estrogen, and oral lactobacillus for prevention of recurrent UTIs in postmenopausal women. However, the overall dearth of data suggests that this is an important but understudied population. Because the effectiveness and safety of available treatments are not well understood, they should be used with caution in older populations, pending further study.

Patient-focused websites related to stress urinary incontinence and pelvic organ prolapse: a DISCERN quality analysis.

INTRODUCTION AND HYPOTHESIS: The quality of information related to pelvic floor disorders is varied and understudied. Using a validated instrument we evaluated the quality of selected websites addressing treatment options for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). METHODS: English-language, patient-focused professional, governmental, and consumer websites related to POP and SUI were identified using the International Urogynecology Association (IUGA) list of continence societies worldwide, search terms, and provider nomination. Websites were evaluated by 10 providers at an academic medical center, representing urogynecology (6), urology (3), and general gynecology (1). Quality assessment utilized the DISCERN instrument, a validated instrument consisting of 16 questions addressing the quality of consumer health information. RESULTS: Websites of 13 organizations met inclusion criteria and were assessed, 12 relating to SUI and 8 to POP. The websites with the highest mean total DISCERN score for POP were those of the IUGA, the American Society of Colon and Rectal Surgeons, and the American Urogynecologic Association, and for SUI, the National Association For Continence, the American Urological Association, and the IUGA. High correlations were obtained for the total DISCERN score and the overall quality scores for POP (0.76) and SUI (0.82). The most commonly omitted components of the DISCERN instrument were a clear statement of the content objectives, references or sources of the content, and a discussion of what patients could expect if they opted for no intervention. CONCLUSIONS: Available English-language professional websites written to inform patients about management choices for SUI and POP miss key components of quality patient information.

A randomized, clinical trial of ketorolac tromethamine vs ketorolac trometamine plus complex B vitamins for cesarean delivery analgesia.

BACKGROUND: Ketorolac is widely used for postoperative analgesia in patients who undergo cesarean delivery. In countries where the use of opioids is considerably restricted, alternatives to narcotics are required. AIM: We hypothesize that the addition of complex B synergize the analgesic effect of ketorolac in postoperative cesarean patients, thus requiring a smaller dose of the anti-inflammatory agent, and therefore decreasing the potential side effects of ketorolac. METHODS: A randomized clinical trial with 100 patients undergoing a primary elective cesarean delivery enrolled in the study. Pain was assessed in the recovery room and then they were randomized to receive ketorolac 30 mg intramuscular (i.m.) or 15 mg of ketorolac plus complex B vitamin (CBV). The pain score with an analog scale was assessed 1, 2, 6, 12, 18, and 24 h after the baseline. The student's t test was performed to compare the demographic differences between the 2 means. RESULTS: 100 patients were included in the study, showing no statistical differences in the demographics. The patient's pain score at 1, 2, 6, 12, 18 and 24 hours showed no statistical differences between the control group (ketorolac 30mg) compared to the group of ketorolac 15mg and complex B vitamins. No changes in the coagulation studies were found in both groups. CONCLUSION: The present study demonstrates that ketorolac 30 mg and ketorolac 15 mg plus complex B vitamins can provide acceptable analgesia in many patients with severe pain.

[Perinatal outcomes of patients with gestational diabetes diagnosed by three different methods]. / Resultados perinatales de pacientes con diabetes gestacional diagnosticada con tres métodos diferentes.

BACKGROUND: Gestational diabetes is one of the most common diseases during pregnancy. Despite this situation, there is still no consensus on methods for screening and diagnosis of this disease. OBJECTIVE: To assess perinatal outcomes of patients with gestational diabetes diagnosed using three different methods. PATIENTS AND METHODS: Clinical observational, longitudinal, randomized trial at the National Institute of Perinatology Isidro Espinosa de los Reyes. We included all patients admitted to the Institute for a period of three months without pregestational diabetes. Patients were screened for gestational diabetes with an oral load of 50 g of glucose. Patients with a positive screen were randomized by a computer program that randomly chose patients and made a curve according to the criteria of the American Diabetes Association 75 g or 100 g and another group with 75 g according to the criteria of the World Health Organization. Patients with gestational diabetes were followed throughout pregnancy until its reclassification in the puerperium. RESULTS: Screening was performed in 863 patients and 87 were diagnosed with gestational diabetes. Perinatal outcomes were similar in patients with gestational diabetes diagnosed using different methods, but there was a higher frequency of pregnancy-induced hypertension in patients diagnosed with the curves of the American Diabetes Association 75 and 100 g compared with the curve of the World Health Organization. CONCLUSIONS: The American Diabetes Association diagnostic method as the World Health Organization are acceptable forms to diagnose gestational diabetes.

Bilateral ovarian krukenberg tumor in a full-term pregnancy.

Objective. Krukenberg tumors in pregnancy are very rare and their management can present a dilemma for the obstetrician gynecologist. Case Report. We present the case of a G3P2002 who presented to us and the 38 weeks gestation with bilateral massive Krukenberg tumors. Despite at surgery and chemotherapy she died 3 months postpartum. Conclusion. Early detection followed by surgery and chemotherapy could possibly result in a favorable outcome with such patients.

Utility of the pulsatility index of the uterine arteries and human chorionic gonadotropin in a series of cases of placenta accreta.

The conservative management of retained placenta accreta has been proposed as an alternative option in selected cases. Three patients under conservative management of placenta accreta were followed using the pulsatility index of the uterine arteries and the ß fraction of human chorionic gonadotropin to determine the degree of vascularity between the uterus and the placenta. In this series of cases of conservative management of placenta accreta, the pulsatility index of the uterine arteries showed a better correlation with the uteroplacental circulation than serum ß fraction of human chorionic gonadotropin.