Estimated Levator Ani Subtended Volume: A Predictive Biomarker for Surgical Outcomes Following Native Tissue Apical Repair.

OBJECTIVE: The aim of the study was to investigate the clinical utility of estimated levator ani subtended volume (eLASV) as a prospective preoperative biomarker for prediction of surgical outcomes. STUDY DESIGN: This is a prospective case-control pilot study. Patients were recruited and gave consent between January 2018 and December 2020. Surgical failure was defined by composite score. The eLASV was calculated for each patient based on a previously published algorithm. Descriptive statistics, Fisher exact test, log-binomial regression, area under a receiver operating characteristics, Bland-Altman plot, Lin coefficient, and κ coefficient were all performed for analysis. RESULTS: Fifty-one patients gave consent, 31 completed preoperative magnetic resonance imaging, 27 underwent surgery (uterosacral ligament suspension), and 19 followed up for 1-year examination. Five patients (26.3%) were defined as surgical failure with median eLASV volume of 57.0 (interquartile range, 50.1-66.2). Fourteen patients (73.7%) were defined as surgical success with median eLASV of 28.2 (interquartile range, 17.2-24.3). Eighty percent of the surgical failure group (4/5) had elevated volume of eLASV, where only 14.3% of the success group (2/14) had an elevated volume (P = 0.0173). No confounders were found and unadjusted log-binomial regression suggested that patients with a high eLASV were 8.7 (95% confidence interval, 1.2-61.9) times more likely to experience surgical failure compared with those with low eLASV. The c-statistic (area under a receiver operating characteristics) was high at 0.829 along with Lin concordance coefficient of 0.949 (95% confidence interval, 0.891-0.977) for continuous data between the 2 interrater observer teams. CONCLUSIONS: In this small prospective pilot study, patients with elevated eLASV on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure at 1 year regardless of age, body mass index, stage, or parity.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT03534830.

Predictive Value of Biomechanical Mapping for Pelvic Organ Prolapse Surgery.

OBJECTIVE: This study examined biomechanical changes in pelvic floor after urogynecological surgery. METHODS: This multisite clinical study was designed to explore changes in tissue elasticity, pelvic support, and certain functions (contractive strength, muscle relaxation speed, muscle motility) after pelvic organ prolapse (POP) surgery. A biomechanical mapping of the pelvic floor was performed before and 4 to 6 months after the surgery. The biomechanical data for 52 parameters were acquired by vaginal tactile imaging for manually applied deflection pressures to vaginal walls and pelvic muscle contractions. The two-sample t-test (P < 0.05) was used to test the null hypothesis that presurgery data in group 1 (positive parameter change after surgery) and presurgery data in group 2 (negative parameter change after surgery) belonged to the same distribution. RESULTS: A total of 78 subjects with 255 surgical procedures were analyzed across 5 participating clinical sites. All 52 t-tests for group 1 versus group 2 had P value in the range from 4.0 × 10-10 to 4.3 × 10-2 associating all of the 52 parameter changes after surgery with the presurgical conditions. The P value of before and after surgery correlation ranged from 3.7 × 10-18 to 1.6 × 10-2 for 50 of 52 tests, with Pearson correlation coefficient ranging from -0.79 to -0.27. Thus, vaginal tactile imaging parameters strongly correlated weak pelvic floor presurgery with the positive POP surgery outcome of improved biomechanical properties. CONCLUSIONS: Pelvic organ prolapse surgery, in general, improves the biomechanical conditions and integrity of the weak pelvic floor. The proposed biomechanical parameters can predict changes resulting from POP surgery.

Evaluation of patient preparedness for surgery: a randomized controlled trial.

BACKGROUND: Patient preparedness for pelvic reconstructive surgery has important implications for patient satisfaction and the perception of improvement after surgery. The ideal method in which to optimally prepare patients for surgery has not been determined. OBJECTIVE: The objective of the study was to evaluate the impact of a preoperative patient education video on patient preparedness prior to sacrocolpopexy as measured by a preoperative preparedness questionnaire. STUDY DESIGN: We performed a single-blind, randomized, stratified clinical trial at a single academic center evaluating the use of a preoperative patient education video as an adjunct to preoperative counseling on patient preparedness. Eligible patients presenting for their preoperative appointment prior to undergoing pelvic reconstructive surgery were randomized to watch a preoperative video vs usual care. Preoperative questionnaires assessing patient preparedness, understanding, perception of time, and actual time spent with a health care team were administered at the end of this visit. The primary outcome was patient preparedness for pelvic reconstructive surgery as measured by a preoperative preparedness questionnaire. Secondary outcomes included actual time spent during the physician-patient encounter, perception of time spent with the health care team, and identification of patient factors associated with patient preparedness. RESULTS: Of the total 100 recruited patients, 52 were randomized to the video group and 48 to the usual-care group. The use of the video did not increase overall patient preparedness (71.1% with video vs 68.8% usual care, P = .79) prior to surgery. The use of the video did not decrease the amount of time spent during the physician-patient encounter (16.9 ± 5.6 min vs 17.1 ± 5.4 min, P = .87). There was a significant association between patient preparedness and perception that the health care team spent sufficient time with the patient (89.5% vs 10.5%; P < .001), but no association was observed between preparedness and actual time spent (17.4 ± 5.4 min vs16.5 ± 5.5 min, P = .47). Those with a history of a previous surgery (82.1% vs 33.3%, P = .002) and those with more significant apical prolapse (0.6 ± 4.6 vs -1.6 ± 3.9, P = .05) were more likely to report feeling prepared for surgery. CONCLUSION: The majority of patients undergoing pelvic surgery at our institution felt prepared prior to undergoing surgery. The use of preoperative education video did not increase overall patient preparedness for surgery. Greater preparedness was associated with patient perception of how much time the health care team spent with the patient but not actual time spent.

Levator Ani Muscle Defects in Patients With Surgical Failure.

INTRODUCTION: The objective of the study was to use a well-described system of measuring levator ani (LA) muscle defects from magnetic resonance images to evaluate whether major defects are correlated to an increased risk of surgical failure. METHODS: A retrospective cohort study performed on patients who underwent laparoscopic uterosacral ligament suspension from 2010 to 2012. Surgical failure was defined as a composite score of anatomic bulge beyond the hymen with sensation of bulge or repeat treatment of prolapse via pessary or surgery by 1-year follow-up. Levator ani muscle defects were graded by a score of 0 (no defect), 1 (<50% muscle bulk missing), 2 (>50% muscle bulk missing), or 3 (complete loss of muscle). Total score is the sum from both graded sides, with 0 classified as having no defect, 1 to 3 classified as having minor defects, and 4 to 6 classified as having major defects. Dichotomous values of LA major defects were compared against dichotomous values of surgical outcomes via a contingency table. Fisher exact test was then performed to correlate major defects to surgical success/failure. P value of less than 0.05 was considered statistically significant. RESULTS: Sixty-six women met the inclusion criteria. Thirteen (19.6%) patients met the criteria for surgical failure at 1 year. Of the 13, 54% (7) had a major defect, and 46% (6) had a minor or no defect (odds ratio, 1.31; 95% confidence interval, 0.39-4.41; P = 0.762). CONCLUSIONS: We did not find a statistical correlation to surgical failure after a laparoscopic uterosacral ligament suspension with LA muscle defects on preoperative magnetic resonance images within this specific patient population.

Estimated levator ani subtended volume: a novel assay for predicting surgical failure after uterosacral ligament suspension.

BACKGROUND: Levator ani muscle complex plays an important role in pelvic support and defects or laxity in this muscle complex contributes to pelvic organ prolapse and recurrence after surgical repair. OBJECTIVE: The purpose of this study was to determine whether estimated levator ani subtended volume can predict surgical outcomes for laparoscopic bilateral uterosacral ligament suspension. STUDY DESIGN: A retrospective cohort study was performed in patients who underwent laparoscopic uterosacral ligament suspension from 2010-2012. Only patients with a preoperative pelvic magnetic resonance image were included. Surgical failure was defined as a composite score that included the presence of anatomic bulge beyond the hymen with sensation of vaginal bulge or repeat treatment for prolapse via pessary or surgery by 1-year follow-up evaluation. Standard protocol pelvic magnetic resonance imaging measurements pubococcygeal line, H-line, and M-line were collected along with the calculation of the width of the levator ani hiatus. Estimated levator ani subtended volume was calculated for each subject. An optimal cutoff point was calculated and compared against categoric values of surgical success/failure. A Fisher exact test, an area under receiver operating characteristics curve, and logistic regression analysis were performed. A probability value of <.05 was considered statistically significant. RESULTS: Ninety-three women underwent laparoscopic bilateral uterosacral ligament suspension during study period. Of these, 66 women had a standardized preoperative pelvic magnetic resonance image per institutional protocol. Thirteen patients (19.6%) met the criteria for surgical failure by 1 year. An optimal cutoff point of 38.5 was calculated by Liu's method for optimization. Among the patients with defined surgical failures, 84.6% (11/13) had an estimated levator ani subtended volume above cutoff point of 38.5. Among the patients with defined surgical success, 39.6% (21/53) had an estimated levator ani subtended volume above the cutoff point (84.6% vs 39.6%; P = .0048) with a significant odds ratio of 8.38 (95% confidence interval, 1.69-41.68; P = .009). An area under receiver operating characteristics curve of 0.725 (95% confidence interval, 0.603-0.847), sensitivity of 84.6% (95% confidence interval, 54.6%-98.1%), and specificity of 60.4% (95% confidence interval, 46%-73.5%) at 38.5 were predictors of surgical success/failure by 1 year. Logistic regression analysis demonstrated no significant confounders among age, body mass index, stage, or parity. CONCLUSIONS: Estimated levator ani subtended volume may predict surgical failure for laparoscopic bilateral uterosacral ligament suspension. Patients with a calculated estimated levator ani subtended volume above 38.5 on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure by 1 year, regardless of age, body mass index, stage, or parity. Future investigation that will include repeatability, reliability analysis, and a prospective study is warranted.

Third sacral foramina morphometry for sacral neuromodulation.

OBJECTIVE: This study is aimed to define the geometry and location of the human S3 foramen, with respect to bony landmarks visible on ultrasound. METHODS: Computed tomographic (CT) image data from an institutional review board-approved database of de-identified pelvic CT images were analyzed. Points along the S3 foramina and bony sacrum were tagged, and their locations saved. The saved points were mathematically analyzed to determine the geometry and relative location of the S3 foramina with respect to other bony landmarks, specifically the sacral hiatus, and the sacral spinous processes, and the caudad aspect of the bilateral SI joints ("SI line"). Descriptive statistics were used to describe the geometry and aggregate location of the S3 foramina bilaterally. CT data sets were excluded if they had evidence of pelvic bone injury, prior bony fixation, severe osteoporosis, or other deformity. RESULTS: One hundred thirty-three data sets met the inclusion criteria. The SI line was superior to the sacral hiatus for reliable S3 localization. The entire circumference of approximately 14% of the S3 foramina is located cephalad to the SI line. The sagittal angle of trajectory for S3 was approximately 70 degrees relative to the dorsal surface of the sacrum. CONCLUSIONS: Clinical localization of the S3 foramen for sacral neuromodulator needle placement is best obtained when the needle tip is positioned 15 to 25 mm lateral to the sacral spinous processes and 0.0 cm to 25 mm caudad to the SI line, at the level of the dorsal sacrum surface. The findings presented in this study may be applied to improve the efficacy and accuracy of neuromodulator lead placement into the S3 foramen. This study provides rationale for the effectiveness of the crosshair placement technique and demonstrates the best location for needle repositioning when this technique is not initially successful.

Cost analysis of open versus robotic-assisted sacrocolpopexy.

OBJECTIVE: This study aimed to report on the costs, operative times, and length of stay for robotic and open sacrocolpopexy. STUDY DESIGN: This retrospective study compares consecutive open and robotic sacrocolpopexies that were performed beyond the surgical learning curve. Hospital direct costs, operative times, and length of stay were compared for the 2 groups. Robot cost and maintenance were included. Statistical significance was considered at P < 0.05. RESULTS: The study comprised 91 open and 73 robotic sacrocolpopexies. Both groups were similar clinically. Median operative times for open and robotic approaches were 166 and 212 minutes (P < 0.001), respectively, and length of stay was 3 versus 2 days (P < 0.001). Of the women in the robotic group, 48% had length of stay less than 24 hours versus 1% in the open group. Median robotic and open procedure direct costs were $6668 and $7804 (P = 0.002), respectively. Readmission rates at 30 days postoperatively were similar. CONCLUSIONS: Robotic sacrocolpopexy costs less but takes slightly longer to perform than the open procedure.

The ureter as a landmark for robotic sacrocolpopexy.

OBJECTIVE: The objective of this study was to report on the location of the ureters in relation to the sacral promontory at the level of the pelvic brim. METHODS: Female patients undergoing indicated computed tomographic (CT) urograms were selected for this study. Charts and images from a defined 3-year study period were reviewed. The GE Centricity software was used to evaluate multiplanar CT views and measure the distance from the bilateral ureters to the midpoint of the distal sacral promontory for each subject. RESULTS: Sixty-three women underwent CT urography during the study period. Of these, 38 met the criteria for inclusion. Among these, the left ureter was 35.9 ± 4.9 mm lateral to the midsacral promontory. The right ureter was 29.7 ± 6.2 mm lateral to the sacral promontory. CONCLUSIONS: On average, the sacral promontory is located 29.7 mm medial to the right ureter at the level of the pelvic brim. This represents a landmark that may prove clinically useful, along with other visual cues, in choosing the proper location for careful dissection toward the anterior longitudinal ligament during robotic sacrocolpopexy.

Technical preferences of surgeons performing a sacrocolpopexy procedure.

The purpose of this study is to report on the surgical preferences of international surgeons in the performance of the sacrocolpopexy procedure. Invitations to complete this Internet-based survey were sent to 2,854 International Urogynecological Association (IUGA) members from December 2010 through February 2011. Questions were related to various aspects of the surgeons' techniques and preferences in the performance of a sacrocolpopexy procedure by the abdominal, laparoscopic, and robotic routes. Descriptive statistics are reported. A total of 235 members from six continents completed the survey. Ninety percent of the respondents perform sacrocolpopexy procedures in their practices, including abdominal (n = 177), laparoscopic (n = 92), and robotic (n = 48) procedures. Participants reported reduced blood loss, shorter hospitalization, and longer operative time during laparoscopic and robotic procedures compared with open abdominal sacrocolpopexy, but no differences were reported in overall major complications. Overall, surgical preferences and techniques of international surgeons for sacrocolpopexy were similar among responders, regardless of the surgical route performed.

Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis.

INTRODUCTION AND HYPOTHESIS: The objectives of this study are to investigate myofascial pain in patients with interstitial cystitis (IC) and to correlate myofascial exam findings with validated questionnaires. METHODS: A retrospective chart review was performed on 186 patients with a diagnosis of IC from April 2007 to December 2008. Demographics, history and physical examination, and validated pelvic floor dysfunction questionnaire scores were extracted. The data was evaluated with SPSS for Windows using Spearman's rho, Mann-Whitney, and Kruskal-Wallis statistical analyses. RESULTS: Myofascial pain was demonstrated in 78.3% of IC patients with at least one myofascial trigger point, and 67.9% of patients had numerous areas of trigger points. Mild correlations were seen with trigger points and scores from the PUF, PFDI-20, and PFIQ-7 questionnaires. CONCLUSIONS: Myofascial pain is prevalent among IC patients and positively correlated with pelvic floor dysfunction scores. These findings support evaluation of pelvic floor myofascial pain in IC patients and suggest a possible benefit from pelvic floor therapy.

Surgery for stress urinary incontinence in the United States: does race play a role?

The objective of this study was to evaluate the prevalence, demographics and complications of stress urinary incontinence (SUI) surgery across races in the United States (US) in 2003. We hypothesized that there would be racial differences in surgical rates. Data from the 2003 National Census and National Hospital Discharge Survey were used. Continuous variables were tested for statistical significance by one-way analysis of variance and categorical variables by chi2 analysis. 129,778 women underwent SUI surgery in the US in 2003, a rate of 12 surgical procedures per 10,000 women (95% CI 10-14). By race, rates (per 10,000 women, 95% CI) of SUI surgery were: ten (7-12) in white women, three (0-9) in black women, and six (0-13) in women of other races. Racial disparities in the receipt of SUI surgery may exist.

The age distribution, rates, and types of surgery for stress urinary incontinence in the USA.

The objective of this study was to describe the distribution of stress urinary incontinence (SUI) surgery across age groups in the USA in 2003. Patients were grouped into four age categories: reproductive, perimenopausal, postmenopausal, and elderly. Data from the 2003 National Hospital Discharge Survey and National Census were used to estimate surgical rates by age group. In 2003, 129,778 women underwent 165,776 surgical procedures for SUI. Of these women, 12.2, 53.0, 30.4, and 4.5% belonged to reproductive, perimenopausal, postmenopausal, and elderly age groups, respectively. Surgical rates (per 10,000 women) were 4, 17, 19, and 9 in these age groups, respectively. Complications occurred most frequently in reproductive age women. Overall, SUI surgical rates were similar for perimenopausal and postmenopausal women and exceeded that in the elderly population. The greatest percentage of surgical procedures occurred in perimenopausal women. Women at all stages of reproductive life may seek surgical treatment for SUI.

The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA.

The objective of this study was to describe the distribution of pelvic organ prolapse (POP) surgery across age groups in the USA in 2003. Patients were grouped into four age categories: Reproductive age, perimenopausal, postmenopausal, and elderly. Data from the 2003 National Hospital Discharge Survey and National Census were used to estimate surgical rates by age group. In 2003, 199,698 women underwent a total of 311,587 surgical procedures for POP. Prolapse surgical rates (per 10,000 women) were 7, 24, 31, and 17 in reproductive age, perimenopausal, postmenopausal, and elderly age groups, respectively. Surgical complications occurred in 28.8, 19.6, 18.6, and 22.1% of women in these age groups, respectively. Mortality was uncommon. Although often considered a condition of the elderly, this study suggests that pelvic organ prolapse is a condition affecting women across the reproductive life cycle and for which women of all ages seek surgical treatment.

Racial characteristics of women undergoing surgery for pelvic organ prolapse in the United States.

OBJECTIVE: This study was undertaken to compare the prevalence, demographics, and complications of pelvic organ prolapse surgery across races in the United States. STUDY DESIGN: Data from the 2003 National Census and the 2003 National Hospital Discharge Survey were used to determine rates of prolapse surgery, demographic characteristics, morbidity, and mortality across races. RESULTS: In 2003, 199,698 women underwent prolapse surgery. Rates of prolapse surgery per 10,000 women were 14.8, 5.6, and 8.7 in women of white, black, and other races. By geographic region, surgical rates per 10,000 white vs black women differed most in the West (16.0 vs 0.8). Of black women, 27% were on public assistance, compared with 5.9% and 9.6% women of white and other races. Complications occurred in 19.4%, 34.1%, and 27.4% of women of white, black, other races. Mortality was uncommon for all races. CONCLUSION: Racial disparities between white and black women undergoing prolapse surgery appear to exist.

Life-threatening reaction to indigo carmine--a sulfa allergy?

Indigo carmine is commonly used during cystoscopy when evaluating for lower urinary tract safety after gynecologic surgery. We report a case of severe hypotension and bradycardia following intravenous indigo carmine injection in a patient with known sulfa allergy.

Tumor detection in the bladder wall with a measurement of abnormal thickness in CT scans.

Virtual cystoscopy is a developing technique for bladder cancer screening. In a conventional cystoscopy, an optical probe is inserted into the bladder and an expert reviews the appearance of the bladder wall. Physical limitations of the probe place restrictions on the examination of the bladder wall. In virtual cystoscopy, a computed tomography (CT) scan of the bladder is acquired and an expert reviews the appearance of the bladder wall as shown by the CT. The task of identifying tumors in the bladder wall has often been done without extensive computational aid to the expert. We have developed an image processing algorithm that aids the expert in the detection of bladder tumors. Compared with an expert observer reading the CT, our algorithm achieves 89% sensitivity, 88% specificity, 48% positive predictive value, and 98% negative predictive value.

Three-dimensional magnetic resonance imaging assessment of levator ani morphologic features in different grades of prolapse.

OBJECTIVE: The study was undertaken to identify the morphologic changes in the levator ani in different grades of prolapse by using reconstructed three-dimensional models of magnetic resonance images (MRI) and to subclassify prolapse into different categories on the basis of their levator ani morphologic characteristics. STUDY DESIGN: Sixty-one women were studied, 8 women in stage I, 15 women in stage II, 22 women in stage III, 7 women in stage IV prolapse, and 9 asymptomatic volunteers with stage 0 prolapse. Axial, sagittal, and coronal T2-weighted pelvic magnetic resonance scans were obtained with the patient in the supine position. The three-dimensional models were reconstructed from the source images by using manual segmentation and surface modeling. The morphologic characteristics of the puborectalis were assessed on these reconstructed models by measuring (1). the levator symphysis gap, (2). the width of the levator hiatus, and (3). the length of the levator hiatus. To assess the iliococcygeus, we measured (1). the maximum width of the iliococcygeus, (2). the direction of its fibers that was assessed by measuring the iliococcygeal angle, and (3) the levator plate angle. Nine nulliparous asymptomatic women were studied as controls. RESULTS: Alterations in levator ani morphologic features are not dependent on the grade of the prolapse, and not all women with pelvic floor prolapse have abnormal morphologic features. In healthy control subjects, the iliococcygeal width measured less than 40 mm and the iliococcygeal angle measured less than 20 degrees. On the basis of the MRI findings, four patterns of changes in the levator ani have been identified. Both the levator symphysis gap and the levator hiatus, which is dependent on the puborectalis function, widen with increasing grade of prolapse. CONCLUSION: It is possible to subclassify prolapse on the basis of morphologic changes in the levator ani by using MRI. This may be a very useful predictor as to which patients have recurrent prolapse develop after surgery.

Tumor detection by virtual cystoscopy with color mapping of bladder wall thickness.

PURPOSE: We determine the value of color mapping of bladder wall thickness for detection of tumor as a component of virtual cystoscopy. MATERIALS AND METHODS: A total of 31 subjects with hematuria and/or a history of bladder tumor underwent helical computerized tomography of the pelvis after distention of the bladder with air. Three-dimensional (D) models were constructed, and thickness of the wall was color mapped according to a fixed and validated mm. scale. Axial source images and 3-D models were reviewed and graded for the presence of wall thickening. A comparison was made with findings on conventional cystoscopy in 31 patients and pathological specimen in 13. RESULTS: Compared with conventional cystoscopy, the analysis of axial image yielded a sensitivity of 0.80, specificity 0.90, positive predictive value 0.80 and negative predictive value 0.90 for the presence of tumor. Examination of color mapped 3-D renderings resulted in 0.83, 0.36, 0.42 and 0.71, respectively. CONCLUSIONS: Thin axial computerized tomography of the air distended bladder shows promise as a potential screening tool for bladder cancer. The low specificity of color mapped 3-D renderings makes the technique inappropriate for screening. It may valuable for guiding urologists to additional suspicious sites in a patient with a known tumor.