Obesity and stress urinary incontinence in women: compromised continence mechanism or excess bladder pressure during cough?

INTRODUCTION AND HYPOTHESIS: We compared two hypotheses as to why obesity is associated with stress urinary incontinence (SUI): (1) obesity increases demand on the continence system (e.g. higher cough pressure) and (2) obesity compromises urethral function and urethrovaginal support. METHODS: A secondary analysis was performed using data from a case-control study of SUI in women. Measurements of urethrovaginal support (POP-Q point Aa, urethral axis), urethral function (maximal urethral closure pressure, MUCP), and measures of continence system demand (intravesical pressures at rest and during maximal cough) were analyzed. Cases and controls were divided into three body mass index (BMI) groups: normal (18.5-24.9 kg/m2); overweight (25.0-29.9 kg/m2); and obese (≥30 kg/m2). Logistic regression models where created to investigate variables related to SUI for each BMI group. Structural equation modeling was used to test the direct and indirect relationships among BMI, SUI, maximal cough pressure, MUCP, and POP-Q point Aa. RESULTS: The study included 108 continent controls and 103 women with SUI. MUCP was the factor most strongly associated with SUI in all BMI groups. Maximal cough pressure was significantly associated with SUI in obese women (OR 3.191, 95% CI 1.326, 7.683; p < 0.01), but not in normal weight or overweight women. Path model analysis showed a significant relationship between BMI and SUI through maximal cough pressure (indirect effect, p = 0.038), but not through MUCP (indirect effect, p = 0.243) or POP-Q point Aa (indirect effect, p = 0.410). CONCLUSIONS: Our results support the first hypothesis that obesity is associated with SUI because of increased intravesical pressure, which therefore increases demand on the continence mechanism.

Core Privileging and Credentialing: Hospitals' Approach to Gynecologic Surgery.

STUDY OBJECTIVE: Privileging and credentialing requirements are determined by medical staff leadership at the hospital level to ensure clinicians provide safe healthcare services. No standardized guidelines exist for gynecologic surgery. The objective of this study is to examine the variability of the criteria used to grant surgical privileges and credentials for gynecologic procedures at 5 high-volume academic and community-based US hospitals. DESIGN: We conducted a cross-sectional study (Canadian Task Force classification III). SETTING: Data was obtained from obtained from 5 geographically diverse hospital systems. INTERVENTION: We examined criteria for designating core gynecologic privileges, credentialing, and other training requirements as well as minimum and annual case numbers for initial granting and maintenance of surgical privileges. MEASUREMENTS AND MAIN RESULTS: Major inconsistencies in privileging were found across the 5 institutions. Hospitals varied widely in procedures designated as core versus those requiring advanced training. Institutions greatly contrasted in the case numbers and temporal factors used to define experience. Of particular concern was absent privileging criteria for 38.4% to 76.9% of minor procedures, 26.7% to 46.7% of endoscopic procedures, and 6.67% to 56.7% of major procedures. Initial and maintenance privileging requirements for special procedures (i.e., robotic-assisted surgery) were likewise discrepant, with minimum annual case numbers ranging from 3 to 48 across hospitals. CONCLUSION: Considerable variability exists in the criteria used by hospitals for granting and maintaining surgical privileges for gynecologic procedures. Standardization will likely require efforts at a national leadership level.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE: Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN: We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS: For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION: Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Systematic review of robotic surgery in gynecology: robotic techniques compared with laparoscopy and laparotomy.

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis.

This systematic review of uterosacral ligament suspension provides a metaanalysis of anatomic outcomes and a summary of subjective outcomes. A successful anatomic outcome was considered present when women had "optimal" or "satisfactory" (pelvic organ prolapse quantification system stage 0 or 1) outcomes. In the anterior, apical, and posterior compartments, the pooled rates for a successful outcome were 81.2% (95% confidence interval [CI], 67.5-94.5%), 98.3% (95% CI, 95.7-100%), and 87.4% (95% CI, 67.5-94.5%). In the anterior compartment, women with preoperative stage 2 prolapse were more likely than those with preoperative stage 3 prolapse to have a successful anatomic outcome (92.4% vs 66.8%; P = .06). Outcomes, with respect to subjective symptoms, were reassuring; however, it was not possible to pool data because of methodologic differences between studies.

Complications requiring reoperation following vaginal mesh kit procedures for prolapse.

OBJECTIVE: The objective of the study was to the characterize the symptoms and management of vaginal mesh-related complications requiring operative intervention. STUDY DESIGN: This was a case series of patients undergoing excision of vaginal graft material. Only women who had vaginal mesh placement for the correction of pelvic organ prolapse (POP) were included. We describe the symptoms, complications, and management of women treated surgically for vaginal mesh-related complications. RESULTS: Thirteen referred women underwent surgery for vaginal mesh-related complications. All meshes were Apogee and/or Perigee. Ten had symptomatic mesh exposures, 1 had an exposure with pelvic abscess, and 2 had pain syndromes without mesh exposure. Patients also had rectovaginal fistula, vesicovaginal fistula, recurrent POP, and persistent discharge. Five women had prior surgery for this problem. All patients underwent transvaginal mesh excision and other indicated procedures at our institution, and 6 women required a second surgery at our institution, with a median of 2 surgeries per patient. CONCLUSION: Vaginal mesh placement for POP can be associated with pain, exposure, and fistula formation, requiring multiple operative interventions.

Vaginal birth and de novo stress incontinence: relative contributions of urethral dysfunction and mobility.

OBJECTIVE: To evaluate the relative contributions of urethral mobility and urethral function to stress incontinence. METHODS: This was a case-control study with group matching. Eighty primiparous women with self-reported new stress incontinence 9-12 months postpartum were compared with 80 primiparous continent controls to identify impairments specific to stress incontinence. Eighty nulliparous continent controls were evaluated as a comparison group to allow us to determine birth-related changes not associated with stress incontinence. Urethral function was measured with urethral profilometry, and vesical neck mobility was assessed with ultrasound and cotton swab test. Urethral sphincter anatomy and mobility were evaluated using magnetic resonance imaging. The associations among urethral closure pressure, vesical neck movement, and incontinence were explored using logistic regression. RESULTS: Urethral closure pressure (+/-standard deviation) in primiparous incontinent women (62.9+/-25.2 cm H(2)0) was lower than in primiparous continent women (83.9+/-21.0, P<.001; effect size d=0.91) who were similar to nulliparous women (90.3+/-25.0, P=.091). Vesical neck movement measured during cough with ultrasonography was the mobility measure most associated with stress incontinence; 15.6+/-6.2 mm in incontinent women compared with 10.9+/-6.2 in primiparous continent women (P<.001, d=0.76) or nulliparas (9.9+/-5.0, P=.322). Logistic regression disclosed the two-variable model (max-rescaled R(2)=0.37, P<.001) was more strongly associated with stress incontinence than either single-variable model, urethral closure pressure (R(2)=0.25, P<.001) or vesical neck movement (R(2)=0.16 P<.001). CONCLUSION: Lower maximal urethral closure pressure is the measure most associated with de novo stress incontinence after first vaginal birth followed by vesical neck mobility. LEVEL OF EVIDENCE: II.

Origin and insertion points involved in levator ani muscle defects.

OBJECTIVE: This project sought to identify and to describe the anatomical connections affected by levator ani defects involving the pubovisceral portion of the muscle. STUDY DESIGN: Fourteen magnetic resonance scans of women with unilateral levator defects were selected. The missing muscle mapping technique was used to characterize the absent muscle. Normal muscle was visualized and compared with the contralateral side. Using a three-dimensional slicer, the outline of the intact muscle was traced; models of this muscle and surrounding structures were generated. RESULTS: The missing muscle originates from the posterior pubic bone and extends laterally over the obturator internus muscle; it inserts into the vaginal wall, perineal body, and the intersphincteric space. Architectural distortion, with an asymmetric lateral spilling of the vagina was present in 50% of women. The defect was right sided in 71% of patients. CONCLUSION: The origin and insertion points of the damaged portion of the levator ani muscle were identified.

Titanium Surgical Tacks: Are They Safe? Do They Work?

OBJECTIVES: Minimally invasive approaches to sacrocolpopexy have transformed it into a primary procedure for treatment of pelvic organ prolapse. Certain modifications are commonly used to facilitate the laparoscopic approach, but have not yet been widely studied. In this study, we investigated the efficacy and safety of titanium surgical tacks for the attachment of mesh to the anterior longitudinal ligament in laparoscopic sacrocolpopexy. METHODS: This retrospective cohort study involved all patients within 1 health care system who underwent laparoscopic sacrocolpopexy between January 2009 and December 2012. Each medical record was reviewed and abstracted. RESULTS: Of the 231 patients included in our study, 190 (82%) had titanium surgical tacks, and 41 (18%) had suture for mesh attachment to the anterior longitudinal ligament. The demographics of the 2 subgroups as well as concomitantly performed procedures were comparable. There was no significant difference found between the 2 cohorts in regards to operative time, estimated blood loss, complication rates, rate of recurrent pelvic organ prolapse symptoms or the rate of reoperation for pelvic organ prolapse. CONCLUSIONS: Surgical tacks are a safe alternative to suture for the attachment of mesh to the anterior longitudinal ligament in laparoscopic sacrocolpopexy. Although we saw no advantage to using tacks over suture, tacking the mesh to the anterior longitudinal ligament may make the laparoscopic approach more accessible to a wider range of gynecologic surgeons. Further studies about the long-term impact of surgical tacks on bone and disk disease are needed.

Appearance of the levator ani muscle subdivisions in magnetic resonance images.

OBJECTIVE: Identify and describe the separate appearance of 5 levator ani muscle subdivisions seen in axial, coronal, and sagittal magnetic resonance imaging (MRI) scan planes. METHODS: Magnetic resonance scans of 80 nulliparous women with normal pelvic support were evaluated. Characteristic features of each Terminologia Anatomica-listed levator ani component were determined for each scan plane. Muscle component visibility was based on pre-established criteria in axial, coronal, and sagittal scan planes: 1) clear and consistently visible separation or 2) different origin or insertion. Visibility of each of the levator ani subdivisions in each scan plane was assessed in 25 nulliparous women. RESULTS: In the axial plane, the puborectal muscle can be seen lateral to the pubovisceral muscle and decussating dorsal to the rectum. The course of the puboperineal muscle near the perineal body is visualized in the axial plane. The coronal view is perpendicular to the fiber direction of the puborectal and pubovisceral muscles and shows them as "clusters" of muscle on either side of the vagina. The sagittal plane consistently demonstrates the puborectal muscle passing dorsal to the rectum to form a sling that can consistently be seen as a "bump." This plane is also parallel to the pubovisceral muscle fiber direction and shows the puboperineal muscle. CONCLUSION: The subdivisions of the levator ani muscle are visible in MRI scans, each with distinct morphology and characteristic features.

Antibiotic prophylaxis for selected gynecologic surgeries.

BACKGROUND: Antibiotic prophylaxis for surgery is commonly used and is recommended by multiple organizations. OBJECTIVE: To critically review gynecology-specific data regarding surgical antibiotic prophylaxis in selected benign gynecologic surgeries. SEARCH STRATEGY: MEDLINE and Cochrane databases were searched from inception to July 2010. SELECTION CRITERIA: Randomized controlled trials of benign vaginal, cervical, transcervical, abdominal, or laparoscopic procedures other than hysterectomy comparing prophylactic antibiotic use with placebo or with another antibiotic. Outcomes of interest were postoperative infections, additional treatments, and adverse events. DATA COLLECTION AND ANALYSIS: In total, 19 trials met the inclusion criteria. Studies were individually assessed for methodologic quality, then grouped by procedure and evaluated for evidence quality. MAIN RESULTS: There was no difference in infectious outcome for loop electrosurgical excision, hysteroscopic ablation, or laparoscopy, although evidence quality was poor. Fair evidence supports antibiotic prophylaxis for suction curettage or laparotomy. There were insufficient data regarding vaginal surgery prophylaxis. CONCLUSION: Antibiotic prophylaxis may be beneficial in first-trimester suction curettage and laparotomy. No advantage was found for loop electrosurgical excision, hysteroscopy, or laparoscopic gynecologic surgery. Newer procedures and vaginal surgery lack research and merit study.

Surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery.

OBJECTIVE: To assess surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery. METHODS: A survey was distributed at the 2011 annual scientific meeting of the Society of Gynecologic Surgeons regarding antibiotic prophylaxis practices. RESULTS: The response rate was 51%. Most surgeons did not use antibiotic prophylaxis for dilation and curettage without products of conception, hysteroscopy, and loop electrocautery excision procedure/cone biopsy. For laparoscopy without graft placement, 45.9% did not use prophylaxis. Prophylaxis was common for hysterectomy. For midurethral slings, 8.2% did not use prophylaxis. When graft material was used in prolapse surgery, at least 93% of surgeons administered some form of antibiotic prophylaxis. Only 70% of respondents prescribe antibiotic prophylaxis for hysterectomy consistent with recommendations from the American College of Obstetricians and Gynecologists, whereas 78% are consistent with specifications from the Joint Commission. CONCLUSIONS: Wide variability exists in antibiotic prophylaxis in gynecologic surgery. Surgeon preference or local hospital policies affect choice of prophylaxis less than 14.9% of the time.

Gynecologic problems following abdominoperineal resection of the anus and rectum - the post-miles syndrome.

BACKGROUND: : Abdominoperineal resection is a surgical technique used to treat a variety of colorectal diseases. Although there are several published studies describing long-term pelvic floor functioning in women who have undergone this procedure, little is known specifically about gynecologic problems that may develop after surgery. CASES: : We describe a series of 3 patients all presenting with similar gynecologic complaints status-post abdominoperineal resection, including copious vaginal discharge, dyspareunia, and difficulty on the part of their health care providers in seeing the cervix during speculum examinations. The presenting syndrome is felt to be due to a reduction in vaginal caliber and steep angulation of the upper vagina due to the plication of the levator ani during the typical closure of the pelvic floor at the completion of surgery. Successful therapy has been achieved with conservative measures as well as surgical treatment. CONCLUSIONS: : Abdominoperineal resection may result in a syndrome of gynecologic complaints. Medical and/or surgical therapies are effective in controlling symptoms.

Self-perceived natural history of pelvic organ prolapse described by women presenting for treatment.

INTRODUCTION AND HYPOTHESIS: This study aimed to describe the self-perceived natural history of pelvic organ prolapse (POP) in women seeking care. METHODS: Women presenting to a university-based urogynecology clinic for POP (n = 107) completed a questionnaire including questions about how and when their prolapse was discovered. A urogynecologic examination including the pelvic organ prolapse quantification (POP-Q) was also performed. RESULTS: Forty-eight percent of these women sought medical attention "immediately" after discovering a bulge. The median time to seek care was 4 months (range from 1 month to 45 years). Twenty-six percent associated their prolapse with a specific event (e.g., moving furniture or pushing a car). POP was self-discovered by 76% (81/107) of women. Self-discovered prolapses were larger than those diagnosed by physicians (Ba +1.3 vs 0.1 cm, P = .03, respectively). CONCLUSIONS: Women seek medical advice within months of discovering their prolapse. Self-discovery is associated with higher stage prolapse than prolapse diagnosed by health care providers.

Pelvic architectural distortion is associated with pelvic organ prolapse.

The aim of this study was to determine whether there is an association between architectural distortion seen on magnetic resonance (MR) scans (lateral "spill" of the vagina and posterior extension of the space of Retzius) and pelvic organ prolapse. Secondary analysis of MR imaging scans from a case-control study of women with prolapse (maximum point > or = + 1 cm; N = 144) and normal controls (maximum point < or = -1 cm; N= 126) was done. Two independent investigators, blinded to prolapse status and previously established levator-defect scores, determined the presence of architectural distortion on axial MR scans. Women were categorized into three groups based on levator defects and architectural distortion. Among the three groups, women with levator defects and architectural distortion have the highest proportion of prolapse (78%; p < 0.001). Among women with levator defects, those with prolapse had an odds ratio of 2.2 for the presence of architectural distortion (95% CI = 1.1-4.6). Pelvic organ prolapse is associated with the presence of visible architectural distortion on MR scans.

Age effects on internal anal sphincter thickness and diameter in nulliparous females.

PURPOSE: Age can affect the delicate physiologic balance of the internal anal sphincter diameters and pressure governed by Laplace's law. This study compares the effect of aging on the internal anal sphincter thickness and diameter in younger and older nulliparous females without symptoms of fecal incontinence undisturbed by an endoanal probe. METHODS: Magnetic resonance images were selected from a large database of nulliparous females to form two groups: "younger" females, aged 30 years and younger (n = 32), and "older" females, aged 50 years and older (n = 32). All patients were scanned without endoanal coils to allow undistorted measurement of the internal anal sphincter diameters. Inner and outer diameters were measured from axial magnetic resonance images and used to calculate sphincter thickness and mean radius by two independent investigators blinded to patient age. RESULTS: The mean age in the younger group was 26 +/- 2.8 years, whereas that of the older group was 61.8 +/- 7.6 years. Older females had a 33 percent thicker internal anal sphincter (younger vs. older: 4.5 +/- 0.7 vs. 5.9 +/- 1 mm; P < 0.001), a 20 percent larger inner diameter (7.1 +/- 1.3 vs. 8.5 +/- 1.8 mm; P = 0.001), and a 27 percent larger outer diameter (16 +/- 2.1 vs. 20.3 +/- 3.3 mm; P < 0.001) than younger females. Neither sphincter thickness nor inner or outer diameter correlated with body mass index. CONCLUSIONS: There is an increase in internal anal sphincter thickness, inner diameter, and outer diameter, which correlates with age in asymptomatic nulliparous females.