Critical Anatomy for Robotic Sacrocolpopexy: A Long-term Follow-up Study.

OBJECTIVE: This study aimed to assess anatomy relative to sacral sutures 20 to 24 months after robotic sacrocolpopexy. METHODS: This was an institutional review board-approved prospective anatomy study of women undergoing robotic sacrocolpopexy. After placement of suture into the anterior longitudinal ligament, a small vascular clip was secured on the base of the suture. Subjects were imaged at 6 weeks and between 20 and 24 months after surgery. Measurements were calculated by the primary investigator and radiologist coinvestigator. RESULTS: Of the 11 subjects enrolled in the initial 6-week postoperative study, 5 (45%) completed the long-term follow-up. Regarding the vascular anatomy, no significant changes were documented. Similarly, the major urologic structure, the right ureter, was stable at 16 mm from the clip. A significant change was noted, however, in the distance from the apex of the vagina to the sacral suture. At 6 weeks postoperatively, the mean (SD) distance from the vaginal apex to the clip was 69.3 (14) mm; this increased to 85.2 (11.3) mm at the long-term follow-up (P = 0.004). CONCLUSIONS: Reassuringly, the position of the clip remained stable, which is reflected in the constancy of the measurements to the vascular landmarks. Nevertheless, alteration in the distance to the vaginal apex suggests elongation of the mesh or vaginal tissue with time. Although the increase in length was greater than 1.5 cm, it may bear clinical relevance in certain patients. This information may help guide surgeons regarding appropriate mesh tensioning during this critical step of the procedure.

Uterosacral Ligament Suspension: A Radiographic Study of Suture Location in Live Subjects.

OBJECTIVES: This study aimed to describe uterosacral ligament suspension (USLS) suture location relative to the surrounding anatomy in a living model using computed tomographic imaging. METHODS: This was an institutional review board-approved prospective descriptive study. Women aged 18 to 85 years undergoing vaginal hysterectomy with USLS were eligible. A size 'small' titanium vascular clip was applied to the base of each USLS suture. Computed tomography of the pelvis was performed on postoperative day 1. Preoperative and postoperative neurologic questionnaires and physical examinations were performed. A sample size of 15 subjects was deemed appropriate for this pilot study. RESULTS: Seventeen subjects were enrolled: 2 excluded and 15 analyzed. The median (interquartile range) age of the subjects was 57 (22) years. The closest branch of the internal iliac complex was 2.6 (0.9) cm (median [interquartile range]) from the proximal suture on the right and 2.6 (0.5) cm on the left. The right ureter was 2.1 (0.7) cm from the right proximal suture. The left ureter was 2.3 (1.0) cm from the left proximal suture. The rectal lumen were 3.0 (1.6) cm from the right proximal suture and 2.8 (1.4) cm from the left proximal suture. No subjects were found to have neurologic involvement of the sutures based on neurologic questionnaire responses and physical examination. CONCLUSIONS: In live subjects, our study confirms that the vasculature, ureter, and rectum of the pelvic side wall are near suture placement for USLS. This information highlights the importance of careful dissection and awareness of anatomic landmarks.

Uterosacral Ligament Suspension Versus Robotic Sacrocolpopexy for Treatment of Apical Pelvic Organ Prolapse.

OBJECTIVE: The aim of the study was to compare long-term outcomes of uterosacral ligament suspension (USLS) versus robotic sacrocolpopexy (RSC) in patients with pelvic organ prolapse. METHODS: This was an institutional review board-approved retrospective cohort study. Women 3 to 7 years after USLS or RSC were contacted for enrollment. Participants were asked to complete validated questionnaires and physical examinations. The primary outcomes were no symptoms of bulge or retreatment for prolapse (subjective) and POP-Q examination demonstrating prolapse above or equal to -1 (objective). For the subjective outcome, a noninferiority calculation with 10% noninferiority margin deemed 91 subjects in each group were required. RESULTS: We identified the following 770 eligible subjects: 205 were contacted, 19 declined, 186 subjects agreed to participate, and 2 were excluded. There were 92 subjects per group in the analysis for the primary subjective outcome, and 84% underwent examinations for the objective outcome. Baseline characteristics were overall similar; however, previous prolapse surgery was more common in the RSC group (P < 0.001). Subjective success was achieved in 83 subjects in the USLS group and 78 subjects in the RSC group (90.2% vs 84.4%, respectively, P = 0.265 [95% confidence interval = -0.036 to 1.000]). Objective success was noted in 93.2% and 91.3% of the USLS and RSC groups, respectively (P = 0.869). Postoperative complication rates were low and did not differ between groups. Mesh complications were noted in 6.6% of the RSC group. One subject in the USLS group reported pain related to surgery. CONCLUSION: Uterosacral ligament suspension was noninferior to RSC at 3- to 7-year postsurgery for subjective symptoms and similar for objective outcomes. Both approaches showed high success rates and strong patient satisfaction.

Incidence of Obstetric Anal Sphincter Injuries After Training to Protect the Perineum.

OBJECTIVES: Obstetric anal sphincter injuries (OASISs) are a devastating postpartum complication; reducing rates is paramount to improving quality of care. In Norway, implementation of a perineal protection program decreased the incidence of OASIS by 48%. We sought to assess impact on OASIS rates following a similar program. METHODS: This institutional review board-approved, retrospective cohort study was performed in an academic hospital system. The periods of analysis were November 2014 through October 2015 for the preintervention arm and November 2015 through October 2016 for the postintervention arm. From November 2 to 6, 2015, 2 Norwegian experts conducted a didactic and hands-on, on-site workshop focusing on perineal protection. The experts were then present on labor and delivery wards to reinforce perineal protection in live deliveries. Teachings were emphasized at departmental meetings for the remainder of the year. Data were extracted from electronic medical records and manually audited. RESULTS: The rate of vaginal delivery was similar among both periods (6504 and 6650; P = 0.059). Obstetric anal sphincter injury rates decreased from 211 (3.2%) preintervention to 189 (2.8%) after the workshop. Although this represented 32 fewer injuries, it was not statistically significant (P = 0.179). Obstetric anal sphincter injuries following forceps-assisted deliveries did decline significantly from 103 (28%) to 81 (21%) (P = 0.014). In addition, incidence of fourth-degree lacerations during resident deliveries decreased significantly from 10 (0.6%) to 3 (0.2%) (P = 0.047). CONCLUSIONS: An educational workshop focusing on perineal support was not associated with a significant reduction in overall OASIS rates. Nevertheless, decreased forceps-related OASIS and fourth-degree lacerations rates support positive influence of the intervention.

Liposomal Bupivacaine During Robotic Colpopexy and Posterior Repair: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effect of liposomal bupivacaine on postoperative pain among patients undergoing robotic sacrocolpopexy with posterior repair. METHODS: This was a randomized, patient-blinded, placebo-controlled trial of women undergoing robotic sacrocolpopexy with posterior repair. Liposomal bupivacaine or normal saline placebo was injected into laparoscopic and vaginal incisions at completion of surgery. Perioperative care was standardized. Visual analog scales were collected at 4, 18, and 24 hours postoperatively in hospital. Starting on postoperative day 1, participants completed twice-daily pain scales and a pain medication diary up until the evening of postoperative day 3. The primary outcome was a 20-mm change in the visual analog scale 18 hours postoperatively. Secondary measures included additional pain scores, satisfaction, and narcotic use. Sample size calculation revealed that 32 patients per arm were required to detect the 20-mm difference with 90% power and an α of 0.05. To allocate for dropout, a goal of 70 was set. RESULTS: Between March 2015 and April 2016, 100 women were screened and 70 women were enrolled: 35 women were randomized to liposomal bupivacaine and 35 to placebo, of whom 64 (91%) were included in the final analysis: 33 liposomal bupivacaine and 31 placebo. No difference in demographics, surgical data, or satisfaction between groups was noted. Median VAS at 18 hours after surgery was not statistically different in those who received liposomal bupivacaine compared with normal saline (15 mm compared with 20 mm; P=.52). Other pain scales and total morphine equivalents were also similar (P=.90). CONCLUSION: In this study of robotic sacrocolpopexy with posterior repair, there were no differences in pain scores or narcotic use between liposomal bupivacaine and placebo injected into laparoscopic and vaginal incisions. Given its lack of clinical benefit, routine use of liposomal bupivacaine is not supported for this surgical intervention. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02449915.

Primary care providers' experience, management, and referral patterns regarding pelvic floor disorders: A national survey.

INTRODUCTION AND HYPOTHESIS: Primary care physicians can impact womens' access to care. We assessed primary care providers' experience and management regarding pelvic floor disorders. METHODS: This Institutional Review Board approved study invited internal and family Medicine Program Directors to complete and distribute to faculty an online survey designed to query demographics, perceptions, management, and referral patterns regarding urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP) in females. RESULTS: A total of 872 residency Program Directors were invited: 74 emails were incorrect; 391 physicians responded. Respondents were evenly distributed with respect to age, gender, and region. The majority practiced family Medicine, identified their practice as community/academic, and practiced >10 years. Forty-one percent perceived UI and 54% believed OAB prevalence to be 11-30%. Most initiated treatment for UI (97%) and OAB (96%), referring to urology when consultation was necessary. Half believed POP prevalence to be <10% of women, and often referred POP to Gynecology. Only 25% reported being 'very familiar' with urogynecology, and 46% were unaware of such providers in their area. Female providers were more likely to screen for OAB (p = .018) and POP (p = .004) and be familiar with urogynecology (p = 0.038). Providers practicing in the Midwest were most likely, while those in the West were least likely, to be aware of urogynecologists for referral, (p = < .001). CONCLUSIONS: Primary care providers nationally are familiar with UI and OAB, but less familiar with POP. Nearly half were uncertain of urogynecologists to whom they could refer. Outreach to these providers may improve patient access to care.

Outcomes and Characteristics of Patients Undergoing Surgical Management for Mesh Related Complications.

OBJECTIVE: The aims of this study were to describe the characteristics of women presenting with mesh-related complications and evaluate postoperative quality of life, sexual functioning, and patient-perceived outcomes. METHODS: This institutional review board-approved study included a retrospective chart review and a cross-sectional follow-up with validated questionnaires. Demographics and medical histories were collected from charts of women treated for mesh-related complaints between 2010 and 2014. Subjects completed follow-up validated questionnaires regarding health, sexual functioning, postoperative symptom improvement/severity, satisfaction, and regret with the decision to pursue treatment. RESULTS: Ninety-three charts were analyzed. Mean subject age was 55 years, median body mass index was 28.7 kg/m, and median time from mesh placement to presentation was 2.7 years. Forty-nine had midurethral sling mesh only, 30 had prolapse-related mesh, and 14 had both. Forty-two subjects (48.9%) had mesh exposures, 19 involving prolapse-related mesh (52.4% transvaginal and 47.4% sacrocolpopexy). Surgical revisions were most often for exposure and pain. Seventy-five women were reached for follow-up; 71 agreed to participate, 53 (75%) returned the questionnaires. Thirty had sling revision, 22 had prolapse mesh revision, and 1 had both. Questionnaire results revealed no changes in health or sexual function after treatment. Postoperatively, subjects reported symptom improvement, low symptom severity, as well as high satisfaction and low regret with the decision to pursue surgical intervention. CONCLUSIONS: Women with mesh complications presented 2 years after initial placement, most often complaining of exposure or pain/dyspareunia. Although no changes in health or sexual functioning were noted postoperatively, participants reported symptom improvement after revision and satisfaction with the decision to pursue treatment.

Liposomal bupivacaine decreases pain following retropubic sling placement: a randomized placebo-controlled trial.

BACKGROUND: Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively. OBJECTIVE: The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement. STUDY DESIGN: This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed "current level of pain"; the evening items queried "current level of pain," "most intense pain today," "average pain today with activity," and "average pain today with rest." Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed. RESULTS: One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m2. Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m2; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted. CONCLUSION: Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful.

The Effect of Intravenous Acetaminophen on Postoperative Pain and Narcotic Consumption After Vaginal Reconstructive Surgery: A Double-Blind Randomized Placebo-Controlled Trial.

OBJECTIVE: This study aimed to determine the effect of intravenous acetaminophen versus placebo on postoperative pain, satisfaction with pain control, and narcotic use after vaginal reconstructive surgery. METHODS: This was an institutional review board-approved, double-blind placebo-controlled randomized trial. Women scheduled for reconstructive surgery including vaginal hysterectomy and vaginal vault suspension were enrolled. Subjects received 1000 mg of intravenous acetaminophen or 100 mL placebo every 6 hours for 24 hours. Pain and satisfaction with pain control were assessed using visual analog scales and a numeric rating scale. Visual analog scales were collected at 18 and 24 hours postoperatively and at discharge. A sample size calculation determined 90 subjects would be required to detect a 30% reduction in postoperative narcotic use with 80% power and significance level of 0.05. RESULTS: One hundred subjects were enrolled. There were no differences in demographics or surgical data and no difference in narcotic consumption at multiple evaluation points. At 18 hours postoperative, median pain scores at rest were 27.0 (interquartile range, 35.0) for acetaminophen and 35.0 (interquartile range, 44.5) for placebo, finding no difference (P = 0.465). Furthermore, pain with activity and numeric rating scale-assessed pain scales were similar (P = 0.328; P = 0.597). Although satisfaction with pain control was high overall (91.5), no difference was noted. CONCLUSIONS: Patients undergoing vaginal reconstructive surgery receiving perioperative intravenous acetaminophen did not experience a decrease in narcotic requirements or postoperative pain when compared with placebo. Reassuringly, pain scores were low and satisfaction with pain control was high for all subjects. The general use of this medication is not supported in these surgical patients.

Comparative Perioperative Pain and Recovery in Women Undergoing Vaginal Reconstruction Versus Robotic Sacrocolpopexy.

BACKGROUND: In this study of patients undergoing vaginal hysterectomy with either robotic or vaginal prolapse repair, there was no difference in quality of life in the weeks following surgery; however, less narcotics were used, less pain was documented by nurses and Surgical Pain Scale (SPS), and better performance on voiding trials was noted in those undergoing robotic sacrocolpopexy. OBJECTIVES: Minimally invasive surgery for pelvic organ prolapse is the preferred surgical route for optimal recovery. However, information regarding patient-centered outcomes among various techniques is lacking. We sought to describe pain and quality of life in patients undergoing vaginal hysterectomy with uterosacral ligament suspension (USLS) compared with robotic-assisted sacrocolpopexy (RSC). METHODS: This institutional review board-approved prospective cohort study enrolled consecutive patients undergoing vaginal hysterectomy with USLS or with RSC. The primary outcome was pain on postoperative day 1 using the SPS. Nursing verbal pain scores, narcotic usage, surgical data, and Short-Form Health Survey 12 at baseline and 2 and 6 weeks after surgery were collected. A sample size calculation revealed 37 subjects per group would be required. RESULTS: Seventy-eight women were enrolled (USLS, n = 39; RSC, n = 39). There were no significant differences in scores on the SPS between groups. Subjects undergoing RSC had lower nursing verbal pain scores (P = 0.04), less narcotic consumption (P = 0.02), and lower estimated blood loss (P = 0.01) and were less likely to fail voiding trials (P < 0.001); however, surgery duration was longer (P < 0.001). After controlling for age, regression analysis revealed SPS "worst pain" was lower in the robotic arm (P = 0.01), but not in other scales of the SPS. At 2 and 6 weeks postoperatively, Short-Form Health Survey 12 scores were not different between cohorts. CONCLUSIONS: Both USLS and RSC are minimally invasive, with similar quality-of-life scores after surgery. However, the robotic approach may be associated with less pain, less narcotic use, and better performance in voiding trials. Surgeons should consider these findings when counseling patients regarding treatment options.

Histologic Anatomy of the Anterior Vagina and Urethra.

BACKGROUND: Vaginal and urethral histology is important to understanding the pathophysiology of the pelvic floor. METHODS: En bloc removal of 4 female cadaveric pelvises was performed, with 18 to 25 serial sections obtained from each. The vaginal and urethral lengths were divided into distal and proximal sections; urethra was divided into anterior and posterior segments as well. Innervation and vasculature were qualified as small and large and quantified per high-power field. RESULTS: The mean vaginal length was 7.45 cm, and the mean urethral length was 3.38 cm. A distinct vaginal fibromuscular layer was noted, without evidence of a dense sheet of continuous collagen. An epithelial, lamina propria, and muscular layer surrounded the urethral lumen. Adipose and loose fibroconnective tissue separated the urethra from the anterior vagina in 41% of slides. Nerves and vasculature were concentrated in the lamina propria. More small nerves and vessels were grossly seen compared with larger counterparts in both the vagina and urethra. No significant differences in layer thickness, innervation, or vasculature were observed along the vaginal length. The posterior urethra had greater innervation than did the anterior (P = 0.012). The distal posterior urethra had more large vessels than did the proximal posterior urethra (P = 0.03). No other differences were noted in urethral sections. CONCLUSIONS: A vaginal fibromuscular layer was confirmed, refuting a true fascia. Innervation and vasculature were quantitatively the same along the anterior vagina. However, the posterior urethra had greater innervation than did anterior and is most innervated proximally. Nerve and vascular histology may relate to pelvic floor disorder etiology.

Primary care providers' attitudes, knowledge, and practice patterns regarding pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: Understanding barriers to seeking care for pelvic floor disorders is necessary. We sought to assess familiarity with pelvic floor disorders, as well as identify screening and referral patterns among primary care providers. METHODS: This Institutional Review Board approved study was distributed through a secure online server (SurveyMonkey®). Primary care providers within a large healthcare system were invited to participate in a 14-question survey regarding the prevalence, diagnosis, and treatment of urinary incontinence (UI), overactive bladder (OAB) syndrome, and pelvic organ prolapse (POP). Demographic information was collected. Descriptive statistics and associations were calculated. RESULTS: A total of 360 emails were delivered, 108 responded (response rate 30.0 %). Respondents were evenly distributed with respect to age and years in practice. Providers correctly estimated the prevalence of UI and OAB, and most reported treating these conditions themselves (92.6 % and 88.9 %, respectively). If treatment failed, however, referral was most often (68.1 %) to urology. The majority reported not screening for POP, and 50.9 % believed the prevalence to be rare. Referrals for POP were most often (61.1 %) to urogynecology. Male providers were less likely to screen for POP than female providers (p < 0.001). Only a minority (35.2 %) described being 'very familiar' with urogynecology, and 19.4 % were unaware of such providers within the system. CONCLUSIONS: Primary care providers within a large healthcare system were more familiar with UI and OAB than POP, often underestimating the prevalence of POP. Nearly one-fifth were unaware of urogynecologists within their system. Educational outreach regarding pelvic floor disorders and the urogynecology specialty would likely improve patient access to care.

Impact of Pelvic Floor Physical Therapy on Quality of Life and Function After Obstetric Anal Sphincter Injury: A Randomized Controlled Trial.

OBJECTIVES: There is no standard of care for women sustaining an obstetric anal sphincter injury (OASIS). We sought to determine whether pelvic floor physical therapy (PFPT) would improve the quality of life and function in women 12 weeks after OASIS. METHODS: This institutional review board-approved randomized trial enrolled primiparous women 2 weeks after delivery complicated by OASIS. After informed consent, all subjects underwent vaginal electromyography and anorectal manometry and completed validated questionnaires; measures were repeated for all subjects at 12 weeks after delivery. The intervention arm completed 4 PFPT sessions. The primary outcome was a change in the Fecal Incontinence Quality of Life. RESULTS: Three hundred four women were screened; 250 were excluded, and 54 were randomized. After four were lost to follow-up, analysis included 27 in the intervention arm and 23 in the control arm. Overall, mean age was 29.8 ± 4.7 years, and there were no demographic differences between groups.Fecal Incontinence Quality of Life domain scores showed improvement for both groups from baseline to 12 weeks for coping (P = 0.006) and depression (P = 0.009); however, there was no difference in domain scores between groups. For the secondary outcome of anorectal manometry, squeezing pressure improved for all subjects (P = 0.035) from baseline to 12 weeks. Vaginal EMG strength (microvolts) increased for all subjects in measures of rest average (P < 0.000), rapid peak (P = 0.006), and work average (P < 0.000), with no difference based on therapeutic arm. CONCLUSIONS: All women showed improvements in quality of life and function at 12 weeks after delivery, regardless of treatment allocation. Further study is needed to determine whether PFPT provides a significant benefit to women having OASIS.

Attitudes Regarding Labial Hypertrophy and Labiaplasty: A Survey of Members of the Society of Gynecologic Surgeons and the North American Society for Pediatric and Adolescent Gynecology.

OBJECTIVE: The aim of this study was to describe gynecologists' attitudes toward labial hypertrophy and explore possible differences among providers for pediatric/adolescent patients. METHODS: This was an institutional review board-approved, cross-sectional survey of physician attendees at 2 national meetings in 2014: the Society of Gynecologic Surgeons (SGS) and the North American Society for Pediatric and Adolescent Gynecology (NASPAG). The survey was designed to query demographics and impressions regarding labial hypertrophy and labiaplasty. RESULTS: Three hundred sixty-five surveys were completed (response rate, 50%); 268 were analyzed: 55% from SGS and 45% from NASPAG. Most were older than 41 years; 170 (63%) were women, and 93 (35%) were men. More men than women attended SGS (60%); however, women were the majority at NASPAG (94%).Most respondents believed labial hypertrophy to be infrequently reported and "a condition that impacts body image." Common symptoms were "discomfort with exercise" and "dissatisfaction with appearance naked." The majority felt this to impact sexual function "in some cases," citing "self-esteem" and "comfort" most often.Concerning therapies for provided labial hypertrophy, 83% of practitioners provide reassurance, whereas 77% would offer labiaplasty. Expertise with labiaplasty varied; 28% felt "very comfortable," and 11% felt "very uncomfortable."Provider preference for treatment differed based on meeting attendance. After logistic regression controlling for sex and age, attendance at SGS remained associated with offering labiaplasty (P = 0.001; odds ratio, 4.1; 95% confidence interval, 1.8-9.3), whereas NASPAG attendance was associated with providing reassurance (P = 0.008; odds ratio, 0.30; 95% confidence interval, 0.10-0.70). CONCLUSIONS: Although the majority surveyed view labial hypertrophy to be bothersome, gynecologists caring for our youngest patients are more likely to provide reassurance. Consensus guidelines are needed to aid practitioners in appropriate management of labial hypertrophy.

To Pack or Not to Pack? A Randomized Trial of Vaginal Packing After Vaginal Reconstructive Surgery.

OBJECTIVE: Placement of vaginal packing after pelvic reconstructive surgery is common; however, little evidence exists to support the practice. Furthermore, patients have reported discomfort from the packs. We describe pain and satisfaction in women treated with and without vaginal packing. METHODS: This institutional review board-approved randomized-controlled trial enrolled patients undergoing vaginal hysterectomy with prolapse repairs. The primary outcome was visual analog scales (VASs) for pain on postoperative day 1. Allocation to "packing" ("P") or "no-packing" ("NP") arms occurred intraoperatively at the end of surgery. Visual analog scales regarding pain and satisfaction were completed early on postoperative day 1 before packing removal. Visual analog scale scores for pain, satisfaction, and bother attributable to packing were recorded before discharge. All packing and perineal pads were weighed to calculate a "postoperative vaginal blood loss." Perioperative data were collected from the hospital record. Our sample size estimation required 74 subjects. RESULTS: Ninety-three women were enrolled. After exclusions, 77 were randomized (P, 37; NP, 40). No differences were found in surgical information, hemoglobin levels, or narcotic use between groups. However, "postoperative vaginal blood loss" was greater in packed subjects (P < 0.001). Visual analog scale scores for pain before removal of packing (P, 41.6 vs NP, 46.3; P = 0.43] and before discharge (P, 35.0 vs NP, 40.0; P = 0.43] were not significantly different between treatment arms. Likewise, VAS scores for satisfaction before removal of packing (P, 81.0 vs NP, 90.0; P = 0.08] and before discharge (P, 90.0 vs NP, 90.5; P = 0.60] were not significantly different. Packed patients noted lower nursing verbal pain scores (P = 0.04) and used less ketorolac (P = 0.01). Bother from packing was low overall. CONCLUSIONS: Although there was no difference based on VAS, women receiving vaginal packing had lower nursing documented pain and used less ketorolac than packed women. Vaginal packing may provide benefit and can remain part of the surgical practice.

Critical Anatomy Relative to the Sacral Suture: A Postoperative Imaging Study After Robotic Sacrocolpopexy.

OBJECTIVE: This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging. METHODS: A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging. RESULTS: Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%. CONCLUSIONS: We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.

Effects of dexamethasone on quality of recovery following vaginal surgery: a randomized trial.

OBJECTIVE: Dexamethasone is a corticosteroid with minimal side effects that may improve quality of recovery. We sought to evaluate standard use of this medication prior to vaginal reconstructive surgery. STUDY DESIGN: This was a double-blind, randomized, placebo-controlled trial of women undergoing vaginal reconstructive surgery for pelvic organ prolapse. Patients scheduled for an intraperitoneal vaginal vault suspension, with general anesthesia and an overnight stay, were enrolled. The intervention arm received dexamethasone 60 minutes prior to surgery, and controls received placebo. Postoperative pain medications, antiemetics, and voiding trials were standardized. Our primary outcome was the difference in Quality of Recovery (QoR-40) scores on postoperative day 1. Secondary measures included Postoperative Nausea and Vomiting Intensity scores, and visual analog scales for nausea/vomiting, and pain. Our power calculation demonstrated 31 subjects in each group would be necessary to document difference in QoR-40 scores; to allow for attrition, a goal of 74 subjects was set. RESULTS: Seventy-four women were enrolled and randomized. Two withdrew, 9 were excluded, and 63 were analyzed (36 placebo, 27 dexamethasone). The mean age was 63 years. No significant differences were noted among demographics other than American Society for Anesthesiologists class; there were greater numbers of dexamethasone subjects that were class 3 (5 vs 11; P = .030). Postoperatively, more patients in the placebo group required promethazine as a rescue antiemetic for control of their nausea/vomiting (11 vs 2; P = .029). Placebo subjects also failed their voiding trials more frequently, which remained following a logistic regression controlling for suburethral sling (30 vs 15; P = .037). Regarding the QoR-40 following surgery, the emotional state domain declined less in dexamethasone patients (-14.3, interquartile range [IQR], 16.8 vs -4.6, IQR, 20.1; P = .042), indicating better symptoms. Whereas pain scales were similar, the visual analog scales for nausea/vomiting was lower in dexamethasone subjects (0.7; IQR, 4.1 vs 0.4; IQR, 1.4; P = .042). Postoperative Nausea and Vomiting Intensity scores were not significantly different; nevertheless, twice as many placebo subjects had severe range symptoms (4 vs 2; P = .47). No adverse effects from the dexamethasone were noted. CONCLUSION: Use of dexamethasone prior to vaginal reconstructive surgery was associated with less nausea/vomiting and need for antiemetics as well as greater success with voiding trials. Furthermore, quality of recovery was enhanced, suggesting use of dexamethasone should be considered for these patients.

Survey of male perceptions regarding the vulva.

OBJECTIVE: The purpose of this study was to characterize male preferences of vulvar appearance, their awareness of labiaplasty, and their knowledge of genital anatomy. STUDY DESIGN: Men 18-80 years old were recruited via emails sent by an Internet provider to participate in a 27-question web-based survey. The questionnaire included images and queried demographics, men's familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. Two deployments to >150,000 email addresses were sent. Demographic data were described using frequencies for categoric variables and mean measures of central tendency for continuous variables. Logistic regression models were used to analyze associations between demographics and responses. RESULTS: Two thousand four hundred three men responded to the survey. After excluding incomplete and ineligible surveys, 1847 surveys were analyzed. The median age of respondents was 55 years. The majority was white (87%), married (68%), employed (69%), and had completed high school or beyond (97%). One-third of the respondents lived in the South, with the other regions nearly equally represented. A significant majority, 95%, reported having been sexually active with women, and 86% felt comfortable labeling the vulvar anatomy. With regard to preferences, more respondents considered smaller labia attractive compared to large labia; yet 36% of the men remained neutral. Men also showed a preference for partially or completely groomed genitals compared to natural hair pattern. Whereas 51% of participants believed the appearance of a woman's labia influenced their desire to engage in sexual activity, 60% denied it affected sexual pleasure. Only 42% of men were familiar with labiaplasty, and 75% of all respondents would not encourage a female partner to change her genital appearance. Multivariable analysis revealed younger age to be associated with preferences for small labia and complete genital hair removal, as well as familiarity with labiaplasty. CONCLUSION: In this national survey, men demonstrated familiarity with the female anatomy, but many did not feel it impacted sexual desire or pleasure. Moreover, the majority lacked strong preferences for a specific vulvar appearance and would not encourage a female partner to alter her genital appearance surgically.

Systemic markers of collagen metabolism and vitamin C in smokers and non-smokers with pelvic organ prolapse.

OBJECTIVE: To evaluate systemic markers of collagen metabolism and vitamin C in female smokers with pelvic organ prolapse (POP). Secondary aims were to compare these levels in women based on prolapse or smoking history alone. STUDY DESIGN: This was a cross-sectional study with four groups: smokers with POP, non-smokers with POP, smokers without POP and non-smokers without POP. Subjects were age-matched based on smoking history and presence of POP. All underwent a fasting blood panel, including plasma procollagen 1-N propeptide (P1NP), matrix metalloproteinase 9 (MMP-9), and vitamin C. RESULTS: Ninety-six subjects were enrolled. There were no differences for any demographics other than stage of prolapse, which was highest in non-smokers with POP. Significant variations in the levels of vitamin C and MMP-9 were noted among the four groups. Smokers with POP had lower levels of vitamin C and higher levels of MMP-9, compared to non-smokers with POP, but this relationship was not statistically significant. However, when contrasting smokers without POP to non-smokers without POP, significant differences in both vitamin C and MMP-9 were documented, confirming an impact of smoking on these markers. Notwithstanding, when evaluated independent of smoking status, vitamin C and MMP-9 levels in women with POP were similar to those of women without POP. CONCLUSION: Lower vitamin C and higher MMP-9 among smokers confirms the usefulness of such markers in documenting the smoking's impact on collagen. However, the lack of a difference based on POP suggests these are poor measures for understanding the pathophysiology of this disorder.

Pelvic floor physical therapy: impact on quality of life 6 months after vaginal reconstructive surgery.

OBJECTIVES: Pelvic floor physical therapy (PFPT) is often used as a treatment of pelvic floor disorders and may improve function after pelvic reconstructive surgery. However, the long-term impact of this modality is not understood. METHODS: This randomized controlled trial compared PFPT to the standard care in women undergoing vaginal reconstruction. The intervention group received PFPT biweekly until 12 weeks postoperatively, in conjunction with a physician assessment. Control subjects underwent a physician assessment alone at all postoperative intervals. The final follow-up was at 24 weeks. Physical examinations (pelvic organ prolapse quantification assessment), intravaginal electromyography, voiding diaries, and validated questionnaires were completed by all subjects. The primary outcome was change in the World Health Organization Quality of Life-BREF. RESULTS: Forty-nine women completed the study, 24 in the PFPT group and 25 in the control group. Although electromyography measures showed better muscular function in PFPT subjects after 12 weeks, at 6 months after surgery, this was no longer noted. However, quality of life parameters improved for the entire sample at 24 weeks, with no difference between groups. Positive change from 12 to 24 weeks was also documented in scores on the Pelvic Floor Distress Inventory-20 (P = 0.04) and Pelvic Floor Impact Questionnaire-7 (P = 0.018), corresponding with continued improvement in bladder symptoms. Finally, Prolapse and Incontinence Sexual Questionnaire-12 and Female Sexual Function Index scores improved between 12 and 24 weeks, suggesting better sexual function overall with time elapsed from surgery. CONCLUSIONS: Quality of life improves in all subjects after vaginal reconstructive surgery, with ongoing benefit between 3 and 6 months. Nevertheless, standardized PFPT was not associated with differences at 24 weeks in this cohort of women.