Synthetic vs nonsynthetic slings for female stress and mixed urinary incontinence: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to systematically review objective and subjective success and surgical outcomes of suburethral sling surgery for female patients with stress or mixed urinary incontinence using synthetic vs nonsynthetic material with corresponding surgical approaches (retropubic or transobturator). DATA SOURCES: We systematically searched Medline, Embase, EBM Reviews, ClinicalTrials.gov, and Web of Science Core Collection using standardized Medical Subject Headings (MeSH) without date restrictions (PROSPERO-registered). We double-screened studies and used backward citation chaining. STUDY ELIGIBILITY CRITERIA: We included peer-reviewed randomized controlled trials and prospective or retrospective comparative studies examining outcomes of retropubic or transobturator synthetic vs nonsynthetic (autologous, allograft, or xenograft) slings for female stress or mixed urinary incontinence, with available English or French full texts. We excluded minislings (single insertion point). We allowed slings for recurrent stress or mixed urinary incontinence, and slings concomitant with prolapse surgery, with at least 6 weeks of postoperative follow-up. We excluded systematic reviews, meta-analyses, review studies, case-control studies, case reports, studies that did not describe surgical approach or material, and studies of combination slings. METHODS: We evaluated study quality using RoB, the Cochrane risk-of-bias tool for randomized controlled trials, and the Newcastle-Ottawa scale for observational studies. We used pooled relative risk with 95% confidence intervals to estimate the effect of sling material type on each outcome through meta-analysis and meta-regression, as appropriate. RESULTS: We screened 4341 abstracts, assessed 104 full texts, and retained 35 articles (30 separate studies). For retropubic synthetic vs nonsynthetic slings, there was no difference in the number of objectively or subjectively continent patients. The rates of reoperation for stress urinary incontinence and overall were higher with nonautologous retropubic slings than with synthetic slings. Compared with autologous slings, retropubic synthetic slings were associated with higher subjective continence in populations with ≥25% recurrent stress urinary incontinence (relative risk, 1.27; 95% confidence interval, 1.12-1.43). There were no differences in continence between transobturator synthetic and nonsynthetic slings. Subjective satisfaction was better in the transobturator synthetic group than in the autologous sling group (relative risk, 1.42; 95% confidence interval, 1.03-1.94). CONCLUSION: Synthetic and nonsynthetic slings have comparable objective and subjective success, with synthetic materials generally showing better operative outcomes and fewer complications.

Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score.

INTRODUCTION AND HYPOTHESIS: We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model. METHODS: We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic. RESULTS: For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all). CONCLUSIONS: A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery. METHODS: We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP). RESULTS: For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90. CONCLUSIONS: A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.

Procedure-specific simulation for vaginal surgery training: A randomized controlled trial.

INTRODUCTION: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS: gov: Registration no. NCT05887570. RESULTS: We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS: Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study.

INTRODUCTION AND HYPOTHESIS: Severe perineal tears can predict bothersome pelvic floor disorders later in life. We have a poor understanding of pelvic floor changes during the third trimester and the first few postpartum months. We aimed to compare women with severe perineal trauma during childbirth with women who experienced minimal trauma, for condition-specific quality of life, sexual function, mental health and overall quality of life in the first 6 months postpartum. METHODS: We recruited primiparous women with third- or fourth-degree tears (obstetric anal sphincter injuries, OASIS) and age-matched controls with no tears or first-degree tears in the immediate postpartum period. Participants completed validated questionnaires at baseline, 2, 4 and 6 months postpartum. Mixed effects linear regression or quantile regression adjusted for baseline score were used to compare the groups as appropriate. RESULTS: A total of 74 women completed at least one questionnaire (35 OASIS, 39 controls). Both groups had similar demographics. Women with OASIS tended to have worse Pelvic Floor Distress Index-40 scores at month 2; median scores were similar in the two groups by month 6. They also had significantly lower Female Sexual Function Index scores (mean difference: -6.1; 95% CI: -11.9, -0.2, p=0.043) at month 2. There were no mental health group differences and quality of life improved over time, mainly in the OASIS group. Six-month participant attrition rate was 52%. CONCLUSIONS: Women with OASIS encounter specific pelvic floor challenges during the first 6 months postpartum. Although our recruitment rate was high, the attrition rate was also high, demonstrating challenges with retention of postpartum women into longitudinal research.

Pelvic Floor Health Index: Initial validation of a practical postpartum tool for busy clinicians.

OBJECTIVE: To design a primary care clinical tool (Pelvic Floor Health Index [PFHI]) to screen for postpartum pelvic floor disorders, as well as complete its psychometric validation. DESIGN: Prospective cohort study. SETTING: Two tertiary care obstetric centres in Vancouver, BC. PARTICIPANTS: Primiparous women older than 19 years of age who were in the immediate postpartum period. MAIN OUTCOME MEASURES: The PFHI was administered to 74 primiparous women immediately postpartum and at 2, 4, and 6 months postpartum. For evaluation of convergent and divergent construct validity, participants also completed several validated questionnaires, including the Female Sexual Functioning Index, the Pelvic Floor Distress Inventory, the 36-Item Short Form Health Survey, and the Edinburgh Postnatal Depression Scale. Fifteen women repeated their 6-month questionnaires 2 weeks later in order to determine test-retest reliability. Responsiveness was assessed by measuring the PFHI score change from baseline to 6 months postpartum. RESULTS: Pelvic Floor Health Index score was inversely correlated with subscale scores on the Pelvic Floor Distress Inventory at all time points. There were moderate correlations between PFHI score and the Female Sexual Functioning Index and 36-Item Short Form Health Survey scores at several time points. There were weak correlations with postpartum depression scores. The intraclass correlation coefficient for test-retest reliability was 0.78 (95% CI 0.47 to 0.92). The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum. CONCLUSION: The PFHI is a 10-item, newly validated, and psychometrically robust questionnaire that can be administered to patients in the postpartum period to screen for pelvic floor dysfunction.

Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model.

AIMS: Postoperative urinary retention (POUR) is a common complication of urogynecological surgery. Our study aimed to identify demographic and perioperative risk factors to construct a prediction model for POUR in urogynecology. METHODS: Our retrospective cohort study reviewed all patients undergoing pelvic reconstructive surgeries at our tertiary care center (Jan 1, 2013-May 1, 2019). Demographic, pre-, intra- and postoperative variables were collected from medical records. The primary outcome, POUR, was defined as (1) early POUR (E-POUR), failing initial trial of void or; (2) late POUR (L-POUR), requiring an indwelling catheter or intermittent catheterization on discharge. Risk factors were identified through univariate and multivariate logistic regression analyses. A clinical prediction model was constructed with the most significant and clinically relevant risk factors. RESULTS: In 501 women, 182 (36.3%) had E-POUR and 61 of these women (12.2% of the entire cohort) had L-POUR. Multivariate logistic regression revealed preoperative postvoid residual (PVR) over 200 ml (odds ratio [OR]: 3.17; p = 0.026), voiding dysfunction symptoms extracted from validated questionnaires (OR: 3.00; p = 0.030), and number of concomitant procedures (OR: 1.30 per procedure; p = 0.021) as significant predictors of E-POUR; preoperative PVR more than 200 ml (OR: 4.07; p = 0.011) and antiincontinence procedure with (OR: 3.34; p = 0.023) and without (OR: 2.64; p = 0.019) concomitant prolapse repair as significant predictors of L-POUR. A prediction model (area under the curve: 0.70) was developed for E-POUR. CONCLUSIONS: Elevated preoperative PVR is the most significant risk factor for POUR. Alongside other risk factors, our prediction model for POUR can be used for patient counseling and surgical planning in urogynecologic surgery.

International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain.

INTRODUCTION AND HYPOTHESIS: This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP. METHODS: An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category. RESULTS: The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies. CONCLUSIONS: The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.

Directive clinique no 413 : Traitement chirurgical du prolapsus génital apical chez les femmes.

OBJECTIF: Comparer les taux de réussite et de complications des interventions de suspension apicale pour le traitement du prolapsus symptomatique de l'utérus ou du dôme vaginal. POPULATION CIBLE: Les femmes présentant un prolapsus symptomatique de l'utérus ou du dôme vaginal qui souhaitent obtenir un traitement chirurgical. OPTIONS: Les interventions abordées sont les méthodes reconstructives apicales par voie abdominale (colposacropexie, hystérosacropexie ou hystéropexie avec suspension aux ligaments utéro-sacrés) par chirurgie ouverte, laparoscopique ou robotisée; les méthodes reconstructives apicales par voie vaginale (suspension du dôme vaginal ou hystéropexie, sacrospinofixation, suspension aux ligaments utéro-sacrés, suspension au muscle ilio-coccygien, culdoplastie de McCall ou amputation du col [technique de Manchester]); et les interventions vaginales oblitérantes (avec ou sans utérus in situ). Les interventions individuelles ou les grandes catégories d'interventions ont été comparées : (1) reconstruction par voie vaginale versus abdominale, (2) interventions reconstructives par voie abdominale, (3) interventions reconstructives par voie vaginale, (4) reconstruction par hystérectomie avec suspension par comparaison à la reconstruction par hystéropexie et (5) options reconstructives versus oblitérantes. RéSULTATS: Le comité d'urogynécologie a sélectionné les résultats cliniques suivants : échec objectif (obtenu par des systèmes validés de quantification du prolapsus génital et défini comme un échec global objectif et un taux d'échec par compartiment); échec subjectif (réapparition de la sensation de protubérance déterminée subjectivement, avec ou sans l'utilisation d'un questionnaire validé); réopération pour un prolapsus génital récidivé; complications postopératoires de troubles mictionnels (incontinence urinaire d'effort de novo ou postopératoire; réopération d'une incontinence urinaire d'effort de novo, persistante ou récidivée; incontinence urinaire par urgenturie; et dysfonction mictionnelle); lésion des voies urinaires détectée en périopératoire (vessie ou uretère); autres complications (exposition prothétique, définie comme un treillis visible et exposé dans le vagin et une douleur pelvienne non sexuelle); et fonction sexuelle (dyspareunie de novo et score de la fonction sexuelle d'après un questionnaire validé). BéNéFICES, RISQUES ET COûTS: Cette directive clinique sera bénéfique pour les patientes qui souhaitent obtenir une correction chirurgicale du prolapsus génital apical en améliorant les conseils sur les options de traitement chirurgical et les résultats cliniques possibles. La directive sera également utile pour les fournisseurs de soins chirurgicaux en améliorant leurs connaissances sur diverses méthodes chirurgicales. Les données présentées pourraient servir à élaborer des cadres et des outils pour la prise de décision partagée. DONNéES PROBANTES: Nous avons effectué des recherches dans les bases de données Medline, Cochrane Central Register of Controlled Trials (CENTRAL) et Embase pour des articles publiés entre 2002 et 2019. Les termes de recherche étaient nombreux et portaient sur les interventions de correction du prolapsus génital apical, les voies d'abord et les complications. Nous avons exclu les reconstructions par treillis transvaginal et les études comparant les interventions sans suspension apicale. Nous avons inclus des essais cliniques randomisés et des études comparatives prospectives ou rétrospectives. Nous avons limité nos recherches aux articles publiés en anglais ou en français dont le texte intégral était accessible. Une revue systématique des articles avec méta-analyse a ensuite été effectuée. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant lecadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CIBLES: Gynécologues, urologues, urogynécologues et autres fournisseurs de soins de santé qui évaluent, conseillent et soignent des femmes ayant un prolapsus génital. DÉCLARATIONS SOMMAIRES: Toutes les déclarations font référence à la correction du prolapsus génital apical à court et à moyen terme (jusqu'à 5 ans), sauf indication contraire. RECOMMANDATIONS.

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women.

OBJECTIVE: To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse. TARGET POPULATION: Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction. OPTIONS: Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ). Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options. OUTCOMES: The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire). BENEFITS, HARMS, AND COSTS: This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. EVIDENCE: We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The search included multiple terms for apical POP surgical procedures, approaches, and complications. We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension. We included randomized controlled trials and prospective or retrospective comparative studies. We limited language of publication to English and French and accessibility to full text. A systematic review and meta-analysis was performed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS: Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP. SUMMARY STATEMENTS: All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified.

Documenting Perineal and Obstetrical Anal Sphincter Injury Care at Childbirth: A Cross-Sectional Study.

OBJECTIVE: This study evaluates whether maternity care providers document guideline-based recommendations for the prevention and care of obstetrical anal sphincter injuries (OASIS) for their labour and delivery patients. METHODS: We performed a cross-sectional study, aiming for a convenience sample of 60 primiparous women, over 19 years of age, equally representative of patients who experienced severe (third- and fourth-degree) and minimal (intact or first-degree) tears during vaginal birth. Information on patient demographics, delivery details, and guideline-endorsed preventative and management measures were collected. Descriptive statistics were used when appropriate. RESULTS: We enrolled a total of 73 women, 34 of whom had severe tears and 39 of whom had minimal tears. Preventative measures, including fetal head control and perineal support during delivery, were documented for 1 out of 73 patients. The use of perineal massage and warm compress to the perineum was not documented. A rectal exam after delivery was documented for 30% (22/73) of all patients and 62% (21/34) of patients with OASIS. Sixty-five percent (22/34) of patients with OASIS received intravenous antibiotics, 88% (30/34) received laxatives, and 100% received nonsteroidal anti-inflammatory drugs. Post-void residual was not documented for any patients. Patients recalled being informed about their OASIS in 68% (23/34) of cases and being referred to pelvic physiotherapy in 47% (16/34) of cases. CONCLUSION: In our study, perineal care practices during and after childbirth, as detailed in the national OASIS guideline, were incompletely documented. This may indicate partial guideline adherence or suboptimal medical record-keeping.

Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting.

AIMS: To determine the percentage of women with symptomatic pelvic organ prolapse who opted for pessary and had a successful pessary fitting trial; to identify the most commonly used size of pessary for stage of prolapse; and to identify risk factors associated with unsuccessful fitting. METHODS: We conducted a prospective cohort study of women with symptoms of genital prolapse referred to a public hospital tertiary care clinic (2013-2019). We used ring and ring with support pessaries for fittings. We collected patient demographics, pelvic organ prolapse quantification, size of pessary used and evaluated factors associated with pessary fittings. We defined unsuccessful fit as failure to continue pessary use at 4 weeks post fitting trial. We used Mann-Whitney and χ2 tests to compare variables between groups of successfully and unsuccessfully fitted. Using logistic regression, we built a prediction model for unsuccessful fit. RESULTS: All 170 women with symptomatic prolapse referred to our clinic accepted to undergo a pessary fitting. More than 70% (n = 124/72.9%) were successfully at 4 weeks. We used an average of 1.7 pessaries (range: 1-6) per patient to identify the best-fitting pessary and #2, 5, 3, 7, and 4 were the sizes commonly used (78.2%). Women with body mass index ≥30 kg/m2 (odds ratio [OR]: 4.74; 95% confidence interval [CI], 1.98-11.32; P < .001), total vaginal length <7.5 cm (OR: 3.78; 95% CI, 1.98-11.32; P < .001), and sexually active women (OR: 2.26; 95% CI, 1.04-4.91; P = .035) were associated with increased unsuccessful fitting. CONCLUSION: The vaginal pessary proved to be an excellent choice, with high acceptance and successful fitting rates.

Urinary tract infection after clean-contaminated pelvic surgery: a retrospective cohort study and prediction model.

INTRODUCTION AND HYPOTHESIS: Postoperative urinary tract infection (UTI) leads to increased patient morbidity and health care costs. A prediction model may identify patients at highest risk for UTI development. Our primary objective was to determine the rate of UTI in the first 6 weeks after benign gynecologic surgery. Our secondary objective was to identify risk factors and build a predictive model for postoperative UTI. METHODS: We reviewed 310 patient records, which represent all patients who underwent clean-contaminated surgery at a tertiary center (2016-2017). UTI was defined as positive urine culture (> 100,000,000 CFU/l) in a symptomatic patient. Pre-, intra- and postoperative variables were collected. The relation between these variables and UTI was assessed through logistic regression. A clinical prediction model was built. RESULTS: Patients' mean age was 58.5 years and mean body mass index was 27.5 kg/m2. Most were inpatients (65.8%) and 269 had urogynecologic procedures, with the remainder undergoing pelvic surgery for other indications. The most common operation was vaginal reconstruction for prolapse (59.7%), associated with concomitant synthetic midurethral sling in 1/3 cases. Forty patients (12.9%) developed UTI. Multivariate prediction modeling showed increasing age (OR 1.33, CI 1.01-1.75), increasing number of procedures (OR 1.42, CI 1.14-1.78) and prolonged voiding dysfunction (OR 3.78, CI 1.66-8.60) to be significant UTI predictors. CONCLUSIONS: Urinary tract infection in the first 6 weeks after complex pelvic surgery is common. Our prediction model identifies that patients who are older women, have prolonged voiding dysfunction and have a greater number of concomitant pelvic floor surgeries have higher risk of postoperative UTI.

Fibroid Surgery and Long-Term Improvement in Bladder Symptoms.

OBJECTIVE: Short-term studies have demonstrated improvement in urinary symptoms after fibroid debulking surgery, yet long-term data are lacking. This study assessed the long-term impact of fibroid debulking on urinary symptoms several years postoperatively. METHODS: This case series prospectively investigated changes in urinary symptoms of women who underwent fibroid debulking surgery by several gynaecological surgeons at one centre (2011-2016). A follow-up demographics questionnaire and the Urinary Distress Inventory (UDI) were administered. Changes in total UDI scores and UDI subscale scores from preoperative baseline to long-term follow-up were calculated. RESULTS: Thirty participants were recruited from the original cohort of 61 women (49% long-term follow-up). There were significant improvements in total UDI scores (P < 0.001), obstructive subscale score (P < 0.001), and irritative subscale score (P < 0.001) 2-7 years postoperatively. Stress subscale scores were not significantly improved even in a subgroup of patients with significant baseline bother (P = 0.101). Six of eight women (75%) were cured of bothersome urge urinary incontinence, and three of eight women (37.5%) were cured of bothersome stress urinary incontinence. Baseline fibroid characteristics or type of surgery did not significantly influence outcomes. There were no significant demographic differences between women with sustained improvements and women with no improvement or worsening symptoms. The results are considered Level III evidence as per the Canadian Task Force on Preventive Health Care Levels of Evidence. CONCLUSION: Surgical fibroid removal produces long-term improvement in most bladder symptoms except for stress-related symptoms that persist over time. Women with bothersome urinary symptoms should be investigated for fibroids and counselled on potential long-term benefits of debulking surgery.

Diagnosis and Management of an Unusual Cyst 3 Years After Sacrocolpopexy.

BACKGROUND: Peritoneal inclusion cysts (PICs) are uncommon tumours that can pose diagnostic challenges. This report describes an unusual etiology and management of recurrent pelvic organ prolapse. CASE: A 48-year-old premenopausal woman presented with recurrent prolapse and urinary frequency after total abdominal hysterectomy and synthetic mesh sacrocolpopexy. On examination, a stage II rectoenterocele was noted. Her post-void residual was 760 mL as measured by bladder scanner, discrepant with in-and-out catheterization. Pelvic ultrasound revealed a 19-cm cystic pelvic mass. At laparoscopy a PIC was identified, and cystectomy, uterosacral plication, and Moschcowitz culdoplasty were performed. Complete symptom resolution was documented at 4 weeks and 3 months postoperatively. CONCLUSION: PICs should be included in the differential diagnosis of recurrent prolapse. Prolapse symptoms attributable to PICs can be treated with laparoscopic cystectomy.

Regional Variation and Temporal Trends in Surgery for Pelvic Organ Prolapse in Canada, 2004-2014.

OBJECTIVES: We sought to examine temporal trends in pelvic organ prolapse (POP) surgery in Canada. METHODS: In this observational cross-sectional study, we used diagnostic and procedure codes from all hospitalizations and outpatient clinic visits in Canada (excluding Québec) from 2004 to 2014 to identify and analyze data on POP surgery. RESULTS: There were 204 301 POP surgery visits from 2004 to 2014, and the rate of POP surgery declined from 19.3 to 16.0 per 10 000 women during this period. The rates of "native tissue reconstructive repair" and "hysterectomy without other procedure" declined from 15.0 to 12.8 per 10 000 women and 2.6 to 1.6 per 10 000 women, respectively. The rate of obliteration increased from 0.1 to 0.3 per 10 000 women (all P values for trend <0.01). Mesh procedures increased from 1.6 per 10 000 women in 2004 to 2.4 per 10 000 women in 2007 and 2008, and then declined to 1.3 per 10 000 women in 2014. Reconstructive mesh surgery using an abdominal open approach declined, while laparoscopic procedures increased over the period examined. CONCLUSION: The rates of POP surgery declined in Canada between 2004 and 2014. An increase was observed in obliteration procedures and in laparoscopic vaginal suspension and fixation with mesh.

Pelvic floor hypertonicity in women with pelvic floor disorders: A case control and risk prediction study.

AIM: Myofascial pelvic pain is a chronic and debilitating condition, sometimes associated with pelvic floor disorders (PFD) such as urinary incontinence, defecatory dysfunction or pelvic organ prolapse. Our aim was to identify risk factors in women with PFD and hypertonic pelvic floor, compared to controls without hypertonicity. METHODS: Case control study (2009-2017) of patients with PFD and a diagnosis of hypertonic pelvic floor. Cases were matched with patients who presented with the same PFD but without pelvic floor hypertonicity. Postoperative patients with hypertonic pelvic floor were matched with patients who underwent surgery for the same PFD but did not develop pain. Risk factors were compared between groups. RESULTS: Ninety-five cases were matched; 71% had urogynecologic surgery as a possible trigger for myofascial pain. Most were post-menopausal. Overall, case patients were younger than controls (mean 54 vs 59, P = 0.002). Multivariate logistic regression identified risk factors of younger age (OR 1.45, 95%CI 1.04-2.07), history of depression (OR 3, 95%CI 1.03-9.09), musculoskeletal spine injury (OR 4.32, 95%CI 1.01-21.26) and transobturator midurethral sling (OR 8.36, 95%CI 2.68-31.32). Retropubic midurethral sling was protective against pelvic floor hypertonicity (OR 0.37, 95%CI 0.15-0.86). A clinical prediction model including depression, endometriosis, irritable bowel, spine injury and type of midurethral sling was developed to estimate the probability for myofascial pain after urogynecologic surgery. CONCLUSIONS: Specific risk factors predispose women with PFD to chronic pelvic floor hypertonicity. Knowledge of these can help with patient counselling and choice of midurethral sling prior to PFD surgery.

Optimizing resident operative self-confidence through competency-based surgical education modules: are we there yet?

INTRODUCTION AND HYPOTHESIS: Self-confidence is the belief in one's ability to perform and can be enhanced by training. Surgical education should aim to optimize trainee confidence. We designed three procedure-specific competency-based modules to teach vaginal hysterectomy (VH), anterior (AR) and posterior repair (PR) to novice gynecology residents. We hypothesized each module would improve self-confidence and satisfaction during index procedure performance in the operating room. METHODS: This was an ancillary analysis of a larger randomized-controlled trial of gynecologic educational interventions. Residents at three Canadian universities were included if they had previously performed fewer than five index procedures independently. Intervention residents received educational modules; controls engaged in self-directed learning. All residents performed one or more of the three surgeries and filled out a validated Self-Confidence Scale and a Satisfaction Scale. Scores were compared between groups. Correlations were sought between self-confidence and various variables. RESULTS: Forty-six residents at three Canadian universities were randomized (21 intervention, 25 control). Most residents had never performed the index procedure. Overall, self-confidence was significantly higher (p = 0.021) in the intervention group for VH, but not for AR and PR (p = 0.94 and p = 0.12, respectively). Compared with controls, self-confidence was also significantly higher in intervention residents who had never performed VH (p = 0.026) or PR (p = 0.027) and in first and second year intervention residents. There was a positive correlation between self-confidence and satisfaction. CONCLUSIONS: Surgical modules improved self-confidence preferentially in the most junior residents and for more complicated procedures. The wide self-confidence ranges observed suggest that optimization should be an important goal for surgical educators.

Urinary tract infection prevention after midurethral slings in pelvic floor reconstructive surgery: A systematic review and meta-analysis.

INTRODUCTION: Synthetic midurethral slings are the most common procedures currently performed for stress urinary incontinence in women. Infection is a frequent complication of urogynecologic surgery. We performed a systematic review and meta-analysis to identify interventions that successfully prevent infections, including urinary tract infection (UTI) and/or bacteriuria, compared with no intervention, in women undergoing midurethral sling surgery with or without concomitant pelvic reconstructive procedures for prolapse. MATERIAL AND METHODS: The primary outcome was the development of any infection post-midurethral sling placement in women. MEDLINE, Embase, CINAHL and the Cochrane Library were searched for comparative studies from inception to July 2017, with no language restrictions. We used search terms related to midurethral sling, infections and infection-reduction interventions. Two independent reviewers abstracted data and assessed study quality. Pooled effect size estimates were calculated. We conducted meta-analysis of eligible studies. A protocol for this review has been registered and can be accessed online (http://hdl.handle.net/2429/64731). RESULTS: We identified seven eligible studies of infection risk-reducing interventions; all focused on UTIs. Only one study assessed preoperative antibiotics with midurethral sling alone and was halted early because of low UTI rates. All other studies (three randomized control trials and three observational studies) examined whether postoperative antibiotics decrease UTI/bacteriuria rates after midurethral sling with or without reconstructive procedures for pelvic organ prolapse and using bladder catheterization postoperatively. Due to considerable clinical heterogeneity, we only combined four studies for meta-analysis. Postoperative oral prophylactic nitrofurantoin showed no significant benefit in reducing UTI/bacteriuria in women post-midurethral sling with or without concomitant reconstructive pelvic surgery and the need for bladder catheterization, when compared with the reference group (pooled relative risk 0.73, 95% confidence interval [CI] 0.42-1.25). CONCLUSIONS: Based on the best available evidence, postoperative oral nitrofurantoin is not effective at reducing UTI/bacteriuria rates in catheterized women after midurethral sling with or without concomitant pelvic reconstructive surgery for prolapse. For midurethral sling alone, preoperative antibiotic prophylaxis may not be needed for UTI prevention.

Fibroid surgery and improvement in bladder symptoms: The FAB study.

AIMS: Uterine fibroids are the most common tumor of the female reproductive tract [Baird et al Am J Obstet Gynecol. 188:100-107, 2003] and bladder symptoms are more prevalent in these women [Pron et al Fertil Steril. 79:112-119, 2003; Volkers et al Am J Obstet Gynecol. 196:519.e1-e11, 2007] However, the effect of various fibroid debulking surgeries on different types of urinary incontinence symptoms is poorly understood. Our primary objective was to determine whether surgical debulking of uterine fibroids affects urinary symptoms. Secondary objectives were: to define the baseline prevalence of bladder symptoms in women undergoing fibroid surgery; to explore links between fibroid characteristics, size of debulked fibroids, type of surgery, and postoperative changes in bladder function. MATERIALS AND METHODS: Prospective cohort study (2011-2016) of women undergoing vaginal or abdominal myomectomy or hysterectomy. Baseline demographics were obtained. All women underwent a detailed pelvic ultrasound preoperatively. The Urinary Distress Inventory (UDI) questionnaire of the validated Pelvic Floor Distress Inventory (PFDI) was administered before and 6 weeks after surgery. Score changes were assessed using Wilcoxon signed rank test. RESULTS: Sixty-one women completed the study. At baseline, regardless of fibroid characteristics, 96.6% of women had various bothersome urinary symptoms including storage, voiding, and incontinence. Following surgical fibroid debulking, median improvement in the UDI total score was clinically and statistically significant at 39.9 (P < 0.001). All urinary subscale scores were also significantly improved. 11/17 women (64.7%) and 11/18 women (61.1%) were cured of moderately to severely bothersome symptoms of urge and stress urinary incontinence respectively. CONCLUSIONS: Urinary symptoms are common in women undergoing surgery for uterine fibroids. Fibroid debulking may be offered as treatment for bladder symptoms in symptomatic women.