Surgical preparation: are patients "ready" for stress urinary incontinence surgery?

INTRODUCTION AND HYPOTHESIS: Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life. METHODS: The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ). RESULTS: Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008). CONCLUSIONS: Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.

Surgical management of uterine prolapse.

The surgical management of uterine prolapse requires an apical suspension procedure, with or without uterine removal. Options in the surgical treatment of uterine prolapse encompass the open, laparoscopic, or vaginal approaches. Vaginal apical suspension procedures include the uterosacral vaginal vault suspension, sacrospinous ligament fixation, iliococcygeus fascia suspension, and the McCall or Mayo culdoplasty. The abdominal sacral colpopexy may be performed via laparotomy or laparoscopy. Uterine preservation techniques include the Manchester procedure, sacrospinous hysteropexy, laparoscopic sacral hysteropexy and laparoscopic uterosacral vault suspension. Most of the data for subjective and objective outcomes for these prolapse procedures are from uncontrolled retrospective case series. Currently there is no definitive gold standard procedure to favor a particular route in the treatment of uterine prolapse. Thus, the optimal procedure to treat uterine prolapse depends on the specific defects that are present, as well as considerations such as the patient's age, comorbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, as well as the skill and comfort level of the surgeon with the particular surgery.

Randomised trial of laparoscopic Burch colposuspension versus tension-free vaginal tape: long-term follow up.

OBJECTIVE: To compare the long-term efficacy of laparoscopic Burch colposuspension with tension-free vaginal tape (TVT) for the treatment of urodynamic stress urinary incontinence (SUI). DESIGN: Long-term follow up from a prospective randomised trial. SETTING: Academic tertiary referral centre. SAMPLE: Seventy-two women with urodynamic SUI from two institutions. METHODS: Subjects were randomised to either laparoscopic Burch or TVT from August 1999 to August 2002. Follow-up evaluations occurred 6 months, 1 year, 2 years, and 4-8 years after surgery. MAIN OUTCOME MEASURES: Subjects completed the Incontinence Severity Index, Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Patient Global Impression of Improvement (PGI-I) scales. RESULTS: Median follow-up duration was 65 months (range 12-88 months) with 92% completing at least one follow-up visit. Seventy-four percent of subjects had long-term (4-8 years) follow up. Fifty-eight percent of subjects receiving laparoscopic Burch compared with 48% of TVT subjects reported any urinary incontinence 4-8 years after surgery (Relative Risk (RR):1.19; 95% CI: 0.71-2.0) with no significant difference between groups. Bothersome SUI symptoms were seen in 11 and 8%, respectively, 4-8 years after surgery (P = 0.26). There was significant improvement in the postoperative UDI-6 and IIQ-7 scores in both groups at 1-2 years that were maintained throughout follow up with no significant differences between the groups. CONCLUSIONS: TVT has similar long-term efficacy to laparoscopic Burch for the treatment of SUI. A substantial proportion of subjects have some degree of urinary incontinence 4-8 years after surgery; however, the majority of incontinence is not bothersome.

Laparoscopic surgery for pelvic organ prolapse.

There is growing interest in laparoscopic procedures for the correction of pelvic organ prolapse. The goals of prolapse surgery are to correct symptomatic pelvic floor defects and reestablish vaginal support resulting in the maintenance or restoration of normal visceral and sexual function. A thorough understanding of pelvic floor support as well as anterior abdominal wall and intra-abdominal, pelvic, and retropubic anatomy must be ascertained before attempting laparoscopic prolapse procedures. As many of these procedures require advanced laparoscopic skills and experienced surgeons, most of the literatures are comprised of case series by expert surgeons, with many of the studies centered on sacral colpopexies. However, the principles of laparoscopic prolapse surgery are based on open procedures and the only difference in the technique should be related to the route of operation; therefore, the efficacy of laparoscopic prolapse procedures should theoretically be comparable to their open abdominal counterparts.