Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis.

OBJECTIVE: To systematically review outcomes after mesh sacrocolpopexy compared with native tissue vaginal repairs in women with apical prolapse. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through June 4, 2012. METHODS OF STUDY SELECTION: For anatomic and functional analyses, we included studies comparing mesh sacrocolpopexy to native tissue vaginal repairs with at least 6 months follow-up. The primary outcome was anatomic "success" after surgery. Secondary outcomes were reoperation and symptom outcomes. We included large case series and comparative studies with shorter follow-up to increase power for adverse event analyses. TABULATION, INTEGRATION, AND RESULTS: Evidence quality was assessed with the Grades for Recommendation, Assessment, Development and Evaluation system. Meta-analyses were performed when at least three studies reported the same outcome. We included 13 comparative studies for anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supports improved anatomic outcomes after mesh sacrocolpopexy; very low-quality evidence shows no differences in reoperation between sacrocolpopexy and native tissue vaginal repairs. Evidence was insufficient regarding which procedures result in improved bladder or bowel symptoms. Low-quality evidence showed no differences in postoperative sexual function. Adverse event data were compiled and meta-analyzed from 79 studies. When including larger noncomparative studies, ileus or small bowel obstruction (2.7% compared with 0.2%, P<.01), mesh or suture complications (4.2% compared with 0.4%, P<.01), and thromboembolic phenomena (0.6% compared with 0.1%, P=.03) were more common after mesh sacrocolpopexy compared with native tissue vaginal repairs. CONCLUSION: When anatomic durability is a priority, we suggest that mesh sacrocolpopexy may be the preferred surgical option. When minimizing adverse events or reoperation is the priority, there is no strong evidence supporting one approach over the other.

The use of a Google search in the diagnosis of a rare condition.

BACKGROUND: This study aims to describe the use of the Internet in aiding the diagnosis of a rare lower urinary tract finding in a primiparous woman. METHODS: A case of bladder schistosomiasis was reviewed. RESULTS: After the referral from the obstetrics service with a bladder lesion noted on dating ultrasound, an asymptomatic primipara with 9 weeks of gestational age presented for cystoscopy. A polypoid lesion was noted, and suspected diagnosis of schistosomiasis was made using a Google image search. Urine cytologic evaluation confirmed the diagnosis, and the patient was treated without need for further invasive testing or bladder biopsy. CONCLUSIONS: The usefulness of Internet searches and other electronic resources should be appreciated in the diagnosis of rare conditions.

Vesicovaginal fistula due to remote history of vaginal foreign body.

OBJECTIVES: To report an interesting case of a young adult girl who developed a vesicovaginal fistula after removal of a vaginal foreign body. METHODS: A chart review was performed for a single patient from the time of presentation in July 2010 until final follow-up encounter. RESULTS: A 22-year-old nulliparous woman with a history of removal of a bottle cap from her vagina developed a large vesicovaginal fistula at the bladder neck, which was identified several years later. Closure was via vaginal approach without graft or flap interposition. CONCLUSIONS: Although fistula formation after foreign body identification is rare, early identification and appropriate surgical approach is important for improved patient outcomes.

Change in urethral sphincter neuromuscular function during pregnancy persists after delivery.

OBJECTIVE: The purpose of this study was to assess the effect of pregnancy and first vaginal delivery on urethral striated sphincter neuromuscular function. STUDY DESIGN: Quantitative electromyographic (EMG) interference pattern analysis of the urethral sphincter of 23 nulligravidas and 31 third trimester primigravidas allowed comparison of mean motor unit parameters before term vaginal delivery and postpartum. RESULTS: Mean electromyographic interference pattern parameters in the primigravidas were significantly lower than nulligravidas even antepartum, with decreased turns, lower amplitude, and less activity. The only significant change at 6 months' postpartum was further decline in number of turns resulting in a further decrease in turns:amplitude. All other electromyographic abnormalities persisted at 6 months' postpartum and remained abnormal compared to the nulligravidas. CONCLUSION: Urethral sphincter neuromuscular function changed significantly during pregnancy and these changes persisted postpartum. Lack of recovery 6 months' postpartum suggests a physiologic impact of pregnancy itself on future risk of urinary incontinence.

Levator ani denervation and reinnervation 6 months after childbirth.

OBJECTIVE: The objective of the study was to assess the prevalence of levator ani denervation and reinnervation 6 months after the first delivery. STUDY DESIGN: Ninety-six primigravida women underwent quantitative electromyography of the levator ani during the third trimester and twice postpartum. A 95% confidence interval for normal function was created using interference pattern analysis. Fifty-seven who completed the study are presented in this secondary data analysis. Postpartum muscle sites outside the normal range were considered abnormal. Obstetric and demographic characteristics were assessed. RESULTS: Of 57 subjects, 70% had no denervation. Of the 30% with denervation at 6 weeks, 35% recovered by 6 months. Obstetric or maternal characteristics were not predictive of denervation or reinnervation, except subjects with persistent denervation tended toward lower body mass index (BMI) independent of mode of delivery. CONCLUSION: Nearly one-third of women have levator ani denervation after first delivery, but many recover by 6 months. Denervation is not clearly associated with mode of delivery, but higher maternal BMI may be protective.

Early vs late midline sling lysis results in greater improvement in lower urinary tract symptoms.

OBJECTIVE: Lower urinary tract symptoms (LUTS) occur in 5-20% of women after antiincontinence procedures. Symptoms include complete urinary retention or storage, voiding, and postmicturition symptoms. The goal of this study was to determine the effect of time from sling placement to midline sling lysis on overall improvement in LUTS. STUDY DESIGN: After institutional review board approval, we conducted a retrospective cohort analysis of 112 subjects undergoing midline sling lysis from January 1997-September 2007. The inclusion criteria were women with a vaginal midline sling lysis for LUTS after a prior pubovaginal or midurethral sling. We excluded any subject with sling erosion without LUTS and those who underwent a repeated sling at the time of lysis. We compared subjects who had an early sling lysis (< or = 1 year from sling to lysis) to a late sling lysis (> 1 year). The primary outcome was based on the subject's report of overall improvement in symptoms. We abstracted data on demographics, presenting symptoms, physical examination, date of antiincontinence procedure, date of midline sling lysis, and postoperative symptoms. Statistical analysis consisted of Student t test, chi(2) test, Fisher exact test, and multivariate logistic regression. RESULTS: Of 112 subjects, 74 (66%) had an early sling lysis and 38 (34%) had a late sling lysis. These 2 groups were similar in age, menopausal status, presence of preoperative LUTS, anterior colporrhaphy at the time of lysis, and presence of an eroded sling. The early lysis group had a higher percentage of midurethral slings (36% vs 8%; P = .001), a lower rate of preoperative complete retention (70% vs 89%; P = .001), and a lower rate of prior urethrolysis (16% vs 45%; P = .003). No significant difference in follow-up time was found between early lysis compared with late lysis (49 +/- 89 months vs 43 +/- 71 months; P = .73). Ten (8.9%) subjects developed recurrent stress urinary incontinence after sling lysis, which was independent of time to lysis. In all, 94 (84%) subjects had improvement in their LUTS after midline sling lysis. Overall improvement occurred more often in the early sling lysis group compared with the late sling lysis group (91% vs 71%; P = .01). This finding retained significance in a multivariate logistic regression model, which included age, prior urethrolysis, preoperative complete retention, and type of sling (odds ratio, 4.0; 95% confidence interval, 1.2-13.2). CONCLUSION: Based on this large cohort, patients may benefit from earlier midline sling lysis within 1 year for LUTS after a pubovaginal or midurethral sling procedure. The development of recurrent stress urinary incontinence after midline sling lysis is relatively low.

Surgical excision of eroded mesh after prior abdominal sacrocolpopexy.

OBJECTIVE: We previously described an endoscopic-assisted transvaginal mesh excision technique. This study compares surgical outcomes after transvaginal mesh excision vs endoscopic-assisted transvaginal mesh excision. In addition, we reviewed our postoperative outcomes with excision via laparotomy. STUDY DESIGN: This was an inclusive retrospective analysis of patients presenting to our institution from 1997 to 2006 for surgical management of vaginal erosion of permanent mesh after sacrocolpopexy. Three techniques were utilized: transvaginal, endoscopic-assisted transvaginal, and laparotomy. For the patients undergoing transvaginal excision, data recorded included number and type of excisions performed, number of prior excisions performed at outside facilities, intraoperative and postoperative complications (including blood transfusions, pelvic abscess, or bowel complications), use of postoperative antibiotics, persistent symptoms of vaginal bleeding and discharge at follow-up, and demographic characteristics. The intraoperative and postoperative complications and the postoperative symptoms were recorded for the laparotomy cases. RESULTS: Thirty-one patients underwent transvaginal mesh excision during this time period: 17 endoscopic-assisted transvaginal and 14 transvaginal without endoscope assistance. In addition, a total of 7 patients underwent abdominal excision via laparotomy. Comparison of the 2 vaginal methods revealed no difference in the demographics or success rate, with success defined as no symptoms at follow-up. Endoscopic-assisted transvaginal excision was successful in 7 of 17 patients and transvaginal without endoscopic assistance in 9 of 13 patients (1 patient excluded for lack of follow-up data) for a total vaginal success rate of 53.3%. No intraoperative and only minor postoperative complications occurred with either vaginal method. Three patients underwent 3 vaginal attempts to achieve complete symptom resolution. The average follow-up time for the entire vaginal group was 14 months. Seven patients ultimately required abdominal excision and all had symptom resolution, however, not without complications. Two patients had bowel injury during lysis of adhesions requiring bowel resection in 1 case and repair in another, 1 had a postoperative wound infection with breakdown, 1 was readmitted for postoperative fever requiring antibiotics, and 1 had an acute coronary syndrome requiring transfer to the cardiology service. CONCLUSION: Transvaginal excision of mesh with or without endoscopy appears to be a safe and less invasive method for excision of eroded vaginal mesh after prior abdominal sacrocolpopexy. Up to 3 vaginal excision attempts may be necessary to achieve symptom resolution, and complete removal of mesh will likely improve outcomes with the transvaginal technique. Although abdominal excision can be considered the gold standard for excision of eroded mesh, it is not without potentially increased morbidity.

A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery.

OBJECTIVE: The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery. STUDY DESIGN: Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery. RESULTS: Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02). CONCLUSION: Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.

Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation.

The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.

The use of non-nutritive sucking to decrease the physiologic pain response during neonatal circumcision: a randomized controlled trial.

OBJECTIVE: The purpose of this research was to study the effects on the physiologic pain response of the neonate during circumcision with the use of a gloved human finger. STUDY DESIGN: This was a randomized controlled trial analyzing the effect of non-nutritive sucking (NNS) on pain response during circumcision. Term neonates were randomized to 2 groups. All infants received oral Tylenol and a dorsal penile nerve block (DPNB) before the circumcision. The study group was offered the addition of NNS before the DPNB and throughout the procedure. The primary outcome measured was heart rate during the circumcision. Other variables studied included crying time and salivary cortisol levels. Each circumcision was filmed to calculate pain profile scores using the Premature Infant Pain Profile. Variables were compared using Student t test, chi-square, and Wilcoxon test. A P value of < .05 was considered significant. RESULTS: Forty-four infants met inclusion criteria. Twenty-two infants were randomized to each arm. No difference in mean heart rate during the procedure was apparent. A significant decrease in crying time, 90-minute post-procedure salivary cortisol level, and post-penile clamping pain score was noted in the study group (all P values < .01). CONCLUSION: NNS significantly decreases some elements of measurable physiologic pain response of the neonate during circumcision. This method is a useful and inexpensive addition to DPNB and oral analgesics.