Intraoperative Evaluation of Urinary Tract Injuries at the Time of Pelvic Surgery: A Systematic Review.

OBJECTIVE: The aim of this study was to determine the safety and efficacy of methods for intraoperative evaluation of urinary tract injury during pelvic surgery. METHODS: PubMed, EMBASE, CINAHL, Web of Science, Scopus, ProQuest, the Cochrane Library, and Clinicaltrials.gov were searched from 1947 to February 2018. Articles or abstracts describing the routine evaluation of urinary tract injuries during pelvic surgery in adults were included, surgical indications of urinary tract anomaly, stones, or malignancy were excluded. There were no restrictions on study design or language. Outcomes included injuries diagnosed intraoperatively, delayed diagnoses, adverse effects, subjective assessments, time to use, and cost. Data were extracted in duplicate at an individual-participant level. Prevalence of injuries, sensitivity, specificity, and predictive values of each diagnostic method were calculated. A combination of generalized linear models and a Bayesian approach were used to separately pool diagnostic accuracy measures. RESULTS: There were 5303 titles, 527 abstracts, and 164 full-text articles assessed for eligibility; 69 articles were analyzed. Diagnostic methods retrieved were cystoscopy using saline, dextrose or unspecified distention media, oral phenazopyridine and vitamin B, intravenous (IV) methylene blue, IV sodium fluorescein, IV indigo carmine, prophylactic retrograde ureteral stents, and transabdominal Doppler ultrasound. Prevalence of urinary tract injury ranged from 0.3% to 2.8%. Sensitivity ranged 63% to 91%, and specificity, 99.7% to 100%, with no significant differences suggested between methods. CONCLUSIONS: All evaluable methods of intraoperative urinary tract assessment during pelvic surgery are safe and effective with specificity of greater than 99% and low rates of complications. Larger, more rigorous studies are required to evaluate the diagnostic accuracy of some newer methods.

The Effect of Commonly Performed Exercises on the Levator Hiatus Area and the Length and Strength of Pelvic Floor Muscles in Postpartum Women.

OBJECTIVE: The aim oft his study was to compare the effects of 10 common exercises to traditional pelvic floor muscle (PFM) contractions (Kegel) on levator hiatus (LH) area and PFM length and strength. METHODS: This is a cross-sectional study of 15 healthy postpartum women. Ten exercises were studied. These were common variations of leg, core, and back exercises used in yoga, Pilates, strength training, and physical therapy. Each participant performed all 10 exercises at a single visit in 2 examination settings: transperineal ultrasound and perineometry. Ultrasound measured the LH area and PFM length, and perineometry measured the muscle strength (peak squeeze pressure). RESULTS: Kegel generates an increase in squeeze pressure (24.3 cm H2O), shortens the muscles (-0.46 cm) and narrows the LH (-0.13 cm). The bird-dog and plank exercises were not different from Kegel in any measurement. While the leg-lift ultrasound dimensions are similar to Kegel, leg lifts generated peak squeeze pressures stronger than any other exercise (including Kegel). Whereas ultrasound dimensions were similar to Kegel, tucked and untucked squats and thigh adductions generated weaker contractions than Kegel. While crunch generated a squeeze pressure similar to Kegel, the ultrasound dimensions showed a significantly wider LH and longer muscle than Kegel. Bridge, clam, and plié exercises affected the PFMs differently than Kegel in all measures. CONCLUSIONS: Bird-dog, plank, and leg-lift exercises should be evaluated as alternative exercises to Kegel as they affect PFM strength and length and LH area similarly to Kegel, and leg lifts generate a stronger contraction than Kegel.

Concurrent midurethral sling excision or lysis at the time of repeat sling for treatment of recurrent or persistent stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Limited evidence guides operative technique in primary midurethral sling (MUS) lysis or excision at the time of repeat sling placement for persistent or recurrent stress urinary incontinence (SUI). Our objective is to compare subjective improvement in patients undergoing repeat MUS placement with and without concurrent primary sling lysis or removal. METHODS: This was a retrospective cohort study with a prospective survey of patients who underwent two MUS placements for SUI at a single institution from January 1996 to December 2015. After patient identification, the electronic record was queried for demographic and perioperative data. Subjects then completed the Urogenital Distress Index, (UDI-6), Incontinence Severity Index (ISI), and the Incontinence Impact Questionnaire (IIQ-7). Subjects were also asked if they would choose to undergo repeat MUS surgery again. RESULTS: Sixty-one patients were included. 17 out of 61 (28%) underwent concomitant primary sling lysis or excision, and 44 out of 61 (72%) did not. Fifty-seven percent (n = 35) completed the survey. Of the respondents, the median ISI score was 4 (1-8), with no difference between groups; 14 out of 35 (40%) reported the presence of bothersome urge incontinence, 11 out of 35 (31%) reported bothersome stress urinary incontinence, and 8 out of 35 (23%) reported symptoms of voiding dysfunction, with no difference between groups. 57% of patients (20 out of 35) would undergo repeat MUS placement again. CONCLUSIONS: In a small cohort, concurrent excision of the primary sling at the time of repeat MUS did not improve subjective outcomes. Many patients reported urinary urgency and voiding symptoms, and only about half of patients would choose to undergo the surgery again if given the choice.