Comparing Postoperative Urinary Retention Rates Between Robotic Apical Prolapse Repairs.

IMPORTANCE: Understanding the risk of urinary retention with different prolapse repair surgical procedures is important for perioperative counseling. OBJECTIVE: The study compared postoperative urinary retention rates between robotic sacrocolpopexy and robotic uterosacral ligament suspension. STUDY DESIGN: This institutional review board-exempt retrospective cohort study compared patients who underwent pelvic organ prolapse repair with robotic sacrocolpopexy (RSCP) and robotic uterosacral ligament suspension (RUSLS) between June 2018 and March 2022. Our primary outcome was the rate of acute postoperative urinary retention (POUR) in these groups. Secondary outcomes were the number of days needed to resolve urinary retention and persistent voiding dysfunction. RESULTS: Out of 298 patients, 258 underwent RSCP and 40 underwent RUSLS. Acute POUR was found in 73 patients (24%): 46 patients (18%) in the RSCP group versus 26 patients (65%) in the RUSLS group (P < 0.001). Multivariate analysis demonstrated a significantly higher rate of acute POUR after RUSLS (odds ratio [OR] = 17.92, confidence interval [CI] = 3.06-104.86; P = 0.001). Patients with an elevated preoperative postvoid residual volume >100 mL or concomitant midurethral sling were more likely to develop POUR (OR = 2.93, CI = 1.43-5.98; P = 0.003 and OR = 2.19, CI = 1.16-4.14; P = 0.016, respectively). While patients with higher parity were less likely to have urinary retention (OR = 0.71, CI = 0.53-0.96; P = 0.024), age, body mass index, prolapse stage, and concurrent posterior repair did not affect the urinary retention rate significantly. The number of days needed to resolve POUR and persistent voiding dysfunction were similar. CONCLUSIONS: Acute POUR appears more likely to develop after RUSLS compared to RSCP. Elevated preoperative postvoid residual volume and concomitant midurethral sling surgery independently increase the risk of POUR.

Long term surgical outcomes of vaginal colposuspension using the Uphold Lite™ mesh system vs. vaginal vault uterosacral ligament suspension for treatment of apical prolapse.

OBJECTIVE: The aim of this study is to compare long-term outcomes (7-10 years) between vaginal hysterectomy with uterosacral ligament suspension (VHUSLS) and sacrospinous hysteropexy with the Uphold™ Lite mesh System (SHU) for management of apical prolapse. METHODS: Patients undergoing VHUSLS or SHU from 2008 to 2012 at a single tertiary referral center were included. Patients were contacted, asked to return for physical examination, and to complete the Pelvic Floor Distress Inventory (PFDI-20) questionnaire. Our primary outcome was anatomic failure defined as Stage 2 POP or higher of any compartment. The secondary outcome was subjective changes in symptoms based upon PFDI-20 responses. RESULTS: Two-hundred and two women were identified to have undergone the index surgeries from 2008 to 2012. Sixty-three agreed to return for follow up symptom evaluation and examination (30 VHUSLS and 33 SHU). Baseline characteristics were similar between groups. Clinical cure was high for both groups reaching 93.4 % and 94.0 % for the VHUSLS and SHU groups, respectively (p = 0.721). Anatomical success was lower with 44.7 % and 66.7 % of patients in the VHUSLS and SHU groups, respectively, meeting criteria for success (p = 0.138). There were no mesh complications among patients returning for exams. However, two patients who were contacted and were not interested in this study reported mesh complications and need for additional surgeries. Anterior vaginal wall support was noted to be significantly better supported for SHU (Ba -2.03 ± 0.75 vs -1.42 ± 0.92, p = 0.008). There were no differences between groups for overall PFDI-20 scores postoperatively. However, SHU patients reported higher rates of stress urinary incontinence compared to VHUSLS patients. CONCLUSION: In women with apical prolapse, VHUSLS and SHU afford similar long-term outcomes. SHU patients reported higher rates of stress urinary incontinence.

Methenamine hippurate compared with trimethoprim for the prevention of recurrent urinary tract infections: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: The objective was to find an alternative treatment to a low-dose antibiotic for the prevention of recurrent urinary tract infections (UTI) and to evaluate the difference in rates of reinfection within 1 year when treated with methenamine hippurate for prophylaxis compared with trimethoprim. METHODS: We present a non-blinded randomized trial comparing methenamine hippurate with trimethoprim for the prevention of recurrent UTI at 12 months after starting treatment. Women over 18 who had at least two culture-positive UTI in the prior 6 months or three in the prior year were included. Ninety-two patients met enrollment criteria and were randomized to receive daily prophylaxis with methenamine hippurate or trimethoprim for a minimum of 6 months. Both intent-to-treat and per-protocol analyses if patients received the alternative drug after randomization were analyzed using Student's t test, Mann-Whitney U test, Kaplan-Meier curves, log-rank test, and a logistic and multivariate regression model. The primary outcome of this study was culture-proven UTI recurrence by 12 months after initiating prophylaxis. RESULTS: In the intent-to-treat analysis, we found no difference between groups in recurrent UTI, with a 65% (28 out of 43) recurrence in the trimethoprim group versus 65% (28 out of 43) in the methenamine hippurate group (p = 1.00). In the per-protocol analysis, 65% (26 out of 40) versus 65% (30 out of 46) of patients had UTI recurrences in the trimethoprim group versus the methenamine hippurate group (p = 0.98). CONCLUSIONS: Methenamine hippurate may be an alternative for the prevention of recurrent UTI, with similar rates of recurrence and adverse effects to trimethoprim.

Can patients independently identify their urinary incontinence symptoms?

INTRODUCTION AND HYPOTHESIS: The objective of our study is to compare patient self-reported urinary incontinence symptoms based on the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-SF) question number 6 (When does urine leak?) with physician-assessed interpretation of the patient's urinary incontinence symptoms. METHODS: This trial is a cross-sectional study of patients who presented to a tertiary urogynecology center with symptoms of urinary incontinence between January 2014 and August 2016. We compared patient-reported symptoms on the ICIQ-SF with physician interpretation of urinary complaints during their initial visit. The urinary incontinence symptoms included stress urinary incontinence (SUI), urgency urinary incontinence (UUI), insensible urine loss, nocturnal enuresis, and post-micturition dribbling. RESULTS: A total of 432 patients with a mean age of 61 were included in this evaluation. The most common urinary incontinence symptoms according to the physician were UUI (n = 357, 83%), followed by SUI (n = 308, 71%). Of the patients who were diagnosed by a physician with the symptom of UUI, only 61% self-identified as having this symptom based on the ICIQ-SF, and for SUI, only 66% self-identified as having SUI symptoms based on the ICIQ-SF. Overall UUI (κ = 0.30) appears to have poor agreement, as does nocturnal enuresis (κ = 0.39), when compared with physician historical assessment. CONCLUSION: There is a discrepancy between patient-reported urinary incontinence symptoms on the ICIQ-SF and physician-assessed symptoms. Symptomatology entered into electronic medical records by patients is often inaccurate. Physician validation is essential in understanding the underlying the precise symptomatology.

Cognitive changes in women starting anticholinergic medications for overactive bladder: a prospective study.

INTRODUCTION AND HYPOTHESIS: To assess cognitive changes in women 12 months after starting anticholinergic medications for overactive bladder syndrome (OAB). METHODS: We present a prospective cohort study assessing changes in cognition in women seen in a referral urogynecology practice. We compared women who started anticholinergic OAB medications with women not on anticholinergic OAB medications. The primary outcome was change over time on the Montreal Cognitive Assessment (MOCA) screening score. At enrollment, women completed a baseline MOCA screening, a Geriatric Depression Screen (GDS), and an assessment of medications to create an anticholinergic burden score (ACB). At 3, 6, 9, and 12 months after enrollment women were administered the MOCA, GDS, and a review of their medications and medical problems. Statistical analysis was performed using a linear mixed effects model taking into account correlated error terms given multiple MOCA assessments at various time points per patient. RESULTS: A total of 106 women were enrolled, 60 in the OAB medication group and 46 in the control (non-OAB medication) group. The mean age was 77 years, 93% of women were Caucasian, and 98% completed high school, with no difference between groups. Over time there was no difference in change of MOCA score between the OAB and control groups when controlling for age, GDS score, and ACB score (p = 0.78). This association did not change when women with a neurological diagnosis were excluded (n = 6). On average MOCA scores for the OAB group increased by 0.76 over 12 months and the control group increased 0.39, with no difference between the groups (p = 0.53). CONCLUSIONS: We found no changes in MOCA scores between OAB medication and control groups after controlling for age, depression, and polypharmacy after 12 months of follow-up.

Anterior Colporrhaphy With and Without Dermal Allograft: A Randomized Control Trial With Long-Term Follow-Up.

OBJECTIVE: The objective of this study was to determine whether anterior colporrhaphy plus insertion of anterior dermal allograft reduces anterior prolapse recurrence at 1 and 7 to 10 years postoperatively compared with anterior colporrhaphy alone. METHODS: We present a nonblinded randomized controlled trial with 1- and 7- to 10-year follow-up. Subjects were randomized between 2005 and 2008 to anterior colporrhaphy or ultralateral anterior colporrhaphy plus insertion of a dermal allograft spanning the anterior compartment between the arcus tendineus fascia pelvis on each side. Eligible subjects had anterior prolapse to the hymen or beyond, were bothered by their prolapse, and were planning to undergo surgical correction. Subjects completed a pelvic organ prolapse quantification system (POPQ) examination and Pelvic Floor Distress Inventory (PFDI)/PFDI-20 before surgery; a POPQ, PFDI, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire at 1 year postoperatively; and a POPQ, PFDI-20, Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, Revised, and Patient-reported Global Impression of Improvement Inventory at 7 to 10 years postoperatively. Our primary outcome was anatomic anterior prolapse recurrence at 1 or 7 to 10 years defined as Aa or Ba greater than or equal to -1. Our secondary outcome was a composite score of anterior prolapse recurrence at 1 or 7 to 10 years defined as anatomic recurrence (Aa or Ba ≥ 0), retreatment for cystocele, or answering yes to PFDI-20 question 3 (subjective report of vaginal bulge). RESULTS: A total of 114 subjects were randomized, 70 to anterior colporrhaphy and 44 to anterior colporrhaphy plus dermal allograft. About 92% of subjects underwent concomitant apical suspension, 98% in the graft group and 89% in the nongraft group. Eighty-nine subjects (32 graft [73%], 57 nongraft [81%]) returned for 1-year follow-up. Fifty-three patients (19 graft [48%], 34 nongraft [49%]) returned for 7- to 10-year follow-up. The primary outcome was met by 8 (18%) graft and 22 (31%) nongraft subjects at 1 year postoperatively (P = 0.26) and by 10 (23%) graft and 24 (34%) nongraft subjects at 7 to 10 years postoperatively (P = 0.37). The secondary outcome was met by 8 (18%) graft and 15 (21%) nongraft subjects at 1 year postoperatively (P = 0.74) and by 13 (30%) graft and 21 (30.0%) nongraft subjects at 7 to 10 years postoperatively (P = 0.99). CONCLUSIONS: We cannot conclude whether there is a difference in anterior recurrence for anterior colporrhaphy with and without dermal allograft and do not recommend changes in clinical practice based on these results.

Subjective and objective responses to PTNS and predictors for success: a retrospective cohort study of percutaneous tibial nerve stimulation for overactive bladder.

INTRODUCTION AND HYPOTHESIS: We investigated the objective improvements in overactive bladder (OAB) symptoms in patients undergoing percutaneous tibial nerve stimulation (PTNS) and predictive factors of patient satisfaction. METHODS: In this single-center retrospective cohort study at a tertiary urogynecology center, we identified all female patients who underwent PTNS therapy from 1 October 2007 - 1 January 2016 and followed them from their initial visit through medication therapy and PTNS treatments. Patients who tried at least one medication prior to starting PTNS therapy and completed at least one PTNS visit were included. Baseline demographic data, urinary data, and details of medication and PTNS therapy sessions were collected from records through chart review. Paired or two-sample t-tests were used to compare changes over time or groups. Bivariate and multivariable logistic regression were performed. RESULTS: Two hundred thirteen patients underwent PTNS therapy and 183 patients met the criteria. Overall patients were able to decrease voiding frequency by 1 h, decrease nocturia episodes by 0.8, and decrease urge incontinence episodes with PTNS therapy by ten episodes per week (p = 0.02). Patients who continued OAB medications did not have additional improvements compared with patients who did not continue OAB medications during PTNS. Overall, 25.4% (43/169) patients reported ≥ 75% improvement during PTNS therapy, and 61.5% (104/169) reported ≥ 50% improvement. When evaluating predictive factors of ≥ 50% overall improvement, the number of PTNS sessions increased odds of subjective success (OR = 1.8, p = 0.004). Other factors were not significant predictors of subjective PTNS success. CONCLUSIONS: PTNS can provide both objective and subjective improvements for patients who do not respond to OAB medication therapy.

Is There a Relationship Between Patient-Reported Satisfaction and Persistence on Overactive Bladder Syndrome Pharmacotherapy?

OBJECTIVES: This study aimed to determine the relationship between patient satisfaction with overactive bladder syndrome (OAB) pharmacotherapy and persistence rates. We compared persistence rates between satisfied and dissatisfied patients at designated study intervals. METHODS: This was a retrospective cohort study of new patients who initiated OAB medication. Patients were classified as either satisfied or dissatisfied on the basis of a single-item treatment satisfaction question. Persistence was defined as continuous days on therapy. The measured rate of persistence was determined as the ratio of patients who persisted on medication at 4, 12, and 24 weeks. Data collection included demographic and prescription information; urinary symptom parameters, symptom and quality-of-life scales, and patient-reported outcomes. Two-sample t test or Wilcoxon rank sum test was used to compare continuous outcomes between both groups (satisfied vs not satisfied). χ Test or Fisher exact test was used to compare categorical outcomes between groups. RESULTS: We analyzed the first 116 charts that met our inclusion criteria. Satisfied and dissatisfied patients did not differ in demographic variables. Satisfied patients had a median of 461 vs 254 persistent days (P = 0.0001). Satisfied patients (12.5% vs 40%) were less likely to discontinue medication (P = 0.0068). The discontinuation-free distribution was significantly different between satisfied and dissatisfied cohorts, favoring those who reported satisfaction with OAB medication at all time points (P < 0.0001). Patients who totally discontinued pharmacotherapy were 7 times more likely to be dissatisfied (odds ratio, 7.0; P = 0.002). CONCLUSIONS: Our study helps clarify the relationship between persistence on OAB medication and treatment satisfaction. We found that persistence could serve as a surrogate marker for patient satisfaction because those who reported being satisfied were more likely to persist on therapy at all study intervals.

Postoperative pain and perceptions of recuperation after suture- and mesh-based apical sacrospinous ligament suspension.

OBJECTIVE: To compare the incidence of postoperative pain after suture- or mesh-based sacrospinous ligament suspension (SSLS). METHODS: In a retrospective study, data were reviewed from patients who underwent suture- or mesh-based SSLS at a center in Skokie, IL, USA, between 2006 and 2011. The primary outcome was self-reported postoperative pain scores (range 0-10) on the day of surgery (day 0) and 1 day later (day 1). RESULTS: Overall, 90 women were included in the study: 66 underwent mesh-based SSLS and 24 underwent suture-based SSLS. Day-0 mean pain score was 4.65 ± 1.57 in the mesh group and 5.24 ± 1.44 in the suture group (adjusted P=0.159). Day-1 mean pain score was 4.06 ± 1.78 in the mesh group and 4.31 ± 1.21 in the suture group (adjusted P=0.596). CONCLUSION: Postoperative pain did not differ between patients undergoing suture-based and those undergoing mesh-based SSLS. These observations should be considered in preoperative counseling of patients.

Vaginal vault prolapse in a patient with Mayer-Rokitansky-Küster-Hauser syndrome: a video case presentation.

INTRODUCTION AND HYPOTHESIS: Several reports have described vaginal prolapse in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome patients after creation of a neovagina. To our knowledge, no reports of primary vaginal prolapse of a blind pouch without previous intervention, or surgery for this condition, have been described. METHODS: In this case report, we describe a 19-year-old woman with MRKH and complete prolapse of her shortened vaginal pouch. Surgical correction utilizing permanent suture-based sacrospinous ligament fixation was performed. RESULTS: The patient had a successful outcome. CONCLUSIONS: Sacrospinous ligament fixation provided a safe and effective method for the management of vaginal pouch prolapse. Long-term follow-up is planned. To our knowledge, this is the first report describing surgical repair of primary prolapse of a blind vaginal pouch in the setting of MRKH.

Which bladder instillations are more effective? DMSO vs. bupivacaine/heparin/triamcinolone: a retrospective study.

INTRODUCTION AND HYPOTHESIS: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic and debilitating condition. Our objective was to compare two different bladder instillation treatments in patients with BPS/IC: dimethyl sulfoxide with triamcinolone (DMSO) vs. bupivacaine with heparin and triamcinolone (B/H/T). Our hypothesis was that both treatments are equally effective. METHODS: A retrospective cohort study of instillation-naïve patients was conducted comparing responses to either DMSO or B/H/T at our tertiary urogynecology center from 2012 to 2014. The primary outcome was patient-reported percent of overall improvement from baseline. Secondary outcomes were change in patient-reported daytime voiding frequency (hours) and change in number of nighttime voiding episodes. Variables analyzed as potential confounders included pelvic pain, cystoscopy findings, levator spasm, and fibromyalgia. The two-sided Student's t test, chi-squared test, Poisson regression, and repeated-measure analysis of variance (ANOVA) were used for analyses. RESULTS: One hundred and ninety-three eligible patients were identified (45 receiving DMSO, 146 receiving B/H/T). Compared with baseline, DMSO patients reported 63% improvement (p < 0.0001), increased time between daytime voids by 1.5 h (p < 0.00), and a 40% reduction in nocturia episodes (p < 0.00). B/H/T patients reported 51% improvement (p < 0.00), increased time between daytime voids by 1.4 h (p < 0.00), and an 8% reduction in nocturia episodes (p = 0.26). When comparing the two treatments, DMSO resulted in a greater percentage of overall improvement (p = 0.02) and a significant decrease in nocturia episodes when compared with B/H/T (p = 0.02). There was no significant difference between treatments for daytime voiding frequency (p = 0.50). CONCLUSION: Bladder instillations with DMSO or B/H/T provide overall symptomatic improvement and improved frequency and nocturia. DMSO appears to provide greater improvement in nocturia and overall.

A prospective study of a single-incision sling at the time of robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the efficacy and safety of the Miniarc Precise® single-incision sling (American Medical Systems, Minnetonka, MN, USA) placed at the time of a robotic sacrocolpopexy. METHODS: This was a prospective study of a single-incision suburethral sling placed at the time of robotic sacrocolpopexy in women with stress urinary incontinence (SUI) and pelvic organ prolapse. Primary outcome measure was cure at 1 year, defined objectively by a negative cough stress test (CST) and subjectively by a score of "0 or 1" on question 17 of the Pelvic Floor Distress Inventory (PFDI-20): "Do you experience urine leakage related to coughing/sneezing/laughing?" Secondary outcome measures included the change in Urinary Distress Inventory (UDI-6) and Urinary Impact Questionnaire (UIQ-7) scores at 1 year. All sling-related complications were reported. Paired Student's t test and the Wilcoxon signed-rank test were used for statistical analysis. RESULTS: One hundred and one patients were included between August 2010 and July 2012. One-year follow-up was available for 97 out of 101 patients (96 %). Objective cure was 90 % and subjective cure was 87 %. Baseline UDI-6 scores improved from 34.8 ± 25.1 to 6.7 ± 11.2 at 1 year (p < 0.001). Similarly, UIQ-7 scores improved from 21.1 ± 22.8 to 2.4 ± 8.2 at 1 year (p < 0.001). There were no intraoperative cystotomies, no mesh erosions, no sling revisions, and no cases of urinary retention. The retreatment rate for persistent SUI was 8 % (8 out of 97). CONCLUSIONS: The addition of a single-incision suburethral sling at the time of robotic sacrocolpopexy in women with SUI resulted in an 87 % cure rate at 1 year.