Postoperative complications and unanticipated healthcare encounters following mini-laparotomy vs. laparoscopic/robotic-assisted sacrocolpopexy: a comparative retrospective study.

BACKGROUND: Pelvic organ prolapse is a debilitating condition impacting lives of millions of women worldwide. Sacrocolpopexy (SCP) is considered an effective and durable surgical technique for treatment of apical prolapse. The aim of this study was to compare short-term outcomes including postoperative complications and unanticipated healthcare encounters between patients who underwent SCP with a mini-laparotomy approach compared to patients treated with laparoscopic and robotic-assisted laparoscopic SCP. METHODS: This was a retrospective cohort study including patients treated for apical prolapse at a university affiliated urogynecology practice. Patients over the age of 18 who underwent abdominal SCP between 2019 and 2023 were included. The cohort was formed into two groups: (1) Patients who underwent SCP through a mini-laparotomy incision (Mini-lap group); (2) Patients who underwent laparoscopic or robotic-assisted laparoscopic SCP (Lap/Robot group). RESULTS: A total of 116 patients were included in the final analysis. Ninety patients underwent either laparoscopic or robotic-assisted SCP, whereas 26 patients underwent SCP with a mini-laparotomy approach. Study participants exhibited a mean age of 63.1 ± 10.3 years, mean body mass index (BMI) of 25.8 ± 4.9 Kg/m2, and 77.6% of them identified as Caucasian. Upon comparison of demographic and past medical history between groups there were no statistically significant differences in age, BMI, menopausal status, race, parity or comorbid conditions. Patients in the Mini-lap group were less likely to have undergone previous abdominal surgery (11.5% vs. 50.6%, p < 0.001) and had more severe apical prolapse (stage 4 prolapse, 40% vs. 21.2%, p < 0.001) than their counterparts in the Lap/robot group. Regarding intraoperative parameters, length of surgery was significantly shorter in the Mini-lap group compared to the Lap/robot group (97.3 ± 35.0 min vs. 242.0 ± 52.6 min, p < 0.001). When focusing on the primary outcome, postoperative complications within the first 30 days after surgery, there were no differences noted between groups. Additionally, the number of unanticipated healthcare encounters, such as phone calls, clinic visits, emergency department visits, urgent care visits, readmissions and reoperations were similar between groups. CONCLUSIONS: Mini-laparotomy approach for SCP is safe with comparable intra- and postoperative complications, and unanticipated healthcare encounters compared to conventional minimally invasive methods.

A prospective, randomized trial comparing intravesical dimethyl sulfoxide (DMSO) to bupivacaine, triamcinolone, and heparin (BTH), for newly diagnosed interstitial cystitis/painful bladder syndrome (IC/PBS).

INTRODUCTION AND HYPOTHESIS: The primary aim of this study was to compare the effect of bladder instillations using dimethyl sulfoxide (DMSO) with triamcinolone versus bupivacaine, triamcinolone, and heparin (BTH) in women with newly diagnosed interstitial cystitis/painful bladder syndrome. The primary outcome was improvement in symptoms measured using the O'Leary-Sant Interstitial Cystitis Symptoms Index (ICSI) score. Secondary comparisons included changes in urinary frequency, nocturia, and bladder capacity. MATERIALS AND METHODS: This was a prospective, randomized study. Patients with a recent diagnosis of interstitial cystitis/painful bladder syndrome (IC/PBS) were randomized 1:1 to treatment with either 6 weekly bladder instillations of DMSO with triamcinolone or BTH. During follow-up visits, patients completed the ICSI questionnaire, and bladder capacity was determined through the retrograde filling of the bladder. The χ2 test or Student's t test were used for data analysis. RESULTS: A total of 83 patients were randomized, and final analysis included 70 participants who completed the 6 weekly instillations (42 DMSO, 28 BTH). The groups were similar in baseline demographics and clinical characteristics, except for cystometric maximum capacity (DMSO 338.62± 139.44 mL, BTH 447.43 ± 180.38 mL, p = 0.01). In the DMSO group, 63% of patients had a greater than 29.5% reduction in total ICSI score versus 43% in the BTH group (p = 0.15). Nocturia and pain were significantly reduced in the DMSO group. There was a significant increase from baseline in bladder capacity for both groups. CONCLUSION: In women with newly diagnosed IC/PBS, bladder instillations with DMSO and triamcinolone provide greater improvement in pain and nocturia compared to BTH.

Risk factors for unplanned admission following surgical repair of apical prolapse.

INTRODUCTION AND HYPOTHESIS: Same-day discharge (SDD) is increasing in popularity following surgical repair of pelvic organ prolapse. The aim of this study was to evaluate factors associated with unplanned admission (UA) in women undergoing apical prolapse repair. METHODS: This retrospective, observational cohort study included patients who underwent apical prolapse repair and planned same-day discharge (SDD) between March 2019 and December 2021. The cohort was divided into two groups: patients who were discharged on the same day as surgery (SDD group) and patients who had an unplanned admission (UA group). Demographic, pre-, intra-, and post-operative data were collected. Risk factors associated with unplanned admission were evaluated using univariate and multivariate analyses. RESULTS: One-hundred and eighty-four cases of apical prolapse repair met the criteria for inclusion in the final analysis; this included 142 in the SDD group and 42 in the UA group. Patients in the UA group had significantly increased estimated blood loss, longer total operative time, later time arriving to the Post-Anesthesia Care unit (PACU) and longer overall stay in the PACU. No differences were observed in the 30-day complication rate, or 30-day unanticipated healthcare encounters, between groups. Multivariate analysis revealed that receiving ketorolac post-operatively was associated with a higher likelihood of SDD (OR=2.6, 95% CI 1.032-6.580, p=0.043). CONCLUSIONS: Among women undergoing apical prolapse repair, same-day discharge was associated with comparable immediate and 30-day complication rates. Within our cohort, post-operative treatment with ketorolac was associated with greater likelihood of SDD.

Same-day Discharge vs Planned Admission after Surgical Treatment for Apical Prolapse.

STUDY OBJECTIVE: Same-day discharge (SDD) after surgery is becoming more common, with studies supporting the safety of this practice in gynecologic surgeries. The aim of this study was to compare short-term outcomes of SDD with planned admission in patients undergoing apical pelvic organ prolapse repair, through 30-day complications and 30-day unanticipated healthcare encounters. SETTING: Female pelvic medicine and reconstructive surgery practice at a university-affiliated tertiary medical center. PATIENTS: Patients with apical prolapse who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients under the age of 18, cases planned for SDD with an unexpected admission, cases with a planned open procedure, and those performed in combination with another surgical service. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 296 patients were included in the final analysis. A total of 154 patients had a planned admission, and 142 were discharged on the day of surgery (SDD group). There were no differences in reoperations, development of venous thromboembolism, and blood transfusions between the 2 groups. Patients in the SDD group were more likely to have no postoperative complications (95% vs 88.3%, p = .037). Number of unanticipated urogynecology office visits, urgent/immediate care visits, readmissions, or unplanned phone calls were also similar between the 2 groups. There was a statistically significant difference observed in mean emergency department (ED) visits (0.16 ± 0.40 in the planned admission group vs 0.06 ± 0.27 in the SDD group, p = .02); however, this number was low in both groups. CONCLUSION: This comparative study suggests that SDD after apical prolapse repair is safe and may be considered for patients interested in this option.

The Effect of Age on Surgical Outcomes Following Uterine Preserving Surgery for Treatment of Apical Prolapse.

STUDY OBJECTIVE: The aim of this study was to evaluate the effect of age on outcomes after uterine-preserving surgical treatment for apical prolapse. DESIGN: Retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery unit at a tertiary, university-affiliated teaching medical center. PATIENTS: Women who underwent surgical management of apical prolapse with uterine preservation between 2010 and 2020. Excluded were women who had ≤1 month of follow-up and those for whom medical records were substantially incomplete. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Included in the study were 140 women who underwent apical prolapse repair with uterine preservation and who met the inclusion criteria. The cohort was divided into 2 groups: (1) women aged 65 years and older (≥65 group) and (2) women younger than 65 years of age (<65 group). Pre-, intra-, and postoperative data were compared between the groups. A total of 103 women (73.6%) were in the <65 group and 37 women (26.4%) in the ≥65 group. Mean age for the entire cohort was 58 ± 9.8 years, body mass index 25.9 ± 4.8 kg/m2, and duration of follow-up was 25.9 ± 21.0 months. Women in the ≥65 group had more comorbidities, were less sexually active, and were less likely to have a midurethral sling performed during their surgery. Clinical and anatomical success rates were somewhat higher in the ≥65 group; however, these differences did not reach statistical significance (97.3% vs 85.4%, p = .069 and 89.2% vs 81.2%, p = .264, respectively). Composite outcome success was higher in the ≥65 group (89.2% vs 72.5%, p = .039). Patient satisfaction recorded using the Patient Global Impression of Improvement questionnaire was high for both groups. A multivariable logistic regression analysis for the dependent parameter of composite outcome success was performed, during which none of the parameters investigated reached statistical significance. Subgroup analysis was performed including only women who were postmenopausal. This was done to address the possible confounding effect that menopausal status may have had on our results. No differences were found between the groups with regard to clinical, anatomical, and composite outcomes. CONCLUSION: Uterine-preserving surgery is a safe and effective surgical treatment for women aged ≥65 years.

Absorbable versus Permanent Suture for Vaginal Uterosacral Ligament Suspension for Treatment of Apical Prolapse.

STUDY OBJECTIVE: The aim of this study was to compare surgical outcomes in women undergoing vaginal uterosacral ligament suspension using permanent as opposed to absorbable sutures. We also aimed to assess for specific risk factors for suture complications. DESIGN: Retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center. PATIENTS: Women with apical prolapse who underwent vaginal hysterectomy with uterosacral ligament suspension during the study period. INTERVENTIONS: none. MEASUREMENTS AND MAIN RESULTS: A total of 197 women were included in the study. Of them, 118 (59.9%) underwent the procedure using a permanent suture and 79 (40.1%) using an absorbable suture. Women in the permanent suture group were less sexually active and had less prolapse of point C on pre-operative exam. With regard to intra-operative and postoperative data, women in the permanent suture group had increased frequency of concomitant procedures, regional anesthesia, surgical time, duration of hospital stay, and change in hemoglobin. Clinical, anatomical, and composite success did not differ between groups. Patient satisfaction recorded using the Patient Global of Improvement Questionnaire was similar as well. Women in the permanent suture group had a higher frequency of suture exposure compared with the absorbable suture group (9.3% vs 0.0%, p = .006). In order to assess for risk factors leading to suture complications, a comparison was performed between women who had suture exposure or granulation tissue and those who did not. Increasing parity by 1 increased the odds of having suture exposure or granulation tissue by a factor of approximately 1.2 (adjusted odds ratio = 1.24; Confidence interval, 1.05-1.47). Women with stage IV prolapse had 3.4 times the odds of suture complication compared with women with stage III prolapse (adjusted odds ratio = 3.4; Confidence interval, 1.1-10.6). CONCLUSION: Use of an absorbable suture affords comparable success and lower frequency of suture exposure compared with permanent sutures in women undergoing vaginal uterosacral ligament suspension for treatment of apical prolapse.

Infected pelvic hematoma following vaginal hysterectomy with uterosacral ligament suspension for treatment of apical prolapse.

OBJECTIVE: Vaginal hysterectomy with uterosacral ligament suspension (VUSLS) is a common procedure for apical prolapse repair. Data regarding pelvic hematoma following this procedure is scarce. The aim of this study was to describe the occurrence of infected and non-infected pelvic hematoma in women following VUSLS and to assess for specific risk factors for infection. METHODS: We performed a retrospective cohort study, including all women who underwent VUSLS for treatment of apical prolapse between 2010 and 2020. Patients with and without pelvic hematoma by ultrasound were compared. A subgroup analysis compared patients with infected vs non infected hematomas. RESULTS: During the study period, 316 women underwent VUSLS for treatment of apical prolapse. Sixty-six (20.9%) were diagnosed with a pelvic hematoma, and in seventeen (5.4%) women the hematoma became infected. The majority (76%) of pelvic hematomas were located above the vaginal cuff. Women in the hematoma group had increased rates of hypothyroidism and concomitant anterior colporrhaphy. However, following multivariate analysis, these differences were no longer significant. Subgroup analysis comparing women with infected versus non-infected pelvic hematoma was performed. No differences were noted with respect to surgical outcomes (clinical, anatomical, or composite). Women with infected hematoma had higher rates of posterior colporrhaphy during surgery (33.3% vs 9.5%, p = 0.039). This difference remained significant following multivariate analysis (aOR = 8.87, CI 1.1-73.0). CONCLUSION: Pelvic hematoma following VUSLS is common as opposed to infected pelvic hematoma which seldom occurs. Concomitant posterior colporrhaphy was associated with infection.

Pelvic floor architectural defects in female patients with urge fecal incontinence versus passive fecal leakage: a dynamic ultrasound study.

INTRODUCTION AND HYPOTHESIS: Fecal incontinence (FI) has two primary subtypes: urgency fecal incontinence (UFI) and passive fecal leakage (PFL). The pathophysiology underlying the subtypes is incompletely understood. OBJECTIVES: To compare the bowel habits, physical examinations and pelvic floor anatomical defects in patients with UFI-dominant FI versus patients with PFL-dominant FI. STUDY DESIGN: This is a retrospective cross-sectional study of female patients who presented with fecal incontinence symptoms to our tertiary urogynecology center. All subjects underwent a comprehensive history, physical examination, 3D-static pelvic floor ultrasound, and 2D-dynamic ultrasound of the posterior compartment. Patients with UFI-dominant FI were compared to patients with PFL-dominant FI. RESULTS: One hundred forty-five patients were included in the analysis; 57 categorized as UFI-dominant FI, 69 PFL-dominant FI and 19 categorized as having "both" leakage patterns. In comparing bowel habits, patient with UFI-dominant FI had more frequent bowel movements (15.5 ± SD 13.0/week vs. 10.9 ± SD 7.6 /week, p = 0.022) and were more likely to have loose stools (48.2% vs. 26.1%, p = 0.01). No statistically significant differences were observed in the prevalence of external anal sphincter defect (11.3% vs. 17.2%, p = 0.38) or internal anal sphincter defect (11.3% vs. 19%, p = 0.26) between groups. Finally, patients with UFI-dominant FI had a higher incidence of rectal hypermobility (loss of rectal support on Valsalva) (58% vs. 36.9%, p = 0.025). CONCLUSION: Patients with urge-predominant FI have increased frequency of bowel movements, looser stools, and increased rectal folding diagnosed via dynamic ultrasound as compared to patients with passive-dominant FI.