Risk of postoperative mesh exposure following sacrocolpopexy with supracervical versus total concomitant laparoscopic hysterectomy.

INTRODUCTION AND HYPOTHESIS: The primary objective was to compare rates of mesh exposure in women undergoing minimally invasive sacrocolpopexy with concurrent supracervical vs total hysterectomy. We hypothesized there would be a lower risk of mesh exposure for supracervical hysterectomy. METHODS: This was a retrospective cohort study using the Premier Healthcare Database. Women undergoing sacrocolpopexy with supracervical or total hysterectomy between 2010 and 2018 were identified using Current Procedural (CPT) codes. Complications were identified using CPT and diagnosis codes; reoperations were identified using CPT codes. Mesh exposures were measured over a 2-year period. A multivariable logistic regression was performed with a priori defined predictors of mesh exposure. RESULTS: This study includes 17,111 women who underwent minimally invasive sacrocolpopexy with concomitant supracervical or total hysterectomy (6708 (39%) vs 10,403 (61%)). Women who underwent supracervical hysterectomy were older (age 60 ± 11 vs 53 ± 13, p < 0.01) and less likely to be obese (4% vs 7%, p < 0.01). Postoperative mesh exposures within 2 years were similar (supracervical n = 47, 0.7% vs total n = 65, 0.62%, p = 0.61). On logistic regression, obesity significantly reduced the odds of mesh exposure (OR 0.2, 95% CI 0.01, 0.8); concomitant slings increased odds (OR 1.91, 95% CI 1.28, 2.83). Supracervical hysterectomy was associated with higher rates of port site hernias (1.3% vs 0.65%, p < 0.01), but lower surgical site infections within 3 months (0.81% vs 1.2%, p = 0.03). Reoperation for recurrent prolapse within 24 months was similar (supracervical n = 94, 1.4% vs total n = 150, 1.4%, p = 0.88). CONCLUSIONS: Postoperative mesh exposure rates do not significantly differ based on type of concomitant hysterectomy in this dataset.

Surgical cost of robotic-assisted sacrocolpopexy: a comparison of two robotic platforms.

IMPORTANCE: Robotic assistance in pelvic organ prolapse surgery can improve surgeon ergonomics and instrument dexterity compared with traditional laparoscopy but at increased costs. OBJECTIVE: To compare total costs for robotic-assisted sacrocolpopexy (RSC) between two robotic platforms at an academic medical center. METHODS: Retrospective cohort of Senhance (Ascensus) RSC between 1/1/2019 and 6/30/21 who were matched 2:1 with DaVinci (Intuitive) RSC. Primary outcome was total costs to hospital system; secondarily we evaluated cost sub-categories. Purchase costs of the robotic systems were not included. T-test, chi-square, and Fisher's exact tests were used. A multivariable linear regression was performed to model total costs adjusting for potential confounders. RESULTS: The matched cohort included 75 subjects. The 25 Senhance and 50 DaVinci cases were similar overall, with mean age 60.5 ± 9.7, BMI 27.9 ± 4.7, and parity 2.5 ± 1.0. Majority were white (97.3%) and postmenopausal (86.5%) with predominantly stage III prolapse (64.9%). Senhance cases had longer OR times (Δ = 32.1 min, p = 0.01). There were no differences in concomitant procedures, intraoperative complications, or short-term postoperative complications between platforms (all p > 0.05). On univariable analysis, costs were similar (Senhance $5368.31 ± 1486.89, DaVinci $5741.76 ± 1197.20, p = 0.29). Cost subcategories (medications, supplies, etc.) were also similar (all p > 0.05). On multivariable linear regression, total cost was $908.33 lower for Senhance (p = 0.01) when adjusting for operative time, estimated blood loss, concomitant mid-urethral sling, and use of the GelPoint mini port system. CONCLUSIONS: Despite longer operating times, total cost of robotic-assisted sacrocolpopexy was significantly lower when using the Senhance compared to the DaVinci system.

Home urinary tract infection testing: patient experience and satisfaction with polymerase chain reaction kit.

INTRODUCTION AND HYPOTHESIS: We sought to evaluate patient satisfaction with a novel multiplex PCR UTI home collection kit for symptomatic UTI in a urogynecologic population. We secondarily sought to characterize reported uropathogens and resistance profiles of uropathogens in this population. We hypothesized that patients would be satisfied. METHODS: This was a cross-sectional study of women who were surveyed later about their experience undergoing evaluation for a UTI with a home UTI test at a large tertiary care urogynecology practice in 2020. Symptomatic patients were sent a home UTI kit. We assessed patient satisfaction at a later time with a 5-point Likert scale and collected baseline information. The primary outcome was patient satisfaction with this experience. Secondary outcomes included type and number of uropathogens on testing. RESULTS: A total of 30 patients [73% white race, mean age 71.9 (SD 12.0) years] were surveyed. Patients responded with a mean score of 4.7/5 to all satisfaction questions. Overall, 86% (26/30) of patients would choose this test again. Of those asked if they would choose this test again outside of the COVID-19 pandemic, 86% responded affirmatively. The most common symptoms reported included dysuria (53%), urgency (37%) and frequency (30%). The most common pathogens identified included Escherichia coli (70%), Enterococcus faecalis (60%) and Aerococcus urinae (43%). CONCLUSIONS: Patients were satisfied with home UTI PCR testing and the majority would choose this option again. Home UTI PCR testing revealed common uropathogens for a population with a high proportion of recurrent UTI, but additional research comparing home versus in-office urine PCR testing is necessary.

Anatomic Variation of Sacral Mesh Attachment During Minimally Invasive Sacrocolpopexy.

IMPORTANCE: Although anatomic level of mesh attachment to the sacrum varied during minimally invasive sacrocolpopexy with a large proportion above S1, this was not associated with pelvic organ prolapse recurrence. OBJECTIVE: This study aimed to describe the anatomic level of sacral mesh attachment and its association with prolapse recurrence after minimally invasive sacrocolpopexy. STUDY DESIGN: This study included a retrospective cohort of women who underwent minimally invasive sacrocolpopexy with subsequent abdominal and pelvic imaging (magnetic resonance imaging or computed tomography) between 2010 and 2019 at a single academic institution. Anatomic level of attachment was determined by a radiologist. Prolapse recurrence was defined as a composite of self-reported bulge symptoms, any prolapse measure beyond the hymen, and any retreatment with pessary or surgery. χ 2 Tests were used for comparative outcomes. RESULTS: Analyses included 212 women. The mean ± SD age was 58.8 ± 9.9 years, the majority have preoperative stage III/IV prolapse (81.1%), and the median follow-up was 269 days (interquartile range, 57-825 days). Mesh was attached using titanium tacks (n = 136 [64.2%]) and suture (n = 76 [35.8%]) at the level of the L5-S1 intervertebral space (n = 113 [53.3%]) or overlying S1 (n = 89 [42.0%]).The surgical approach was significantly associated with attachment location with a greater proportion of laparoscopy cases demonstrating mesh attachment above S1 (85 [62.5%] vs robotically, 30 [39.5%]; P < 0.01). Dichotomized level of attachment was not associated with composite prolapse recurrence (above S1, n = 18 [22.2%] vs below S1, n = 24 [24.7%]; P = 0.69) or any compartment recurrence ( P ≥ 0.36). CONCLUSIONS: Mesh was primarily attached to the anterior longitudinal ligament at the level of the L5-S1 intervertebral space or S1. Level of mesh attachment was not associated with composite prolapse recurrence.

Reducing pelvic floor injury by induction of labor.

INTRODUCTION AND HYPOTHESIS: We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor. METHODS: Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion. RESULTS: Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL. CONCLUSIONS: Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.

Preprocedure and Immediate Postoperative Changes to Genital Hiatus Following Minimally Invasive Sacrocolpopexy.

IMPORTANCE: This study assesses resting genital hiatus (GH) measurements under anesthesia as compared with in-office measurements for intraoperative planning purposes. OBJECTIVES: The aim of this study was to determine the influence of general anesthesia and apical suspension on GH measurements compared with office measurements. STUDY DESIGN: This was a retrospective cohort of women who underwent minimally invasive sacrocolpopexy within an academic urogynecology practice. Genital hiatus for each patient was measured at 4 time points: (1) preoperative office examination (baseline) at rest (GH rest ) and with strain (GH strain ); (2) following anesthesia induction, at rest (GH induction ); (3) immediately after sacrocolpopexy, at rest (GH colpopexy ); and (4) 4- to 6-week postoperative visit, strain (GH postop ). Enlarged baseline GH strain was defined as ≥4 cm. Paired statistics and analysis of variance were used for comparisons. RESULTS: Fifty-one women were included, whose mean age was 61.3 ± 8.2 years; the majority had stage ≥3 prolapse (n = 39 [76.4%]). Concomitant procedures included hysterectomy (n = 33 [64.7%]) and posterior colporrhaphy or perineorrhaphy (n = 8 [15.7%]). The majority had an enlarged baseline GH strain (n = 39 [76.4%]), and overall cohort mean was 4.7 ± 1.3 cm. Compared with baseline GH rest , mean GH induction was larger (GH induction : 4.6 ± 1.4 cm vs GH rest : 3.8 ± 1.2 cm, P < 0.01) but not different from baseline GH strain (GH induction : 4.6 ± 1.4 cm vs GH strain : 4.7 ± 1.3 cm, P = 0.81). GH colpopexy was decreased from baseline GH strain with a mean difference of 1.1 ± 1.3 cm ( P < 0.01). This difference was driven by women with enlarged baseline GH strain who experienced a mean decrease of 1.5 ± 1.1 cm ( P < 0.01). CONCLUSIONS: Genital hiatus after induction of anesthesia does not significantly differ from preoperative straining GH. Apical suspension with sacrocolpopexy alone resulted in immediate reduction in GH measures, with greater decreases observed in women with enlarged preoperative GH.

Operative Time for Minimally Invasive Sacrocolpopexy: Comparison of Conventional Laparoscopy versus Robotic Platform.

STUDY OBJECTIVE: To evaluate the operative time for minimally invasive sacrocolpopexy using conventional laparoscopy vs robotic assistance. In addition, we sought to compare intraoperative complications, mesh complications, anatomic prolapse recurrence, and retreatment. DESIGN: Retrospective cohort study. SETTING: Academic hospital. PATIENTS: All 142 women who underwent minimally invasive sacrocolpopexy between January 1, 2019, and December 31, 2019. INTERVENTION: We compared operative time between laparoscopic and robotic-assisted sacrocolpopexies. MEASUREMENTS AND MAIN RESULTS: A total of 142 women were included. Mean age was 61.8 ± 9.6 years and mean body mass index 27.1 ± 4.4 kg/m2. A total of 86 (60.6%) sacrocolpopexies were performed laparoscopically and 56 (39.4%) with robotic assistance. There were no significant differences in baseline demographic variables. A higher proportion of concomitant hysterectomies were performed with robotic assistance as compared with laparoscopic cases (n = 42, 73.7% robotic vs n = 43, 50.6% laparoscopic; p <.01). Mean operative times were significantly different between robotic and laparoscopic groups (176.3 ± 45.5 minutes and 195.0 ± 45.4 minutes, p = .02). On linear regression, the variables predicting significant change in operative time were robotic assistance, concomitant hysterectomy, age, body mass index, and no resident involvement. There were no differences in intraoperative bladder or bowel injury, anatomic recurrence beyond the hymen, retreatment, or mesh complications (all p >.05). CONCLUSIONS: Contrary to previous research, the use of robotic assistance does not appear to increase operative time for patients undergoing minimally invasive sacrocolpopexy in a large academic practice.

Sacrocolpopexy experience with a novel robotic surgical platform.

INTRODUCTION AND HYPOTHESIS: The objective was to describe early experience performing sacrocolpopexy using a novel robotic surgical platform. METHODS: This is a case series of all women who underwent robotic-assisted sacrocolpopexy using a new robotics platform (TransEnterix Senhance) between January 2019 and July 2021. All sacrocolpopexies were performed by a single Female Pelvic Medicine and Reconstructive surgeon at a large academic institution. Perioperative information including complications was abstracted from the medical record. Anatomical recurrence was defined as any anatomical point at or past the hymen (≥0). Data are descriptive, with Mann-Whitney U test used for comparison of operative time between the first and second half of the patients. RESULTS: A total of 25 sacrocolpopexies were performed using the new robotics platform. Mean age was 62.3 years (±9.2) and mean BMI was 26.5 (±3.8). Ten (40.0%) patients had a prior hysterectomy. Most (n = 21, 84.0%) had stage III or IV prolapse preoperatively. Mean operative time was 210.2 min (±48.6) and median estimated blood loss was 35 ml (IQR 25-50). Mean operative time decreased between the first and second half of the patients (231.7 min vs 190.3 min, p = 0.047). There were no major intraoperative complications. Median follow-up time was 16 weeks (IQR 4-34) and there were no subjective recurrences or retreatments during this period. Two patients (8.0%) had anatomical recurrence without subjective bother. There were two postoperative readmissions (8.0%) within 30 days for small bowel obstruction, one treated surgically and the other with nonsurgical management. CONCLUSIONS: Our case series demonstrates feasibility and successful early adoption of a new robotics platform for robotic sacrocolpopexy.

Complications After Reperitonealization of Mesh at Time of Sacrocolpopexy: A Retrospective Cohort Study.

OBJECTIVES: To determine if there is a difference in rates of surgical complications among patients who have reperitonealization of mesh versus no reperitonealization at time of sacrocolpopexy. METHODS: This was a retrospective cohort study of all patients who underwent sacrocolpopexy at an academic medical center between 2008 and 2017. The medical record was reviewed for the operative method of sacrocolpopexy, concomitant surgeries, intraoperative or postoperative complications, and readmissions. Groups were compared on whether mesh was reperitonealized under pelvic peritoneum or not. RESULTS: A total of 209 patients underwent sacrocolpopexy, with mesh reperitonealization performed in 115 (55%). Demographics were similar in both groups, except race/ethnicity and stage of prolapse. The majority (190 [91%]) of surgeries included concomitant procedures. A total of 18 intraoperative or postoperative complications (8.6%) were recorded. Relative risk of complication with mesh reperitonealization is 0.81 (95% confidence interval, 0.1-1.70). Complications for subjects without mesh reperitonealization included 4 cystostomies, 1 urethrotomy, 3 postoperative ileuses, and 1 small bowel obstruction. Among subjects with mesh reperitonealization, complications included 5 cystotomies, 2 proctotomies, 1 ureteral obstruction, and 1 small bowel obstruction. Rates of hospital readmission among both groups were not significantly different, with 3.2% of subjects without mesh reperitonealization versus 3.5% of mesh reperitonealization patients (P = 0.91) (relative risk, 1.09; 95% confidence interval, 0.38-2.56). CONCLUSIONS: There is no significant difference in rates of complications or readmissions among patients with and without mesh reperitonealization at time of sacrocolpopexy. The only intraoperative complication solely attributed to mesh closure was a case with ureteral obstruction at time of reperitonealization.

Effect of Surgery for Stress Incontinence on Female Sexual Function.

OBJECTIVE: To evaluate the effects of four different surgical interventions for stress urinary incontinence (SUI) on 2-year postoperative sexual function. METHODS: This is a combined secondary analysis of SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) and TOMUS (Trial of Mid-Urethral Slings). Women in the original trials were randomized to receive surgical treatment for SUI with an autologous fascial sling or Burch colposuspension (SISTEr), or a retropubic or transobturator midurethral sling (TOMUS). Sexual function (assessed by the short version of the PISQ-12 [Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire]) was compared between groups at baseline, 12 and 24 months. Secondarily, the effects of subjective and objective surgical cure rates and the effect of concomitant surgical procedures on 24-month sexual function was explored. RESULTS: Nine hundred twenty-four women were included in this study: 249 (26.9%) had an autologous fascial sling, 239 (25.9%) underwent Burch colposuspension, 216 (23.3%) had a retropubic midurethral sling placed, and 220 (23.8%) had transobturator midurethral sling placed. Baseline characteristics (including PISQ-12 scores) were similar between the four treatment arms, with notable exceptions including race-ethnicity, prolapse stage, concomitant surgery, and number of vaginal deliveries. After adjustment for differences between the groups, there was a clinically important improvement in PISQ-12 scores over the 24-month postoperative period for all treatment groups, with no significant differences attributed to the type of anti-incontinence procedure (baseline PISQ-12: 32.6, 33.1, 31.9, 31.4; 24-month PISQ-12: 37.7, 37.8, 36.9, 37.1, P<.01). There was no significant difference in mean PISQ-12 scores between 12 months and 24 months (12-month PISQ-12: 37.7, 37.8, 36.9, 37.1; 24 months as above, P=.97). Multivariable analysis showed independent associations between objective and subjective cure rates as well as concomitant procedures with a 24-month PISQ-12 score. CONCLUSION: Women undergoing anti-incontinence surgery show overall improvement in sexual function from baseline to 24 months postoperatively, without significant differences based on surgical procedure performed. The majority of this improvement occurs in the first 12 months and is maintained over 24 months.

Use of Ultrasound Urodynamics to Identify Differences in Bladder Shape Between Individuals With and Without Overactive Bladder.

OBJECTIVES: The objective of this study was to identify differences in bladder shape changes between individuals with overactive bladder (OAB) and unaffected individuals during ultrasound urodynamics. METHODS: A prospective urodynamic study was performed with concurrent transabdominal ultrasound (ultrasound urodynamics) on individuals with and without OAB based on validated International Consultation on Incontinence Questionnaire - OAB survey scores. Three-dimensional ultrasound images were acquired at 1-minute increments during filling and used to measure bladder diameters in the height, width, and depth orientations. The engineering strain for each diameter was compared between participants with OAB and controls during urodynamic filling. The height-to-width ratio at capacity was used to determine if individuals were shape outliers. RESULTS: A total of 22 subjects were enrolled, including 11 with OAB and 11 without OAB. During urodynamic filling in both groups, the greatest degree of geometric strain was found in the height orientation, indicating that bladders generally fill in a craniocaudal shape. The mean ± SD height-to-width ratio of the control group was 1.06 ± 0.12 yielding a 95% confidence interval of 0.82 to 1.30. Five (45.5%) of 11 OAB subjects had height-to-width ratios outside this interval as compared with none of the control subjects, identifying a potential shape-mediated subgroup of OAB. CONCLUSIONS: Three-dimensional ultrasound urodynamics can be used to identify differences in bladder shape comparing individuals with and without OAB. This method may be used to identify a subset of OAB patients with abnormal bladder shapes which may play a role in the pathophysiology of their OAB symptoms.