Chronic Pelvic Pain, Quality of Life, and Patient Satisfaction After Robotic Sacrocolpopexy for Pelvic Organ Prolapse.

Background and objective When evaluating repair outcomes in robotic sacrocolpopexy (RSC) for the treatment of pelvic organ prolapse (POP), it has become evident that surgeons usually focus on anatomical improvements and neglect equally important parameters of patient satisfaction and quality of life (QoL). Investigating these factors would aid in achieving a more patient-centered approach to treatment. This study aimed to examine QoL and satisfaction outcomes in women after RSC. Methods This study analyzed self-reported patient data regarding RSC for POP performed between October 2009 and February 2017 by fellowship-trained urologists in female pelvic medicine and reconstructive surgery. These patients participated in a survey to assess overall satisfaction and QoL, as well as contributing factors, such as changes in bladder and bowel function, vaginal bulge, and vaginal pain on a 7-point Likert scale (ranging from markedly worse to markedly improved). Data were examined using multivariate regression analysis. Positive treatment response was defined as scores of 6 or 7, whereas negative response was defined as scores of 1 to 5. Results The response rate was 41% (156/380), and the median age of the participants was 70 years [interquartile range (IQR): 63, 73]. Of note, 98.7% were Caucasian, with 73% currently in a significant relationship. The median duration since RSC was 2.12 years (IQR: 1.2, 3.7). Overall, 93 (66.9%), patients (23.0%), and 123 patients (88.5%) had a positive treatment response for bladder function, bowel function, and vaginal bulge, respectively. Furthermore, 66% of women had improved QoL, 84% reported improved overall satisfaction, and 91.4% stated that they would recommend RSC to a friend. After controlling for significant covariates, results of a multivariate analysis demonstrated positive treatment response for bladder function [odds ratio (OR): 14.6; p < 0.0001], bowel function (OR: 9.72; p = 0.003), and vaginal bulge (OR: 41.7; p < 0.0001), significantly associated with increased odds of having improved QoL, whereas positive treatment response for vaginal bulge (OR: 26.9; p = 0.023) and recommending RSC to a friend (OR: 175; p = 0.0009) were associated with positive overall satisfaction. Conclusions Our findings endorse using RSC surgery for patients with POP based on both QoL improvement and overall post-procedure satisfaction perspective. This study may help encourage surgeons and clinicians to employ a surgical modality that incorporates each patient's unique treatment desires and goals and provide patients with realistic post-procedure goals and expectations regarding treatment.

Fipronil and Acetamiprid Poisoning: New Perils.

Suicides due to insecticide poisoning represent a major public health concern. Introduction of newer synthetic pesticides like neonicotinoids and fipronil, with novel mechanisms of action, have led to widespread adoption of these in the agriculture industry. They act by altering the neuronal transmission mechanisms in the central nervous system, specifically of the invertebrates, and lead to death of the organism. Though they were perceived to be invertebrate-specific, there have been few case reports of these, leading to notable clinical adverse effects on human exposure. We present a case of acetamiprid and fipronil consumption, who presented to us with central nervous system manifestations and his clinical management. With increasing use of newer pesticides, clinical knowledge regarding the toxic effects of these seems indispensable. How to cite this article: Jayaprakash R, Elangovan A, Nagaraju P. Fipronil and Acetamiprid Poisoning: New Perils. Indian J Crit Care Med 2022;26(4):526-527.

Perioperative Outcomes, Complications, and Efficacy of Robotic-Assisted Prolapse Repair: A Single Institution Study of 196 Patients.

Abdominal pelvic organ prolapse repair is efficacious for uterovaginal and apical prolapse. We describe the safety and efficacy of robotic prolapse repair in a large teaching institution. METHODS: Consecutive robotic-assisted prolapse repairs at a single institution between 2006 and 2014 were retrospectively reviewed for patient characteristics, operative information, and outcomes. RESULTS: A total of 196 women (mean age, 61 ± 9 years) underwent robotic prolapse repair (189 sacrocolpopexy, 6 sacrohysteropexy, 1 enterocele repair). Concomitant procedures included hysterectomy (88), midurethral sling (84), and/or Burch colposuspension (7). Mean odds ratio time was 242 ± 69.9 minutes, and median length of stay was 1 day. Intraoperative complications were as follows: cystotomy (4), vaginotomy (4), conversion to open (2), bowel injury/aborted (1), adhesions/aborted (1), and ureteral injury (1). Women with complications had greater blood loss than those without complications (P = 0.0015). Immediate (<30 days) postoperative complications were rare: port-site hernia (2), discitis (1), ileus (1), and ulnar neuropraxia (3). At median follow-up of 9 months (range, 0-85 months), 14 women had recurrent grade 3 prolapse, and 4 had grade 2 apical prolapse. Nine of 14 women had additional prolapse repair at a mean of 9.5 ± 6.3 months. Vaginal mesh exposure was detected in 12 (6.3%) of 192 women. There were 6 procedures for mesh exposure and 2 procedures for exposed sutures. One mesh erosion into the bladder required open excision. CONCLUSIONS: In this large series of robotic prolapse repair, complications are infrequent. Short-term apical outcomes are excellent. Few women required additional compartment repairs within 1 year with 6% rate of mesh exposure.

Exploring predictors of mesh exposure after vaginal prolapse repair.

OBJECTIVES: To evaluate clinical, demographic, and surgical factors that may be associated with mesh exposure after vaginal repair of pelvic organ prolapse (POP). METHODS: Records of women who underwent POP repair with Elevate or Prolift were retrospectively reviewed. Body mass index (BMI), prolapse grade, smoking history, diabetes, steroid and estrogen use, parity, compartment repaired, concurrent hysterectomy, operative time, postoperative pain, change in hemoglobin (ΔHgb) and other characteristics were evaluated for associations with mesh exposure.Categorical variables were examined using Pearson χ test where appropriate, or the Fisher exact test was used. The continuous variables were examined using Wilcoxon rank tests. A multivariable logistic regression analysis was completed to examine predictors of mesh exposure. All analyses used SAS for Windows version 9.2 (Cary, NC). RESULTS: Three hundred thirty-five women underwent repair from 2006 to 2011. Vaginal mesh exposure was identified in 27 (8.1%) of the 335 women. Patients with exposure had longer median follow-up than the group with no exposure (357 vs 145 days; P = 0.0003). The median time to exposure was 96 days (15-1129 days). Mesh exposure was associated with lower BMI (25.2 ± 2.5 vs 27.4 ± 5.1; P = 0.020) and greater ΔHgb (-3.7 ± 1.7 mg/dL vs -2.5 ±1.3; P = 0.0011). Change in hemoglobin decreased over time (P = 0.0005). Exposure rates also decreased over time (17% in 2005 to 12% in 2006, then 5%-8% in 2006-2011) but were not statistically significant (P = 0.49). CONCLUSIONS: In this study, vaginal mesh exposure was only associated with ΔHgb and lower BMI.

Symptoms of combined prolapse and urinary incontinence in large surgical cohorts.

OBJECTIVE: To estimate whether prolapse severity is a major contributor to urinary incontinence severity, as measured by validated incontinence questionnaires. METHODS: We analyzed data from two large female stress urinary incontinence (SUI) surgical cohorts: the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) study (N=655) and the subsequent Trial of Mid-Urethral Slings (TOMUS) study (N=597). All participants completed a standardized baseline assessment including validated measures of symptom severity, quality of life, objective measures of urine loss (Urogenital Distress Inventory [UDI], Medical, Epidemiologic, and Social Aspects of Aging questionnaire, Incontinence Impact Questionnaire, and pad test), as well as the Pelvic Organ Prolapse Quantification assessment. Groups were compared using the chi; test (categorical measures) or the one-way analysis of variance (continuous measures). Statistical significance was defined as P<.05. RESULTS: The SISTEr and TOMUS samples were similar for many variables including age (52 and 53 years, respectively), nulliparity (9% and 12%), prior urinary incontinence (UI) surgery (14% and 13%), and prior hysterectomy (31% and 28%), but other differences necessitated separate analysis of the two cohorts. There was not a statistically significant difference in UDI scores according to prolapse stage in either study population. Patients with prior surgery for pelvic organ prolapse and SUI had more incontinence symptoms and were more bothered by their UI regardless of prolapse stage. CONCLUSION: Prolapse stage is not strongly or consistently associated with incontinence severity in women who select surgical treatment of SUI. Prior pelvic organ prolapse and UI surgery is associated with worse UI severity and bother. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00064662 and NCT00325039. LEVEL OF EVIDENCE: II.

The anatomy of incontinence--what practitioners and patients need to know.

Stress urinary incontinence, a common problem for many women, is caused by hypermobility of the urethra and sphincteric deficiency. Vaginal detachments result in urethral hypermobility and vaginal prolapse. The focus for most clinicians has been solely on the urethra as the contributing factor to stress incontinence. However, to ensure success of continence surgery, a frequently used treatment with many procedural options, a concerted effort must be made to evaluate the global health of the vagina, treat all existing defects, and recreate normal pelvic support anatomy. The anatomy of urinary incontinence, the history of surgical procedures, as well as the advantages and disadvantages of current surgical techniques are described.