Successful sacral neuromodulation treatment of refractory faecal incontinence in a patient with spina bifida and partial sacral agenesis.

A woman in her early 20s with a history of lumbosacral lipomyelomeningocele with associated partial sacral agenesis and tethered cord was referred for possible sacral neuromodulation treatment of her refractory faecal incontinence. Anorectal testing revealed a thinned and weakened anal sphincter complex with absent left-sided bulbocavernosus and anal wink reflexes.Through a two-stage approach, she underwent successful placement of a chronic tined quadripolar sacral nerve lead and implanted pulse generator. Despite significant distortion of normal bony anatomic landmarks, bilateral S3 and S4 foraminal entry was possible, with intraoperative motor and sensory testing providing key confirmation of appropriate lead placement. The patient had a substantial improvement in her baseline frequency and urgency with a near-complete resolution of faecal incontinence episodes during her test phase.

Surgical Alteration of Genital Hiatus Size and Anatomic Failure After Vaginal Vault Suspension.

OBJECTIVE: To compare anatomic outcomes after native tissue vaginal vault suspension among women categorized by their preoperative and 6-week postoperative genital hiatus size. METHODS: We performed a retrospective cohort study in women who underwent native tissue vaginal vault suspension between 2005 and 2015. We defined a wide genital hiatus as 4 cm or greater and a normal genital hiatus as less than 4 cm. We compared three groups: 1) women with a wide genital hiatus preoperatively and 6 weeks postoperatively (persistently wide group), 2) women with a wide genital hiatus preoperatively but normal genital hiatus 6 weeks postoperatively (improved group), and 3) women with a normal genital hiatus preoperatively and 6 weeks postoperatively (stably normal group). Our primary outcome was composite anatomic failure at medium term, defined as either recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or a pessary. Data were analyzed with appropriate bivariate analysis and logistic regression. RESULTS: Our study population consisted of 260 women, with 39 of 260 (15.0%) in the persistently wide group, 157 of 260 (60.4%) improved, and 64 of 260 (24.6%) stably normal. Composite anatomic failure was significantly more likely in the persistently wide cohort as compared with the other groups (persistently wide 51.3%, improved 16.6%, stably normal 6.3%, overall P<.01, significant for all pairwise comparisons). These results were consistent when examining the anterior, apical, and posterior compartments individually. In a logistic regression analysis, the persistently wide group was associated with a 4.4-fold increased odds of composite failure (adjusted odds ratio [OR] 4.41, 95% CI 1.99-9.76, P<.01) compared with the improved group and a 15.8-fold increased odds compared with the stably normal group (adjusted OR 15.79, 95% CI 4.66-53.57, P<.01). CONCLUSION: Women with a preoperative genital hiatus 4 cm or greater that is not surgically normalized after native tissue vaginal vault suspension are at significantly increased odds of anatomic failure in all compartments.

Robotic-assisted sacrocolpopexy: early postoperative outcomes after surgical reduction of enlarged genital hiatus.

BACKGROUND: Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy is not standardized. OBJECTIVE: We sought to compare anatomic failure after robotic-assisted sacrocolpopexy among 3 groups of patients categorized by their preoperative and postoperative genital hiatus size. STUDY DESIGN: We performed a retrospective cohort study of women who underwent robotic-assisted sacrocolpopexy, from January 2013 through September 2016. We defined a wide genital hiatus as ≥4 cm and a normal genital hiatus as <4 cm. We compared 3 groups: (1) wide preoperative and postoperative genital hiatus (persistently wide); (2) wide preoperative and normal postoperative genital hiatus (improved); and (3) normal preoperative and postoperative genital hiatus (stably normal). Our primary outcome was composite anatomic failure defined as either recurrent prolapse in any compartment past the hymen or retreatment for prolapse with either surgery or pessary. Our data were analyzed using 1-way analysis of variance and χ2 test. Logistic regression was performed to evaluate for independent risk factors for anatomic failure among the 3 groups. P < .05 was considered significant. RESULTS: Our study population consisted of 452 women with a mean age of 59.3 ± 10.0 years and a mean body mass index of 27.8 ± 5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The genital hiatus groups were distributed as follows: 57 (12.6%) were persistently wide, 296 (65.5%) were improved, and 99 (21.9%) were stably normal. The stably normal group had less advanced preoperative prolapse (stage ≥3) than the other groups (P < .01). A similar percentage of patients among groups had a concomitant posterior repair/perineoplasty (P = .09) with a total of 84 (18.6%) women undergoing this procedure. There was a statistically significant difference in overall composite anatomic failure among the groups (P = .03). There was an increase in failure in the persistently wide group (14.0%) compared to the improved group (5.7%, P = .04) and compared to the stably normal group (4.0%, P = .03). In a logistic regression model, controlling for number of vaginal deliveries and posterior repair/perineoplasty, there was a 5.3-fold increased odds of composite anatomic failure in the persistently wide group (adjusted odds ratio, 5.3; 95% confidence interval, 1.4-19.1; P = .01) compared to the stably normal group. In a subanalysis of failure by compartment, there was an increase in failure of the posterior compartment in the persistently wide group compared to the improved group (8.8% vs 2.0%, P < .01), but not the stably normal group (3.0%, P = .12). There was not a statistically significant difference in failure of the combined apical and anterior compartments among groups (P = .29). CONCLUSION: Surgical reduction of an enlarged preoperative genital hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of genital hiatus to postoperative genital hiatus are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy.

Do Mixed-Flora Preoperative Urine Cultures Matter?

OBJECTIVES: To determine whether mixed-flora preoperative urine cultures, as compared with no-growth preoperative urine cultures, are associated with a higher prevalence of postoperative urinary tract infections (UTIs). METHODS: This was a retrospective cohort study. Women who underwent urogynecologic surgery were included if their preoperative clean-catch urine culture result was mixed flora or no growth. Women were excluded if they received postoperative antibiotics for reasons other than treatment of a UTI. Women were divided into two cohorts based on preoperative urine culture results-mixed flora or no growth; the prevalence of postoperative UTI was compared between cohorts. Baseline characteristics were compared using χ2 or Student t tests. A logistic regression analysis then was performed. RESULTS: We included 282 women who were predominantly postmenopausal, white, and overweight. There were many concomitant procedures; 46% underwent a midurethral sling procedure and 68% underwent pelvic organ prolapse surgery. Preoperative urine cultures resulted as mixed flora in 192 (68%) and no growth in 90 (32%) patients. Overall, 14% were treated for a UTI postoperatively. There was no difference in the proportion of patients treated for a postoperative UTI between the two cohorts (25 mixed flora vs 13 no growth, P = 0.77). These results remained when controlling for potentially confounding variables in a logistic regression model (adjusted odds ratio 0.92, 95% confidence interval 0.43-1.96). CONCLUSIONS: In women with mixed-flora compared with no-growth preoperative urine cultures, there were no differences in the prevalence of postoperative UTI. The clinical practice of interpreting mixed-flora cultures as negative is appropriate.

Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial.

OBJECTIVE: To evaluate whether nitrofurantoin prophylaxis prevents postoperative urinary tract infection (UTI) in patients receiving transurethral catheterization after pelvic reconstructive surgery. METHODS: In a randomized, double-blind, placebo-controlled trial, participants undergoing pelvic reconstructive surgery were randomized to 100 mg nitrofurantoin or placebo once daily during catheterization if they were: 1) discharged with a transurethral Foley or performing intermittent self-catheterization; or 2) hospitalized overnight with a transurethral Foley. Our primary outcome was treatment for clinically suspected or culture-proven UTI within 3 weeks of surgery. Statistical analysis was performed by χ2 and logistic regression. Assuming 80% power at a P value of .05, 156 participants were needed to demonstrate a two-thirds reduction in UTI. RESULTS: Of 159 participants, 81 (51%) received nitrofurantoin and 78 (49%) received placebo. There were no significant differences in baseline demographics, intraoperative characteristics, duration and type of catheterization, or postoperative hospitalization, except a lower rate of hysterectomy in the nitrofurantoin group. Nitrofurantoin prophylaxis did not reduce the risk of UTI treatment within 3 weeks of surgery (22% UTI with nitrofurantoin compared with 13% UTI with placebo, relative risk 1.73, 95% confidence interval 0.85-3.52, P=.12). Urinary tract infection treatment was higher in premenopausal women, lower in diabetics, and increased with longer duration of catheterization. In logistic regression adjusting for menopause, diabetes, preoperative postvoid residual volume, creatinine clearance, hysterectomy, and duration of catheterization, there was still no difference in UTI with nitrofurantoin as compared with placebo. CONCLUSION: Prophylaxis with daily nitrofurantoin during catheterization does not reduce the risk of postoperative UTI in patients receiving short-term transurethral catheterization after pelvic reconstructive surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01450800. LEVEL OF EVIDENCE: I.

Obesity as a risk for the recurrence of anterior vaginal wall prolapse after anterior colporrhaphy.

OBJECTIVE: To determine whether obese body mass index is associated with the recurrence of anterior vaginal wall prolapse after anterior colporrhaphy. STUDY DESIGN: We conducted a retrospective cohort study of the risk of recurrent anterior prolapse 6 months after anterior colporrhaphy in normal weight/overweight versus obese women from January 2004 to December 2010. Women who underwent a concurrent apical prolapse procedure were excluded. Data were abstracted regarding sociodemographics, physical examination, operative reports, and postoperative follow-up visits. RESULTS: Of 282 subjects 192 (68%) were normal/overweight and 90 (32%) were obese. Median time of follow-up was 1.8 months (interquartile range [IQR] 1.4-6.2) in the normal/overweight group and 2.0 months (IQR 1.4-5.9) in the obese group. The overall risk of recurrent prolapse was 15.2%. In bivariate analysis there was a trend towards higher recurrence in the obese versus the normal/overweight cohort (21.1% vs. 12.5%, p = 0.06). In the logistic regression model, which adjusted for age, race, diabetes, constipation, cigarette use, concurrent sling, and prior hysterectomy, obesity became significantly associated with recurrent anterior prolapse (odds ratio 2.5, 95% confidence interval 1.2-5.3). CONCLUSION: The risk of recurrence after anterior colporrhaphy is relatively high in the short-term. Obesity is associated with increased odds of anatomic recurrence of anterior vaginal wall prolapse.

Comparing the risk of urethrolysis for the treatment of voiding dysfunction between two retropubic mesh slings: a case-control study.

INTRODUCTION AND HYPOTHESIS: Long-term outcome data exist with Gynecare TVT tension-free support for incontinence (TVT), yet few comparisons have been made to newer retropubic sling delivery systems, especially with regards to urethrolysis for postoperative voiding dysfunction. Our objective was to compare the odds of urethrolysis for the treatment of voiding dysfunction between two retropubic sling systems. METHODS: We performed a case-control study comparing the risk of urethrolysis between TVT versus the Bard ALIGN Urethral Support System (Bard Align). We identified surgical procedures described as urethrolysis, sling revision, loosening, or lysis performed for the treatment of voiding dysfunction by urogynecologists at Duke University between January 2007 and June 2011. Slings placed at outside institutions were excluded. Controls were matched for both concomitant prolapse procedures and academic year. RESULTS: Of 818 total slings placed during the study period, there were 28 (3.4 %) urethrolysis cases, which were matched to 84 controls. Among urethrolysis cases, 6/28 (21.4 %) had received TVT, while 22/28 (78.6 %) had received Bard Align slings. Of the 84 matched controls, 30/84 (35.7 %) had undergone TVT and 54/84 (64.3 %) had undergone Bard Align. There was no significant difference in the odds of urethrolysis following the use of TVT or Bard Align [odds ratio (OR) 2.00, 95 % confidence interval (CI) 0.74-5.50]. In a conditional logistic regression model, which adjusted for age, body mass index, prior anti-incontinence or prolapse surgery, and postvoid residual, there remained no significant difference in odds of urethrolysis between the two sling types (OR 1.50, 95 % CI 0.42-5.33). CONCLUSIONS: Despite different instrument designs, there was no significant difference in the risk of urethrolysis following TVT or Bard Align retropubic sling.

Impact of staged InterStim implantation on the postoperative activities of daily living and pain.

OBJECTIVES: To evaluate the short-term effects of staged InterStim implantation on activities of daily living (ADL) and pain. METHODS: This prospective study assessed women undergoing staged InterStim implantation. The Older Americans Resources and Services Program Multidimensional Functional Assessment Questionnaire asked participants about their ability to complete activities without help or what help they needed following stage I lead placement and stage II neurostimulator implantation. Narcotic use and a visual analog scale (VAS) for pain were recorded daily. RESULTS: Thirty-eight women underwent stage I with 33 (86.8%) progressing to stage II. On stage I postoperative day (POD) 2, more women required help shopping compared with baseline (40 vs 17%, p < 0.004). The median pain score increased on Stage I POD1 (P < 0.001) and the use of narcotics increased on POD1 and 2 compared with baseline (50% vs 14%, p = 0.001). The same trends were seen following stage II. CONCLUSIONS: Staged InterStim implantation has minimal impact on ADL, pain or narcotic requirements.

Computer modeling informs study design: vaginal estrogen to prevent mesh erosion after different routes of prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Many clinicians use perioperative vaginal estrogen therapy (estradiol, E(2)) to diminish the risk of mesh erosion after prolapse surgery, though supporting evidence is limited. We assessed the feasibility of a factorial randomized trial comparing mesh erosion rates after vaginal mesh prolapse surgery (VM) versus minimally invasive sacral colpopexy (MISC), with or without adjunct vaginal estrogen therapy. METHODS: A Markov state transition model simulated the probability of 2-year outcomes of visceral injury, mesh erosion, and reoperation after four possible prolapse therapies: VM or MISC, each with or without estrogen therapy (E(2)). We used pooled estimates from a systematic review to generate probability distributions for the following outcomes after each procedure: visceral injury, postoperative mesh erosion, and reoperation for either recurrent prolapse or mesh erosion. Assuming different assumptions for E(2) efficacies (50 and 75 % reduction in erosion rates), Monte Carlo simulations estimated outcomes rates, which were then used to generate sample size estimates for a four-arm factorial trial. RESULTS: While E(2) reduced the risk of mesh erosion for both VM and MISC, absolute reduction was small. Assuming 75 % efficacy, E(2) decreased the risk of mesh erosion for VM from 7.8 to 2.0 % and for MISC from 2.0 to 0.5 %. Total sample sizes ranged from 448 to 1,620, depending on power and E(2) efficacy. CONCLUSIONS: The required sample size for a trial to determine which therapy results in the lowest erosion rates would be prohibitively large. Because this remains an important clinical issue, further study design strategies could include composite outcomes, cost-effectiveness, or value of information analysis.

Long-term outcomes after stress urinary incontinence surgery.

OBJECTIVES: To compare the long-term risk of repeat stress urinary incontinence (SUI) surgery after different types of initial SUI surgery and to identify predictors of time to repeat SUI surgery in a large, population-based cohort. METHODS: We used de-identified, adjudicated health care claims data from approximately 100 employer-based plans across the United States from 2000 to 2009. We identified the index SUI surgery in women aged 18 to 64 years. Kaplan-Meier survival curves were used to estimate cumulative incidence of repeat surgery through 9 years. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with recurrent SUI surgery. RESULTS: Over 10 years, we identified 155,458 eligible women who underwent one or more SUI surgeries, with a total of 294,855 person-years of follow-up. Of these index surgeries, 127,848 (82.2%) were slings. The 9-year cumulative incidence of repeat surgery after any SUI surgery was 14.5% (95% CI 13.4-15.5). As expected, bulking agents had the highest cumulative incidence of repeat surgery (61.2%, 95% CI 56.3-66.0) followed by needle suspension (22.2%, 95% CI 16.5-27.9); the lowest 9-year incidences were for Burch (10.8%, 95% CI 9.3-12.3) and sling (13.0%, 95% CI 11.7-14.3). In a Cox proportional hazards model that adjusted for age, year of index surgery, and region of the United States, the rate of repeat surgery was 28% higher for slings compared with Burch (adjusted HR 1.28, 95% CI 1.19-1.37). CONCLUSION: In this population-based analysis of women aged 18 to 64 years, Burch procedures had the lowest 9-year cumulative incidence of repeat SUI surgery.

Do urodynamic parameters predict persistent postoperative stress incontinence after midurethral sling? A systematic review.

INTRODUCTION AND HYPOTHESIS: It is unclear whether preoperative urodynamic study (UDS) values are predictive of outcomes after midurethral sling. MATERIALS AND METHODS: We systematically reviewed multiple databases from January 1989 to October 2011 for English-language studies correlating UDS data with postoperative outcomes after midurethral slings. We performed random effects model meta-analyses, as indicated. Relative risk (RR) ratios for the outcome of stress urinary incontinence (SUI) cure were calculated using high maximum urethral closure pressure (MUCP) and Valsalva leak point pressure (VLPP) values as the reference group. RESULTS: High preoperative MUCP was associated with cure after retropubic [RR 0.67; 95% confidence interval (CI) 0.47-0.97)] and transobturator slings (RR 0.65; 95% CI 0.49-0.90). High preoperative VLPP was also associated with cure after retropubic sling (RR 0.89; 95% CI 0.82-0.96), but this relationship did not achieve statistical significance for cure after transobturator sling (RR 0.86; 95% CI 0.74-1.00). CONCLUSIONS: Preoperative MUCP and VLPP values may add insight into postoperative outcomes after surgical treatment for SUI.

The efficacy of posterior tibial nerve stimulation for the treatment of overactive bladder in women: a systematic review.

INTRODUCTION AND HYPOTHESIS: Posterior tibial nerve stimulation (PTNS) is a percutaneous method of peripheral, sacral neuromodulation. Its current use is limited; however, published data suggest PTNS may be an effective treatment for overactive bladder (OAB). METHODS: We systematically reviewed the literature on PTNS for treatment of idiopathic OAB in women from January 2000 to August 2010 published in English in MEDLINE/PubMed, Embase, and Cochrane databases. We included randomized controlled trials or observational studies reporting objective outcome measures with the use of either the Urgent PC or Stoller Afferent Nerve Stimulator (SANS) for PTNS. Studies were considered "good quality" if results from objective measures were provided for ≥20 women, results distinguished between type of OAB symptom, and data were reported separately for female subjects. RESULTS: Of the 136 identified articles, 17 met inclusion criteria for data abstraction; 4 of the 17 studies met our criteria for good quality and reported success rates of 54-93 %. Recurrent limitations in the literature were pooling of results for male and female subjects and lack of differentiation in the data on specific symptoms of OAB treated. Short-term follow-up and infrequent use of a control arm were also noted shortcomings of reviewed studies. CONCLUSIONS: Limited high quality data exist on PTNS for OAB in women. Although initial studies have demonstrated promise, more comprehensive evaluation of PTNS is needed to support its universal use for the treatment of OAB in women.

Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050.

OBJECTIVE: We sought to estimate the number of women who will undergo inpatient and outpatient surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP) in the United States from 2010 through 2050. STUDY DESIGN: Using the 2007 Nationwide Inpatient Sample and the 2006 National Survey of Ambulatory Surgery, we calculated the rates for inpatient and outpatient SUI and POP surgery. We applied the surgery rates to the US Census Bureau population projections from 2010 through 2050. RESULTS: The total number of women who will undergo SUI surgery will increase 47.2% from 210,700 in 2010 to 310,050 in 2050. Similarly, the total number of women who will have surgery for prolapse will increase from 166,000 in 2010 to 245,970 in 2050. CONCLUSION: If the surgery rates for pelvic floor disorders remain unchanged, the number of surgeries for urinary incontinence and POP will increase substantially over the next 40 years.

Correlation of maximum urethral closure pressure with Valsalva leak point pressure using air-charged urodynamic catheters.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to measure the correlation of maximum urethral closure pressure (MUCP) with Valsalva leak point pressure (VLPP) in women with urodynamic stress incontinence using air-charged urodynamic catheters. METHODS: Records of all women who underwent urodynamic testing for urinary incontinence using air-charged catheters over a 3-year period were reviewed. Data included scores on the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7). RESULTS: One hundred ninety-three women met the criteria for urodynamic stress incontinence. There was a modest correlation of MUCP with VLPP at 200 mL (r = 0.46, p < 0.001) and a low correlation of MUCP with VLPP at maximum capacity (r = 0.35, p < 0.001). There was no correlation of UDI-6 or IIQ-7 scores with MUCP or VLPP. CONCLUSIONS: The low to modest correlation of VLPP with MUCP with air-charged catheters is similar to what has been reported with water-filled and microtransducer catheters.