High uterosacral ligament hysteropexy for the management of pelvic organ prolapse

ABSTRACT Objective: To demonstrate our transvaginal high uterosacral ligament (HUL) hysteropexy technique as an alternative mesh-free uterine-preserving pelvic organ prolapse (POP) repair approach and present our institutional outcomes. Concurrent hysterectomy with POP repair is controversial as uterine-preserving techniques may beneficially allow fertility, body image and sexual function preservation (1, 2). Materials and Methods: This video illustrates a step-by-step sequence of our HUL hysteropexy technique in a symptomatic Stage III POP patient. Retrospective single-institution, single-surgeon analysis of patients treated by either HUL hysteropexy or hysterectomy with HUL suspension for symptomatic prolapse was performed with minimum 2 years of follow-up. Patient demographics, operative characteristics, pre and post-operative POP-Q evaluation, American Urological Association Symptom scores (AUASS) and post-operative Pelvic Floor Distress Inventory (PFDI-20) were compared. Results: Surgery time was 3 hours 24 minutes. No immediate/early complications were noted, with successful repair on follow-up. Outcomes of 18 patients (10 HUL hysteropexy, 8 hysterectomy and HUL suspension) were assessed (Supplemental Table). The only baseline difference was a lower body mass index in the HUL hysteropexy cohort (25.8 vs. 35.8kg/m2, p=0.008). In the HUL hysteropexy cohort, blood loss (mean: 58 vs. 205ml, p=0.00086) and operative time (190.4 vs. 279.1minutes, p=0.0021) were significantly reduced. There was no difference in post-operative AUASS, POP-Q or PFDI-20 at 2 years. Conclusion: We present our HUL hysteropexy technique. Although limited by sample size and retrospective design, resulted in significantly reduced blood loss and operative time with comparable post-operative 2 year outcomes to non-uterine-preserving techniques. In our opinion, HUL hysteropexy is a safe, durable POP management option for women without significant endometrial pathology risk factors.

Effect of Morbid Obesity on Midurethral Sling Efficacy for the Management of Stress Urinary Incontinence.

OBJECTIVES: The aim of our study was to assess midurethral sling (MUS) failure rate in the morbidly obese (body mass index [BMI] ≥40 kg/m) population as compared with normal-weight individuals. Our secondary objective was to assess the difference in complication rates. METHODS: This is a retrospective cohort study. We included all patients who underwent a synthetic MUS procedure from January 1, 2008, to December 31, 2015, in our health system. Failure was defined as reported stress urinary incontinence symptoms or treatment for stress urinary incontinence. Variables collected were BMI; smoking status; comorbidities; perioperative (≤24 hours), short-term (≤30 days), and long-term (>30 days) complications; and follow-up time. Statistics include analysis of variance, χ test, logistic regression, Kaplan-Meier method, and Cox regression. RESULTS: There were 431 patients included in our analysis. Forty-nine patients were in class 3 with a BMI mean of 44.9 ± 5.07 kg/m. Median follow-up time was 52 months (range, 6-119 months). Class 3 obesity (BMI ≥40 kg/m) was the only group that had an increased risk of failure when compared with the normal-weight group (P = 0.03; odds ratio, 2.47; 95% confidence interval, 1.09-5.59). Obesity was not a significant predictor of perioperative, short-term, or long-term postoperative complications (P = 0.19, P = 0.28, and P = 0.089, respectively) after controlling for other comorbidities. CONCLUSIONS: Patients in the class 3 obesity group who are treated with an MUS are 2 times as likely to fail when compared with those in the normal-weight category on long-term follow-up with similar low complication rates.

Propofol-Related Infusion Syndrome in the Peripartum Period.

Background Propofol is a widely known, commonly used drug. Complications can occur with the use of this drug, including propofol-related infusion syndrome (PRIS). PRIS, in the obstetric population, has not been documented; however, we report a case of a patient who developed PRIS after an emergent cesarean delivery of a preterm infant. Case Study A 35-year-old multigravida woman presented complaining of leakage of fluid and decreased fetal movement. Her pregnancy was complicated by methadone maintenance therapy due to a history of opioid abuse. Complications after admission for prolonged monitoring and a prolonged fetal heart tone deceleration was noted with no recovery despite intrauterine resuscitation. An emergent cesarean delivery was performed using general anesthesia and endotracheal intubation after which she developed aspiration pneumonia. She was admitted to the intensive care unit and reintubation and sedation were required secondary to respiratory distress. Sedation was achieved using propofol infusion. She subsequently developed changes in her electrocardiogram, an increase of her serum creatinine, creatinine protein kinase, lipase, amylase, and triglycerides, making the diagnosis of PRIS. Conclusion PRIS should be included in the differential diagnosis of intubated or postoperative patients in the obstetric population.

Quality of life outcomes in peri-urethral calcium hydroxylapatite injection.

INTRODUCTION AND HYPOTHESIS: Peri-urethral calcium hydroxylapatite injection is an established treatment for patients with stress urinary incontinence. Information is limited regarding calcium hydroxylapatite treatment and quality of life (QOL) outcomes. We hypothesize that patients might improve QOL after peri-urethral calcium hydroxylapatite injection, which was reflected in validated questionnaires. METHODS: The peri-urethral calcium hydroxylapatite injection billing code was used to identify patients who underwent injection from 2011-2013. Female patients who completed the American Urological Association Symptom Score (AUASS), the AUASS QOL and Michigan Incontinence Symptom Index (M-ISI), and the bother score (M-ISI bother), or pad count at baseline and follow-up were included. Change in questionnaire scores and pads were assessed using the paired t test. RESULTS: Sixty patients underwent 1 (30), 2 (63) or 3 (7 %) peri-urethral calcium hydroxylapatite injections performed by a single surgeon. Thirty-seven patients provided questionnaires and 38 provided pad counts, all with a mean age of 75 years. The overall AUASS, AUASS QOL, and overall M-ISI scores improved in 67.6, 54.8, and 61.3 % respectively (4.5 ± 7.9, 1.3 ± 1.7 and 5.5 ± 8.6 respectively). The M-ISI bother score improved in 44.8 % with a mean improvement of 0.5 ± 2.9, but did not reach significance. There was a 1.7 ± 3.7 decrease in the mean number of pads used daily after the procedure (p = 0.006) and 19 % experienced transient urinary retention. CONCLUSIONS: Peri-urethral calcium hydroxylapatite injections can improve urinary QOL scores in patients with initial and recurrent stress urinary incontinence. This short-term retrospective analysis suggests that larger long-term studies focusing on QOL outcomes are needed to evaluate the effect of peri-urethral calcium hydroxylapatite has on incontinence-specific QOL.

Social networking and Internet use among pelvic floor patients: a multicenter survey.

BACKGROUND: Internet resources are becoming increasingly important for patients seeking medical knowledge. It is imperative to understand patient use and preferences for using the Internet and social networking websites to optimize patient education. OBJECTIVES: The purpose of this study was to evaluate social networking and Internet use among women with pelvic floor complaints to seek information for their conditions as well as describe the likelihood, preferences, and predictors of website usage. STUDY DESIGN: This was a cross-sectional, multicenter study of women presenting to clinical practices of 10 female pelvic medicine and reconstructive surgery fellowship programs across the United States, affiliated with the Fellows' Pelvic Research Network. New female patients presenting with pelvic floor complaints, including urinary incontinence, pelvic organ prolapse, and fecal incontinence were eligible. Participants completed a 24 item questionnaire designed by the authors to assess demographic information, general Internet use, preferences regarding social networking websites, referral patterns, and resources utilized to learn about their pelvic floor complaints. Internet use was quantified as high (≥4 times/wk), moderate (2-3 times/wk), or minimal (≤1 time/wk). Means were used for normally distributed data and medians for data not meeting this assumption. Fisher's exact and χ2 tests were used to evaluate the associations between variables and Internet use. RESULTS: A total of 282 surveys were analyzed. The majority of participants, 83.3%, were white. The mean age was 55.8 years old. Referrals to urogynecology practices were most frequently from obstetrician/gynecologists (39.9%) and primary care providers (27.8%). Subjects were well distributed geographically, with the largest representation from the South (38.0%). Almost one third (29.9%) were most bothered by prolapse complaints, 22.0% by urgency urinary incontinence, 20.9% by stress urinary incontinence, 14.9% by urgency/frequency symptoms, and 4.1% by fecal incontinence. The majority, 75.0%, described high Internet use, whereas 8.5% moderately and 4.8% minimally used the Internet. Women most often used the Internet for personal motivations including medical research (76.4%), and 42.6% reported Google to be their primary search engine. Despite this, only 4.9% primarily used the Internet to learn about their pelvic floor condition, more commonly consulting an obstetrician-gynecologist for this information (39.4%). The majority (74.1%) held a social networking account, and 45.9% visited these daily. Nearly half, 41.7%, expressed the desire to use social networking websites to learn about their condition. Women <65 years old were significantly more likely to have high Internet use (83.4% vs 68.8%, P = .018) and to desire using social networking websites to learn about their pelvic floor complaint (P = .008). The presenting complaint was not associated with Internet use (P = .905) or the desire to use social networking websites to learn about pelvic floor disorders (P = .201). CONCLUSION: Women presenting to urogynecology practices have high Internet use and a desire to learn about their conditions via social networking websites. Despite this, obstetrician-gynecologists remain a common resource for information. Nonetheless, urogynecology practices and national organizations would likely benefit from increasing their Internet resources for patient education in pelvic floor disorders, though patients should be made aware of available resources.