Mix and Mesh: An Electronic Database of FPMRS Mesh Products Through 2020.

IMPORTANCE: A sequelae of the removal of pelvic organ prolapse (POP) transvaginal mesh products from the U.S. market is that current and future women's health providers may be unfamiliar with mesh products historically used to treat pelvic floor disorders. OBJECTIVES: Our goal was to create an easily accessible resource to address this knowledge gap. STUDY DESIGN: An online database of mesh products used to treat POP and urinary incontinence was created with information, photographs, and videos collated from internet searches; manufacturer materials; and other primary sources. The database was then linked to a free smartphone application. RESULTS: This smartphone application includes, to the best of our knowledge, all mesh products used in the United States for the treatment of POP and stress urinary incontinence through December 2020. Included in the application are product descriptions of mesh color, size, design, and attachment points. Photographs and videos, when available, are included. The application is organized by mesh product name, but it is also searchable by other categories, such as manufacturer name and color.To download the application to a smart phone, go to vaginalmeshcatalogue.glideapp.io/ on a web browser or access via the QR code. Once the website is loaded, you can interact with the mesh catalog as a website or save it to the phone's home screen as an application. CONCLUSIONS: Health care providers of all experience levels can use this free application for educational and clinical purposes to better understand patients' histories, improve preoperative planning, and enhance patient counseling.

Bladder Instillations With Triamcinolone Acetonide for Interstitial Cystitis-Bladder Pain Syndrome: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the utility of adding triamcinolone acetonide to a standard bladder instillation solution for treatment of interstitial cystitis-bladder pain syndrome. METHODS: This was a single-center, randomized, double-blind trial that compared symptom response in women with interstitial cystitis-bladder pain syndrome who underwent six bladder instillations with triamcinolone acetonide or six instillations without. All instillation solutions contained heparin, viscous lidocaine, sodium bicarbonate, and bupivacaine. The primary outcome was the change in interstitial cystitis-bladder pain syndrome symptoms from the first to sixth bladder instillation between groups based on the total OLS (O'Leary-Sant Questionnaire) score. Assuming a 4.03-point or larger difference in the mean total OLS score from the first to sixth bladder instillation as compared between the groups, 64 participants were needed to show a significant difference with 80% power at the 0.05 significance level. RESULTS: From January 2019 to October 2020, 90 women were enrolled-45 per group; 71 (79%) completed all six bladder instillations. Randomization resulted in groups with similar characteristics. There was no difference between groups in the primary outcome (bladder instillation with triamcinolone acetonide: mean OLS change -6.7 points, 95% CI 4.6-8.8 and bladder instillation without triamcinolone acetonide: mean OLS change -5.8 points, 95% CI 3.4-8.1; P=.31). Women in both groups had improvement in their interstitial cystitis-bladder pain syndrome symptoms as indicated by a decrease in the total OLS score from the first to sixth bladder instillation. CONCLUSION: The addition of triamcinolone acetonide to a standard bladder instillation solution does not improve symptoms associated with interstitial cystitis-bladder pain syndrome. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03463915.

Anticholinergic prescribing pattern changes of urogynecology providers in response to evidence of potential dementia risk.

INTRODUCTION AND HYPOTHESIS: Recent publications show an association between exposure to anticholinergic medications and the risk of developing dementia. We hypothesized that urogynecology providers have changed their overactive bladder syndrome treatment as a result of this literature. METHODS: This was an anonymous, cross-sectional, web-based survey of American Urogynecologic Society members. Survey questions queried awareness of the referenced literature, prescribing practices, the impact of insurance on treatment plans, and demographics. Our primary outcome measured the change in prescribing practice in response to literature linking anticholinergic medications with the risk of dementia. Descriptive statistics were used. RESULTS: A total of 222 urogynecology providers completed the survey. Nearly all respondents (99.1%) were aware of the recent literature, and, as a result, 90.5% reported changing their practice. Prior to the publication of recent literature, a "non-CNS-sparing" anticholinergic (e.g., oxybutynin) was most commonly prescribed (64.4%), whereas after the literature was published, this shifted to ß3-adrenoceptor agonists (58.5%, p < 0.001). A majority of respondents (96.6%) reported that insurance restrictions led to a change in treatment for some patients, with 73.5% describing the prior-authorization process as difficult. Many providers (61.8%) reported that a trial of anticholinergics was required by insurance companies prior to authorizing mirabegron. CONCLUSIONS: The recent literature associating anticholinergic medications with the development of dementia has changed practice patterns among survey respondents, with a shift away from anticholinergic medications and toward ß3-adrenoceptor agonists. The majority of respondents report insurance barriers to non-anticholinergic therapies, resulting in alteration of their preferred practices.

Rethinking Second-Line Therapy for Overactive Bladder to Improve Patient Access to Treatment Options.

Idiopathic overactive bladder (OAB) is a chronic condition that negatively affects quality of life, and oral medications are an important component of the OAB treatment algorithm. Recent literature has shown that anticholinergics, the most commonly prescribed oral medication for the treatment of OAB, are associated with cognitive side effects including dementia. ß3-adrenoceptor agonists, the only alternative oral treatment for OAB, are similar in efficacy to anticholinergics with a more favorable side effect profile without the same cognitive effects. However, there are marked cost variations and barriers to access for OAB medications, resulting in expensive copays and medication trial requirements that ultimately limit access to ß3-adrenoceptor agonists and more advanced procedural therapies. This contributes to and perpetuates health care inequality by burdening the patients with the least resources with a greater risk of dementia. When prescribing these medications, health care professionals are caught in a delicate balancing act between cost and patient safety. Through multilevel collaboration, we can help disrupt health care inequalities and provide better care for patients with OAB.

Proper assembly of a self-retaining, vaginal Magrina-Bookwalter retractor and demonstration of its use during a vaginal hysterectomy.

INTRODUCTION/AIM OF THE VIDEO: Vaginal surgery often presents challenges of access. To gain adequate visualization of relevant structures, surgical assistants often assume awkward positioning with inadequate stability of handheld retractors. Additionally, the lead surgeon is typically the only member of the surgical team who can adequately visualize the procedure being performed. To that end, devices have been manufactured with aims of optimizing both visualization and workspace while reducing the need of handheld retractors during vaginal surgery. This video presents one of those retractors: a reusable, self-retaining, vaginal Magrina-Bookwalter, with details to help achieve the optimal visualization and workspace with its use. METHODS: A narrated video provides a brief history, components and proper assembly of the retractor with stepwise application of components demonstrated during a vaginal hysterectomy. CONCLUSION: The self-retaining, vaginal Magrina-Bookwalter retractor is a helpful tool to optimize the visualization and workspace while reducing the need for handheld retractors during vaginal procedures deeper into the pelvis.

Association of Patient Race With Type of Pelvic Organ Prolapse Surgery Performed and Adverse Events.

OBJECTIVES: This study aimed to determine if there are differences in (1) surgical procedures performed for pelvic organ prolapse (POP) and (2) rates of adverse events between racial groups. METHODS: We conducted a retrospective cohort study of women 18 years and older who underwent POP surgery using the 2005-2015 American College of Surgeons National Surgical Quality Improvement Program database. Race was categorized as Black, White, Hispanic, and other minority. Pelvic organ prolapse procedures were organized into 4 groups: (1) hysterectomy without concurrent POP procedures, (2) vaginal wall repair(s) only without apical suspension, (3) apical suspension with or without vaginal wall repair(s), and (4) obliterative procedures. Patient characteristics and rates of adverse events were noted. A multivariable logistic regression model was used to assess the association between patient race and surgical procedures performed for POP. RESULTS: We identified 48,005 women who met the inclusion criteria. Most women who underwent POP surgery were White (79.6% [n = 38,191]). Although only contributing to 4.7% (2,299) of the cohort, Black women experienced higher complication rates compared with White women (10.7% [246] for Black vs 8.9% [3,417] for White women, P < 0.01). Hispanic and other minority women were less likely to undergo an apical suspension than White women (adjusted odds ratios [aORs], 0.79 [0.75-0.84] for Hispanic women and 0.78 [0.71-0.86] for other minority women; P < 0.001 for both). Obliterative procedures were more likely to be performed in Black, in Hispanic, and especially in other minority women (aORs, 1.53 [1.20-1.92] for Black, 1.33 [1.12-1.58] for Hispanic, and 3.67 [3.04-4.42] for other minority women; P < 0.001 for all). CONCLUSIONS: Racial differences exist among women who undergo POP surgery.

Candy Cane Compared With Boot Stirrups in Vaginal Surgery: A Randomized Controlled Trial.

OBJECTIVE: To evaluate differences in physical function at 6 weeks after vaginal surgery among women positioned in candy cane and boot stirrups. METHODS: We conducted a single-masked, randomized controlled trial of women undergoing vaginal surgery with either candy cane or boot stirrup use. The primary outcome was a change in the PROMIS (Patient-Reported Outcomes Measurement Information System) physical function short form-20a from baseline to 6 weeks after surgery. To achieve 80% power to detect a moderate Cohen effect (d=0.5), we required 64 participants in each group. RESULTS: From March 2018 to October 2019, 141 women were randomized, and 138 women (72 in the candy cane group and 66 in the boot stirrup group) were included in the final analysis. There were no baseline differences in participant characteristics including age, body mass index, comorbidities, or preoperative history of joint replacements. There were no between-group differences in surgery type, duration of surgery, estimated blood loss, or adverse events at 6 weeks postoperation. Participants in the candy cane group demonstrated worse physical function at 6 weeks compares with the improvement seen in those in the boot stirrup group; this was significantly different between groups (-1.9±7.9 candy cane vs 1.9±7.0 boot, P<.01). CONCLUSION: Women undergoing vaginal surgery positioned in boot stirrups have significantly better physical function at 6 weeks after surgery when compared with women positioned in candy cane stirrups. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03446950.

Development of a safety zone for rectus abdominis fascia graft harvest based on dissections of the ilioinguinal and iliohypogastric nerves.

BACKGROUND: As a result of the vaginal mesh controversy, surgeons are performing more nonmesh, autologous fascia pubovaginal slings to treat stress urinary incontinence in women. The rectus abdominis fascia is the most commonly harvested site for autologous pubovaginal slings, so it is crucial that surgeons are familiar with the relationship between this graft harvest site and the ilioinguinal and iliohypogastric nerves, which can be injured during this procedure. OBJECTIVE: The aims of this study were as follows: (1) to estimate the safest area between the bilateral courses of the ilioinguinal and iliohypogastric nerves in which a rectus abdominis fascia graft could be harvested with minimal risk of injury to these nerves and (2) to determine the location and dimensions of a graft harvest site that maximized graft length while remaining close to the pubic symphysis. STUDY DESIGN: The ilioinguinal and iliohypogastric nerves were dissected bilaterally in 12 unembalmed female anatomical donors. The distances of these nerves to a 10 × 2 cm rectus abdominis fascia graft site located 4 cm above the pubic symphysis were measured. Nerve courses inferior to the graft site were determined for each donor by linearly extrapolating measurement points; analysis was performed with and without extrapolation. Average nerve trajectories were estimated assuming a linear regression function to predict the horizontal measurement as a quadratic function of the vertical distance; 95% confidence bands were also estimated. An estimated safety zone was determined to be the region between all credible nerve bounds. RESULTS: The largest safety zone that was closest to the pubic symphysis was located at 5.4 cm superior to the pubic symphysis. At this location, the inferior border of the graft could measure 9.4 cm in length (4.7 cm bilaterally from the midline). Extrapolated nerve courses below the study graft site yielded a smaller safety zone located 2.7 cm superior to the pubic symphysis, allowing for the inferior border of the graft to be 4.8 cm (2.4 cm bilaterally from the midline). CONCLUSION: A rectus abdominis fascia graft harvested 5.4 cm superior to the pubic symphysis with the inferior border of the graft measuring 9.4 cm in length should minimize injury to the ilioinguinal and iliohypogastric nerves. These dimensions allow for the longest graft while remaining relatively close to the pubic symphysis. The closer a graft is harvested to the pubic symphysis, the smaller in length the graft must be to avoid injury to the ilioinguinal and iliohypogastric nerves.

Cadaveric surgical demonstration of middle to distal ureteral injury repairs in urologic and gynecologic surgeries.

INTRODUCTION AND HYPOTHESIS: Iatrogenic ureteral injuries can occur during any surgery but are more likely to occur during urologic and gynecologic procedures. The middle and distal ureter are especially at risk of injury during these surgeries. METHODS: The objective of this surgical educational video was to demonstrate how to repair middle to distal ureteral injuries with the following techniques: direct ureteroureterostomy, ureteroneocystotomy, vesico-psoas hitch, and Boari-Ockerblad bladder flap. RESULTS: A female cadaver was used to show how to surgically repair injuries to the middle and distal ureter. CONCLUSIONS: Middle to distal ureteral injuries occurring during urologic and gynecologic surgeries can be repaired by the techniques demonstrated in this video manuscript.

Citation classics: the 100 most cited articles in Urogynecology.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to utilize objective citation analyses to describe the 100 most cited articles in the field of Female Pelvic Medicine & Reconstructive Surgery (FPMRS) and to review their characteristics. METHODS: We searched the Thomas Reuters Web of Science database for the most cited articles within all journals classified as Obstetrics and Gynecology (Ob/Gyn), Urology (Uro), Colorectal Surgery (CRS), and vital General Medicine (GM) journals (New England Journal of Medicine; Journal of the American Medical Association; Lancet; The BMJ). We reviewed search results for FPMRS content and compiled a list of the top 100 most cited articles relevant to FPMRS. RESULTS: We screened 34,934 articles yielded by the initial search and compiled the 100 most cited articles relevant to FPMRS. Of these 100 titles, 40% (42 out of 105) were published in Ob/Gyn, 46.7% (49 out of 105) in Uro, 1.9% (2 out of 105) in CRS, and 11.4% (12 out of 105) in GM journals. The most cited FPMRS article was "The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society" (3,810 total and 242 citations per year). Over half the articles were observational in nature and the majority (58%) of them were related to urinary incontinence in women. CONCLUSIONS: Highly cited FPMRS articles come from a variety of journals, and nearly 50% of the 100 most cited FPMRS articles are from the urology literature. The most cited articles were largely observational rather than interventional studies and mostly related to female urinary incontinence.

Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database.

STUDY OBJECTIVE: The objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH). DESIGN: This was a retrospective cohort study. A secondary analysis of the 2006-2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned. SETTING: Hospitals participating in the NSQIP program. PATIENTS: Women who underwent hysterectomy with MISCP. INTERVENTIONS: Not applicable. MEASUREMENT AND MAIN RESULTS: A total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3-3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome. CONCLUSION: Regardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.

Comparison of Perioperative Outcomes of Autologous Bladder Neck Fascial Slings Based on Fascial Harvest Site: A Secondary Analysis of the National Surgical Quality Improvement Program Database.

OBJECTIVES: The objective of this study was to compare perioperative outcomes of autologous bladder neck fascial slings (ABNFS) between rectus fascia and fascia lata harvest sites. METHODS: We analyzed women undergoing ABNFS in the 2006 to 2015 American College of Surgeons National Surgical Quality Improvement Program database, separating rectus fascia and fascia lata harvest sites by Current Procedural Terminology codes. We compared the 2 harvest sites for perioperative outcomes within 30 days including adverse events, readmission, and reoperation as well as operative time and length of hospital stay. The primary outcome was a composite of postoperative adverse events, readmission, and reoperation. A multivariable logistic regression model was used incorporating race, smoking status, surgical specialty, anesthesia class, concurrent procedures, body mass index, operating time, and length of hospital stay. RESULTS: A total of 161 women in the database underwent ABNFS: 126 (78.3%) rectus fascia and 35 (21.7%) fascia lata harvest. Patients undergoing rectus fascial harvest were more likely to be white (140 [90.5%] rectus vs 26 [74.3%] fascia lata, P=0.02) and more likely to have ABNFS by a urologist (117 [93%] rectus vs 23 [66%] fascia lata, P < 0.01). There were no significant differences in operative time, length of stay, rate of reoperation, nonserious or serious adverse events, or readmission between the 2 harvest site groups. The 2 harvest sites had similar composite morbidity (adjusted odds ratio of 0.88 for rectus fascia; 95% confidence interval, 0.21-3.75; P=0.87). CONCLUSIONS: Rectus fascia and fascia lata harvest for ABNFS have similar perioperative outcomes.

Association of Urinary Phytoestrogens With Pelvic Organ Prolapse and Fecal Incontinence Symptoms in Postmenopausal Women.

OBJECTIVES: The aim of this study was to investigate the association between urinary phytoestrogen levels with symptoms of pelvic organ prolapse (POP) and fecal incontinence (FI) in postmenopausal women. METHODS: This is a cross-sectional study using the National Health and Nutrition Examination Survey database from 2005 to 2010 including postmenopausal women 40 years or older who either had both ovaries removed and/or had no period in the past year due to hysterectomy and/or menopause. Urinary concentrations of 6 phytoestrogens were measured. Pelvic organ prolapse symptoms were defined as a positive response to the question, "Do you see or feel a bulge in the vaginal area?" Fecal incontinence was defined as leakage of mucus, liquid, or solid stool occurring at least monthly. Using appropriate sample weights, prevalence estimates and 95% confidence intervals were calculated. Logistic regression was performed assessing associations between pelvic floor symptoms and log-transformed phytoestrogen levels adjusting for appropriate covariates. RESULTS: Participants included 1341 postmenopausal women with phytoestrogen data; 1213 with or without POP symptoms and 1221 with or without FI symptoms. Multivariable analysis revealed no association of urinary phytoestrogen levels with POP symptoms. Higher urinary O-desmethylangolensin level was associated with decreased odds of FI symptoms in postmenopausal women (adjusted odds ratio, 0.92; 95% confidence interval, 0.86-0.99). CONCLUSIONS: Increased urinary O-desmethylangolensin level was associated with lower odds of FI. Future research may be warranted to further investigate the potential of specific phytoestrogens as mediators of FI, as well as the role of phytoestrogens on POP symptoms.

Ergonomics: making the OR a comfortable place.

INTRODUCTION: The objective of this video is to highlight strategies to improve operating room (OR) ergonomics, which will result in increased surgeon comfort during minimally invasive gynecologic surgery and decreased risk of musculoskeletal injury. METHODS: Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons, including those who perform minimally invasive gynecologic surgery. WMSDs are repetitive strain injuries that can damage a surgeon's muscles, nerves, and/or joints and commonly affect the neck, back, wrist, and hands. In addition to chronic pain, these injuries can lead to decreased job satisfaction and productivity. RESULTS: This video will discuss general ergonomic principles and demonstrate ergonomic techniques in conventional laparoscopic, vaginal, and robotic surgery. CONCLUSIONS: Minimally invasive gynecologic surgery can be physically taxing on the surgeon. Understanding principles and utilizing techniques of OR ergonomics can minimize these physical demands and result in a long, healthy, and pain-free surgical career.

A Review of Phytoestrogens and Their Association With Pelvic Floor Conditions.

INTRODUCTION: Urinary incontinence, pelvic organ prolapse, and fecal incontinence are pelvic floor disorders (PFDs) disproportionately experienced by postmenopausal women. Limited data exist suggesting that phytoestrogens may have an impact on the pathophysiology and symptom of PFDs. PURPOSE OF REVIEW: The aim of the study was to review the current literature addressing the role of phytoestrogens on PFDs, including the pathophysiology, symptom, treatment, and possible prevention. FINDINGS: Qualifying literature spans from 2003 to 2017 and included 14 studies ranging from in vitro, animal, and observational studies to randomized clinical trials. SUMMARY: Although the literature is limited, most studies on phytoestrogens and PFDs support associations with pathophysiologic mechanisms, symptoms, and treatment for urinary incontinence and pelvic organ prolapse, but not fecal incontinence. Less is known regarding the prevention of PFDs with phytoestrogen intake over time. Overall, the potential influence of phytoestrogens on PFDs is not well understood, and more research is needed.

Associations Between Type and Route of Hormone Use on Urinary Incontinence and Pelvic Organ Prolapse in Premenopausal and Postmenopausal Women.

OBJECTIVE: The aim of this study was to evaluate the associations between type and route of hormone use and urinary incontinence (UI) and pelvic organ prolapse (POP) in premenopausal and postmenopausal women. METHODS: The authors used the National Health and Nutritional Examination Survey database for data from 2005-2006, 2007-2008, 2009-2010, and 2011-2012. Seven thousand sixty-six of the women included were premenopausal, and 5387 were postmenopausal. Premenopausal women were younger than 51 years and reported menstrual periods in the last 12 months. Postmenopausal women reported being in natural or surgical menopause. Urinary incontinence was defined as experiencing urinary leakage "less than once a month" or more. Pelvic organ prolapse was defined as an affirmative response to "experience bulging in the vaginal area." Hormone route and use were stratified in years. Pearson χ and Pearson correlations were used, with P < 0.05 considered significant. RESULTS: In premenopausal women, birth control pills, estrogen/progestin pills, and estrogen-only patch use are associated with UI (P < 0.05). Birth control pills are associated with both UI and POP in premenopausal women (P < 0.05 for UI and POP). In postmenopausal women, estrogen-only pills, and estrogen/progestin pill use are associated with UI (P < 0.05). Birth control pill use is associated with POP in postmenopausal women (P = 0.029). Neither estrogen patch nor estrogen/progestin patch is associated with UI or POP in postmenopausal women. CONCLUSIONS: Type and route of hormone use have varied associations with UI and POP in premenopausal and postmenopausal women. Prospective studies are needed to further evaluate the effect of hormone type and route on UI and POP in premenopausal and postmenopausal women.

Simple and effective: transvaginal vesico-vaginal fistula repair with a modified Latzko technique.

INTRODUCTION AND HYPOTHESIS: The incidence of vesico-vaginal fistulas after hysterectomies for benign indications in developed countries is less than one percent. The objective of this video is to demonstrate an easy-to-follow, step-by-step approach to repairing a small, uncomplicated vesico-vaginal fistula transvaginally using a modified Latzko technique. METHODS: In this video, we present a case of a 46-year-old woman who developed a simple, uncomplicated vesico-vaginal fistula after a total abdominal hysterectomy. To correct her fistula, we used a modified Latzko technique, which is a transvaginal approach to vesico-vaginal fistula repair that involves mobilizing the vaginal mucosa around the fistula and then closing the pubo-vesical fascia and vaginal mucosa in layers. RESULTS: The patient had successful surgical correction of her vesico-vaginal fistula without recurrence of the fistula. CONCLUSIONS: For small, uncomplicated vesico-vaginal fistulas, a transvaginal approach has an equivalent success rate to that of other approaches with less invasiveness and faster recovery times. Therefore, it is reasonable to use a modified Latzko technique to help restore the quality of life to women affected by small, uncomplicated vesico-vaginal fistulas.

Vaginal Mesh Removal Outcomes: Eight Years of Experience at an Academic Hospital.

OBJECTIVES: The purpose of this study is to describe the clinical history leading up to and the outcomes after vaginal mesh removal surgery at an academic hospital. METHODS: A retrospective case series of patients who underwent vaginal mesh removal from 2008 to 2015 was conducted. Demographics, clinical history, physical examination, pre- and postoperative symptoms, and number and type of reoperations were abstracted. RESULTS: Between February 2008 and November 2015, 83 patients underwent vaginal mesh removal surgery at our hospital. The median time interval from initial mesh placement to removal was 58 months (range, 0.4-154 months). The most common preoperative symptoms were vaginal pain (n = 52, 62%), dyspareunia (n = 46, 55%), and pelvic pain (n = 42, 50%). Intraoperative complications were infrequent (n = 3, 4%). Of patients presenting for follow-up within 4 to 6 weeks postoperatively, the most common symptoms were urinary incontinence (n = 15, 28%), vaginal pain (n = 7, 13%), buttock pain (n = 5, 9%), and urinary tract infection (n = 5, 9%). There were no identifiable risk factors to predict which patients would have persistent postoperative symptoms or who would require more than 1 mesh removal surgery. After vaginal mesh removal, 29 patients (35%) required 1 or more reoperations, with 3 being the highest number of reoperations per patient. The total number of reoperations was 43, with a total of 63 individual procedures performed. Forty-four percent (n = 28) of the procedures were graft removals, 40% (n = 25) were pelvic organ prolapse surgeries (only native tissue repairs), and 16% (n = 10) were stress incontinence surgeries. More than 1 procedure was performed in 49% (n = 21) of the reoperations. CONCLUSIONS: Vaginal mesh removal surgery is safe; however, some patients require more than 1 procedure, and the risk factors for reoperations are unclear.