Association between body mass index and pain following transobturator sling.

We aimed to prospectively evaluate the association between body mass index (BMI) and development of postoperative-onset pain in women undergoing transobturator midurethral sling procedures. We conducted a prospective, observational cohort study of women undergoing inside-to-out transobturator midurethral sling. At preoperative visit, height, weight, self-reported activity level and baseline pain were documented. At postoperative visits, patients indicated pain location and severity, procedure success, and satisfaction. We used log binomial regression to calculate risk ratios, controlling for potential confounders. For the 129 women included, median age was 50.0 years and BMI was 27.2 kg/m2. Adjusting for age and activity level, overweight and obese women had significantly increased risk of postoperative-onset pain compared to normal BMI women. Overweight women were at 1.70 (95%CI 1.05-2.75) times the risk compared to leaner counterparts, whereas obese women were at 1.76 times the risk (95%CI 1.04-2.89). Neither success nor satisfaction was associated with BMI. Impact statement Over three million midurethral slings have been placed worldwide for the treatment or prevention of stress urinary incontinence. The procedure has been studied in lean, overweight and obese populations, and found to have similar efficacy regardless of BMI. Similarly, the risks of midurethral sling have been well-documented, including the risk of pain after transobturator sling. Little attention has been given to whether this risk of postoperative pain varies based on patient BMI. Our previous work suggesting that leaner patients might be at increased risk of postoperative pain following transobturator sling was limited by the shortcomings of a retrospective study design. In this prospective study, we were able to adjust for age and activity level, finding that higher BMI women were at increased risk of postoperative pain, while reporting similar levels of satisfaction with the procedure. Future research is needed to find what differences in anatomy or physiology can explain this finding. From a clinical standpoint, thorough counselling of all patients but particularly those with elevated BMI, is required so that appropriate expectations regarding recovery can be set preoperatively.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial.

OBJECTIVE: To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. METHODS: We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. RESULTS: One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P≤0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0-4.0) days. CONCLUSIONS: Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE: I.

Characterization of pain after inside-out transobturator midurethral sling.

OBJECTIVES: This study aimed to evaluate the prevalence, severity, duration, and location of pain after transobturator midurethral sling. METHODS: We evaluated patients who underwent inside-out transobturator sling from March 2011 through February 2013. Presence of pelvic girdle pain, its severity, and location were documented preoperatively and at 2- and 6-week postoperative visits. Pain severity was measured on a scale of 1 to 10, with 10 being the "worst imaginable" pain. RESULTS: Of the 130 women analyzed, the median age was 50.0 years (interquartile range, 44.0-62.0). Thirty-nine percent of women reported preoperative pain, mostly mild with a median score of 1.0 (1.0-5.0). The most common sites of postoperative-onset pain were the lateral leg, medial leg, groin, and low back. Women reporting preoperative pain were not more likely to report postoperative-onset pain than women without preoperative pain (P = 0.42). Twelve percent of women at 2 weeks and 0.8% at 6 weeks reported severe postoperative-onset pain. Women reporting postoperative-onset pain were equally likely to be satisfied with the procedure as those without pain at 2 (P = 0.76) and 6 (P = 0.74) weeks. CONCLUSIONS: Women undergoing transobturator sling commonly report preoperative pain. An expected postoperative increase in pain generally resolved by the sixth postoperative week. The lateral leg was the most common site of pain. Postoperative-onset pain was not associated with decreased patient satisfaction.