Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review.

OBJECTIVE: To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. DATA SOURCES: PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. METHODS OF STUDY SELECTION: This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. TABULATION, INTEGRATION, AND RESULTS: The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. CONCLUSION: Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021233300.

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES: PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION: In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION: Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022326255.

Combined Robotic Ventral Mesh Rectopexy and Sacrocolpopexy for Multicompartmental Pelvic Organ Prolapse.

BACKGROUND: Multispecialty management should be the preferred approach for the treatment of pelvic floor dysfunction because there is often multicompartmental prolapse. OBJECTIVE: To assess the safety of combined robotic ventral mesh rectopexy and either uterine or vaginal fixation for the treatment of multicompartmental pelvic organ prolapse at our institution. DESIGN: Retrospective analysis. SETTINGS: Tertiary referral academic center. PATIENTS: All patients who underwent a robotic approach and combined procedure and whose cases were discussed at a biweekly pelvic floor multidisciplinary team meeting. MAIN OUTCOME MEASURES: Operative time, intraoperative blood loss and complications, postoperative pelvic organ prolapse quantification score, length of stay, 30-day morbidity, and readmission. RESULTS: From 2018 to 2021, there were 321 operations for patients with multicompartmental prolapse. The mean age was 63.4 years. The predominant pelvic floor dysfunction was rectal prolapse in 170 cases (60%). Pelvic organ prolapse quantification scores were II in 146 patients (53%), III in 121 patients (44%), and IV in 9 patients (3%); 315 of 323 cases included robotic ventral mesh rectopexy (98%). Sacrocolpopexy or sacrohysteropexy was performed in 281 patients (89%). Other procedures included 175 hysterectomies (54%), 104 oophorectomies (32%), 151 sling procedures (47%), 149 posterior repairs (46%), and 138 cystocele repairs (43%). The operative time for ventral mesh rectopexy was 211 minutes and for combined pelvic floor reconstruction was 266 minutes. Average length of stay was 1.6 days. Eight patients were readmitted within 30 days: 1 with a severe headache and 7 with postoperative complications (2.5%), such as pelvic collection and perirectal collection, both requiring radiologic drainage. Four complications required reoperation: epidural abscess, small-bowel obstruction, missed enterotomy requiring resection, and urinary retention requiring sling revision. There were no mortalities. LIMITATIONS: Retrospective single-center study. CONCLUSIONS: A combined robotic approach for multicompartmental pelvic organ prolapse is a safe and viable procedure with a relatively low rate of morbidity and no mortality. This is the highest volume series of combined robotic pelvic floor reconstruction in the literature and demonstrates a low complication rate and short length of stay. See Video Abstract . RECTOPEXIA Y SACROCOLPOPEXIA ROBTICA VENTRAL COMBINADAS CON MALLA PARA EL PROLAPSO DE RGANOS PLVICOS MULTICOMPARTIMENTALES: ANTECEDENTES:El tratamiento multiespecializado debe ser el enfoque preferido para el tratamiento de la disfunción del suelo pélvico, ya que a menudo hay prolapso multicompartimental.OBJETIVO:Evaluar la seguridad de la rectopexia robótica combinada con malla ventral y fijación uterina o vaginal para el tratamiento del prolapso multicompartimental de órganos pélvicos en nuestra institución.DISEÑO:Análisis retrospectivo.AJUSTES:Centro académico de referencia terciarioPACIENTES:Todos los pacientes que se sometieron a un enfoque robótico y un procedimiento combinado y se discutieron en una reunión quincenal del equipo multidisciplinario sobre el piso pélvico.MEDIDAS DE RESULTADO:Tiempo operatorio, pérdida de sangre intraoperatoria y complicaciones. Puntuación de cuantificación del prolapso de órganos pélvicos posoperatorio, duración de la estancia hospitalaria, morbilidad a 30 días y reingreso.RESULTADOS:De 2018 a 2021, se realizaron 321 operaciones de pacientes con prolapso multicompartimental. La edad media fue 63.4 años. La disfunción del suelo pélvico predominante fue el prolapso rectal en 170 casos (60%). Las puntuaciones de cuantificación del prolapso de órganos pélvicos fueron II en 146 pacientes (53%), III en 121 (44%) y IV en 9 (3%); 315 de los 323 casos incluyeron rectopexia robótica de malla ventral (98%). Se realizó sacrocolpopexia o sacrohisteropexia en 281 pacientes (89%). Otros procedimientos incluyeron 175 histerectomías (54%), 104 ooforectomías (32%), 151 procedimientos de cabestrillo (47%), 149 reparaciones posteriores (46%) y 138 reparaciones de cistocele (43%). El tiempo operatorio para la rectopexia con malla ventral fue de 211 minutos y la reconstrucción combinada del piso pélvico de 266 minutos. La estancia media fue de 1.6 días. Ocho pacientes reingresaron dentro de los 30 días, 1 con dolor de cabeza intenso y 7 pacientes con complicaciones posoperatorias (2.5%): colección pélvica y colección perirrectal, ambas requirieron drenaje radiológico. Cuatro complicaciones requirieron reoperación: absceso epidural, obstrucción del intestino delgado, enterotomía omitida que requirió resección y retención urinaria que requirió revisión del cabestrillo. No hubo mortalidades.LIMITACIONES:Estudio retrospectivo unicéntrico.CONCLUSIONES:Un enfoque robótico combinado para el prolapso multicompartimental de órganos pélvicos es un procedimiento seguro y viable con una tasa relativamente baja de morbilidad y ninguna mortalidad. Esta es la serie de mayor volumen de reconstrucción robótica combinada del suelo pélvico en la literatura y demuestra una baja tasa de complicaciones y una estancia hospitalaria corta. (Traducción-Dr. Aurian Garcia Gonzalez )See Editorial on page 195.

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review.

OBJECTIVE: To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications. DATA SOURCES: A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal. METHODS OF STUDY SELECTION: All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible. TABULATION, INTEGRATION, AND RESULTS: We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent. CONCLUSION: Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD 42018093099.

A systematic review of neurocognitive dysfunction with overactive bladder medications.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to report cognitive dysfunction with commonly used antimuscarinic overactive bladder medications in patients suffering from overactive bladder disorder with and without baseline neurologic conditions. METHODS: We conducted an Ovid MEDLINE, Embase, and PsycINFO search from January 1998 to December 2018 using PRISMA guidelines. Eighteen studies met the inclusion criteria, including 5 randomized controlled trials and 13 observational studies. RESULTS: Cognitive decline was reported with oxybutynin use (5 of 8 studies) and tolterodine use (4 of 7 studies) among patients with and without baseline cognitive impairment. Oxybutynin use was linked to functional, mental, and behavioral decline among patients with Alzheimer's disease (2 studies). No cognitive decline was detected among patients with and without baseline cognitive impairment taking trospium (6 studies), darifenacin (3 studies), imidafenacin (2 studies), and fesoterodine (1 study). Solifenacin was not associated with cognitive decline (2 studies) but was linked to an increased risk of dementia among patients with diabetes (1 study). CONCLUSION: In this review, cognitive decline was reported with oxybutynin and tolterodine use and should be used with caution in adults over 65 years of age. Solifenacin, fesoterodine, and imidafenacin showed mixed results related to central nervous system effect. Trospium and darifenacin were not associated with cognitive decline among patients with and without baseline cognitive impairment.

Generic Health-Related Quality of Life in Patients Seeking Care for Pelvic Organ Prolapse.

OBJECTIVE: Using the American Urogynecologic Society multicenter Pelvic Floor Disorder Registry for Research, we (1) compared generic quality of life (QOL) in women planning pelvic organ prolapse (POP) treatment (surgery vs pessary), (2) correlated generic and condition-specific QOL scores, and (3) identified associations between generic QOL and other factors. METHODS: This cross-sectional analysis assessed generic physical and mental QOL using the Patient-Reported Outcomes Measurement Information System Global Health Scale at baseline. Global Physical and Mental T-scores center on a representative US population sample (mean [SD], 50 [10]; higher scores, better health). Condition-specific QOL was assessed with Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and POP/Urinary Incontinence Sexual Function Questionnaire. Linear regression models identified associations between clinical factors and Global Physical/Mental scores. RESULTS: Five hundred sixty-eight women (419 surgery, 149 pessary) were included. Surgery patients were younger, heavier, and more often sexually active (all P's ≤ 0.01). Global Physical scores were lower in the surgery versus pessary group, but not likely clinically meaningful (mean [SD], 48.8 [8.1] vs 50.4 [8.5]; P = 0.035); Global Mental scores were similar (51.4 [8.4] vs 51.9 [9.5], P = 0.56). Global Health scores correlated with Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and POP/Urinary Incontinence Sexual Function Questionnaire scores (all P's < 0.0001). In multivariable models, menopause was associated with better physical QOL, and constipation, coronary artery disease, pelvic pain, and increased body mass index with worse physical QOL. Age was associated with better mental QOL, and constipation, fecal incontinence, pelvic pain, and coronary artery disease with worse mental QOL. CONCLUSIONS: Women choosing POP surgery versus pessary had similar physical and mental generic QOL.

Hydronephrosis Associated With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVES: The aim of this study was to report the prevalence of hydronephrosis associated with pelvic organ prolapse (POP). METHODS: We conducted a MEDLINE and PubMed search from 1996 to October 2016 using PRISMA guidelines. Eight studies met criteria for inclusion, including 3 prospective and 5 retrospective studies. RESULTS: The prevalence of hydronephrosis ranged from 3.5% to 30.6% in studies that included multiple stages of prolapse. Hydronephrosis correlated with prolapse severity in multiple studies, but serum creatinine did not consistently predict hydronephrosis. Two studies reported a significantly higher prevalence of hydronephrosis in patients with uterovaginal prolapse compared with vaginal vault prolapse. Complete resolution of hydronephrosis was described in 56% to 83% of patients after undergoing surgical treatment for advanced prolapse. CONCLUSIONS: Hydronephrosis among patients with POP is not rare, and we suggest consideration of upper tract evaluation in patients presenting with POP, particularly in those with advanced uterovaginal prolapse electing to proceed with expectant or conservative management.

The Relationship Between Urinary Incontinence, Mobility Limitations, and Disability in Older Women.

PURPOSE OF THE REVIEW: To describe current understanding and the relationship between urinary incontinence (UI), mobility limitations, and disability in older women with pelvic floor disorders. RECENT FINDINGS: UI is a prevalent pelvic floor disorder in older women and is considered to be one of the most common geriatric problems. There is no clear classification of UI as a disease versus UI as a geriatric syndrome in the current literature. Since the disability is also prevalent in older women, an evaluation of the relationship between UI and disability, may improve ourunderstanding of UI as a disease or a geriatric syndrome. This relationship may be classified through different pathways. Some evidence suggests that mobility disabilities and UI in older women may have bidirectional pathophysiologic mechanisms through generalized muscle dysfunction. SUMMARY: Expanding research on the mechanisms of UI, mobility limitations, and disability in older women as well as their associations will enhance our insight into clinical, pharmacological, environmental, behavioral, and rehabilitative interventions. It will also lead to improved measures for prevention and treatment UI in older women. Thus, understanding UI, mobility limitations, and disability can have substantial implications for both clinical work and research in this area.

Effects of bilateral salpingo-oophorectomy at the time of hysterectomy on pelvic organ prolapse: results from the Women's Health Initiative trial.

OBJECTIVE: This study aims to estimate the effects of bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy and estrogen therapy on vaginal prolapse. METHODS: A retrospective analysis of the Women's Health Initiative estrogen-alone trial was performed. Women who retained their ovaries were compared with women who had BSO at the time of hysterectomy for the presence of cystocele or rectocele at entry into the study. Based on BSO and hormone therapy (HT) status, participants were categorized into groups. We hypothesized that BSO and prolonged hypoestrogenemia may be associated with an increased risk of prolapse. Univariate and multivariate analyses were used to determine the effects of BSO and HT status on cystocele and rectocele. RESULTS: Of 10,739 participants in the estrogen-alone trial, 8,879 women were included in the analysis. Older age, higher parity, higher body mass index, higher waist-to-hip ratio, and non-African-American race/ethnicity were associated with increased odds of developing cystocele or rectocele. Women who retained their ovaries had higher rates of cystocele or rectocele at screening (39%) compared with all women who had BSO (31-36%; odds ratio, 1.18; 95% CI, 1.04-1.33). After controlling for multiple variables, our analysis showed that women who retained their ovaries had higher odds of developing cystocele or rectocele compared with women who had BSO and no subsequent HT (odds ratio, 1.23; 95% CI, 1.07-1.41). All other comparisons were nonsignificant. CONCLUSIONS: BSO at the time of hysterectomy is not associated with increased risk of cystocele or rectocele. BSO and no subsequent HT may even have a protective effect against cystocele or rectocele.

Hysterectomy and urinary incontinence in postmenopausal women.

INTRODUCTION AND HYPOTHESIS: To evaluate an association between hysterectomy and urinary incontinence (UI) in postmenopausal women. METHODS: Women (aged 50-79) with uteri (N = 53,569) and without uteri (N = 38,524) who enrolled in the Women's Health Initiative (WHI) Observational Study between 1993 and 1996 were included in this secondary analysis. Baseline (BL) and 3-year demographic, health/physical forms and personal habit questionnaires were used. Statistical analyses included univariate and logistic regression methods. RESULTS: The baseline UI rate was 66.5 %, with 27.3 % of participants having stress urinary incontinence (SUI), 23 % having urge UI (UUI), and 12.4 % having mixed UI (MUI). 41.8 % of women had undergone hysterectomy, with 88.1 % having had the procedure before age 54. Controlling for health/physical variables, hysterectomy was associated with UI at BL (OR 1.25, 95 % CI 1.19, 1.32) and over the 3-year study period (OR 1.23, 95 % CI 1.11, 1.36). Excluding women with UI at BL, a higher incidence of UUI and SUI episodes was found in hysterectomy at year 3. Among women who had undergone hysterectomy, those with bilateral oophorectomy (BSO) did not have increased odds of developing UI at BL or over the 3-year study period. Hormone use was not associated with a change in UI incidence (estrogen + progesterone, p = 0.17; unopposed estrogen, p = 0.41). CONCLUSIONS: Risk of UI is increased in postmenopausal women who had undergone hysterectomy compared with women with uteri.

The effect of uterine fibroid embolization on lower urinary tract symptoms.

INTRODUCTION AND HYPOTHESIS: The objective was to determine the effect of uterine fibroid embolization (UFE) on lower urinary tract symptoms (LUTS) and quality of life (QoL). METHODS: This prospective study included women with symptomatic fibroids and LUTS who underwent UFE between March 2008 and May 2010. Subjects underwent pre-procedural pelvic magnetic resonance imaging (MRI) and completed the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Prolapse and Incontinence Sexual Questionnaire (PISQ-12), Uterine Fibroid Symptom Quality of Life questionnaire (UFS-QoL), and a standardized 48-h bladder diary at baseline and 3 months after the procedure. Patient Global Impression of Improvement (PGI-I) assessed post-procedural patient satisfaction. The primary outcome was subjective improvement in LUTS at 3 months, as measured by a decrease in UDI-6 score. Univariate analysis, paired t test and a stepwise regression analysis were appropriately conducted. RESULTS: Fifty-seven patients underwent UFE and completed bladder diaries and questionnaires. At 3 months after UFE, patients reported a significant decrease in UDI-6, IIQ-7, and UFS-QoL, indicating an improvement in urinary symptoms and QoL. Bladder diaries showed a significant reduction in daytime and night-time voids. No difference was found in incontinence episodes. Uterine volume, dominant fibroid size, fibroid location, and MRI-confirmed bladder compression did not affect the difference in UDI-6 scores. In a stepwise regression model, BMI had a significant impact on the change in UDI-6 score, with a decrease of 1.18 points for each 1 unit increase in BMI. CONCLUSION: Uterine fibroid embolization significantly improves LUTS and urinary-related QoL. Obesity seems to attenuate this effect.

Patient goal attainment in vaginal prolapse repair with and without mesh.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to describe patient-centered goals and their attainment in vaginal prolapse repair, with and without mesh. METHODS: A secondary analysis of a multicenter randomized controlled trial of prolapse repair with or without vaginal mesh was performed. Participants (n = 65) selected three preoperative goals ranked by importance. At 3 and 12 months postoperatively, patients graded their goal attainment on a scale of 1 (not at all) to 5 (100 % attainment). Goal attainment was compared with anatomical outcome, symptoms, quality of life, and satisfaction scores. Nonparametric tests and the log-rank test were used to determine statistical significance (p < 0.05). RESULTS: A total of 176 goals were selected. The first goal in 37 women (57 %) was improving prolapse symptoms, in 15 (23 %) urinary symptoms, in 7 (11 %) appearance, activity, and self-image, in 2 (3.1 %) bowel symptoms, and in 2 (3.1 %) sexual function. At 3 and 12 months postoperatively, goal achievement for prolapse symptoms was 96.1 and 93.6 %, for urinary symptoms 75.6 and 70.0 %, and for appearance, activity, and self-image 90.5 and 94.7 %, respectively. The effect of anatomical outcome, mesh use, or the presence of mesh erosion on goal attainment could not be demonstrated. Women who achieved their first goal had significantly better symptoms, quality of life, and satisfaction scores than women who did not. CONCLUSIONS: Patient goal attainment after vaginal prolapse repair was high and not consistently related to objective anatomical outcome or mesh use. It persisted between 3 and 12 months postoperatively and was associated with better satisfaction, quality of life, and symptom scores.

One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse.

OBJECTIVE: The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh. STUDY DESIGN: Women with stage ≥2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ≤1 at 12 months. Secondary outcomes included quality of life and complications. RESULTS: All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh. CONCLUSION: Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.

Vaginal mesh colpopexy for the treatment of concomitant full thickness rectal and pelvic organ prolapse: a case series.

OBJECTIVE: To present our case series of concomitant rectal and pelvic organ prolapse (POP) treated with vaginal colpopexy with synthetic mesh. STUDY DESIGN: Charts of patients with full thickness rectal prolapse and POP were reviewed for presenting symptoms, physical examination with POP-Q including rectal prolapse evaluation, and perioperative complications and outcomes. RESULTS: Four patients aged 63-78 were identified with full thickness rectal prolapse and POP. All of them had symptoms related to both conditions. Rectal prolapse protrusion ranged from 2 cm to 3 cm outside the anus. All patients had vaginal mesh colpopexy; two of them with anterior and posterior vaginal mesh and 2 with posterior mesh only. At a follow-up of 6-44 months, all patients had resolution of both POP and rectal prolapse signs and symptoms. CONCLUSION: Vaginal colpopexy with mesh may be a unique treatment to address both POP and full thickness rectal prolapse in selected patients. Further research is needed to determine the safety and efficacy of this method.

Risk factors for prolapse development in white, black, and Hispanic women.

OBJECTIVES: : This study aimed to examine the risk factors for prevalence and incidence of pelvic organ prolapse (POP) in whites, Hispanics, and blacks. METHODS: : This is a secondary analysis of the Women's Health Initiative (WHI) Estrogen plus Progestin Clinical Trial (E + P). Of the original E + P trial population of 16,608, 12,667 women (78.3%; 11,194 whites, 804 blacks, and 669 Hispanics) were included in the final study sample and evaluated during the 5-year period. The outcomes evaluated were any prolapse (WHI prolapse grades 1-3) and WHI prolapse grade 2 or 3. Descriptive analyses, logistic regression, and proportional hazard modeling were performed. RESULTS: : Increasing parity correlates with increasing WHI prolapse grades (0-3) in whites and blacks but not Hispanics. The incidence of grade 2 or 3 POP increased by 250% in white women with 1 child (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.68-3.71) in comparison to nulliparous women and grew with higher parity. For blacks, a weak association between the parity and grade 2 or 3 POP was noted only in women who had 5 or more kids (HR, 10.41; 95% CI, 1.38-78.77). Blacks were less likely (HR, 0.53; 95% CI, 0.40-0.71) to develop grade 2 or 3 POP compared with whites. For grade 2 or 3 POP, age was found to be a risk factor in whites (odds ratio [OR], 1.03; 95% CI, 1.02-1.04) only and body mass index (≥25 kg/m, <30 kg/m) in whites (OR, 1.64; 95% CI, 1.34-2.02) and Hispanics (OR, 2.87; 95% CI, 1.03-2.02). CONCLUSIONS: : White women are at a much greater risk for developing grade 2 or 3 POP compared with blacks. Parity correlates most strongly with the risk of prolapse development in whites and possibly in grand multiparous blacks.

Vaginal mesh for prolapse: a randomized controlled trial.

OBJECTIVE: To present 3-month outcomes of a double-blind, multicenter randomized controlled trial comparing traditional vaginal prolapse surgery without mesh with vaginal surgery with mesh. METHODS: Women with pelvic organ prolapse quantification prolapse stages 2-4 were randomized to vaginal colpopexy repair with mesh or traditional vaginal colpopexy without mesh. The primary outcome measure was objective treatment success (pelvic organ prolapse quantification stage 1 or lower) at 3 months. Secondary outcome measures included quality-of-life variables and complication rates. RESULTS: Sixty-five women were recruited from January 2007 to August 2009, when the study was halted due to predetermined stopping criteria for vaginal mesh erosion at a median follow-up of 9.7 months (range, 2.4-26.7 months). Thirty-two women underwent mesh colpopexy (24 anterior mesh, eight total mesh), and 33 women had vaginal colpopexies without mesh (primarily uterosacral ligament suspension) and concurrent colporrhaphy. There were no statistically significant baseline differences between the mesh and no-mesh groups with respect to demographics, menopausal status, and race. Analysis of the mesh and no-mesh women found no difference with respect to overall recurrence (mesh: 19 [59.4%] compared with no mesh: 24 [70.4%], P=.28). There were five (15.6%) vaginal mesh erosions. Two cystotomies and one blood transfusion occurred in the mesh group only. Subjective cure of bulge symptoms was noted in 93.3% of mesh patients and 100% of no-mesh patients. Furthermore, subjective quality-of-life measurements did not differ between the two groups at baseline or 3 months postoperatively. CONCLUSION: At 3 months, there is a high vaginal mesh erosion rate (15.6%) with no difference in overall objective and subjective cure rates. This study questions the value of additive synthetic polypropylene mesh for vaginal prolapse repairs. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00475540. LEVEL OF EVIDENCE: I.

Delivery route preferences of urban women of low socioeconomic status.

OBJECTIVE: To identify the main determinants of mode of delivery preference among urban dwelling women of lower socioeconomic status (SES). METHODS: Over a 12-month period, a self-completion 36-item questionnaire was administered to a convenience sample of 308 women within the first 3 postpartum days. Non-parametric tests were used for analysis. RESULTS: Study participants were mostly African American (>85%), single mothers (>75%), and unemployed (≥55%). Among the women, 85.7% had vaginal delivery (VD) and 14.3% had cesarean delivery (CD). Women who preferred CD (10%) were more likely to be concerned about a vaginal tear/episiotomy during VD, forceps, and a "big" baby compared with women who preferred VD, for whom "pushing the baby out myself" and "fear of cesarean" were the most important factors. In the final model of 7 factors, the 3 main factors found to positively impact maternal preference for CD were a vaginal cut during VD (P<0.001), higher mean BMI (P=0.001), and cesarean as the most recent delivery type (P<0.001). The total explained variance by this model was 46%. CONCLUSIONS: Short-term complications of a VD, higher BMI, and a previous cesarean delivery are the most significant factors that impact the preferences of women of lower SES for future mode of delivery.

Posterior wall prolapse and repair.

Most posterior wall defects occur in combination with other pelvic support disorders. Some patients with rectoceles, the most common posterior wall defect, are asymptomatic, whereas others experience a range of symptoms from a sensation of lower pelvic fullness to defecatory and/or sexual dysfunction. If patients are symptomatic, rectoceles can be treated conservatively with pelvic floor physiotherapy, behavioral therapy, or pessaries. Surgically, the most common rectocele repair is a traditional posterior colporrhaphy which provides excellent cure rates of up to 95%. The studies published to date do not support the use of biologic or synthetic absorbable grafts in reconstructive surgical procedures of the posterior compartment as these repairs have not improved anatomic or functional outcomes over traditional posterior colporrhaphy.

A comparison of transobturator versus retropubic midurethral slings for mixed urinary incontinence.

PURPOSE: : The primary objective of this study was to compare improvement and/or cure of mixed urinary incontinence (MUI) symptoms after retropubic (RP) versus transobturator (TO) slings. The secondary objective was to compare improvement and/or cure of the urge urinary incontinence (UUI) component of MUI. METHODS: : This retrospective cohort study included all patients with MUI who underwent a midurethral sling from January 2006 to May 2007. IRB approval was obtained to perform telephone interviews to collect the Patient Global Impression of Improvement (PGI-I) questionnaire for MUI and to elicit any changes in the SUI and/or UUI components of MUI. The primary outcome was based on a 7-point Likert scale for the PGI-I questionnaire. The secondary outcome was improvement or resolution of the UUI component of MUI based on a 4-point Likert scale of patient responses to the question, "Is your urge incontinence worse, the same, or improved after surgery?" Subjects who had RP slings were compared with those with TO with respect to these outcomes. Patient satisfaction, adverse events, urinary retention, and worsening of urge incontinence symptoms were also assessed. RESULTS: : For the primary outcome (MUI), no significant difference was found in the PGI-I scores between the 2 groups. Similarly, no difference was found in UUI improvement/resolution between the 2 groups. UUI improvement was noted in 46.4% of the TO group and 56.5% of the RP group, and UUI cure in 39.3% of the TO group and 26.1% of the RP group. An 84.3% overall improvement/cure rate of UUI was noted when both groups were combined. Ten (19.6%) women required anticholinergic use after slings. A total of 52.6% of subjects were "completely satisfied" and 14.3% were "not at all satisfied" with the procedure in the TO group, versus 65.2% and 7.7% in the RP group (Mann-Whitney U test, P = 0.23). There was no difference in perioperative adverse events between the 2 groups. CONCLUSIONS: : RP and TO slings result in similar global improvement in MUI symptoms. A total of 84.3% of patients undergoing RP or TO sling for MUI have improvement/cure of the UUI component.

Robotic sacrocolpopexy versus vaginal colpopexy with mesh: choosing the right surgery for anterior and apical prolapse.

OBJECTIVES: : To describe patients' characteristics and anatomic outcome of robotic sacrocolpopexy (RSC) and vaginal mesh colpopexy (VMC). METHODS: : Retrospective cohort study involving RSC (n = 17) and VMC (n = 37) procedures performed over an 18 month period in a teaching hospital. The primary outcome was 1 year anatomic cure at the apex and anterior wall. Descriptive and univariate analyses were used to determine statistical significance (P < 0.05). RESULTS: : VMC subjects were more likely to be older, menopausal, and had increased BMI and more severe prolapse than the RSC group. At a mean follow-up of 13 and 12.3 months for the VMC and RSC, respectively, both groups showed significant improvement of prolapse (P < 0.001) with a cure rate of 94.1% for RSC and 70.2% for VMC (P = 0.07). Total vaginal length was significantly shorter after VMC. RSC had longer operative time and hospital stay, but lower blood loss. Complication rates were similar among the groups. CONCLUSIONS: : RSC and VMC are being offered to different patient populations. These minimally invasive prolapse repair procedures have comparable results with a trend toward higher cure rate in RSC and similar complications rate.