Attitudes toward COVID-19 vaccination among urogynecology patients.

Objective: Urogynecology patients skew older and often require intimate exams to treat non-life-threatening conditions, thus making care particularly susceptible to the effects of COVID-19. We aim to understand COVID-19 vaccination attitudes amongst urogynecology patients during the pandemic, which has adversely affected healthcare delivery, to identify measures that can be undertaken to improve care going forward. Study design: Cross-sectional surveys of urogynecology patients were conducted in three different states (Delaware, New Jersey, and Pennsylvania) between March and August 2021. Demographics, vaccination status, and COVID-19 attitudes were analyzed. Chi-square tests investigated group differences between vaccine-hesitant and unhesitant subjects. Results: Out of 158 surveys, eighty-three percent of respondents were vaccinated or planning to get vaccinated. Older age and regular flu vaccination predicted COVID-19 vaccination. Ninety-three percent of subjects were comfortable attending in-person visits. However, vaccine-hesitant individuals were less comfortable attending in-person and were significantly less likely to be comforted by clinic interventions, such as masking. Hesitant and unhesitant groups trusted doctors or medical professionals most for their source of COVID-19 information. Conclusions: Urogynecology patients mirror the general older population's COVID-19 vaccination attitudes, with distinct differences between hesitant and unhesitant groups. Vaccine-hesitant subjects appear less comfortable coming to in-person visits and less comforted by possible interventions, posing a difficult obstacle for clinics to overcome. High levels of patient trust suggest healthcare providers can play a crucial role in encouraging COVID-19 vaccination and combating misinformation.

Quality of Pelvic Floor Therapy Videos on YouTube: Does Popularity Predict Reliability?

ABSTRACT: This study reviewed instructional videos on YouTube regarding pelvic floor physical therapy and assessed the association between the videos' popularity and the reliability of the videos' content. YouTube was searched using the terms relevant to pelvic floor muscle training. The first 100 videos for each search term were screened, and relevant metrics were collected for those meeting the inclusion criteria. Videos were assessed by 2 independent, trained health care professionals for reliability using the Medical Quality Video Evaluation (MQ-VET) tool, the modified DISCERN tool, the Journal of American Medical Association benchmark criteria, and the Global Quality Score. Popularity was assessed using the Video Power Index (VPI). Higher values for all scoring systems correlated with greater reliability and greater popularity, respectively. Five hundred videos were screened. Two hundred thirty-four videos were duplicates, and 99 did not meet the inclusion criteria. A total of 167 videos were reviewed. The median VPI and MQ-VET score was 201,114.76 (interquartile range, 7,194,020.29) and 48.00 (interquartile range, 12.75), respectively. Spearman's R value was 0.292 (P < 0.001), demonstrating a weak positive correlation between MQ-VET scores and VPI. The interrater reliability of the MQ-VET was good, with an intraclass correlation coefficient of 0.86 (95% confidence interval, 0.71-0.92). In summary, we identified a statistically significant but weak positive correlation between the reliability and popularity of YouTube videos about pelvic floor physical therapy.

Urinary Sphingosine-1-Phosphate as a Biomarker for Bladder Pain Syndrome.

IMPORTANCE: Sphingosine-1-phosphate (S1P) is a signaling molecule involved in inflammation and bladder contraction. OBJECTIVES: The aims of this case-control pilot study were to compare urinary S1P concentrations in bladder pain syndrome (BPS) participants to controls and determine whether these concentrations correlate with disease severity and duration. STUDY DESIGN: Adult females with BPS and controls were enrolled. Bladder pain syndrome participants completed an O'Leary-Sant questionnaire. Information on duration of symptoms and treatment history was obtained. Urinary S1P and creatinine concentrations were determined. Mann-Whitney U tests were used to compare groups, and Spearman correlation was used to test for associations between concentrations and duration and severity of symptoms. RESULTS: Twenty-five participants were in each group. Median S1P concentration was 1,225 ng/dL in the BPS group and 2,183 ng/dL in the control group, which was significantly different (P < 0.0001). This difference did not persist when normalized to urinary creatinine (P = 0.58). No differences were noted in urinary S1P concentrations between treated and untreated participants (P = 0.53) or with symptom scores of 13 or greater and less than 13 (P = 0.69). Sphingosine-1-phosphate levels did not correlate with O'Leary-Sant scores (P = 0.08) or duration of symptoms (P = 0.67). Results did not change when using S1P concentrations normalized to creatinine. CONCLUSIONS: This study demonstrated successful quantification of human urinary S1P concentrations. A difference in urinary S1P was found between BPS participants and controls but not when normalized to creatinine. While this is the first study to investigate urinary S1P as a biomarker for BPS, results suggest that it may have a potential role as a biomarker requiring further research.

Triangulation of a Needs Assessment on High-Tone Pelvic Floor Dysfunction.

IMPORTANCE: High-tone pelvic floor dysfunction is a complex condition that is challenging to manage effectively. Pelvic floor physical therapy (PFPT) is often used in the treatment and relies on a coordinated effort between the physician, patient, and physical therapist. Collaboration is crucial for therapy success, but there is limited research that includes personal perspectives from these individuals. OBJECTIVE: The objective of this qualitative study was to gain further insight from these groups to identify areas for improvement in patient counseling and understanding of the diagnosis of high-tone pelvic floor dysfunction and the role of physical therapy. STUDY DESIGN: The following participants were recruited: urogynecologists, pelvic floor physical therapists, and patients. Semistructured interviews were conducted exploring participant experiences with therapy and management of the condition and surrounding phenomena. RESULTS: Participants interviewed included 5 urogynecologists, 5 pelvic floor physical therapists, and 15 patients. Similarities in key themes were identified: (1) the usefulness of pelvic models and illustrations in counseling, (2) appropriate descriptions of therapy, (3) motivating factors for patients, and (4) patient barriers to completing therapy. Several emergent themes revealed a misalignment in perspectives, including (1) patients reporting an unclear understanding of PFPT, (2) patient unawareness of the intimacy of therapy, and (3) reports of unsupportive and unempathetic physician providers. CONCLUSIONS: There are both similarities and discrepancies in the perspectives among physicians, pelvic floor physical therapists, and patients regarding high-tone pelvic floor dysfunction and PFPT. Acknowledging these comparisons and adapting practices could facilitate patient-centered care and improve patient understanding of their diagnosis.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review.

OBJECTIVE: To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION: The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS: Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION: Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021234511.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVE: To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated. DATA SOURCES: PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines. METHODS OF STUDY SELECTION: Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded. TABULATION, INTEGRATION, AND RESULTS: Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes. CONCLUSION: Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021278796.

Foley Balloon Pull Test of Pelvic Floor Muscle Strength.

IMPORTANCE: Methods for pelvic floor muscle (PFM) strength testing are limited by their subjective nature, prohibitive cost, training burden, or lack of validation. OBJECTIVES: The objectives of this study are to validate a new, inexpensive, and accessible method for PFM strength testing using a 30-mL Foley balloon inserted into the vagina, the Foley Balloon Pull Test (FPT), and to demonstrate external validity by comparing the subjective Oxford Muscle Grading Scale (OMGS) scores to measurements obtained with the FPT. Secondary objectives include demonstrating repeatability and internal validity of the FPT. STUDY DESIGN: Participants underwent PFM strength testing with the OMGS on a 0 to 5 scale. A gauge was attached to the Foley balloon to measure the force required to remove the balloon from the vagina. Three measures at rest and 3 measures during maximal muscle contraction were recorded. Cross-sectional data were analyzed. RESULTS: One hundred one participants were included; there were no adverse events. The ratio of contraction FPT measurements to at-rest measurements revealed moderate linear and rank order correlation with the OMGS ( R2 = 0.54, P < 0.001, and R2 = 0.58, P < 0.001). The reliability of repeated measurements was highly correlated, with intraclass correlation coefficients >0.95. An FPT ratio of 1.75 discriminated between weak (0-2) and strong (3-5) OMGS scores with an area under the curve of 0.86. CONCLUSION: The FPT is an internally reliable, simple, and externally valid method of PFM strength testing.

Urinary tract infection following intradetrusor onabotulinumtoxina injection for non-neurogenic urgency incontinence: single- vs. multi-dose prophylactic antibiotic treatment regimens.

INTRODUCTION AND HYPOTHESIS: Urinary tract infection is one of the most common adverse events following onabotulinumtoxinA injection for urgency incontinence. Our hypothesis was that those undergoing injection for urgency incontinence who received more than one dose of prophylactic antibiotics have lower post-procedure urinary tract infection rates compared to those who receive a single dose. METHODS: We conducted a multi-center retrospective cohort study in females who underwent onabotulinumtoxinA injection for non-neurogenic urgency incontinence to evaluate the effect of single- vs. multi-dose prophylactic antibiotic regimens on the risk of post-procedure urinary tract infection. The primary outcome was the rate of urinary tract infection within 30 days of injection. Our sample size calculation required 136 subjects per group. RESULTS: Two hundred eighty-one patients were included from four centers. The single-dose cohort included 145 patients (51.6%), and the multi-dose cohort included 136 patients (48.4%). The mean age was 65 years, and patients were primarily Caucasian (81.4%). There was no difference in the rate of urinary tract infections diagnosed within 30 days of injection between the cohorts (single dose 13.8% vs. multi-dose 10.3%, p = 0.369). Those with a positive urine culture within 30 days of injection had a 15.2 times greater odds of having a post-procedure infection than those who did not (95% CI 3.19-72.53). There was no significant difference between the two cohorts in terms of adverse health events following injection. CONCLUSIONS: In females with non-neurogenic urgency incontinence undergoing onabotulinumtoxinA injection, multi-dose prophylactic antibiotic regimens were not associated with lower post-procedure urinary tract infection rates.

Thirty-six-month Prospective Study of Transvaginal Bovine Graft vs Native Tissue Repair for the Treatment of Pelvic Organ Prolapse.

OBJECTIVE(S): To compare the safety and effectiveness of dermal bovine transvaginal graft, Xenform, to native tissue in the surgical treatment of anterior and/or apical pelvic organ prolapse. This study was designed in conjunction with Food and Drug Administration requirements. METHODS: This was a prospective, non-randomized, parallel cohort, multi-center trial. The primary objective was to demonstrate noninferiority between transvaginal graft and native tissue repair at 36 months compared to baseline. Treatment success was based on a composite of objective and subjective measures. The co-primary outcome was the rate of serious device- or procedure-related adverse events. A total of 228 patients at 25 sites were included in the study arm and 485 patients underwent native tissue repair. Propensity score stratification was applied to achieve balance between treatment groups. Study outcomes were compared in per protocol and intent-to-treat analysis. RESULTS: The primary outcome, treatment success at 36 months, was 83.6% (191/228) for transvaginal graft and 80.5% (390/485) native tissue repair (0.2%, 90% confidence interval [-5.6% to 5.9%]), demonstrating noninferiority at a preset margin of -12%. The overall rate of severe adverse events was 5.3% (12/228) in transvaginal graft vs 2.7% (13/485) in native tissue repair groups. The study group demonstrated noninferiority in serious adverse events at the preset margin of 11.6% (2.0%, 90% confidence interval [-0.8% to 4.7%]). There were no reports of graft erosion, and graft exposure rates were low (0.9% [2/228]). CONCLUSIONS: Transvaginal repair of anterior and/or apical prolapse with a biological graft is noninferior to traditional native tissue repair in effectiveness and safety at 36 months.

Transvaginal Mesh Compared With Native Tissue Repair for Pelvic Organ Prolapse.

OBJECTIVE: To compare the safety and effectiveness of transvaginal mesh repair and native tissue repair, in response to a U.S. Food and Drug Administration (FDA) 522 study order to assess co-primary endpoints of superiority and noninferiority. METHODS: This was a prospective, nonrandomized, parallel cohort, multi-center trial comparing transvaginal mesh with native tissue repair for the treatment of pelvic organ prolapse. The primary endpoints were composite treatment success at 36 months comprised of anatomical success (defined as pelvic organ prolapse quantification [POP-Q] point Ba≤0 and/or C≤0), subjective success (vaginal bulging per the PFDI-20 [Pelvic Floor Distress Inventory]), and retreatment measures, as well as rates of serious device-related or serious procedure-related adverse events. Secondary endpoints included a composite outcome similar to the primary composite outcome but with anatomical success defined as POP-Q point Ba<0 and/or C<0, quality-of-life measures, mesh exposure and mesh- and procedure-related complications. Propensity score stratification was applied. RESULTS: Primary endpoint composite success at 36 months was 89.3% (201/225) for transvaginal mesh and 80.2% (389/485) for native tissue repair, demonstrating noninferiority at the preset margin of 12% (propensity score-adjusted treatment difference 6.5%, 90% CI -0.2% to 13.2%). Using the primary composite endpoint, transvaginal mesh was not superior to native tissue repair (P=.056). Using the secondary composite endpoint, superiority of transvaginal mesh over native tissue repair was noted (P=.009), with a propensity score-adjusted difference of 10.6% (90% CI 3.3-17.9%) in favor of transvaginal mesh. Subjective success for both the primary and secondary endpoint was 92.4% for transvaginal mesh, 92.8% for native tissue repair, a propensity score-adjusted difference of -4.3% (CI -12.3% to 3.8%). For the primary safety endpoint, 3.1% (7/225) of patients in the transvaginal mesh (TVM) group and 2.7% (13/485) of patients in the native tissue repair (NTR) group developed serious adverse events, demonstrating that transvaginal mesh was noninferior to native tissue repair (-0.4%, 90% CI -2.7% to 1.9%). Overall device-related and/or procedure-related adverse event rates were 35.1% (79/225) in the TVM group and 46.4% (225/485) in the NTR group (-15.7%, 95% CI -24.0% to -7.5%). CONCLUSION: Transvaginal mesh repair for the treatment of anterior and/or apical vaginal prolapse was not superior to native tissue repair at 36 months. Subjective success, an important consideration from the patient-experience perspective, was high and not statistically different between groups. Transvaginal mesh repair was as safe as native tissue repair with respect to serious device-related and/or serious procedure-related adverse events. FUNDING SOURCE: This study was sponsored by Boston Scientific and developed in collaboration with FDA personnel from the Office of Surveillance and Biometrics, Division of Epidemiology. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01917968.

Vaginal Hysterectomy Rates Before and After Implementation of a Multiple-Tier Intervention.

OBJECTIVE: To assess a multiple-tier intervention to increase vaginal hysterectomy rates. METHODS: We performed a cohort study assessing hysterectomy performance before and after implementation of a multiple-tier intervention to increase vaginal hysterectomy rates at a single tertiary care medical center. This intervention involved resident and attending education and simulation, professional development, design of a clinical pathway to assist in hysterectomy decision making, and development of a surgical mentorship program. RESULTS: Data from 698 hysterectomies (253 preintervention and 445 postintervention) were included. The preintervention time period extended from January 1, 2016, to December 31, 2017 (24 months), and the postintervention period from January 1, 2018, to February 28, 2020 (26 months). The intervention was implemented over the month of December 2017 but was not complete until January 1, 2018. The preintervention and postintervention cohorts were similar in most demographic and clinical aspects. Postintervention, the proportion of vaginal hysterectomies was higher (26.5% vs 5.5%, odds ratio 6.2, 95% CI 3.52-11.35), including in those performed for reasons other than prolapse (6.8% vs 0%, P<.001). Logistic regression revealed that prolapse, uterine weight less than 250 g, and surgery during the postintervention cohort were significantly associated with vaginal hysterectomy. Operative complications did not differ significantly by hysterectomy type. CONCLUSION: Implementation of a multiple-tier intervention was associated with an increase in vaginal hysterectomies.

Pelvic Floor Organ Prolapse After Radical Cystectomy in Patients With Uroepithelial Carcinoma.

OBJECTIVE: The aim of this study was to identify whether women who undergo a radical cystectomy for uroepithelial carcinoma are at increased risk of pelvic organ prolapse after surgical treatment. METHODS: A retrospective cohort study compared female subjects who had undergone a radical cystectomy for uroepithelial carcinoma, as identified through an institutional cancer survivor database, with subjects who presented to the Pelvic Health and Continence Clinic with symptoms of either uterovaginal prolapse or urinary incontinence. Demographic data were collected regarding risk factors for prolapse, and study subjects were asked to complete a Pelvic Organ Prolapse Distress Inventory (POPDI-6). Data were collected through retrospective chart review. The primary outcome is difference in the POPDI-6 between the groups. Statistical evaluation of responses was performed, with analysis of variance used to compare the questionnaire scores between groups and correction for risk factors with χ2 tests, with a P value of 0.05 selected for statistical significance. RESULTS: There were 36 postcystectomy subjects who responded to the survey, 37 subjects in the prolapse group, and 44 subjects in the incontinence group. With correction for age, body mass index, and number of vaginal deliveries, the postcystectomy group reported significantly lower scores on the POPDI-6 than both the prolapse group (P < 0.0001) and the incontinence group (P = 0.0003). CONCLUSIONS: Radical cystectomy for uroepithelial carcinoma does not correlate with an increased risk of patient-reported symptoms of pelvic organ prolapse.

A Randomized Controlled Trial of a Multimedia Patient Education Tool for Stress Versus Urgency Urinary Incontinence.

OBJECTIVE: The aim of this study was to determine whether there was a difference in patient education when comparing traditional conversation-based patient counseling with multimedia-based patient counseling about stress and urgency urinary incontinence. METHODS: Patients seeking treatment for urinary incontinence were randomized to traditional, conversation-based counseling from a physician regarding stress and urgency urinary incontinence (control group) or view a video (multimedia) as their counseling (treatment group). A vignette-based assessment of the patient's knowledge of stress and urgency urinary incontinence was administered as a pretest, immediate posttest, and 6- to 8-week delayed posttest. The Incontinence Impact Questionnaire, short form, was used to assess quality of life and was administered at the initial visit and at the 6- to 8-week follow-up call. Patient satisfaction was recorded at the end of the initial visit using a continuous visual analog scale, and health literacy was evaluated using the Rapid Estimate of Adult Literacy in Medicine-Short Form or Short Assessment of Health Literacy-Spanish. RESULTS: In the 98 participants, immediate posttest scores trended toward significance between the control and treatment groups (P = 0.086). This trend was lost at the delayed posttest (P = 0.122). Both methods of education showed a significant difference between pretest, immediate posttest, and delayed posttest (P < 0.001). There were no demographic differences between groups. CONCLUSIONS: Multimedia-based patient education represents an effective method of providing patient education regarding urinary incontinence because those who received video education showed comparable comprehension of this topic when compared with standard physician counseling. Video education can feasibly be used as an alternative to, or in conjunction with, current patient education practices in a urogynecology setting.

Urinary incontinence and quality of life in endometrial cancer patients after robotic-assisted laparoscopic hysterectomy with lymph node dissection.

To determine the long-term effects of lymph node dissection on lower urinary tract symptoms in patients treated for endometrial cancer. We conducted a retrospective cohort study of 74 patients with International Federation of Gynaecology and Obstetrics (FIGO) Stage I endometrial cancer who underwent surgical intervention with and without lymph node dissection, and evaluated them with the Urinary Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). Patients who underwent lymph node dissection reported higher but not statistically different rates of bother by lower urinary tract symptoms compared to those without lymph node dissection. The scores for the lymph node dissection group and the control group were a mean IIQ-7 score of 14.9 ± 23 and 10.5 ± 22.9 (p=.419) and a mean UDI-6 score of 30.0 ± 25.3 and 20.7 ± 22.9 (p=.104), respectively. Lymph node dissection at the time of robotic-assisted surgery did not have a significant effect on lower urinary tract symptoms nor did it affect patient responses on quality of life questionnaires. IMPACT STATEMENT What is already known on this subject? The aetiology of urinary incontinence is multifactorial and there has been debate on how a patient's surgical history affects their risk of developing urinary incontinence. Prior studies have highlighted the relationship between hysterectomy and urinary incontinence (Milsom et al. 1993 ). Additional research has also been done to elucidate the prevalence of pelvic floor disorders in patients who have been surgically treated for endometrial cancer (Erekson et al. 2009 ; Nosti et al. 2012 ). There is limited information on how robotic-assisted lymphadenectomy during surgical staging for endometrial cancer affects patients' urinary function and their quality of life. What do the results of this study add? In this manuscript, we demonstrate that patients who underwent robotic-assisted total laparoscopic hysterectomy (TLH) with lymphadenectomy neither had significant difference in lower urinary tract symptoms nor on quality of life questionnaires as compared to those who did not undergo lymphadenectomy. Worsening of quality of life in regards to urinary incontinence should not be considered a factor of long term surgical morbidity associated with lymph node dissection. What are the implications of these findings for clinical practice and/or further research? There is a need for further studies that focus on the prevalence of pelvic floor disorders in patients after undergoing surgical staging for endometrial cancer and potential interventions that may address these issues.

Do anxiety traits predict subjective short-term outcomes following prolapse repair surgery?

BACKGROUND: Studies conducted in orthopedic surgery have suggested that patients with anxiety have less symptomatic improvement following surgery than those without. We hypothesized for this study that patients with anxiety traits experience less symptomatic improvement following pelvic organ prolapse surgery than patients without. METHODS: All patients presenting for prolapse repair surgery were offered enrollment in this prospective cohort study. Prior to surgery, subjects were asked to complete the Spielberger State-Trait Anxiety Inventory and the Pelvic Floor Distress Inventory 20. Subjects were also asked to list up to five goals related to the outcome of surgery for goal-attainment scaling. At the 6-8-week postoperative visit, subjects were asked to repeat the STAI and PFDI questionnaires and respond to the single question tool assessing Patient Global Impression of Improvement. Subjects were also asked to rate on a Visual Assessment Scale how well preoperative goals were met. All three questionnaires were repeated at >12 weeks following surgery. RESULTS: A total of 32 patients with anxiety trait and 58 without were recruited. Preoperatively, the mean STAI-T was 45.0 (± 7.2.) and 27.7 (± 4.9) for subjects with and without anxiety; PFDI 20 scores were 96.1 (± 48.8) and 94.7 (± 57.5), respectively. At 12+ weeks postoperatively, the mean PFDI-20 for subjects with anxiety was 31.3 (± 20.9) and 30.3 (± 27.9) (p = 0.22) for those without. CONCLUSIONS: We did not find the anxiety trait to be a predictor of subjective outcomes following pelvic organ prolapse surgery.

Surface and boney landmarks for sacral neuromodulation: a cadaveric study.

INTRODUCTION AND HYPOTHESIS: Standard external landmarks have been suggested as a guide for in-office percutaneous nerve evaluation (PNE), but validity of these landmarks has not been assessed. Our objective was to determine whether the standard 9 cm from the tip of the coccyx indicates the position of the S3 sacral foramen and whether other boney landmarks and measurements improved positioning. METHODS: Measurements and distances between external boney landmarks were obtained in 22 embalmed cadavers. Spinal needles were placed 9 cm superior to the coccyx and 2 cm lateral to midline bilaterally. After dissection, internal measurements relating to sacral length, position of S3, and location of the needle in relation to S3 were recorded. Correlations among measured variables were assessed using descriptive statistics. RESULTS: Mean distance from the tip of coccyx to S3 was 9.26 cm (±0.84), from S3 to midline 2.30 cm (±0.2); from needle to S3 1.25 cm, and needle placement was as likely to be placed above or below S3; and S2-S3 and S3-S4 interforamenal distance 1.48 cm (±0.30) and 1.48 cm (±0.24), respectively. Mean distance from S3 to sacroiliac joint (SIJ) was shorter than S2 to SIJ. All associations between external measurements and length from tip of coccyx to S3 were not significant. CONCLUSION: A distance 9 cm from the tip of the coccyx is a reasonable starting landmark for in-office blind PNE. However, given the variability in coccyx length, caution should be taken; also, sensory-motor response is necessary to confirm proper placement.

Evaluation of surgical instrument handling on polypropylene mesh using scanning electron microscopy.

INTRODUCTION AND HYPOTHESIS: To evaluate the effect of surgical instruments handling on polypropylene mesh using scanning electron microscopy (SEM). METHODS: We applied different surgical instruments, including a few robotic ones, to pieces of polypropylene mesh. SEM was used to evaluate the morphological changes with this intervention. RESULTS: Straight hemostat, laparoscopic atraumatic grasper, laparoscopic needle driver, and robotic instruments (Bipolar forceps, Cadiere forceps, PK dissecting forceps and SutureCut) were applied to the mesh. SEM images of tool-affected mesh regions in specimens handled by different instruments along with the images of intact mesh were obtained. Average mesh fiber diameters, as well as the average parameters characterizing instrument-affected regions, were measured. There was substantial widening of the fibers in specimens handled by hemostat or a needle holder. An elliptical but much longer and narrower tool marking with more surface roughness was observed in mesh handled by a grasper. A ∼25-µm-wide and ∼200-µm-long strap was split on one side from the core of the fiber caused by Cadiere. CONCLUSIONS: There are morphological changes to polypropylene mesh caused by instrument handling. These changes are different depending on the instrument used. These alterations vary from changes in the surface creating roughness of the fiber, compression of the mesh with narrowing of the fiber in at least one direction or actual splitting or pitting of the fiber. Since there are no data regarding the effect of these morphological changes to the ultimate functioning of the mesh, surgeons should minimize mesh handling by instruments.

Laparoscopic use of a hyaluronic acid carboxycellulose membrane slurry in gynecological oncology.

OBJECTIVES: We evaluated the use of a hyaluronic acid-carboxycellulose membrane (HAC) slurry in complex laparoscopies. MATERIALS AND METHODS: A gel-like mixture of HAC was prepared and applied in 171 consecutive complex laparoscopies on a gynecologic oncology service. The HAC slurry was used to coat deperitonealized surfaces and surgical pedicals to prevent postoperative adhesions. The technique is described and the outcomes are prospectively evaluated for feasibility and safety. RESULTS: There were no postoperative bowel obstructions, 1 pelvic hematoma in a patient on clopidogrel (Plavix) immediately prior to surgery, 8 postoperative ilea, and 1 bowel perforation. The bowel perforation occurred in a patient with extensive adhesiolysis and intraoperative bowel suturing. CONCLUSION: This report describes an easy approach to the laparoscopic application of HAC. Caution should be taken if HAC slurry is applied after significant bowel suturing because 1 of 9 patients with extensive adhesiolysis requiring suturing of the sigmoid colon developed sigmoid perforations.