Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared.

METHODS OF STUDY SELECTION

In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted.

TABULATION, INTEGRATION, AND RESULTS

Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39).

CONCLUSION

Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022326255.

Pain Related to Intradetrusor BotulinumtoxinA: A Randomized Clinical Trial

IMPORTANCE

OnabotulinumtoxinA (BTX-A) is an effective treatment for overactive bladder (OAB), but few studies have been done to evaluate injection techniques.

OBJECTIVE

The primary objective was to evaluate procedural discomfort between 2 commonly used injection techniques for BTX-A.

STUDY DESIGN

This was a single-blinded, randomized clinical trial of women undergoing injection of 100 U BTX-A for idiopathic OAB. Patients were randomized to 5 mL/5 injection or 10 mL/10 injection groups. Bladder pain was assessed by a validated Numeric Pain Rating Scale. Overactive bladder symptoms were assessed with a standardized questionnaire (Overactive Bladder Questionnaire Short Form). Patient satisfaction, treatment efficacy, and adverse events were assessed at 30 days after procedure.

RESULTS

One hundred eight patients were randomized to 52 in the 5 mL/5 injection arm and 56 in the 10 mL/10 injection arm. Mean procedural pain scores were 3.2 (±2.3) in the 5 mL/5 injection group versus 3.6 (±2.1) in the 10 mL/10 injection group (P = 0.21). No difference was found when categorizing pain scores into ordinal outcomes of low (P = 0.55), medium (P = 0.70), and high (P = 1.0) or a binary outcome of low (P = 0.55) versus medium + high (P = 0.55). Multivariate analyses did not effect statistical significance between the 2 groups for the ordinal outcome (odds ratio = 1.86; 95% confidence interval = 0.77 = 4.52; P = 0.17) or the binary outcome (odds ratio = 1.81; 95% confidence interval = 0.68-4.77; P = 0.28). No difference was observed between overall patient satisfaction, global impression of improvement, Overactive Bladder Questionnaire Short Form scores, or adverse outcomes.

CONCLUSIONS

Procedural discomfort related to BTX-A injection for idiopathic OAB was not different between 2 injection protocols. Overall satisfaction was high for both groups, and there was no difference in symptom scores or adverse events.

Repair of Vesicovaginal Fistulae: A Systematic Review

OBJECTIVE

To assess and compile the current level of evidence regarding successful surgical treatment of vesicovaginal fistulae and how these perioperative interventions affect anatomic, patient-centered, and adverse outcomes.

DATA SOURCES

PubMed and EMBASE were searched from inception through September 9, 2022.

METHODS OF STUDY SELECTION

This review included comparative studies (of any sample size) and single-group studies (1,000 or more participants) of primary or recurrent vesicovaginal fistula (ie, vesicovaginal fistula, urethrovaginal fistula, and bladder neck-vaginal fistula). We evaluated preintervention assessment or management, various techniques for intraoperative management, and postoperative management. Outcomes of interest included anatomic and objective outcomes (such as successful repair, fistula closure, urinary incontinence, recurrent fistula, perioperative complications) and subjective outcomes (such as voiding symptoms and quality of life). Abstracts and full-text articles were screened in duplicate, and study descriptions and findings were extracted into standardized extraction forms. Risk of bias was assessed independently by two investigators and adjudicated by a third. Study quality was summarized with standardized tools. We conducted random-effects model and restricted maximum-likelihood meta-analyses of relative risks when at least three studies compared similar interventions and reported similar outcome measures.

TABULATION, INTEGRATION, AND RESULTS

Forty-six studies met the inclusion criteria. Studies were categorized into 11 domains: 1) preoperative assessment, 2) preoperative and postoperative physical therapy, 3) route of surgery, 4) incorporation of a flap, 5) trimming, 6) layered closure, 7) intraoperative antibiotics, 8) fibrin glue, 9) fascial sling, 10) postoperative Foley catheter duration, and 11) quality of life. Although the strength of the data is insufficient, preoperative phenazopyridine, physical therapy, layered closure, and intraoperative antibiotics seemed to improve the rate of successful fistula repair. Route of surgery (vaginal vs abdominal laparotomy) was determined primarily by surgeon preference and showed no difference in successful fistula repair. In addition, use of interpositional flaps, trimming fistula edges, fibrin glue, and fascial sling did not show significant improvement in rates of fistula cure. Overall, quality-of-life scores improved postoperatively regardless of route of repair and use of interpositional flaps.

CONCLUSION

Our findings highlight the limited information available to guide evidence-based treatment of vesicovaginal fistula repair. Overall, high-quality evidence is lacking to provide guidelines; therefore, expert opinion remains the primary influence for fistula repair recommendations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021214948.

Healthcare disparities and pelvic organ prolapse operative complications: a nationwide analysis

INTRODUCTION AND HYPOTHESIS

The objective of this study was to evaluate the differences in the incidence of peri-operative complications at the time of pelvic organ prolapse (POP) repair based on health care disparities such as race and socioeconomic status.

METHODS

The National Inpatient Sample (NIS) database was queried using ICD-9/-10 codes for patients aged >18 years undergoing POP repair in 2008-2018. Demographic information, Elixhauser Comorbidity Index (ECI), insurance status, and peri-operative complications were extracted. Multivariate weighted logistic regression using the discharge weights from NIS were constructed on binary outcomes. Complications with at least 1% incidence were included in the analysis.

RESULTS

A total of 172,483 POP repair patients were analyzed: 130,022 (75.4%) were white, 10,561 (6.1%) were Black, 21,915 (12.7%) were Hispanic, and 9,985 (5.8%) were of other races. Patients with Medicaid as well as Black, Hispanic, and other races had higher odds of developing postoperative complications such as urinary tract infections, sepsis, and acute renal failure (p value <0.001-0.02). These were also more common in smaller, rural hospitals and with patients with an annual income of $45,999 or less (p value <0.001-0.03). Black and Hispanic patients had lower odds of intraoperative complications such as hemorrhage (aOR 0.77, 95% CI 0.71-0.84; aOR 0.75, 95% CI 0.7-0.8 respectively) or abdominopelvic injury (aOR 0.86, 95% CI 0.81-0.92; aOR 0.93, 95% CI 0.79-0.88 respectively) compared with white patients.

CONCLUSION

Nonwhite patients with lower socioeconomic status had increased postoperative complications and fewer intraoperative complications from POP surgery, whereas white patients with higher socioeconomic status had more intraoperative complications.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review

OBJECTIVE

To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications.

DATA SOURCES

PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022.

METHODS OF STUDY SELECTION

The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies.

TABULATION, INTEGRATION, AND RESULTS

Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy.

CONCLUSION

Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021234511.

Educating Women About Pelvic Floor Disorders During Pregnancy From the First to the "Fourth Trimester": A Randomized Clinical Trial

IMPORTANCE

Pregnancy and childbirth are risk factors for developing pelvic floor disorders (PFDs), and this continues postpartum ("fourth trimester"). Knowledge of PFDs among women of childbearing age is lacking and presents an opportunity for education.

OBJECTIVES

The aim of this study was to compare the increase in knowledge of PFDs in patients who received written handouts versus interactive workshops as measured by the Prolapse and Incontinence Knowledge Questionnaire (PIKQ).

STUDY DESIGN

This was a randomized clinical trial of pregnant patients 18 years or older. Patients either received written handouts only or received handouts and attended an interactive workshop. Handouts were created in collaboration with communication specialists focusing on risk factors and prevention strategies. The primary outcome was the change in PIKQ score. Secondary outcomes were Pelvic Floor Distress Inventory score and postpartum phone interviews of workshop group participants. Questionnaires were assessed at recruitment and 6 weeks postpartum. The nonparametric Wilcoxon test compared continuous variables, and the Fisher exact test compared categorical variables.

RESULTS

One hundred twenty patients were randomized. Demographics were similar between groups. Median PIKQ score change showed no difference between groups (P = 0.37). Pelvic Floor Distress Inventory-20 scores were similar between groups at baseline (P = 0.78) and postpartum (P = 0.82). Quantile regression showed posteducation PIKQ scores were significantly higher in the workshop (21.00 vs 17.00; P = 0.011) and written (21.00 vs 17.00; P < 0.001) groups. Phone interviews showed consistent themes: (1) greater awareness of PFDs, (2) more likely to discuss PFDs, and (3) relief that PFDs are treatable. Fifty-nine percent of patients preferred learning through workshops compared with the handouts.

CONCLUSIONS

Both groups showed improvement in knowledge of PFDs. Well-written, illustrated handouts were effective in increasing patient knowledge of PFDs.

Surgeon Counseling Regarding Return to Sexual Activity After Pelvic Reconstructive Surgery

IMPORTANCE

Patients highly value surgeon counseling regarding the first sexual encounters after pelvic reconstructive surgery.

OBJECTIVES

We performed a qualitative analysis of usual surgeon counseling regarding return to sexual activity after surgery for pelvic organ prolapse and/or urinary incontinence.

METHODS

Participating surgeons provided a written description of their usual patient counseling regarding return to sexual activity after pelvic organ prolapse or urinary incontinence surgery. Counseling narratives were coded for major themes by 2 independent reviewers; disagreements were arbitrated by the research team. Analysis was performed utilizing Dedoose software and continued until thematic saturation was reached.

RESULTS

Twenty-two surgeons participated, and thematic saturation was reached. Six major themes were identified: "Safety of Intercourse," "Specific Suggestions," "Surgical Sequelae," "Patient Control," "Partner Related," "Changes in Experience," and "No Communication." Nearly all participating surgeons included counseling on the safety of intercourse and reassurance that intercourse would not harm the surgical repair. Specific suggestions included different positions, use of lubrication, vaginal estrogen use, specific products/vendors, alternatives to (vaginal) intercourse, and the importance of foreplay. Surgical sequelae discussion included possible interventions for complications, such as persistent sutures in the vagina, abnormal bleeding, or de novo dyspareunia. Counseling regarding changes to the patient's sexual experience ranged from suggestion of improvement to an anticipated negative experience. Surgeons more commonly advised patients that their sexual experience would be worsened or different from baseline; discussion of improvement was less frequent.

CONCLUSIONS

Surgeon counseling regarding the postoperative return to sexual activity varies among pelvic reconstructive surgeons. Most reassure patients that intercourse is safe after surgery.

Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review

OBJECTIVE

To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms.

DATA SOURCES

PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans.

METHODS OF STUDY SELECTION

Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible.

TABULATION, INTEGRATION, AND RESULTS

Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature.

CONCLUSION

Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272678.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review

OBJECTIVE

To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated.

DATA SOURCES

PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines.

METHODS OF STUDY SELECTION

Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded.

TABULATION, INTEGRATION, AND RESULTS

Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes.

CONCLUSION

Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021278796.

Reducing psychiatric illness in the perinatal period: A review and commentary

This brief overview highlights the global crisis of perinatal psychiatric illness (PPI). PPI is a major contributor to many adverse pregnancy, childbirth, and childhood development outcomes. It contributes to billions of dollars in spending worldwide each year and has a significant impact on the individual, their family, and their community. It is also highly preventable. Current recommendations for intervention and management of PPI are limited and vary considerably from country to country. Furthermore, there are several significant challenges asso-ciated with implementation of these recommendations. These challenges are magnified in number and consequence among women of color and/or minority populations, who experience persistent and negative health disparities during pregnancy and the postpartum period. This paper aims to provide a broad overview of the current state of recommendations and implementation challenges for PPI and layout a framework for overcoming these challenges. An equity-informed model of care that provides universal intervention for pregnant women may be one solution to address the preventable consequences of PPI on child and maternal health. Uniquely, this model emphasizes the importance of managing and eliminating known barriers to traditional health care models. Culturally and contextually specific challenges must be overcome to fully realize the impact of improved management of PPI.

An evaluation of pelvic floor disorders in a public and private healthcare setting

INTRODUCTION AND HYPOTHESIS

The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans.

METHODS

A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type.

RESULTS

A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size.

CONCLUSIONS

Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.

Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse

(1) Background: There is wide variation in the reported prevalence rates for pelvic organ prolapse (POP). There is also wide variation in the rate at which surgical interventions for pelvic organ prolapse are performed, as well as the type of interventions undertaken. As part of the International Consultation on Incontinence (ICI), our committee was tasked to produce evidence-based pathways for the surgical management of POP, any associated stress urinary incontinence (SUI), and bowel dysfunction. (2) Methods: To enable us to generate such evidence, we undertook a thorough search for the POP surgery-related, English-language scientific literature published up to April 2021. (3) Results: The committee evaluated the literature and made recommendations based on the Oxford grading system. (4) Conclusions: This review serves to provide a summary of the 2021 ICI surgical management of an evidence-based prolapse pathway and outline the evidence used to inform this guidance.

Sexual function after pelvic organ prolapse surgery: a systematic review comparing different approaches to pelvic floor repair

OBJECTIVE

Women consider preservation of sexual activity and improvement of sexual function as important goals after pelvic organ prolapse surgery. This systematic review aimed to compare sexual activity and function before and after prolapse surgery among specific approaches to pelvic organ prolapse surgery including native tissue repairs, transvaginal synthetic mesh, biologic grafts, and sacrocolpopexy.

DATA SOURCES

MEDLINE, Embase, and ClinicalTrials.gov databases were searched from inception to March 2021.

STUDY ELIGIBILITY CRITERIA

Prospective comparative cohort and randomized studies of pelvic organ prolapse surgeries were included that reported the following specific sexual function outcomes: baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Notably, the following 4 comparisons were made: transvaginal synthetic mesh vs native tissue repairs, sacrocolpopexy vs native tissue repairs, transvaginal synthetic mesh vs sacrocolpopexy, and biologic graft vs native tissue repairs.

METHODS

Studies were double screened for inclusion and extracted for population characteristics, sexual function outcomes, and methodological quality. Evidence profiles were generated for each surgery comparison by grading quality of evidence for each outcome across studies using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Screening of 3651 abstracts was performed and identified 77 original studies. The overall quality of evidence was moderate to high. There were 26 studies comparing transvaginal synthetic mesh with native tissue repairs, 5 comparing sacrocolpopexy with native tissue repairs, 5 comparing transvaginal synthetic mesh with sacrocolpopexy, and 7 comparing biologic graft with native tissue repairs. For transvaginal synthetic mesh vs native tissue repairs, no statistical differences were found in baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, persistent dyspareunia, and de novo dyspareunia. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form change scores were not different between transvaginal synthetic mesh and native tissue repairs (net difference, -0.3; 95% confidence interval, -1.4 to 0.8). For sacrocolpopexy vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, de novo dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form score differences were not different. For biologic graft vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form changes were also not different. For transvaginal synthetic mesh vs sacrocolpopexy, there was no difference in sexual activity and sexual function score change. Based on 2 studies, postoperative total dyspareunia was more common in transvaginal synthetic mesh than sacrocolpopexy (27.5% vs 12.2%; odds ratio, 2.72; 95% confidence interval, 1.33-5.58). The prevalence of postoperative dyspareunia was lower than preoperative dyspareunia after all surgery types.

CONCLUSION

Sexual function comparisons are most robust between transvaginal synthetic mesh and native tissue repairs and show similar prevalence of sexual activity, de novo dyspareunia, and sexual function scores. Total dyspareunia is higher after transvaginal synthetic mesh than sacrocolpopexy. Although sexual function data are sparse in the other comparisons, no other differences in sexual activity, dyspareunia, and sexual function score change were found.

Sexual Function After Pelvic Reconstructive Surgery

Improvement in sexual function is an important goal for many women undergoing surgery for pelvic organ prolapse, and patient counseling regarding changes in sexual function and activity is necessary prior to pelvic reconstructive surgery. Based on validated questionnaires, sexual function either remains unchanged or improves after pelvic reconstructive surgery for prolapse, while dyspareunia prevalence is reduced. De novo dyspareunia ranges from 0% to 9% after various types of prolapse surgery, with the exception of posterior repair.

Relationship of postoperative vaginal anatomy and sexual function: a systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018.

METHODS

The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes.

RESULTS

We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12.

CONCLUSION

Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery.

A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence

Introduction and hypothesis

The COVID-19 pandemic and the desire to “flatten the curve” of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic.

Methods

We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19.

Results

Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission.

Conclusions

We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

Differences between mid-urethral sling outcomes in diabetic and nondiabetic women

AIMS

The aim is to assess whether subjects with diabetes mellitus (DM) have greater urinary retention and increased post-void residual volume (PVR) following mid-urethral sling (MUS) surgery.

METHODS

This multi-center retrospective study included patients who underwent MUS (2012-2016). Baseline data included demographics, comorbidities, urinary symptoms, urodynamics data, PVR, and responses to validated questionnaires (UDI6 and IIQ7). Intraoperative data, postoperative voiding trial results, postop questionnaires, and complications were also noted. Patients with and without DM were compared. Significance was defined as P < .05.

RESULTS

A total of 605 MUS were included, 538(89%) without DM and 67(11%) with DM, of which 69% were transobturator and 31% retropubic. No differences were seen in urinary retention and passing void trial(79% DM vs 81% non-DM; P = .72). Mean PVR at discharge was similar between groups (136 mL DM vs 139 mL non-DM; P = .922). There were no differences between groups in UDI6 and IIQ7 sum scores at baseline and 1 month. DM subjects reported more bother at baseline on certain UDI-6 and IIQ-7 items including frequent urination, leakage related to urgency, and feeling frustrated. At 3 months postop, all subjects demonstrated improvement in scores. Interestingly, patients with DM reported worse quality of life on the IIQ7 sum.

CONCLUSIONS

Among subjects with well-controlled diabetes and more comorbidities who underwent MUS there were few differences in postoperative voiding dysfunction or PVR compared to nondiabetic women. DM patients were more bothered at baseline by urge-related symptoms. Quality of life following sling surgery appears to be worse in patients with DM at 3 months based on IIQ7. This data suggests that diabetic women with lower HbA1C can be counseled similarly to these complication rates and voiding dysfunction after MUS.

FPMRS challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium (CoRPS): managing complicated cases : Series 3: Challenging recurrent prolapse in a medically complicated patient

This case presents the work-up and management of a spina bifida patient with recurrent prolapse. Four international experts also provide their evaluation of and approach to this complex case. According to the literature, little is known regarding the approach to the management of this specific patient population.

Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines

OBJECTIVE

We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.

DATA SOURCES

The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.

STUDY ELIGIBILITY CRITERIA

We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.

RESULTS

We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.

CONCLUSION

Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.

Social networking and Internet use among pelvic floor patients: a multicenter survey

BACKGROUND

Internet resources are becoming increasingly important for patients seeking medical knowledge. It is imperative to understand patient use and preferences for using the Internet and social networking websites to optimize patient education.

OBJECTIVES

The purpose of this study was to evaluate social networking and Internet use among women with pelvic floor complaints to seek information for their conditions as well as describe the likelihood, preferences, and predictors of website usage.

STUDY DESIGN

This was a cross-sectional, multicenter study of women presenting to clinical practices of 10 female pelvic medicine and reconstructive surgery fellowship programs across the United States, affiliated with the Fellows' Pelvic Research Network. New female patients presenting with pelvic floor complaints, including urinary incontinence, pelvic organ prolapse, and fecal incontinence were eligible. Participants completed a 24 item questionnaire designed by the authors to assess demographic information, general Internet use, preferences regarding social networking websites, referral patterns, and resources utilized to learn about their pelvic floor complaints. Internet use was quantified as high (≥4 times/wk), moderate (2-3 times/wk), or minimal (≤1 time/wk). Means were used for normally distributed data and medians for data not meeting this assumption. Fisher's exact and χ² tests were used to evaluate the associations between variables and Internet use.

RESULTS

A total of 282 surveys were analyzed. The majority of participants, 83.3%, were white. The mean age was 55.8 years old. Referrals to urogynecology practices were most frequently from obstetrician/gynecologists (39.9%) and primary care providers (27.8%). Subjects were well distributed geographically, with the largest representation from the South (38.0%). Almost one third (29.9%) were most bothered by prolapse complaints, 22.0% by urgency urinary incontinence, 20.9% by stress urinary incontinence, 14.9% by urgency/frequency symptoms, and 4.1% by fecal incontinence. The majority, 75.0%, described high Internet use, whereas 8.5% moderately and 4.8% minimally used the Internet. Women most often used the Internet for personal motivations including medical research (76.4%), and 42.6% reported Google to be their primary search engine. Despite this, only 4.9% primarily used the Internet to learn about their pelvic floor condition, more commonly consulting an obstetrician-gynecologist for this information (39.4%). The majority (74.1%) held a social networking account, and 45.9% visited these daily. Nearly half, 41.7%, expressed the desire to use social networking websites to learn about their condition. Women <65 years old were significantly more likely to have high Internet use (83.4% vs 68.8%, P = .018) and to desire using social networking websites to learn about their pelvic floor complaint (P = .008). The presenting complaint was not associated with Internet use (P = .905) or the desire to use social networking websites to learn about pelvic floor disorders (P = .201).

CONCLUSION

Women presenting to urogynecology practices have high Internet use and a desire to learn about their conditions via social networking websites. Despite this, obstetrician-gynecologists remain a common resource for information. Nonetheless, urogynecology practices and national organizations would likely benefit from increasing their Internet resources for patient education in pelvic floor disorders, though patients should be made aware of available resources.

Lumbosacral Osteomyelitis and Discitis with Phlegmon Following Laparoscopic Sacral Colpopexy

Lumbosacral osteomyelitis and discitis are usually a result of hematogenous spread; rarely it can result from direct inoculation during a surgical procedure. Bacteria may also track along implanted devices to a different location. This is a rare complication seen from pelvic organ prolapse surgery with sacral colpopexy. A 67-year-old female developed increasing lower back pain four months following a laparoscopic sacral colpopexy. Imaging revealed lumbar 5-sacral 1 (L5-S1) osteomyelitis and discitis with associated phlegmon confirmed by percutaneous biopsy and culture. The patient was treated conservatively with antibiotics, but required laparoscopic removal of the pelvic and vaginal mesh followed by twelve weeks of intravenous antibiotics. The patient has experienced clinical improvement of her back pain. This is an uncommon complication of sacral colpopexy, but physicians must be vigilant and manage aggressively to avoid more serious complications and permanent deficit.

Significance of cystoscopic bladder trabeculations in women undergoing midurethral sling

INTRODUCTION

To determine the significance of bladder trabeculations seen on preoperative cystoscopy prior to midurethral sling surgery with respect to lower urinary tract symptoms and sling outcomes.

MATERIALS AND METHODS

This retrospective study included women with preoperative cystoscopy who underwent midurethral slings for urinary incontinence from 2006-2009. Cystoscopic findings of bladder trabeculations, as well as pre and postoperative urinary symptoms were recorded. Patients with and without bladder trabeculations were compared with respect to baseline characteristics, lower urinary tract symptoms, and sling outcomes.

RESULTS

Of the 241 women included in the study, 14.9% had trabeculations on preoperative cystoscopy. At baseline, women with trabeculations were more likely to be older (64.8 years versus 57.8 years, p < 0.01), and have lower mean maximum cystometric capacity (341 mL +/- 136 versus 436 mL +/- 148, p < 0.01), compared to those without trabeculations. More women with trabeculations had mixed incontinence (p < 0.01) and less pure stress incontinence (p < 0.01) preoperatively. There was no difference between women with and without trabeculations with respect to pre and postoperative symptoms of urgency, frequency, and nocturia. Women with preoperative trabeculations were more likely to have preoperative treatment with anticholinergics (p = 0.02) and had a three times higher risk of postoperative sling failure (HR 2.95 [CI 1.11-7.85], p = 0.03).

CONCLUSIONS

Preoperative cystoscopic bladder trabeculations are associated with significantly higher rate of midurethral sling failure. Trabeculations were not associated with pre or postoperative lower urinary tract symptoms.

Increased morbidity in combined abdominal sacrocolpopexy and abdominoplasty procedures

INTRODUCTION AND HYPOTHESIS

This study was performed to determine whether abdominoplasty combined with abdominal sacrocolpopexy (ASC + A) increases perioperative morbidity compared with ASC alone. We hypothesized that patients undergoing combined procedures would have increased complications.

METHODS

This was a multicenter, retrospective cohort study of all women undergoing ASC + A from 2002 to 2010 at Washington Hospital Center and Johns Hopkins University. We selected two women undergoing ASC alone for comparison with each ASC + A patient. Baseline demographics, surgical data, length of hospitalization, and perioperative complications were recorded. The primary outcome was any major complication within 6 weeks of surgery, including intraoperative complications, pulmonary embolism (PE), deep venous thrombosis (DVT), cardiac compromise, intensive care unit (ICU) admission, reoperation, and readmission. Surgical data and minor complications were also compared.

RESULTS

Twenty-six ASC + A patients and 52 ASC patients were identified. There were no significant differences in baseline characteristics between groups. Patients with ASC + A had longer operating times (337 vs 261 min, p < 0.01), more intravenous fluid administration intraoperatively (4,665 vs 3181 ml, p < 0.01), and longer hospital stays (3.7 vs 2.7 days, p < 0.01). Major complications occurred in 23 % of the ASC + A group compared with 12 % of the ASC group (p = 0.20). The ASC + A group had greater declines in hematocrit levels and higher rates of PE, ICU admission, and blood transfusion, all of which were statistically significant.

CONCLUSIONS

ASC + A increases length of stay and perioperative complications, such as PE, ICU admission, and blood transfusion, compared with ASC alone. Surgeons should consider recommending interval abdominoplasty due to increased morbidity risk with a combined procedure.

Interest in cosmetic vulvar surgery and perception of vulvar appearance

OBJECTIVE

The objective of the study was to determine whether reproductive-age women are more likely to perceive their vulva as abnormal compared with older-aged women.

STUDY DESIGN

Women aged 18-44 years (group 1) and 45-72 years (group 2) completed a survey on demographics, grooming patterns, vulvar perceptions, and source of information about the vulva.

RESULTS

There was no difference between group 1 and group 2 in how often women looked at their vulva or their perception of having a normal vulva (91% vs 93%, P = .76). Both groups were satisfied with the appearance of their vulva (81% vs 82%, P = .71). A higher percentage in group 2 would consider cosmetic surgery if cost were not an issue versus group 1 (15% vs 8%, P = .05).

CONCLUSION

A woman's age does not have an impact on her perception of a normal vulva. The majority of women perceived their vulva to be normal and were satisfied with its appearance. However, older women are more interested in cosmetic vulvar surgery.

Outcome assessment with blinded versus unblinded POP-Q exams

OBJECTIVE

To determine whether blinded and unblinded Pelvic Organ Prolapse Quantification (POP-Q) examinations differ in a randomized trial.

STUDY DESIGN

Blinded POP-Q examinations performed at 3 months and 1 year were compared with unblinded examinations performed by the surgeon in a randomized trial of vaginal mesh for pelvic organ prolapse.

RESULTS

Sixty-five patients were included in the study. Correlations between the blinded and unblinded POP-Q points and stages varied from low to moderate (rho = 0.29-0.78). At 3 months, the blinded overall prolapse recurrence rate was 45.3% compared with 39.1% based on unblinded staging (P = .34). At 1 year, the blinded overall recurrence rate was significantly higher than the unblinded recurrence rate: 68.3% vs 53.3% (P = .004). The 1-year blinded anterior wall recurrence rate was also higher than the recurrence based on unblinded staging: 56.7% vs 43.3% (P = .021).

CONCLUSION

Use of unblinded POP-Q staging resulted in underestimation of 1-year overall recurrence after prolapse repair.