Surgical management of pelvic organ prolapse.

Despite pelvic organ prolapse being a universal problem experienced in nearly 50% of parous women, the surgical management of vaginal prolapse remains an enigma to many, with wide variation in the rates and types of intervention performed. As part of the 6th International Consultation on Incontinence (ICI) our committee, charged with producing an evidence-based report on the surgical management of prolapse, produced a pathway for the surgical management of prolapse. The 2017 ICI surgical management of prolapse evidence-based pathway will be presented and summarized. Weaknesses of the data and pathway will be discussed and avenues for future research proposed.

Quality of life after surgery for stress incontinence.

This study investigated changes in condition-specific quality of life (QOL) after surgery for stress urinary incontinence. Data from 655 women in a clinical trial comparing the Burch and fascial sling were examined. Improvement in QOL, measured with the Incontinence Impact Questionnaire (mean decrease 133.1; SD 109.8), was observed 6 months after surgery and persisted at 24 months. Women for whom surgery was successful (regardless of surgery type) had greater improvement in QOL (mean decrease 160.0; SD 103.9) than did women for whom surgery was not successful (mean decrease 113.6; SD 110.9; p < 0.0001), although not statistically significant after adjusting for covariates. Multivariable analysis showed that QOL improvement was related to decreased urinary incontinence (UI) symptom bother, greater improvement in UI severity, younger age, Hispanic ethnicity, and receiving Burch surgery. Among sexually active women, worsening sexual function had a negative impact on QOL. Improved QOL was explained most by UI symptom improvement.

Reference urodynamic values for stress incontinent women.

OBJECTIVE: To determine reference urodynamic values for preoperative urodynamic studies in women undergoing surgery for pure or predominant stress urinary incontinence (SUI). MATERIALS AND METHODS: Six hundred fifty-five women with pure or predominant SUI were enrolled in a multicenter surgical trial and were randomized to undergo a Burch or autologous fascia sling procedure as part of the Urinary Incontinence Treatment Network (UITN) Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Preoperative free uroflowmetry, filling cystometry, and pressure flow studies were performed in all women using a standardized research protocol and standardized urodynamic interpretation guidelines. We define the normal range of urodynamic values in this population as the values that encompass 95% of the results. RESULTS: In 655 women undergoing filling cystometry in the standing position, baseline vesical and abdominal pressures were between 12 and 60 cm H(2)O. The upper limit of detrusor pressure increase during bladder filling to maximum cystometric capacity was 16 cm H(2)O. Ten percent of women who qualified for stress incontinence surgery with a positive cough stress test on physical exam did not demonstrate urodynamic stress incontinence (USI) and less than 10% of subjects in this study demonstrated detrusor overactivity. CONCLUSIONS: Results from a large cohort of women with SUI are now available for quantitative plausibility assessments or as reference values when interpreting urodynamic studies.

Interrater reliability of filling cystometrogram interpretation in a multicenter study.

PURPOSE: As part of a continuous quality control effort to measure the interrater reliability of urodynamic studies performed at multiple centers, we compared agreement levels for urodynamic studies between central and local physician reviewers. We report interrater reliability findings for the filling cystometrogram. MATERIALS AND METHODS: Following a satisfactory interrater reliability study among 4 central physician reviewers in 33 tracings 36 urodynamic study tracings from 9 Urinary Incontinence Treatment Network continence treatment centers and 13 Urinary Incontinence Treatment Network certified urodynamic study testers were randomly selected for review. These tracings were originally interpreted by 11 local physician reviewers using standardized Urinary Incontinence Treatment Network interpretation guidelines. Each of the 4 central physician reviewers reviewed 9 randomly assigned tracings and none reviewed tracings from his or her center. Local and central physician reviewers were instructed to categorize values as invalid if specified technical quality assurance standards were not met or the signal pattern suggested implausible values because of technical deficiencies. An intraclass correlation coefficient was calculated for continuous (numerical) variables and a kappa statistic was calculated for qualitative values with acceptable agreement defined a priori as an intraclass correlation coefficient of greater than 0.6. RESULTS: Filling cystometrogram baseline pressure, Valsalva leak point pressure, and volume and pressure measurements at maximum cystometric capacity had excellent intraclass correlation coefficients of 0.74 to 0.99. There were no significant differences between local and central physician reviewer means, indicating excellent agreement. CONCLUSIONS: With proper quality control measures in place and a set of standardized interpretive guidelines excellent interrater reliability between local and central physician reviewer can be achieved for numerical cystometrogram variables.

Ureteral injury presenting with hyponatremia.

BACKGROUND: Ureteral injuries in gynecologic surgery, although rare, classically present with a well-described constitution of symptoms. Hyponatremia in association with ureteral injury has not been described. CASE: A 44-year-old multiparous woman presented with chronic pelvic pain and a persistent adnexal mass underwent exploratory laparotomy, lysis of adhesions, and left salpingo-oophorectomy. On postoperative day 5, she demonstrated classic signs and symptoms of ureteral obstruction. In addition, she developed hyponatremia with a serum sodium concentration of 124 mEq/L that immediately resolved after percutaneous drainage of the urinoma. CONCLUSION: Hyponatremia may develop with untreated and unrecognized ureteral injuries. Serum electrolytes may be helpful in the evaluation of suspected ureteral injury.

False-positive diagnosis of spina bifida in a fetus with triploidy.

BACKGROUND: Neural tube defects can be difficult to diagnose using ultrasound. Cranial markers, such as the lemon and banana signs, are useful sonographic findings that alert the ultrasonographer to examine the spine more carefully. The false-positive rate for the banana sign has been reported previously as zero. CASE: A patient with elevated maternal serum alpha-fetoprotein presented for a fetal ultrasound examination. Findings on the scan included a lemon sign, a banana sign, an effaced cisterna magna, and splayed lumbar vertebrae. After pregnancy termination, no spinal abnormality was detected on autopsy. X-rays of the fetal spine demonstrated narrowing in the thoracic spine. The karyotype of the fetus was 69,XXY. CONCLUSION: The sonographic cranial findings suggestive of a neural tube defect were misleading in this case.

Single-dose systemic methotrexate for the treatment of persistent ectopic pregnancy after conservative surgery.

OBJECTIVE: To determine whether a single outpatient methotrexate injection successfully treats persistent ectopic pregnancy. METHODS: Nineteen consecutive patients with increasing beta-hCG titers after conservative surgery for ectopic pregnancy were treated with a single intramuscular methotrexate (50 mg/m2) injection. RESULTS: All 19 patients had resolution of their beta-hCG titers without subsequent surgery. Beta-hCG levels commonly increased during the first 3 days after treatment, but subsequently declined. Two patients required hospital admission for observation and analgesia. One of these two patients had probable self-limited intra-abdominal bleeding and required a blood transfusion. CONCLUSION: A single methotrexate injection is a safe and successful treatment for persistent ectopic pregnancy. Delayed hemorrhage may be a rare complication, and close surveillance is necessary.

Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial.

STUDY OBJECTIVE: To compare prospectively operative laparoscopy to laparotomy in the management of hemodynamically stable patients with ectopic pregnancy (EP). DESIGN, PATIENTS, Intervention: Patients with suspected EP presenting to a university-based residency teaching program were prospectively allocated to laparoscopy (n = 26) or laparotomy (n = 37) on alternating months for operative management. RESULTS: Operative times between laparoscopy and laparotomy did not differ significantly. Laparoscopy-treated patients had a significant reduction in estimated intraoperative blood loss, postoperative hospital stay, narcotic requirement, time to normal activity, and total hospital cost. There was no statistical difference in intrauterine pregnancy rates or in EP rates. CONCLUSIONS: In a university-based residency program, operative laparoscopy is a safe alternative for the management of appropriately selected patients with suspected EP.

Ectopic pregnancy.

The diagnosis and management of ectopic pregnancy is changing rapidly. More sensitive pregnancy tests and high-resolution transvaginal sonography are making the diagnosis of ectopic pregnancy easier and earlier. In the future, we may become more confident with the ultrasound diagnosis of some ectopic pregnancies such that laparoscopic confirmation will not be required. These patients may be treated with systemic methotrexate. However, at the present time laparoscopy is essential for diagnostic confirmation of most ectopic pregnancies. It is senseless for a skilled laparoscopist to perform a diagnostic laparoscopy, remove the laparoscope, and then proceed with laparotomy or some nonsurgical treatment. There is sufficient evidence in the literature to demonstrate that laparoscopic management of ectopic pregnancies is equally safe, equally effective, and less traumatic than laparotomy. It should replace laparotomy as treatment for most ectopic pregnancies. Unfortunately, there are not enough trained laparoscopists to manage the 88,000 ectopic pregnancies per year in the United States. Operative laparoscopy deserves more emphasis in postgraduate and residency training programs.