Posterior Compartment Surgery Provides No Differential Benefit for Defecatory Symptoms Before or After Concomitant Mesh-Augmented Apical Suspension.

OBJECTIVES: The aim of this study was to determine the value of posterior compartment surgery during concomitant mesh-augmented apical suspension by comparing obstructed defecatory symptoms after laparoscopic sacrocolpopexy (LSC) with LSC with posterior repair (LSC + PR) and laparoscopic sacrocolpoperineopexy (LSCP) procedures. METHODS: This was a retrospective cohort study of women who underwent LSC, LSC + PR, and LSCP between July 2007 and July 2016 at a tertiary referral center in Indianapolis, Ind. Our primary outcome was differential change in Colorectal-Anal Distress Inventory (CRADI-8) and Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores between the groups including patient-specific symptoms of splinting, straining, incomplete emptying, and pain with defecation. Our secondary outcomes were the rates of postoperative persistent, new, and resolved obstructed defecation symptoms. Anatomic outcomes were also compared between the groups as measured by change in Pelvic Organ Prolapse Quantification System points Ap, GH, and PB. RESULTS: A total of 312 women were included in the study (47 LSC, 133 LSC + PR, and 132 LSCP), with a median follow-up time of 366 days. The majority of patients who underwent surgery had stage III pelvic organ prolapse (61%). Baseline demographics were similar between groups, including preoperative CRADI-8 and CRAIQ-7 scores. All surgical groups demonstrated improvement in CRADI-8 and CRAIQ-7 scores postoperatively (P < 0.001). However, despite differential change in Pelvic Organ Prolapse Quantification System points Ap, GH, and PB, there was no change in CRADI-8 and CRAIQ-7 scores or rates of persistent, new, and resolved symptoms of splinting to defecate, incomplete emptying, and pain with defecation between the groups. The only factor that seemed to be differentially improved by the addition of a posterior compartment repair was postoperative straining. There was a greater rate of de novo straining in the LSC group compared with LSCP (P = 0.01) (LSC + PR v LSCP, P = NS, for both). CONCLUSIONS: We cannot recommend posterior compartment surgery as providing any patient-centered benefit beyond improved cosmesis because the addition of perineal body stabilization either before (LSCP) or posterior repair after (LSC + PR) concomitant mesh-augmented apical suspension did not differentially affect bowel symptoms compared with LSC alone.

If you could see what we see, would it bother you?

OBJECTIVE: The purpose of our study was to determine whether the anatomic threshold for pelvic organ prolapse (POP) diagnosis and surgical success remains valid when the patient sees what we see on exam. METHODS: Two hundred participants were assigned, by computer-generated block randomization, to see one of four videos. Each video contained the same six clips representative of various degrees of anterior vaginal wall support. Participants were asked questions immediately after each clip. They were asked: "In your opinion, does this patient have a bulge or something falling out that she can see or feel in the vaginal area?" Similarly, they were asked to give their opinion on surgical outcome on a 4-point Likert scale. RESULTS: The proportion of participants who identified the presence of a vaginal bulge increased substantially at the level of early stage 2 prolapse (1 cm above the hymen), with 67 % answering yes to the question regarding bulge. The proportion of participants who felt that surgical outcome was less desirable also increased substantially at early stage 2 prolapse (1 cm above the hymen), with 52 % describing that outcome as "not at all" or "somewhat" successful. CONCLUSION: Early stage 2 POP (1 cm above the hymen) is the anatomic threshold at which women identify both a vaginal bulge and a less desirable surgical outcome when they see what we see on examination.

Suprapubic versus transurethral bladder drainage following reconstructive pelvic surgery: a comparison of patient satisfaction and quality of life.

INTRODUCTION AND HYPOTHESIS: To assess the differences in patient-reported, catheter-specific satisfaction and quality of life with either suprapubic or transurethral postoperative bladder drainage following reconstructive pelvic surgery. METHODS: This was a prospective study of all eligible women who were scheduled to undergo reconstructive surgery requiring bladder drainage during the study period November 2013 to March 2015. Women who did not undergo the planned procedure(s) or did not require bladder drainage were excluded. The primary outcome was patient-reported quality of life using catheter-specific instruments including the Catheter-related Quality of Life (CIQOL) instrument, and a modified version of the Intermittent Self-Catheterization Questionnaire (ISC-Q), designed to evaluate aspects of catheter-related quality of life and satisfaction specific to the needs of the individual. RESULTS: A total of 178 women were analyzed, 108 in the transurethral catheter group and 70 in the suprapubic group. Women with suprapubic bladder drainage had higher quality of life and satisfaction scores than women with transurethral bladder drainage as measured by the ISC-Q (68.31 ± 16.87 vs. 54.04 ± 16.95, mean difference 14.27, 95 % CI 9.15 - 19.39). There was no difference in quality of life by the CIQOL. After regression analysis, women with suprapubic bladder drainage were more satisfied with their catheter-specific needs despite longer duration of catheter use, more concurrent continence surgery, and higher trait anxiety. CONCLUSIONS: Differences in catheter-specific quality of life and patient satisfaction scores favoring suprapubic bladder drainage support its continued use in appropriately selected women for treatment of temporary postoperative urinary retention after reconstructive pelvic surgery.

Impact of a Novel Vaginal Bowel Control System on Bowel Function.

BACKGROUND: Bowel dysfunction, including frequency, fecal urgency, stool consistency, and evacuation symptoms, contributes to fecal incontinence. OBJECTIVE: The purpose of this study was to examine the impact of a vaginal bowel control system on parameters of bowel function, including frequency, urgency, stool consistency, and evacuation. DESIGN: This was a secondary analysis of a multicenter, prospective clinical trial. SETTINGS: This study was conducted at 6 sites in the United States, including university hospitals and private practices in urogynecology and colorectal surgery. PATIENTS: A total of 56 evaluable female subjects aged 19 to 75 years with 4 or more fecal incontinence episodes on a 2-week bowel diary were included. INTERVENTIONS: The study intervention was composed of the vaginal bowel control system, consisting of a vaginal insert and pressure-regulated pump. MAIN OUTCOME MEASURES: Subjects completed a 2-week baseline diary of bowel function before and after treatment completed at 1 month. Fecal urgency, consistency of stool (Bristol score), and completeness of evacuation were recorded for all bowel movements. RESULTS: Use of the insert was associated with an improvement in bowel function across all 4 categories. Two thirds (8/12) of subjects with a high frequency of daily stools (more than 2 per day) shifted to a normal or low frequency of stools. Analysis of Bristol stool scale scores demonstrated a significant reduction in the proportion of all bowel movements reported as liquid (Bristol 6 or 7), from 36% to 21% (p = 0.0001). On average, 54% of stools were associated with urgency at baseline compared with 26% at 1 month (p < 0.0001). Incomplete evacuations with all bowel movements were reduced from 39% to 26% of subjects at 1 month (p = 0.0034). LIMITATIONS: The study follow-up period was 1 month (with an optional additional 2 months). CONCLUSIONS: The vaginal bowel control system was associated with an improvement in bowel symptoms and function, including reduced bowel movement frequency, less fecal urgency, increased solid consistency, and improved evacuation in patients with significant fecal incontinence.

Consistently inconsistent, the posterior vaginal wall.

Posterior vaginal wall prolapse is one of the most common prolapses encountered by gynecological surgeons. What appears to be a straightforward condition to diagnose and treat surgically for physicians has proven to be frustratingly unpredictable with regard to symptom relief for patients. Functional disorders such as dyssynergic defecation and constipation are often attributed to posterior vaginal wall prolapse. Little scientific evidence supports this assumption, emphasizing that structure and function are not synonymous when treating posterior vaginal wall prolapse. Rectoceles, enteroceles, sigmoidoceles, peritoneoceles, rectal and intraanal intussusception, rectal prolapse, and descending perineal syndrome are all conditions that have an impact on the posterior vaginal wall. All too often these different anatomic conditions are treated with the same surgical approach, addressing a posterior vaginal wall bulge with a traditional posterior colporrhaphy. Studies that examine the correlation between stage of posterior wall prolapse and patient symptoms have failed to reliably do so. Surgical outcomes measured by prolapse staging appear successful, yet patient expectations are often not met. As increasing attention is being placed on patient satisfaction outcomes concerning surgical treatments, this fact will need to be addressed. Surgeons will have to clearly communicate what can and what cannot be expected with surgical repair of posterior vaginal wall prolapse.

Obliterative Surgery for the Treatment of Pelvic Organ Prolapse: A Patient Survey on Reasons for Surgery Selection and Postoperative Decision Regret and Satisfaction.

OBJECTIVES: To identify patient-reported reasons for selecting obliterative surgery for the purpose of predicting decision regret and satisfaction. METHODS: We created a deidentified database of patients who underwent an obliterative procedure for prolapse from 2006 to 2013. Patients were excluded if they declined study participation, were deceased, or had dementia. Participants completed a survey regarding reasons for selecting obliterative surgery and a modified version of validated questionnaires on decision regret (Decision Regret Scale-Pelvic Floor Disorder) and satisfaction (Satisfaction with Decision Scale-Pelvic Floor Disorder). Parsimonious multivariate linear regression models were constructed to determine if any of the reasons given for choosing obliterative surgery were independent predictors of decision regret and satisfaction after controlling for significant sociodemographic, clinical, and surgical outcome data identified by bivariate analysis. RESULTS: Seventy-seven women completed the surveys. "To follow my doctor's recommendations" and "no longer sexually active," and/or "did not plan to be" as reasons for selecting obliterative surgery made the most difference; however, these reasons were not identified as independent predictors of decision regret or satisfaction after controlling for confounders. The regret linear regression models identified preoperative sexual activity rather than the patient-reported reason "no longer sexually active and/or did not plan to be," as the only independent predictor of more decision regret after obliterative surgery (B coefficient 1.68, P < 0.01). The satisfaction linear regression models identified reoperation for any reason as an independent predictor of lower satisfaction (ß, -0.24; P = 0.04) and the patient-reported reason for choosing obliterative surgery "not interested in pessary" as a predictor of higher satisfaction (ß, 0.30, P = 0.01). CONCLUSIONS: This study advances our knowledge about the obliterative surgical decision making process. Behavioral and educational interventions directed at improving patient and physician communications concerning the dynamics of sexual health issues in an aging population will likely decrease regret when obliterative surgery is chosen. Minimizing reoperation after obliterative surgery through increased experience, knowledge, and improved surgical skills and patient validation when pessary is declined will likely improve satisfaction when obliterative surgery is chosen.

Balloon expulsion testing for the diagnosis of dyssynergic defecation in women with chronic constipation.

INTRODUCTION AND HYPOTHESIS: Dyssynergic defecation can be difficult to diagnose. Anorectal manometry and defecography are often used to make this diagnosis. However, these tests are expensive and require expertise. Balloon expulsion testing may be a simple alternative. We compared balloon expulsion to anorectal manometry and defecography for diagnosing dyssynergia in women with chronic constipation. METHODS: We conducted a retrospective review. All women presenting for evaluation of chronic constipation who underwent concurrent balloon testing, manometry, and defecography were included. A diagnosis of dyssynergic defecation was established by either defecography revealing prolonged/incomplete rectal evacuation and/or by manometry revealing paradoxical contraction/inadequate relaxation of the pelvic floor. Inability to expel a 50-ml balloon defined dyssynergic defecation by balloon testing. Sensitivity, specificity, and predictive values were calculated. RESULTS: A total of 61 women met inclusion criteria. Mean age was 50 years. There were 36 women (59 %) who met Rome III criteria for dyssynergic defecation on defecography and/or manometry. Only 12 of these 36 (33 %) were similarly diagnosed by balloon testing. The sensitivity and positive predictive value of balloon testing for dyssynergia were 33 and 71 %, respectively. Of the 25 (41 %) women who did not meet Rome III criteria for dyssynergia on defecography and/or manometry, 20 (80 %) also had negative balloon testing. Thus, the specificity and negative predictive value of balloon testing for diagnosing dyssynergia were 80 and 50 %, respectively. CONCLUSIONS: In our population, balloon expulsion was not an ideal screening test for dyssynergic defecation in women with constipation. Multimodal testing is necessary for more accurate diagnosis.

A vaginal bowel-control system for the treatment of fecal incontinence.

OBJECTIVE: To evaluate the effectiveness and safety of a vaginal bowel-control device and pump system for fecal incontinence treatment. METHODS: Women with a minimum of four fecal incontinence episodes over 2 weeks were fit with the intravaginal device. Treatment success, defined as a 50% or greater reduction of incontinent episodes, was assessed at 1 month. Participants were invited into an optional extended-wear period of another 2 months. Secondary outcomes included symptom improvement measured by the Fecal Incontinence Quality of Life, Modified Manchester Health Questionnaire, and Patient Global Impression of Improvement. Adverse events were collected. Intention-to-treat analysis included participants who were successfully fit entering treatment. Per protocol, analysis included participants with a valid 1-month treatment diary. RESULTS: Sixty-one of 110 (55.5%) participants from six clinical sites were successfully fit and entered treatment. At 1 month, intention-to-treat success was 78.7% (48/61, P<.001); per protocol success, 85.7% (48/56, P<.001) and 85.7% (48/56) considered bowel symptoms "very much better" or "much better." There was significant improvement in all Fecal Incontinence Quality of Life (P<.001) and Modified Manchester (P≤.007) subscales. Success rate at 3 months was 86.4% (38/44; 95% confidence interval 73-95%). There were no serious adverse events; the most common study-wide device-related adverse event was pelvic cramping or discomfort (25/110 participants [22.7%]), the majority of events (16/25 [64%]) occurring during the fitting period. CONCLUSION: In women successfully fit with a vaginal bowel-control device for nonsurgical treatment for fecal incontinence, there was significant improvement in fecal incontinence by objective and subjective measures. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01655498. LEVEL OF EVIDENCE: : II.

Documentation of specific mesh implant at the time of midurethral sling surgery in women with stress incontinence.

OBJECTIVE: We aimed to assess documentation completeness of the operative record for mesh implanted at the time of midurethral sling surgery and to identify modifiable predictors of documentation completeness. METHODS: A retrospective cross-sectional study of women with stress incontinence who underwent midurethral sling placement between January 2009 and December 2011 was conducted. Data from the dictated operative note and nursing operative record were extracted to determine if the specific mesh implanted during surgery was documented. The primary outcome was the rate of documentation of mesh implanted in the physician's dictated operative note and in the nursing record. Logistic regression was used to determine if any characteristics were associated with the rate of documentation while accounting for correlation of patients from the same dictating surgeon. RESULTS: There were 816 surgeries involving the implantation of a midurethral sling during the study period. All surgeries were performed at 6 Indiana University hospitals. Fifty-two surgeons of varying specialties and levels of training dictated the operative notes. A urogynecologist dictated 71% of the operative notes. The rate of documentation completeness for mesh implanted in the physician's note was 10%. The rate of documentation completeness for mesh implanted in the nursing operative record was 92%. Documentation of mesh implanted in the physician's note was not significantly associated with the level of training, specialty, or year of surgery. CONCLUSIONS: Documentation completeness for specific mesh implant in the physician's note is low, independent of specialty and level of training. Nursing documentation practices are more rigorous. Postmarket surveillance, currently mandated by the Food and Drug Administration, may not be feasible if only the physician's note is available or if nursing practices are inconsistent. Development of documentation guidelines for physicians would improve the feasibility of surveillance.

Sacral colpopexy versus transvaginal mesh colpopexy in obese patients.

OBJECTIVES: Obesity can predispose women to pelvic organ prolapse and can also affect the success of pelvic organ prolapse surgery. The purpose of this study was to compare the postoperative anatomical outcomes following sacral colpopexy (SC) and transvaginal mesh colpopexy in a group of obese women with pelvic organ prolapse. METHODS: We conducted a retrospective cohort study of obese women who underwent SC (n = 56) or transvaginal mesh colpopexy (n = 35). Follow-up ranged from 6 to 12 months. Preoperative, perioperative, and postoperative variables were compared using Student t, Mann-Whitney U, and Fisher exact tests, and by analysis of covariance. RESULTS: The women in the SC group had significantly higher mean apical vaginal measurements (P < 0.05), and significantly fewer stage II recurrences than women in the transvaginal mesh colpopexy group. There were no significant differences between the groups for other postoperative outcomes, including mesh erosion, recurrent prolapse symptoms, dyspareunia, and surgical satisfaction (P > 0.05). CONCLUSION: In these 91 obese patients with pelvic organ prolapse, SC resulted in better anatomical outcomes than transvaginal mesh colpopexy. However, the two procedures had similar outcomes with regard to recurrent symptoms and surgical satisfaction.

Objectifs : L'obésité peut prédisposer les femmes au prolapsus des organes pelviens et peut également affecter la réussite de la chirurgie visant à rectifier ce dernier. Cette étude avait pour objectif de comparer, chez un groupe de femmes obèses présentant un prolapsus des organes pelviens, les issues anatomiques postopératoires constatées à la suite d'une colpopexie sacrée (CS) à celles qui sont constatées à la suite d'une colpopexie par treillis transvaginal. Méthodes : Nous avons mené une étude de cohorte rétrospective portant sur des femmes obèses qui ont subi une CS (n = 56) ou une colpopexie par treillis transvaginal (n = 35). Le suivi a été d'une durée allant de six à douze mois. Les variables préopératoires, périopératoires et postopératoires ont été comparées au moyen des tests t de Student, U de Mann­Whitney et exact de Fisher, ainsi qu'au moyen d'une analyse de covariance. Résultats : Les femmes du groupe « CS ¼ présentaient des mesures vaginales apicales moyennes considérablement plus élevées (P < 0,05) et des récurrences de stade II considérablement moins fréquentes que les femmes du groupe « colpopexie par treillis transvaginal ¼. Aucune différence significative n'a été constatée entre les groupes en ce qui concerne d'autres issues postopératoires, y compris l'érosion du treillis, les symptômes récurrents de prolapsus, la dyspareunie et la satisfaction chirurgicale (P > 0,05). Conclusion : Chez ces 91 patientes obèses présentant un prolapsus des organes pelviens, la CS s'est soldée en de meilleures issues anatomiques que la colpopexie par treillis transvaginal. Toutefois, ces deux interventions ont obtenu des issues similaires pour ce qui est des symptômes récurrents et de la satisfaction chirurgicale.

Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: which is the "functional" examination for anorectal and pelvic floor dysfunction?

"Functional" imaging of anorectal and pelvic floor dysfunction has assumed an important role in the diagnosis and management of these disorders. Although defecography has been widely practiced for decades to evaluate the dynamics of rectal emptying, debate concerning its clinical relevance, how it should be done and interpreted continues. Due to the recognition of the association of defecatory disorders with pelvic organ prolapse in women, the need to evaluate the pelvic floor as a unit has arisen. To meet this need, defecography has been extended to include not only evaluation of defecation disorders but also the rest of the pelvic floor by opacifying the small bowel, vagina, and the urinary bladder. The term "dynamic cystocolpoproctography" (DCP) has been appropriately applied to this examination. Rectal emptying performed with DCP provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing defecatory disorders, this method of examination demonstrates maximum pelvic organ descent and provides organ-specific quantification of organ prolapse, information that is only inferred by means of physical examination. It has been found to be of clinical value in patients with defecation disorders and the diagnosis of associated prolapse in other compartments that are frequently unrecognized by history taking and the limitations of physical examination. Pelvic floor anatomy is complex and DCP does not show the anatomical details pelvic magnetic resonance imaging (MRI) provides. Technical advances allowing acquisition of dynamic rapid MRI sequences has been applied to pelvic floor imaging. Early reports have shown that pelvic MRI may be a useful tool in pre-operative planning of these disorders and may lead to a change in surgical therapy. Predictions of hypothetical increase cancer incidence and deaths in patients exposed to radiation, the emergence of pelvic floor MRI in addition to questions relating to the clinical significance of DCP findings have added to these controversies. This review analyses the pros and cons between DCP and dynamic pelvic floor MRI, addresses imaging and interpretive controversies, and their relevance to clinical management.

Laparoscopic sacrocolpopexy versus transvaginal mesh for recurrent pelvic organ prolapse.

Both expert surgeons agree with the following: (1) Surgical mesh, whether placed laparoscopically or transvaginally, is indicated for pelvic floor reconstruction in cases involving recurrent advanced pelvic organ prolapse. (2) Procedural expertise and experience gained from performing a high volume of cases is fundamentally necessary. Knowledge of outcomes and complications from an individual surgeon's audit of cases is also needed when discussing the risks and benefits of procedures and alternatives. Yet controversy still exists on how best to teach new surgical techniques and optimal ways to efficiently track outcomes, including subjective and objective cure of prolapse as well as perioperative complications. A mesh registry will be useful in providing data needed for surgeons. Cost factors are also a consideration since laparoscopic and especially robotic surgical mesh procedures are generally more costly than transvaginal mesh kits when operative time, extra instrumentation and length of stay are included. Long-term outcomes, particularly for transvaginal mesh procedures, are lacking. In conclusion, all surgery poses risks; however, patients should be made aware of the pros and cons of various routes of surgery as well as the potential risks and benefits of using mesh. Surgeons should provide patients with honest information about their own experience implanting mesh and also their experience dealing with mesh-related complications.

Use of suprapubic tube to assess voiding function after synthetic midurethral slings.

INTRODUCTION: Up to 50% of patients are unable to void immediately after midurethral sling (MUS) procedures. The objective of this study was to present our case series of use of suprapubic tube (SPT) to assess voiding function after MUS procedures. METHODS: This was a retrospective cohort study of patients who underwent MUS procedures along with insertion of SPT between January 2007 and August 2010. RESULTS: A total of 123 patients were identified. Among the patients who met criteria for SPT removal within 4 weeks, the mean number of days of SPT use was 6 (4.6) days. One major complication involved a urinoma after SPT removal. CONCLUSION: The use of SPT after MUS procedures is practical. In our cohort of patients, it took up to 1 week for voiding function to return to normal.

High uterosacral ligament vaginal vault suspension: comparison of absorbable vs. permanent suture for apical fixation.

INTRODUCTION AND HYPOTHESIS: The primary objective of this study was to compare outcomes of absorbable and permanent suture for apical support with high uterosacral ligament vaginal vault suspension (HUSLS). The secondary objective was to investigate the rate of suture erosion. METHODS: This was a retrospective study of patients who underwent HUSLS with delayed absorbable and primarily permanent suture. Apical support was calculated as a new variable: Percent of Perfect Ratio (POP-R). This variable measures apical support as the position of the apex in relation to vaginal length. RESULTS: At 1-year follow-up, there was no significant difference in apical support between the two groups. The number of patients who suffered from suture erosion in the cohort that received permanent suture was 11 (22%). CONCLUSIONS: Permanent suture, in comparison with delayed absorbable suture, for HUSLS does not offer significantly better apical support at short-term follow-up. It is also associated with a high rate of suture erosion.

Use of preoperative prolapse reduction stress testing and the risk of a second surgery for urinary symptoms following laparoscopic sacral colpoperineopexy.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine the reoperation rate for sling placement or revision in patients who had primary continence procedures based on prolapse reduction stress testing (RST) prior to laparoscopic sacral colpoperineopexy (LSCP). METHODS: This was a retrospective cohort study of women who had RST prior to LSCP for symptomatic pelvic organ prolapse. Patients with positive test (Pos RST) had a concomitant midurethral sling procedure and those with negative test (Neg RST) did not. Variables were compared with either Student's t test or Fisher's exact test. RESULTS: In Neg RST group (n = 70), the rate of surgery for de novo urodynamic stress incontinence was 18.6%. In Pos RST group (n = 82), the rate of sling revision for bladder outlet obstruction was 7.3%. Overall, 88% of patients did not require a second surgery. CONCLUSIONS: The use of RST to recommend concomitant continence procedures during LSCP results in a single surgery for the majority of our patients.

Female pelvic floor symptoms before and after bariatric surgery.

BACKGROUND: Obesity is a risk factor for female pelvic floor disorders. The study objective was to determine whether there was a difference in the subjective reporting of pelvic symptoms before and after bariatric surgery. METHODS: This was a prospective cohort study of female patients that underwent bariatric surgery. Patients completed a demographic questionnaire, the Pelvic Floor Distress Inventory-20 (PFDI-20), and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) before surgery and at 6 and 12 months following surgery. Body mass index (BMI) was compared between time points using Student's t tests (P < 0.05 significant). Symptom and impact on quality of life prevalence were compared using McNemar's test and questionnaire scores were compared using the Wilcoxon matched pairs test (P < 0.025 significant). RESULTS: At 12 months after surgery, 63 patients had completed the study. Even with significant weight loss (BMI, 43.7 kg/m(2) to BMI, 29 kg/m(2); P < 0.001), there was no significant difference in the prevalence of pelvic floor symptoms before and after surgery (94% to 81%, P = 0.2). Prevalence of pelvic floor symptom impact on quality of life did significantly decrease after surgery (56% to 30%; P = 0.004). Baseline PFDI-20 and PFIQ-7 scores were low; however, there was still a significant reduction in PFDI-20 and PFIQ-7 scores after surgery (P < 0.001). CONCLUSIONS: Prevalence of pelvic floor symptoms did not vary greatly after surgery; however, significant weight reduction did improve the degree of bother and quality of life related to these symptoms.

Surgical outcomes of abdominal versus laparoscopic sacral colpopexy related to body mass index.

OBJECTIVE: Obesity can predispose women to pelvic organ prolapse and can also affect the success of prolapse surgery. Sacral colpopexy is a common surgical approach used to treat significant prolapse, and may be performed by laparotomy or laparoscopy. The objective of this study was to determine whether surgical outcomes following abdominal sacral colpopexy (ASC) and laparoscopic sacral colpopexy (LSC) varied according to BMI. METHODS: We conducted a retrospective cohort study of women who had undergone ASC (n = 90) and LSC (n = 150). Preoperative, perioperative, and postoperative information was collected from patient charts and entered into a database according to BMI category (normal weight 18.5 to 24.9 kg/m², overweight = 25 to 29.9 kg/m², obese ≥ 30 kg/m²). Within each BMI group, outcomes were compared between ASC and LSC patients using Student t, Mann-Whitney U, and Fisher exact tests, and analyses of covariance. RESULTS: In normal weight patients, postoperative apical measurements were worse in ASC patients (P = 0.01). In overweight patients, the ASC group had worse posterior measurements (P = 0.05) and fewer mesh/suture erosions (P = 0.03) but more recurrent prolapse symptoms (P = 0.007). In obese patients, the ASC group had better anterior measurements (P = 0.008). There were no differences in any BMI category for prolapse stage, surgical satisfaction, or classification of surgical success or failure (P > 0.05). CONCLUSION: Differences between ASC and LSC were identified when patients were categorized according to BMI. These findings may be useful in counselling patients and planning the appropriate surgical approach for sacral colpopexy based on BMI.

De novo stress urinary incontinence after negative prolapse reduction stress testing for total vaginal mesh procedures: incidence and risk factors.

OBJECTIVE: The primary objective was to estimate the incidence of de novo stress urinary incontinence after total vaginal mesh procedures in women with negative preoperative urodynamics with prolapse reduction. Secondary objective was to identify associated risk factors. STUDY DESIGN: A retrospective cohort study with a nested case-control study of women who underwent total vaginal mesh procedures without midurethral sling after a negative preoperative urodynamics. RESULT: Sixty patients were included in the final analysis. Fifteen (25%) patients were diagnosed with de novo stress urinary incontinence. Although no significant associated risk factors were identified, there was a trend for higher gravidity and better anterior wall support among women who had stress urinary incontinence develop. CONCLUSION: The incidence of de novo stress urinary incontinence after total vaginal mesh procedures in this cohort was 25%. Patients should be appropriately counseled regarding the same.

"J" cut of sling for postoperative voiding dysfunction following synthetic midurethral slings.

INTRODUCTION: This study evaluates the efficacy of dividing the sling in a "J" fashion in the management of refractory voiding dysfunction with obstructive voiding symptoms after midurethral slings. The sling is cut at 9 or 3 o'clock position, such that a part of the sling posterior to the urethra is intact. METHODS: This was a retrospective pilot study; analyzing patients who underwent sling division using the J cut technique for postoperative voiding dysfunction after midurethral slings between 2006 and 2010. RESULTS: Fifteen patients were identified during the study period. Mean post-void residual dropped from 239 mL (169.1) to 44.8 mL (47.5). The success rate for resolution of voiding dysfunction was 100%. CONCLUSION: The J cut of the sling is an effective technique to manage voiding dysfunction after midurethral sling procedures.