Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis.

OBJECTIVE: To systematically review outcomes after mesh sacrocolpopexy compared with native tissue vaginal repairs in women with apical prolapse. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through June 4, 2012. METHODS OF STUDY SELECTION: For anatomic and functional analyses, we included studies comparing mesh sacrocolpopexy to native tissue vaginal repairs with at least 6 months follow-up. The primary outcome was anatomic "success" after surgery. Secondary outcomes were reoperation and symptom outcomes. We included large case series and comparative studies with shorter follow-up to increase power for adverse event analyses. TABULATION, INTEGRATION, AND RESULTS: Evidence quality was assessed with the Grades for Recommendation, Assessment, Development and Evaluation system. Meta-analyses were performed when at least three studies reported the same outcome. We included 13 comparative studies for anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supports improved anatomic outcomes after mesh sacrocolpopexy; very low-quality evidence shows no differences in reoperation between sacrocolpopexy and native tissue vaginal repairs. Evidence was insufficient regarding which procedures result in improved bladder or bowel symptoms. Low-quality evidence showed no differences in postoperative sexual function. Adverse event data were compiled and meta-analyzed from 79 studies. When including larger noncomparative studies, ileus or small bowel obstruction (2.7% compared with 0.2%, P<.01), mesh or suture complications (4.2% compared with 0.4%, P<.01), and thromboembolic phenomena (0.6% compared with 0.1%, P=.03) were more common after mesh sacrocolpopexy compared with native tissue vaginal repairs. CONCLUSION: When anatomic durability is a priority, we suggest that mesh sacrocolpopexy may be the preferred surgical option. When minimizing adverse events or reoperation is the priority, there is no strong evidence supporting one approach over the other.

A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain.

INTRODUCTION AND HYPOTHESIS: Our aim was to determine the effects of pelvic floor physical therapy (PT) and levator-directed trigger-point injections (LTPI) on sexual function and levator-related pelvic pain. STUDY DESIGN: A randomized trial among women with pelvic floor myalgia (PFM) was performed wherein participants received either PT or LTPI. Pain was assessed and 1 month posttreatment completion. Levator-based pain was assessed using a numeric rating scale (NRS) and the Patient Global Impression of Improvement (PGI-I) scale. Sexual function was assessed using the Female Sexual Function Index (FSFI). RESULTS: Twenty-nine women completed the study (17 had PT, 12 had LTPI). Both groups reported reduction in vaginal pain: mean NRS change from baseline of 4.47 [standard deviation (SD) 2.12) for PT and 4.67 (SD 1.72) for LTPI (p = 0.8)]. A >50 % improvement in NRS was documented among 59 % of women receiving PT and 58 % receiving LTPI (p = 1.0). Consistent with NRS scores, mean PGI-I score was 2.50 (SD 1.17) for PT and 2.17 (SD 1.01) for LTPI (p = 0.5). Mean change in FSFI favored PT [PT +8.87 (SD 5.60), LTPI +4.00 (SD 5.24), p = 0.04], reflecting improvement in the sexual pain domain favoring PT (p = 0.02). However, the time in weeks to effect improvement favored LTPI if controlling for the degree of change in NRS (p = 0.01) and FSFI (p = 0.01). CONCLUSIONS: Vaginal myalgia and sex-related pain improved with pelvic floor PT and LTPI. Time-to-effect improvement and significance of therapy are dependent on treatment type.

The use of a Google search in the diagnosis of a rare condition.

BACKGROUND: This study aims to describe the use of the Internet in aiding the diagnosis of a rare lower urinary tract finding in a primiparous woman. METHODS: A case of bladder schistosomiasis was reviewed. RESULTS: After the referral from the obstetrics service with a bladder lesion noted on dating ultrasound, an asymptomatic primipara with 9 weeks of gestational age presented for cystoscopy. A polypoid lesion was noted, and suspected diagnosis of schistosomiasis was made using a Google image search. Urine cytologic evaluation confirmed the diagnosis, and the patient was treated without need for further invasive testing or bladder biopsy. CONCLUSIONS: The usefulness of Internet searches and other electronic resources should be appreciated in the diagnosis of rare conditions.

Systematic review of robotic surgery in gynecology: robotic techniques compared with laparoscopy and laparotomy.

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Vesicovaginal fistula due to remote history of vaginal foreign body.

OBJECTIVES: To report an interesting case of a young adult girl who developed a vesicovaginal fistula after removal of a vaginal foreign body. METHODS: A chart review was performed for a single patient from the time of presentation in July 2010 until final follow-up encounter. RESULTS: A 22-year-old nulliparous woman with a history of removal of a bottle cap from her vagina developed a large vesicovaginal fistula at the bladder neck, which was identified several years later. Closure was via vaginal approach without graft or flap interposition. CONCLUSIONS: Although fistula formation after foreign body identification is rare, early identification and appropriate surgical approach is important for improved patient outcomes.

Sacral neuromodulation for nonobstructive urinary retention: a meta-analysis.

OBJECTIVE: : The objective of this study is to systematically review the literature regarding the efficacy of sacral neuromodulation (InterStim) for treatment of nonobstructive urinary retention. METHODS: : Eligible studies were selected through an electronic literature search of PubMed, Cochrane Collaboration, EMBASE, Web of Science and Scopus databases from January 1980 to August 2008. Two investigators independently reviewed all studies to assess methodological quality and inclusion criteria. Eligible studies evaluated sacral neuromodulation using implanted generators with permanent lead placement for treating nonobstructive urinary retention. The primary outcomes assessed were the change in pre- and postoperative postvoid residual and voided volume. Exclusion criteria were neurogenic etiology (ie, spinal cord injury) for urinary retention and non-English studies. The lead authors of all selected studies were contacted to identify ongoing or unpublished research, as was Medtronic, Inc. (Minneapolis, MN). Data were extracted from the selected studies and analyzed using RevMan 5 (Review Manager, Cochrane Collaboration, 2008). The mean difference with a 95% confidence interval was the effect of interest. RESULTS: : A total of 14 articles met all inclusion criteria for the systematic review. This included one randomized control trial (RCT) and 13 observational studies. Outcome data was available from a total of 7 studies and used in the final analysis. After implantation, the mean difference in postvoid residual decreased 236 mL (95% CI: 219-253, P < 0.00001) and voided volume increased by 299 mL (95% CI: 280-318, P < 0.00001). The randomized control trial alone (n = 51) showed a mean decrease in postvoid residual volume in the implanted group compared with control of 270 mL (95% CI: 180-360, P < 0.00001) and a mean increase in voided volume of 104 mL (95% CI: 55-152, P < 0.0002). CONCLUSIONS: : Based on the available literature, sacral neuromodulation is an effective therapy for treatment of nonobstructive urinary retention.

Change in urethral sphincter neuromuscular function during pregnancy persists after delivery.

OBJECTIVE: The purpose of this study was to assess the effect of pregnancy and first vaginal delivery on urethral striated sphincter neuromuscular function. STUDY DESIGN: Quantitative electromyographic (EMG) interference pattern analysis of the urethral sphincter of 23 nulligravidas and 31 third trimester primigravidas allowed comparison of mean motor unit parameters before term vaginal delivery and postpartum. RESULTS: Mean electromyographic interference pattern parameters in the primigravidas were significantly lower than nulligravidas even antepartum, with decreased turns, lower amplitude, and less activity. The only significant change at 6 months' postpartum was further decline in number of turns resulting in a further decrease in turns:amplitude. All other electromyographic abnormalities persisted at 6 months' postpartum and remained abnormal compared to the nulligravidas. CONCLUSION: Urethral sphincter neuromuscular function changed significantly during pregnancy and these changes persisted postpartum. Lack of recovery 6 months' postpartum suggests a physiologic impact of pregnancy itself on future risk of urinary incontinence.

Levator ani denervation and reinnervation 6 months after childbirth.

OBJECTIVE: The objective of the study was to assess the prevalence of levator ani denervation and reinnervation 6 months after the first delivery. STUDY DESIGN: Ninety-six primigravida women underwent quantitative electromyography of the levator ani during the third trimester and twice postpartum. A 95% confidence interval for normal function was created using interference pattern analysis. Fifty-seven who completed the study are presented in this secondary data analysis. Postpartum muscle sites outside the normal range were considered abnormal. Obstetric and demographic characteristics were assessed. RESULTS: Of 57 subjects, 70% had no denervation. Of the 30% with denervation at 6 weeks, 35% recovered by 6 months. Obstetric or maternal characteristics were not predictive of denervation or reinnervation, except subjects with persistent denervation tended toward lower body mass index (BMI) independent of mode of delivery. CONCLUSION: Nearly one-third of women have levator ani denervation after first delivery, but many recover by 6 months. Denervation is not clearly associated with mode of delivery, but higher maternal BMI may be protective.

Early vs late midline sling lysis results in greater improvement in lower urinary tract symptoms.

OBJECTIVE: Lower urinary tract symptoms (LUTS) occur in 5-20% of women after antiincontinence procedures. Symptoms include complete urinary retention or storage, voiding, and postmicturition symptoms. The goal of this study was to determine the effect of time from sling placement to midline sling lysis on overall improvement in LUTS. STUDY DESIGN: After institutional review board approval, we conducted a retrospective cohort analysis of 112 subjects undergoing midline sling lysis from January 1997-September 2007. The inclusion criteria were women with a vaginal midline sling lysis for LUTS after a prior pubovaginal or midurethral sling. We excluded any subject with sling erosion without LUTS and those who underwent a repeated sling at the time of lysis. We compared subjects who had an early sling lysis (< or = 1 year from sling to lysis) to a late sling lysis (> 1 year). The primary outcome was based on the subject's report of overall improvement in symptoms. We abstracted data on demographics, presenting symptoms, physical examination, date of antiincontinence procedure, date of midline sling lysis, and postoperative symptoms. Statistical analysis consisted of Student t test, chi(2) test, Fisher exact test, and multivariate logistic regression. RESULTS: Of 112 subjects, 74 (66%) had an early sling lysis and 38 (34%) had a late sling lysis. These 2 groups were similar in age, menopausal status, presence of preoperative LUTS, anterior colporrhaphy at the time of lysis, and presence of an eroded sling. The early lysis group had a higher percentage of midurethral slings (36% vs 8%; P = .001), a lower rate of preoperative complete retention (70% vs 89%; P = .001), and a lower rate of prior urethrolysis (16% vs 45%; P = .003). No significant difference in follow-up time was found between early lysis compared with late lysis (49 +/- 89 months vs 43 +/- 71 months; P = .73). Ten (8.9%) subjects developed recurrent stress urinary incontinence after sling lysis, which was independent of time to lysis. In all, 94 (84%) subjects had improvement in their LUTS after midline sling lysis. Overall improvement occurred more often in the early sling lysis group compared with the late sling lysis group (91% vs 71%; P = .01). This finding retained significance in a multivariate logistic regression model, which included age, prior urethrolysis, preoperative complete retention, and type of sling (odds ratio, 4.0; 95% confidence interval, 1.2-13.2). CONCLUSION: Based on this large cohort, patients may benefit from earlier midline sling lysis within 1 year for LUTS after a pubovaginal or midurethral sling procedure. The development of recurrent stress urinary incontinence after midline sling lysis is relatively low.

Surgical excision of eroded mesh after prior abdominal sacrocolpopexy.

OBJECTIVE: We previously described an endoscopic-assisted transvaginal mesh excision technique. This study compares surgical outcomes after transvaginal mesh excision vs endoscopic-assisted transvaginal mesh excision. In addition, we reviewed our postoperative outcomes with excision via laparotomy. STUDY DESIGN: This was an inclusive retrospective analysis of patients presenting to our institution from 1997 to 2006 for surgical management of vaginal erosion of permanent mesh after sacrocolpopexy. Three techniques were utilized: transvaginal, endoscopic-assisted transvaginal, and laparotomy. For the patients undergoing transvaginal excision, data recorded included number and type of excisions performed, number of prior excisions performed at outside facilities, intraoperative and postoperative complications (including blood transfusions, pelvic abscess, or bowel complications), use of postoperative antibiotics, persistent symptoms of vaginal bleeding and discharge at follow-up, and demographic characteristics. The intraoperative and postoperative complications and the postoperative symptoms were recorded for the laparotomy cases. RESULTS: Thirty-one patients underwent transvaginal mesh excision during this time period: 17 endoscopic-assisted transvaginal and 14 transvaginal without endoscope assistance. In addition, a total of 7 patients underwent abdominal excision via laparotomy. Comparison of the 2 vaginal methods revealed no difference in the demographics or success rate, with success defined as no symptoms at follow-up. Endoscopic-assisted transvaginal excision was successful in 7 of 17 patients and transvaginal without endoscopic assistance in 9 of 13 patients (1 patient excluded for lack of follow-up data) for a total vaginal success rate of 53.3%. No intraoperative and only minor postoperative complications occurred with either vaginal method. Three patients underwent 3 vaginal attempts to achieve complete symptom resolution. The average follow-up time for the entire vaginal group was 14 months. Seven patients ultimately required abdominal excision and all had symptom resolution, however, not without complications. Two patients had bowel injury during lysis of adhesions requiring bowel resection in 1 case and repair in another, 1 had a postoperative wound infection with breakdown, 1 was readmitted for postoperative fever requiring antibiotics, and 1 had an acute coronary syndrome requiring transfer to the cardiology service. CONCLUSION: Transvaginal excision of mesh with or without endoscopy appears to be a safe and less invasive method for excision of eroded vaginal mesh after prior abdominal sacrocolpopexy. Up to 3 vaginal excision attempts may be necessary to achieve symptom resolution, and complete removal of mesh will likely improve outcomes with the transvaginal technique. Although abdominal excision can be considered the gold standard for excision of eroded mesh, it is not without potentially increased morbidity.

A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery.

OBJECTIVE: The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery. STUDY DESIGN: Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery. RESULTS: Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02). CONCLUSION: Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.

Levator ani abnormality 6 weeks after delivery persists at 6 months.

OBJECTIVE: Assess postpartum changes in the levator ani muscle using magnetic resonance imaging and relate these changes to obstetric events and risk factors associated with pelvic floor dysfunction. STUDY DESIGN: A board-certified radiologist specializing in abdominal imaging evaluated 146 pelvic magnetic resonance studies from 57 primiparous women 6 weeks and 6 months after first obstetric delivery and 32 nulliparous women. A yes/no determination of muscle body and insertion integrity, muscle thinning, and measurement of muscle thickness in millimeters was made for each of 4 muscle sites: right and left puborectalis and right and left ileococcygeous. Incidence of muscle abnormality and mean muscle thickness was tested in pairs between (1) nulliparous women and 6-week primiparous women; (2) 6 week and 6 month primiparous pairs; and (3) 3 age/race groups using test of 2 proportions and 1-way analysis of variance. RESULTS: Initial review indicated only 3 subjects not of African American or white race, and only 1 African American primiparous woman of age 30 years or older; therefore, statistical analysis was limited to 45 primiparous women and 25 nulliparous women. Incidence of any abnormality at any of the 4 sites was considered abnormal. In those subjects recovering to normal magnetic resonance by 6 months, an average of nearly 60% increase in right puborectalis muscle thickness compared with that seen at 6 weeks indicated the extent of the injury. Subjects with injury to both the puborectalis and ileococcygeous at 6 weeks did not recover to normal at 6 months, whereas those with injury only to the puborectalis tended to have normal magnetic resonance images at 6 months. CONCLUSION: Nulliparity did not guarantee a normal assessment of levator ani anatomy by our blinded reader, and frequency of injury in this series is somewhat greater than that previously reported for primiparous women. Younger white primiparous women had a better recovery at 6 months than older white women. Subjects experiencing more global injury, in particular to the ileococcygeous, tended not to recover muscle bulk.

Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation.

The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.

Overt rectal prolapse following repair of stage IV vaginal vault prolapse.

Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.

The use of non-nutritive sucking to decrease the physiologic pain response during neonatal circumcision: a randomized controlled trial.

OBJECTIVE: The purpose of this research was to study the effects on the physiologic pain response of the neonate during circumcision with the use of a gloved human finger. STUDY DESIGN: This was a randomized controlled trial analyzing the effect of non-nutritive sucking (NNS) on pain response during circumcision. Term neonates were randomized to 2 groups. All infants received oral Tylenol and a dorsal penile nerve block (DPNB) before the circumcision. The study group was offered the addition of NNS before the DPNB and throughout the procedure. The primary outcome measured was heart rate during the circumcision. Other variables studied included crying time and salivary cortisol levels. Each circumcision was filmed to calculate pain profile scores using the Premature Infant Pain Profile. Variables were compared using Student t test, chi-square, and Wilcoxon test. A P value of < .05 was considered significant. RESULTS: Forty-four infants met inclusion criteria. Twenty-two infants were randomized to each arm. No difference in mean heart rate during the procedure was apparent. A significant decrease in crying time, 90-minute post-procedure salivary cortisol level, and post-penile clamping pain score was noted in the study group (all P values < .01). CONCLUSION: NNS significantly decreases some elements of measurable physiologic pain response of the neonate during circumcision. This method is a useful and inexpensive addition to DPNB and oral analgesics.