Body image, regret, and satisfaction following colpocleisis.

OBJECTIVE: Colpocleisis is a definitive surgical treatment for prolapse resulting in vaginal obliteration. We sought to evaluate body image, regret, satisfaction, and pelvic floor symptoms following this procedure. STUDY DESIGN: This was a prospective multicenter study through the Fellows' Pelvic Research Network. All women electing colpocleisis for management of pelvic organ prolapse were screened for enrollment. The Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory, and the modified Body Image Scale (BIS) were completed preoperatively and 6 weeks following surgery. Additionally, the Decision Regret Scale and the Satisfaction with Decision Scale were administered at the 6-week postoperative visit. A sample size of 88 subjects was calculated to evaluate change in the BIS score. RESULTS: In all, 87 patients were analyzed. Mean age was 79 years (SD 5.8) with a mean body mass index of 27 (SD 5.3). The majority (89.3%) was Caucasian. Six weeks after surgery, significant improvements were noted in all parameters. Mean BIS scores decreased from 4.8 to 1.2 (P < .001), signifying improved body image. Indeed, the overall number of subjects with BIS scores in the normal range doubled after surgery. Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores decreased significantly (P < .001 and P < .001), suggesting a positive impact on bladder, bowel, and prolapse symptoms. Finally, low levels of regret (mean score 1.35) and concurrent high satisfaction (mean score 4.73) were documented. CONCLUSION: Colpocleisis improves body image and pelvic floor symptoms while giving patients a definitive surgical option that results in low regret and high satisfaction.

A case-control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery.

OBJECTIVE: To identify risk factors leading to the development of postoperative ileus and small-bowel obstruction (SBO) after benign gynecologic surgery. METHODS: In a multicenter case-control study across the United States, data were examined from women with International Classification of Diseases 9 (ICD-9) and Current Procedural Terminology (CPT) codes who underwent benign gynecologic surgery between January 2005 and June 2010 and subsequently developed an ileus or SBO. Each patient with ileus or SBO was matched to 2 control women who underwent the same benign gynecologic procedure but did not develop ileus or SBO. RESULTS: During the study period, 144 cases and 288 controls were identified. By conditional multivariate logistic regression, risk factors for ileus or SBO included cystotomy (odds ratio [OR], 8.7; 95% confidence interval [CI], 1.48-51.47), concomitant bowel surgery (OR, 4.3; 95% CI, 1.18-15.78), perioperative transfusion (OR, 2.9; 95% CI, 1.44-5.95), and lysis of adhesions (OR, 1.7; 95% CI, 1.03-2.83). CONCLUSION: Lysis of adhesions, concomitant bowel surgery, and perioperative complications such as blood transfusion and cystotomy were found to be risk factors for the development of ileus and/or SBO after benign gynecologic surgery.

Biologic grafted repair of urethrovaginal fistula and concomitant synthetic sling.

The utilization of a biologic graft interposition allows for a successful fistula repair and concomitant synthetic sling without an increase in complications.

Obliterative LeFort colpocleisis in a large group of elderly women.

OBJECTIVE: To report on anatomical and functional outcomes, patient satisfaction, and associated morbidity and mortality in patients undergoing LeFort colpocleisis. METHODS: This was a retrospective case series of LeFort colpocleisis performed from January 2000 to October 2011. Data obtained from a urogynecologic database included demographics, comorbidities, medications, and urinary and bowel symptoms. Prolapse was quantified using the pelvic organ prolapse quantification (POP-Q) examination. Operative characteristics were recorded. All patients underwent pelvic examination and POP-Q assessment at follow-up visits. Patients also were asked about urinary and bowel symptoms as well as overall satisfaction. All intraoperative and postoperative surgical complications were recorded. RESULTS: Three hundred twenty-five patients underwent LeFort colpocleisis. Fifteen patients were excluded from the analysis because of incomplete data. The mean age was 81.3±5.3 years. Comorbidities were common, with 74.1% of the patients having at least one concomitant medical condition. The procedure was performed under spinal anesthesia in 67%. Additional procedures at the time of colpocleisis included incontinence procedures (79%) and dilation and curettage (46%). Mean follow-up was 45 (range 2-392) weeks. Anatomical success rate was 98.1% and patients were highly satisfied, with 92.9% reported being "cured" or "greatly improved." Complication and mortality rates were 15.2% and 1.3%, respectively. CONCLUSION: Colpocleisis is an effective and low-risk procedure with high anatomical success rates and patient satisfaction. Associated morbidity and mortality related to the procedure are low. Colpocleisis remains an excellent surgical option for the elderly patient with advanced pelvic organ prolapse. LEVEL OF EVIDENCE: III.

Management of ileus and small-bowel obstruction following benign gynecologic surgery.

OBJECTIVE: To describe practice preferences for the diagnosis and management of ileus and small-bowel obstruction (SBO) following benign gynecologic surgery. METHODS: A secondary descriptive analysis was performed on data from a multicenter case-control study of patients who underwent gynecologic surgery and subsequently developed ileus or SBO. Information was collected regarding interventions such as type of imaging ordered for diagnosis, diet alterations, antiemetic administration, and need for reoperation. RESULTS: In total, 144 cases were identified. Abdominal X-ray was the most common imaging modality, occurring in 54 (37.5%) cases. Sixty-nine (65.1%) of the 106 women who underwent imaging were given definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]); 57.9% (n=11) of the SBO diagnoses and 90.0% (n=45) of the ileus diagnoses were managed conservatively. Eighteen (12.5%) patients underwent reoperation for bowel obstruction. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P=0.18), or between diet statuses on postoperative day 1 (P=0.08). CONCLUSION: Most study centers initially performed an abdominal X-ray for diagnostic purposes. The majority used a multimodal treatment approach. None of the management options decreased the likelihood of reoperation.

Spanish translation and validation of four short pelvic floor disorders questionnaires.

INTRODUCTION AND HYPOTHESIS: Globally, Spanish is the primary language for 329 million people; however, most urogynecologic questionnaires are available in English. We set out to develop valid Spanish translations of the Questionnaire for Urinary Incontinence Diagnosis (QUID), the Three Incontinence Questions (3IQ), and the short Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7). METHODS: The TRAPD method (translation, review, adjudication, pretesting, and documentation) was used for translation. Eight native Spanish-speaking translators developed Spanish versions collaboratively. These were pretested with cognitive interviews and revised until optimal. For validation, bilingual patients at seven clinics completed Spanish and English questionnaire versions in randomized order. Participants completed a second set of questionnaires later. The Spanish versions' internal consistency and reliability and Spanish-English agreement were measured using Cronbach's alpha, weighted kappa, and intraclass correlation coefficients. RESULTS: A total of 78 subjects were included; 94.9 % self-identified as Hispanic and 73.1 % spoke Spanish as their primary language. The proportion of per-item missing responses was similar in both languages (median 1.3 %). Internal consistency for Spanish PFDI-20 subscales was acceptable to good and for PFIQ-7 and QUID excellent. Test-retest reliability per item was moderate to near perfect for PFDI-20, substantial to near perfect for PFIQ-7 and 3IQ, and substantial for QUID. Spanish-English agreement for individual items was substantial to near perfect for all questionnaires (kappa range 0.64-0.95) and agreement for PFDI-20, PFIQ-7, and QUID subscales scores was high [intraclass correlation coefficient (ICC) range 0.92-0.99]. CONCLUSIONS: We obtained valid Spanish translations of the PFDI-20, PFIQ-7, QUID, and 3IQ. These results support their use as clinical and research assessment tools in Spanish-speaking populations.

Repeat versus primary slings in patients with intrinsic sphincter deficiency.

INTRODUCTION AND HYPOTHESIS: Our goal was to compare outcomes of repeat vs. primary synthetic slings in patients with stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). MATERIALS AND METHODS: We reviewed patients who underwent a sling for SUI with ISD from 2003 to 2010. The patients were divided into two groups according to whether they underwent primary or repeat sling. Surgical success was defined as no incontinence and no reintervention (i.e., urethral bulking) during follow-up. Statistical analysis included the unpaired t test, Wilcoxon rank sums test, chi-squared/Fisher's exact tests, and logistic regression to identify risk factors associated with failure. RESULTS: Six hundred and thirty-seven patients with ISD underwent a sling procedure at our institution; 557 (87 %) a primary sling and 80 (13 %) a repeat sling. Patient demographics were similar. Preoperatively, patients with recurrent SUI reported more subjective bother. Mean follow-up was 66.5 weeks (24-374). Success was achieved in 81 % of primary compared with 55 % of repeat slings (p<0.0001). Repeat patients were 3.4 times more likely to fail surgery [odds ratio (OR) =3.43, 95 % confidence interval (CI) 2.1-5.6]. Additionally 30 % of the repeat group underwent urethral bulking postoperatively compared with 8.6 % in the primary group (OR=4.4, 95 % CI 2.5-7.7). Prior incontinence procedures, a positive supine stress test, and transobturator sling were independent risk factors for failure. Among the types of slings placed (transobturator, retropubic, tensioned pubovaginal), pubovaginal slings were most successful (OR=2.7, 95 % CI 1.4-5.2). CONCLUSION: In women with ISD, repeat slings are associated with lower success rates compared with primary slings. Pubovaginal slings resulted in the highest success rate compared with both transobturator and retropubic slings.

Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: outcomes based on location and periurethral distribution of the bulking agent.

INTRODUCTION AND HYPOTHESIS: Our aim was to use three-dimensional enodovaginal ultrasound (3D EVUS) to identify sonographic parameters that are associated with successful outcomes following injection of Macroplastique. METHODS: Three hundred and sixty degree 3D EVUS was performed in 100 treatment-naïve patients following Macroplastique injection. The location, volumes, periurethral distribution, and distance of the hyperechoic densities from the urethrovesical junction were assessed. The patients were divided into two groups: group A (n = 72): patients who had good clinical outcome and group B (n = 28): patients who were not improved or worsened. The two groups were compared with respect to the ultrasound parameters measured. RESULTS: Group A had a greater proportion of women with Macroplastique located in the proximal urethra, while midurethral location was found to be significantly more frequent in group B (p = 0.036). The odds of a circumferential periurethral distribution in group A were 13.62 times the odds in group B (95% CI: 5.12-56.95). When the location of the injection and the type of periurethral distribution were considered together, it was found that when the site of injection was proximal, the odds of circumferential distribution in group A was significantly greater than those in group B (odds ratio [95% CI]: 22 [3.05-203.49]; p < 0.001). CONCLUSION: Proximally located Macroplastique and circumferential periurethral distribution of Macroplastique are individually associated with successful outcomes following the injection. The combination of circumferentially distributed and proximally located Macroplastique is associated with the best short-term clinical outcomes.

Reattachment of the endopelvic fascia to the apex during anterior colporrhaphy: does the type of suture matter?

INTRODUCTION AND HYPOTHESIS: We aimed to determine if the use of permanent suture for the apical fixation during traditional anterior colporrhaphy results in improved outcomes compared to delayed absorbable suture. METHODS: A retrospective case-control study was performed in patients who underwent traditional non-grafted anterior colporrhaphy with reattachment of the anterior endopelvic fascia to the apex/cervix comparing permanent (group 1) or absorbable suture (group 2). Patients were matched based on age, body mass index, and presenting stage of prolapse. The primary outcome assessed was anterior wall vaginal prolapse recurrence defined as Pelvic Organ Prolapse Quantification (POP-Q) points Aa or Ba ≥ -1 cm. Secondary outcome measures included overall prolapse stage, subjective reporting of satisfaction, and any healing abnormalities or complications resulting from suture type. RESULTS: A total of 230 patients were reviewed (80 in group 1 and 150 in group 2) and median follow-up was 52 (24-174) weeks. A statistically significant improvement in anterior wall anatomy was seen in group 1 compared to group 2 [(Aa -2.70 ± 0.6 cm vs -2.5 ± 0.75 cm, p = 0.02) and Ba (-2.68 ± 0.65 cm vs -2.51 ± 0.73 cm, p = 0.03), respectively]. Comparing prolapse stage, there were no observed differences between the groups. Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure. CONCLUSIONS: Reattachment of endopelvic fascia to the apex at the time of anterior colporrhaphy results in low recurrence rates. Use of permanent suture for apical fixation is associated with improved anatomic correction at the expense of increased suture exposures.

Predictors of successful salpingo-oophorectomy at the time of vaginal hysterectomy.

STUDY OBJECTIVE: To determine prognostic factors related to successful salpingo-oophorectomy in menopausal women at the time of vaginal hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force Classification II-2). SETTING: Tertiary care center. PATIENTS: A total of 309 postmenopausal ≥60 years old with pelvic floor disorders. INTERVENTIONS: Vaginal hysterectomy with attempted prophylactic salpingo-oophorectomy. MEASUREMENTS: Factors associated with ability to achieve vaginal salpingo-oophorectomy. MAIN RESULTS: 203 (65.7%) achieved successful removal of 1 or both ovaries, and 106 (34.3%) were not amenable to removal. Younger age and shorter cervical length were predictors of salpingo-oophorectomy. Cervical elongation of ≥7 cm, exteriorized cervical/uterine prolapse, and anterior vaginal wall prolapse beyond the hymen were associated with lower likelihood of achieving salpingo-oophorectomy. CONCLUSIONS: Patient age and cervical length are independent factors that influence the success of accomplishing salpingo-oophorectomy at the time of vaginal hysterectomy.

LeFort colpocleisis and stress incontinence: weighing the risk of voiding dysfunction with sling placement.

INTRODUCTION AND HYPOTHESIS: This study aims to evaluate clinical outcomes of concomitant suburethral sling with LeFort colpocleisis including its effect on postoperative voiding. METHODS: We performed a retrospective review of all LeFort colpocleisis procedures from our institution. We reviewed demographics, symptoms of stress urinary incontinence, incontinent events/day, pads usage/day, urodynamic parameters, and presence of voiding dysfunction. RESULTS: Two hundred ten patients underwent colpocleisis during the study period. Mean age was 82.2 ± 4.9 and median follow-up was 22 weeks (2-169). Preoperatively, 73 (35%) complained of stress urinary incontinence (SUI) symptoms, and an additional 105 (50%) were diagnosed with occult SUI. One hundred sixty-one (77%) patients underwent concurrent suburethral sling. Overall, sling placement resulted in a 92.5% subjective stress continent rate. Fifty-six patients presented with voiding dysfunction (VD). Postoperatively, VD resolved in 91%. De novo VD occurred in two patients (1.9%) and one (0.6%) required sling revision. CONCLUSIONS: Sling placement at time of colpocleisis is associated with high continence rates with minimal risk of postoperative voiding dysfunction.

An inexpensive polypropylene patch sling for treatment of intrinsic sphincteric deficiency.

STUDY OBJECTIVE: To evaluate an inexpensive polypropylene sling in patients with intrinsic sphincteric deficiency (ISD). DESIGN: Case series (Canadian Task Force classification II-2). SETTING: Cleveland Clinic Florida teaching hospital. PATIENTS: Analysis of 161 patients with ISD who underwent a surgeon-assembled polypropylene (Prolene) patch sling procedure. INTERVENTION: Polypropylene patch sling surgery was performed in all study patients with urinary stress incontinence due to ISD. MEASUREMENTS AND MAIN RESULTS: All patients underwent urogynecologic evaluation including multichannel urodynamics. Outcome measures included a standardized stress test, patient-reported cure rate, surgical complications, and postoperative voiding dysfunction. Medical records for the 161 patients who underwent the procedure were available for review. Mean patient age was 62.4 years. Twenty-five patients (16%) had concomitant detrusor overactivity. Mean follow-up was 3.6 years. The stress test yielded negative findings in 93.4% of patients. Complete continence was reported by 80.3% of patients, and marked improvement by 7%. The estimated cost of the sling was $17 to $272, depending on the materials used. Two patients experienced urinary retention requiring urethrolysis. Three required sling revision because of healing problems. CONCLUSION: Use of a polypropylene patch sling is an effective treatment for ISD and is less expensive than currently available sling kits.

Survey of obstetrics and gynecology residents' training and opinions on robotic surgery.

To investigate obstetrics and gynecology residents' access to training in robotics and their opinions of its utility and future in gynecologic surgery a 31-item questionnaire was developed and distributed to Ob/Gyn residents in the United States via email. Results were tabulated via SurveyMonkey.com(©). A total of 470 residents representative of all ACOG districts and PGY levels responded. A total of 72% of residents reported ≥3 staff surgeons performing robotic gynecologic surgery at their institution and 70% had participated in robotic surgery in the past 12 months. Robotic hysterectomy (81%) and oncologic surgery (76%) were the most frequently performed procedures. A total of 79% believe their institution should provide formal training in robotics, but only 38% report access to it. A total of 23% have operated at the surgeon console, and 44% plan to incorporate robotic surgery into their practice after completing residency. A total of 3.6% feel equipped to perform robotic surgery without additional training. A total of 63% believe robotic surgery in gynecology will continue to increase in popularity. Exposure to gynecologic robotic procedures during residency is increasing. Although residents believe robotics has a place in gynecology, many feel formalized training has not been successfully implemented into their residency. Development of a structured program for training residents in robotics merits further investigation.