Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension.

OBJECTIVES: To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS). METHODS: A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status. RESULTS: During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses. CONCLUSIONS: In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Permanent suture used in uterosacral ligament suspension offers better anatomical support than delayed absorbable suture.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the outcomes of uterosacral ligament suspension (USLS) procedures in relation to suture material used for apical suspension. METHODS: A retrospective chart review was performed for two senior surgeons who supervised and performed USLS with both suture types in 2008-2009. Permanent and delayed absorbable sutures were compared for failure of anatomical support. Failure, defined as recurrent prolapse beyond the hymen, was evaluated using survival analysis. RESULTS: Two hundred forty-eight procedures were performed. One percent in the permanent group had a loss of support beyond the hymen compared to 6% in the delayed absorbable group (p = 0.034). The preoperative prolapse stage and duration of follow-up did not differ between the two groups. The number of sutures used did not differ between patients who failed and those who did not fail. CONCLUSIONS: The use of permanent sutures for USLS of the vaginal apex was associated with a lower failure rate than delayed absorbable sutures in the short-term.

Incidence and risk factors of postoperative urinary tract infection after uterosacral ligament suspension.

INTRODUCTION AND HYPOTHESIS: We assessed the incidence of and risk factors for developing urinary tract infection (UTI) after uterosacral ligament suspension (USLS). METHODS: Retrospective analysis of patients undergoing USLS in 2008-2009 was performed. Postoperative UTI was defined as a positive urine culture within 1 month following surgery. Factors analyzed were patient age, body mass index, parity, history of UTI before surgery, passing voiding trial, discharge with Foley catheter or intermittent self-catheterization, antibiotics at discharge, history of diabetes or renal disease, and surgeon. RESULTS: Surgical records from 169 patients were reviewed. Twenty-three patients (14%) developed UTI. There were no differences in preoperative factors between patients who developed UTI and those who did not. Subgroup analysis revealed those patients who went home with a Foley catheter and did not receive antibiotics had the highest proportion of UTI. CONCLUSION: Patients requiring Foley catheter at discharge following vaginal prolapse repair are at highest risk for UTI and require prophylactic antibiotics.

A novel transvaginal approach to correct recurrent apical prolapse after failed sacral colpopexy: case series.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to describe the transvaginal approach utilizing the existing sacral colpopexy (SC) graft for recurrent apical prolapse following failed SC. METHODS: Twenty-two patients with recurrent vaginal vault prolapse following a prior SC were treated between January 2000 and December 2009. Twelve patients had a standard uterosacral ligament cuff suspension (USLS) performed. In ten patients, the vaginal cuff was suspended to the left uterosacral ligament and reattached to the graft material from the prior SC. One of these ten subsequently failed and a standard USLS was performed. Patient characteristics, preoperative pelvic floor assessment, operative information, and postoperative follow-up were collected. Cases in which the graft material was used were compared with those undergoing standard USLS. RESULTS: Demographic characteristics and preoperative Baden-Walker scores were similar. Of 23 cases, 21 (91 %) were a consequence of graft separation from the vagina and not the sacrum. Two of nine patients with follow-up where the SC graft was utilized transvaginally had recurrent prolapse. One required reoperation. Of 13 patients in the group that underwent traditional USLS, 2 had asymptomatic recurrent anterior prolapse; neither required additional surgery. CONCLUSIONS: A transvaginal surgical approach for recurrent vaginal prolapse after a history of failed abdominal SC should be considered. If feasible, the SC graft material can be used when performing USLS instead of the right uterosacral ligament for these patients with a prior history of abdominal SC.

Tension-free vaginal tape bowel perforation.

A 73-year-old para 3 white female with posthysterectomy pelvic organ prolapse and stress urinary incontinence underwent pelvic reconstructive surgery and placement of tension-free vaginal tape. On postoperative day 4, she underwent exploratory laparotomy for small bowel obstruction. She was found to have an injury to the small bowel secondary to a through-and-through perforation by tension-free vaginal tape. The entire tape was removed. Partial small bowel resection and primary anastomosis were performed. Her subsequent recovery was uneventful.

Magnetic resonance imaging of the levator ani in the squirrel monkey: a comparison of muscle volume between a cohort with pelvic organ prolapse and matched normals.

OBJECTIVE: Magnetic resonance imaging was used to test whether squirrel monkeys with pelvic organ prolapse have reduced pelvic muscle volumes, compared with matched normals. STUDY DESIGN: Levator ani and obturator internus volumes obtained from T1-weighted axial scans of matched groups were measured. Muscle volumes and weights were compared for animals necropsied after magnetic resonance imaging. RESULTS: Two observers concurred on measures of levator ani and obturator internus (Kendal tau > or = 0.60 with P < .003). Levator ani volume was related to mass (R2 = 0.62, P = .0009). Animals with pelvic organ prolapse did not differ (P = .67, Wilks multivariate test) from those without pelvic organ prolapse in age, parity, and weight. Levator ani differed between groups (pelvic organ prolapse = 520 mm3 versus normals = 392 mm3, P = .015) and not sides (P = .80). The obturator internus did not differ between groups (P = .29) or sides (P = .72). CONCLUSION: Magnetic resonance imaging demonstrates that levator ani volumes in parous squirrel monkeys with pelvic organ prolapse were not reduced, suggesting that prolapse is not related to pelvic muscle size reduction in this species.

A randomized comparison of bupivacaine versus saline during placement of tension-free vaginal tape.

OBJECTIVES: To compare postoperative urinary retention and pain control when bupivacaine versus saline for hydrodissection is used while placing tension-free vaginal tape midurethral slings. METHODS: A prospective, randomized, double-blind trial was performed after institutional review board approval. Sixty women were randomized to receive bupivacaine or saline for hydrodissection. Subjects and research team were blinded to subject assignments. Group characteristics were compared using the Student t test, the χ test, and the Mann-Whitney U test. Proportions of subjects with a successful postoperative voiding trial along with measurements of postoperative pain and analgesic use were compared using similar appropriate tests. The study was powered to detect differences in voiding trial success from an estimated 58% to greater than 90% with P < 0.05 and 0.8 power using 25 subjects per group. RESULTS: Thirty patients were allocated to each group. One subject in the saline-only group was excluded. Group characteristics were not different. After surgery, pain medication use (20/30 vs 25/29 for bupivacaine vs saline only; P = 0.08), pain scores (36 ± 22 vs 31 ± 24; P = 0.49), and successful voiding trials did not differ (14/30 vs 19/29; P = 0.14), whereas postvoid residuals did differ (225 ± 180 mL vs 140 ± 147 mL; P = 0.043). CONCLUSIONS: Bupivacaine was not seen to improve immediate postoperative pain after placement of a tension-free vaginal tape. It did not increase the risk of failing a postoperative voiding trial. Without an obvious benefit, the use of an additional medicine is not supported. We suggest saline alone be used for hydrodissection.

Does body mass index impact passing voiding trial after midurethral sling procedures for stress urinary incontinence?

OBJECTIVE: : To test the hypothesis that body mass index (BMI) is a factor associated with passing a voiding trial after midurethral sling procedures for stress urinary incontinence (SUI). STUDY DESIGN: : The medical records of 136 consecutive patients who underwent placement of either tension-free vaginal tape (TVT) or transobturator tape (TOT) for SUI during a 1-year period (September 1, 2007 to August 31, 2008) were retrospectively reviewed. Variables assessed were BMI, age, and passing or failing a postoperative urinary voiding trial. Patients with concomitant pelvic organ prolapse surgeries were not included in this analysis. RESULTS: : Sixty-seven patients underwent TVT, whereas 69 had TOT procedures. In the TVT group, 30 patients (42%) were unable to void immediately postoperatively compared with 11 patients (16%) in the TOT group (P = 0.0003). The mean (SD) age and BMI of patients who failed or passed voiding trials was 58.6 (12.0) years and 28.0 (4.9) kg/m or 53.5 (12.3) years and 29.8 (5.7) kg/m, respectively. Of 38 patients who did not pass a voiding trial on the day of the procedure, 31 (82%) passed on postoperative day 1, and all patients had passed a voiding trial by postoperative day 11. The mean (SD) BMI for 7 patients who did not pass voiding trial by postoperative day 1 was 28.3 (5.2) kg/m. CONCLUSIONS: : Women with higher BMIs were more likely to pass voiding trials after midurethral sling procedures. Patients who had TOT placement had greater success passing a postprocedure voiding trial than did patients who had TVT placement.

A serious complication following placement of posterior Prolift.

A 32-year-old female with Crohn's disease experienced a rectovaginal fistula and abscess with rectal expulsion of posterior Prolift. She underwent diagnostic laparoscopy, transanal incision and drainage of abscess, transanal excision of mesh, and laparotomy with loop ileostomy. Weeks later, she underwent colectomy, near-total proctectomy, end ileostomy, and fistula repair.

Transverse cystocele repair with uterine preservation using native tissue.

The goals of this study were to describe the surgical procedure of the transverse cystocele repair with uterine preservation using native tissue and to examine the surgical complications and short-term anatomical outcomes of this operation. Patients who underwent transverse cystocele repair with uterine preservation at our institution were identified by retrospective chart review for the interval from January 2001 to September 2006. Sixty-nine patients were identified. Median point for first postoperative visit was 6.1 weeks (range 3-101 weeks). Average age was 66.6 +/- 13.1 years (range 33-89). Patients undergoing this procedure had no intraoperative complications and high frequency of initial anatomic success (defined as Baden-Walker halfway system grade 0 or 1 for anterior compartment) during a relatively short follow-up interval. Preoperatively, bladder grade averaged 2.6 with postoperative grade averaging 0.02. Based on our initial anatomical findings, we conclude that this surgical approach has merit for a subset of patients with adequate uterine support.

Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms.

OBJECTIVE: Measure acceptance and use of extending the number of active oral contraceptive (OC) pills beyond 21 days and/or shortening the hormone-free interval to reduce the frequency and severity of hormone withdrawal symptoms. STUDY DESIGN: A retrospective review was performed of patients on OCs with unwanted hormone withdrawal symptoms who were counseled by one osbtetrician-gynecologist (P. J. S.) on altering their standard 21/7 regimen. All patients used a monophasic 30 to 35 microg pill and underwent an initial counseling visit between December 1993 and October 2000. RESULTS: Of 318 patients counseled on "extending the number of active pills," 292 (92%) had documented follow-up after the initial counseling session. The primary reason for extending the number of active pills was to decrease symptoms of headache (35%), dysmenorrhea (21%), hypermenorrhea (19%), and premenstrual symptoms (13%). The remaining 12% of patients cited convenience, endometriosis, and other reasons such as menstrual-associated acne. Twenty-five (9%) of 292 chose not to extend, with a preference for monthly menses as the most common reason (40%) followed by a concern that symptoms were not severe enough to warrant extension (32%). Of 267 patients who initiated an extended regimen, 57 discontinued OCs, 38 returned to a standard regimen, and 172 were extending use at the time of last follow-up. Using survival analysis methods, at 5 years 46% +/- 5% (mean +/- SE) of patients continued an extended OC pattern. The regimen of OC use by patients continuing an extended pattern was 12 +/- 12 (mean +/- SD) weeks of active pills (median of 9 weeks and range to 104 weeks) with pill-free interval of 6 +/- 2 days (median of 5 days and range of 0-7 days). CONCLUSION: The majority of patients with hormone withdrawal symptoms on OCs will initiate a regimen of extending active pills, often with a shortened hormone-free interval to reduce frequency and severity of associated symptoms.

A comparison of preoperative and intraoperative evaluations for patients who undergo site-specific operation for the correction of pelvic organ prolapse.

OBJECTIVE: We compared preoperative and intraoperative assessments of pelvic organ prolapse to ascertain whether differences existed. STUDY DESIGN: This study is a retrospective analysis of information that was collected of 193 women who underwent reconstructive operation for pelvic organ prolapse between January 1994 and April 1999 by the senior author (B. L. S.) in this institution. Support for the urethra, bladder, cervix or vaginal cuff, cul-de-sac, and rectum were assessed with the Baden-Walker halfway system before and during the operations. RESULTS: Preoperative and intraoperative assessments were significantly correlated (Spearman rank order correlation, 0.85-0.94). A comparison of the assessments revealed significantly greater prolapse at the urethra, cervix/cuff, cul-de-sac, and rectum on intraoperative evaluation (P