Specialty-Specific Trends in Surgery for Apical Pelvic Organ Prolapse Post Vaginal Mesh.

IMPORTANCE: Since transvaginal mesh (VM) kits for apical pelvic organ prolapse (APOP) were labeled "high-risk" in 2016 and subsequently banned in 2019 by the U.S. Food and Drug Administration, the most common remaining surgical options include abdominal mesh-augmented sacrocolpopexy (AS) and transvaginal native tissue suspension (VN). OBJECTIVE: The objective of this study was to determine temporal trends in APOP procedures for urologists and gynecologists. STUDY DESIGN: Between 2011 and 2020, the American College of Surgeons National Surgical Quality Improvement Program database was queried for AS, VM, and VN. RESULTS: There were 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with more medical comorbidities. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists ( P < 0.0001). Transvaginal mesh utilization has decreased over time for both specialties ( P < 0.05); nonsignificant trends toward increasing AS ( P = 0.1646) in urologists and VN ( P = 0.0913) in gynecologists concurrently occurred. Significant independent predictors of the operating surgeon being a urologist were surgery being performed in the latter half of the cohort (2016-2020; odds ratio [OR], 1.22), non-White patient race (OR < 1 for all), a concomitant sling being placed (OR = 0.89), the surgery being VM (OR = 2.95) or AS (OR = 4.36), the patient being older (OR > 1 for each age range), and having a higher frailty index score (OR = 1.16). CONCLUSIONS: Significant differences in APOP repair choices exist between specialties. Urologists operate on older, more medically complex patients while demonstrating a strong preference for mesh-augmented compared with transvaginal native tissue repairs.

Safety and economics of an enhanced recovery after surgery protocol in pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: We hypothesized that an enhanced recovery after surgery (ERAS) protocol for patients undergoing female pelvic reconstructive surgery would conserve hospital resources without compromising patient safety. METHODS: In June 2020, an ERAS protocol designed to promote same-day discharge was initiated that included pre-operative hydration, a urinary anesthetic, non-narcotic analgesia, perineal ice, a bowel regimen, enrollment of the family to assist with care, and communication regarding planned same-day discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients undergoing pelvic organ prolapse or incontinence surgery over 4 sequential months pre (PRE; N = 82) and post (POST; N = 91) ERAS implementation using univariate statistics. RESULTS: There were no differences in demographics, operative details, or complications (p > 0.05). There were no significant differences in overall revenues or expenses (p > 0.05), but bed unit cost was significantly lower in the POST group ($210 vs $533, p < 0.0001). There was a trend toward an increased operating margin in POST patients ($4,554 vs $2,151, p = 0.1163). Significantly more POST surgeries were performed in an ambulatory setting (73.6% vs 48.8%, p = 0.0008) and resulted in same-day discharge (80.2% vs 50.0%, p = 0.0003). There were no differences in the rates of emergency room or unexpected clinic visits (p > 0.05). Prescribed post-operative opiate dose was significantly reduced in POST patients (p < 0.0001). CONCLUSIONS: In patients undergoing female pelvic reconstructive surgery, an ERAS protocol facilitated transfer of procedures to an ambulatory surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It also reduced bed unit cost and may improve operating margins.

Voiding function after sacrocolpopexy versus native tissue transvaginal repair for apical pelvic organ prolapse in an ERAS era: A retrospective cohort study.

OBJECTIVE: The objectives of this study were to compare time to return of voiding function and associated complications in women undergoing minimally invasive sacrocolpopexy (SCP) versus transvaginal native tissue repair in patients with same-day or early discharge. METHODS: This was a retrospective cohort study conducted at a tertiary care center. The electronic medical record system was queried for women who underwent native tissue vaginal repair or SCP for apical prolapse between March and December 2020 using CPT codes for sacrocolpopexy (57425), extraperitoneal (57282), and intraperitoneal colpopexy (57283). Voiding success was our primary outcome and was defined by a postvoid residual < 150 ml. Secondary outcomes included catheter days and urinary tract infections. The total number of participants was based on a power calculation using internal institutional rates. Participants were compared based on the surgical approach. A multivariate regression analysis was performed to assess for confounding factors. RESULTS: We included 134 women: 63 SCP and 71 native tissue. The failure rate of the first postoperative voiding trial was 34 vs. 11% (odds ratio: 4.91; 95% CI 1.96-12.3, p < 0.01) in the vaginal and SCP groups, respectively. Both groups had a similar success rate of a second voiding trial (100% in SCP group vs. 95.7% in the vaginal repair group, p = 1). The total number of days (3.108 vs. 1.603 days, p < 0.01) to return of bladder function, postoperative urinary tract infections (23.9 vs. 6.35%, p < 0.01) and emergency department visits (15.5 vs. 1.59%, p < 0.01) were all higher in the vaginal repair group. CONCLUSIONS: Vaginal apical native tissue repair had a fivefold greater risk of acute postoperative urinary retention compared to sacrocolpopexy in addition to increased rates of post-operative urinary tract infection and emergency department visits for urinary tract concerns.

Regenerative medicine for anal incontinence: a review of regenerative therapies beyond cells.

INTRODUCTION AND HYPOTHESIS: Current treatment modalities for anal sphincter injuries are ineffective for many patients, prompting research into restorative and regenerative therapies. Although cellular therapy with stem cells and progenitor cells show promise in animal models with short-term improvement, there are additional regenerative approaches that can augment or replace cellular therapies for anal sphincter injuries. The purpose of this article is to review the current knowledge of cellular therapies for anal sphincter injuries and discusses the use of other regenerative therapies including cytokine therapy with CXCL12. METHODS: A literature search was performed to search for articles on cellular therapy and cytokine therapy for anal sphincter injuries and anal incontinence. RESULTS: The article search identified 337 articles from which 33 articles were included. An additional 12 referenced articles were included as well as 23 articles providing background information. Cellular therapy has shown positive results for treating anal sphincter injuries and anal incontinence in vitro and in one clinical trial. However, cellular therapy has disadvantages such as the source and processing of stem cells and progenitor cells. CXCL12 does not have such issues while showing promising in vitro results for treating anal sphincter injuries. Additionally, electrical stimulation and extracorporeal shock wave therapy are potential regenerative medicine adjuncts for anal sphincter injuries. A vision for future research and clinical applications of regenerative medicine for anal sphincter deficiencies is provided. CONCLUSION: There are viable regenerative medicine therapies for anal sphincter injuries beyond cellular therapy. CXCL12 shows promise as a focus of therapeutic research in this field.

Midurethral Slings.

Urinary incontinence (UI) is a common symptom affecting almost one-third of adult women. UI can occur because of hypermobility or intrinsic sphincter deficiency of the urethra. Regardless its etiology, it is associated with poor quality of life and most of the incontinent women develop symptoms such as anxiety, depression, and social isolation over time. The synthetic midurethral sling (MUS) was first introduced in 1995 and quickly became the gold standard treatment for women with stress UI because of intrinsic sphincter deficiency and/or urethral hypermobility. This session addresses the indications, preoperative preparation, surgical steps, postoperative care, and complications related to synthetic MUSs. Owing to the exponential increase in the prevalence of mesh-related complications, we also developed a rational evidence-based algorithm that will help urologists to diagnose and manage this specific subset of patients.

Outlet constipation 1 year after robotic sacrocolpopexy with and without concomitant posterior repair.

OBJECTIVES: The aim of this study was to estimate the rate of outlet constipation at 1 year after robotic sacrocolpopexy (RSCP) with and without a concomitant distal posterior repair (PR). We sought, first, to determine the rate of persistent outlet constipation and second, to determine de novo outlet constipation. METHODS: This was a cohort study of women who underwent RSCP alone versus RSCP + PR, at each surgeon's discretion, between November 2007 and February 2011 at an academic center. Specific questions in the Pelvic Floor Distress Inventory Short Form correlating to outlet constipation and its colorectal-anal subscale scores were compared between and within groups. Rates of posterior compartment reoperation were assessed. RESULTS: Of the 77 women who underwent RSCP, 21 (27%) had a concomitant distal PR. Overall, there was significant improvement in pelvic floor function and quality of life at 1 year after surgery (P = 0.01). Preoperatively, outlet constipation was present in 63.4% of those who underwent RSCP only and in 53.3% of those with concomitant PR. Postoperatively at 1 year, 56% of preoperative outlet constipation resolved and 44% persisted (P = 0.001), with no differences between groups (RSCP vs RSCP + PR). The rate of postoperative de novo outlet constipation was 13.6%. At 1 year after RSCP, 18.2% of patients had symptomatic posterior prolapse, with no difference between both groups (P = 0.746). Overall, 11.7% underwent a subsequent PR, none of whom underwent PR with the initial RSCP (P = 0.104). CONCLUSIONS: At 1 year after RSCP, there was a high rate of persistent outlet constipation and a moderate rate of de novo outlet constipation. Concomitant PR did not significantly affect these bowel symptoms.

Diagnostic accuracy of visual urethral mobility exam versus Q-Tip test: a randomized crossover trial.

OBJECTIVE: The objective of the study was to compare the diagnostic accuracy of a visual urethral mobility examination (VUME) with a Q-Tip test in the assessment of urethral hypermobility. STUDY DESIGN: Subjects were randomized to a VUME or Q-Tip test first, followed by the alternate assessment. Outcomes included hypermobile, not hypermobile, or indeterminate. Hypermobility was defined as 30° or greater from the horizontal. Pain perception and test preference were assessed. RESULTS: For the 54 subjects, 61.1% demonstrated hypermobility on VUME vs 72.2% on the Q-Tip test (P = .39). Assessment of hypermobility was correlated between the 2 tools (ρ = 0.47, P = .001). Positive and negative predictive value, sensitivity, and specificity for VUME were 88%, 56%, 78%, and 71%, respectively, with a Q-Tip test as the reference standard. Mean pain score on visual analog scale was 0.72 for VUME and 3.15 for Q-tip test (P < .001). VUME was preferred by 83% of subjects. CONCLUSION: VUME is a diagnostic alternative to the Q-Tip test for the assessment of urethral hypermobility and is preferred by subjects.