Retropubic Versus Transobturator Midurethral Slings at Time of Colpocleisis.

IMPORTANCE: This study aimed to evaluate if there is a difference between outcomes when retropubic or transobturator midurethral sling surgery is performed at the time of colpocleisis. OBJECTIVES: The purpose of this study was to compare the surgical outcomes of the retropubic midurethral sling (RP-MUS) versus the transobturator midurethral sling (TO-MUS) in women who underwent concomitant colpocleisis, specifically 2-year MUS failure and 1-year lower urinary tract symptoms (LUTSs). A secondary aim was to identify factors associated with these surgical outcomes. STUDY DESIGN: All cases of concomitant MUS and colpocleisis within a closed, integrated health care delivery system were reviewed between April 1, 2010, and March 31, 2020. Postoperative MUS failure was defined as (1) postoperative stress urinary incontinence symptoms and/or (2) additional anti-incontinence surgery. Postoperative LUTSs were defined as (1) MUS lysis and/or (2) overactive bladder requiring management with a new treatment. RESULTS: Of the 558 women included, 454 (81%) received RP-MUS and 104 (19%) received TO-MUS. Cohort demographics were similar. Neither MUS failure (7% RP-MUS and 9% TO-MUS, P = 0.450) nor LUTSs (7% RP-MUS and 12% TO-MUS, P = 0.171) were significantly different between RP-MUS and TO-MUS. In multivariable analysis, age was found to be significantly associated with LUTSs (odds ratio 0.29, 95% confidence interval 0.09-0.93, P = 0.038 among 70-74-year-olds; odds ratio 0.28, 95% confidence interval 0.09-0.83, P = 0.022 among 75-79-year-olds). CONCLUSIONS: At the time of colpocleisis, both RP-MUS and TO-MUS were highly successful and associated with a low incidence of LUTSs, including MUS lysis. The findings of this large study support RP-MUS and TO-MUS as similarly effective anti-incontinence options at time of colpocleisis.

Factors Associated With Long-Term Use of Percutaneous Tibial Nerve Stimulation for Management of Overactive Bladder Syndrome.

OBJECTIVES: The aims of the study were to estimate the rate of percutaneous tibial nerve stimulation maintenance therapy (PTNS-MT) among women with overactive bladder syndrome (OAB) and evaluate factors associated with long-term use of PTNS. METHODS: Patients who completed 12 weekly sessions of PTNS (PTNS-IN) for OAB between 2009 and 2016 within the Kaiser Permanente Northern California were identified using Current Procedural Terminology and International Classification of Diseases codes. Bivariate analysis was performed to compare demographic and clinical variables. A logistic regression model was used to determine factors associated with PTNS-MT compared with the use of alternative treatments following PTNS-IN. RESULTS: Of the 1331 patients who initiated PTNS for OAB, 347 (26%) completed PTNS-IN. Of these, 46% (n = 158) continued with long-term PTNS therapy, defined as completion of at least 8 additional PTNS sessions for a 32-week period. On bivariate analysis, those choosing PTNS-MT were more likely to be white (88%, P < 0.0001), nondiabetic (89%, P = 0.03), did not use anticholinergics before PTNS initiation (41%, P = 0.04), and had no prior surgery for stress incontinence (SUI; 84%, P = 0.01). In multivariable analysis, race was a significant factor with black, Hispanic, and Asian women less likely to continue with PTNS-MT. Women with prior use of first-line OAB therapy were 78% more likely to undergo PTNS-MT. Women with prior surgery for SUI were 53% less likely to continue PTNS-MT. CONCLUSIONS: Almost half of patients who completed PTNS-IN continued with PTNS-MT. White race, prior use of first-line OAB therapy, and no prior surgery for SUI were associated with long-term therapy.

The impact of pessary use on bowel symptoms: one-year outcomes.

OBJECTIVES: The literature states that patients with pelvic organ prolapse have a higher prevalence of bothersome bowel symptoms and that surgical correction of prolapse may improve bowel function. There is limited knowledge regarding the impact of pessary use on bowel function in patients with prolapse. The aim of this study was to evaluate if there is a change in bowel symptoms in patients with prolapse treated with a vaginal pessary. METHODS: Women who presented for pessary insertion completed the validated questionnaires on the bowel symptom severity and on the effect of bowel symptoms on the quality of life at baseline and again at 12 months of continuous pessary use. Inferential statistics comprised Student t test for evaluating differences in continuous Gaussian data between groups and paired t tests were used to evaluate differences among subjects between the baseline and 12 months of use. RESULTS: One hundred four women participated in the original study, and 43 had complete data for analysis. Women who completed 12 months of pessary use reported significant improvements in both bowel-related symptoms and bowel-related quality of life (95% confidence interval of the difference 1.6-11.4 and 2.0-14.0, respectively). Patients who completed the 12-month follow-up were significantly older and more likely to have stage 3 or 4 prolapse than noncompleters, but there were no differences in body mass index, race, history of prior prolapse surgery, or menopause status. CONCLUSIONS: In women with prolapse, the use of a pessary is associated with a decrease in complaints related to bowel symptoms.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE: Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN: We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS: For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION: Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Constipation symptoms before and after vaginal and abdominal pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: This article aims to evaluate how constipation symptoms change after pelvic reconstructive surgery using the Patient Assessment of Constipation Symptom Questionnaire (PAC-SYM). Our primary hypothesis was that constipation would improve after surgery. METHODS: Ninety-four subjects completed the PAC-SYM before and 7 weeks after pelvic reconstructive surgery from 2007 through 2009 inclusive. PAC-SYM scores were compared for the cohort before and 7 weeks post-surgery and based on route of surgery: vaginal or abdominal. RESULTS: Baseline PAC-SYM scores between those undergoing abdominal or vaginal reconstructive surgery were not significantly different (0.76 versus 0.83, respectively; p = 0.586). Subjects in the vaginal surgery group had a significant reduction in PAC-SYM scores, 0.83 to 0.62 (p = 0.049). After abdominal surgery, subjects had an increase in abdominal subscale scores, 0.69 to 1.03 (p = 0.012). CONCLUSIONS: Women undergoing vaginal prolapse surgery may have a short-term improvement in constipation symptoms, while those undergoing abdominal surgery have worsening of abdominal constipation symptoms.

Pessary use and impact on quality of life and body image.

OBJECTIVES: : The objective of the study was to determine if vaginal pessaries improve symptoms of prolapse and body image in women with pelvic organ prolapse. Our hypothesis was that pessary use would improve prolapse-related symptoms and body image up to 1 year. METHODS: : Women presenting for pessary insertion completed questionnaires regarding pelvic floor-related symptoms and body image with successful pessary insertion and after 6 to 12 months of continued pessary use. Scores were compared with a paired t test. RESULTS: : Forty-three subjects had complete data for analysis. Scores on both prolapse-related and body image questionnaires showed improvements at 6 months (P < 0.001) and 12 months (P < 0.010). Younger women and those with prior prolapse surgery were less likely to continue to use a pessary past 3 to 6 months. Stage of prolapse, body mass index, and scores on symptom questionnaires did not correlate with likelihood of continued pessary use versus surgery. CONCLUSIONS: : The use of a pessary for more than 12 months improves symptoms of prolapse and self perception of body image.

Abdominal extraperitoneal excision of a foreign body in the pararectal space.

Permanent suture material and synthetic grafts can be used as part of pelvic organ prolapse surgery. These materials are often attached to the sacrospinous ligament or passed in retroperitoneal spaces. There is a risk for erosion and granulation tissue formation with any of these materials. Typically, this is managed through a transvaginal incision.We present a case of a postmenopausal woman with persistent granulation tissue and a sinus tract from a braided polyester (Ethibond) suture placed in the right sacrospinous ligament fixation. After failing several attempts at treating this granulation tissue through a vaginal incision, we managed this via an abdominal retroperitoneal approach.

The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: The objective of the study was to compare time to first bowel movement (BM) after surgery in subjects randomized to placebo or senna with docusate. STUDY DESIGN: Ninety-six subjects completed a baseline 7-day bowel diary before and after surgery. After pelvic reconstructive surgery, the subjects were randomized to either placebo (n=45) or senna (8.6 mg) with docusate (50 mg) (n=48). Time to first BM and postoperative use of magnesium citrate were compared. RESULTS: There was a significant difference in the time to first BM in those receiving senna with docusate vs placebo (3.00+/-1.50 vs 4.05+/-1.50 days; P<.002). More subjects in the placebo group needed to use magnesium citrate to initiate a bowel movement (43.6% vs 7.0%; P<.001). CONCLUSION: The use of senna with docusate decreases time to first BM in those undergoing pelvic reconstructive surgery compared with placebo. Subjects using senna with docusate are also significantly less likely to use magnesium citrate.

Impact of pessary use on prolapse symptoms, quality of life, and body image.

OBJECTIVE: We sought to evaluate whether use of a vaginal pessary would change body image, bother symptoms, and quality of life in women with pelvic organ prolapse. STUDY DESIGN: Women presenting for pessary insertion completed the short forms of Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire, and Body Image Scale. After successful pessary insertion and use for at least 3 months, subjects completed the surveys again. Scores were compared with a paired t test. RESULTS: A total of 75 subjects were enrolled and follow-up responses were available for 54 subjects for analysis. Body Image Scale scores showed a significant decrease (6.1-3.4; P<.001), indicating an improvement in these women's perception of themselves, as did Pelvic Floor Distress Inventory-20 scores (81.34-45.83; P<.001) and Pelvic Floor Impact Questionnaire scores (50.32-17.98; P=.003). CONCLUSION: The use of a pessary for 3 months reduces bother symptoms and improves both quality of life and perception of body image in women.

Use of a beef tongue model and instructional video for teaching residents fourth-degree laceration repair.

INTRODUCTION AND HYPOTHESIS: This study seeks to compare the utility of the beef tongue model versus an instructional video in teaching obstetric and gynecology residents how to repair a fourth-degree laceration. METHODS: Twenty-seven residents were randomized to participate in a workshop with a beef tongue model or assigned to watch an instructional video on repair of fourth-degree lacerations and read a chapter on the repair. All subjects were tested with a pre- and postintervention written test. These scores were compared with paired t test at 0.05 significance level. RESULTS: Residents with no prior experience in fourth-degree laceration repairs showed an improvement in knowledge (49.5% versus 64.1%, p<0.001) on written exams about the repairs. CONCLUSIONS: An instructional video or beef tongue model and textbook chapter on fourth-degree laceration repair can improve skills in repair of a fourth-degree laceration among residents with no experience in these repairs.

Symptoms of anal incontinence and impact on sexual function.

OBJECTIVE: To evaluate whether symptoms of anal incontinence (AI) have an impact on sexual function in a cohort of women with pelvic floor disorders and/or incontinence. STUDY DESIGN: We analyzed a cohort of women presenting to an academic urogynecology practice. The control group consisted of those who answered "no" to questions 9-11 on the Pelvic Floor Distress Inventory. The AI group consisted of those selecting "yes" to at least 1 of these questions. Student t test was used to compare differences between groups for the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). RESULTS: The control group had a significantly lower mean score on the PISQ-12 than the AI group. There was no difference in PISQ-12 scores when controlling for stage of prolapse. CONCLUSION: Symptoms of AI were not associated with worse sexualfunction as measured by the PISQ-12.

Difference in quality of life in women with urge urinary incontinence compared to women with stress urinary incontinence.

INTRODUCTION: We evaluated whether women with urge urinary incontinence (UUI) have lower quality of life (QOL) than women with other forms of urinary incontinence. METHODS: Patients completed three validated questionnaires when presenting for evaluation at a urogynecology practice and were divided into four groups based on their responses: those with symptoms of stress urinary incontinence (SUI), UUI, both SUI and UUI (mixed UI), and neither SUI nor UUI (controls). RESULTS: A total of 465 women were included: 53 women with UUI (11.4%), 101 with SUI (21.7%), 200 with mixed UI (43%), and 111 controls (23.9%). Overall, there was a significant difference (p < 0.001) in PFIQ bladder scale scores as a function of UI group, with individual mean PFIQ scores of 17.1 for controls, 22.3 for SUI, 32.7 for UUI, and 36.8 for mixed UI. Individually, all seven questions in the PFIQ bladder domain were significantly different by group (p

Is Burch or mid-urethral sling better with abdominal sacral colpopexy?

INTRODUCTION AND HYPOTHESIS: This study aims to compare the post-operative rates of stress urinary incontinence (SUI) after abdominal sacral colpopexy (ASC) with either Burch or mid-urethral sling, tension-free vaginal tape (TVT), or no anti-incontinence procedure. The null hypothesis was there would be no difference in SUI among groups. METHODS: A cohort of women who had undergone ASC (n = 150) either alone or with an anti-continence procedure were analyzed to determine the rates of post-operative SUI. Statistically significant differences were evaluated with a Student's t-test. RESULTS: A total of 150 subjects were evaluated, with 115 having SUI preoperatively. Post-operatively, 10% (15/150) of all subjects had SUI. Subjects with preoperative SUI who had a Burch were more likely to have post-operative SUI than those who had a TVT (10 versus 0, p = 0.007). CONCLUSIONS: Burch and TVT procedures improve SUI symptoms in patients undergoing ASC. Mid-urethral slings performed with ASC have lower rates of post-operative SUI.

A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy.

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy.

What are patient preferences for follow-up after low-grade cervical intraepithelial neoplasia?

OBJECTIVE: To determine preference for follow-up after low-grade cervical intraepithelial neoplasia (CIN) among women presenting to a colposcopy clinic and ascertain basic knowledge about the human papillomavirus (HPV). MATERIALS AND METHODS: We surveyed 220 women presenting for care to the colposcopy clinic at Magee Women's Hospital, Pittsburgh, PA, between January and May 2007. The results of completed surveys were analyzed using univariate and bivariate analysis. RESULTS: Two hundred two surveys were complete and available for analysis. Forty percent of women knew that HPV is associated with warts, abnormal Papanicolaon (Pap) smears, and cervical cancer. Sixty-seven percent of women stated they would choose Pap smear screening at 6 and 12 months for follow-up after a diagnosis of CIN 1, compared with 19% of women who chose HPV testing at 12 months for the same diagnosis (p < .001). Sixty-four percent of women stated that they would be more likely to follow up for a Pap smear at 6 and 12 months after a diagnosis of CIN 1, compared with 27% who stated that they would be more likely to follow up for an HPV test at 12 months (p < .001). CONCLUSIONS: Women's preferences for serial Pap testing at 6 and 12 months rather than HPV test at 12 months may reflect the perception that they may be more likely to comply with and remember about follow-up testing if done in shorter visit intervals. The option of either treatment plan should be discussed with women and preferences assessed.

Recurrent gynandroblastoma of ovary-A case report: a molecular and immunohistochemical analysis.

Gynandroblastoma is a rare ovarian tumor that is composed of both Sertoli cells and granulosa cells. Only 23 cases have been reported in the literature, and recurrence has never been described. We report the first case of a recurrent gynandroblastoma along with its molecular analysis and immunohistochemical studies. A 49-year-old Gravida 0 woman with a 10-year prior diagnosis of ovarian-mixed stromal tissue tumor (well-differentiated Sertoli cell and granulosa cell tumor) and staging laparotomy, presented now with a retroperitoneal mass and an elevated inhibin level. CT scan was suspicious for recurrence. The patient had no prior adjuvant therapy. The histomorphological features of the recurrent tumor had both Sertoli cell and granulosa cell tumor. The molecular analysis of both primary and recurrent tumor showed minor genetic instability in the 17q12.2 gene locus with no dedifferentiation or progression, which is consistent with a low-grade tumor. The immunohistochemical staining profile showed positivity for CD99, inhibin, calretinin, and vimentin; focal positivity for cytokeratin AE1/AE3 and negative for EMA and melan-A. All the previously mentioned immunostainings support the diagnosis. We report the first case of a recurrent gynandroblastoma 10 years after initial presentation along with its molecular analysis and immunohistochemical studies.