Thirty-six-month Prospective Study of Transvaginal Bovine Graft vs Native Tissue Repair for the Treatment of Pelvic Organ Prolapse.

OBJECTIVE(S): To compare the safety and effectiveness of dermal bovine transvaginal graft, Xenform, to native tissue in the surgical treatment of anterior and/or apical pelvic organ prolapse. This study was designed in conjunction with Food and Drug Administration requirements. METHODS: This was a prospective, non-randomized, parallel cohort, multi-center trial. The primary objective was to demonstrate noninferiority between transvaginal graft and native tissue repair at 36 months compared to baseline. Treatment success was based on a composite of objective and subjective measures. The co-primary outcome was the rate of serious device- or procedure-related adverse events. A total of 228 patients at 25 sites were included in the study arm and 485 patients underwent native tissue repair. Propensity score stratification was applied to achieve balance between treatment groups. Study outcomes were compared in per protocol and intent-to-treat analysis. RESULTS: The primary outcome, treatment success at 36 months, was 83.6% (191/228) for transvaginal graft and 80.5% (390/485) native tissue repair (0.2%, 90% confidence interval [-5.6% to 5.9%]), demonstrating noninferiority at a preset margin of -12%. The overall rate of severe adverse events was 5.3% (12/228) in transvaginal graft vs 2.7% (13/485) in native tissue repair groups. The study group demonstrated noninferiority in serious adverse events at the preset margin of 11.6% (2.0%, 90% confidence interval [-0.8% to 4.7%]). There were no reports of graft erosion, and graft exposure rates were low (0.9% [2/228]). CONCLUSIONS: Transvaginal repair of anterior and/or apical prolapse with a biological graft is noninferior to traditional native tissue repair in effectiveness and safety at 36 months.

The American Urogynecologic Society Action Plan on Diversity, Equity, and Inclusion: Developed by the Diversity, Equity, and Inclusion Task Force.

ABSTRACT: The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

A Physician-Led Communication Initiative to Inform OAB Patients of Dementia Risk Associated With Anticholinergic Medications.

OBJECTIVES: Anticholinergic medications are a core treatment strategy for overactive bladder (OAB). There is evidence that exposure to anticholinergic medications is associated with an increased risk of developing dementia. We launched an initiative to inform our patients of this risk and give them an opportunity to engage in shared decision-making about their treatment. This quality improvement initiative encompassed 3 aims: (1) to evaluate the feasibility of 2 different routes to deliver the written outreach; (2) to evaluate if and how patients changed their OAB treatment; and (3) to assess satisfaction with the outreach initiative. METHODS: A query was performed via the electronic medical record for all patients who had been prescribed an anticholinergic for treatment of OAB. We sent either electronic messages or traditional mail to patients. We contacted patients by telephone to assess if they received the message, were satisfied with their respective method of communication, and decided for ongoing treatment. Health care provider satisfaction was also measured. RESULTS: Of the 231 patients sent the outreach, 32 were still taking the anticholinergic at the time they received the communication. The majority of patients, 84.38%, were satisfied with the initiative and elected to change therapy after learning about the increased risk of dementia. The physicians also uniformly reported satisfaction with the initiative. CONCLUSIONS: Overall, this outreach initiative resulted in an increase in patient counseling that led to a change in treatment for most patients. This initiative was received favorably by patients and health care providers.

Surgical Outcomes in Benign Gynecologic Surgery Patients during the COVID-19 Pandemic (SOCOVID study).

STUDY OBJECTIVE: To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. DESIGN: A multicenter prospective cohort study. SETTING: Ten institutions in the United States. PATIENTS: Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. INTERVENTIONS: Benign gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4-50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). CONCLUSION: In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.

Pelvic organ prolapse recurrence after apical prolapse repair: does obesity matter?

INTRODUCTION AND HYPOTHESIS: We hypothesized obesity increases the risk of pelvic organ prolapse recurrence (POP-R) after primary apical prolapse repair. METHODS: We conducted a retrospective cohort study of 353 women who underwent primary apical prolapse surgery from 2011 to 2016. Demographic and clinical data were abstracted from medical records. Multivariable Cox proportional hazard models were used to generate hazard ratios (HR) for association between obesity (BMI ≥ 30 kg/m2) and POP-R (leading edge > 0), adjusting for potential confounders. Given the potential for outcome ascertainment bias due to differential loss to follow-up, a sensitivity analysis was performed assuming all patients with < 6 months of follow-up developed POP-R. RESULTS: Ten percent of women developed POP-R. The median follow-up time was 7 months (range 1.4, 63.9). Twenty-four percent of patients were Black and 70% were White; 37% were obese. After controlling for confounders, obese women did not have an increased risk of POP-R (aHR 1.39; 95% CI 0.67, 2.86, p = 0.38). Although only marginally statistically significant, patients who developed POP-R were more likely to be current smokers (aHR 3.48, 95% CI 1.14, 10.67; p = 0.06) or previous smokers (aHR 1.86, 95% CI 0.82, 4.24, p = 0.06) in comparison to non-smokers. Sensitivity analysis showed loss to follow-up had the potential to influence our results. CONCLUSIONS: Obesity was not a risk factor for POP-R in our cohort. Larger, prospective studies with longer postoperative follow-up time are needed to fully elucidate the relationship between obesity and POP-R.

Biofilm Production by Uropathogens in Postmenopausal Women with Recurrent and Isolated Urinary Tract Infection.

OBJECTIVES: The aims of this study were to assess the in vitro biofilm-producing capabilities of uropathogens grown from a postmenopausal urogynecologic population with isolated and recurrent urinary tract infection (UTI) and to determine whether the biofilm-producing bacterial phenotype was associated with recurrent infection. METHODS: This was an institutional review board-approved cross-sectional analysis within a large academic referral center. Uropathogens were cultured from postmenopausal women with either isolated or recurrent acute UTI and then screened for in vitro biofilm formation using crystal violet microtiter assays. Demographic and clinical variables, including pelvic floor symptoms and surgical history were collected and analyzed. A multivariate model was developed to determine whether recurrent UTI was independently associated with biofilm production. RESULTS: Eighty-nine women were included: 67.4% White, 25.8% Black, 3.4% Asian, and 1.1% Hispanic with a mean age of 72 ± 10.5 years. Ninety-five uropathogen strains were isolated. Most uropathogens produced biofilm (n = 53, 55.8%). Uropathogens from women with recurrent UTI were significantly more likely to produce biofilm (70%) than uropathogens collected from women with isolated UTI (38.6%, P = 0.0033). Adjusting for age, prior pelvic reconstructive surgery, and body mass index, recurrent UTI bacteria were more likely to produce biofilm, compared with isolated UTI (odds ratio, 5.37; 95% confidence interval, 2.0-14.4; P = 0.001). CONCLUSIONS: In this cohort of postmenopausal urogynecology patients, in vitro biofilm formation was more frequently observed in uropathogens isolated from women with recurrent UTI compared with women with isolated UTI. Further study is needed to assess the role of biofilms in recurrent UTIs in postmenopausal women.

Racial Differences in Pelvic Organ Prolapse Symptoms Among Women Undergoing Pelvic Reconstructive Surgery for Prolapse.

OBJECTIVE: The aim of this study was to determine if there is a difference in Pelvic Floor Disability Index Questionnaire (PFDI-20) scores between black and white women seeking surgical management for pelvic organ prolapse (POP). METHODS: A retrospective cohort study of 232 women who underwent pelvic reconstructive surgery with apical suspension for POP was performed. Demographic and clinical data were collected. All women completed the PFDI-20 and had a Pelvic Organ Prolapse Quantification examination at the initial consultation. Appropriate statistical tests were used to compare black and white women. Multivariable regression models adjusting for demographic and clinical variables were developed to determine the independent relationship between race and POP symptoms. RESULTS: In our cohort, 174 (75%) were white and 58 (25%) were black. Compared with white women, black women had higher parity, body mass index, Charlson Comorbidity Index score, and anterior POP stage. White women had higher total PFDI-20 scores corresponding to higher scores on all symptom subscales. After controlling for potential confounders, white race and prior anti-incontinence surgery remained associated with higher total PFDI scores. Higher Urogenital Distress Inventory 6 scores were significantly associated with white race, prior anti-incontinence procedures, and increasing body mass index, whereas higher CRADI-8 scores were associated with prior anti-incontinence surgery and higher POP stages. CONCLUSIONS: White women appeared to have more overall symptom bother from prolapse, as well as urinary symptoms, as compared with black women, when assessed by validated questionnaire tools in a cohort of patients who underwent prolapse surgery. Further research is required to determine if racial differences in symptoms translate to differences in outcomes.

Retrospective Cohort Study on the Perioperative Risk Factors for Transient Voiding Dysfunction After Apical Prolapse Repair.

OBJECTIVES: The primary aim was to compare the incidence of transient voiding dysfunction (TVD) between vaginal uterosacral ligament suspension, sacrospinous ligament fixation, and robotic sacrocolpopexy. Secondarily, we identified risk factors for TVD and associated postoperative complications. METHODS: This was a retrospective cohort study of women who underwent apical repair at 1 institution. Data were collected from electronic medical records and were presented as means (SD) or numbers (percent) as appropriate. Univariate and multivariate analyses were performed to identify risk factors for TVD and its associated postoperative complications. RESULTS: Three hundred sixty women were included in analysis. Two hundred nineteen (60.8%) passed their voiding trial and 141 (39.2%) experienced TVD. The TVD group demonstrated a higher age, age-adjusted Charlson Comorbidity Index score, and preoperative postvoid residual (all P < 0.05). Univariate analysis demonstrated higher rates of TVD in the vaginal uterosacral ligament suspension and sacrospinous ligament fixation groups compared with the robotic sacrocolpopexy group (P = 0.012). Transient voiding dysfunction occurred more frequently with a concomitant anti-incontinence procedure, anterior repair, and/or posterior repair (all P < 0.05). In multivariate analysis, only an anti-incontinence procedure and concomitant anterior repair were independently associated with a risk of TVD (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.37-3.62, and OR, 2.20; CI, 1.14-4.27, respectively). Transient voiding dysfunction was associated with a culture-proven urinary tract infection within 6 weeks (OR, 3.2; CI, 1.3-8.55). CONCLUSIONS: There was no difference in TVD between types of apical repair. Concomitant anti-incontinence procedure and anterior repair were associated with TVD. Women with TVD have an increased risk of postoperative urinary tract infections.

Health Care-Seeking Characteristics of Women With Pelvic Floor Disorders After Obstetric Anal Sphincter Injury.

OBJECTIVES: Obstetric anal sphincter injury (OASIS) is a potentially serious complication of vaginal delivery and can lead to both short-term and long-term sequelae. This study sought to identify health care seeking patterns of women who developed pelvic floor symptoms including pelvic pain after OASIS. It also identified demographic and clinical factors associated with seeking subspecialty care from a pelvic floor specialist and demographic and clinical factors associated with seeking care for pelvic pain after OASIS. METHODS: This study is a retrospective cohort study of 69 women who developed pelvic floor disorders after OASIS. RESULTS: For women diagnosed with a pelvic floor symptom, the mean time to follow-up was 2.4 years, the mean number of visits until diagnosis was 2.2 visits, and 2.9 visits were needed for treatment. The most common diagnoses were pelvic pain, lower urinary tract symptoms including incontinence, and defecatory dysfunction. Twenty-five percent of the cohort received treatment from a pelvic floor specialist. These women were more likely to be older and have urinary incontinence. Women with pain were more likely to be seen by a primary care provider and have longer time to diagnosis. CONCLUSIONS: The study showed that multiple visits were needed to both diagnose and treat pelvic floor disorders (PFD) after OASIS. Pelvic pain was the most common primary PFD after OASIS. There should be a high level of suspicion for pelvic floor disorders, especially pain disorders, in women who have sustained a third- or fourth-degree laceration.

Delayed Presentation of Cecal Perforation With Tension-Free Vaginal Tape.

BACKGROUND: Tension-free vaginal tape (TVT) is a popular operative treatment for stress urinary incontinence (SUI). It has a low risk of adverse events, and injuries, particularly to the bowel, are rare. Case reports that have previously discussed these injuries and subsequent removal of TVT have not provided additional insight into management of SUI after these injuries occur. CASE: A postmenopausal woman with persistent SUI presented more than 1 year after TVT placement with bowel perforation incidentally discovered on routine screening colonoscopy. She underwent removal of the TVT and subsequent placement of a fascial sling with postoperative resolution of SUI. CONCLUSION: This case provides additional evidence for bowel injury as a postoperative TVT complication and describes an approach to complicated TVT and persistent SUI.

Obesity and Perioperative Complications in Pelvic Reconstructive Surgery in 2013: Analysis of the National Inpatient Sample.

OBJECTIVES: The primary aim of this study was to determine the impact of obesity on national rates of perioperative complications in women undergoing pelvic reconstructive surgery in 2013 in the United States. METHODS: Women who underwent pelvic reconstructive surgery were identified in the 2013 National Inpatient Sample using International Classification of Diseases, Ninth Revision procedure codes. Demographic data and comorbidities including obesity (body mass index ≥30 kg/m) were abstracted. Perioperative complications and mortalities that occurred during the same admission were abstracted from the data set using International Classification of Diseases, Ninth Revision diagnosis codes. The complication rates were compared between obese and nonobese subjects. Univariate analysis was performed to determine factors associated with the primary outcome. Significant factors were included in the regression model to determine the adjusted odds ratio for perioperative complications in obese women. RESULTS: A total of 16,639 women underwent pelvic reconstructive surgery in the 2013 National Inpatient Sample data set and were included in the analysis. Approximately 10% of the study cohort was obese. The overall perioperative complication rate during the surgical admission was 25%. On multivariate analysis, obesity was found to increase the odds of perioperative complications by approximately 40% after controlling for age, race, income, concomitant hysterectomy, and medical comorbidities (adjusted odds ratio, 1.40; 95% confidence interval, 1.24-1.58; P < 0.0001). CONCLUSIONS: Obesity is an independent risk factor for perioperative complications in women who undergo pelvic reconstructive surgery. This information can be used for preoperative counseling and risk stratification.

Urinary neurotrophic peptides in postmenopausal women with and without overactive bladder.

AIMS: The aim of this study was to compare the expression of urinary nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), substance P (SP), and calcitonin-gene related peptide (CGRP) in women with and without overactive bladder (OAB). We sought to determine factors associated with higher expression of these neuropeptides. METHODS: Participants with OAB and age-matched controls were enrolled. Symptom severity was assessed with validated questionnaires. Urinary neurotrophin levels, symptom scores, and clinical data were compared between the groups. Multivariate analysis determined independent factors associated with urinary neurotrophin levels. RESULTS: Sixty-seven women (38 OAB, 29 controls) were included. Women with OAB and controls were similar in age, race, body mass index, parity, and smoking status. Women with OAB were more likely to report a history of pelvic pain and pelvic surgery. Neurotrophic factor levels normalized to urinary creatinine did not differ between the groups. Increasing age was associated with greater urinary levels of BDNF and NGF (ß = 0.23, 95%CI 0.11-0.34 and 0.75, 95%CI 0.17-1.33, respectively, P < 0.02). Higher urinary NGF was associated with increasing BMI (ß = 0.81, 95%CI 0.05-1.57, P = 0.04) while pain was associated with elevated urinary SP (ß = 0.21, 95%CI 0.09-0.33, P = 0.001). CONCLUSIONS: Our data does not support a relationship between urinary neurotrophin levels and OAB in age-matched postmenopausal women. Further research is necessary to elucidate the role of urinary neurotrophins in the diagnosis and management of OAB. Neurourol. Urodynam. 36:740-744, 2017. © 2016 Wiley Periodicals, Inc.

Concomitant apical suspensory procedures in women with anterior vaginal wall prolapse in the United States in 2011.

INTRODUCTION: Although the surgical restoration of apical support has been shown to decrease reoperation rates, it is unclear whether this has been incorporated into current practice. The aims of this study were to determine the rate of concomitant apical suspensory procedures in women with anterior vaginal wall prolapse undergoing surgical repair in 2011 and to identify associated factors. METHODS: This cross-sectional study queried the Nationwide Inpatient Sample for women with a primary diagnosis of cystocele who underwent prolapse repair in 2011. The study cohort was analyzed for demographics, concomitant procedures, and hospital characteristics. The rate of apical suspensory procedures was determined. Factors potentially associated with receiving concomitant apical suspensory procedure were evaluated using univariate analysis and multivariate logistic regression. RESULTS: A total of 2,900 women in the database had a primary diagnosis of cystocele and underwent surgical prolapse repair in 2011. 925 (31.9 %) subjects underwent a concomitant apical suspensory procedure. The mean age in the study cohort was 61.9 ± 12.8 years. Hysterectomies were performed in 11.1 % of subjects. 61.1 % were performed vaginally, 26.5 % laparoscopically, and 12.5 % abdominally. On multivariate analysis, age greater than 50 years, Caucasian race, concomitant hysterectomy, and an urban teaching hospital setting were independently associated with receiving concomitant apical suspensory procedure in 2011. CONCLUSIONS: Despite evidence that the restoration of apical support is important for optimal anterior support, the overall rate of concomitant apical suspensory procedures is low. Several factors may play a role in whether or not women receive an apical suspensory procedure. This study highlights opportunities to improve the quality of surgical care provided to women with anterior vaginal prolapse.

The IUGA/ICS classification of synthetic mesh complications in female pelvic floor reconstructive surgery: a multicenter study.

INTRODUCTION AND HYPOTHESIS: The objective was to report patterns of sling and transvaginal mesh-related complications using the IUGA/ICS classification of prosthesis-related complications. METHODS: This was a retrospective chart review of all patients who underwent surgical removal of sling, transvaginal mesh, and sacrocolpopexy for mesh-related complications from 2011 to 2013 at three tertiary referral centers. The International Urogynecological Association (IUGA)/International Continence Society (ICS) classification system was utilized. RESULTS: We identified 445 patients with mesh complications, 506 pieces of synthetic mesh were removed, and 587 prostheses-related complications were classified. 3.7 % of patients had viscus organ penetration or vaginal exposure as their presenting chief complaint and 59.7 % were classified as not having any vaginal epithelial separation or category 1. The most common category was spontaneous pain (1Be: 32.5 %) followed by dyspareunia (1Bc: 14.7 %). The sling group was 20 % more likely to have pain compared with the pelvic organ prolapse (POP) mesh group (OR 1.2, 95 % CI 0.8-1.6). The most commonly affected site (S2) was away from the suture line (49 %). Compared with the sling group, the POP group had a higher rate of mesh exposure, which mostly occurred at the suture line area. The majority of patients presented with mesh-related complications more than 1 year post-insertion (T4; average 3.68 ± 2.47 years). CONCLUSION: Surgeons should be aware that patients with vaginal mesh complications routinely exhibit complications more than 1 year after the implantation with pain as the most common presenting symptom.

Apical Suspension at the Time of Hysterectomy for Uterovaginal Prolapse: A Comparative Analysis of 2001 and 2011.

OBJECTIVES: The primary aim of this study was to compare the proportion of concomitant apical procedures in women undergoing hysterectomy for uterovaginal prolapse in 2001 and 2011. The secondary aim was to identify factors associated with receiving concomitant apical procedures in 2001 and 2011. METHODS: The Nationwide Inpatient Sample database was queried for women with a primary diagnosis of uterovaginal prolapse who underwent hysterectomy in 2001 and 2011. The study cohort was analyzed for demographics, clinical factors, and concomitant procedures. Factors potentially associated with receiving concomitant apical procedure were evaluated using univariable analysis and multivariate logistic regression. RESULTS: A total of 14,647 women were identified (5867 in 2001 and 8780 in 2011). In 2001, 26.9% women received a concomitant apical procedure, and this proportion increased to 48.2% in 2011 (odds ratio, 2.53; 95% confidence interval, 2.36-2.72; P < 0.0001). In 2001, the mean (SD) age was 53.8 (14.1) years compared with 56.8 (13.3) years in 2011. Although vaginal hysterectomy was most common in both years, a concomitant apical procedure was more likely to be performed with abdominal hysterectomy (P < 0.001). On multivariate analysis, age older than 50 years (P = 0.0001), abdominal route of hysterectomy (P < 0.0001), and undergoing hysterectomy at an academic teaching hospital (P < 0.0001) were independently associated with concomitant apical procedures in both 2001 and 2011. CONCLUSIONS: Although the proportion of concomitant apical repair was higher in 2011 compared with 2001, it is still low given the existing data demonstrating the importance of a concomitant apical procedure at the time of hysterectomy for uterovaginal prolapse.

Short-term postoperative functional outcomes in older women undergoing prolapse surgery.

OBJECTIVE: To evaluate whether preoperative markers of functional status predict postoperative functional outcomes in older women undergoing surgery for pelvic organ prolapse (POP). METHODS: Prospective cohort study of women aged 60 years or older who underwent surgery for prolapse. Preoperative functional status was measured using number of functional limitations (such as difficulty walking or climbing), American Society of Anesthesiologists class, anemia, and history of recent weight loss. Our primary outcome was the number of postoperative functional limitations and secondary outcomes were failure to return to baseline functional status and length of stay after surgery. We determined the association of preoperative functional status markers with postoperative outcomes using univariable and multivariable regression. RESULTS: In 127 women, presence of a preoperative functional limitation was a significant predictor of a 0.55 (95% confidence interval [CI] 0.36-0.74) increase in the number of postoperative functional limitations after controlling for age, number of preoperative functional limitations, comorbidities, depression, surgeon, type of procedure, and complications (P<.001). History of recent weight loss and anemia increased risk for failure to return to baseline functional status after controlling for surgeon, type of surgery, and complications (relative risk 2.44, 95% CI 1.26-4.71 and relative risk 2.72, 95% CI 1.29-5.75), respectively). Preoperative markers associated with longer length of stay after surgery were American Society of Anesthesiologists class III (0.83 days, 95% CI 0.20-1.46) and history of weight loss (0.84 days, 95% CI 0.13-1.54). CONCLUSION: Preoperative markers of functional status are useful in predicting short-term postoperative functional outcomes in older women undergoing surgery for POP. LEVEL OF EVIDENCE: : II.

Bowel and bladder dysfunction following surgery within the presacral space: an overview of neuroanatomy, function, and dysfunction.

INTRODUCTION AND HYPOTHESIS: The presacral space contains a dense and complex network of nerves that have significant effects on the innervation of the pelvic viscera and support structures. The proximity of this space to the bony promontory of the sacrum has lead to its involvement in an array of corrective surgical procedures for pelvic floor disorders including sacrocolpopexy and rectopexy. Other procedures involving the same space include presacral neurectomy which involves intentional transection of the contained neural plexus to relieve refractory pelvic pain and resection of retrorectal or presacral tumors. Potential complications of these procedures are postoperative constipation and voiding dysfunction. METHODS: Our aim was to review the current published literature on outcomes following a variety of procedures involving the presacral space and review postoperative bowel and urinary function. We also include an overview of the functional and structural anatomy of the presacral space and its corresponding neural plexi. RESULTS/CONCLUSIONS: We conclude that quality data are lacking on the short-term and long-term rates for bowel and bladder dysfunction following surgical procedures involving the presacral space.

Outcomes of robotic sacrocolpopexy: a systematic review and meta-analysis.

OBJECTIVES: Robotic sacrocolpopexy has been rapidly incorporated into surgical practice without comprehensive and systematically published outcome data. The aim of this study was to systematically review the currently published peer-reviewed literature on robotic-assisted laparoscopic sacrocolpopexy with more than 6 months of anatomic outcome data. METHODS: Studies were selected after applying predetermined inclusion and exclusion criteria to a MEDLINE search. Two independent reviewers blinded to each other's results abstracted demographic data, perioperative information, and postoperative outcomes. The primary outcome assessed was anatomic success rate defined as less than or equal to pelvic organ prolapse quantification system (POP-Q) stage 1. A random effects model was performed for the meta-analysis of selected outcomes. RESULTS: Thirteen studies were selected for the systematic review. Meta-analysis yielded a combined estimated success rate of 98.6% (95% confidence interval, 97.0%-100%). The combined estimated rate of mesh exposure/erosion was 4.1% (95% confidence interval, 1.4%-6.9%), and the rate of reoperation for mesh revision was 1.7%. The rates of reoperation for recurrent apical and nonapical prolapse were 0.8% and 2.5%, respectively. The most common surgical complication (excluding mesh erosion) was cystotomy (2.8%), followed by wound infection (2.4%). CONCLUSIONS: The outcomes of this analysis indicate that robotic sacrocolpopexy is an effective surgical treatment of apical prolapse with high anatomic cure rate and low rate of complications.