Bowel function after minimally invasive urogynecologic surgery: a prospective randomized controlled trial.

OBJECTIVES: The goals of this study were to assess the effect of a standardized postoperative bowel regimen of over-the-counter medications on (1) time to first bowel movement (BM) and (2) pain level associated with first BM in subjects undergoing minimally invasive urogynecologic surgery. METHODS: Eligible patients scheduled to undergo minimally invasive urogynecologic surgery were offered participation. Enrolled subjects were randomized by computerized schedule. Demographic and perioperative data were collected. Subjects completed a validated questionnaire preoperatively and postoperatively assessing preexisting constipation, frequency and consistency of bowel movements, use of pain medications, mean daily pain level (using visual analog scale), stool consistency, and pain associated with first postoperative bowel movement. The control group was instructed to take docusate sodium twice daily postoperatively. The treatment group took docusate sodium plus Miralax, fiber wafers, and bisacodyl suppositories as directed by protocol. Wilcoxon or t testing was used to compare continuous variables; χ testing was used for categorical relationships, and backward-elimination multiple regression was used to assess independent effects. RESULTS: Seventy-two subjects were enrolled and randomized. Twelve subjects withdrew, leaving 60 (30 per group) completing the study. There were no statistically significant differences between groups in baseline characteristics. Mean (SD) age was 63 (9) years for the control group and 58 (10) for the study group (P = 0.06). Mean pelvic organ prolapse stage was III in each group. The mean (SD) operating room time was 198 (65) minutes for the controls and 216 (74) for the study subjects. Sixty-five percent underwent robot-assisted surgery (50% hysterectomy and 63% sacrocolpopexy). Ninety-eight percent of surgeries were performed under general anesthesia.Before adjustment, the mean (SD) time to first BM was 77 (24) hours in controls versus 64 (21) in the study patients (P = 0.03). Using multiple regression, baseline frequency of defecation (1-2 BMs/wk) was directly associated with the time to first BM (added 25.2 hours; P = 0.009) and being in the study group was inversely associated (first BM, 11.7 hours sooner; P = 0.04). No other variables were retained.There was no difference in pain associated with first postoperative BM (visual analog scale, 3.6 (3.2) vs 3.7 (2.8); P = 0.98), but those with prior complaints of vaginal or rectal splinting had higher pain scores (1.9 and 2.8 points higher, respectively; P = 0.04 for both). There was a trend toward higher pain scores with higher postoperative daily narcotic intake (P = 0.06). No other variables were retained.There was a significant difference in recorded compliance between control versus study regimens (94% vs 81%, respectively; P = 0.002). CONCLUSIONS: Mean time to first postoperative BM after minimally invasive urogynecologic surgery is more than 3.5 days with use of docusate sodium alone and is only slightly shorter when combination therapy is used. First BM after surgery is considered to be painful despite the use of medications. Future studies targeting postoperative discomfort/pain with defecation could target preoperative bowel regimens or more aggressive postoperative interventions. Regimens should remain simple to increase compliance.

The effect of intrapartum clindamycin on vaginal group B streptococcus colony counts.

OBJECTIVE: To determine the temporal relationship between intrapartum clindamycin and vaginal Group B Streptococcus (GBS) colony counts. METHODS: In this prospective observational study, women with GBS-positive, clindamycin-sensitive, antenatal rectovaginal cultures, intrapartum vaginal cultures were collected just before the first clindamycin dose (T(0)) and then every 2 h for 8 h or until delivery. Colony counts were quantified using serial dilution. Results were standardized as percent of initial colony count and analyzed using sequential Friedman tests. RESULTS: Twenty-one women had positive intrapartum vaginal GBS cultures at T(0). With T(0) colony counts standardized to 100%, subsequent percents-of-baseline fell rapidly and significantly by T(2) and fell further at each subsequent point, reaching 0% by T(6). For 12 women cultured for the full 8 hours, the decline in GBS was significant at p < 0.001. CONCLUSIONS: Vaginal GBS colony counts fall rapidly after intrapartum clindamycin administration, similar to declines after penicillin. This represents a possible mechanism for efficacy of chemoprophylaxis.

Recovery after robot-assisted laparoscopic sacrocolpopexy: the patients' perspective.

Little information exists about recovery after robot-assisted laparoscopic sacrocolpopexy. We sought to report on subjects' perioperative experience. Subjects were queried about resumption of activities such as work and driving, bowel function, whether recovery went as expected, and whether they would recommend this surgery. Use of pain medications, pain scores, and perioperative data were collected N = 21. All would recommend surgery to a friend. 13/18 (72%) felt their recovery went better than expected, and none responded it was worse than expected. 9/21 (43%) did not use narcotics after the day of surgery, with 15/21 (71%) no longer taking narcotics by postoperative day 4. Fifty-five percent experienced their first postoperative bowel movement as painful. Based on this survey, most patients undergoing robot-assisted laparoscopic sacrocolpopexy will not require narcotics beyond postoperative day 3. Nonsteroidals are the mainstay of pain management. This survey highlights the importance of preventing postoperative constipation/ painful defecation.

Symptom-based, clinical, and urodynamic diagnoses of urinary incontinence: how well do they correlate in postmenopausal women?

OBJECTIVE: : The objective of this study was to determine the correlation between symptom-based, clinical, and urodynamic (UD) diagnoses of urinary incontinence in postmenopausal women. METHODS: : This is a review of results of UD findings in postmenopausal women with signs and/or symptoms of urinary incontinence. Positive predictive values (PPVs) were calculated for symptom-based and clinically assigned diagnoses by subtype of incontinence and UD diagnosis. RESULTS: : A total of 105 postmenopausal women with signs and/or symptoms of urinary incontinence underwent UD testing. Subjects were predominantly white (95.1%), with average age 61 (SD, ±9). Overall, symptom diagnosis matched UD diagnosis 27% of the time. Similarly, clinical diagnosis matched UD diagnosis 27% of the time. All 3 diagnoses (symptom, clinical, and UD) matched 18% of the time. Report of urine loss with Valsalva had a PPV of 0.57, for UD diagnosis of stress incontinence. For symptoms of urge and mixed incontinence, PPVs were 0.22 and 0.11, respectively. Clinical diagnoses of stress, urge, and mixed incontinence as compared with UD diagnosis showed PPVs of 0.64, 0.30, and 0.09, respectively. PPV for any UD diagnosis of incontinence was 0.69 by symptoms and 0.71 by clinical evaluation. CONCLUSIONS: : The correlation between type of urinary incontinence based on symptoms, clinical evaluation, and UD findings is poor overall in postmenopausal women. It is highest with stress and lowest with mixed incontinence. The voiding diary and cough stress test are valuable tools in predicting type of incontinence by UD testing.

Urodynamic prediction of occult stress urinary incontinence before vaginal surgery for advanced pelvic organ prolapse: evaluation of postoperative outcomes.

OBJECTIVES: : To evaluate the use of urodynamics for assessment of occult stress urinary incontinence (SUI) in women undergoing vaginal surgery for advanced pelvic organ prolapse (POP). METHODS: : Retrospective chart review of women who underwent vaginal surgery for advanced POP at the University of Rochester Medical Center. RESULTS: : The study sample was composed of 41 women (mean age: 65.6 years; range: 42-88 years). Prolapse was stage 3 or 4 in 40 (97.6%) women. Urodynamics identified 17 (41.5%) women with occult SUI. Postoperatively, 3 (7.3%) women reported urinary incontinence: 1 with stress and 2 with urge-related symptoms. The woman with postoperative SUI had been diagnosed with occult SUI, but declined continence repair. None of the women without occult SUI on urodynamics reported postoperative SUI. CONCLUSIONS: : Urodynamic evaluation prior to vaginal surgery for advanced POP can identify women at risk for SUI, who may benefit from concomitant continence repair.

Uroflow measurements in healthy female volunteers.

OBJECTIVE: : There is not currently a standard definition of "normal" for uroflowmetry parameters, particularly with respect to spontaneous voids or multiple repeated measurements within an individual. Our study aimed to describe uroflow parameters for "normal" in a group of healthy women based on repeated measurements. METHODS: : Spontaneous voids of twelve healthy women were recorded over two weeks. Additionally, one prompted void per subject was recorded. Prompted voids were compared to the subjects' spontaneous voids. These voids were also compared to those of patients evaluated for urinary incontinence. Groups were compared using paired t tests. RESULTS: : The mean voided volume was 306 ml and the mean maximum flow rate was 49 ml/s. The prompted voids were lower in volume, maximum flow, and duration than spontaneous voids. When corrected for volume, these differences were not significant. Maximum flow rates in patients evaluated for urinary incontinence were lower than those of volunteers. CONCLUSIONS: : Uroflowmetry parameters vary widely between and within healthy volunteers. Prompted voids are representative of spontaneous voids. Maximum flow rates of patients evaluated for urinary incontinence were lower than those of volunteers. In a group of healthy volunteers voiding in a private, spontaneous setting, a maximum flow rate of lower than 17 ml/s (2 SDs below the mean) might be considered abnormally low.

TVT or TOT? When to avoid retropubic trocar passage.

Most surgeons have a preferred method for placing a minimally invasive suburethral sling for treatment of stress urinary incontinence. However, unique clinical circumstances may necessitate altering this approach. We describe two cases for which a retropubic approach to sling placement may be contraindicated.

Inherited pelvic organ prolapse in the mouse: preliminary evaluation of a new murine model.

The objective of this study was to report the initial anatomic, radiographic, and genetic evaluations of a novel form of spontaneous pelvic organ prolapse (S-POP) in mice. We observed S-POP in a colony of UPII-SV40T transgenic mice developed for studies on bladder cancer. We utilized magnetic resonance imaging and necropsy to characterize this finding. We have established a breeding colony to identify inheritance patterns and for future studies. Selective breeding isolated the S-POP phenotype from the transgene. In contrast to other animal models, the S-POP mouse does not require an obligatory antecedent event to manifest pelvic organ prolapse. Necropsy and imaging demonstrate significant displacement of the pelvic organs distal to the pelvic floor in both sexes. The appearance of the POP is similar to that seen in the human female phenotype. Preliminary breeding studies indicate an autosomal dominant inheritance pattern. This mouse may be an effective animal model for the study of POP in humans.

The effect of intrapartum penicillin on vaginal group B streptococcus colony counts.

OBJECTIVE: The objective of the study was to determine the temporal relationship between intrapartum penicillin-G (PCN-G) and vaginal group B streptococcus (GBS) counts. STUDY DESIGN: In 50 women with GBS-positive antenatal cultures, intrapartum cultures were collected just before the first PCN-G dose and every 2 hours x 4 or until delivery. Colony counts were quantified using serial dilution. Results were standardized as percent of initial colony count and analyzed using sequential Wilcoxon tests. RESULTS: Of 50 subjects with GBS-positive antepartum cultures, 35 (70%) had positive intrapartum vaginal cultures, of which 27 received intrapartum PCN-G. Degree of vaginal colonization varied greatly between subjects, and counts (percents) were not normally distributed. From the T(0) (time = zero) colony count standardized to 100%, counts fell rapidly to means +/- SE and medians of 18.2 +/- -7.5% and 0.5% at T(2) (P < .0001), 2.5 +/- 1.7% and 0.02% at T(4) (P = .006), and less than 0.2% and 0.0% at T(6 and 8) (P = .07 and P = .46, respectively). CONCLUSION: Vaginal GBS colony counts fall rapidly after intrapartum PCN-G administration, which may partly explain the effectiveness of chemoprophylaxis.