Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry

OBJECTIVE

The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research.

STUDY DESIGN

This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy).

RESULTS

A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036).

CONCLUSION

Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women

INTRODUCTION

Most causes of microscopic hematuria (MH) are benign but may indicate an underlying malignancy. Current MH evaluation guidelines are reflective of male urologic malignancy risks. The objective of this systematic review was to evaluate whether the finding of MH predicts subsequent urologic malignancy in women.

METHODS

MEDLINE was searched between January 1990 and June 8, 2018. The positive predictive value (PPV) of MH as a screening tool for urologic malignancy was calculated for each study individually and collectively. The pooled relative risk of urologic malignancy associated with MH was calculated.

RESULTS

Seventeen studies were included. Eight studies included only women. In total, 300 urinary tract cancers were identified in 110,179 women with MH. The PPV of MH as a screening tool for cancer ranged from approximately 0.6% to 2.8%; confidence intervals (CIs) suggested this is a relatively unstable performance indicator because of small sample sizes. Average PPV across all studies was 2.13%, but the weighted average PPV was 0.24%. The risk of urologic malignancies among women with relative those without MH was 2.01 (95% CI, 1.61-2.51). Based on these limited data, we estimate that 859 (95% CI, 654-1250) women with MH would require complete evaluation to identify 1 urinary tract malignancy.

CONCLUSIONS

A very small proportion of women with MH are likely to have a urologic malignancy. Approximately 859 women require full screening to identify 1 malignancy. Current evidence is limited, and further studies, specifically in women, are needed.

Female pelvic medicine & reconstructive surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 7: can fibroids worsen incontinence?

This case presents the work-up and management of a patient with a fibroid uterus and urinary incontinence. Five international experts also provide their evaluation and approach to this case. According to the literature, there is uncertainty surrounding the relationship between fibroids and urinary incontinence. The experts emphasize patient counseling and a staged approach.

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.

Female Pelvic Medicine & Reconstructive Surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 2: management of urinary incontinence in a neurogenic patient

Discussion and management of incontinence in a patient with spina bifida by four international experts followed by a literature review.

Minimally Invasive Surgery Survey: A Survey of Surgical Team Members' Perceptions for Successful Minimally Invasive Surgery

STUDY OBJECTIVE

To develop a valid and reliable survey to measure surgical team members' perceptions regarding their institution's requirements for successful minimally invasive surgery (MIS).

DESIGN

Questionnaire development and validation study (Canadian Task Force classification II-2).

SETTING

Three hospital types: rural, urban/academic, and community/academic.

PARTICIPANTS

Minimally invasive staff (team members).

INTERVENTION

Development and validation of a minimally invasive surgery survey (MISS).

MEASUREMENT AND MAIN RESULTS

Using the Safety Attitudes questionnaire as a guide, we developed questions assessing study participants' attitudes regarding the requirements for successful MIS. The questions were closed-ended and responses based on a 5-point Likert scale. The large pool of questions was then given to 4 focus groups made up of 3 to 6 individuals. Each focus group consisted of individuals from a specific profession (e.g., surgeons, anesthesiologists, nurses, and surgical technicians). Questions were revised based on focus group recommendations, resulting in a final 52-question set. The question set was then distributed to MIS team members. Individuals were included if they had participated in >10 MIS cases and worked in the MIS setting in the past 3 months. Participants in the trial population were asked to repeat the questionnaire 4 weeks later to evaluate internal consistency. Participants' demographics, including age, gender, specialty, profession, and years of experience, were captured in the questionnaire. Factor analysis with varimax rotation was performed to determine domains (questions evaluating similar themes). For internal consistency and reliability, domains were tested using interitem correlations and Cronbach's α. Cronbach's α > .6 was considered internally consistent. Kendall's correlation coefficient τ closer to 1 and with p < .05 was considered significant for the test-retest reliability. Two hundred fifty participants answered the initial question set. Of those, 53 were eliminated because they did not meet inclusion criteria or failed to answer all questions, leaving 197 participants. Most participants were women (68% vs 32%), and 42% were between the ages 30 and 39 years. Factor analysis identified 6 domains: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. Interitem correlations testing for redundancy for each domain ranged from .2 to .7, suggesting similar themed questions while avoiding redundancy. Cronbach's α, testing internal consistency, was .87. Sixty-two participants from the original cohort repeated the question set at 4 weeks. Forty-three were analyzed for test-retest reliability after excluding those who did not meet inclusion criteria. The final questions showed high test-retest reliability (τ = .3-.7, p < .05). The final questionnaire was made up of 29 questions from the original 52 question set.

CONCLUSION

The MISS is a reliable and valid tool that can be used to measure how surgical team members conceptualize the requirements for successful MIS. The MISS revealed that participants identified 6 important domains of a successful workenvironment: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. The questionnaire can be used to understand and align various surgical team members' goals and expectations and may help improve quality of care in the MIS setting.

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.

Practice patterns of general gynecologic surgeons versus gynecologic subspecialists for concomitant apical suspension during vaginal hysterectomy for uterovaginal prolapse

OBJECTIVES

We hypothesized that subspecialists perform more concomitant apical suspensions during transvaginal hysterectomy for uterovaginal prolapse as compared with general gynecologists.

METHODS

Retrospective analysis of the MedStar Health EXPLORYS database for women undergoing transvaginal hysterectomy for prolapse. Appropriate International Classification of Diseases-9 codes for uterine prolapse and incomplete and complete uterovaginal prolapse along with Current Procedural Terminology codes were used to determine frequency of transvaginal hysterectomy alone, transvaginal hysterectomy plus nonapical repair, and transvaginal hysterectomy plus concomitant apical suspension.

RESULTS

A total of 946 patients underwent vaginal hysterectomy for prolapse, with 5.5 years follow-up. Thirty-five percent (n = 334) underwent transvaginal hysterectomy alone, 20% (n = 184) underwent transvaginal hysterectomy plus nonapical repair, and 45% (n = 428) underwent transvaginal hysterectomy plus apical suspension. Seventy-two percent of patients operated on by general gynecologists compared with 4% of patients operated on by urogynecologists had a transvaginal hysterectomy alone. Only 10% of patients operated on by general gynecologic surgeons compared with 78% operated on by urogynecologists received a concomitant apical suspension for prolapse (P < 0.0001). Forty-four patients (4.7%) required repeat surgery for recurrent prolapse. Because of the small number of repeat surgeries, preoperative degree of prolapse and type of index procedure did not significantly affect the need for repeat surgery.

CONCLUSIONS

The majority of prolapse procedures involving hysterectomies performed by general gynecologists do not include apical suspension, whereas urogynecologic subspecialists consistently perform apical suspension.

Postural stress experienced by vaginal surgeons

Increasing attention has been drawn to the prevalence of work-related musculoskeletal disorders (MSDs) among surgeons in various medical specialties; however, the risk of work-related MSDs among gynecologic surgeons has not received much attention. This study aimed to investigate the postural load among gynecologic surgeons for various surgical tasks during vaginal surgery. The frequency and percentage of duration of awkward upper body postures experienced by vaginal surgeons during eleven different vaginal surgical tasks observed during thirteen surgeries were collected using a new observational ergonomic job analysis tool, Ergonomic Posture Assessment in Real Time (ErgoPART). Results indicate that the postural loading is high for many surgical tasks but that the frequency and duration of awkward neck, shoulder, and trunk postures is variable across tasks. Surgeons’ postural load was significantly higher for the transvaginal hysterectomy compared to others. This task, in particular, is a candidate for ergonomics interventions designed to reduce postural stress.

Vulvar anatomy and labia minoraplasty

AIM OF VIDEO/INTRODUCTION

Female genital cosmetic surgery is performed for aesthetic reasons as well as for medical and functional indications, such as congenital labia minora hypertrophy. The purpose of this video is to teach vulvar anatomy and review labia minorplasty techniques.

METHODS

We demonstrate one technique in this video.

CONCLUSIONS

There are a variety of different techniques for labia minorplasty. When deciding the most appropriate technique to use, the patient's goals must be considered.

The use of biological materials in urogynecologic reconstruction: a systematic review

There are numerous randomized controlled trials examining biological materials in urogynecologic surgery. For prolapse surgery, the addition of a biological graft adds no benefit compared with native tissue repairs for rectocele repair. Conflicting data exist regarding cystocele repair. Synthetic mesh repairs provide superior anatomical support for sacral colpopexy and cystocele repair compared with biologic grafts. However, biological and synthetic mesh slings have equivalent success rates for the treatment of stress urinary incontinence. Contrary to prior assumptions that biologic grafts add tissue strength without graft-related complications, there appears to be no benefit to the use of biological materials for prolapse and incontinence surgery.

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.