OnabotulinumtoxinA discontinuation in patients with prior nerve stimulation.

PURPOSE: The objective of this study is to describe the characteristics of patients who discontinue onabotulinumtoxinA treatment for overactive bladder (OAB) and to determine the impact of prior sacroneuromodulation or peripheral nerve stimulation on the discontinuation rates of onabotulinumtoxinA. MATERIALS AND METHODS: This is a retrospective cohort study of women with at least two onabotulinumtoxinA (BTX-A) treatments for OAB with a Female Pelvic Medicine and Reconstructive surgeon at a referral center between January 2014 and July 2019. Patients were excluded if they underwent BTX-A treatment in the operating room or utilized clean intermittent catheterization at baseline. Women who continued injections throughout the study period were compared to those who did not. Discontinuation was defined as stopping BTX-A during the study period. Treatment failure was defined as a documented failure in the chart and/or moving to other OAB treatments. Loss to follow-up was defined as no follow-up greater than 12 months after the last injection. Discontinuation-free and failure-free survival were estimated by Kaplan-Meier analysis. RESULTS: A total of 214 women met the inclusion criteria with a mean age of 62.9 ± 14 years. Fifty percent were Black. Eighty-six (40.2%) discontinued onabotulinumtoxinA treatment during the study period. There were no demographic differences between patients who discontinued BTX-A and those who continued with the following exceptions: patients who discontinued had higher rates of prior pelvic reconstructive surgery (19.8% vs. 10.2%, p = 0.04) and were more likely to have the concurrent diagnosis of painful bladder syndrome (9.3% vs. 2.3%, p = 0.03). Patients diagnosed with a urinary tract infection (UTI) after ≥50% of treatments were more likely to discontinue (27.9% vs. 14.1%, p = 0.01). On multivariate logistic regression analysis, patients with recurrent UTIs after treatment were significantly more likely to discontinue than those who do not (odds ratio: 2.61, [1.17, 5.82]). Of the cohort, 54 (25%) patients had previously undergone nerve stimulation. A total of 27.8% of patients with prior nerve stimulation discontinued BTX-A compared to 44.4% of those without prior third line treatment (p = 0.03). Patients with prior nerve stimulation had a higher discontinuation-free survival rate (p = 0.013) but there was no difference in failure-free survival. CONCLUSIONS: Patients who have recurrent UTIs after onabotulinumtoxinA injections are 2.6 times more likely to discontinue treatment than those who do not have infections. Patients with prior exposure to nerve stimulation have a significantly lower onabotulinumtoxinA discontinuation rate, but there is no difference in failure rates.

Assessing the Impact of Vaginal Hysterectomy with Vaginal Mesh Attachment on Outcomes and Complications during Minimally Invasive Sacrocolpopexy.

STUDY OBJECTIVE: To compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy. DESIGN: Single-center retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Women with symptomatic pelvic organ prolapse who elected for MISC. INTERVENTIONS: Laparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse. MEASUREMENTS AND MAIN RESULTS: Between 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p = .31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p >.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p = .07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p = .57), or composite failure (9.0% vs 3.7% vs 4.8%; p = .07). CONCLUSIONS: TVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.

Current Clinical Practice Patterns in Total Vaginal Hysterectomy.

OBJECTIVES: There are no data on current surgical practice patterns for benign total vaginal hysterectomy (TVH) despite recently published guidelines. The objective was to determine gynecologic surgeon practice patterns regarding TVH perioperative interventions and to assess adherence to clinical practice guidelines. METHODS: A survey to assess TVH practice patterns was distributed to gynecologic surgical society members for completion. The primary outcome was to compare adherence to practice guidelines between fellowship-trained and non-fellowship-trained gynecologic surgeons. Secondary outcomes included comparing adherence based on age, practice location, and hysterectomy volume. RESULTS: Of the 204 respondents, there were 163 (80%) fellowship-trained and 41 (20%) non-fellowship-trained gynecologic surgeons. Fellowship-trained surgeons were more likely than non-fellowship-trained surgeons to use vaginal packing (34% vs 15%, P = 0.028), which is contrary to the recommendations. No cohort followed the guideline recommending a circular cervicovaginal incision. Fellowship-trained surgeons also were more likely than non-fellowship-trained surgeons to use the clamp and suture technique for vessel ligation (88% vs 68%, P = 0.004); otherwise, there were no significant differences between cohorts for adherence to any of the other guidelines. Although fellowship-trained surgeons were adherent to fewer of the guidelines as compared with surgeons without fellowship training, both groups generally adhered to a majority of the clinical practice guidelines for benign TVH. CONCLUSIONS: This information demonstrates a need for the development of targeted education and interventions to increase the use of evidence-based clinical practice guidelines during TVH for both fellowship-trained and non-fellowship-trained gynecologic surgeons.

Mesh Exposure Following Vaginal Versus Laparoscopic Hysterectomy at the Time of Sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: To compare vaginal mesh exposure rates, adverse events and composite failure within 1 year postoperatively in patients who undergo vaginal hysterectomy with vaginal mesh attachment (TVH) versus laparoscopic hysterectomy with abdominal mesh attachment (TLH) for minimally invasive sacrocolpopexy. METHODS: This multicenter retrospective cohort study is a secondary analysis of data collected retrospectively at one institution and the multicenter randomized control PACT trial. Women were excluded for no follow-up between 9 months and 2 years postoperatively or undergoing concurrent non-urogynecologic procedures. RESULTS: Between 2010 and 2019, 182 patients underwent TLH and 132 TVH. There were 15 (4.8%) vaginal mesh exposures: 12 (6.6%) in the TLH and 3 (2.3%) in the TVH group (p = 0.133) with zero mesh erosions. Logistic regression analysis for mesh exposure in the TLH vs. TVH groups controlling for BMI, posterior repair and surgeon training also showed no significant difference (OR 4.8, 95% CI 0.94, 24.8, p = 0.059). The overall intraoperative complication rate was low (19/314, 6.1%) with a higher rate of bladder injury in the TLH group (4.4% vs. 0.8%, p = 0.049). The TLH group had a higher rate of UTI (8.2% vs. 2.3%, p = 0.027) and clean intermittent catheterization (11% vs. 3%, p = 0.009). At 1-year follow-up, there was no difference in composite failure (6%), bulge symptoms (5%) or retreatment (1%) between groups. CONCLUSIONS: At 1 year, there is no significant difference in vaginal mesh exposure rates between vaginal hysterectomy with vaginal mesh attachment and laparoscopic hysterectomy with abdominal mesh attachment. Both groups have equal efficacy with low rates of complications.

Vaginal surgery: don't get bent out of shape.

Vaginal hysterectomy rates in the United States are decreasing, despite it being the recommended hysterectomy route for benign hysterectomy by multiple societies. Visualization issues are a known barrier to a medical student learning in the operating room, and it is likely that this also extends to resident training. In addition, vaginal surgery can be taxing on both the surgeons and assistants, with high rates of musculoskeletal work disorders reported in vaginal surgeons. The use of a camera is integral to endoscopic surgery, and table-mounted retractor systems have been used for decades in open surgery. We bring these 2 features into vaginal surgery, that is, using a table-mounted camera system and a table-mounted vaginal retractor. When used together as demonstrated in this video, these tools can improve visualization and may improve ergonomics for the entire surgical team, including learners, during vaginal surgery.

Perioperative adverse events in women undergoing concurrent urogynecologic and gynecologic oncology surgeries for suspected malignancy.

INTRODUCTION AND HYPOTHESIS: This study's objectives were to compare the incidence of adverse events after concurrent urogynecologic and gynecologic oncology surgery to gynecologic oncology surgery alone and to describe the frequency of modification in planned urogynecologic procedures. The authors hypothesized there would be no difference in major complications. METHODS: This was a retrospective matched cohort study of women who underwent concurrent surgery at a large tertiary care center between January 2004 and June 2017. Cohorts were matched by surgeon, surgery route, date, and final pathologic diagnosis. Perioperative data and postoperative adverse events classified by Clavien-Dindo grade were compared. RESULTS: One hundred and eight patients underwent concurrent surgeries, with 216 matched cohorts. Concurrent-case patients were more likely to be older, postmenopausal, have greater vaginal parity, have had preoperative chemotherapy, and have preoperative cardiac or pulmonary disease. There were no differences in intraoperative complications or Dindo grade ≥ 3 adverse events between groups, but there were more grade 2 adverse events in the concurrent cohort (44 vs 19%, p < 0.0001) including postoperative urinary tract infection (UTI) (26 vs 7%, p < 0.0001). Concurrent surgery remained associated with a higher incidence of grade ≥ 2 events on multivariate analysis [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2, p = 0.0004). Discharge with a urinary catheter was more frequent after concurrent cases (35 vs 2%, p < 0.0001). Planned urogynecologic procedures were modified in 10% (n = 11) of cases. CONCLUSIONS: Concurrent surgeries have an increased incidence of minor but not serious perioperative adverse events. One in ten planned urogynecologic procedures is either modified or abandoned during combined surgeries.

Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery.

IMPORTANCE: Vaginal hysteropexy can be performed via the uterosacral or the sacrospinous ligament(s), but little data exist comparing these routes. OBJECTIVE: The aim of the study was to compare prolapse recurrence, retreatment, and symptoms along with the incidence of adverse events between patients undergoing vaginal uterosacral hysteropexy and sacrospinous hysteropexy. STUDY DESIGN: This was a multicenter retrospective cohort study of patients who underwent vaginal uterosacral or sacrospinous hysteropexy (SSHP) between 2015 and 2019. Anatomic failure was the primary outcome, defined as prolapse beyond the hymen. Composite failure was defined as anatomic failure, bulge symptoms, and/or retreatment for prolapse. RESULTS: At 4 geographically diverse referral centers, 147 patients underwent SSHP and 114 underwent uterosacral hysteropexy. The 1-year follow-up rate was 32% (83/261) with no difference between groups. There were 10 (3.8%) anatomic failures: 3 (2%) sacrospinous and 7 (6.1%) uterosacral ( P = 0.109). There was no difference in bulge symptoms (9.9%), composite failure (13%), or median prolapse stage (2).The overall incidence of complications was low (7%; 95% confidence interval, 4.12%-10.43%) with a higher rate of ureteral kinking in the uterosacral group (7% vs 1.4%, P = 0.023). With a median follow-up of 17 months, 4.6% underwent subsequent hysterectomy and 6.5% had treatment for uterine/cervical pathology. CONCLUSIONS: One year after hysteropexy, 1 in 3 patients were available for follow-up, and there were no differences in prolapse recurrence between patients who underwent uterosacral hysteropexy versus SSHP. The incidence of adverse events was low, and less than 5% of patients underwent subsequent hysterectomy for prolapse.

Mix and Mesh: An Electronic Database of FPMRS Mesh Products Through 2020.

IMPORTANCE: A sequelae of the removal of pelvic organ prolapse (POP) transvaginal mesh products from the U.S. market is that current and future women's health providers may be unfamiliar with mesh products historically used to treat pelvic floor disorders. OBJECTIVES: Our goal was to create an easily accessible resource to address this knowledge gap. STUDY DESIGN: An online database of mesh products used to treat POP and urinary incontinence was created with information, photographs, and videos collated from internet searches; manufacturer materials; and other primary sources. The database was then linked to a free smartphone application. RESULTS: This smartphone application includes, to the best of our knowledge, all mesh products used in the United States for the treatment of POP and stress urinary incontinence through December 2020. Included in the application are product descriptions of mesh color, size, design, and attachment points. Photographs and videos, when available, are included. The application is organized by mesh product name, but it is also searchable by other categories, such as manufacturer name and color.To download the application to a smart phone, go to vaginalmeshcatalogue.glideapp.io/ on a web browser or access via the QR code. Once the website is loaded, you can interact with the mesh catalog as a website or save it to the phone's home screen as an application. CONCLUSIONS: Health care providers of all experience levels can use this free application for educational and clinical purposes to better understand patients' histories, improve preoperative planning, and enhance patient counseling.

Postprocedural Pain Associated With 5 Versus 20 Intradetrusor Injections of onabotulinumtoxinA for Treatment of Overactive Bladder: A Multicenter Randomized Clinical Trial.

IMPORTANCE: Intradetrusor injection of onabotulinumtoxinA is performed via varying injection paradigms but no studies have studied the various effects of these paradigms on patient experience with the procedure. OBJECTIVES: This randomized clinical trial aims to compare pain and procedure time between patients receiving a 100-unit dose of onabotulinumtoxinA in 5 injections compared to 20 injections for the treatment of idiopathic overactive bladder or urgency urinary incontinence. STUDY DESIGN: Patients presenting with refractory overactive bladder or urgency urinary incontinence at 2 clinical sites were identified and randomized to undergo onabotulinumtoxinA treatment with 5 injections versus 20 injections. Patients rated their pain level on a 10-point visual analog scale at procedure completion. The procedure duration was recorded with a stopwatch. Patients were followed up 6 weeks postprocedure, at which time they completed a Global Response Assessment to determine subjective efficacy of treatment. Participants were additionally monitored for incidence of adverse events in the follow-up period. RESULTS: The average pain score was not statistically significant between groups (2; interquartile range, 1-4 for the 5 injection group vs 3; interquartile range, 2-4 for the 20 injection group; P = 0.27). Patients who received 5 injections experienced significantly shorter mean procedure time as compared with patients who received 20 injections (76 seconds vs 176 seconds; P < 0.001). There were no differences in subjective efficacy or adverse events between groups. CONCLUSIONS: Perceived pain, efficacy, and postprocedure complications did not significantly differ between patients receiving 5 injections and 20 injections, but procedure time was significantly shorter.

Common locations of parathyroid adenomas.

BACKGROUND: We have developed a nomenclature system that succinctly specifies the locations of parathyroid adenomas in the neck. We report our experience using the system in a large, contemporary cohort of patients. METHODS: A prospective, endocrine surgery database at a single, tertiary care center was retrospectively analyzed. We reviewed the records of 271 patients operated on for sporadic primary hyperparathyroidism between January 2006 and May 2008 and analyzed the effect of adenoma location at operative intervention and outcome. RESULTS: Adenomatous gland locations were classified intraoperatively as: A (adherent to posterior thyroid capsule) in 12.5% of cases; B (tracheoesophageal groove) in 17.3%; C TE groove but (close to clavicle) in 13.7%; D (directly over the recurrent laryngeal nerve) in 12.2%; E (easy to identify, inferior thyroid pole) in 25.8%; F (fallen into thymus) in 7.4%; and G gauge (within thyroid gland) in 0.4%. More than one enlarged gland was present in 10.7% of patients and usually involved coexistence of enlarged types A and E glands. Type F glands were associated with a longer mean operative time (p = 0.0487) and type E glands with a higher rate of outpatient surgery (p = 0.0195). At 6 months from the surgery, 94.5% of the patients were normocalcemic. CONCLUSIONS: Our nomenclature system provides a simple way to describe the locations of parathyroid adenomas. Type E adenomas were associated with a higher rate of outpatient surgery and type F adenomas with a longer operative time. Biochemical cure rates were comparable for all locations of single adenomas.

Compliance With Pelvic Floor Physical Therapy in Patients Diagnosed With High-Tone Pelvic Floor Disorders.

OBJECTIVE: The primary objective of this study was to describe patient compliance with pelvic floor physical therapy (PFPT) for high-tone pelvic floor disorders (HTPFD) and to compare patients who are compliant with prescribed therapy to those who are not. The secondary objective is to describe second-line treatments offered for HTPFD for returning patients. METHODS: This is a retrospective cohort study of women with a HTPFD who were prescribed PFPT at a tertiary care referral center. Patients were excluded if they had a primary diagnosis of urinary incontinence, had undergone prior PFPT, or if PFPT was part of preoperative planning. Noncompliance with PFPT was defined as not being formally discharged from therapy by the treating therapist. RESULTS: Data on PFPT compliance were available for 662 patients (87.3%). A total of 128 patients (19.4%) were fully compliant. Noncompliant patients were more likely to smoke and to have mental health disease compared with compliant patients (18% vs 8.7%, P = 0.01, and 50.4% vs 37.5%, P = 0.009, respectively). A total of 285 patients (43.1%) returned to their prescribing provider. Noncompliant patients were less likely to return to their provider: 63.4% versus 29.7%, P = <0.0001. Of the patients who returned, 183 (64.2%) were offered second-line treatment. CONCLUSIONS: Only 1 in 5 patients referred to PFPT for management of a high-tone pelvic floor disorder is compliant with the recommended therapy. Patients who are noncompliant are less likely to return to their prescribing provider, and less than half of referred patients return. Sixty percent of patients who return are offered second-line treatment.

The fallen one: the inferior parathyroid gland that descends into the mediastinum.

BACKGROUND: Inferior parathyroid glands are located along the embryologic migration path of the thymus and can rest in the thyrothymic ligament or anterior mediastinum. Our nomenclature system designates these glands as "fallen" (type F) glands. This study reviews our experience with type F parathyroid glands to determine which can be retrieved successfully through a cervical incision. STUDY DESIGN: A retrospective review of patients who underwent parathyroidectomy between June 1998 and May 2008 was performed. Patient demographics, localization studies, and operative and pathologic reports were analyzed. Distance from the superior aspect of the clavicle to the target parathyroid gland was measured. RESULTS: Sixty (9.2%) patients had a type F parathyroid gland. Parathyroidectomy was performed through cervical incision in 54 (90%) patients and 6 (10%) required a thoracic approach. Preoperative imaging identified parathyroid glands located >or=6 cm below the superior aspect of the clavicle in eight patients. Of these, six (75%) required a thoracic approach and two (25%) were resected through a cervical incision with concomitant thymectomy. Parathyroidectomy was successfully performed through a cervical incision in all 52 (100%) patients in whom the target parathyroid gland was <6 cm below the superior aspect of the clavicle (Fisher's exact test, p < 0.001). CONCLUSIONS: A cervical approach allows successful retrieval of type F parathyroid glands located <6 cm below the superior aspect of the head of the clavicle in the anterior mediastinum. Parathyroidectomy for glands located >or=6 cm below the superior aspect of the clavicle can be attempted from the neck with concomitant thymectomy, but the majority will require a thoracic approach.