An Introduction to Cystoscopy for OB/GYN Residents.

INTRODUCTION: OB/GYN residents' preparedness to perform cystoscopy after residency may vary as the ACGME requires only 10 cystoscopic cases to be performed during training. Given residents' potentially limited exposure to cystoscopy, supplemental educational activities centered around increasing familiarity with the procedure may be useful. The objective of this workshop was to provide an opportunity for OB/GYN residents to become more comfortable with cystoscopic equipment and performing cystoscopy. METHODS: We showed a video of common pathology seen on cystoscopy and then progressed through two hands-on stations. One station focused on equipment familiarity, with learners identifying equipment and then practicing assembling and disassembling the cystoscope. The other station allowed for simulated cystoscopy utilizing a pig bladder. We used a checklist assessment and pre- and postcourse surveys to evaluate familiarity with equipment and anxiety surrounding performing cystoscopy. RESULTS: Twenty residents ranging from PGY 1s to PGY 4s who participated in this workshop over the past 2 years completed both pre- and postcourse evaluations. There was statistically significant improvement in ratings of familiarity with equipment and anxiety surrounding the procedure. All participants whom we assessed showed improvement in identifying and assembling equipment as well as in performing the steps of the procedure independently. DISCUSSION: This workshop provided OB/GYN residents with an opportunity for hands-on cystoscopic experience. Through direct assessment and evaluation forms, the workshop was shown to be a beneficial activity for improving cystoscopic knowledge.

Dyspareunia is associated with chronic pain in premenopausal women with sickle cell disease.

OBJECTIVES: Pain is common in women with sickle cell disease (SCD), but the prevalence of dyspareunia in this unique patient population is unknown. In this study, we sought to determine whether chronic pain is associated with an increased prevalence of dyspareunia in premenopausal women with SCD. METHODS: A cross-sectional study of premenopausal women with SCD was systematically assessed for symptoms of dyspareunia and chronic pain using a standard questionnaire. These results were correlated with each subject's clinical pain phenotype determined by a review of the patient's electronic medical record. RESULTS: Ninety-one premenopausal women with SCD were examined. Thirty-two percent of the women reported dyspareunia. Women with dyspareunia were more likely to have a history of chronic pain (90% versus 61%, p = .006), report more pain days per week (median (interquartile range): 6 (4-7) vs. 3 (0-7), p = .005)), and had a higher oral morphine equivalent dose (145 (45-226) mg vs. 60 (9-160) mg, p = .030). Using a multivariable classification tree analysis, number of days of pain experienced per week was an important predictor of dyspareunia (p = .001). CONCLUSION: Dyspareunia is common in women with SCD, and more common in women with SCD and chronic pain. Providers should assess women with SCD for dyspareunia, especially those with a chronic pain syndrome.

InTone: a novel pelvic floor rehabilitation device for urinary incontinence.

INTRODUCTION: InTone(TM) (InControl Medical) is a nonimplanted vaginal device providing biofeedback and electrical stimulation of pelvic floor muscles. The purpose of this study was to assess its efficacy and usability for treating urinary incontinence (UI). METHODS: Women with UI (stress, urge, mixed) were recruited for this pilot trial. InTone was used 5-6 days a week for 12 weeks. Patients were assessed at baseline and monthly with symptom questionnaires [Urinary Distress Index (UDI6), Incontinence Impact Questionnaire (IIQ7)], bladder diaries. and 24-h pad-weight testing (PWT). Efficacy was assessed by comparing 12-week results to baseline values using chi-square and Wilcoxon rank-sum tests. Usability was assessed with a device-usage log and the System Usability Scale (SUS), which evaluates patients' global impression of usability. RESULTS: Thirty-three women were enrolled; five patients withdrew and were excluded. Median age was 50 years (range 35-69). After 12 weeks of InTone therapy, median UDI6 and IIQ7 scores improved from 50.0 to 29.2 (p < 0.001) and from 42.9 to 14.3 (p < 0.001), respectively. Statistically significant reductions in median PWT (35.5-4.6 g, p < 0.001), median daily pad use (4.0-2.0, p < 0.001), and median daily incontinence frequency (4.3-1.0, p < 0.001) were noted; 68 % of patients achieved a > 50 % reduction in daily pad usage and PWT. Device usability was good, with a median SUS of 86.3 and a median expected use of 107 % (33-140 %). CONCLUSIONS: Twelve weeks of InTone usage resulted in significant objective and subjective reductions in UI. Device usability was very good.

Preoperative Valsalva voiding increases the risk of urinary retention after midurethral sling placement.

INTRODUCTION AND HYPOTHESIS: A subset of neurologically normal females void by efficient Valsalva, not detrusor contraction. We determined the incidence of urinary retention following midurethral sling (MUS) placement in women that void by detrusor contraction versus Valsalva. METHODS: Review of patients undergoing MUS insertion between 2002 and 2009 for urodynamic stress incontinence was performed. Women with concomitant pelvic surgery, previous incontinence surgery, or preoperative incomplete bladder emptying were excluded. Patients were divided into two cohorts based on preoperative urodynamic findings--those that voided with a detrusor contraction >10 cm of water and those that voided by Valsalva. RESULTS: One hundred seven patients were available for analysis. The postoperative urinary retention rate was 22% and 5% in the Valsalva and non-Valsalva groups, respectively (p < 0.05). Mean retention duration was 3 weeks for each cohort (range 1-6). CONCLUSIONS: Women voiding by Valsalva are at increased risk of urinary retention following MUS placement.

Predicting urinary tract infections in a urogynecology population.

A retrospective chart review was performed on all new patients presenting to a urogynecology clinic. Urine dipsticks, symptoms, and cultures were evaluated to identify urinary tract infections. The most sensitive result was for the combination of nitrites or leukocytes (59%) without significant change in specificity (95%) for either result individually. The addition of the statistically significant symptoms did not improve the outcome. Based on these findings, it was determined that no combination of dipstick and/or symptoms adequately predicted an infection to the point that a recommendation to dispense with the need for a culture in this urogynecology population could be made.

Factors influencing the long-term success of periurethral collagen therapy in the office.

INTRODUCTION: Glutaraldehyde crosslinked bovine collagen has been used for periurethral bulking for the treatment of urodynamic stress incontinence since 1989 with variable success. A retrospective study was undertaken to evaluate the factors involved in the long-term success of glutaraldehyde crosslinked bovine collagen used for periurethral bulking in the office. METHODS: Patients were followed objectively with stress testing after receiving periurethral collagen injection in the office under local anesthesia. Repeat injections were done as necessary during their follow-up appointments. The "success" group was defined as those women who demonstrated negative stress tests for over 1 year following their first injection. RESULTS: Nineteen of 184 women (10.3%) demonstrated negative stress tests for over 1 year following only one initial injection of glutaraldehyde crosslinked collagen. Their success lasted a mean of 829 days up to the time of follow-up. CONCLUSION: Prior anti-incontinence surgery was the one factor analyzed that showed a trend toward this long lasting success. No other factors were predictive of negative stress tests for over 1 year. Prior anti-incontinence surgery seems to represent a factor involved in the long-term success of periurethral bulking in the office with glutaraldehyde crosslinked bovine collagen for the treatment of urodynamic stress incontinence.

A prospective randomized trial using solvent dehydrated fascia lata for the prevention of recurrent anterior vaginal wall prolapse.

OBJECTIVE: This study was undertaken to compare outcomes after anterior colporrhaphy with and without a solvent dehydrated cadaveric fascia lata graft. STUDY DESIGN: A total of 162 women were enrolled in a prospective, randomized trial that evaluated the impact of a solvent dehydrated cadaveric fascia lata patch on recurrent anterior vaginal prolapse. Subjects were randomly assigned to standard colporrhaphy with or without a patch. Before and after surgery, subjects were evaluated by both the Baden-Walker and pelvic organ prolapse quantification systems. "Failure" was defined as stage II anterior wall prolapse or worse. RESULTS: Of 154 women randomly assigned (76 patch: 78 no patch), all underwent surgery and 153 (99%) returned for follow-up. Sixteen women (21%) in the patch group and 23 (29%) in the control group experienced recurrent anterior vaginal wall prolapse (P = .229). Only 26% of all recurrences were symptomatic. Concomitant transvaginal Cooper's ligament sling procedures were associated with a dramatic decrease in recurrent prolapse (odds ratio [OR] 0.105 , P < .0001). CONCLUSION: Solvent dehydrated fascia lata as a barrier does not decrease recurrent prolapse after anterior colporrhaphy. Transvaginal bladder neck slings were associated with a significant reduction in the risk of recurrent anterior wall prolapse.

The tensile strength of Cooper's ligament suturing: comparison of abdominal and transvaginal techniques.

This study was designed to compare the strength and position of sutures anchored into Cooper's ligament utilizing a minimally invasive transvaginal suturing technique, versus the 'open' abdominal approach. In 12 fresh cadavers, Cooper's ligament was accessed via abdominal and vaginal incisions. After randomization, polytetrafluoroethylene (00) sutures were spaced along one ligament with the transvaginal device (n=36). Contralaterally, sutures were placed abdominally (n=36). Progressive load was applied until suture breakage or dislodgement, and tensile strength was measured using a digital tensiometer. Peak tension averaged 14.5 psi for abdominal and 12.96 psi for vaginal (p=0.28). Suture breakage rather than ligament 'pullout' was more likely for abdominal (95 vs. 56%, p=0.0001). Vaginal and abdominal sutures demonstrated nearly identical mean distances from mid-symphysis (4.62 vs. 4.24 cm, p=0.56). Peak tension was not correlated with suture location (r2=0.17, p=0.28). We conclude that transvaginal suturing, using the minimally invasive device, achieved similar tensile strength and position to the open technique. Transvaginal sutures were associated with greater likelihood of ligament 'pullout' before suture breakage under maximal load; however, the clinical implications of this finding are uncertain.

Incidence of pubic osteomyelitis after bladder neck suspension using bone anchors.

OBJECTIVES: To determine the incidence of pubic osteomyelitis after bladder neck suspension using suprapubic bone anchors. METHODS: The target population consisted of 290 consecutive women who underwent bladder neck suspension using suprapubic bone anchors between June 1994 and November 1999 at two referral centers. A structured telephone questionnaire was designed to elicit any history of clinical symptoms suspicious for pubic osteomyelitis. Positive responses were followed up by a detailed review of the medical records. Nonresponders were evaluated by chart review, with negative cases included only if the documented follow-up reached 1 year. RESULTS: The sample consisted of 225 women, representing 77.6% of the study population, with a mean age of 69.7 years (range 40 to 88) and a mean follow-up of 31.8 months (range 13.4 to 42.2). Of the 225 women, 179 (80%) completed the telephone survey; 46 patients (20%) were evaluated by long-term chart review. Three patients (1.3%) reported positive responses to the screening questionnaire and were confirmed to have developed pubic osteomyelitis. Each had undergone exploratory laparotomy, anchor removal, bony debridement, and prolonged parenteral antibiosis. The most common noninfectious complaints were irritative voiding symptoms and pubic or groin pain responding to "conservative" therapy (3.5%), including 1 case of osteitis pubis. One subject underwent repeated operation because of erosion of the sling sutures into the bladder. CONCLUSIONS: The estimated incidence of osteomyelitis after bone-anchored bladder neck suspension was 1.3%. Although postoperative osteomyelitis is rare, each case incurs substantial morbidity and a complicated postoperative course.

The development of pelvic organ prolapse following isolated Burch retropubic urethropexy.

The purpose of our study was to examine the incidence of prolapse in a group of women who had had an isolated Tanagho modification of the Burch colposuspension performed without significant pelvic organ prolapse preoperatively. Sixty women were identified who underwent an isolated Burch procedure for genuine stress incontinence between 1991 and 1999. Thirty-four women returned for postoperative Pelvic Organ Prolapse Quantification (POP-Q) staging evaluation. Overall, 6 (17.6%) had stage II anterior prolapse. Eleven (32.4%) had stage II posterior prolapse. Three (8.8%) had stage II uterine prolapse. None of these patients with identified support defects was symptomatic. Two patients had subsequently undergone vaginal hysterectomy. One had this performed for dysfunctional uterine bleeding 3 years after her Burch procedure. One patient developed symptomatic uterine prolapse and underwent a vaginal hysterectomy 5 months after her Burch procedure. The majority of patients undergoing an isolated Tanagho modification Burch procedure without preoperative prolapse do not appear to be placed at increased risk for subsequent operative intervention.

The use of intraoperative cystoscopy in major vaginal and urogynecologic surgeries.

OBJECTIVE: Our purpose was to examine the frequency of significant intraoperative cystoscopic findings during major vaginal reconstructive and urogynecologic surgeries. STUDY DESIGN: The records of 526 consecutive women who underwent routine cystoscopy with intravenous injection of indigo carmine at the time of their urogynecologic and major vaginal reconstructive procedures between January 1, 1997, and April 20, 2001, were reviewed. We determined the incidence of significant cystoscopic findings and their effect on intraoperative management. Two-tailed t tests and logistic regression analyses were used to compare characteristics between the groups with and without significant cystoscopic findings. RESULTS: During the 526 operations, 26 significant findings (4.9%) were unsuspected before cystoscopy and 15 (2.9%) of these findings were operative injuries that required intervention. Seventy-nine subjects (15.0%) had no anti-incontinence operation performed. Of these patients, there was one partial ureteral obstruction from an anterior colporrhaphy (1.3%). Seven of 184 Burch procedures (3.8%) resulted in injuries to the lower urinary tract, of which 3 (1.6%) required intervention that were unrecognized before cystoscopy. Seven of the 15 cases resulting in changes in intraoperative management were caused by anterior colporrhaphy sutures (2.0% of all anterior colporrhaphies). There were no unrecognized injuries that caused morbidity after surgery. There were no significant differences between patients with abnormal and normal cystoscopic findings in regard to mean age, weight, parity, estimated blood loss, previous surgery, or previous incontinence surgeries. No complications or morbidity occurred as a direct result of intraoperative cystoscopy. CONCLUSION: Intraoperative cystoscopy with intravenous indigo carmine is a safe and effective way to detect injury of the lower urinary tract. Cystoscopy detected unsuspected operative injuries in 2.9%. In cases that did not involve anti-incontinence procedures, the rate of injury was 1.3%. With a significant rate of detection, cystoscopy allows for immediate recognition and easier repair of lower urinary tract injury, lowering the patient's risk for morbidity. Anterior colporrhaphy was the most common cause of unrecognized ureteral compromise.