Cadaveric Nerve and Artery Proximity to Sacrospinous Ligament Fixation Sutures Placed by a Suture-Capturing Device.

OBJECTIVE: To simulate sacrospinous ligament fixation on cadaveric specimens, describe the surrounding retroperitoneal anatomy, and estimate the risk to nerves and arteries for the purposes of optimizing safe suture placement. METHODS: Sacrospinous ligament fixation was performed on eight fresh-tissue female cadavers using a Capio ligature capture device. Distances from placed sutures to the following structures were measured: ischial spine; fourth sacral root; pudendal nerve; the nerve to coccygeus muscle; the nerve to levator ani muscle; inferior gluteal artery; and internal pudendal artery. Periligamentous anatomy was examined in an additional 17 embalmed cadaver dissections. RESULTS: Sacrospinous ligament length was not seen to differ significantly between sides. The fourth sacral spinal nerve was seen most commonly associated with the medial third of the ligament, whereas the pudendal nerve and the nerves to coccygeus and levator ani muscles were associated with the lateral third. The inferior gluteal artery was seen leaving the greater sciatic foramen a median 15.8 mm (range 1.8-48.0, CI 14.9-22.3) above the ligament, whereas the internal pudendal artery exited just above the ischial spine. The two sets of sutures were placed 20.5 mm (range 9.2-34.4, CI 19.7-24.7) and 24.8 mm (range 12.4-46.2, CI 24.0-30.0) medial to the ischial spine, respectively. No structures were directly damaged by placed sutures. The nerves to coccygeus and levator ani were closest and arteries farthest from the placed sutures. CONCLUSION: The middle segment of the sacrospinous ligament has the lowest incidence of nerves and arteries associated with it. This study confirms that the nerves supplying the pelvic floor muscles are at a higher risk from entrapment than the pudendal nerve.

Symptoms of combined prolapse and urinary incontinence in large surgical cohorts.

OBJECTIVE: To estimate whether prolapse severity is a major contributor to urinary incontinence severity, as measured by validated incontinence questionnaires. METHODS: We analyzed data from two large female stress urinary incontinence (SUI) surgical cohorts: the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) study (N=655) and the subsequent Trial of Mid-Urethral Slings (TOMUS) study (N=597). All participants completed a standardized baseline assessment including validated measures of symptom severity, quality of life, objective measures of urine loss (Urogenital Distress Inventory [UDI], Medical, Epidemiologic, and Social Aspects of Aging questionnaire, Incontinence Impact Questionnaire, and pad test), as well as the Pelvic Organ Prolapse Quantification assessment. Groups were compared using the chi; test (categorical measures) or the one-way analysis of variance (continuous measures). Statistical significance was defined as P<.05. RESULTS: The SISTEr and TOMUS samples were similar for many variables including age (52 and 53 years, respectively), nulliparity (9% and 12%), prior urinary incontinence (UI) surgery (14% and 13%), and prior hysterectomy (31% and 28%), but other differences necessitated separate analysis of the two cohorts. There was not a statistically significant difference in UDI scores according to prolapse stage in either study population. Patients with prior surgery for pelvic organ prolapse and SUI had more incontinence symptoms and were more bothered by their UI regardless of prolapse stage. CONCLUSION: Prolapse stage is not strongly or consistently associated with incontinence severity in women who select surgical treatment of SUI. Prior pelvic organ prolapse and UI surgery is associated with worse UI severity and bother. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00064662 and NCT00325039. LEVEL OF EVIDENCE: II.

Does mental imagery prior to cystoscopy make a difference? A randomized controlled trial.

OBJECTIVE: We sought to determine whether mental imagery improves surgical performance of residents novice to cystoscopy. STUDY DESIGN: We performed a multicenter randomized controlled trial. Residents who had performed < or = 3 cystoscopies were randomized to preoperative mental imagery sessions or reading a book chapter describing cystoscopy. The primary outcome was comparison of groups' surgical performance scores. Secondary outcomes were measurements of operative times and resident ratings of helpfulness of their preparation. Scores were compared using 2-factor analysis of variance. RESULTS: In all, 68 residents were randomized; 33 to imagery and 35 to control groups. Groups did not differ in age, cystoscopic experience, residency level, or sex. The imagery group's surgical assessment scores were 15.9% higher than controls (P = .03). Operative times did not differ between groups. Imagery residents rated imagery preparation as more helpful than controls (P < .0001). CONCLUSION: Residents considered mental imagery to be a more useful preoperative preparation. The mental imagery group's surgical performance was superior to controls.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study.

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence.

OBJECTIVE: The purpose of this study was to determine the relative effects of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. STUDY DESIGN: This was a prospective, observational multicenter study of women presenting to 6 gynecology clinics. Demographic data collected included: height, weight, gravidity, parity, and number of vaginal deliveries. Patients were diagnosed with incontinence by questionnaire. Standard univariate logistic regression analyses' were performed to determine the contribution of pregnancy, mode of delivery, and BMI on the prevalence of urinary and fecal incontinence. RESULTS: One thousand and four women were enrolled over an 18-month period. Two hundred and thirty-seven and 128 subjects had urinary and fecal incontinence, respectively. Odds ratio (95% CI) calculated for the prevalence of urinary incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.46 (1.53-3.95), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.95 (0.99-3.80), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.53 (1.57-4.07), and any term pregnancy but no vaginal delivery (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 1.30 (0.77-3.95). Odds ratio (95% CI) calculated for the prevalence of fecal incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.26 (1.22-4.19), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.13 (0.43-2.96), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.41 (1.30-4.49), and any term pregnancy but no vaginal deliveries (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 2.15 (0.97-4.77). BMI and age did not impact these results. CONCLUSION: Pregnancy increases the risk of urinary and fecal incontinence. Cesarean section does not decrease the risk of urinary or fecal incontinence compared to pregnancy with a vaginal delivery.

Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population.

OBJECTIVE: The purpose of this study was to evaluate the association of constipation symptoms and anal incontinence with vaginal wall and pelvic organ descent in a general gynecologic population. STUDY DESIGN: In this multicenter, cross-sectional study, 1004 women attending routine gynecologic healthcare underwent pelvic organ prolapse quantification (POPQ) measurements, and were surveyed regarding anal incontinence, digitation, < 2 bowel movements (BMs)/week, and > 25% frequency of: straining, hard/lumpy stools, and incomplete emptying. Constipation scores reflected the sum of positive responses. Associations between POPQ measurements (Ba, C, Bp, gh+pb), constipation scores, and anal incontinence were evaluated using multivariable regression. RESULTS: Of 119 women with Bp > or = -1.00, 47% reported no constipation symptoms. Hard/lumpy stools (26%), incomplete emptying (24%), and straining (24%) were more prevalent; fewer women reported < 2 BMs/week (15%) or digitation (7%). Constipation scores were weakly correlated with Bp, gh+pb (both r < .1, P < .02). Women reporting > or = 2 symptoms had greater gh+pb measurements than women reporting 0 or 1 symptom (P = .03). Women with anal incontinence had greater gh+pb and gh values than women without anal incontinence (P < .01). POPQ measurements were regressed separately onto (1) total constipation scores, (2) dichotomized scores, and (3) individual symptoms, with BMI, age, number of vaginal deliveries (NVD), weight of largest vaginal delivery (WLVD), race, hysterectomy, study site, and income included as covariates. Total constipation scores and dichotomized scores were nonsignificant in all models. With regard to individual symptoms, straining at stool was significant in the models for Ba and gh+pb, with greater Ba and gh+pb measurements among strainers relative to nonstrainers. CONCLUSION: Most associations between bowel symptoms and vaginal or pelvic organ descent were weak. After controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent.

Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects.

OBJECTIVE: The purpose of this study was to describe the distribution of pelvic organ support in a gynecologic clinic population to define the clinical disease state of pelvic organ prolapse and to analyze its epidemiologic condition. STUDY DESIGN: This was a multicenter observational study. Subjects who were seen at outpatient gynecology clinics who required an annual gynecologic examination underwent a pelvic organ prolapse quantification examination and completed a prolapse symptom questionnaire. Receiver operator characteristic curves were used to define pelvic organ prolapse with the use of symptoms and pelvic organ prolapse quantification examination measures. Standard age-adjusted univariate and multivariate logistic regression analysis were used to evaluate various relationships. RESULTS: The population consisted of 1004 women who were aged 18 to 83 years. The prevalence of pelvic organ prolapse quantification stages was 24% (stage 0), 38% (stage 1), 35% (stage 2), and 2% (stage 3). The definition of pelvic organ prolapse that was determined by the receiver operator characteristic curve was the leading edge of their vaginal wall that was -0.5 cm above the hymenal remnants. Multivariate analysis revealed age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus as risk factors for pelvic organ prolapse, as defined in this population. CONCLUSION: The results from this population suggest that there is a bell-shaped distribution of pelvic organ support in a gynecologic clinic population. Advancing age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus have the strongest correlations with prolapse.