Increased Rate of Mesh Erosion in Breast Cancer Survivors Taking Antiestrogen Therapy.

IMPORTANCE: There are no current data investigating the relationship between mesh-exposure complications after midurethral sling surgery and antiestrogen therapy. OBJECTIVES: We sought to determine if there are increased mesh-exposure complications between a breast cancer population versus a noncancer population particularly in conjunction with hormone suppression (HS) therapy. STUDY DESIGN: A retrospective chart review was performed on patients with a history of breast cancer undergoing tension-free vaginal tape (TVT) surgery at our institution between 2013 and 2021. A group of patients who underwent TVT surgery without a history of cancer served as our control. Univariate and multivariate logistic regression analyses were performed to identify predictors of mesh exposure complications. RESULTS: One hundred twenty-one patients with breast cancer had TVT surgery. Two hundred ninety-seven patients without cancer had TVT surgery during the same period. Baseline characteristics across all groups were similar. Twenty-nine patients (6.9%) experienced mesh exposure. This occurred at a higher rate in our cancer (15.7%) versus the noncancer population (3.4%). Women with breast cancer taking HS therapy had a higher rate of mesh exposure complications compared with those not taking HS therapy (25.0% versus 6.6%; P = 0.005). The highest rate of mesh exposure complications occurred in the cohort taking estrogen receptor modulators, selective estrogen receptor modulator (10/36 [27.8%]) versus aromatase inhibitors (5/24 [20.8%]) versus no HS therapy (4/61 [6.6%]; P = 0.014). On multivariate analysis, HS therapy use (odds ratio, 1.57; P = 0.007) and diabetes mellitus (odds ratio, 4.53; P = 0.018) were associated with increased TVT-related complications. CONCLUSION: Women with breast cancer had a higher rate of mesh exposure complications from TVT surgery compared with women without cancer, particularly those taking antiestrogenic therapy.

Prolapse repair after anterior exenteration.

This report presents our experience in performing prolapse repair after anterior exenteration. The patient had a history of invasive bladder cancer and underwent a robotically assisted laparoscopic anterior exenteration with extended bilateral pelvic lymph node dissection and creation of an Indiana pouch continent diversion. Her pelvic organ prolapse progressed over time despite multiple pessary fittings. She eventually decided to proceed with pelvic reconstructive surgery 6 years after her cancer surgery. She underwent a successful vaginal native tissue reconstruction with uterosacral ligament suspension, posterior repair and reconstruction of the anterior compartment. The patient has been followed for 16 months without recurrent prolapse. Vaginal native tissue pelvic reconstruction is feasible in a patient with a history of pelvic exenteration.

Serial Assessment of Urinary Incontinence in Breast Cancer Survivors Undergoing (Neo)Adjuvant Therapy.

BACKGROUND: Among breast cancer survivors, urinary incontinence (UI) is often attributed to cancer therapy. We prospectively assessed urinary symptoms before and after (neo)adjuvant treatment of early-stage breast cancer. METHODS: With consent, women with stage I-III breast cancer completed the Urogenital Distress Inventory and the Incontinence Impact Questionnaire before and 3 months after initiating (neo)adjuvant therapy. Patients with UI were at least slightly bothered by urinary symptoms. If UI was present pretreatment, it was considered prevalent; if UI was new or worse at 3 months posttreatment, it was considered incident; if prevalent UI was no worse at 3 months posttreatment, it was considered stable. Ordinal logistic regression models identified characteristics associated with the level of prevalent UI and with the degree of UI impact on quality of life (QoL). RESULTS: On pretreatment surveys, participants (N=203; age 54.5 ± 11.4 years) reported 79.8% prevalence of UI, including overactive bladder (29.1%), stress incontinence (10.8%), or both (39.9%). The level of prevalent UI increased with body mass index (BMI; P<.05). Of 163 participants assessed at both time points, incident UI developed in 12 of 32 patients without prevalent UI and 27 of 131 patients with prevalent UI. Regardless of whether UI was prevalent (n=162), incident (n=39), or stable (n=94) at QoL assessment, the impact of UI increased (P<.01) with the number and severity of UI symptoms, subjective urinary retention, and BMI. Adjusted for those characteristics, incident UI had less impact on QoL (P<.05) than did prevalent or stable UI. CONCLUSIONS: We found that UI is highly prevalent at breast cancer diagnosis and that new or worsened UI is common after (neo)adjuvant therapy. Because UI often impairs QoL, appropriate treatment strategies are needed.

Concurrent pelvic reconstruction and minimally invasive pelvic cancer surgery.

INTRODUCTION AND HYPOTHESIS: We present our experience in performing concurrent prolpase repair at the time of gynecologic cancer surgery. METHODS: The uterosacral ligaments are tagged before performing hysterectomy and pelvic dissection. The uterosacral ligament suspensory sutures are then placed laparoscopically after completion of pelvic cancer surgery. The remainder of the prolapse surgery is performed through a transvaginal approach. RESULTS: Many of our patients who undergo concurrent prolapse repair and gynecolgical cancer surgery receive chemotherapy and pelivc radiation. Concuurent prolapse repair improves their prolaspe symptoms. CONCLUSION: Concurrent prolapse repair should be performed at the same time as gynecologic cancer surgery.

Management of pelvic floor disorder in a diethylstilbestrol daughter.

Between 1947 and 1971, the synthetic estrogen diethylstilbestrol (DES) was prescribed to pregnant women to prevent spontaneous abortions. Many studies have demonstrated adverse consequences of prenatal DES exposure. This report describes a DES daughter treated for uterine cancer who presented with a foreshortened vagina of 4 cm and stage III pelvic organ prolapse. She underwent successful vaginal native tissue reconstructive surgery with uterosacral colpopexy and anterior and posterior repair to lengthen her vagina and treat her prolapse. She then developed stress incontinence and underwent periurethral bulking 5 months later. She has been followed for 2 years with no recurrence of prolapse or incontinence.

Perineal body length and perineal lacerations during delivery in primigravid patients.

This study assessed the relation between perineal body length and the risk of perineal laceration extending into the anal sphincter during vaginal delivery in primigravid patients at an institution with a low utilization of episiotomy. This was a prospective study of primigravid patients in active labor. Primigravid women with singleton pregnancies who were in the first stage of labor at 37 weeks gestation or greater were recruited, and the admitting physician measured the length of the perineal body. The degree of perineal laceration and other delivery characteristics were recorded. Data were analyzed using univariate analyses, receiver-operator curve analyses, and multiple logistic regression for factors associated with increased severity of vaginal lacerations. The perineal body length, duration of second stage of labor, type of delivery, and patient age were associated (P < 0.1) with third- and fourth-degree (severe) perineal lacerations in primigravid women using receiver-operator curve analysis. Using logistic regression, only the duration of second stage of labor and length of the perineal body were significant (P < 0.04) predictors of third- and fourth-degree lacerations, with odds ratios of 32 (1.3 to 807 as 95% CI) and 24 (1.3 to 456), respectively. Both a perineal body length of ≤3.5 cm and a duration of second stage of labor >99 minutes were associated with an increased risk of third- and fourth-degree lacerations in primigravid patients.

Anatomic relation between single-incision slings and the obturator vessels.

The risk of arterial vascular injury within the retropubic space is a potentially life-threatening complication associated with mid-urethral sling placement for the treatment of female stress urinary incontinence. To determine the relationship between the major blood vessels and a single incision sling, these slings were placed in 12 fresh female cadavers. Following the insertion of each sling, the retropubic space was dissected and sling placement was observed relative to the obturator neurovascular bundle bilaterally. The distance between the most distal aspect of each sling arm, or the point of anchoring, was measured from the most medial aspect of the obturator vessels bilaterally. The mean distance between each sling arm and the medial portion of the obturator vessels was an average of 3.4 cm (range 2.0-6.0 cm) in 24 observations. Placement of the single incision sling may have a lower risk of injuring major vessels within the retropubic space compared to full-length mid-urethral slings.

Graft-versus-Host Disease-Associated Vulvovaginal Symptoms after Bone Marrow Transplantation.

We conducted a retrospective review to assess the prevalence of graft-versus-host disease (GVHD)-associated gynecologic conditions among bone marrow transplantation (BMT) patients at City of Hope Medical Center. We calculated the associations among the estimated risks of various gynecologic complications, including vaginal stenosis, by performing chi-square tests and t-test statistics. Between 2010 and 2014, 180 patients were referred to the gynecologic clinic after their BMT. One hundred twenty-four patients (69%) had GVHD; among these patients, 51 (41%) experienced dyspareunia and 43 (35%) had vaginal stenosis. GVHD patients were significantly more likely to have vaginal stenosis (P < .0001), more likely to have used a vaginal dilator (P = .0008), and less likely to have urinary incontinence (UI) than those without GVHD (P < .001). There was no difference in developing pelvic organ prolapse (POP) in patients with or without GVHD (P = .4373). GVHD was a common complication after allogenic BMT. Patients with BMT were more likely to have vulvovaginal symptoms, such as dyspareunia and pelvic pain. Patients with GVHD are at high risk for vaginal stenosis requiring the use of a vaginal dilator. However, they are at low risk for developing UI and POP.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension.

OBJECTIVES: To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS). METHODS: A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status. RESULTS: During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses. CONCLUSIONS: In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Indigo carmine extravasation to upper limb after pelvic reconstructive surgery.

BACKGROUND: The use of dyes during cystoscopy to visualize the ureters adequately is prevalent in gynecologic surgery. Observing ureteral patency after procedures such as a hysterectomy or pelvic reconstruction is important for identifying injury to the upper urinary tract. Indigo carmine is commonly used. Knowing the possible adverse effects and being aware of unusual presentations with the use of indigo carmine are important in managing and counseling patients. CASE: We present a case in which a patient developed indigo carmine extravasation to her upper limb after pelvic reconstructive surgery. The blue discoloration disappeared after 1 day. CONCLUSION: Indigo carmine extravasation to other parts of the body can occur without long-term complications. It takes 24-48 hours for the dye to clear subcutaneously.

Computed tomography-guided S3 lead placement for sacral neuromodulation.

Computed tomography (CT)-guided lead placement for sacral neuromodulation was used in a patient with arthritis and narrow S3 foramina. Bilateral S3 foramina were localized and guide needles were placed with CT guidance. Lead placement was further modified by placement of a tined, quadripolar lead through a dilated S3 tract without initial somatosensory testing. The lead was then interrogated to assess placement and to differentiate superiority of response between two leads. The patient has had greater than 50 % improvement in urinary symptoms by voiding diary. Using CT guidance, satisfactory localization of bilateral S3 foramina may be achieved where prior attempts with conventional fluoroscopy have failed.

Risk factors for mesh extrusion after prolapse surgery: a case-control study.

OBJECTIVES: To identify risk factors for mesh extrusion in women undergoing pelvic organ prolapse repair by abdominal sacral colpopexy (ASC) or vaginal mesh procedure (VMP). METHODS: A multicenter case-control study of patients who underwent ASC or VMP from 2006 to 2009 identified using diagnosis and procedure coding. Cases were defined as women who underwent eligible index procedure with synthetic mesh and had mesh visible through the vaginal epithelium at postoperative evaluation; controls were matched in an approximate 1:3 ratio by date and type of procedure. Two conditional logistic regression models were constructed to assess variables associated with mesh extrusion among women who underwent ASC and among women who underwent VMP. RESULTS: Eighty-four cases were identified (43 cases after ASC and 41 cases after VMP), and 252 patients were matched as controls (147 patients who underwent ASC and 105 patients who underwent VMP). Concomitant hysterectomy was positively associated with mesh extrusion) among women who underwent ASC (adjusted odds ratio, 3.18; 95% confidence interval, 1.27-7.93; P = 0.01) and VMP (adjusted odds ratio, 3.72, 95% confidence interval, 1.20-11.54; P = 0.02). Age, race, type of vaginal incision, menopausal status, medical comorbidities, and smoking were not significantly associated with extrusion in either group. CONCLUSIONS: Concomitant hysterectomy is a risk factor for mesh extrusion after ASC and VMPs. This information may be helpful during informed preoperative counseling and planning.

Recognition and management of nerve entrapment pain after uterosacral ligament suspension.

OBJECTIVE: To estimate the incidence, risk factors, and characteristics of neuropathic pain related to nerve entrapment after uterosacral ligament suspension. METHOD: A review of patients who underwent uterosacral ligament suspension from January 2007 to August 2011 was performed. Patients with neuropathic pain attributable to nerve entrapment from uterosacral ligament suspensory suture placement were identified. Factors including surgeon's dominant hand, side of pain, onset of pain, day of suture removal, number of sutures placed and removed, patient age, and body mass index (BMI) were collected. Follow-up of patients with neuropathic pain was performed at postoperative visits and by telephone contact. RESULT: Eight (1.6%) of 515 patients had neuropathic pain requiring suture removal from the affected side. The postoperative pain was recognized after discontinuation of intravenous narcotics on postoperative day 1. Patients reported their pain improved after removal of all sutures on the affected side. Patients with neuropathic pain did not differ from those without in regard to age, BMI, and preoperative prolapse stage, or in the number of sutures placed. None of the eight had recurrent pelvic organ prolapse (POP), with a median follow-up of 5 months. CONCLUSION: Eight patients (1.6%) had postoperative neuropathic pain that resolved after all sutures were removed on the affected side. The removal of sutures was not associated with recurrent POP in the short-term. LEVEL OF EVIDENCE: II.

Periurethral angioleiomyoma in a female patient.

A 51-year-old white woman, gravida 4, para 3-0-1-3 referred to our urogynecology clinic for evaluation of questionable symptomatic pelvic organ prolapse was found to have a periurethral mass with associated urinary urgency. She underwent transvaginal excision of this mass, and pathology revealed angioleiomyoma. Her urinary urgency has resolved after surgery. No prior periurethral angioleiomyoma has been reported in female patients.

Incidence and risk factors of postoperative urinary tract infection after uterosacral ligament suspension.

INTRODUCTION AND HYPOTHESIS: We assessed the incidence of and risk factors for developing urinary tract infection (UTI) after uterosacral ligament suspension (USLS). METHODS: Retrospective analysis of patients undergoing USLS in 2008-2009 was performed. Postoperative UTI was defined as a positive urine culture within 1 month following surgery. Factors analyzed were patient age, body mass index, parity, history of UTI before surgery, passing voiding trial, discharge with Foley catheter or intermittent self-catheterization, antibiotics at discharge, history of diabetes or renal disease, and surgeon. RESULTS: Surgical records from 169 patients were reviewed. Twenty-three patients (14%) developed UTI. There were no differences in preoperative factors between patients who developed UTI and those who did not. Subgroup analysis revealed those patients who went home with a Foley catheter and did not receive antibiotics had the highest proportion of UTI. CONCLUSION: Patients requiring Foley catheter at discharge following vaginal prolapse repair are at highest risk for UTI and require prophylactic antibiotics.

Permanent suture used in uterosacral ligament suspension offers better anatomical support than delayed absorbable suture.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the outcomes of uterosacral ligament suspension (USLS) procedures in relation to suture material used for apical suspension. METHODS: A retrospective chart review was performed for two senior surgeons who supervised and performed USLS with both suture types in 2008-2009. Permanent and delayed absorbable sutures were compared for failure of anatomical support. Failure, defined as recurrent prolapse beyond the hymen, was evaluated using survival analysis. RESULTS: Two hundred forty-eight procedures were performed. One percent in the permanent group had a loss of support beyond the hymen compared to 6% in the delayed absorbable group (p = 0.034). The preoperative prolapse stage and duration of follow-up did not differ between the two groups. The number of sutures used did not differ between patients who failed and those who did not fail. CONCLUSIONS: The use of permanent sutures for USLS of the vaginal apex was associated with a lower failure rate than delayed absorbable sutures in the short-term.