A prospective pilot study to assess for histologic changes on vulvar biopsies in postmenopausal women with lichen sclerosus treated with fractionated CO2 laser therapy.

OBJECTIVES: To investigate the histologic characteristics of vulvar tissues before and after completion of fractionated carbon dioxide (CO2 ) laser therapy (FxCO2) for vulvar lichen sclerosus (LS). The secondary objective was to assess subjective improvement in symptoms via the Skindex-16 questionnaire. METHODS: This prospective single-arm study was conducted from April 2021 to August 2022 at one academic medical center. Ten postmenopausal women with biopsy-proven LS planning FxCO2 laser treatment were enrolled. Exclusion criteria included prior transvaginal mesh for prolapse, topical corticosteroid use within 8 weeks, prior pelvic radiation, malignancy, active genital infection, or pregnancy. The vulvovaginal SmartXide2-V2-LR laser system fractionated CO2 laser (DEKA) was utilized to treat visually affected areas of vulvar and perianal LS with a single pass. Subjects underwent three treatments 4-6 weeks apart. Subjects completed the Skindex-16 questionnaire and had vulvar biopsy at baseline and at 4 weeks after completion of fractionated CO2 laser therapy. Blinded histologic slides were scored by one dermatopathologist (Michael A. Cardis) rating from 1 to 5 the degree of dermal sclerosis, inflammation, and epidermal atrophy. Change scores were calculated as the difference between pre- and post-treatment scores for each subject. RESULTS: The 10 subjects enrolled had a mean age of 61 and most were white, privately insured, and had a college/graduate-level education. Post-fractionated CO2 laser treatment vulvar biopsies showed significant improvement in sclerosis and epidermal atrophy compared with pretreatment baseline biopsy specimens (p < 0.05) with no statistically significant change found in inflammation score. Skindex-16 and FSFI scores showed a trend towards improvement (p > 0.05 for both). A statistically significant correlation was found between change in sclerosis and Skindex-16 symptoms scores with an average change of 21.4 units in Skindex-16 symptoms score for every one-point change in histologic sclerosis score (p = 0.03). CONCLUSIONS: In postmenopausal women with vulvar LS undergoing fractionated CO2 laser, symptomatic improvements correlated with histologic change in degree of sclerosis on vulvar biopsy. These results demonstrate FxCO2 laser therapy as a promising option for the treatment of LS and suggest that further studies should assess degree of sclerosis on histopathology.

Assessing the Impact of Vaginal Hysterectomy with Vaginal Mesh Attachment on Outcomes and Complications during Minimally Invasive Sacrocolpopexy.

STUDY OBJECTIVE: To compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy. DESIGN: Single-center retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Women with symptomatic pelvic organ prolapse who elected for MISC. INTERVENTIONS: Laparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse. MEASUREMENTS AND MAIN RESULTS: Between 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p = .31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p >.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p = .07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p = .57), or composite failure (9.0% vs 3.7% vs 4.8%; p = .07). CONCLUSIONS: TVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.

Mesh Exposure Following Vaginal Versus Laparoscopic Hysterectomy at the Time of Sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: To compare vaginal mesh exposure rates, adverse events and composite failure within 1 year postoperatively in patients who undergo vaginal hysterectomy with vaginal mesh attachment (TVH) versus laparoscopic hysterectomy with abdominal mesh attachment (TLH) for minimally invasive sacrocolpopexy. METHODS: This multicenter retrospective cohort study is a secondary analysis of data collected retrospectively at one institution and the multicenter randomized control PACT trial. Women were excluded for no follow-up between 9 months and 2 years postoperatively or undergoing concurrent non-urogynecologic procedures. RESULTS: Between 2010 and 2019, 182 patients underwent TLH and 132 TVH. There were 15 (4.8%) vaginal mesh exposures: 12 (6.6%) in the TLH and 3 (2.3%) in the TVH group (p = 0.133) with zero mesh erosions. Logistic regression analysis for mesh exposure in the TLH vs. TVH groups controlling for BMI, posterior repair and surgeon training also showed no significant difference (OR 4.8, 95% CI 0.94, 24.8, p = 0.059). The overall intraoperative complication rate was low (19/314, 6.1%) with a higher rate of bladder injury in the TLH group (4.4% vs. 0.8%, p = 0.049). The TLH group had a higher rate of UTI (8.2% vs. 2.3%, p = 0.027) and clean intermittent catheterization (11% vs. 3%, p = 0.009). At 1-year follow-up, there was no difference in composite failure (6%), bulge symptoms (5%) or retreatment (1%) between groups. CONCLUSIONS: At 1 year, there is no significant difference in vaginal mesh exposure rates between vaginal hysterectomy with vaginal mesh attachment and laparoscopic hysterectomy with abdominal mesh attachment. Both groups have equal efficacy with low rates of complications.

Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study.

BACKGROUND: There is growing interest in uterine conservation at the time of surgery for uterovaginal prolapse, but limited data compare different types of hysteropexy. OBJECTIVE: We sought to compare 1-year efficacy and safety of laparoscopic sacral hysteropexy and vaginal mesh hysteropexy. STUDY DESIGN: This multicenter, prospective parallel cohort study compared laparoscopic sacral hysteropexy to vaginal mesh hysteropexy at 8 institutions. We included women ages 35-80 years who desired uterine conservation, were done with childbearing, and were undergoing 1 of the above procedures for stage 2-4 symptomatic anterior/apical uterovaginal prolapse (anterior descent at or beyond the hymen [Aa or Ba ≥ 0] and apical descent at or below the midvagina [C ≥ -TVL/2]). We excluded women with cervical elongation, prior mesh prolapse repair, cervical dysplasia, chronic pelvic pain, uterine abnormalities, and abnormal bleeding. Cure was defined as no prolapse beyond the hymen and cervix above midvagina (anatomic), no vaginal bulge sensation (symptomatic), and no reoperations. Pelvic Organ Prolapse Quantification examination and validated questionnaires were collected at baseline and 12 months including the Pelvic Floor Distress Inventory Short Form, Female Sexual Function Index, and Patient Global Impression of Improvement. In all, 72 subjects/group were required to detect 94% vs 75% cure (80% power, 15% dropout). Intention-to-treat analysis was used with logistic regression adjusting for baseline differences. RESULTS: We performed 74 laparoscopic sacral hysteropexy and 76 vaginal mesh hysteropexy procedures from July 2011 through May 2014. Laparoscopic patients were younger (P < .001), had lower parity (P = .006), were more likely premenopausal (P = .008), and had more severe prolapse (P = .02). Laparoscopic procedure (174 vs 64 minutes, P < .0001) and total operating time (239 vs 112 minutes, P < .0001) were longer. There were no differences in blood loss, complications, and hospital stay. One-year outcomes for the available 83% laparoscopic and 80% vaginal hysteropexy patients revealed no differences in anatomic (77% vs 80%; adjusted odds ratio, 0.48; P = .20), symptomatic (90% vs 95%; adjusted odds ratio, 0.40; P = .22), or composite (72% vs 74%; adjusted odds ratio, 0.58; P = .27) cure. Mesh exposures occurred in 2.7% laparoscopic vs 6.6% vaginal hysteropexy (P = .44). A total of 95% of each group were very much better or much better. Pelvic floor symptom and sexual function scores improved for both groups with no difference between groups. CONCLUSION: Laparoscopic sacral hysteropexy and vaginal mesh hysteropexy had similar 1-year cure rates and high satisfaction.

Minimally Invasive Surgery Survey: A Survey of Surgical Team Members' Perceptions for Successful Minimally Invasive Surgery.

STUDY OBJECTIVE: To develop a valid and reliable survey to measure surgical team members' perceptions regarding their institution's requirements for successful minimally invasive surgery (MIS). DESIGN: Questionnaire development and validation study (Canadian Task Force classification II-2). SETTING: Three hospital types: rural, urban/academic, and community/academic. PARTICIPANTS: Minimally invasive staff (team members). INTERVENTION: Development and validation of a minimally invasive surgery survey (MISS). MEASUREMENT AND MAIN RESULTS: Using the Safety Attitudes questionnaire as a guide, we developed questions assessing study participants' attitudes regarding the requirements for successful MIS. The questions were closed-ended and responses based on a 5-point Likert scale. The large pool of questions was then given to 4 focus groups made up of 3 to 6 individuals. Each focus group consisted of individuals from a specific profession (e.g., surgeons, anesthesiologists, nurses, and surgical technicians). Questions were revised based on focus group recommendations, resulting in a final 52-question set. The question set was then distributed to MIS team members. Individuals were included if they had participated in >10 MIS cases and worked in the MIS setting in the past 3 months. Participants in the trial population were asked to repeat the questionnaire 4 weeks later to evaluate internal consistency. Participants' demographics, including age, gender, specialty, profession, and years of experience, were captured in the questionnaire. Factor analysis with varimax rotation was performed to determine domains (questions evaluating similar themes). For internal consistency and reliability, domains were tested using interitem correlations and Cronbach's α. Cronbach's α > .6 was considered internally consistent. Kendall's correlation coefficient τ closer to 1 and with p < .05 was considered significant for the test-retest reliability. Two hundred fifty participants answered the initial question set. Of those, 53 were eliminated because they did not meet inclusion criteria or failed to answer all questions, leaving 197 participants. Most participants were women (68% vs 32%), and 42% were between the ages 30 and 39 years. Factor analysis identified 6 domains: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. Interitem correlations testing for redundancy for each domain ranged from .2 to .7, suggesting similar themed questions while avoiding redundancy. Cronbach's α, testing internal consistency, was .87. Sixty-two participants from the original cohort repeated the question set at 4 weeks. Forty-three were analyzed for test-retest reliability after excluding those who did not meet inclusion criteria. The final questions showed high test-retest reliability (τ = .3-.7, p < .05). The final questionnaire was made up of 29 questions from the original 52 question set. CONCLUSION: The MISS is a reliable and valid tool that can be used to measure how surgical team members conceptualize the requirements for successful MIS. The MISS revealed that participants identified 6 important domains of a successful workenvironment: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. The questionnaire can be used to understand and align various surgical team members' goals and expectations and may help improve quality of care in the MIS setting.

Defining Cervical Elongation: A Prospective Observational Study.

OBJECTIVES: Our primary aim was to define cervical elongation (CE) using the following methods: (1) measurement of pathology specimen, (2) physician perception, (3) intraoperative estimate of anterior cervical length, and (4) office Pelvic Organ Prolapse Quantification (POP-Q) points C and D. Our secondary aim was to determine whether these definitions correlate with perioperative outcomes. METHODS: Women undergoing vaginal hysterectomy and prolapse repair were enrolled. Office POP-Q measurements were collected. Estimates of cervical length were made based on points C minus D of the POP-Q and by manual exam using the surgeon's index and middle fingers. Cervical dimensions were measured from the pathology specimen at the end of the case. CE was defined as one standard deviation (SD) above the mean for each definition. Additional intraoperative data was collected to determine the surgeon perception of cervical anatomy. RESULTS: A total of 90 patients were enrolled during the study period. Our definitions for CE were as follows: (1) 5 cm (70 without and 20 with CE), (2) physician perception (67 without and 23 with CE), (3) 3.4 cm (79 without and 11 with CE), and (4) 8.3 cm (77 without and 13 with CE). After controlling for uterine weight and the presence of fibroids, the operative time was the only outcome measure that remained elevated for patients with CE using our first definition (42.4 ± 20.1 without vs. 53.8 ± 19.2 with CE, P = 0.03). CONCLUSIONS: CE using our first definition was associated with a statistically significant increase in operative time in women undergoing hysterectomy at the time of prolapse repair.

Significance of cystoscopic bladder trabeculations in women undergoing midurethral sling.

INTRODUCTION: To determine the significance of bladder trabeculations seen on preoperative cystoscopy prior to midurethral sling surgery with respect to lower urinary tract symptoms and sling outcomes. MATERIALS AND METHODS: This retrospective study included women with preoperative cystoscopy who underwent midurethral slings for urinary incontinence from 2006-2009. Cystoscopic findings of bladder trabeculations, as well as pre and postoperative urinary symptoms were recorded. Patients with and without bladder trabeculations were compared with respect to baseline characteristics, lower urinary tract symptoms, and sling outcomes. RESULTS: Of the 241 women included in the study, 14.9% had trabeculations on preoperative cystoscopy. At baseline, women with trabeculations were more likely to be older (64.8 years versus 57.8 years, p < 0.01), and have lower mean maximum cystometric capacity (341 mL +/- 136 versus 436 mL +/- 148, p < 0.01), compared to those without trabeculations. More women with trabeculations had mixed incontinence (p < 0.01) and less pure stress incontinence (p < 0.01) preoperatively. There was no difference between women with and without trabeculations with respect to pre and postoperative symptoms of urgency, frequency, and nocturia. Women with preoperative trabeculations were more likely to have preoperative treatment with anticholinergics (p = 0.02) and had a three times higher risk of postoperative sling failure (HR 2.95 [CI 1.11-7.85], p = 0.03). CONCLUSIONS: Preoperative cystoscopic bladder trabeculations are associated with significantly higher rate of midurethral sling failure. Trabeculations were not associated with pre or postoperative lower urinary tract symptoms.

Hysterectomy and urinary incontinence in postmenopausal women.

INTRODUCTION AND HYPOTHESIS: To evaluate an association between hysterectomy and urinary incontinence (UI) in postmenopausal women. METHODS: Women (aged 50-79) with uteri (N = 53,569) and without uteri (N = 38,524) who enrolled in the Women's Health Initiative (WHI) Observational Study between 1993 and 1996 were included in this secondary analysis. Baseline (BL) and 3-year demographic, health/physical forms and personal habit questionnaires were used. Statistical analyses included univariate and logistic regression methods. RESULTS: The baseline UI rate was 66.5 %, with 27.3 % of participants having stress urinary incontinence (SUI), 23 % having urge UI (UUI), and 12.4 % having mixed UI (MUI). 41.8 % of women had undergone hysterectomy, with 88.1 % having had the procedure before age 54. Controlling for health/physical variables, hysterectomy was associated with UI at BL (OR 1.25, 95 % CI 1.19, 1.32) and over the 3-year study period (OR 1.23, 95 % CI 1.11, 1.36). Excluding women with UI at BL, a higher incidence of UUI and SUI episodes was found in hysterectomy at year 3. Among women who had undergone hysterectomy, those with bilateral oophorectomy (BSO) did not have increased odds of developing UI at BL or over the 3-year study period. Hormone use was not associated with a change in UI incidence (estrogen + progesterone, p = 0.17; unopposed estrogen, p = 0.41). CONCLUSIONS: Risk of UI is increased in postmenopausal women who had undergone hysterectomy compared with women with uteri.

Blinded assessment of operative performance after fundamentals of laparoscopic surgery in gynecology training.

STUDY OBJECTIVE: To determine the pass rate for the Fundamentals of Laparoscopic Surgery (FLS) examination among senior gynecology residents and fellows and to find whether there is an association between FLS scores and previous laparoscopic experience as well as laparoscopic intraoperative (OR) skills assessment. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: Three gynecology residency training programs. PARTICIPANTS: Third- and fourth-year gynecology residents and urogynecology fellows. INTERVENTIONS: All participants participated in the FLS curriculum, written and manual skills examination, and completed a survey reporting baseline characteristics and opinions. Fourth-year residents and fellows underwent unblinded and blinded pre- and post-FLS OR assessments. Objective OR assessments of fourth-year residents after FLS were compared with those of fourth-year resident controls who were not FLS trained. MEASUREMENTS AND MAIN RESULTS: Twenty-nine participants were included. The overall pass rate was 76%. The pass rate for third- and fourth-year residents and fellows were 62%, 85%, and 100%, respectively. A trend toward improvement in OR assessments was observed for fourth-year residents and fellows for pre-FLS curriculum compared with post-FLS testing, and FLS-trained fourth-year residents compared with fourth-year resident controls; however, this did not reach statistical significance. Self-report of laparoscopic case load experience of >20 cases was the only baseline factor significantly associated with passing the FLS examination (p = .03). CONCLUSION: The FLS pass rate for senior residents and fellows was 76%, with higher pass rates associated with increasing levels of training and laparoscopic case experience.

One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse.

OBJECTIVE: The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh. STUDY DESIGN: Women with stage ≥2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ≤1 at 12 months. Secondary outcomes included quality of life and complications. RESULTS: All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh. CONCLUSION: Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.

Interest in cosmetic vulvar surgery and perception of vulvar appearance.

OBJECTIVE: The objective of the study was to determine whether reproductive-age women are more likely to perceive their vulva as abnormal compared with older-aged women. STUDY DESIGN: Women aged 18-44 years (group 1) and 45-72 years (group 2) completed a survey on demographics, grooming patterns, vulvar perceptions, and source of information about the vulva. RESULTS: There was no difference between group 1 and group 2 in how often women looked at their vulva or their perception of having a normal vulva (91% vs 93%, P = .76). Both groups were satisfied with the appearance of their vulva (81% vs 82%, P = .71). A higher percentage in group 2 would consider cosmetic surgery if cost were not an issue versus group 1 (15% vs 8%, P = .05). CONCLUSION: A woman's age does not have an impact on her perception of a normal vulva. The majority of women perceived their vulva to be normal and were satisfied with its appearance. However, older women are more interested in cosmetic vulvar surgery.

Patient goal attainment in vaginal prolapse repair with and without mesh.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to describe patient-centered goals and their attainment in vaginal prolapse repair, with and without mesh. METHODS: A secondary analysis of a multicenter randomized controlled trial of prolapse repair with or without vaginal mesh was performed. Participants (n = 65) selected three preoperative goals ranked by importance. At 3 and 12 months postoperatively, patients graded their goal attainment on a scale of 1 (not at all) to 5 (100 % attainment). Goal attainment was compared with anatomical outcome, symptoms, quality of life, and satisfaction scores. Nonparametric tests and the log-rank test were used to determine statistical significance (p < 0.05). RESULTS: A total of 176 goals were selected. The first goal in 37 women (57 %) was improving prolapse symptoms, in 15 (23 %) urinary symptoms, in 7 (11 %) appearance, activity, and self-image, in 2 (3.1 %) bowel symptoms, and in 2 (3.1 %) sexual function. At 3 and 12 months postoperatively, goal achievement for prolapse symptoms was 96.1 and 93.6 %, for urinary symptoms 75.6 and 70.0 %, and for appearance, activity, and self-image 90.5 and 94.7 %, respectively. The effect of anatomical outcome, mesh use, or the presence of mesh erosion on goal attainment could not be demonstrated. Women who achieved their first goal had significantly better symptoms, quality of life, and satisfaction scores than women who did not. CONCLUSIONS: Patient goal attainment after vaginal prolapse repair was high and not consistently related to objective anatomical outcome or mesh use. It persisted between 3 and 12 months postoperatively and was associated with better satisfaction, quality of life, and symptom scores.

Outcome assessment with blinded versus unblinded POP-Q exams.

OBJECTIVE: To determine whether blinded and unblinded Pelvic Organ Prolapse Quantification (POP-Q) examinations differ in a randomized trial. STUDY DESIGN: Blinded POP-Q examinations performed at 3 months and 1 year were compared with unblinded examinations performed by the surgeon in a randomized trial of vaginal mesh for pelvic organ prolapse. RESULTS: Sixty-five patients were included in the study. Correlations between the blinded and unblinded POP-Q points and stages varied from low to moderate (rho = 0.29-0.78). At 3 months, the blinded overall prolapse recurrence rate was 45.3% compared with 39.1% based on unblinded staging (P = .34). At 1 year, the blinded overall recurrence rate was significantly higher than the unblinded recurrence rate: 68.3% vs 53.3% (P = .004). The 1-year blinded anterior wall recurrence rate was also higher than the recurrence based on unblinded staging: 56.7% vs 43.3% (P = .021). CONCLUSION: Use of unblinded POP-Q staging resulted in underestimation of 1-year overall recurrence after prolapse repair.

A case report of antepartum bladder outlet obstruction following transobturator sling placement.

We present a case of urinary retention due to bladder outlet obstruction in a pregnant patient who had a prior transobturator synthetic sling procedure for stress urinary incontinence 2 years earlier. After the sling was released at 19 weeks, the voiding dysfunction resolved, but the patient remained incontinent. This case emphasizes a potential unique complication of suburethral sling in pregnancy.

Laparoscopic hysterectomy.

The use of laparoscopy to perform all or part of hysterectomy has become widely accepted, with laparoscopic hysterectomy accounting for up to 15% of all hysterectomies performed in the United States. A recent Cochrane analysis has clearly shown that laparoscopic hysterectomy is associated with decreased length of stay and faster recovery time compared with laparotomy. There is no evidence to support a supracervical hysterectomy over a total hysterectomy in terms of frequency of pelvic support disorders or sexual function. This does not preclude the use of a supracervical hysterectomy in some clinical situations.

Pelvic Organ Prolapse---Vaginal and Laparoscopic Mesh: The Evidence.

This report summarizes the current literature on abdominal, laparoscopic, and transvaginal mesh for the treatment of pelvic organ prolapse. This article reviews objective and subjective cure rates as well as complications associated with synthetic mesh use for pelvic organ prolapse repair. The focus is on the latest literature that provides evidence for when synthetic mesh use is most appropriate. The use of mesh for the repair of urinary incontinence is not reviewed in this article.

Utilizing Technology in Assessment of Lower Urinary Tract Symptoms: A Randomized Trial of Electronic Versus Paper Voiding Diaries.

OBJECTIVES: The aim of this study was to compare a Web app developed by the American Urogynecologic Society, called "BladderTrakHer," to the traditional paper voiding diary (PVD) for reliability and satisfaction. METHODS: Women presenting to our urogynecology practice with lower urinary tract symptom and access to an iPhone/iPad were randomized to a 3-day electronic voiding diary (EVD), using the BladderTrakHer Web app or PVD. Participants then completed a second voiding diary using the alternate format. Estimated fluid intake and output, number of voids, and episodes of incontinence were compared between formats. Patient and practitioner surveys assessed ease of use, ease of data interpretation, time to data entry, and overall satisfaction. RESULTS: Thirty-one of 122 patients completed both diary formats and the survey. The EVD and PVD showed good test-retest reliability. Patients recorded a higher number of entries for both voids and leaks while using the PVD (28.0 vs 25.5 [P = 0.03] and 4.5 vs 2.8 [P = 0.02], respectively). There was no significant difference in time to data entry among diary formats; 51.6% of patients preferred the EVD, and 78% of patients would prefer an electronic format if the app were improved. Four of 6 practitioners found the PVD easier to interpret, but all stated a preference for an EVD if the data were presented in a more organized fashion. CONCLUSIONS: The use of an EVD is acceptable and reliable in our population of adult female patients with lower urinary tract symptom. Electronic voiding diary and PVD have good test-retest reliability, although the number of voids and leaks entered is slightly lower for the EVD.

Transvaginal Versus Transabdominal Placement of Synthetic Mesh at Time of Sacrocolpopexy.

OBJECTIVES: Our primary aim was to compare mesh-related complications at the time of total vaginal hysterectomy with laparoscopic sacrocolpopexy (TVH-LSC) versus laparoscopic placement of sacrocolpopexy mesh at time of laparoscopic supracervical hysterectomy (LSH-LSC). Our secondary aim was to compare operative time, intraoperative and postoperative complications, as well as subjective and objective success between these groups. METHODS: We performed a retrospective cohort study with prospective follow-up for patients with uterovaginal prolapse who underwent TVH-LSC or LSH-LSC from June 2008 to July 2012. We collected baseline demographics, mesh-related complications, intraoperative and postoperative complications, and pelvic organ prolapse quantification data. We contacted patients postoperatively for telephone interviews and to request a return to the office for repeat examination. RESULTS: One hundred eighty-two patients were included: 123 TVH-LSC and 59 LSH-LSC. There was no difference in the rate of mesh-related complications (1.6% [2/123]; 95% confidence interval, 0-3.86% vs 1.7% [1/59]; 95% confidence interval, 0-4.99%; P = 1.0). Median examination follow-up was similar between groups (9 (2-17) months TVH-LSC vs 9 (2-17) months LSH-LSC, P = 1.0).The TVH-LSC was associated with a significantly shorter operative time (256 ± 53 vs 344 ± 81 minutes; P < 0.01). There were no differences in intraoperative or postoperative complications or subjective and objective success between groups. CONCLUSIONS: There was no difference in mesh-related complications between groups (1.6% TVH-LSC vs 1.7% LSH-LSC; P = 1.0). Vaginal mesh attachment during TVH-LSC decreased operative time by over 1 hour with no differences in intraoperative complications, reoperation for recurrent prolapse, and subjective or objective outcomes compared to LSH-LSC.

Anatomic relationships of infracoccygeal sacropexy (posterior intravaginal slingplasty) trocar insertion.

OBJECTIVE: The purpose of this study was to describe the distances of the major bony, vascular, neurologic, and visceral structures to the path of the infracoccygeal sacropexy trocar and to determine the point of trocar entry into the vagina. STUDY DESIGN: Infracoccygeal sacropexy trocars were inserted bilaterally into 6 fresh frozen cadavers. Dissection was performed and the maximal length of the vagina, ischiorectal fossa, and pararectal spaces were measured bilaterally. Mean distances with 95% CIs to important anatomic structures were made from fixed points along the trocar's path. RESULTS: The path of the trocar began dorsal and lateral to the anus, passed through the ischiorectal fossa, iliococcygeus muscle, into the pararectal space, and into the posteriolateral vagina. Along this course, the mean distance (95% CI) to the pudendal vessels at the exit of Alcock's canal was 2.8 cm (2.1 to 3.4 cm) and rectum was 0.5 cm (0.2 to 0.9 cm). The closest inferior rectal vessel was 0.1 cm (0 to 0.3 cm). In the pararectal space, the mean distance to the ischial spine was 2.6 cm (1.7 to 3.5 cm). In 12 of 12 trocar passages, the inferior rectal branches of the pudendal artery and the rectum were within 1 cm or less of the trocar. The mean distance of trocar entry into the vagina was only 4.8 cm (4.3 to 5.4 cm) proximal to the hymenal ring compared with a mean total vaginal length of 8.7 cm (8.0 to 9.3 cm). CONCLUSION: This anatomic study suggests that the rectum and the inferior rectal branches of the pudendal neurovascular bundle may be at risk of injury during infracoccygeal sacropexy trocar placement. Additionally, this procedure appears to provide support to the mid-posterior vaginal wall, not the vaginal apex.

Effects of bilateral salpingo-oophorectomy at the time of hysterectomy on pelvic organ prolapse: results from the Women's Health Initiative trial.

OBJECTIVE: This study aims to estimate the effects of bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy and estrogen therapy on vaginal prolapse. METHODS: A retrospective analysis of the Women's Health Initiative estrogen-alone trial was performed. Women who retained their ovaries were compared with women who had BSO at the time of hysterectomy for the presence of cystocele or rectocele at entry into the study. Based on BSO and hormone therapy (HT) status, participants were categorized into groups. We hypothesized that BSO and prolonged hypoestrogenemia may be associated with an increased risk of prolapse. Univariate and multivariate analyses were used to determine the effects of BSO and HT status on cystocele and rectocele. RESULTS: Of 10,739 participants in the estrogen-alone trial, 8,879 women were included in the analysis. Older age, higher parity, higher body mass index, higher waist-to-hip ratio, and non-African-American race/ethnicity were associated with increased odds of developing cystocele or rectocele. Women who retained their ovaries had higher rates of cystocele or rectocele at screening (39%) compared with all women who had BSO (31-36%; odds ratio, 1.18; 95% CI, 1.04-1.33). After controlling for multiple variables, our analysis showed that women who retained their ovaries had higher odds of developing cystocele or rectocele compared with women who had BSO and no subsequent HT (odds ratio, 1.23; 95% CI, 1.07-1.41). All other comparisons were nonsignificant. CONCLUSIONS: BSO at the time of hysterectomy is not associated with increased risk of cystocele or rectocele. BSO and no subsequent HT may even have a protective effect against cystocele or rectocele.