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Ringel NE, Lenger SM, High R, Alas A, Houlihan S, Chang OH, Pennycuff J, Singh R, White A, Lipitskaia L, Behbehani S, Sheyn D, Kudish B, Nihira M, Sleemi A, Grimes C, Gupta A, Balk EM, Antosh DD. Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis. Obstet Gynecol 2024; 143:539-549. [PMID: 38330397 DOI: 10.1097/aog.0000000000005525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/21/2023] [Indexed: 02/10/2024]
Abstract
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.
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Affiliation(s)
- Nancy E Ringel
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville, Louisville, Kentucky; the Division of Urogynecology, Department of Obstetrics and Gynecology, Houston Methodist, Houston, the Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, and the Department of Obstetrics and Gynecology, University of Texas at Austin Dell Medical School, Austin, Texas; the Department of Obstetrics and Gynecology, Royal Columbian Hospital, University of British Columbia, Vancouver, British Columbia, Canada; the Division of Female Urology and Pelvic Reconstructive Surgery, Department of Urology, University of California, Irvine, Orange, the Department of Obstetrics and Gynecology, University of California, Riverside School of Medicine, Riverside, and KPC Healthcare, Hemet, California; the Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; the Department of Obstetrics and Gynecology, University of Florida Health, Jacksonville, and Bela Vida Urogynecology, Celebration, Florida; the Division of Urogynecology, Department of Obstetrics and Gynecology, Cooper Health University, Camden, New Jersey; the Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, Ohio; the International Medical Response Foundation, Brooklyn, and the Departments of Obstetrics and Gynecology and Urology, New York Medical College, Valhalla, New York; and the Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island
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Carbone L, Webber V, Rothenberger R, Lenger SM, Gupta A, Messer J, Francis S. Robotic Vaginal Hernia Repair for Recurrent Vaginal Prolapse Status Post-Radical Cystectomy with an Indiana Pouch. Int Urogynecol J 2024:10.1007/s00192-024-05755-x. [PMID: 38472342 DOI: 10.1007/s00192-024-05755-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic organ prolapse following a radical cystectomy is challenging to treat and recurrence of prolapse after primary repair is common owing to compromised pelvic floor support and tissue quality. Vaginal prolapse repairs are often preferred because of concern for patients' complex intraabdominal pathological conditions. However, for those with recurrent prolapse following colpocleisis, limited definitive treatment options exist. METHODS This surgical video presents a 64-year-old G4P4 with a history of radical cystectomy with an Indiana Pouch for invasive urothelial carcinoma who presented with recurrent stage IV vaginal prolapse two years following colpocleisis. Owing to thin vaginal tissue, a sacrocolpopexy with vaginal mesh could not be performed, thus, the patient underwent robotic-assisted vaginal hernia repair with a polypropylene-reinforced ovine tissue matrix attached to Cooper's ligament and the levator ani muscles. RESULTS The surgery was free from complications and her postoperative Pelvic Organ Prolapse Quantification examination revealed a leading vaginal tissue remnant at the level of the hymen. The patient reported overall improved health and quality of life following surgery and recovery on postoperative validated questionnaires. CONCLUSIONS Vaginal and pelvic floor hernia repair with a polypropylene-reinforced tissue matrix is a feasible definitive surgical treatment for patients with prior radical cystectomy in whom colpocleisis has failed.
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Affiliation(s)
- Laurel Carbone
- Department of Obstetrics, Gynecology, and Women's Health, Division of Urogynecology, Female Pelvic Medicine, and Reconstructive Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY, 40202, USA.
| | - Victoria Webber
- Department of Obstetrics, Gynecology, and Women's Health, University of Louisville, Louisville, KY, USA
| | - Rodger Rothenberger
- Department of Obstetrics, Gynecology, and Women's Health, Division of Urogynecology, Female Pelvic Medicine, and Reconstructive Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY, 40202, USA
| | - Stacy M Lenger
- Department of Obstetrics, Gynecology, and Women's Health, Division of Urogynecology, Female Pelvic Medicine, and Reconstructive Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY, 40202, USA
| | - Ankita Gupta
- Department of Obstetrics, Gynecology, and Women's Health, Division of Urogynecology, Female Pelvic Medicine, and Reconstructive Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY, 40202, USA
| | - Jamie Messer
- Department of Urology, Urologic Oncology, University of Louisville, Louisville, KY, USA
| | - Sean Francis
- Department of Obstetrics, Gynecology, and Women's Health, Division of Urogynecology, Female Pelvic Medicine, and Reconstructive Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY, 40202, USA
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Warehime JM, Gaskins JT, Gupta AS, Hattab EM, Feroz RT, Rothenberger RW, Lenger SM, Francis SL, Herring NR. Proximity of percutaneous tibial nerve stimulation needle insertion to surrounding anatomic structures: a cadaveric study. Am J Obstet Gynecol 2023; 229:430.e1-430.e6. [PMID: 37419167 DOI: 10.1016/j.ajog.2023.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Percutaneous tibial nerve stimulation is a third-line treatment for overactive bladder and urgency urinary incontinence. During the procedure, a needle is inserted cephalad to the medial malleolus and posterior to the tibia. In recent years, permanent implants and leads have been developed for insertion into the medial ankle via a small incision. There are many important structures present in the medial compartment of the ankle, including the great saphenous vein, saphenous nerve, tibial nerve, posterior tibial vessels, and tendons of the posterior compartment leg muscles. OBJECTIVE The primary objective of this study was to identify the proximity of the percutaneous tibial nerve stimulation needle placed per Food and Drug Administration-approved device instructions to nearby important anatomic structures. The secondary objectives were to identify the proximity of the tibial nerve to the needle site, identify clinically relevant ankle anatomic structures, and confirm the tibial nerve and posterior tibial vasculature by histologic analysis. STUDY DESIGN Detailed medial ankle dissections were performed bilaterally on 10 female lightly embalmed anatomic donors (cadavers) obtained from the Willed Body Program at the University of Louisville. A pin was inserted at the percutaneous tibial nerve stimulation needle site, and the medial ankle was minimally dissected so the surrounding anatomic structures were visible but not disrupted. The shortest distance from the pin to the selected structures of the medial ankle region was measured. On completion of each dissection and set of measurements, tissue was harvested for histologic examination. The distances between the pin and each structure were assessed using means and standard deviations. A paired t test was used to assess the difference in the locations between the left and right ankles. Statistical analysis was performed on left-sided, right-sided, and combined measurements. An 80% prediction interval was found to represent the expected range of values for the measurement of a new cadaver or patient, and the 95% confidence interval of the mean was computed to characterize the average distance across all cadavers or patients. RESULTS The medial ankle of 10 adult female lightly embalmed cadavers were examined bilaterally. Dissections were completed from October 2021 to July 2022. Of note, 80% prediction intervals for the tibial nerve, the posterior tibial artery or vein, and the flexor digitorum longus tendon had a lower range of 0.0 mm from the pin and extending to 12.1, 9.5, and 13.9 mm, respectively. Moreover, 2 of the structures were found to be asymmetrical between the right and left ankles. The great saphenous vein was further from the pin on the left (20.5 mm [standard deviation of 6.4 mm] on the left vs 18.1 mm [standard deviation of 5.3 mm] on the right; P=.04). The calcaneal (Achilles) tendon was further from the pin on the right side (13.2 mm [standard deviation of 6.8 mm] vs 7.9 mm [standard deviation of 6.7 mm]; P=.04). Tibial neurovascular structures were confirmed with microscopic analysis. CONCLUSION The anatomic structures within the medial ankle lie unexpectedly close to the percutaneous tibial nerve stimulation needle site as noted per Food and Drug Administration-approved device instructions. There is a possibility that some medial ankle structures are not symmetrical. It is crucial that practitioners understand medial ankle anatomy when performing percutaneous tibial nerve stimulation or permanent device insertion.
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Affiliation(s)
- Jenna M Warehime
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville School of Medicine, Louisville, KY.
| | - Jeremy T Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, KY
| | - Ankita S Gupta
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville School of Medicine, Louisville, KY
| | | | - Rehan T Feroz
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville School of Medicine, Louisville, KY
| | - Rodger W Rothenberger
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville School of Medicine, Louisville, KY
| | - Stacy M Lenger
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville School of Medicine, Louisville, KY
| | - Sean L Francis
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville School of Medicine, Louisville, KY
| | - Nicole R Herring
- Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, Louisville, KY
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Feroz R, Gaskins JT, Shah V, Warehime J, Lenger SM, Francis S, Gupta A. General anesthesia versus regional anesthesia in patients undergoing obliterative vaginal procedures for pelvic organ prolapse. Int Urogynecol J 2023; 34:2033-2039. [PMID: 36811633 DOI: 10.1007/s00192-023-05488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/24/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to compare outcomes in patients receiving general versus regional anesthesia when undergoing obliterative vaginal surgery for pelvic organ prolapse. METHODS Obliterative vaginal procedures performed from 2010 to 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgeries were categorized into general anesthesia (GA) or regional anesthesia (RA). Rates of reoperation, readmission, operative time, and length of stay were determined. A composite adverse outcome was calculated including any of the following: nonserious or serious adverse events, 30-day readmission, or reoperation. Propensity score-weighted analysis of perioperative outcomes was performed. RESULTS The cohort included 6,951 patients, of whom 6,537 (94%) underwent obliterative vaginal surgery under GA and 414 (6%) received RA. When comparing outcomes under the propensity score-weighted analysis, operative times were shorter (median 96 vs 104 min, p<0.01) in the RA group versus GA. There were no significant differences between composite adverse outcomes (10% vs 12%, p=0.06), or readmission (5% vs 5%, p=0.83) and reoperation rates (1% vs 2%, p=0.12) between the RA and GA groups. Length of stay was shorter in patients receiving GA than in those receiving RA, especially when undergoing concomitant hysterectomy (67% discharged within 1 day in GA vs 45% in RA, p<0.01). CONCLUSIONS Composite adverse outcomes, reoperation rates, and readmission rates were similar in patients who received RA for obliterative vaginal procedures compared with GA. Operative times were shorter in patients receiving RA than in those receiving GA, and length of stay was shorter in patients receiving GA than in those receiving RA.
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Affiliation(s)
- Rehan Feroz
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health, University of Louisville, 550 South Jackson Street, Louisville, KY, USA.
| | - Jeremy T Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA
| | - Vishwa Shah
- Department of Obstetrics, Gynecology & Women's Health, University of Louisville, Louisville, KY, USA
| | - Jenna Warehime
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health, University of Louisville, 550 South Jackson Street, Louisville, KY, USA
| | - Stacy M Lenger
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health, University of Louisville, 550 South Jackson Street, Louisville, KY, USA
| | - Sean Francis
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health, University of Louisville, 550 South Jackson Street, Louisville, KY, USA
| | - Ankita Gupta
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health, University of Louisville, 550 South Jackson Street, Louisville, KY, USA
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Gupta A, Balk EM, Lenger SM, Yang LC, Misal M, Balgobin S, Chang OH, Sharma V, Stuparich M, Behbehani S, Nihira M, Alas A, Jampa A, Sheyn D, Meriwether K, Antosh DD. Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review. Obstet Gynecol 2023; 142:319-329. [PMID: 37411023 DOI: 10.1097/aog.0000000000005260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/11/2023] [Indexed: 07/08/2023]
Abstract
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.
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Affiliation(s)
- Ankita Gupta
- Division of Female Pelvic Medicine & Reconstructive Surgery, University of Louisville Health, and the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology, & Women's Health, University of Louisville School of Medicine, Louisville, Kentucky; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Northwestern Medicine, Chicago, Illinois; the Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland, Ohio; the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, the Department of OBGYN, Division of Urogynecology, UT Health Science Center at San Antonio, San Antonio, and the Division of Urogynecology, Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas; the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington; the Department of Obstetrics and Gynecology, Jacobi Medical Center, and the Albert Einstein College of Medicine, Bronx, New York; the Department of Obstetrics and Gynecology, University of California, Riverside School of Medicine, Riverside, and KPC Healthcare, Hemet, California; the Jawaharlal Nehur Medical College, Belgaum, India; and the Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico
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Warehime J, Carbone L, Gupta A, Francis S, Lenger SM. Use of coconut oil leads to multiple bladder foreign bodies. Int Urogynecol J 2023; 34:1659-1660. [PMID: 37060371 DOI: 10.1007/s00192-023-05536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Jenna Warehime
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Ob/Gyn and Women's Health, University of Louisville, 2nd floor, Chair's Suite, 550 S. Jackson Street, Louisville, KY, 40202, USA.
| | - Laurel Carbone
- Department of Ob/Gyn, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Ankita Gupta
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Ob/Gyn and Women's Health, University of Louisville, 2nd floor, Chair's Suite, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Sean Francis
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Ob/Gyn and Women's Health, University of Louisville, 2nd floor, Chair's Suite, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Stacy M Lenger
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Ob/Gyn and Women's Health, University of Louisville, 2nd floor, Chair's Suite, 550 S. Jackson Street, Louisville, KY, 40202, USA
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Ligon MM, Liang B, Lenger SM, Parameswaran P, Sutcliffe S, Lowder JL, Mysorekar IU. Bladder Mucosal Cystitis Cystica Lesions Are Tertiary Lymphoid Tissues That Correlate With Recurrent Urinary Tract Infection Frequency in Postmenopausal Women. J Urol 2023; 209:928-936. [PMID: 36715657 DOI: 10.1097/ju.0000000000003196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 01/19/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE We identify correlates and clinical outcomes of cystitis cystica, a poorly understood chronic inflammatory bladder change, in women with recurrent urinary tract infections. MATERIALS AND METHODS A retrospective, observational cohort of women with recurrent urinary tract infections who underwent cystoscopy (n=138) from 2015 to 2018 were identified using electronic medical records. Cystitis cystica status was abstracted from cystoscopy reports and correlations were identified by logistic regression. Urinary tract infection-free survival time associated with cystitis cystica was evaluated by Cox proportional hazards regression. Exact logistic regression was used to identify factors associated with changes to cystitis cystica lesions on repeat cystoscopy. Biopsies of cystitis cystica lesions were examined by routine histology and immunofluorescence. RESULTS Fifty-three patients (38%) had cystitis cystica on cystoscopy. Cystitis cystica was associated with postmenopausal status (OR: 5.53, 95% CI: 1.39-37.21), pelvic floor myofascial pain (6.82, 1.78-45.04), having ≥4 urinary tract infections in the past year (2.28, 1.04-5.09), and a shorter time to next urinary tract infection (HR: 1.54, 95% CI: 1.01-2.35). Forty-two patients (82%) demonstrated improvement or resolution of lesions. Ten/11 (91%) biopsied cystitis cystica lesions were tertiary lymphoid tissue with germinal centers and resembled follicular cystitis. CONCLUSIONS Cystitis cystica lesions were associated with postmenopausal status, pelvic floor myofascial pain, and number of urinary tract infections in the prior year and predicted worse recurrent urinary tract infection outcomes. Cystitis cystica lesions are tertiary lymphoid tissue/follicular cystitis that may improve or resolve over time with treatment. Identifying cystitis cystica in recurrent urinary tract infection patients may be useful in informing future urinary tract infection risk and tailoring appropriate treatment strategies.
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Affiliation(s)
- Marianne M Ligon
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Brooke Liang
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Stacy M Lenger
- Department of Obstetrics & Gynecology and Women's Health, University of Louisville School of Medicine, Louisville, Kentucky
| | - Priyanka Parameswaran
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Siobhan Sutcliffe
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Jerry L Lowder
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Indira U Mysorekar
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St Louis, Missouri
- Department of Medicine, Section of Infectious Diseases and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
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O'Brien MS, Gupta A, Quevedo A, Lenger SM, Shah V, Warehime J, Gaskins J, Biscette S. Postoperative Complications of Appendectomy in Gynecologic Laparoscopic Surgery for Benign Indications. Obstet Gynecol 2023; 141:354-360. [PMID: 36649317 DOI: 10.1097/aog.0000000000005033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess whether concomitant appendectomy in patients who undergo laparoscopic surgery for benign gynecologic indications is associated with increased rates of complications in the 30-day postoperative period. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if diagnoses of cancer or appendicitis were present. There were 246,987 patients included in the population cohort from 2010 to 2020. Demographic information and postoperative outcomes of patients who underwent concomitant appendectomy were compared with patients who did not undergo appendectomy. A matched cohort was created by computing propensity scores, and outcomes were again compared between groups. All patients undergoing appendectomy were 1:1 matched to a unique patient who did not undergo appendectomy using a greedy matching based on the propensity score calculated from demographic and surgical characteristics. RESULTS A total of 1,760 patients (0.7%) underwent concomitant appendectomy. There was an 8.0% complication rate in the appendectomy group, compared with 5.5% in the group of those without appendectomy ( P <.001), and this was similar to the results in the propensity-matched sample. Patients who underwent appendectomy had significantly higher rates of readmission (4.3% vs 2.3%), which remained significant in the propensity-matched sample. There were no differences in the rates of postoperative thromboembolic events, blood transfusion, or reoperation. CONCLUSION Patients who are undergoing concomitant appendectomy have an increased risk of any complication and hospital readmission. Additional studies may be conducted to identify patients with optimal risk benefit profiles when considering performing concomitant appendectomy at time of gynecologic surgery.
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Affiliation(s)
- M Shea O'Brien
- Department of Obstetrics, Gynecology, and Women's Health, the Department of Urogynecology, Female Pelvic Medicine and Reconstruction, the Department of Minimally Invasive Gynecologic Surgery, and the School of Public Health and Information Science, University of Louisville, Louisville, Kentucky
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Warehime JM, Lenger SM, Feng XY, Cope Z, Feroz R, Gaskins J, Gupta A, Francis S, Hamm J. Video Playback as an Educational Tool for Improving Resident Laparoscopic Performance: A Randomized Controlled Trial. J Minim Invasive Gynecol 2023; 30:39-44. [PMID: 36223862 DOI: 10.1016/j.jmig.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 01/05/2023]
Abstract
STUDY OBJECTIVE In this single-masked randomized controlled study, we evaluate whether watching video recordings of oneself performing Fundamentals of Laparoscopic Skills (FLS) exercises results in an improvement on the 30-point Global Operative Assessment of Laparoscopic Skills (GOALS) assessment among Obstetrics and Gynecology (Ob/Gyn) residents. DESIGN Twenty-three Ob/Gyn residents in the 2020-2021 academic year completed the FLS exercises while being timed, video recorded, and receiving real-time feedback from an Ob/Gyn faculty member. Baseline GOALS assessment was completed by participants and faculty. After the intervention, all participants then repeated the FLS exercises while being timed and were again scored using the GOALS assessment. Each participant completed the study in a single session. In addition, all participants completed a pre- and post-test survey. SETTING University of Louisville Laparoscopic Skills Labortaory. PARTICIPANTS University of Louisville Ob/Gyn residents in the 2020-2021 academic year. INTERVENTION Twelve participants were randomized to the intervention and were allowed to watch their video recording in addition to receiving verbal feedback whereas the remaining 11 received verbal feedback only. MEASUREMENTS AND MAIN RESULTS There were significant improvements in faculty (p <.01) and self-reported GOALS scores (p <.01) when comparing both the intervention and control group with baseline scores. The intervention group improved by 3.2 points more than that of the control group based on masked faculty evaluation (95% confidence interval, 1.4-5.0 points; p <.01). The difference was not significant in resident self-scores. Overall time improved for all participants (15:54 ± 0.21 minutes before and 13:13 ± 0.14 minutes after), but this difference was not significant between the 2 groups. Higher postgraduate year (PGY) residents reported significantly more comfort performing laparoscopic tasks, earned higher GOALS score (faculty and self-scores), and completed the first set of exercises in less time. A significant interaction between PGY and intervention was detected with improvement in GOALS score most strongly associated with PGY4 residents (p <.01). CONCLUSION Although all learners objectively benefit from watching recordings of themselves performing surgical tasks, advanced learners may benefit the most when video recordings are used as an educational tool.
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Affiliation(s)
- Jenna M Warehime
- From the Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Warehime, Lenger, Cope, Feroz, Gupta, and Francis), University of Louisville, Louisville, Kentucky.
| | - Stacy M Lenger
- From the Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Warehime, Lenger, Cope, Feroz, Gupta, and Francis), University of Louisville, Louisville, Kentucky
| | - Xiang Yu Feng
- Department of Obstetrics and Gynecology and Women's Health (Drs. Feng and Hamm), University of Louisville, Louisville, Kentucky
| | - Zebulun Cope
- From the Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Warehime, Lenger, Cope, Feroz, Gupta, and Francis), University of Louisville, Louisville, Kentucky
| | - Rehan Feroz
- From the Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Warehime, Lenger, Cope, Feroz, Gupta, and Francis), University of Louisville, Louisville, Kentucky
| | - Jeremy Gaskins
- and Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences (Dr. Gaskins), University of Louisville, Louisville, Kentucky
| | - Ankita Gupta
- From the Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Warehime, Lenger, Cope, Feroz, Gupta, and Francis), University of Louisville, Louisville, Kentucky
| | - Sean Francis
- From the Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Warehime, Lenger, Cope, Feroz, Gupta, and Francis), University of Louisville, Louisville, Kentucky
| | - Jennifer Hamm
- Department of Obstetrics and Gynecology and Women's Health (Drs. Feng and Hamm), University of Louisville, Louisville, Kentucky
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Cope ZS, Francis S, Gupta A, Lenger SM. History of Surgical Treatments for Female Urinary Incontinence. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zebulun S. Cope
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Sean Francis
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Ankita Gupta
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Stacy M. Lenger
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville, Louisville, Kentucky, USA
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Lenger SM, Chu CM, Ghetti C, Hardi AC, Lai HH, Pakpahan R, Lowder JL, Sutcliffe S. Adult female urinary incontinence guidelines: a systematic review of evaluation guidelines across clinical specialties. Int Urogynecol J 2021; 32:2671-2691. [PMID: 33881602 DOI: 10.1007/s00192-021-04777-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To systematically review evaluation guidelines of uncomplicated urinary incontinence (UI) in community-dwelling adult women to assess guidance available to the full range of providers treating UI. METHODS Systematic literature search of eight bibliographic databases. We included UI evaluation guidelines written for medical providers in English after January 1, 2008. EXCLUSION CRITERIA guidelines for children, men, institutionalized women, peripartum- and neurologic-related UI. A quantitative scoring system included assessed components and associated recommendation level and clarity. RESULTS Twenty-two guidelines met the criteria. All guidelines included: history taking, UI characterization, physical examination (PE) performance, urinalysis, and post-void residual volume assessment. At least 75% included medical and surgical history assessment, other disease process exclusion, medication review, impact on quality of life ascertainment, observing stress UI, mental status assessment, performing a pelvic examination, urine culture, bladder diary, and limiting more invasive diagnostics procedures. Fifty to 75% included other important evaluation components (i.e., assessing obstetric history, bowel symptoms, fluid intake, patient expectations/preferences/values, obesity, physical functioning/mobility, other PE [abdominal, rectal, pelvic muscle, and neurologic], urethral hypermobility, and pad testing. Less than 50% of guidelines included discussing patient treatment goals. Guidelines varied in level of detail and clarity, with several instances of unclear or inconsistent recommendations within the same guideline and evaluation components identified only by inference from treatment recommendations. Non-specialty guidelines reported fewer components with a lesser degree of clarity, but this difference was not statistically significant (p = 0.20). CONCLUSIONS UI evaluation guidelines varied in level of comprehensiveness, detail, and clarity. This variability may lead to inconsistent evaluations in the work-up of UI, contributing to missed opportunities for individualized care.
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Affiliation(s)
- Stacy M Lenger
- Department of Obstetrics, Gynecology, and Women's Health, Division of Female Pelvic Medicine and Reconstructive Surgery, The University of Louisville School of Medicine, Louisville, KY, USA.,Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA
| | - Christine M Chu
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA
| | - Chiara Ghetti
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA
| | - Angela C Hardi
- Washington University School of Medicine, Becker Medical Library, St. Louis, MO, USA
| | - H Henry Lai
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ratna Pakpahan
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis Center for Outpatient Health, 9th floor, Campus, Box 8064, St. Louis, MO, 63110, USA.
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Lenger SM, Bradley MS, Thomas DA, Bertolet MH, Lowder JL, Sutcliffe S. D-mannose vs other agents for recurrent urinary tract infection prevention in adult women: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 223:265.e1-265.e13. [PMID: 32497610 DOI: 10.1016/j.ajog.2020.05.048] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/23/2020] [Accepted: 05/28/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We performed a systematic review and meta-analysis to determine whether D-mannose reduces urinary tract infection recurrence (ie, cumulative incidence) in adult women with recurrent urinary tract infection compared with other prevention agents. Secondary outcomes included side effects and compliance with D-mannose use. DATA SOURCES Ovid Medline 1946-, Embase 1947-, Scopus 1823-, Cochrane Library, Web of Science 1900-, and ClinicalTrials.gov were searched through 4/15/2020. STUDY ELIGIBILITY CRITERIA Systematic review inclusion: randomized controlled trials, prospective cohorts, and retrospective cohorts written in English of women ≥18 years old with recurrent urinary tract infection in which D-mannose was utilized as an outpatient prevention regimen. Systematic review exclusion: lab or animal-based research, study protocols only, and conference abstracts. Meta-analysis inclusion: stated D-mannose dose, follow-up time ≥6 months, a comparison arm to D-mannose, and data available from women ≥18 years of age. STUDY APPRAISAL AND SYNTHESIS METHODS Two independent reviewers made abstract, full text, and data extraction decisions. Study methodologic quality was assessed using the Cochrane Risk of Bias tool. Relative risks, confidence intervals, and heterogeneity were computed. RESULTS Searches identified 776 unique citations. Eight publications met eligibility: 2 using D-mannose only; 6 using D-mannose combined with another treatment. Seven studies were prospective: 2 randomized controlled trials, 1 randomized cross-over trial, and 4 prospective cohort studies. One retrospective cohort study was included. Three studies met meta-analysis eligibility (1 randomized controlled trial, 1 randomized cross-over trial, and 1 prospective cohort). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to placebo was 0.23 (95% confidence interval, 0.14-0.37; heterogeneity=0%; D-mannose n=125, placebo n=123). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to preventative antibiotics was 0.39 (95% confidence interval, 0.12-1.25; heterogeneity=88%; D-mannose n=163, antibiotics n=163). Adverse side effects were reported in 2 studies assessing D-mannose only (1 study (n=10) reported none; the other reported a low incidence (8/103 participants) of diarrhea). Two studies reported compliance, which was high. CONCLUSION D-mannose appears protective for recurrent urinary tract infection (vs placebo) with possibly similar effectiveness as antibiotics. Overall, D-mannose appears well tolerated with minimal side effects-only a small percentage experiencing diarrhea. Meta-analysis interpretation must consider the small number of studies with varied study design and quality and the overall small sample size.
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Affiliation(s)
- Stacy M Lenger
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.
| | - Megan S Bradley
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Debbie A Thomas
- Becker Library, Washington University School of Medicine, St. Louis, MO
| | - Marnie H Bertolet
- Departments of Epidemiology, Biostatistics, and the Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
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Lenger SM, White WM. Conventional laparoscopic and robotic sacrocolpopexy: tips and tricks. Minerva Ginecol 2016; 68:67-77. [PMID: 26448443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The demand for surgical correction of symptomatic pelvic organ prolapse has significantly increased as the general population has aged. In the modern era, patients with bothersome prolapse desire durable corrective surgery that offers tangible improvement in quality of life and is associated with minimal morbidity. Open abdominal sacral colpopexy (ASC) had long been considered the "gold standard" approach to achieve these reconstructive goals but was construed as being overly invasive with prolonged recovery and unacceptable pain. Transvaginal approaches were favored as a less invasive alternative, but durability and the more recent climate of fear engendered by mesh complications has made many surgeons and patients averse to these procedures. Improved laparoscopic dexterity and experience has led to renewed interest in ASC. Laparoscopic ASC achieves the aforementioned reconstructive goals but with decreased pain and faster recovery inherent to minimally invasive surgery. More recently, the widespread advent and adoption of robotics has made minimally invasive ASC more accessible to surgeons through its enabling technology. This article will review our team's robust experience with laparoscopic and robotic ASC with a focus on our patient evaluation, consent process, and our tips and tricks gained through experience.
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Affiliation(s)
- Stacy M Lenger
- Department of Obstetrics and Gynecology, The University of Tennessee Medical Center, Knoxville, TN, USA -
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Lenger SM. Observations: A Reflection on International Lessons in Residency. J Grad Med Educ 2016; 8:109. [PMID: 26913116 PMCID: PMC4763383 DOI: 10.4300/jgme-d-15-00406.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Stacy M Lenger
- Resident Physician, Postgraduate Year 3, University of Tennessee Graduate School of Medicine
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