Patient Perceptions Impact Progression to Third-Line Therapy for Treatment of Overactive Bladder.

PURPOSE: We aimed to understand the reasons patients choose to pursue third-line overactive bladder (OAB) therapy. MATERIALS AND METHODS: We conducted a mixed methods study that included patient interviews and survey data. Eligible patients were diagnosed by symptoms, had tried behavioral modifications, and OAB medications enrolled from October 2018 to August 2019. In addition to interviews, patients completed 4 surveys: the Pelvic Floor Distress Inventory, Overactive Bladder Questionnaire Short Form, Life Orientation Test-Revised, and a patient confidence in the health care system survey. Qualitative interview data were analyzed thematically. Logistic regression and chi-square analysis was used to analyze survey data. RESULTS: A total of 69 patients were consented, 4 withdrew, and 51 completed both interview and survey data. Overall 55% of patients were Caucasian, 45% were African American, and their average age was 71 (SD=10.4); 75% intended to pursue third-line OAB therapy and 31 (61%) expressed interest in a specific third-line therapy. Major interview themes included a desire for a better quality of life, embarrassment with accidents, and problems with medication. Themes leading patients away from third-line OAB treatment included concern about invasiveness and side effects of treatments, and restrictions to accessing care. CONCLUSIONS: Most patients desired to progress to third-line OAB therapy, were motivated by embarrassment, but were concerned about treatment side effects. We found that economic burden of OAB treatment is associated with patient interest in and decision to receive third-line therapies to include onabotulinumtoxinA and percutaneous tibial nerve stimulation. Improved quality of life, medication frustration, and concerns about side effects of further therapy are themes patients identified when patients considered third-line overactive bladder therapy.

Cognitive changes in women starting anticholinergic medications for overactive bladder: a prospective study.

INTRODUCTION AND HYPOTHESIS: To assess cognitive changes in women 12 months after starting anticholinergic medications for overactive bladder syndrome (OAB). METHODS: We present a prospective cohort study assessing changes in cognition in women seen in a referral urogynecology practice. We compared women who started anticholinergic OAB medications with women not on anticholinergic OAB medications. The primary outcome was change over time on the Montreal Cognitive Assessment (MOCA) screening score. At enrollment, women completed a baseline MOCA screening, a Geriatric Depression Screen (GDS), and an assessment of medications to create an anticholinergic burden score (ACB). At 3, 6, 9, and 12 months after enrollment women were administered the MOCA, GDS, and a review of their medications and medical problems. Statistical analysis was performed using a linear mixed effects model taking into account correlated error terms given multiple MOCA assessments at various time points per patient. RESULTS: A total of 106 women were enrolled, 60 in the OAB medication group and 46 in the control (non-OAB medication) group. The mean age was 77 years, 93% of women were Caucasian, and 98% completed high school, with no difference between groups. Over time there was no difference in change of MOCA score between the OAB and control groups when controlling for age, GDS score, and ACB score (p = 0.78). This association did not change when women with a neurological diagnosis were excluded (n = 6). On average MOCA scores for the OAB group increased by 0.76 over 12 months and the control group increased 0.39, with no difference between the groups (p = 0.53). CONCLUSIONS: We found no changes in MOCA scores between OAB medication and control groups after controlling for age, depression, and polypharmacy after 12 months of follow-up.

Subjective and objective responses to PTNS and predictors for success: a retrospective cohort study of percutaneous tibial nerve stimulation for overactive bladder.

INTRODUCTION AND HYPOTHESIS: We investigated the objective improvements in overactive bladder (OAB) symptoms in patients undergoing percutaneous tibial nerve stimulation (PTNS) and predictive factors of patient satisfaction. METHODS: In this single-center retrospective cohort study at a tertiary urogynecology center, we identified all female patients who underwent PTNS therapy from 1 October 2007 - 1 January 2016 and followed them from their initial visit through medication therapy and PTNS treatments. Patients who tried at least one medication prior to starting PTNS therapy and completed at least one PTNS visit were included. Baseline demographic data, urinary data, and details of medication and PTNS therapy sessions were collected from records through chart review. Paired or two-sample t-tests were used to compare changes over time or groups. Bivariate and multivariable logistic regression were performed. RESULTS: Two hundred thirteen patients underwent PTNS therapy and 183 patients met the criteria. Overall patients were able to decrease voiding frequency by 1 h, decrease nocturia episodes by 0.8, and decrease urge incontinence episodes with PTNS therapy by ten episodes per week (p = 0.02). Patients who continued OAB medications did not have additional improvements compared with patients who did not continue OAB medications during PTNS. Overall, 25.4% (43/169) patients reported ≥ 75% improvement during PTNS therapy, and 61.5% (104/169) reported ≥ 50% improvement. When evaluating predictive factors of ≥ 50% overall improvement, the number of PTNS sessions increased odds of subjective success (OR = 1.8, p = 0.004). Other factors were not significant predictors of subjective PTNS success. CONCLUSIONS: PTNS can provide both objective and subjective improvements for patients who do not respond to OAB medication therapy.

Transvaginal mesh: a historical review and update of the current state of affairs in the United States.

INTRODUCTION: Transvaginal mesh usage has been at the forefront of popular media and academic debate for the past 10 years. Several US Food and Drug Administration (FDA) communications, society statements, and research articles have been written in an attempt to define and articulate the classification system, safety data, and efficacy of this approach to transvaginal surgery. In this review, we explore the history of transvaginal mesh surgery for pelvic organ prolapse (POP), review FDA and society statements, and research current practice in the United States. METHODS: We searched the English language literature using PubMed for articles related to safety and monitoring of transvaginal mesh and reviewed all FDA publication and notices and gynecology and urogynecology society statements on its use in the United States. We then reviewed 22 articles and grouped them into several sections. RESULTS: Mesh used to augment transvaginal repair of POP was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several FDA notifications and warnings. The type of mesh used, reporting and classifications systems, and provider usage has varied widely over time. CONCLUSION: We present a historical review of transvaginal mesh use for pelvic organ prolapse in the United States from 2005 to 2016. There continues to be heated debate among practitioners about balancing the efficacy of mesh use to decrease recurrent prolapse and complications. Research into safety and efficacy, along with tighter FDA regulations, is ongoing.

Does physician specialty affect persistence to pharmacotherapy among patients with overactive bladder syndrome?

INTRODUCTION AND HYPOTHESIS: We compared persistence on overactive bladder (OAB) pharmacotherapy in patients treated in the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) department compared with patients treated in the Internal Medicine (IM) and General Urology (GU) departments within an integrated health-care system. We hypothesized that persistence would be higher among FPMRS patients. METHODS: This was a retrospective cohort study. Patients with at least one prescription for OAB between January 2003 and July 2014 were identified. Demographic, prescription and treatment specialty data and data on the use of third-line therapies were collected. The primary outcome was persistence, defined as days on continuous pharmacotherapy. Discontinuation was defined as a treatment gap of ≥45 days. Discontinuation-free probabilities were calculated using the Kaplan-Meier method and compared among the specialties. Predictors of persistence were estimated using logistic regression with adjustment for covariates. Pearson correlation coefficients were calculated to identify risk associations. RESULTS: A total of 252 subjects were identified. At 12 weeks, 6 months and 1 year, FPMRS patients had the highest persistence rates of 93 %, 87 % and 79 % in contrast to 72 %, 68 % and 50 % in GU patients, and 83 %, 71 % and 63 % in IM patients (p = 0.006, p = 0.007, p = 0.001, respectively). The median persistence in FPMRS patients was 738 days, in GU patients 313 days and in IM patients 486 days (p = 0.006). Of the FPMRS patients, 61 % switched to at least a second medication, as compared to 27 % of IM patients and 14 % of GU patients (p < 0.0001). CONCLUSIONS: Persistence on OAB pharmacotherapy was higher among FPMRS patients than among GU and IM patients in this community setting. These results suggest that persistence is higher under subspecialist supervision.

Which bladder instillations are more effective? DMSO vs. bupivacaine/heparin/triamcinolone: a retrospective study.

INTRODUCTION AND HYPOTHESIS: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic and debilitating condition. Our objective was to compare two different bladder instillation treatments in patients with BPS/IC: dimethyl sulfoxide with triamcinolone (DMSO) vs. bupivacaine with heparin and triamcinolone (B/H/T). Our hypothesis was that both treatments are equally effective. METHODS: A retrospective cohort study of instillation-naïve patients was conducted comparing responses to either DMSO or B/H/T at our tertiary urogynecology center from 2012 to 2014. The primary outcome was patient-reported percent of overall improvement from baseline. Secondary outcomes were change in patient-reported daytime voiding frequency (hours) and change in number of nighttime voiding episodes. Variables analyzed as potential confounders included pelvic pain, cystoscopy findings, levator spasm, and fibromyalgia. The two-sided Student's t test, chi-squared test, Poisson regression, and repeated-measure analysis of variance (ANOVA) were used for analyses. RESULTS: One hundred and ninety-three eligible patients were identified (45 receiving DMSO, 146 receiving B/H/T). Compared with baseline, DMSO patients reported 63% improvement (p < 0.0001), increased time between daytime voids by 1.5 h (p < 0.00), and a 40% reduction in nocturia episodes (p < 0.00). B/H/T patients reported 51% improvement (p < 0.00), increased time between daytime voids by 1.4 h (p < 0.00), and an 8% reduction in nocturia episodes (p = 0.26). When comparing the two treatments, DMSO resulted in a greater percentage of overall improvement (p = 0.02) and a significant decrease in nocturia episodes when compared with B/H/T (p = 0.02). There was no significant difference between treatments for daytime voiding frequency (p = 0.50). CONCLUSION: Bladder instillations with DMSO or B/H/T provide overall symptomatic improvement and improved frequency and nocturia. DMSO appears to provide greater improvement in nocturia and overall.

Applying to subspecialty fellowship: clarifying the confusion and conflicts!

Of graduating obstetrics and gynecology residents, 40% apply for fellowship training and this percentage is likely to increase. The fellowship interview process creates a substantial financial burden on candidates as well as significant challenges in scheduling the multiple interviews for residents, residency programs, and fellowship programs. Coverage with relatively short lead time is needed for some resident rotations, multiple residents may request time off during overlapping time periods, and applicants may not be able to interview based on conflicting interview dates or the inability to find coverage from other residents for their clinical responsibilities. To address these issues, we propose that each subspecialty fellowship within obstetrics and gynecology be allocated a specified and limited time period to schedule their interviews with minimal overlap between subspecialties. Furthermore, programs in close geographic areas should attempt to coordinate their interview dates. This will allow residents to plan their residency rotation schedules far in advance to minimize the impact on rotations that are less amenable to time away from their associated clinical duties, and decrease the numbers of residents needing time off for interviews during any one time period. In addition, a series of formal discussions should take place between subspecialties related to these issues as well as within subspecialties to facilitate coordination.

Predictive modeling and threshold scores for care seeking among women with urinary incontinence: The short forms of the Pelvic Floor Distress Inventory and Urogenital Distress Inventory.

AIMS: To further the interpretability of the Pelvic Floor Distress Inventory (PFDI-20) and Urogenital Distress Inventory (UDI-6) by (i) evaluating the ability of these measures to distinguish between women with urinary incontinence who do and do not seek care, (ii) defining PFDI-20 and UDI-6 threshold scores above which women with urinary incontinence seek care, and (iii) developing a predictive model for incontinence care seeking. METHODS: An observational study was conducted with two groups of women with urinary incontinence: 256 who had not sought care and 90 seeking initial care at a tertiary center. Sample sizes were based upon the prevalence of care seeking for urinary incontinence and the number of potential predictors for care seeking. Wilcoxon rank-sum tests, receiver operating characteristics, and multivariable logistic regression were use to achieve the study aims. RESULTS: Women with urinary incontinence who sought care had higher median PFDI-20 and UDI-6 scores compared to non-care seekers (73.96 vs. 16.67, P < 0.0001, and 41.67 vs. 8.33, P < 0.0001). A PFDI-20 score of 33.33 (83.33% sensitivity and 79.30% specificity) had very good discriminatory accuracy in distinguishing care and non-care seekers (AUC 0.886 ± 0.019 [95%CI 0.8518, 0.9254] P < 0.0001). A UDI-6 score of 25.00 (83.33% sensitivity and 83.59% specificity) had excellent discriminatory accuracy in distinguishing care and non-care seekers (AUC 0.9025 ± 0.0190 [95%CI 0.8653, 0.9398] P < 0.0001). A multivariable predictive model accurately identified 82.4% of care and non-care seekers. CONCLUSIONS: A PFDI-20 score of 33.33 and UDI-6 score of 25.00 provide meaningful benchmarks for care seeking among women with urinary incontinence. Neurourol. Urodynam. 35:949-954, 2016. © 2015 Wiley Periodicals, Inc.

Measuring the success of combined intravesical dimethyl sulfoxide and triamcinolone for treatment of bladder pain syndrome/interstitial cystitis.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to investigate change in bladder capacity as a measure of response to combined intravesical dimethyl sulfoxide (DMSO) and triamcinolone instillations for the treatment of newly diagnosed bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS: 141 newly diagnosed women were identified retrospectively. 79 were treated with weekly DMSO/triamcinolone instillations. Change in bladder capacity with bladder retrofill, daytime urinary frequency, nocturia episodes per night, and Likert scale symptom scores were reviewed. Wilcoxon signed-rank tests, Wilcoxon rank-sum tests, Spearman's rank correlations, COX regression analysis, and a Kaplan-Meier survival curve were performed. RESULTS: Significant changes (median (25(th)-percentile to 75(th)-percentile) were noted for bladder capacity (75 mL (25 to 130 mL), p < 0.0001), inter-void interval (0 hrs (0 to 1 hour), p < 0.0001), nocturia episodes per night (-1 (-2 to 0), p < 0.0001), and aggregate Likert symptom scores (-2 points (-5 to 0), p < 0.0001). Percent change in bladder capacity correlated positively with percent change in inter-void interval (p = 0.03) and negatively with percent changes in nocturia (p = 0.17) and symptom scores (p = 0.01). Women without detrusor overactivity (DO) had greater percent changes in capacity than women with DO (62.5 % vs. 16.5 %, p = 0.02). 61.3 % of patients were retreated with a 36 weeks median time to retreatment and no difference in time to retreatment based upon DO. Greater capacity was protective against retreatment (hazard ratio = 0.997 [95 % CI 0.994,0.999], p = 0.02). CONCLUSIONS: Percent change in bladder capacity is a useful objective measure of response to intravesical DMSO/triamcinolone for newly diagnosed BPS/IC. Clinical outcomes do not differ based upon presence of DO.

Transforming growth factor ß 1 gene expression during vaginal vs cutaneous surgical woundexpression during vaginal vs cutaneous surgical wound healing in the rabbit.

INTRODUCTION AND HYPOTHESIS: Reconstructive pelvic surgery outcome is closely related to the vaginal and pelvic wound healing processes. Transforming growth factor beta 1 (TGF-ß1) is a principal mediator of wound repair in dermal tissue. We sought to assess this factor's expression in vaginal and dermal surgical wound repair in the rabbit. METHODS: We excised bilateral 6-mm full-thickness circular segments from the abdominal skin and vagina in 36 New Zealand White (NZW) nulliparous female rabbits. Animals were sacrificed before, on the day of, and 4, 7, 10, 14, 21, 28, and 35 days after tissue wounding, and their wounds were assessed for surface area and TGF-ß1 gene transcription by real-time polymerase chain reaction (PCR). RESULTS: In both the abdominal skin and vagina, TGF-ß1 gene transcription increased immediately after tissue injury, reaching maximal levels on days 4-7, and decreased shortly thereafter, attaining minimal values on day 35. A significant correlation between TGF-ß1 expression and the wound's closure rate was found in both tissues. CONCLUSIONS: TGF-ß1 gene transcription significantly correlates with the surgical vaginal and dermal wound closure rate, implying that this factor is involved in the process of wound repair in both tissues.

Enhanced interpretability of the PFDI-20 with establishment of reference scores among women in the general population.

AIMS: To enhance the interpretability of the PFDI-20 by establishing a score distribution for women in the general population and to determine whether scores correspond with urinary and anal incontinence (UI and AI). METHODS: Subjects recruited during Twins Day Festivals from 2004 to 2009 completed a survey assessing for stress and urgency urinary incontinence (SUI and UUI) and AI of flatus and stool. Score distributions for the PFDI-20 and each of its subscales were determined for all subjects and for women with isolated forms of incontinence. Scores were compared between continent and incontinent women and between incontinent subtypes by Wilcoxon rank-sum tests. RESULTS: One thousand three hundred seventy-six women completed the survey with PFDI-20 (Median = 8.9, IQR 31.3), POPDI-6 (Median = 0, IQR = 8.3), CRADI-8 (Median = 0, IQR = 10.7), and UDI-6 (Median = 0, IQR = 16.7). PFDI-20, POPDI-6, CRADI-8, and UDI-6 scores were significantly greater among women reporting isolated SUI (P < 0.0001, P = 0.04, P < 0.0001, P < 0.0001, respectively), UUI (P < 0.0001, P = 0.02, P < 0.0001, P < 0.0001, respectively), mixed UI (P < 0.0001 each), AI flatus (P < 0.0001 each), and AI stool (P < 0.0001 each) compared to those denying incontinence. Women with mixed UI had significantly greater PFDI-20 and UDI-6 scores compare to those with SUI (P < 0.0001) or UUI (P < 0.0001). Subjects with AI stool had significantly greater PFDI-20 and CRADI-8 scores compared to those with AI flatus (P = 0.01). CONCLUSIONS: PFDI-20 scores from a sample of the general population correspond with the presence or absence of UI and AI. These normative and symptom-specific score distributions for the PFDI-20 provide reference points to gauge the effect of disease and intervention on quality of life for women with incontinence.

Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery.

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

Factors influencing women's participation in urogynecology research in the UK and USA.

AIMS: To explore factors influencing willingness to participate in urogynecology trials and explore associations between demographics, quality of life score (ICIQ-SF), and willingness to participate. METHODS: The Bladder Clinic Questionnaire (BCQ) was developed, piloted, and validated. The BCQ and ICIQ-SF were distributed to women attending urogynecologists in tertiary referral centers in the UK and USA. The BCQ collected demographic data and data on previous involvement in research and posed eight research scenarios. Women were asked to record their willingness to participate on a Likert scale, collapsed for analysis into "any yes," "unsure," or "any no," giving a BCQ score between 0 and 16 (higher scores indicating greater willingness). RESULTS: Two hundred sixty-seven UK women and 200 US women returned completed questionnaires. Median BCQ score differed between UK and US women (11 [0-16] vs. 10 [0-16]; P = 0.004); median ICIQ score was similar (9 [0-21] vs. 9 [0-20]). ICIQ score was higher in UK women willing to participate in two scenarios: standard operation versus new operation (P = 0.007), and new operation versus new operation (P = 0.001). UK women were uniformly more willing to take part in all scenarios involving established treatments. CONCLUSION: We identified cultural differences in willingness to participate and differences depending on type of intervention proposed which supports the growing evidence that detailed pilot work is required during planning of intervention studies.

Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is a coexistence of stress (SUI) and urgency urinary incontinence (UUI). There is conflicting evidence on the effectiveness of midurethral slings (MUS) in this condition. The objective of this study is to evaluate the effectiveness of MUS in women with MUI by systematic review of the literature. METHODS: Systematic literature search was carried (June 2010) using relevant search terms in Medline, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis was performed with random effects model using STATA 8. RESULTS: There were six randomised trials and seven prospective studies with average to good quality included in this systematic review. There was heterogeneity in outcomes reported. The overall subjective cure from seven prospective nonrandomised studies that included patients with symptomatic ± urodynamically proven MUI was found to be 56.4% (95% confidence interval 45.7-69.6%) at 34.9 ± 22.9 months follow-up. The overall cure of urgency and UUI component was 30-85% at a follow-up of few months up to 5 years. Most of the studies described that this cure does not persist over the time. The cure rate of SUI following MUS varies from 85% to 97%. On meta-analysis of five RCTs which included women with MUI symptoms, the odds of overall subjective cure with TVT versus transobturator tapes are similar at 6-33 months follow-up (OR, 0.9; 95% CI, 0.63-1.27). This was true when a subgroup analysis was performed on women with MUI who were negative for DO on UDS (OR, 1.21; 95% CI, 0.7-2.08) CONCLUSIONS: There is evidence of persistent and good cure of stress component following MUS in women with MUI. The cure of the urge component is variable but less than stress component. Methodologically sound RCTs of retropubic and transobturator tapes with long-term follow-up are needed specifically for women with urodynamically proven and symptomatic mixed incontinence.

Urge incontinence: estimating environmental and obstetrical risk factors using an identical twin study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to determine risk factors for urge urinary incontinence (UUI). METHODS: A multi-item survey was administered to a community sample of identical twin sisters from 2002-2008. Generalized estimating equations accounting for co-twin correlation were used to perform three different regression models on the outcome: UUI (yes vs. no). RESULTS: Mean age, median parity, and BMI were 41.4 +/- 16.4 (18-85), 1.0, and 26.0 +/- 6.5 (13.5-55.8), respectively. Thirty-five percent of women were post-menopausal, and 27.5% had UUI. Urge urinary incontinence was reported in 40.1% of parous versus 14.1% among nulliparous women (p < .0001). The rate of UUI was 40.6% after vaginal delivery, 36.7% after cesarean delivery, and 14.1% in nulliparous women (p < .0001). Obesity, age >40, and chronic constipation were also identified as risk factors for urge urinary incontinence. CONCLUSION: Risk factors for UUI include parity, age, obesity, and chronic constipation. There was a 2.5-fold increased risk of UUI after one or more births, regardless of type of delivery.

A Comparison of Sacrospinous Hysteropexy Augmented With Polypropylene Mesh Versus Human Dermis at 12-Month Follow-up: An Ambidirectional Study.

BACKGROUND: Suture-based hysteropexy is performed for pelvic organ prolapse with varying results. Graft augmentation may improve outcomes. OBJECTIVE: The aim of this study was to determine whether vaginal hysteropexy with mesh reduces recurrence at 1-year postoperative examination compared with hysteropexy with allograft. METHODS: Data were collected for patients who underwent vaginal hysteropexy with either mesh "Uphold" (referred to as "mesh") or a cadaveric allograft "Axis or Repliform" (referred to as "dermal"). The primary outcome was anatomic success defined as no prolapse Pelvic Organ Prolapse Quantification System stage II or less at 12 months postoperative. The secondary outcomes were recurrence to the hymen and a composite score (any positive response to the 20-item Pelvic Floor Distress Inventory question 3 and cervix ≥ -1/2 total vaginal length at rest or as reference point 3 cm proximal to or above the hymenal ring anteriorly [Ba] ≥0) measured at 12 months. RESULTS: Two hundred seventy-four patients returned for their 1-year postoperative examination: 93.5% of the mesh group (231/247 subjects) and 95.5% of the dermal group (43/45 subjects). The mesh group had fewer recurrences to or beyond Pelvic Organ Prolapse Quantification System stage II (mesh 18% vs dermal 29%, P = 0.03), to the hymen (2.6% vs 9.3%, P = 0.007), or based on composite score (19 vs 33%, P = 0.007). Questionnaire data improved more in the mesh group (P < 0.0001). The exposure rate was 5.75% (13/247) in the mesh group. Reoperation rate was greater in the dermal group (mesh 4.3%vs dermal 7.3%, P = 02). CONCLUSIONS: Hysteropexy augmented with mesh reduced the recurrence at 1 year compared with hysteropexy with allograft. Fewer patients in the mesh group felt a bulge at 1 year (4.5% vs 20.9%, P < 0.0001). These findings need to be weighed against the mesh exposure rate of 5.75%.

Anterior Colporrhaphy With and Without Dermal Allograft: A Randomized Control Trial With Long-Term Follow-Up.

OBJECTIVE: The objective of this study was to determine whether anterior colporrhaphy plus insertion of anterior dermal allograft reduces anterior prolapse recurrence at 1 and 7 to 10 years postoperatively compared with anterior colporrhaphy alone. METHODS: We present a nonblinded randomized controlled trial with 1- and 7- to 10-year follow-up. Subjects were randomized between 2005 and 2008 to anterior colporrhaphy or ultralateral anterior colporrhaphy plus insertion of a dermal allograft spanning the anterior compartment between the arcus tendineus fascia pelvis on each side. Eligible subjects had anterior prolapse to the hymen or beyond, were bothered by their prolapse, and were planning to undergo surgical correction. Subjects completed a pelvic organ prolapse quantification system (POPQ) examination and Pelvic Floor Distress Inventory (PFDI)/PFDI-20 before surgery; a POPQ, PFDI, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire at 1 year postoperatively; and a POPQ, PFDI-20, Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, Revised, and Patient-reported Global Impression of Improvement Inventory at 7 to 10 years postoperatively. Our primary outcome was anatomic anterior prolapse recurrence at 1 or 7 to 10 years defined as Aa or Ba greater than or equal to -1. Our secondary outcome was a composite score of anterior prolapse recurrence at 1 or 7 to 10 years defined as anatomic recurrence (Aa or Ba ≥ 0), retreatment for cystocele, or answering yes to PFDI-20 question 3 (subjective report of vaginal bulge). RESULTS: A total of 114 subjects were randomized, 70 to anterior colporrhaphy and 44 to anterior colporrhaphy plus dermal allograft. About 92% of subjects underwent concomitant apical suspension, 98% in the graft group and 89% in the nongraft group. Eighty-nine subjects (32 graft [73%], 57 nongraft [81%]) returned for 1-year follow-up. Fifty-three patients (19 graft [48%], 34 nongraft [49%]) returned for 7- to 10-year follow-up. The primary outcome was met by 8 (18%) graft and 22 (31%) nongraft subjects at 1 year postoperatively (P = 0.26) and by 10 (23%) graft and 24 (34%) nongraft subjects at 7 to 10 years postoperatively (P = 0.37). The secondary outcome was met by 8 (18%) graft and 15 (21%) nongraft subjects at 1 year postoperatively (P = 0.74) and by 13 (30%) graft and 21 (30.0%) nongraft subjects at 7 to 10 years postoperatively (P = 0.99). CONCLUSIONS: We cannot conclude whether there is a difference in anterior recurrence for anterior colporrhaphy with and without dermal allograft and do not recommend changes in clinical practice based on these results.

Predictors of persistent detrusor overactivity after transvaginal sling procedures.

OBJECTIVE: Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence STUDY DESIGN: Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models. RESULTS: Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001). CONCLUSION: When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.

Impact of hysterectomy on stress urinary incontinence: an identical twin study.

OBJECTIVE: This study uses the unique properties of twin research design to evaluate whether hysterectomy impacts stress urinary incontinence (SUI). STUDY DESIGN: As part of the Evanston Twins Sister Study, we performed bivariate and multivariate analyses on 83 identical twin pairs discordant for hysterectomy. RESULTS: In bivariate analysis, SUI was less common in women who had prior hysterectomy (P =0.028). Multivariate analysis suggested that SUI was significantly less common after hysterectomy (odds ratio [OR], 0.55, confidence interval [CI], 0.30 to 1.00). Exclusion of twin pairs with a history of pelvic floor defect surgery eliminated the statistical relationship between hysterectomy and SUI (OR, 0.79, CI, 0.4 to 1.40). CONCLUSION: Hysterectomy, when analyzed with all cases, was associated with reduced SUI. When concurrent pelvic floor defect surgeries were excluded from the analysis, we found no relationship between hysterectomy and the risk of SUI afterward.