Variation in bony landmarks and predictors of success with sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: We assessed variations in sacral anatomy and lead placement as predictors of sacral neuromodulation (SNM) success. Based solely on bony landmarks, we also assessed the accuracy of the 9 and 2 protocol for locating S3. METHODS: This is a retrospective cohort study performed from October 2008 to December 2016 at the University of North Carolina at Chapel Hill. Fluoroscopic images were used to assess sacral anatomy and lead location. Success was defined as >50% symptom improvement after stage I and clinical response at most recent follow-up. RESULTS: Of 249 procedures, 209 were primary implants and 40 were revisions among 187 (89.5%) women and 22 (10.5%) men. Success rate was 83.3% for primary implants and 89.4% for revisions. Success was associated with shorter implant duration (21.3 ± 22.2 vs 33.6 ± 25.8 months), higher body mass index (30.3 ± 7.8 vs 27.6 ± 6.1 kg/m2), and straight vs curved lead (90.5% vs 80.5%) (all p = .05), but not with sacral anatomy or lead placement. In assessing the 9 and 2 protocol, mean distance from coccyx to S3 did not equal 9 cm: 7.4 ± 1.0 vs 7.2 ± 0.8 cm (p = .26), while mean distance from midline to S3 did equal 2 cm: 1.9 ± 0.4 vs 2.0 ± 0.7 cm (p = .37). CONCLUSIONS: Variations in sacral anatomy and lead placement did not predict SNM success. The 2-cm protocol was verified while the 9-cm protocol was not, although neither was predictive of success, which may obviate the need to mark bony landmarks prior to fluoroscopy.

Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study.

INTRODUCTION AND HYPOTHESIS: Understanding of pelvic floor disorders among women with gynecological cancer is limited. The objective of this study was to describe the prevalence of pelvic floor disorders in women with suspected gynecological malignancy before surgery. METHODS: A cross-sectional study was performed of women aged ≥18 with a suspected gynecological malignancy who enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort (HR/CSC) from August 2012 to June 2013. Demographics were obtained from the HR/CSC self-reported data; clinical data were abstracted from the electronic medical record. Subjects completed validated questionnaires (Rotterdam Symptom Checklist and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms) to assess bladder and bowel function. RESULTS: Among 186 women scheduled for surgery for gynecological malignancy, 152 (82 %) completed baseline assessments before surgery. Mean age was 58.1 ± 13.3 years, and mean BMI was 33.6 ± 8.8 kg/m(2). The majority of subjects had uterine cancer (61.8 %), followed by ovarian (17.1 %) and cervical (11.1 %). At baseline, the rate of urinary incontinence (UI) was 40.9 %. A third of subjects reported stress UI, and one quarter reported urge UI. The overall rate of fecal incontinence was 3.9 %, abdominal pain was 47.4 %, constipation was 37.7 %, and diarrhea was 20.1 %. When comparing cancer types, there were no differences in pelvic floor symptoms. CONCLUSION: Pelvic floor disorders are common in women with suspected gynecological malignancy at baseline before surgery. Recognizing pelvic floor disorders in the preoperative setting will allow for more individualized, comprehensive care for these women.

The effect of sacral neuromodulation on pudendal nerve function and female sexual function.

AIMS: To quantify changes in pudendal nerve function with sacral neuromodulation (SNM). To understand the relationship of pudendal nerve function to SNM treatment response for overactive bladder. To assess the relationship between female sexual function and pudendal nerve function after SNM. METHODS: Women undergoing SNM between January 2010 and May 2011 were enrolled. Baseline pudendal nerve terminal motor latencies (PNTML) were measured bilaterally. Subjects underwent peripheral nerve evaluation (PNE) prior to SNM therapy. PNTML was measured at 1 and 6 weeks after sacral neuromodulator implant. Women who did not undergo permanent implantation were reassessed at the end of the 1-week PNE testing phase. Pelvic floor and sexual function questionnaires were administered at baseline and follow-up to assess pelvic floor and sexual function. RESULTS: Of 34 women enrolled, 31 were evaluated. Mean age was 67.4 ± 14.2 years with 29/34 (85.3%) treated for refractory overactive bladder. Thirty of 31 (96.7%) went on to a permanent implant. PNE success rate was 73.5% (25/33). Mean PNTML changed from 2.74 ± 0.52 msec at baseline to 2.57 ± 0.50 msec at 6 weeks postop (P = 0.198). Baseline amplitude remained stable at 1 and 6 weeks. At 6 weeks PISQ-12 scores showed improved sexual function (P = 0.034) and PFDI-20 and PFIQ-7 scores showed improved pelvic floor, colorectal and urinary symptoms (P < 0.05). CONCLUSIONS: Women with refractory overactive bladder and non-obstructive urinary retention have abnormal pudendal nerve function, which showed a non-significant trend toward improvement after SNM. Sexually active women undergoing sacral neuromodulation experienced improvement in sexual function. Quality of life improved due to improvement in urinary and colorectal function.

Robotic vs abdominal sacrocolpopexy: 44-month pelvic floor outcomes.

OBJECTIVE: To evaluate longer-term clinical outcomes after robotic vs abdominal sacrocolpopexy for the treatment of advanced pelvic organ prolapse (POP). MATERIAL AND METHODS: This was a retrospective cohort assessment of women undergoing either robotic or abdominal sacrocolpopexy between March 2006 and October 2007. Pelvic floor support was measured using Pelvic Organ Prolapse Quantification (POP-Q) examination, and pelvic floor function was assessed via validated questionnaires, including the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). RESULTS: The analysis included 51 subjects: 23 robotic and 28 abdominal. Mean time since surgery was 44.2 ± 6.4 months. Postoperative POP-Q improved similarly from baseline in both the robotic and abdominal groups: C (-8 vs -7), Aa (-2.5 vs -2.25), Ap (-2 vs -2) (all P >.05 based on route of surgery). Pelvic floor function also improved similarly in both groups: PFDI-20 (61.0 vs 54.7), PFIQ-7 (19.1 vs 15.7), with high sexual function PISQ-12 (35.1 vs 33.1) (all P >.05 based on route of surgery). Two mesh exposures occurred in each group for a rate of 8% and 7%, respectively. CONCLUSION: Robotic sacrocolpopexy demonstrates similar long-term outcomes compared with abdominal sacrocolpopexy. The robotic approach offers an effective treatment alternative to abdominal sacrocolpopexy for the lasting treatment of advanced POP.

Bupivacaine injection during midurethral sling and postoperative pain: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to investigate the impact of retropubic injection of 0.125% bupivacaine during midurethral sling placement on postoperative pain. METHODS: A randomized, double-blind trial of 42 women undergoing midurethral sling for stress incontinence was conducted. The intervention group received an injection of 0.125% bupivacaine in the retropubic space prior to midurethral sling placement, while the control group received no injection. Pain scores were recorded via a 10-cm visual analog scale at 2, 6, and 24 h postoperatively. RESULTS: Pain scores were lower in the bupivacaine group compared to the control group at 2 h (1.9 versus 2.6, p = 0.05). Mean pain scores were similar at all other time points (all p > 0.45). Participants in both groups used similar amounts of pain medication in the hospital, except that patients in the bupivacaine group used more PO non-steroidal anti-inflammatory drugs (p = 0.047). CONCLUSIONS: Retropubic injection of 0.125% bupivacaine at the time of midurethral sling placement decreases short-term postoperative pain.