The effect of sugammadex on postoperative urinary retention post-laparoscopic and robotic hysterectomy with and without concomitant procedures.

INTRODUCTION AND HYPOTHESIS: This study was aimed at determining the effect of sugammadex versus a combination of glycopyrrolate and neostigmine (GN) for neuromuscular reversal blockage on transient postoperative urinary retention (TPOUR) in patients undergoing a laparoscopic and robot-assisted laparoscopic hysterectomy. METHODS: We conducted a retrospective cohort study in patients undergoing a laparoscopic or robotic hysterectomy between February 2017 and December 2021. Patients with and without concomitant procedures were included. Demographics and perioperative data were extracted from the patient's medical record. Before discharge, all patients were required to spontaneously void and have a post-void residual of less than 150 ml. RESULTS: We identified 500 patients and 485 were included in the final analysis. We had 319 subjects who received sugammadex and 166 GN combination. Both groups had overall similar demographics and perioperative characteristics. Most patients had a conventional laparoscopy procedure (391 [82.5%]) compared with robotic (83 [17.5%]). Patients who received GN were significantly more likely to be discharged home with an indwelling catheter (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.09-3.05). After adjusting for perioperative medications and sling implantation during the surgery a logistic regression model continued to demonstrate that patients who received GN had significantly higher odds of being discharged with a catheter (OR, 1.79; 95% CI, 1.03-3.12). CONCLUSIONS: Our findings suggest that sugammadex decreases the odds of TPOUR after laparoscopic hysterectomies with and without slings compared with the combination of GN. Additional prospective trials are required to confirm this finding.

Postoperative Urinary Retention.

ABSTRACT: This clinical consensus statement on the management of postoperative (<6 weeks) urinary retention (POUR) reflects statements drafted by content experts from the American Urogynecologic Society's POUR writing group. The writing group used a modified Delphi process to evaluate statements developed from a structured literature search and assessed for consensus. After the definition of POUR was established, a total of 37 statements were assessed in the following 6 categories: (1) incidence of POUR, (2) medications, (3) patient factors, (4) surgical factors, (5) urodynamic testing, and (6) voiding trials. Of the 37 original statements, 34 reached consensus and 3 were omitted.

Perinatal outcomes in women referred to the West Virginia University Assist Connect and Encourage (ACE) - A program of the Drug Free Moms and Babies Project (DFMB) for women with substance use during pregnancy.

The main objective of this study was to analyze perinatal outcomes of women with substance use disorder in pregnancy who participated in the West Virginia University Medicine Drug Free Moms and Babies Assist Connect and Encourage program (DFMB/ACE) compared to women who were not enrolled in the program. This was a retrospective cohort study conducted in an l Academic Tertiary Care Center. Women who enrolled in DFMB/ACE services from 2018 to 2019 were termed as the intervention group. Their outcomes were compared to 734 women who delivered at the hospital between July 2015 and December 2019 with a positive urine drug screen on admission but were not enrolled in the DFMB/ACE program. Perinatal outcomes evaluated include low birth weight, preterm labor, neonatal intensive care unit (NICU) admission, preterm birth, neonatal abstinence syndrome (NAS), cesarean delivery, cord toxicology result, hepatitis c prevalence, and breastfeeding at the time of discharge. Participants of the DFMB/ACE group had a lower risk of having a preterm birth (OR = 0.56 95% CI 0.36-0.86) compared to the control group. The DFMB/ACE group had higher birth weight compared to the non-DFMB group (2865.7 g. vs. 2657.9 g, p = 0.004). NICU admission, NAS, mode of delivery, cord toxicology, and breastfeeding rates were not statistically different between the two groups. Hepatitis C rates were significantly higher in the intervention vs. non-intervention group (OR = 2.74 95 %CI 1.80 - 4.16). We concluded that the DFMB/ACE program interventions for women with substance use in pregnancy improves some perinatal outcomes for mothers and their newborns.

Assessing the effectiveness of antimicrobial pouch use for infection prevention in sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: Sacral neuromodulation (SNM) is a commonly performed procedure for various conditions. Infection rates range as high as 10% and often require operative explantation with resultant increased cost and morbidity. Pouches impregnated with antibiotic have been utilized in cardiovascular procedures with decreasing infectious complications. TYRX is an antibiotic pouch utilizing minocycline and rifampin manufactured by Medtronic. The objective of this study is to investigate the utility of antimicrobial pouches for patients undergoing SNM. METHODS: We retrospectively analyzed our patients undergoing SNM using an antimicrobial pouch and compared them with a historic cohort. Additional variables of interest included post-operative infection, diagnosis of diabetes, weight, and revision case or virgin implant. RESULTS: A total of 170 cases were identified, ranging from March 2017 to November 2022. Overall infection rate was 2.9% with 0 in the antimicrobial pouch cohort (0%) versus 5 in the historic cohort (5.5%; p = 0.04). Groups were similar in terms of body habitus. The group receiving an antimicrobial pouch was noted to be older with a higher percentage of female patients. 85 patients received an antimicrobial pouch and 85 did not. Of the infections, 4 occurred in revision cases (6.9%) and 1 in a virgin implant (0.9%; p = 0.03). No difference was noted in infection rate with regard to a diagnosis of diabetes or body habitus. CONCLUSION: The use of antimicrobial pouches in SNM is associated with a decreased rate of infectious complications. Revision cases displayed a higher rate of infectious complications.

Development and validation across trimester of the Prenatal Eating Behaviors Screening tool.

Rapid screening tools are useful for identifying at-risk patients and referring them for further assessment and treatment, but none exist that consider the unique medical needs of pregnant women with eating disorders (EDs). There is a need for a rapid, sensitive, and specific screening tool that can be used to identify a potential ED in pregnancy. We started with a set of 25 questions, developed from our qualitative work along with other ED screening tools, and tested on a development (n = 190) and validation sample (n = 167). Statistical analysis included factor analysis and logistic regressions with ROC curves. Development and validation samples were combined for trimester analysis (n = 357). Refining the tool to 12 items demonstrated strong internal reliability (development alpha = 0.95, validation alpha = 0.91). With correlated errors, questions demonstrated acceptable CFA fit (development: GFI: 0.91, RMSEA: 0.10, NNFI: 0.95; validation: GFI: 0.85, RMSEA: 0.14, NNFI: 0.86). Similar fits were seen by trimester: first trimester n = 127, GFI: 0.89, RMSEA: 0.12, NNFI: 0.94; second trimester n = 150, GFI: 0.83, RMSEA: 0.14, NNFI: 0.88; third trimester n = 80, GFI: 0.99, NNFI: 0.99. Validation against current ED diagnosis demonstrated acceptable sensitivity and specificity using a cutoff of 39 (development sensitivity = 80.7%, specificity = 79.7%, OR = 16.42, 95% CI: 7.51, 35.88; validation sensitivity = 69.2%, specificity = 86.5%, OR: 17.43, 95% CI: 6.46, 47.01). Findings suggest the PEBS tool can reliably and sensitively detect EDs across pregnancy trimesters with 12 questions. A further implication of this work is to reduce health and mental health treatment disparities through this standard and rapid screening measure to ensure early identification and treatment.

Evaluation of Uroflowmetry Curve Patterns and Nomogram Construct in Healthy Nulliparous Female Adults.

OBJECTIVE: The aims of the study were to construct uroflowmetry nomograms, evaluate uroflowmetry flow rate patterns, and graphically illustrate overlaid uroflowmetry curves in nulliparous female adult volunteers. METHODS: We performed a prospective cross-sectional study evaluating uroflowmetry curve and flow rate patterns on a cohort of nulliparous female adult volunteers. Primary outcome was construction of uroflowmetry maximum and average flow rate nomograms. Secondary outcomes included evaluation of uroflowmetry flow rate patterns and graphical illustrations of overlaid uroflowmetry curves. Uroflowmetry printouts were overlaid and used to create a model of uroflow patterns, and nomogram curves were analyzed in 5 groups based on voided volumes. RESULTS: We enrolled 164 participants and 158 had voided volumes between 50 mL and 800 mL. Participants' mean age and body mass index were 25 years and 23, respectively. Maximum and average flow rate nomograms were created, and analysis of uroflow parameters was performed. Median voided volume was 241 mL (149-431 mL), the median maximum flow was 29 mL/s (20-38 mL/s), and the median average flow was 15 mL/s (10-19 mL/s). Participants were divided into 5 groups based on voided volumes. The nomogram patterns for each voided volume group were visually different from typical nomogram patterns. CONCLUSIONS: Uroflowmetry curves and flow rates vary significantly according to voided volume. Our study suggests that in normal healthy nulliparous female adults there is likely a broader range of normal flow rates and uroflowmetry curves than what has been previously reported. Further research is needed to investigate the accuracy of these finding.

A Comparative Study of Braided versus Barbed Suture for Cystotomy Repair.

BACKGROUND: In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups. METHODS: A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant. RESULTS: Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005). CONCLUSION: Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Post-partum rectus sheath hematoma complication: case report.

Pregnancy, surgery, and trauma are known risk factors for the development of rectus sheath hematomas (RSHs). The exact incidence of RSH during pregnancy is unknown, however this disease carries a risk of complication and even mortality. The role of infection in this condition is less known with only a few reported case studies in medical literature. In our case a 26-year-old G4P2113 1-month status post cesarean section presented with 2 weeks of progressive lower abdominal pain after her 50-pound daughter jumped on her. Upon further work up a computed tomography (CT) scan found a 15-cm RSH. Expectant management is the recommended first line of treatment, however, this failed after the patient presented with signs and symptoms of infection. An exploratory laparotomy was performed that had evidence of necrotizing fasciitis of the rectus muscle and subcutaneous tissue. This is a very atypical presentation of a RSH complicated with myonecrosis after a cesarean delivery. Review of the medical literature shows appropriate work up and diagnosis of RSH in pregnant patients is critical for early intervention. Furthermore, while conservative treatment is typically appropriate for non-pregnant patients it may not be sufficient for pregnant and post-partum patients. Improved understanding of this condition will result in heightened clinical suspicion, faster intervention, and more appropriate treatment. This is critical to reducing the maternal and perinatal morbidity/mortality associated with this disease.

Recurrent Incontinence After Transvaginal Partial Sling Excision in Patients with Prior Mid-Urethral Sling.

INTRODUCTION: Patients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision. OBJECTIVE: The primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients. METHODS: From 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant. RESULTS: About 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate >16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009). CONCLUSION: In conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of >16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.

Safety and Efficacy of a Disposable Vaginal Device for Stress Urinary Incontinence.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of an over-the-counter device for the treatment of stress urinary incontinence (SUI) in females. METHODS: A multicenter, interventional, single-arm study involving 5 different sites was conducted including women diagnosed with symptomatic SUI using a self-inserted pessary device. A 1-week baseline period was followed by a 2-week period of wearing the device. The main outcome of our study was to determine if the device was able to reduce at least 50% the number of leakage events and pad weight. RESULTS: Across all study sites, 73 subjects were enrolled and 51 completed the study. Efficacy analyses were conducted on the modified intent-to-treat population (n = 48), whereas the safety analysis was conducted on all consented participants. The average pad weight gain was 0.9 g/h at baseline and 0.5 g/h during the treatment phase. The number of leakage episodes per day decreased from 2 at baseline to 0.9 during the treatment phase (P < 0.0001). Seventy-one percent of the study population experienced a more than 50% reduction in leakage volume, leakage episodes, or both. The quality of life scores improved from baseline to posttreatment phase by 4.35 points on average (P < 0.0001). A total of 40 adverse events were recorded, and only 4 subjects withdrew due to adverse events. CONCLUSIONS: The self-deployable pessary device evaluated in this study is an alternative option for women seeking an over-the-counter method to manage symptoms of SUI. Further studies are required to determine the long-term effects and compliance using the device.

Urethral Diverticulum following Polypropylene Mesh Midurethral Slings: A Literature Review.

AIMS: It is currently unknown whether an association exists between polypropylene mesh and urethral diverticulum formation following placement of polypropylene midurethral slings (MUS) for the treatment of stress urinary incontinence (SUI). We aimed to examine the literature associating MUS with the occurrence of urethral diverticula. METHODS: Multiple online research databases, including PubMed, Google Scholar, EBSCOhost, and the Cochrane Library, were searched, from January 2019 to February 2019, for evidence related to the occurrence of urethral diverticula following polypropylene MUS procedures. RESULTS: Four case reports were published demonstrating the occurrence of urethral diverticula following the use of polypropylene mesh for surgical treatment of SUI. Subjects of these cases were menopausal and had an elevated body mass index (BMI), recurrent urinary tract infections (UTIs), autoimmune conditions, or prior pelvic floor surgeries. A thorough urologic workup, including imaging prior to sling placement, was not always performed. CONCLUSION: No clear association exists between polypropylene MUS placement and subsequent urethral diverticulum formation. Factors that diminish polypropylene mesh biocompatibility include elevated BMI, menopause, recurrent UTIs, prior pelvic surgeries, and preexisting medical conditions. Symptoms associated with urethral diverticula should prompt a complete urologic workup prior to MUS placement.

Recurrent Anterior Vaginal Wall Hernia after a Radical Cystectomy.

True pelvic floor areas are uncommon conditions, but they can occur after extensive pelvic surgery including radical cystectomies or pelvic exenteration. We present the case of a patient with a persistent hernia that failed a native tissue repair and required a prosthetic mesh implant as definitive surgical treatment.

Accuracy of Bladder Scanner for the Assessment of Postvoid Residual Volumes in Women With Pelvic Organ Prolapse.

OBJECTIVES: The aim of the study was to evaluate the accuracy of the bladder scanner in assessing postvoid residual (PVR) volumes in patients with pelvic organ prolapse (POP). METHODS: We performed a prospective parallel cohort study evaluating the accuracy of the BVI 3000 bladder scanner in patients with POP. Patients with POP to the hymen were offered inclusion. Primary outcome was the absolute difference between bladder scanner and catheterization PVR. We also investigated the effect of prolapse stage on bladder scanner accuracy. A prevoid bladder volume was obtained by bladder scan. Subjects voided volume was then collected. A PVR was obtained by bladder scan, followed by a PVR by catheterization. Descriptive statistics, Wilcoxon signed-rank test, linear regression analysis, and sensitivity/specificity analysis were performed. RESULTS: We enrolled 87 subjects. There was a statistically significant difference between catheter and bladder scan PVR, with an absolute median difference of 20 mL (SD = 37.7), P < 0.001. Linear regression analysis showed a difference between mild and advanced prolapse groups. The regression coefficients of the mild prolapse group and advanced prolapse were 0.91 (confidence interval = 0.75-1.06) and 0.66 (confidence interval = 0.54-0. 78), P = 0.015, respectively, indicating a deterioration of accuracy of the bladder scanner for advanced prolapse. The sensitivity of the bladder scanner identifying catheterized PVR volumes less than 100 mL was 93.7%. For catheter PVRs greater than 100 mL, the specificity of the bladder scanner was 72.7%. CONCLUSIONS: Bladder scanner PVRs are less accurate in advanced prolapse, and PVRs of greater than 100 mL should be confirmed by catheterization.

The Effect of Toileting Position in Uroflow Curves in Young Healthy Nulliparous Women.

The objective of our study was to determine the effect of voiding positions on uroflow parameters in young, healthy nulliparous women with no pelvic floor disorders. Material and Methods. From December 2017 to February 2018, we performed a single-institution cross-sectional study with 30 healthy volunteers comparing uroflow curves in sitting and hovering positions. 49 participants were initially prescreened with a validated tool questionnaire for pelvic floor disorders and 30 participants who had absent symptoms were included for the final analysis. From the selected participants, demographics were collected and comparisons between the sitting and hovering position groups regarding the maximum flow rate (Qmax), average flow rate (Qave), voided volume (VV), and time to peak flow (TQmax) were conducted using either the paired t-test or the Wilcoxon rank sum test. In addition, linear regression analysis was performed to determine whether height, BMI, and age have significant impact on the log-transformed average of the pre- and postvalues of either Qmax, Qave, VV, or TQmax, as the average of these values are not normally distributed. Results. There were no statistical differences between the hovering and sitting position groups on the maximum flow rate (p=0.93), average flow rate (p=0.82), voided volume (p=0.53), and time to peak flow (p=0.82). BMI had borderline significant impact on Qave with p value = 0.0531. Conclusion. Different voiding toileting habits do not affect the most commonly used uroflow parameters in young healthy nulliparous patients. Results need to be corroborated by a larger scale study considering the small sample size of our study.

The Effect of Oral Phenazopyridine on Perioperative Voiding After Midurethral Slings (EPIPhANy Study).

OBJECTIVE: To determine the effect of preoperative oral phenazopyridine on postoperative voiding dysfunction in women undergoing a retropubic midurethral sling. METHODS: A single-institution randomized clinical trial was performed from September 2015 to March 2017, comparing 200 mg of oral phenazopyridine versus no phenazopyridine in patients undergoing a retropubic midurethral sling under general anesthesia with no concomitant procedures. A power calculation indicated that we required at least 40 subjects per arm. Preoperative demographics, intraoperative medications, blood loss, and complications were recorded. A standardized voiding trial was performed before discharge. Voiding dysfunction was determined by the proportion of subjects who failed a postoperative voiding trial. Pain scores were obtained before and 2 to 3 hours after the surgical procedure. Patient characteristics and surgical data were compared using χ, Fisher exact test, or Wilcoxon rank sum test. RESULTS: Ninety-two subjects were enrolled in the study. Three patients cancelled their surgery and 1 had an intraoperative urethral injury, leaving 88 patients for the final analysis (44 per arm). Patient demographics showed no differences between groups. Phenazopyridine did not reduce the proportion of patients who failed the voiding trial (27%) compared with subjects who did not receive the medication (21%) (P = 0.453). Postoperative visual analog pain scores were higher in those not receiving phenazopyridine (1.76 vs 1.21, P = 0.046), but after adjusting for the difference in preoperative and postoperative pain scores, the groups showed no difference (P = 0.087). CONCLUSIONS: Our prospective trial shows that phenazopyridine has no effect on short-term postoperative voiding dysfunction. This condition appears to be multifactorial, and further research is needed.

The Effect of Preoperative Phenazopyridine on Urinary Retention Following Midurethral Sling.

OBJECTIVE: The aim of this study was to determine the effect of preoperative oral phenazopyridine on short-term voiding dysfunction in patients undergoing a retropubic midurethral sling. METHODS: We conducted a retrospective cohort study in subjects undergoing a retropubic midurethral sling comparing those who received preoperative oral phenazopyridine with those who did not. We included all women who underwent a retropubic midurethral sling without concomitant procedures under general anesthesia at our institution. Slings were placed by either suprapubic or transvaginal approach, per surgeon's preference. Demographics and intraoperative data on preoperative dose of phenazopyridine and medications linked to voiding dysfunction were captured. RESULTS: One hundred seventy-four subjects were identified. Twenty-five subjects failed to meet inclusion and exclusion criteria and were excluded, and 149 subjects comprised the final groups. Eighty-two subjects (55.03%) received phenazopyridine, and 67 (44.97%) did not. Most subjects received a 200-mg dose (97.6%). Except for surgical approach, both groups receiving and not receiving phenazopyridine had similar demographic characteristics. Eighty-eight percent of the subjects who received phenazopyridine passed the voiding trial versus 73.1% (odds ratio, 2.98; 95% confidence interval, 1.23-7.17). After adjusting for medications, estimated blood loss, number of trocar passages, or bladder perforation, the patients receiving phenazopyridine were still more likely to pass the postoperative voiding trials compared with those who did not (odds ratio, 2.97; 95% confidence interval, 1.10-7.98). CONCLUSIONS: Our findings suggest that the preoperative administration of phenazopyridine may improve postoperative voiding function after a retropubic midurethral sling. Additional prospective trials are needed to confirm this finding.

Knot integrity using different suture types and different knot-tying techniques for reconstructive pelvic floor procedures.

INTRODUCTION AND HYPOTHESIS: Surgeons use a variety of sutures and knot-tying methods during pelvic reconstructive procedures. We hypothesized that knot-strength integrity will be similar with regards to type of knot, type of suture, and the knot-tying process. METHODS: Using six different suture materials, flat square knots and slip knots were tied robotically and by hand by two surgeons. Knot integrity was evaluated using an Instron 5544 machine. We measured force and elongation at suture failure or knot slippage (whichever came first) as well as force at 3-mm displacement. RESULTS: Four hundred and thirty-two knots were tie; one unraveled before the analysis, and 431 were tested. Three hundred and ninety-two knots reached or surpassed tensile strength of 30 N, the force at which tissue itself will fail. Knots tied with polyglyconate suture achieved the greatest tensile strength and those with OO-polydioxanone had the lowest. Hand-tied knots, regardless of technique and suture material, had greater tensile strength but greater elongation than robotically tied knots. Slip knots and flat square knots have similar integrity regardless of the tying technique. CONCLUSION: Hand-tied knots had greater tensile strength than robotic knots, but the strength to break all knots required supraphysiological conditions. The decision to use a specific type of suture based on strength is not supported by our results, suggesting that surgeons may choose sutures based on other characteristics and personal comfort.