The Effect of Intravenous Acetaminophen on Postoperative Pain and Narcotic Consumption After Vaginal Reconstructive Surgery: A Double-Blind Randomized Placebo-Controlled Trial.

OBJECTIVE: This study aimed to determine the effect of intravenous acetaminophen versus placebo on postoperative pain, satisfaction with pain control, and narcotic use after vaginal reconstructive surgery. METHODS: This was an institutional review board-approved, double-blind placebo-controlled randomized trial. Women scheduled for reconstructive surgery including vaginal hysterectomy and vaginal vault suspension were enrolled. Subjects received 1000 mg of intravenous acetaminophen or 100 mL placebo every 6 hours for 24 hours. Pain and satisfaction with pain control were assessed using visual analog scales and a numeric rating scale. Visual analog scales were collected at 18 and 24 hours postoperatively and at discharge. A sample size calculation determined 90 subjects would be required to detect a 30% reduction in postoperative narcotic use with 80% power and significance level of 0.05. RESULTS: One hundred subjects were enrolled. There were no differences in demographics or surgical data and no difference in narcotic consumption at multiple evaluation points. At 18 hours postoperative, median pain scores at rest were 27.0 (interquartile range, 35.0) for acetaminophen and 35.0 (interquartile range, 44.5) for placebo, finding no difference (P = 0.465). Furthermore, pain with activity and numeric rating scale-assessed pain scales were similar (P = 0.328; P = 0.597). Although satisfaction with pain control was high overall (91.5), no difference was noted. CONCLUSIONS: Patients undergoing vaginal reconstructive surgery receiving perioperative intravenous acetaminophen did not experience a decrease in narcotic requirements or postoperative pain when compared with placebo. Reassuringly, pain scores were low and satisfaction with pain control was high for all subjects. The general use of this medication is not supported in these surgical patients.

Comparative Perioperative Pain and Recovery in Women Undergoing Vaginal Reconstruction Versus Robotic Sacrocolpopexy.

BACKGROUND: In this study of patients undergoing vaginal hysterectomy with either robotic or vaginal prolapse repair, there was no difference in quality of life in the weeks following surgery; however, less narcotics were used, less pain was documented by nurses and Surgical Pain Scale (SPS), and better performance on voiding trials was noted in those undergoing robotic sacrocolpopexy. OBJECTIVES: Minimally invasive surgery for pelvic organ prolapse is the preferred surgical route for optimal recovery. However, information regarding patient-centered outcomes among various techniques is lacking. We sought to describe pain and quality of life in patients undergoing vaginal hysterectomy with uterosacral ligament suspension (USLS) compared with robotic-assisted sacrocolpopexy (RSC). METHODS: This institutional review board-approved prospective cohort study enrolled consecutive patients undergoing vaginal hysterectomy with USLS or with RSC. The primary outcome was pain on postoperative day 1 using the SPS. Nursing verbal pain scores, narcotic usage, surgical data, and Short-Form Health Survey 12 at baseline and 2 and 6 weeks after surgery were collected. A sample size calculation revealed 37 subjects per group would be required. RESULTS: Seventy-eight women were enrolled (USLS, n = 39; RSC, n = 39). There were no significant differences in scores on the SPS between groups. Subjects undergoing RSC had lower nursing verbal pain scores (P = 0.04), less narcotic consumption (P = 0.02), and lower estimated blood loss (P = 0.01) and were less likely to fail voiding trials (P < 0.001); however, surgery duration was longer (P < 0.001). After controlling for age, regression analysis revealed SPS "worst pain" was lower in the robotic arm (P = 0.01), but not in other scales of the SPS. At 2 and 6 weeks postoperatively, Short-Form Health Survey 12 scores were not different between cohorts. CONCLUSIONS: Both USLS and RSC are minimally invasive, with similar quality-of-life scores after surgery. However, the robotic approach may be associated with less pain, less narcotic use, and better performance in voiding trials. Surgeons should consider these findings when counseling patients regarding treatment options.

Histologic Anatomy of the Anterior Vagina and Urethra.

BACKGROUND: Vaginal and urethral histology is important to understanding the pathophysiology of the pelvic floor. METHODS: En bloc removal of 4 female cadaveric pelvises was performed, with 18 to 25 serial sections obtained from each. The vaginal and urethral lengths were divided into distal and proximal sections; urethra was divided into anterior and posterior segments as well. Innervation and vasculature were qualified as small and large and quantified per high-power field. RESULTS: The mean vaginal length was 7.45 cm, and the mean urethral length was 3.38 cm. A distinct vaginal fibromuscular layer was noted, without evidence of a dense sheet of continuous collagen. An epithelial, lamina propria, and muscular layer surrounded the urethral lumen. Adipose and loose fibroconnective tissue separated the urethra from the anterior vagina in 41% of slides. Nerves and vasculature were concentrated in the lamina propria. More small nerves and vessels were grossly seen compared with larger counterparts in both the vagina and urethra. No significant differences in layer thickness, innervation, or vasculature were observed along the vaginal length. The posterior urethra had greater innervation than did the anterior (P = 0.012). The distal posterior urethra had more large vessels than did the proximal posterior urethra (P = 0.03). No other differences were noted in urethral sections. CONCLUSIONS: A vaginal fibromuscular layer was confirmed, refuting a true fascia. Innervation and vasculature were quantitatively the same along the anterior vagina. However, the posterior urethra had greater innervation than did anterior and is most innervated proximally. Nerve and vascular histology may relate to pelvic floor disorder etiology.

Impact of Pelvic Floor Physical Therapy on Quality of Life and Function After Obstetric Anal Sphincter Injury: A Randomized Controlled Trial.

OBJECTIVES: There is no standard of care for women sustaining an obstetric anal sphincter injury (OASIS). We sought to determine whether pelvic floor physical therapy (PFPT) would improve the quality of life and function in women 12 weeks after OASIS. METHODS: This institutional review board-approved randomized trial enrolled primiparous women 2 weeks after delivery complicated by OASIS. After informed consent, all subjects underwent vaginal electromyography and anorectal manometry and completed validated questionnaires; measures were repeated for all subjects at 12 weeks after delivery. The intervention arm completed 4 PFPT sessions. The primary outcome was a change in the Fecal Incontinence Quality of Life. RESULTS: Three hundred four women were screened; 250 were excluded, and 54 were randomized. After four were lost to follow-up, analysis included 27 in the intervention arm and 23 in the control arm. Overall, mean age was 29.8 ± 4.7 years, and there were no demographic differences between groups.Fecal Incontinence Quality of Life domain scores showed improvement for both groups from baseline to 12 weeks for coping (P = 0.006) and depression (P = 0.009); however, there was no difference in domain scores between groups. For the secondary outcome of anorectal manometry, squeezing pressure improved for all subjects (P = 0.035) from baseline to 12 weeks. Vaginal EMG strength (microvolts) increased for all subjects in measures of rest average (P < 0.000), rapid peak (P = 0.006), and work average (P < 0.000), with no difference based on therapeutic arm. CONCLUSIONS: All women showed improvements in quality of life and function at 12 weeks after delivery, regardless of treatment allocation. Further study is needed to determine whether PFPT provides a significant benefit to women having OASIS.

Attitudes Regarding Labial Hypertrophy and Labiaplasty: A Survey of Members of the Society of Gynecologic Surgeons and the North American Society for Pediatric and Adolescent Gynecology.

OBJECTIVE: The aim of this study was to describe gynecologists' attitudes toward labial hypertrophy and explore possible differences among providers for pediatric/adolescent patients. METHODS: This was an institutional review board-approved, cross-sectional survey of physician attendees at 2 national meetings in 2014: the Society of Gynecologic Surgeons (SGS) and the North American Society for Pediatric and Adolescent Gynecology (NASPAG). The survey was designed to query demographics and impressions regarding labial hypertrophy and labiaplasty. RESULTS: Three hundred sixty-five surveys were completed (response rate, 50%); 268 were analyzed: 55% from SGS and 45% from NASPAG. Most were older than 41 years; 170 (63%) were women, and 93 (35%) were men. More men than women attended SGS (60%); however, women were the majority at NASPAG (94%).Most respondents believed labial hypertrophy to be infrequently reported and "a condition that impacts body image." Common symptoms were "discomfort with exercise" and "dissatisfaction with appearance naked." The majority felt this to impact sexual function "in some cases," citing "self-esteem" and "comfort" most often.Concerning therapies for provided labial hypertrophy, 83% of practitioners provide reassurance, whereas 77% would offer labiaplasty. Expertise with labiaplasty varied; 28% felt "very comfortable," and 11% felt "very uncomfortable."Provider preference for treatment differed based on meeting attendance. After logistic regression controlling for sex and age, attendance at SGS remained associated with offering labiaplasty (P = 0.001; odds ratio, 4.1; 95% confidence interval, 1.8-9.3), whereas NASPAG attendance was associated with providing reassurance (P = 0.008; odds ratio, 0.30; 95% confidence interval, 0.10-0.70). CONCLUSIONS: Although the majority surveyed view labial hypertrophy to be bothersome, gynecologists caring for our youngest patients are more likely to provide reassurance. Consensus guidelines are needed to aid practitioners in appropriate management of labial hypertrophy.

To Pack or Not to Pack? A Randomized Trial of Vaginal Packing After Vaginal Reconstructive Surgery.

OBJECTIVE: Placement of vaginal packing after pelvic reconstructive surgery is common; however, little evidence exists to support the practice. Furthermore, patients have reported discomfort from the packs. We describe pain and satisfaction in women treated with and without vaginal packing. METHODS: This institutional review board-approved randomized-controlled trial enrolled patients undergoing vaginal hysterectomy with prolapse repairs. The primary outcome was visual analog scales (VASs) for pain on postoperative day 1. Allocation to "packing" ("P") or "no-packing" ("NP") arms occurred intraoperatively at the end of surgery. Visual analog scales regarding pain and satisfaction were completed early on postoperative day 1 before packing removal. Visual analog scale scores for pain, satisfaction, and bother attributable to packing were recorded before discharge. All packing and perineal pads were weighed to calculate a "postoperative vaginal blood loss." Perioperative data were collected from the hospital record. Our sample size estimation required 74 subjects. RESULTS: Ninety-three women were enrolled. After exclusions, 77 were randomized (P, 37; NP, 40). No differences were found in surgical information, hemoglobin levels, or narcotic use between groups. However, "postoperative vaginal blood loss" was greater in packed subjects (P < 0.001). Visual analog scale scores for pain before removal of packing (P, 41.6 vs NP, 46.3; P = 0.43] and before discharge (P, 35.0 vs NP, 40.0; P = 0.43] were not significantly different between treatment arms. Likewise, VAS scores for satisfaction before removal of packing (P, 81.0 vs NP, 90.0; P = 0.08] and before discharge (P, 90.0 vs NP, 90.5; P = 0.60] were not significantly different. Packed patients noted lower nursing verbal pain scores (P = 0.04) and used less ketorolac (P = 0.01). Bother from packing was low overall. CONCLUSIONS: Although there was no difference based on VAS, women receiving vaginal packing had lower nursing documented pain and used less ketorolac than packed women. Vaginal packing may provide benefit and can remain part of the surgical practice.

The Impact of Robotic-Assisted Surgery on Training Gynecology Residents.

INTRODUCTION: To investigate the changes in surgical route of hysterectomy after implementation of robotics and to assess the impact on the surgical training of gynecology residents. METHODS: This was an institutional review board-approved retrospective analysis at 2 large academic community hospitals. Subjects undergoing hysterectomy during 2005 and 2011 were identified. A stratified random sample representative of the overall number of hysterectomies, 20 per month for each year, was obtained. Charts were reviewed for route of hysterectomy and resident involvement. Chi-square analysis was used for main outcomes. RESULTS: A total of 193 cases from 2005 and 146 cases from 2011 were included. A significant decline in vaginal hysterectomies was noted from 2005 to 2011: 62.2% (n = 120) to 27.4% (n = 40) (P < 0.001). Laparoscopic hysterectomies also declined from 30.1% to 19.9% during the same period (P < 0.026). In addition, although no robotic hysterectomies were performed in 2005, by 2011, this approach accounted for more than one fourth of all such surgeries. Of all cases examined, 40 in 2005 and 45 in 2011 were not attended by a resident. In 2005, 52% (21 of 40) of the uncovered cases were vaginal hysterectomies. However, in 2011, 55% (25 of 45) of the uncovered cases were robotic-assisted and only 11% (5 of 45) were vaginal hysterectomies. CONCLUSIONS: The resultant decline in vaginal and laparoscopic hysterectomies coupled with an additional procedure to master places an increased burden on training programs. Although the impact of the changes on surgical competency is not yet known, our results identify potential areas for focus in training to ensure surgically competent physicians.

Critical Anatomy Relative to the Sacral Suture: A Postoperative Imaging Study After Robotic Sacrocolpopexy.

OBJECTIVE: This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging. METHODS: A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging. RESULTS: Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%. CONCLUSIONS: We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.

Effects of dexamethasone on quality of recovery following vaginal surgery: a randomized trial.

OBJECTIVE: Dexamethasone is a corticosteroid with minimal side effects that may improve quality of recovery. We sought to evaluate standard use of this medication prior to vaginal reconstructive surgery. STUDY DESIGN: This was a double-blind, randomized, placebo-controlled trial of women undergoing vaginal reconstructive surgery for pelvic organ prolapse. Patients scheduled for an intraperitoneal vaginal vault suspension, with general anesthesia and an overnight stay, were enrolled. The intervention arm received dexamethasone 60 minutes prior to surgery, and controls received placebo. Postoperative pain medications, antiemetics, and voiding trials were standardized. Our primary outcome was the difference in Quality of Recovery (QoR-40) scores on postoperative day 1. Secondary measures included Postoperative Nausea and Vomiting Intensity scores, and visual analog scales for nausea/vomiting, and pain. Our power calculation demonstrated 31 subjects in each group would be necessary to document difference in QoR-40 scores; to allow for attrition, a goal of 74 subjects was set. RESULTS: Seventy-four women were enrolled and randomized. Two withdrew, 9 were excluded, and 63 were analyzed (36 placebo, 27 dexamethasone). The mean age was 63 years. No significant differences were noted among demographics other than American Society for Anesthesiologists class; there were greater numbers of dexamethasone subjects that were class 3 (5 vs 11; P = .030). Postoperatively, more patients in the placebo group required promethazine as a rescue antiemetic for control of their nausea/vomiting (11 vs 2; P = .029). Placebo subjects also failed their voiding trials more frequently, which remained following a logistic regression controlling for suburethral sling (30 vs 15; P = .037). Regarding the QoR-40 following surgery, the emotional state domain declined less in dexamethasone patients (-14.3, interquartile range [IQR], 16.8 vs -4.6, IQR, 20.1; P = .042), indicating better symptoms. Whereas pain scales were similar, the visual analog scales for nausea/vomiting was lower in dexamethasone subjects (0.7; IQR, 4.1 vs 0.4; IQR, 1.4; P = .042). Postoperative Nausea and Vomiting Intensity scores were not significantly different; nevertheless, twice as many placebo subjects had severe range symptoms (4 vs 2; P = .47). No adverse effects from the dexamethasone were noted. CONCLUSION: Use of dexamethasone prior to vaginal reconstructive surgery was associated with less nausea/vomiting and need for antiemetics as well as greater success with voiding trials. Furthermore, quality of recovery was enhanced, suggesting use of dexamethasone should be considered for these patients.

Impact of robotic technology on hysterectomy route and associated implications for resident education.

OBJECTIVE: We sought to compare the proportion of benign hysterectomies performed vaginally and the mean number of hysterectomies with resident involvement by route before and after robot implementation. STUDY DESIGN: This multicenter, retrospective cohort study using nonsynchronous controls was conducted through the Society of Gynecologic Surgeons Fellows' Pelvic Research Network. The route of hysterectomy for benign disease was compared for 1-year periods before (prerobot) and after (postrobot) robotic introduction at 4 academic institutions. We reviewed medical records and recorded patient demographics, hysterectomy approach, preoperative and postoperative diagnosis, and resident involvement. RESULTS: In all, 1440 hysterectomies were included: 732 in the prerobot group and 708 in the postrobot group. Median age was 46 years and mean body mass index was 29.5 (standard deviation, 6.9). The proportion of hysterectomies performed via the vaginal route decreased from 42.5% prerobot to 30.5% postrobot (P < .0001) and via the abdominal route from 22.1% prerobot to 16.5% postrobot (P = .001). The proportion of hysterectomies performed laparoscopically increased from 1.6% prerobot to 11.9% postrobot (P < .0001). At a mean of 2.3 years after introduction of the robot into an institution, hysterectomies performed using robotic assistance accounted for 23.3% of hysterectomies for benign disease. Mean uterine weight was similar in the prerobot and postrobot groups. Resident involvement in all hysterectomies done via all routes other than robotic increased from 81.0% prerobot to 88.6% postrobot; however, residents were involved in only 58.9% of robotic hysterectomies. CONCLUSION: The proportion of hysterectomies performed vaginally has significantly decreased since the adoption of robotic technology at institutions included in this study. The proportion of hysterectomies with resident involvement is lower with a robotic approach than any other route.

Age as a predictor of osteoporotic fracture compared with current risk-prediction models.

OBJECTIVE: To compare several fracture risk-prediction models and their predictive values. METHODS: Women older than age 49 years were sent for dual-energy X-ray absorptiometry screening between January 2007 and March 2009. Data collection included multiple osteoporosis risk factors. The ability to identify fractures was analyzed and compared using the North American Menopause Society 2006 and 2010 Position Statements, The Fracture Risk Assessment Tool, along with age alone. The area under the curve (AUC) comparison with chance (AUC 0.50) and paired AUC comparisons between models were used to investigate the efficacy of each model in predicting osteoporotic fractures. RESULTS: Among the 615 women studied, with mean (standard deviation) age of 61.4 (8.3) years and 94.5% being white, 15 have experienced a fracture. All screening approaches were significantly better than chance at predicting fractures. Paired comparisons of the detection ability of fracture prediction models showed no significant differences. Age alone was a significant predictor for fracture (AUC 0.79, 95% confidence interval [CI] 0.67-0.91, P<.001) with the optimal cutoff age of 65 years, which was associated with a sensitivity (95% CI) of 80% (77-83%) and specificity (95% CI) of 73% (70-77%). Compared with young postmenopausal women (younger than 65 years), the odds ratio (95% CI) of fractures in older women (65 years or older) is 10.2 (2.32-44.97). In addition, when age was added, it significantly increased the AUC of each model. CONCLUSION: These data suggest that all current screening modalities are effective in predicting fracture but not significantly better than age alone. Age should be considered carefully while evaluating patients for osteoporosis screening and treatment. LEVEL OF EVIDENCE: II.

Delayed presentation of an enterocutaneous fistula after tension-free vaginal tape sling.

BACKGROUND: : Bowel injury is a rare but serious complication associated with tension-free vaginal tape (TVT) sling procedures. CASE: : A 50-year-old woman with a previous history of pelvic surgery underwent TVT for stress urinary incontinence. Surgery and the immediate postoperative period were unremarkable; however, she returned 5 months later with bloody, purulent discharge from a suprapubic exit site. This was unresponsive to antibiotic therapy, and when the patient returned with abdominal pain and fever, a computed tomographic scan showed an enterocutaneous fistula. At the time of exploratory laparotomy, the mesh was noted to have perforated the small bowel and led to a sinus tract that communicated with the skin. CONCLUSIONS: : Bowel perforation is a recognized, but rare, complication of TVT. This case highlights the need for a high index of suspicion for bowel injury after TVT maintained beyond the more commonly described peritonitis or obstructive symptoms presenting in the immediate perioperative period.