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%.

Physician Attitudes Toward Urinary Incontinence Identification.

UNLABELLED: Urinary incontinence (UI) is a prevalent condition. Urinary incontinence impacts health, quality of life, and financial resources. Most barriers research is evaluated from the patient perspective. Research from physician perspective is needed to determine how best to address UI barriers. OBJECTIVE: This study aimed to elucidate physician barriers to UI identification and treatment. METHODS: After institutional review board waiver, we surveyed 78 NorthShore University HealthSystem primary care physicians. The survey was designed to assess physician comfort, familiarity with UI, and current practice patterns. RESULTS: Fifty-five (71%) of the 78 physicians completed the survey. Most indicated that they clearly understood UI and that UI was a common problem in their practice. Fifty-six percent of the physicians were very comfortable inquiring about UI. Only 19% of the physicians were very comfortable diagnosing UI and 11% of the physicians were very comfortable treating UI. Fifty-nine percent of the physicians agreed that differentiating the different types of UI is difficult and 69% of the physicians believed that managing UI is difficult. However, only 26% of the physicians agreed that managing UI takes too much time. Overall, 65% of the physicians would like to diagnose and treat UI more in their practices. The most common barriers listed were (1) "not familiar with algorithm available for treatment," (2) "no good screening tool," and (3) "uncomfortable with diagnosis and treatment." CONCLUSIONS: We initially thought that time would be the biggest barrier to care for UI, but we identified discomfort with diagnosis and treatment as barriers. The most common barrier was the lack of an accessible algorithm. Attention to physician education implementation of a screening tool algorithm for treatment of UI could improve UI identification.

An automatic female pelvic medicine and reconstructive surgery registry and complications manager developed in an electronic medical record.

OBJECTIVES: The aim of this study is to incorporate a structured clinical documentation system (SCDS) into the electronic medical record (EMR), allowing for automatic flow of clinical data into an enterprise data warehouse (EDW) and clinical registry. METHODS: The SCDS programming was developed within inpatient and ambulatory EMR domains, allowing routine documentation in these settings to trigger data flow into an EDW. An extensive set of clinical outcomes was included, focusing on data points likely to exist in the forthcoming American Urogynecologic Society Pelvic Floor Disorders Registry. An electronic complications manager was developed to link immediate and/or delayed complications to the index surgery, allowing for accurate morbidity tracking. RESULTS: All aspects of EMR documentation were successfully reconfigured for charting in both inpatient and office settings. Clinicians transitioned to clinical documentation such that no additional data entry beyond routine charting was required, and this resulted in data flow into the EDW. Physician feedback led to the refinement of SCDS entry fields. CONCLUSIONS: This SCDS system allows for automatic flow of a comprehensive data set from our EMR into an EDW and registry. It also provides the ability to systematically track complications and longitudinal clinical outcomes. Integrated systems may eliminate barriers associated with free-standing registries including those relating to cost, maintenance, data integrity, and consistent clinician participation. In addition, it should improve ascertainment of a complete patient population in comparison to voluntary registries.

Oxybutynin: past, present, and future.

Oxybutynin chloride is primarily indicated for the treatment of overactive bladder syndrome (OAB). It remains the most widely prescribed compound for OAB in the world. OAB is defined as the presence of urinary urgency, usually accompanied by daytime urinary frequency and nocturia, with or without urgency urinary incontinence, in the absence of infection or other identifiable etiology. This is a significant problem for men and women said to affect over 33 million adults in the USA, with the prevalence increasing with age. These symptoms can alter quality of life, with both physical and psychological impairment, as well as cause significant financial burden including the cost of sanitary supplies and decreased work productivity. Both pharmacological and non-pharmacological methods may be employed to aid in the treatment of OAB. The mainstay of treatment for OAB relies on pharmacological management, most specifically treatment with antimuscarinic medications. These medications are thought to prevent involuntary bladder contractions and/or urgency by inhibiting the muscarinic receptors within the urothelium and detrusor muscle. Currently, there are six different medications approved by the US Food and Drug Administration (FDA) for the treatment of OAB, with more than nine formulations including immediate- and extended-release tablets, transdermal patch and gel, vaginal ring, and suppository. This review will focus specifically on oxybutynin chloride, which has been used to treat OAB for four decades in numerous formulations.

Minimal mesh repair for apical and anterior prolapse: initial anatomical and subjective outcomes.

INTRODUCTION AND HYPOTHESIS: Here we describe anatomic and quality of life (QOL) outcomes of an anterior and apical compartment prolapse repair involving a reduced mesh implant size and apex-only fixation. METHODS: One hundred and fifteen patients undergoing the repair at a single urogynecology center were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) and inpatient chart reviews. A horizontal incision eliminated overlap with the mesh, and each sacrospinous ligament was approached anteriorly by blunt dissection. Recurrence was defined as apical (C), or anterior (Aa or Ba) ≥0, and secondary analyses were performed using POP-Q ≥ -1 as the anatomic threshold. Pelvic Floor Distress Inventory (PFDI), Surgical Satisfaction Questionnaires (SSQ) and a dyspareunia symptom scale were analyzed pre- and postoperatively. RESULTS: Fifty-three women with uterus in situ demonstrated a combined anterior-apical recurrence rate of 1.89 %, including no anterior (Ba ≥ -1) and one apical (C ≥ -1) recurrence. Forty-seven women undergoing repair for vault prolapse had recurrence rates ranging from 0 % in those with prior hysterectomy to 4.2 % in those undergoing concurrent hysterectomy. The rate of mesh exposure was 3/115 (2.6 %), including two in women with concurrent hysterectomy. Self-reported dyspareunia was more common preoperatively (13.4 %) than postoperatively (9.3 %). PFDI scores improved in all domains, and 93 % completing the SSQ reported they were satisfied and would choose the surgery again. CONCLUSIONS: This technique resulted in successful outcomes within both anterior and apical compartments with a low rate of mesh complication, and no cases required mesh removal or hospital readmission. High rates of satisfaction and improved condition-specific QOL were observed.

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.