Return to Baseline Functional Status in Older Women Undergoing Surgery for Pelvic Organ Prolapse.

OBJECTIVE: The aim of the study was to determine the rate of return to baseline functional status 3 months after surgery for pelvic organ prolapse (POP) in women 65 years or older. METHODS: This is a multicenter prospective cohort study of women older than 65 years undergoing POP surgery. Functional status was determined by the Activities Assessment Scale at the preoperative visit and 3 months after surgery. We compared a variety of clinical variables and preoperative functional status scores for women who worsened, improved, or returned to baseline functional status after surgery using univariable and multivariable analysis. RESULTS: A total of 192 women were enrolled in the study. Of 176 women who completed both sets of questionnaires, 59% improved, 35% returned, and 6% worsened from their baseline functional status. Variables significantly associated with postoperative functional status score were depression (P < 0.002) and preoperative functional status score (P < 0.001). The group that improved from baseline had the lowest (worst) preoperative functional status score (78.7 ± 16.4), whereas the group that worsened after surgery had the highest (best) preoperative functional status score (98.6 ± 2.2). After adjusting for age and depression, higher preoperative functional status score was predictive of failure to return to baseline functional status. CONCLUSIONS: Most older women undergoing surgery for POP, including those with low preoperative functional status, return to or improve from their baseline functional status within 3 months of surgery. Women with higher functional status before surgery are less likely to report improvement in physical functioning after surgery.

Patient Preferences and Knowledge Regarding Hysterectomy: A Study from the Fellows' Pelvic Research Network (FPRN)®.

OBJECTIVE: The purpose of this study was to describe preference for and knowledge of hysterectomy routes in women presenting to urogynecology/gynecology clinics throughout the United States and to determine association with health literacy. Our primary aim was preference for hysterectomy route, and secondary aims were knowledge of basic pelvic structures and function, knowledge of various hysterectomy routes, and baseline health literacy level. METHODS: This multicenter, cross-sectional study was conducted through the Fellows' Pelvic Research Network. Patients' preference and knowledge for hysterectomy routes were assessed at initial presentation to the urogynecology/gynecology clinic with an anonymous, voluntary, self-administered questionnaire along with a validated health literacy test (Medical Term Recognition Test). RESULTS: Two hundred four women participated. Forty-five percent of patients were unsure which hysterectomy modality they would choose. Of patients who selected a preferred modality, 50% selected laparoscopic and 33% selected vaginal. Patients indicated that safety was considered highest priority when selecting route. The mean score for "knowledge about gynecology/hysterectomy" was 68%, with the high literacy group scoring higher compared with the low health literacy group (70% vs 60.1%, P = 0.01). More than 50% of patients incorrectly answered knowledge questions related to vaginal hysterectomy. Majority of the respondents had high health literacy (79.4%). CONCLUSIONS: Patients prefer laparoscopic hysterectomy approach, although have limited understanding of vaginal hysterectomy. Higher health literacy levels are associated with increased knowledge of gynecology and hysterectomy routes, but were not found to influence patient preference for hysterectomy route. Overall, patients have limited knowledge of vaginal hysterectomy.

Comparing Force of Stream With a Standard Fill Voiding Trial After Surgical Repair of Apical Prolapse: A Randomized Controlled Trial.

OBJECTIVE: To estimate whether the urinary force of stream method is noninferior to a standard fill voiding trial for rate of catheterization within 6 weeks after apical prolapse surgery in those discharged without a catheter. METHODS: A noninferiority randomized controlled trial was conducted in postoperative women comparing force of stream with standard fill voiding trials after vaginal, abdominal, or laparoscopic-robotic apical pelvic organ prolapse (POP) surgery. Before discharge, women in both groups were backfilled with 300 mL normal saline. Successful voiding criteria in the force of stream group was subjective force of stream of at least 50 using a visual analog scale; reporting less than 50 prompted a bladder scan. Successful voiding was defined as a postvoid residual volume of less than 500 mL. For the standard fill voiding trial group, voiding two thirds of the instilled amount indicated success. The primary outcome was the rate of catheterization within the 6-week postoperative period after surgical repair of apical prolapse among those discharged without a urinary catheter. Secondary endpoints included trial of void failure rates. A sample size of 59 patients per group who passed trial of void at discharge was needed to achieve 80% power using a noninferiority margin (delta of 10%). Total enrollment of 169 patients was necessary to account for an estimated 30% trial of void failure rate. RESULTS: From April 2016 and April 2017, 184 patients were enrolled (six enrolled before the trial registration date), with the first patient enrolled on April 1, 2016. One hundred seventy-four patients were randomized (86 in the force of stream group and 88 in the standard fill voiding trial group). No differences were observed in demographic or perioperative characteristics, except for stage 2 apical prolapse (52% in the force of stream group vs 36% in the standard fill voiding trial group). For the primary outcome, similar rates were found in those patients who passed their trial of void but subsequently needed catheterization for voiding dysfunction (force of stream 2.8% [2/71] vs standard fill voiding trial 3.1% [2/64]; difference -0.3%, 95% CI -8.69% to 8.08%). The incidence of trial of void failures at discharge was similar (force of stream 17.4% [15/86] vs standard fill voiding trial 26.4% [23/87]; risk ratio 0.65, 95% CI 0.37-1.18, P=nonsignificant). CONCLUSION: Force of stream was noninferior to standard fill voiding trial when comparing the rate of catheter insertion during the 6-week postoperative period after apical POP surgery in those discharged without a catheter. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02753920.

Patients' Knowledge of and Attitude Toward Robotic Surgery for Pelvic Organ Prolapse.

OBJECTIVES: Robotic sacrocolpopexy for pelvic organ prolapse (POP) has increased, along with marketing and media coverage. It is unknown whether this exposure influences patients' opinions on POP repair. This study describes the preference for and knowledge of robotic surgery in women with POP. METHODS: We performed a cross-sectional survey of new patients presenting with POP at 7 academic sites. Subjects had no prior surgical counseling. A self-administered questionnaire was designed to investigate robotic surgery knowledge, preference, and exposure. Subjects expressed their preferred route of POP repair (robotic, vaginal, abdominal, laparoscopic, or no preference). Knowledge was determined by the number of correctly answered questions (range, 0-7). Perception of robotic surgery was compared with other surgical routes. RESULTS: One hundred seventy-six subjects were included. Most had no surgical preference (66.3%), whereas 27.3% preferred nonrobotic and 6.4% preferred robotic routes. The mean knowledge score was 2.3 (SD, 1.7). Women preferring robotic surgery were more likely to view it as faster than laparoscopic surgery (P < 0.001). These same subjects did not perceive any advantages for robotic surgery related to blood loss, pain, and organ injury (P > 0.05). Most reported no prior exposure to robotic surgery information (56.2%) or advertisements (65.2%). Those with prior exposure most frequently obtained information via the Internet and encountered hospital advertisements. CONCLUSIONS: The majority of women with POP reported no preference for robotic approach to POP surgery. Knowledge about robotic surgery was low, even among subjects who expressed preference. Comprehensive counseling may help patients make informed decisions even when surgical preferences exist.

A randomized controlled trial comparing two voiding trials after midurethral sling with or without colporrhaphy.

INTRODUCTION AND HYPOTHESIS: To compare the force of the stream (FOS) voiding trial with the standard voiding trial (SVT) after outpatient midurethral sling (MUS) whether or not colporrhaphy was performed. METHODS: This is a randomized controlled non-inferiority trial of patients scheduled for MUS or colporrhaphy. Sample size of 102 patients was calculated for 80% power. Patients were randomized to FOS or SVT. Primary outcome was the number of unexpected postoperative visits (UPOVs) for voiding dysfunction (VD) or urinary tract infection (UTI). Voiding dysfunction was defined as urinary retention or post-void residual (PVR) > 200 cc. Subjects rated FOS using a visual analog scale (VAS). Criterion for non-inferiority was an upper limit of < 10% for the 95% CI. Analyses were performed using SAS version 9.4 (SAS Institute. Cary, NC). RESULTS: One hundred two subjects were included (49 FOS, 53 SVT). Immediate postoperative catheterization for FOS and SVT was 8.2% (n = 4) and 9.4% (n = 5), respectively. Recovery time was significantly less for FOS versus SVT (p = 0.0002). Total UPOVs were five (10.2%) and two (3.8%) for FOS and SVT, respectively. Two FOS subjects who had MUS + colporrhaphy passed their VT and had subsequent UPOVs for VD. No evidence of non-inferiority was noted when comparing FOS to SVT for total UPOVs: CI: 6.0% (-5.2, 17.2) for postoperative VD [CI: 6.1% (-4.0, 16.2)] or UTIs [CI: 0.3% (-9.4, 10.1)]. CONCLUSIONS: No evidence of non-inferiority was noted comparing FOS with SVT for unexpected postoperative visits for voiding dysfunction or UTI. This study shows the need for larger studies to assess the use of the FOS method in patients undergoing surgery for prolapse with or without MUS.

Putting POP-Q to the test: does C - D = cervical length?

INTRODUCTION AND HYPOTHESIS: We investigated the correlation between calculated cervical length (CCL) and gross specimen cervical length (GCL) after total vaginal hysterectomy (TVH) at the time of surgery for pelvic organ prolapse (POP). METHODS: This was a retrospective chart review of patients who had undergone TVH with reconstructive surgery for POP between 2013 and 2015. Patients without an intact specimen or documented cervical length in the pathology report were excluded. CCL was defined as the absolute difference between Pelvic Organ Prolapse Quantification (POP-Q) points C and D. GCL was obtained from the pathology report as the distance from the external to the internal os. The Bland-Altman method was used to assess the accuracy of POP-Q measurements with a priori ranges. Symptom severity was evaluated using the PFDI-20 questionnaire. Analysis of variance was used to model both GCL and CCL as a function of prolapse stage and the leading compartment. RESULTS: The final analysis included 202 subjects. Of the CCL measurements, 56.93% were within ±2 cm of GCL, while 36.14% were within ±1 cm. POP stage was significantly associated with GCL (P < 0.0024). CCL was significantly longer in patients with stage 4 POP (3.57 cm, 95% CI 3.13-4.00) than in those with stage 2 POP (P < 0.0017; mean 2.68 cm, 95% CI 2.45-2.92) and stage 3 POP (P < 0.0300; mean 2.94 cm, 95% CI 2.73-3.15). There were no significant correlations between PFDI scores and CCL or GCL. CONCLUSIONS: The agreement between POP-Q CCL (|C - D|) and GCL decreases with increasing POP-Q stage. There was no correlation between POP symptom severity and GCL or CCL. GCL significantly increased with increasing POP stage.

Comparison of strength of sacrocolpopexy mesh attachment using barbed and nonbarbed sutures.

INTRODUCTION AND HYPOTHESIS: We aimed to assess the pull-out strength of barbed and nonbarbed sutures used in sacrocolpopexy mesh fixation. We hypothesized there are no differences in the force needed to dislodge mesh from tissue using barbed and nonbarbed sutures of similar size. METHODS: Using the rectus fascia of three unembalmed cadavers, a 6 × 3 cm strip of polypropylene mesh was anchored to the fascia with sutures. The barbed sutures investigated were 2-0 V-Loc 180 (nine trials) and 3-0 bidirectional Quill™ SRS PDO (five trials). The nonbarbed sutures included 2-0 PDS (nine trials), CV-2 GORE-TEX (nine trials) and 2-0 Prolene (nine trials). The free-end of the mesh was anchored to a pulley system fixed to a tensiometer to measure the peak force applied at the moment of mesh dislodgement (termed the pull-out force). The pull-out force was recorded. Continuous variables are presented as medians and interquartile ranges (IQR). Analysis of variance was used to compare the forces across the suture types. RESULTS: The highest pull-out force observed was with GORE-TEX (median 65.14 N, IQR 53.37-68.77 N) followed by Prolene (median 58.98 N, IQR 54.64-62.59 N), V-Loc (median 55.23 N, IQR 51.60-58.57 N), PDS (53.96 N, IQR 51.60-57.88 N), and Quill (44.44 N, IQR 17.27-47.38 N). All 2-0 and CV-2 caliber sutures had greater pull-out forces than 3-0 Quill sutures (p < 0.01). No significant differences in pull-out forces were observed between 2-0 and CV-2 caliber sutures (p > 0.05). In 35 of the 41 trials (85%), the mesh sheared from the tissue. CONCLUSION: CV-2 ad 2-0 barbed and nonbarbed sutures had similar pull-out forces in an assessment of mesh fixation strength.

Inflammatory Urinary Cytokine Expression and Quality of Life in Patients With Overactive Bladder.

OBJECTIVE: The aims of this study were to analyze levels of selected inflammatory urinary cytokines/chemokines in subjects with overactive bladder (OAB) and to determine if cytokine/chemokine levels correlate with quality of life and symptom distress. METHODS: This prospective, case-control pilot analysis included 23 women with OAB and 22 control subjects. Overactive bladder subjects were enrolled if they had symptoms of urinary frequency, urgency, or urge incontinence for more than 3 months and urodynamic evidence of detrusor overactivity. Control subjects denied urinary symptoms. Subjects and control subjects were excluded if they had known inflammatory bladder or systemic conditions, cystitis, stones, or recent anticholinergic use. Urine samples were collected from each subject and control. Subjects filled out the Incontinence Quality of Life Questionnaire and the Urinary Distress Inventory Questionnaire 6. Cytokine/chemokine levels were determined using the multiplexed Meso Scale Discovery Platform and were corrected for urinary creatinine concentrations. Statistical analysis comparing cytokine/chemokine levels was performed using the Mann-Whitney U test; relationships between cytokine/chemokine and questionnaire scores were calculated with Spearman correlation coefficient. RESULTS: Subjects with OAB had significantly lower urinary interleukin 10 (IL-10), IL-12-p70, and IL-13 levels compared with control subjects. Interleukin 1 correlated with worsening symptom distress on Urinary Distress Inventory Questionnaire 6. CONCLUSIONS: To our knowledge, this is at present the only study correlating inflammatory cytokine/chemokine levels in women with OAB with quality of life and distress. Interleukin 1 signified worsening distress, whereas IL-10, IL-12p70, and IL-13 were the only cytokines found at different levels in subjects. Our findings support a larger study in order to evaluate the value of urinary cytokines/chemokines as potential biomarkers.

To Morcellate or Not to Morcellate: A Cross-Sectional Survey Of Gynecologic Surgeons.

BACKGROUND AND OBJECTIVES: The inadvertent dissemination of uterine cancer cells with the power morcellator has received much attention in the press and a warning from the U.S. Food and Drug Administration. Many hospitals prohibit the use of the morcellator in gynecologic surgery. We conducted a survey in an attempt to assess gynecologic surgeons' beliefs regarding the intracorporeal power morcellation of fibroids in light of the risk of dissemination of malignancy in patients in whom the presence of cancer is unknown before surgery. METHODS: We conducted an Internet-based survey of 3505 members of the Society of Laparoendoscopic Surgeons (SLS) to assess demographics, current use of the intracorporeal power morcellator, and whether the recent negative press has affected gynecologic surgeons' use of the morcellator. RESULTS: Of the 3505 SLS members surveyed, 518 responded (response rate, 14.77%). Three hundred thirteen (61%) of the respondents were not using the intracorporeal power morcellator. Of those, 48% reported the reason was a hospital-wide ban, and an additional 17% reported lack of availability (not in stock). Senior attendings with >20 years of experience used the morcellator more often than junior attendings and fellows (P = .007). Furthermore, the morcellator was used significantly less among those with the belief that morcellation of occult malignancy affects survival (P = .013). Three hundred sixty-one (76%) of the participants currently perform laparotomy in fewer than a quarter of their cases; most those cases are still performed using laparoscopic and robot-assisted techniques. CONCLUSION: The recent negative press suggesting that intracorporeal power morcellation can disseminate occult malignancy and affect survival has decreased the use of the morcellator. Despite the declining use of power morcellation, most practicing gynecologic surgeons have not converted their procedures to laparotomy.