Synthetic vs nonsynthetic slings for female stress and mixed urinary incontinence: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to systematically review objective and subjective success and surgical outcomes of suburethral sling surgery for female patients with stress or mixed urinary incontinence using synthetic vs nonsynthetic material with corresponding surgical approaches (retropubic or transobturator). DATA SOURCES: We systematically searched Medline, Embase, EBM Reviews, ClinicalTrials.gov, and Web of Science Core Collection using standardized Medical Subject Headings (MeSH) without date restrictions (PROSPERO-registered). We double-screened studies and used backward citation chaining. STUDY ELIGIBILITY CRITERIA: We included peer-reviewed randomized controlled trials and prospective or retrospective comparative studies examining outcomes of retropubic or transobturator synthetic vs nonsynthetic (autologous, allograft, or xenograft) slings for female stress or mixed urinary incontinence, with available English or French full texts. We excluded minislings (single insertion point). We allowed slings for recurrent stress or mixed urinary incontinence, and slings concomitant with prolapse surgery, with at least 6 weeks of postoperative follow-up. We excluded systematic reviews, meta-analyses, review studies, case-control studies, case reports, studies that did not describe surgical approach or material, and studies of combination slings. METHODS: We evaluated study quality using RoB, the Cochrane risk-of-bias tool for randomized controlled trials, and the Newcastle-Ottawa scale for observational studies. We used pooled relative risk with 95% confidence intervals to estimate the effect of sling material type on each outcome through meta-analysis and meta-regression, as appropriate. RESULTS: We screened 4341 abstracts, assessed 104 full texts, and retained 35 articles (30 separate studies). For retropubic synthetic vs nonsynthetic slings, there was no difference in the number of objectively or subjectively continent patients. The rates of reoperation for stress urinary incontinence and overall were higher with nonautologous retropubic slings than with synthetic slings. Compared with autologous slings, retropubic synthetic slings were associated with higher subjective continence in populations with ≥25% recurrent stress urinary incontinence (relative risk, 1.27; 95% confidence interval, 1.12-1.43). There were no differences in continence between transobturator synthetic and nonsynthetic slings. Subjective satisfaction was better in the transobturator synthetic group than in the autologous sling group (relative risk, 1.42; 95% confidence interval, 1.03-1.94). CONCLUSION: Synthetic and nonsynthetic slings have comparable objective and subjective success, with synthetic materials generally showing better operative outcomes and fewer complications.

Surgical sexism in Canada: structural bias in reimbursement of surgical care for women.

BACKGROUND: It is well established that female physicians in Canada are reimbursed at lower rates than their male counterparts. To explore if a similar discrepancy exists in reimbursement for care provided to female and male patients, we addressed this question: Do Canadian provincial health insurers reimburse physicians at lower rates for surgical care provided to female patients than for similar care provided to male patients? METHODS: Using a modified Delphi process, we generated a list of procedures performed on female patients, which we paired with equivalent procedures performed on male patients. We then collected data from provincial fee schedules for comparison. RESULTS: In 8 out of 11 Canadian provinces and territories studied, we found that surgeons were reimbursed at significantly lower rates (28.1% [standard deviation 11.1%]) for procedures performed on female patients than for similar procedures performed on male patients. CONCLUSION: The lower reimbursement of the surgical care of female patients than for similar care provided to male patients represents double discrimination against both female physicians and their female patients, as female providers predominate in obstetrics and gynecology. We hope our analysis will catalyze recognition and meaningful change to address this systematic inequity, which both disadvantages female physicians and threatens the quality of care for Canadian women.

Perioperative complication rates of colpocleisis performed with or without concomitant hysterectomy: a large population-based study.

INTRODUCTION AND HYPOTHESIS: We aimed to compare perioperative complications for women who underwent colpocleisis with and without concomitant hysterectomy, and report the rate of concomitant hysterectomy. METHODS: We conducted a retrospective study using the Healthcare Cost and Utilization Project (HCUP) - Nationwide Inpatient Sample 2004 to 2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify women with pelvic organ prolapse (POP) who underwent colpocleisis with or without concomitant hysterectomy. Trend over time of each procedure type was created. We calculated odds ratios (ORs) to determine the risk of perioperative complications with or without concomitant hysterectomy. ORs were adjusted for age, race, income, insurance plan, and hypertension. RESULTS: Of 253,100 adult women who underwent POP repair, 7,431 had colpocleisis. Colpocleisis with concomitant hysterectomy was performed in 1,656 (22.2%) and 5,775 (77.7%) underwent colpocleisis alone (2,469 [33.2%] had a previous hysterectomy). Hysterectomy rates among women with POP undergoing colpocleisis remained relatively steady, whereas those undergoing colpocleisis without hysterectomy declined over time. Prevalence of any complications was higher among those with concomitant hysterectomy (11.4% vs 9.5%, p=0.023). Adjusted OR showed that concomitant hysterectomy increased the risk of complications (OR 1.93, 95% CI 1.45-2.57, p<0.001). CONCLUSIONS: Our large administrative data analysis suggests an increased risk of complications when performing a hysterectomy at the time of colpocleisis. A concomitant hysterectomy was performed in 22% of cases. Whether or not to include hysterectomy at the time of colpocleisis is based on shared decision making, influenced by individual patients' values, comorbidities, and risk of complications.

Adverse events associated with pessary use over one year among women attending a pessary care clinic.

INTRODUCTION AND HYPOTHESIS: The primary objective was to determine the adverse event rate associated with pessary use. Secondary objectives were to determine discontinuation, patient satisfaction, and factors associated with adverse events. METHODS: A retrospective observational study included patients attending a nurse-led pessary clinic with ≥ 1 year follow-up. Patients were fitted with a pessary by a urogynecologist and pessary care by a nurse was performed every 3-4 months. Demographic characteristics, pessary fitting, adverse events, their management and discontinuation were recorded. Pearson Chi-square and Fisher exact tests assessed the association between predetermined risk factors and pessary complications or discontinuation. Relative risk and 95% confidence intervals were computed. RESULTS: 215 women were followed for a mean (standard deviation) of 4.4 (1.9) years. Mean age was 73.8 (8.7) years. Adverse event rate was 83.7%; most commonly vaginal discharge, vaginal bleeding and erosions. Women with cardiovascular risk factors were less likely to develop pessary-related adverse events (79.7% vs. 91.9%, p = 0.03). Gellhorn and donut pessaries were more commonly associated with pessary erosions than ring with support pessaries or incontinence rings (RR 2.37 [1.67; 3.38]). Thirty-five (16.3%) women discontinued pessary use at a mean of 3.3 (1.7) years after initial fitting. Having a pessary erosion was not associated with discontinuation (p = 0.698), but recurrent erosions were (p = 0.012). CONCLUSION: Adverse events were common among women continuing to use pessaries past 1 year, but adherence and satisfaction rates remained high after 4.4 years. Pessary type and absence of cardiovascular factors were associated with pessary-related adverse events.

Surgical Management of Symptomatic Apical Pelvic Organ Prolapse: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review objective and subjective success and complications of apical suspensions for symptomatic uterine or vaginal vault pelvic organ prolapse (POP). DATA SOURCES: MEDLINE, CENTRAL, ClinicalTrials.gov, and EMBASE (2002-2019) were searched using multiple terms for apical POP surgeries, including comparative studies in French and English. METHODS OF STUDY SELECTION: From 2,665 records, we included randomized controlled trials and comparative studies of interventions with or without hysterectomy, including abdominal apical reconstruction through open, laparoscopic, or robotic approaches and vaginal apical reconstructions. Repairs using transvaginal mesh, off-the-market products, procedures without apical suspension, and follow-up less than 6 months were excluded. TABULATION, INTEGRATION, AND RESULTS: Relative risk (RR) was used to estimate the effect of surgical procedure on each outcome. For each outcome and comparison, a meta-analysis was conducted to pool the RRs when possible. Meta-regression and bias tests were performed when appropriate. The GRADE (Grades for Recommendation, Assessment, Development and Evaluation) system for quality rating and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting were used. Sixty-two articles were included in the review (N=22,792) and 50 studies in the meta-analyses. There was heterogeneity in study quality, techniques used, and outcomes reported. Median follow-up was 1-5 years. Vaginal suspensions showed higher risk of overall and apical anatomic recurrence compared with sacrocolpopexy (RR 1.82, 95% CI 1.22-2.74 and RR 2.70, 95% CI 1.33-5.50) (moderate), whereas minimally invasive sacrocolpopexy showed less overall and posterior anatomic recurrence compared with open sacrocolpopexy (RR 0.59, 95% CI 0.47-0.75 and RR 0.59, 95% CI 0.44-0.80, respectively) (low). Different vaginal approaches, and hysterectomy and suspension compared with hysteropexy had similar anatomic success. Subjective POP recurrence, reintervention for POP recurrence and complications were similar between most procedures. CONCLUSION: Despite variations in anatomic outcomes, subjective outcomes and complications were similar for apical POP procedures at 1-5 years. Standardization of outcome reporting and comparative studies with longer follow-up are urgently needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019133869.

Directive clinique no 413 : Traitement chirurgical du prolapsus génital apical chez les femmes.

OBJECTIF: Comparer les taux de réussite et de complications des interventions de suspension apicale pour le traitement du prolapsus symptomatique de l'utérus ou du dôme vaginal. POPULATION CIBLE: Les femmes présentant un prolapsus symptomatique de l'utérus ou du dôme vaginal qui souhaitent obtenir un traitement chirurgical. OPTIONS: Les interventions abordées sont les méthodes reconstructives apicales par voie abdominale (colposacropexie, hystérosacropexie ou hystéropexie avec suspension aux ligaments utéro-sacrés) par chirurgie ouverte, laparoscopique ou robotisée; les méthodes reconstructives apicales par voie vaginale (suspension du dôme vaginal ou hystéropexie, sacrospinofixation, suspension aux ligaments utéro-sacrés, suspension au muscle ilio-coccygien, culdoplastie de McCall ou amputation du col [technique de Manchester]); et les interventions vaginales oblitérantes (avec ou sans utérus in situ). Les interventions individuelles ou les grandes catégories d'interventions ont été comparées : (1) reconstruction par voie vaginale versus abdominale, (2) interventions reconstructives par voie abdominale, (3) interventions reconstructives par voie vaginale, (4) reconstruction par hystérectomie avec suspension par comparaison à la reconstruction par hystéropexie et (5) options reconstructives versus oblitérantes. RéSULTATS: Le comité d'urogynécologie a sélectionné les résultats cliniques suivants : échec objectif (obtenu par des systèmes validés de quantification du prolapsus génital et défini comme un échec global objectif et un taux d'échec par compartiment); échec subjectif (réapparition de la sensation de protubérance déterminée subjectivement, avec ou sans l'utilisation d'un questionnaire validé); réopération pour un prolapsus génital récidivé; complications postopératoires de troubles mictionnels (incontinence urinaire d'effort de novo ou postopératoire; réopération d'une incontinence urinaire d'effort de novo, persistante ou récidivée; incontinence urinaire par urgenturie; et dysfonction mictionnelle); lésion des voies urinaires détectée en périopératoire (vessie ou uretère); autres complications (exposition prothétique, définie comme un treillis visible et exposé dans le vagin et une douleur pelvienne non sexuelle); et fonction sexuelle (dyspareunie de novo et score de la fonction sexuelle d'après un questionnaire validé). BéNéFICES, RISQUES ET COûTS: Cette directive clinique sera bénéfique pour les patientes qui souhaitent obtenir une correction chirurgicale du prolapsus génital apical en améliorant les conseils sur les options de traitement chirurgical et les résultats cliniques possibles. La directive sera également utile pour les fournisseurs de soins chirurgicaux en améliorant leurs connaissances sur diverses méthodes chirurgicales. Les données présentées pourraient servir à élaborer des cadres et des outils pour la prise de décision partagée. DONNéES PROBANTES: Nous avons effectué des recherches dans les bases de données Medline, Cochrane Central Register of Controlled Trials (CENTRAL) et Embase pour des articles publiés entre 2002 et 2019. Les termes de recherche étaient nombreux et portaient sur les interventions de correction du prolapsus génital apical, les voies d'abord et les complications. Nous avons exclu les reconstructions par treillis transvaginal et les études comparant les interventions sans suspension apicale. Nous avons inclus des essais cliniques randomisés et des études comparatives prospectives ou rétrospectives. Nous avons limité nos recherches aux articles publiés en anglais ou en français dont le texte intégral était accessible. Une revue systématique des articles avec méta-analyse a ensuite été effectuée. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant lecadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CIBLES: Gynécologues, urologues, urogynécologues et autres fournisseurs de soins de santé qui évaluent, conseillent et soignent des femmes ayant un prolapsus génital. DÉCLARATIONS SOMMAIRES: Toutes les déclarations font référence à la correction du prolapsus génital apical à court et à moyen terme (jusqu'à 5 ans), sauf indication contraire. RECOMMANDATIONS.

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women.

OBJECTIVE: To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse. TARGET POPULATION: Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction. OPTIONS: Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ). Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options. OUTCOMES: The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire). BENEFITS, HARMS, AND COSTS: This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. EVIDENCE: We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The search included multiple terms for apical POP surgical procedures, approaches, and complications. We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension. We included randomized controlled trials and prospective or retrospective comparative studies. We limited language of publication to English and French and accessibility to full text. A systematic review and meta-analysis was performed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS: Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP. SUMMARY STATEMENTS: All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified.

Preoperative Depression and Anxiety Impact on Inpatient Surgery Outcomes: A Prospective Cohort Study.

Objectives: To determine the association of preoperative mood symptoms and postoperative adverse outcomes; to explore sex-specific differences. Background: Depression and anxiety can increase postoperative mortality. Psychological stress is associated with a chronic inflammatory response unfavorable to postsurgical healing. Methods: Prospective cohort study. Patients were recruited from surgical preadmission clinics at a university hospital. Preoperative depression and anxiety were measured via the Beck Depression and Beck Anxiety Inventories (BDI-II and BAI). Our primary outcome was a composite of postoperative complications, extended length of stay (ELOS) and early readmission. Associated variables included demographics, preoperative pain, pain tolerance/catastrophizing, coping mechanisms, postoperative pain, and opioid use. We adjusted for age, comorbidities, and surgical specialty. Results: Of 1061 recruited patients (ten surgical specialties, 2015-2020), 455 males and 486 females had preoperative and postoperative data available. Mean age was 62.9 (range 20.2-96.2). At baseline, 9.3% of patients had moderate or severe depression; 7.4% had moderate or severe anxiety. Females were more likely to be moderately or severely depressed (11% vs 7%, P = 0.036) and moderately or severely anxious (9% vs 6%, P = 0.034). Females had significantly fewer reported comorbidities and lower American Society of Anesthesiologists category (P < 0.001). Increasing BDI-II and BAI scores significantly increased likelihood of postoperative complications, ELOS, and/or hospital readmission in females (adjusted odds ratio [aOR] = 2.57 for BDI-II 1-19 vs 0, P = 0.041; aOR = 4.48 for BDI-II > 19 vs 0, P = 0.008; aOR = 1.54 for BAI ≤ 6 vs >6, P = 0.038) but not in males. Mood symptoms did not influence postoperative pain or opioid use. Conclusion: Preoperative depression and anxiety negatively impact surgical outcomes in female patients undergoing major surgery.

Urinary symptoms and quality of life in women living with HIV: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: To determine prevalence and quality of life impact of lower urinary tract symptoms (LUTS) in women living with HIV (WLWH). METHODS: Cross-sectional urinary questionnaires were included in a multicenter national prospective study of the HPV vaccine in WLWH. Demographic and clinical information was abstracted from the parent study. The Urinary Distress Inventory (UDI-6) and Urinary Impact Questionnaire (UIQ-7) were administered. Wilcoxon rank sum, two-sample chi-square or Fisher's exact tests were used as appropriate to compare women with UDI-6 score ≥ 25 to those with lower UDI-6 scores on demographic and HIV-related factors. Significant categorical variables were followed up with logistic regression to estimate odds ratios (OR). RESULTS: One hundred seventy-seven women completed urinary questionnaires (85.5% of cohort). Median age was 44.1 (37.2-50.6). Mean CD4 count was 621 (410-785), and 132 women (74.6%) were virologically suppressed. Median UDI-6 score was 4.2 (0-25). Fifty-one women (28.8%) had a UIQ-7 score > 0. Among those with a UDI-6 score of at least 25, median UIQ-7 was 9.5 (0-47.6). UDI-6 ≥ 25 was significantly associated with increasing age, higher BMI, Canada as country of origin, peri-/postmenopausal status (OR 3.37, 95% CI = 1.71 to 6.75) and being parous (OR 2.92, 95% CI = 1.27 to 7.59) (all p < 0.05). HIV-related factors were not associated with UDI-6 ≥ 25. CONCLUSIONS: LUTS were common, but we did not demonstrate a negative impact on quality of life in this sample of WLWH. Large comparative studies are needed to determine whether HIV is a risk factor for bothersome LUTS in women.

Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications?

OBJECTIVES: To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database. METHODS: We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors. RESULTS: We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62 years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01). CONCLUSION: In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.

What do we really know about the role of caffeine on urinary tract symptoms? A scoping review on caffeine consumption and lower urinary tract symptoms in adults.

AIMS: The purpose of this scoping review was to map out the existing literature on caffeine intake and lower urinary tract symptoms (LUTS) in adults. METHODS: In this scoping review, we searched for all studies available until June 2019 in MEDLINE, Embase, CINAHL, Cochrane Central Register, PsycINFO, LILACS, LiSSa, Web of Science, and Joanna Briggs Institute electronic databases, in addition to a hand search of the bibliographies of all relevant articles and a gray literature search. Both intervention studies on the effects of caffeine reduction in adults with LUTS and observational studies on the association between caffeine intake and LUTS-related outcomes in adults were included and assessed for methodological quality by two independent reviewers. RESULTS: Fourteen intervention and 12 observational studies were included. Overall, there was a decrease in urgency episodes (level of evidence 2, grade of recommendation B) and nocturnal enuresis episodes (4, C) with caffeine reduction. Observational studies reported an unclear association between caffeine intake and LUTS-related outcomes. Most importantly, this present review highlighted high heterogeneity in the studied populations, caffeine measures, and reported outcomes. There was also unknown or high risk of bias in most identified studies. CONCLUSIONS: Caffeine reduction appears to reduce LUTS. Future studies on caffeine reduction interventions should target populations with urgency and urge urinary incontinence, which show the most promising results, and include valid and reliable measures of caffeine intake and LUTS. Finally, future studies should also use reporting guidelines to ensure lower risk of bias.

Regional Variation and Temporal Trends in Surgery for Pelvic Organ Prolapse in Canada, 2004-2014.

OBJECTIVES: We sought to examine temporal trends in pelvic organ prolapse (POP) surgery in Canada. METHODS: In this observational cross-sectional study, we used diagnostic and procedure codes from all hospitalizations and outpatient clinic visits in Canada (excluding Québec) from 2004 to 2014 to identify and analyze data on POP surgery. RESULTS: There were 204 301 POP surgery visits from 2004 to 2014, and the rate of POP surgery declined from 19.3 to 16.0 per 10 000 women during this period. The rates of "native tissue reconstructive repair" and "hysterectomy without other procedure" declined from 15.0 to 12.8 per 10 000 women and 2.6 to 1.6 per 10 000 women, respectively. The rate of obliteration increased from 0.1 to 0.3 per 10 000 women (all P values for trend <0.01). Mesh procedures increased from 1.6 per 10 000 women in 2004 to 2.4 per 10 000 women in 2007 and 2008, and then declined to 1.3 per 10 000 women in 2014. Reconstructive mesh surgery using an abdominal open approach declined, while laparoscopic procedures increased over the period examined. CONCLUSION: The rates of POP surgery declined in Canada between 2004 and 2014. An increase was observed in obliteration procedures and in laparoscopic vaginal suspension and fixation with mesh.

Depression, Anxiety, and Pelvic Floor Symptoms Before and After Surgery for Pelvic Floor Dysfunction.

OBJECTIVES: We aimed to explore the correlation between perioperative symptoms of depression and anxiety with pelvic floor symptoms after urogynecologic surgery. Postoperative pain, goal attainment, quality of life, and satisfaction were assessed. METHODS: A prospective cohort study of women undergoing inpatient urogynecologic surgery was conducted. Preoperative questionnaires included Beck Depression and Beck Anxiety Inventories, Pain Catastrophizing Scale, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and a detailed goals and perioperative supports questionnaire. Postoperative pain was assessed via the Short-Form McGill Pain Questionnaire. Questionnaires were readministered 6 weeks postoperatively. Descriptive statistics were obtained. Spearman correlation determined the relationship between preoperative and postoperative questionnaire scores. Quantile regression assessed the potential moderating effect of patient characteristics on these relationships. RESULTS: Sixty women (mean age, 58.5 years) were recruited. Fifty-seven (95%) completed follow-up. Most common surgical indication was pelvic organ prolapse (59/60; 98%). Depression and anxiety symptoms were minimal in most women. There was significant median change in preoperative to postoperative scores for Beck Anxiety Inventory (-2.0, P = 0.011), Pelvic Floor Distress Inventory-20 (-69.4, P < 0.001), and Pelvic Floor Impact Questionnaire-7 (-23.8, P = 0.001). Baseline depression and anxiety symptoms were correlated with higher immediate postoperative pain, but not other outcomes. The most common goal, achieved by 47 (92%) of 51, was to reduce condition-specific symptoms. Postoperative depression and anxiety symptoms, and pelvic floor distress and impact were significantly correlated. CONCLUSIONS: Baseline depression and anxiety symptoms were not significantly associated with postoperative pelvic floor symptom burden or surgical satisfaction. Bothersome postoperative pelvic floor symptoms were associated with postoperative depressive symptoms.

Urinary tract infection prevention after midurethral slings in pelvic floor reconstructive surgery: A systematic review and meta-analysis.

INTRODUCTION: Synthetic midurethral slings are the most common procedures currently performed for stress urinary incontinence in women. Infection is a frequent complication of urogynecologic surgery. We performed a systematic review and meta-analysis to identify interventions that successfully prevent infections, including urinary tract infection (UTI) and/or bacteriuria, compared with no intervention, in women undergoing midurethral sling surgery with or without concomitant pelvic reconstructive procedures for prolapse. MATERIAL AND METHODS: The primary outcome was the development of any infection post-midurethral sling placement in women. MEDLINE, Embase, CINAHL and the Cochrane Library were searched for comparative studies from inception to July 2017, with no language restrictions. We used search terms related to midurethral sling, infections and infection-reduction interventions. Two independent reviewers abstracted data and assessed study quality. Pooled effect size estimates were calculated. We conducted meta-analysis of eligible studies. A protocol for this review has been registered and can be accessed online (http://hdl.handle.net/2429/64731). RESULTS: We identified seven eligible studies of infection risk-reducing interventions; all focused on UTIs. Only one study assessed preoperative antibiotics with midurethral sling alone and was halted early because of low UTI rates. All other studies (three randomized control trials and three observational studies) examined whether postoperative antibiotics decrease UTI/bacteriuria rates after midurethral sling with or without reconstructive procedures for pelvic organ prolapse and using bladder catheterization postoperatively. Due to considerable clinical heterogeneity, we only combined four studies for meta-analysis. Postoperative oral prophylactic nitrofurantoin showed no significant benefit in reducing UTI/bacteriuria in women post-midurethral sling with or without concomitant reconstructive pelvic surgery and the need for bladder catheterization, when compared with the reference group (pooled relative risk 0.73, 95% confidence interval [CI] 0.42-1.25). CONCLUSIONS: Based on the best available evidence, postoperative oral nitrofurantoin is not effective at reducing UTI/bacteriuria rates in catheterized women after midurethral sling with or without concomitant pelvic reconstructive surgery for prolapse. For midurethral sling alone, preoperative antibiotic prophylaxis may not be needed for UTI prevention.

No. 351-Transvaginal Mesh Procedures for Pelvic Organ Prolapse.

OBJECTIVE: This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011. INTENDED USERS: Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse. TARGET POPULATION: Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse. OPTIONS: The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh). OUTCOMES: The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation. EVIDENCE: PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse. RESULTS: were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included. VALUES: The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request. BENEFITS, HARMS, AND/OR COSTS: It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified. GUIDELINE UPDATE: Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SUMMARY STATEMENTS: RECOMMENDATIONS.

Is Pelvic Floor Dysfunction an Independent Threat to Sexual Function? A Cross-Sectional Study in Women With Pelvic Floor Dysfunction.

INTRODUCTION: Prior studies have reported an association of sexual dysfunction with pelvic floor dysfunction (PFD), but without defining causation. AIM: To investigate predictors of sexual function in women with PFD, including pelvic organ prolapse, stress urinary incontinence, overactive bladder, obstructed defecation, and fecal incontinence. METHODS: This retrospective cross-sectional study included 755 women (mean age = 56 years, 68% postmenopausal) referred for PFD (2008-2013). Subjects underwent standardized history and examination, including demographics and assessment of pelvic floor function and sexual function using validated quality-of-life instruments. The physical examination included body mass index, Pelvic Organ Prolapse Quantification measurements, and pelvic muscle strength (Oxford scale). Proportional odds regression analysis tested patient characteristics, PFD, and other determinants of sexual dysfunction as predictors of sexual function. MAIN OUTCOME MEASURES: The Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) to assess PFD and the Short Personal Experiences Questionnaire to assess sexual function. RESULTS: The prevalence of PFD included pelvic organ prolapse (72%), stress urinary incontinence (66%), overactive bladder (78%), fecal incontinence (41%), and obstructed defecation (70%). Most subjects (74%) had a sexual partner and most (56%) reported recent sexual intercourse. Participants reported a low level of sexual desire and sexual enjoyment and moderate levels of sexual arousal and orgasm. When stratified by sexual enjoyment, 46% enjoyed sex and this group had lower PFDI and PFIQ scores, reflecting less quality-of-life burden. Pelvic organ prolapse, obstructed defecation, and fecal incontinence were associated with not enjoying sex. However, when adjusted for other determinants of sexual dysfunction (eg, aging, dyspareunia, atrophy, and partner issues), these associations disappeared. CONCLUSION: Women with PFD also have a large burden of sexual dysfunction, although this appears to be mediated by factors not unique to PFD.

Teaching Vaginal Surgery to Junior Residents: Initial Validation of 3 Novel Procedure-Specific Low-Fidelity Models.

OBJECTIVE: Competency-based surgical education relies on operative models to teach surgical skills within a curriculum. Low fidelity simulation has been shown to improve surgical performance. Our objectives were: to develop procedure-specific models to teach anterior repair (AR), posterior repair (PR), and vaginal hysterectomy (VH) to junior residents; to establish model reliability and validity. DESIGN: Residents were randomized to control (no training) and intervention (model training) groups. They were filmed while performing a series of tasks. Experts were also filmed. Each video was scored by 2 blinded raters. SETTING: Multicenter collaboration within the Western Society of Pelvic Medicine (Vancouver, Calgary, and Edmonton). Face and content validity were evaluated. A standard scoring tool was developed for performance evaluation. Interrater reliability was assessed using intraclass correlation coefficient. Cronbach α was calculated for internal consistency. Jonckheere-Terpstra test verified whether the scores increased with operator skill level. PARTICIPANTS: A total of 14 junior gynecology residents, 2 urogynecology fellows, and 3 staff urogynecologists were rated by a total of 6 gynecologic surgeons who scored 42 videos each. RESULTS: Experienced pelvic surgeons from 3 participating sites agreed the models captured essential elements of real surgical skills (face validity) and of the true procedures (content validity). Intraclass correlation coefficient was adequate (AR = 0.86, PR = 0.90, and VH = 0.87). Cronbach α for the total scores was adequate (AR = 0.85, PR = 0.8, and VH = 0.71). Performance score increased with operator skill level for all 3 procedures (AR, p = <0.001; PR, p = 0.008; and VH, p = 0.007). CONCLUSIONS: Our low fidelity procedure-specific vaginal surgery models had adequate initial validity. Future research will investigate transferability of acquired skills to the operating room.