Performance of Perioperative Tasks for Women Undergoing Anti-incontinence Surgery: Developed by the AUGS Quality Improvement and Outcomes Research Network.

OBJECTIVES: Surgery for the correction of stress urinary incontinence is an elective procedure that can have a dramatic and positive impact on quality of life. Anti-incontinence procedures, like inguinal hernia repairs or cholecystectomies, can be classified as high-volume/low-morbidity procedures. The performance of a standard set of perioperative tasks has been suggested as one way to optimize quality of care in elective high-volume/low-morbidity procedures. Our primary objective was to evaluate the performance of 5 perioperative tasks-(1) offering nonsurgical treatment, (2) performance of a standard preoperative prolapse examination, (3) cough stress test, (4) postvoid residual test, and (5) intraoperative cystoscopy for women undergoing surgery for stress urinary incontinence-compared among surgeons with and without board certification in female pelvic medicine and reconstructive surgery (FPMRS). STUDY DESIGN: This study was a retrospective chart review of anti-incontinence surgical procedures performed between 2011 and 2013 at 9 health systems. Cases were reviewed for surgical volume, adverse outcomes, and the performance of 5 perioperative tasks and compared between surgeons with and without FPMRS certification. RESULTS: Non-FPMRS surgeons performed fewer anti-incontinence procedures than FPMRS-certified surgeons. Female pelvic medicine and reconstructive surgery surgeons were more likely to perform all 5 perioperative tasks compared with non-FPMRS surgeons. After propensity matching, FPMRS surgeons had fewer patients readmitted within 30 days of surgery compared with non-FPMRS surgeons. CONCLUSIONS: Female pelvic medicine and reconstructive surgery surgeons performed higher volumes of anti-incontinence procedures, were more likely to document the performance of the 5 perioperative tasks, and were less likely to have their patients readmitted within 30 days.

Retrospective claims analysis of physical therapy utilization among women with stress or mixed urinary incontinence.

OBJECTIVE: To describe the characteristics of women with stress or mixed urinary incontinence (SUI/MUI) receiving physical therapy (PT) services, including referral patterns and PT utilization. METHODS: Female patients with claims associated with an SUI or MUI diagnosis (International Classification of Disease-Clinical Modification [ICD-9-CM]: 625.6, 788.33, or ICD-10-CM: N39.3, N39.46) between July 01, 2014 and June 30, 2016 were identified in International business machines (IBM)'s MarketScan Research Database. Inclusion criteria included the absence of pregnancy claims and ≥80% medical and pharmacy enrollment pre- and postindex. First SUI/MUI diagnosis claim determined index. Patients were followed for 2 years, and associated UI-associated PT encounters were identified. Descriptive statistics were calculated for patients with at least one PT visit during the postindex period. RESULTS: In a cohort of 103,813 women with incident SUI or MUI diagnosis, 2.6% (2792/103,813) had at least one PT visit in the 2 years following their diagnosis. Mean age at index PT encounter was 50.55 years. A total of 52.36% (1462/2792) women had one to four PT visits; 21.2% (592/2792) had >8 PT visits. In subanalysis of the PT cohort (1345/2792), women who received PT only had the lowest average 2-year postindex total medical cost (mean: $12,671; SD: $16,346), compared with PT plus medications (mean: $27,394; SD: $64,481), and PT plus surgery (mean: $33,656; SD: $26,245), respectively. Over 40% had their first PT visit ≥3 months after their index date. CONCLUSIONS: The percentage of women with a PT visit associated with an incident SUI or MUI diagnosis was low (2.6%), and 30% of this group completed three or more PT visits. This suggests poor adherence to clinical guidelines regarding supervised treatment of UI in women. IMPACT STATEMENT: Our study suggests underutilization of PT among insured women with SUI and MUI in the 2 years following diagnosis. Interventions to improve this gap in first-line care may represent an opportunity for an increased role for PTs in the care of women with UI.

Is a Postvoid Residual Necessary? A Randomized Trial of Two Postoperative Voiding Protocols.

OBJECTIVES: This study aimed to compare a backfill-assisted voiding trial (VT) with and without a postvoid residual (PVR) after pelvic reconstructive surgery. METHODS: This was a nonblinded randomized controlled trial of women undergoing pelvic organ prolapse and/or stress incontinence surgery. Participants were randomized immediately after surgery to either a PVR VT or a PVR-free VT. Our primary outcome was the rate of VT failure at discharge. Secondary outcomes included days of catheterization, urinary tract infection (UTI), and prolonged voiding dysfunction. With a power of 80% and an α of 0.05, we needed 126 participants to detect a 25% difference in VT failure (60% in PVR VT vs 35% in PVR-free VT). RESULTS: Participants were enrolled from March 2017 to October 2017. Of the 150 participants, mean age was 59 years, and 33% underwent vaginal hysterectomy, 48% underwent anterior repair, and 75% underwent midurethral sling. Seventy-five (50%) were randomized to PVR VT and 75 (50%) to PVR-free VT, with no differences in baseline demographic or intraoperative characteristics between the 2 groups. Our primary outcome, VT failure, was not significantly different (53% PVR VT vs 53% PVR-free VT, P = 1.0). There were no significant differences in days of postoperative catheterization (1 [0, 4] in PVR VT vs 1 [0, 4] in PVR-free VT, P = 0.90), UTI (20% PVR VT vs 20% PVR-free VT, P = 1.0), or postoperative voiding dysfunction (4% PVR VT vs 5% PVR-free VT, P = 1.0). CONCLUSIONS: When performing a backfill-assisted VT, checking a PVR does not affect VT failure, postoperative duration of catheterization, UTI, or voiding dysfunction.

Association of Anticholinergic Risk Score With Functional Status in Patients Preparing for Pelvic Reconstructive Surgery.

OBJECTIVES: Anticholinergic medication use has been associated with cognitive impairment and other functional limitations, particularly in older patients. The anticholinergic risk score (ARS) can be used to measure a patient's cumulative exposure to medications with anticholinergic properties. Our primary objective was to evaluate the correlation between ARS and functional status, as measured by instrumental activities of daily living (IADL), in patients preparing to undergo urogynecologic surgery. The secondary objective was to examine the correlation between ARS and physical function in this same cohort. METHODS: This was a planned cross-sectional analysis of a prospective cohort study to evaluate the impact of urogynecologic surgery on functional status. The ARS was calculated by summing the ARSs of each patient's medications and classified as high (ARS > 5) or low (ARS ≤ 5). A patient's ability to live independently was determined using the IADL questionnaire. The patient's physical function status was determined using the functional comorbidity index. RESULTS: One hundred twenty-two patients were evaluated. A total of 89.3% of subjects had a low and 10.7% had a high ARS score. For our primary outcome, high ARS was associated with low IADL in logistic regression controlling for age and formal education level (odds ratio, 8.0; 95% confidence interval, 1.4-46.9). For our secondary outcome, ARS was not associated with the functional comorbidity index (P = 0.24). CONCLUSIONS: These data support recognition of ARS as a potential risk factor for low functional status in patients planning urogynecologic surgery.

American Urogynecologic Society Prolapse Consensus Conference Summary Report.

OBJECTIVES: The 2016 American Urogynecologic Society Prolapse Consensus Conference brought together thought leaders in the field of pelvic organ prolapse (POP). The goal was to identify critical areas of need for future research. This article summarizes the findings. METHODS: Prior to the conference, 5 major focus areas were identified. Focus areas were explored over the 2-day conference. Clinicians, clinical and basic science researchers, and representatives from government agencies, industry, patient advocacy groups, and the public convened to identify the major gaps in knowledge in each of these focus areas. RESULTS: The 5 major topics were as follows: (1) mechanistic research on pelvic supportive structures and how these are altered with pregnancy, delivery, and aging; (2) novel prostheses or implants that address pathophysiology and provide mechanical support; (3) large-scale community-based research; (4) clinical trials to optimize outcomes after POP surgery; and (5) evidence-based quality measures for POP outcomes. Key recommendations were made for each topic. CONCLUSIONS: Critical gaps in our knowledge were identified. These limit scientific discovery across all 5 topic areas. Further scientific progress would be advanced by (1) developing a standardized group of POP outcomes and quality measures for large trials and community-based research, (2) creating specimen biorepositories that are integrated with robust clinical data, and (3) developing collaborative teams with expertise from a variety of disciplines, convened to tackle our most challenging and complex scientific questions.

Hormone Modulation of Toll-Like Receptor 5 in Cultured Human Bladder Epithelial Cells.

AIM: The effect of hormone levels on the stimulation of Toll-like receptor 5 (TLR5) in the bladder is unknown. We aimed to study the effect of estradiol and progesterone on TLR5 expression and function in human bladder epithelial cells. METHODS: After growing to near confluence, T24 human urinary bladder (HUB) cells were incubated in hormone-free (HF) media for 72 hours. Human urinary bladder cells were then incubated in (1) HF media, (2) estradiol media, (3) progesterone media, or (4) media containing estradiol and progesterone at physiologic concentrations. Following flagellin exposure, cells and media were collected. Toll-like receptor 5 expression and stimulated cytokine release were analyzed using enzyme-linked immunosorbent assays. Results were normalized with cellular protein assays. A TLR5 antagonist was used to confirm that stimulation from flagellin was mediated by TLR5 signaling. RESULTS: Cultured HUB cells express TLR5 protein. Estradiol and progesterone environments suppress TLR5 expression compared to HF environment. The function of TLR5 was measured by interleukin 6 (IL-6) and monocyte chemoattractant protein 1 production after flagellin exposure. Interleukin 6 production was 75% higher in the estradiol than progesterone environment. The progesterone environment produced IL-6 levels twice that observed in HF and combined estrogen-progesterone environments. Interestingly, higher TLR5 expression was associated with lower IL-6 production. CONCLUSION: Our study demonstrated that TLR5 expression and functional activity as measured by IL-6 are modulated by hormones. The increase in TLR5-associated IL-6 may play a role in increasing the rate of symptomatic urinary tract infection. Likewise, low TLR5 functional activity may dampen the response of the innate immune system, thereby lessening the likelihood of a symptomatic bladder infection.

Differences in Patterns of Preoperative Assessment Between High, Intermediate, and Low Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.

OBJECTIVE: The aim of the study was to determine whether surgeon case volume is associated with preoperative evaluation of pelvic organ prolapse before a hysterectomy for uterovaginal prolapse including a complete objective evaluation of prolapse (Baden-Walker or Pelvic Organ Prolapse Quantification), an offer of nonsurgical options for therapy (pessary), and a preoperative assessment of urinary incontinence METHODS: We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008 and December 31, 2011. The number of hysterectomies per surgeon for 4 years was evaluated to establish low-volume (≤10 cases), intermediate-volume (11-49 cases), and high-volume (≥50 cases) groups. Rates of preoperative standardized prolapse evaluations, offer of pessary, and evaluation of stress urinary incontinence were determined by chart review of 15% of the hysterectomy cases. Adjustment was made in a logistic regression model for age, race, insurance status, and prolapse size. RESULTS: Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Rates of preoperative assessment by standardized pelvic examination differed between high-, intermediate-, and low-volume surgeons (91.2% vs. 61.3% vs. 48.8%, respectively), as did offer of a pessary (86.5% vs. 71.9% vs. 69.9%, respectively) and preoperative stress test for urinary incontinence (93.5% vs. 72.8% vs. 63.5%, respectively). Regression analysis revealed that high-volume surgeons were more likely than intermediate- or low-volume surgeons to perform a standardized pelvic examination, offer a pessary, or perform preoperative evaluation for urinary incontinence. CONCLUSIONS: High-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and evaluate stress urinary incontinence.

Analysis of High-, Intermediate-, and Low-Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.

OBJECTIVES: To determine if surgeon volume is associated with differences in the use of apical colpopexy and cystoscopy and in the rate of intraoperative complications during hysterectomy for prolapse. METHODS: We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008, and December 31, 2011. Low (≤10 cases)-, intermediate (11-49 cases)-, and high (≥50 cases)-volume surgeon groups for the 4-year period were established a priori. Rates of concomitant colpopexy, cystoscopy, and intraoperative complications were determined by chart review for 15% of the cases. Multivariate logistic regression models adjusted for site and other clinical and patient variables were used to estimate associations between surgeon case volume and the use of apical colpopexy and cystoscopy and the rate of intraoperative complications. RESULTS: Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Six hundred thirty-eight patients were selected for chart review. The rates among high-, intermediate-, and low-volume surgeons for performing colpopexy were 85.2% versus 77.8% versus 61.1% (P < 0.001) and for cystoscopy were 96.8% versus 78.3% versus 74.7% (P < 0.001), respectively. Rates of intraoperative complications among the 3 groups were 4.4%, 11.6%, and 6.3% (P = 0.011), respectively. With adjustment, high-volume surgeons were more likely to do a colpopexy than low-volume surgeons (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.1); however, the likelihood of colpopexy did not differ between high- and intermediate-volume surgeons (OR, 1.9; 95% CI, 0.84-4.3) or between intermediate- and low-volume surgeons (OR, 0.99; 95% CI, 0.50-2.0). High-volume surgeons were more likely than intermediate-volume (OR, 4.4; 95% CI, 1.7-11.0) and low-volume (OR, 4.5; 95% CI, 2.6-8.0) surgeons to do a cystoscopy. High-volume (OR, 0.42; 95% CI, 0.30-0.61) and low-volume (OR, 0.32; 95% CI, 0.15-0.66) surgeons were less likely than intermediate-volume surgeons to have intraoperative complications. The difference between high- and low-volume surgeons was not statistically significant (OR, 0.77; 95% CI, 0.5-1.2). CONCLUSIONS: Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and avoidance of injury.

Clinical application of IUGA/ICS classification system for mesh erosion.

AIMS: Our aim was to assess the usability of the IUGA/ICS classification system for mesh erosion in a tertiary clinical practice and to determine if assigned classification is associated with patient symptoms, treatment, and outcome. METHODS: We retrospectively identified women who had mesh erosion after prolapse or incontinence surgery. Each erosion was classified using the IUGA/ICS category time site (CTS) system. Associations between classification and presenting symptom (asymptomatic, pain, bleeding, voiding, or defecatory dysfunction, infection, prolapse), treatment type, and outcome were evaluated with chi-squared test, student's t-test, and univariate logistic regression. RESULTS: We identified 74 subjects with mesh erosion; only 70% were classifiable. Asymptomatic patients (n = 19) (Category A) were more likely to be managed conservatively (P = 0.001). Symptomatic patients (n = 55) (Category B) were more likely to be managed surgically (P = 0.003). Other variables had no association with treatment. No variables were associated with outcome. Presenting symptom was associated with both treatment (P = 0.005) and outcome (P = 0.03). Asymptomatic subjects were more likely to have satisfactory outcome (P = 0.03). Urinary frequency and urgency were highly correlated with surgical management (P = 0.02). CONCLUSIONS: One third of mesh erosions could not be retrospectively coded using the IUGA/ICS classification. The components of the system were not predictive of treatment nor outcome with exception of the Category A (asymptomatic) and Category B (symptomatic). Asymptomatic women with mesh erosion can be successfully managed with conservative measures. Use of a classification system may be enhanced if the system is simplified by limiting the number of variables to those associated with interventions and patient outcome. Neurourol. Urodynam. 35:589-594, 2016. © 2015 Wiley Periodicals, Inc.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort.

BACKGROUND: The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined. METHODS: A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management. RESULTS: Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15). CONCLUSION: Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

Low back pain does not improve with surgical treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Our goal was to determine if there is a correlation between low back pain (LBP) and pelvic organ prolapse (POP) by assessing for change in LBP after surgical correction of prolapse. METHODS: Patients undergoing POP surgery were recruited to participate. They completed the Oswestry Disability Index (ODI), a validated back pain questionnaire, at their preoperative and postoperative visits at 1, 3, and 6 months. A higher ODI score (0-100) represents more severe disability. A 9-point change represents a minimal clinically important difference (MCID). The primary outcome was the change in ODI scores from preoperative to 3 months postoperative. We analyzed ODI scores with repeated measures analysis of variance (ANOVA). Power analysis showed that a sample size of 50 was needed for 88 % power to resolve a MCID on ODI. RESULTS: A total of 51 patients were recruited and 43 (84 %), 34 (67 %), and 36 (71 %) completed the 1-, 3-, and 6-month follow-up, respectively. The mean ODI scores at the preoperative and the 1-, 3-, and 6-month postoperative visits were 15, 19, 9, and 9. The mean ODI score from preoperative to 3 months postoperative improved by 5 points [confidence interval (CI) -9.2 to -0.5, p = 0.03]. Of the participants 7 (20.6 %, CI 11-35 %) experienced a MCID improvement, 24 (70.6 %, CI 56-83 %) reported no substantial change, and 3 (8.8 %, CI 3-20 %) experienced a MCID worsening. CONCLUSIONS: Our study found a statistically significant but not clinically significant improvement of LBP after surgical repair of prolapse.

Minimally invasive apical sacropexy: a retrospective review of laparoscopic and robotic operating room experiences.

OBJECTIVES: Minimally invasive apical sacropexies (MI-APSC) can be performed using robotics or laparoscopy. We hypothesized that operative characteristics of MI-APSC, laparoscopic (LSC) and robotic (RSC), were similar. The objective of our study was to compare operative characteristics, objective prolapse outcomes, and robotic learning curve. METHODS: Ninety-two women planning MI-APSC for treatment of apical pelvic organ prolapse from 2006 to 2010 were included in the study. The primary outcome was operative time. The secondary outcomes included estimated blood loss, rate of conversion, intraoperative complications, hospital stay, and objective prolapse outcome. We also analyzed the robotic learning curve. Statistical analysis included independent samples t test, Wilcoxon rank sum test, χ, and multiple logistic regressions; significance was set at P < 0.05. Learning curve was graphed with moving average and analyzed with moving block technique. RESULTS: Forty-eight RSCs and 43 LSCs were analyzed. Mean operative times were LSC, 238 ± 59 minutes; and RSC, 242 ± 54 minutes. Robotic MI-APSC setup was longer (P = 0.02). Complications, conversions, estimated blood loss and hospital stay were low and similar between groups. Patients' characteristics were similar. Concomitant procedures produced longer operative times. CONCLUSIONS: Operating room experiences with laparoscopic- and robotic-assisted approaches to MI-APSC were similar, but setup time is longer for the robotic-assisted approach. The robotic learning curve is short for surgeons who have experience with LSC.

Hysterectomies and Urologic Symptoms: Results from the Boston Area Community Health (BACH) Survey.

OBJECTIVES: To describe the characteristics of women who have had a hysterectomy and to assess the association of a past hysterectomy on current urologic symptoms. METHODS: The Boston Area Community Health (BACH) survey is a random sample of Boston, Massachusetts residents aged 30-79 years using a stratified two-stage cluster design (3202 women; 1067 Black, 1111 Hispanic, 1024 White). Urologic symptoms, hysterectomy, co-morbidities, lifestyle factors, and medical indications for a hysterectomy were by self-report. Socioeconomic status was measured as a combination of education and income. RESULTS: Hysterectomies were reported by 587 women and 1782 women reported one or more urologic symptoms. Minorities and those of lower socioeconomic status are more likely to have had a hysterectomy, even after adjusting for age and potential medical indications for a hysterectomy. Hispanic women were least likely to report fibroids, polycystic ovarian syndrome, or genitourinary cancers, but they were more likely to have had a hysterectomy if they reported these conditions than Black or White women. Women with a hysterectomy were more likely to report lower urinary tract symptoms, painful bladder syndrome, urinary frequency, urgency, and overactive bladder after adjusting for age, race/ethnicity, socioeconomic status, body mass index, depression, diabetes, heart disease, hypertension, smoking history, alcohol use, and physical activity. CONCLUSIONS: Minorities and those of lower socioeconomic status are more likely to report having a hysterectomy and urologic symptoms (including painful bladder syndrome) may be an unintended consequence of a hysterectomy.

The relationship of common medical conditions and medication use with symptoms of painful bladder syndrome: results from the Boston area community health survey.

PURPOSE: The etiology of painful bladder syndrome is currently unknown. We investigated the relationship between medical factors and symptoms suggestive of painful bladder syndrome in a population based random sample. MATERIALS AND METHODS: Data were collected from the Boston Area Community Health Survey, an epidemiological study conducted from 2002 to 2005 in a racially and ethnically diverse population (30 to 79 years old) from Boston, Massachusetts. The operational definition of painful bladder syndrome was symptom based. Those reporting pain increasing as the bladder fills and/or pain relieved by urination (fairly often/usually/almost always) for 3+ months were considered to have symptoms suggestive of painful bladder syndrome. We used multivariate logistic regression to estimate odds ratios and 95% confidence intervals (adjusted for demographics, anthropometric and other factors) for the association of comorbidities, surgery and medication use with painful bladder syndrome symptoms. RESULTS: The prevalence of painful bladder syndrome symptoms was 1.3% in men and 2.6% in women. In men only depression was associated in a multivariate model (OR 4.96; 95% CI 1.65, 14.92). In women associations were observed for depression (OR 3.35; 95% CI 1.93, 5.81), history of urinary tract infections (OR 2.17; 95% CI 1.49, 4.96), chronic yeast infections (OR 3.11; 95% CI 1.29, 7.51), hysterectomy (OR 2.82; 95% CI 1.20, 6.62), calcium channel blockers (OR 4.59; 95% CI 2.71, 9.72) and cardiac glycosides (OR 10.28; 95% CI 1.46, 72.35), while thyroid medications and statins were inversely associated (OR 0.13; 95% CI 0.03, 0.47 and OR 0.24; 95% CI 0.08, 0.76; respectively). CONCLUSIONS: Gynecologic factors and certain medications may be associated with the painful bladder syndrome in women. Our results for medications suggest potentially modifiable risk factors.

Prevalence and psychosocial correlates of symptoms suggestive of painful bladder syndrome: results from the Boston area community health survey.

PURPOSE: We estimated the prevalence of symptoms suggestive of painful bladder syndrome defined as pain increasing as the bladder fills and/or pain relieved by urination for at least 3 months, and its association with sociodemographics (gender, age, race/ethnicity and socioeconomic status), lifestyle (smoking, alcohol consumption, physical activity) and psychosocial variables (sexual, physical, emotional abuse experienced as a child or as an adult, worry, trouble paying for basics, depression). MATERIALS AND METHODS: The data used come from the Boston Area Community Health Survey, an epidemiological study of 5,506 randomly selected adults 30 to 79 years old of 3 race/ethnic groups (black, Hispanic, white). RESULTS: The overall prevalence of symptoms suggestive of painful bladder syndrome was 2% (1.3% in men and 2.6% in women) with increased prevalence in middle-aged adults and those of lower socioeconomic status. Symptoms suggestive of painful bladder syndrome were more common in those who experienced abuse, in those who were worried about someone close to them and in those who were having trouble paying for basics. This pattern held even after adjusting for depression. CONCLUSIONS: Painful bladder syndrome is associated with a number of lifestyle and psychosocial correlates. This suggests that the treatment of patients with painful bladder syndrome (physical symptoms) may benefit from a multifaceted approach of combining medical, psychological and cognitive treatment.

Use of synthetic mesh in pelvic reconstructive surgery: a survey of attitudes and practice patterns of urogynecologists.

This study surveyed attitudes and practice patterns of urogynecologists regarding the use of synthetic mesh in pelvic reconstructive surgery. A web-based survey was administered to members of the American Urogynecologic Society. The survey evaluated the use of the mesh for sacrocolpopexy, suburethral sling, and vaginal pelvic reconstructive surgery. The survey had a 30.5% response rate. One hundred one (39%) respondents were women, and 158 (61%) were men. One hundred forty-seven (56.8%) participated in fellowship training. Two hundred forty-seven (99.5%) currently perform procedures using synthetic mesh, including 93% who perform sacrocolpopexy and 93% who perform suburethral slings. In a logistic regression model including gender, fellowship training, and practice setting, male surgeons and those who had not undergone fellowship training were more likely to use the mesh than those who were fellowship trained. Respondents use the mesh most commonly when performing sacrocolpopexies and suburethral slings. The use of the mesh for anterior and posterior colporrhaphy is less common.

Suprapubically assisted operative cystoscopy in the management of intravesical TVT synthetic mesh segments.

The tension-free vaginal tape (TVT) sling has become one of the most common procedures performed for the treatment of female stress incontinence. Perforations of the bladder during the TVT placement are relatively common, but are usually noted on cystoscopy and corrected at the time of the procedure. Undetected perforation may result in several complications including recurrent urinary tract infections, bladder stone formation, and pelvic pain. A novel technique is described using operative cystoscopy with suprapubic assistance, which provides an effective means for resection of intravesical mesh. Unlike traditional approaches via laparotomy, this minimally invasive procedure may allow for successful mesh removal while avoiding the morbidity of an open procedure.