Does a Preoperative Bowel Regimen Change Time to Bowel Movement? A Randomized Clinical Trial.

IMPORTANCE: This study is important because it aimed to assess an intervention to decrease patient discomfort after a robotic sacral colpopexy. OBJECTIVE: Our primary outcome was to determine whether preoperative use of polyethylene glycol decreases time to first bowel movement postoperatively. Secondary outcomes include degree of pain with first bowel movement and stool consistency. STUDY DESIGN: This was a randomized controlled trial. The experimental group was assigned polyethylene glycol daily for 7 days before surgery and the control group was not. All patients received polyethylene glycol postoperatively. RESULTS: There was no statistically significant reduction in the time to first postoperative bowel movement when preoperative polyethylene glycol was used (mean [SD] in days for the control and experimental groups of 2.32 [0.99] and 1.96 [1.00], P = 0.21). There was a statistically significant reduction in pain levels with the first postoperative bowel movement in the experimental group (median [IQR] of 4 [2-5] vs 1 [0-2], P = 0.0007). Postoperative day 1 pain levels were also significantly lower in the experimental group (median [IQR] of 4 [3-6] vs 2 [0-4], P = 0.0484). In addition, patients had decreased average postoperative pain levels over 7 days with an estimated difference in the median pain levels of 1.88 units (95% confidence interval, 0.64-3.12; P = 0.0038). CONCLUSIONS: Preoperative administration of polyethylene glycol did not decrease time to first postoperative bowel movement. Patients in the experimental group exhibited less pain with their first postoperative bowel movement and had improved pain levels on postoperative day 1.

Dynamic, High-Fidelity, 3-Dimensional Pelvic Model Improves Education on Pelvic Organ Prolapse and the Pelvic Organ Prolapse Quantification System and Interest in Urogynecology.

IMPORTANCE: Pelvic organ prolapse (POP) affects millions of women globally. Still, medical students and obstetrics and gynecology residents gain minimal exposure to POP during training. OBJECTIVES: Our goal was to increase exposure to POP by creating a high-fidelity, dynamic, 3-dimensional pelvic model of prolapse and using it to teach through didactic learning sessions. STUDY DESIGN: This was a prospective cohort study from November 2021 to July 2022. Presession and postsession surveys were administered to assess for change in POP knowledge both subjectively and objectively. Statistical analysis was performed using the Wilcoxon signed-rank test with a P value of 0.05 denoting significance. RESULTS: Thirty-three learners participated in the study, including 18 residents and 15 medical students. Most participants had interacted with urogynecologists and had seen at least 1 patient with POP. Fewer participants had received prior education on POP and the Pelvic Organ Prolapse Quantification (POP-Q) examination, witnessed or performed a POP-Q examination, or participated in POP surgical procedures. After learning with the model, comfort with identifying POP doubled (P < 0.001), the ability to understand the POP-Q examination quadrupled (P < 0.001), the ability to perform a POP-Q examination tripled (P < 0.001), and the ability to teach a POP-Q examination doubled (P < 0.001). The median score on a multiple-choice knowledge assessment increased by 40% (P < 0.001). Learners felt that the pelvic model was an effective teaching tool that increased interest in the field of urogynecology. CONCLUSIONS: Using a high-fidelity, dynamic model in didactic sessions enhances education about POP and the POP-Q system and should be used to improve learner exposure and experience.

A robotic approach to management of failed sacrocolpopexy and sacrocolpopexy complications: a case series.

INTRODUCTION AND HYPOTHESIS: Approximately 5% of patients pursue reoperation after sacrocolpopexy (SCP). Reasons for re-operation include recurrence of prolapse, mesh erosion, bowel and bladder dysfunction, and pain. We aim to describe patient presentation, intraoperative findings, and subsequent robotic approach to management of SCP failures and complications. METHODS: This is a case series of patients who underwent abdominal re-exploration after SCP over 7 years at a single institution. Demographic data, previous prolapse surgery, presenting complaint, prolapse stage, operative notes, and outcomes were reviewed. Nineteen patients were identified by CPT codes; ten met inclusion criteria. RESULTS: Seven of the ten patients presented with vaginal bulge, urinary frequency and urgency; four also had stress urinary incontinence. Two patients presented with vaginal bleeding and another with vaginal pain. Operative findings on reoperation for patients who had vaginal bulge included detachment from the vagina or cervix (n = 4, 57%) and the anterior longitudinal ligament (n = 3, 43%). Of these, two had their SCP mesh reattached, and five had SCP mesh removal and replacement. The patients with vaginal bleeding and pain underwent mesh excisions. All ten patients had uncomplicated postoperative courses with resolution of symptoms in most cases. CONCLUSIONS: Prolapse recurrence and complications after SCP have a significant impact on patient quality of life. Recurrent prolapse after SCP theoretically occurs because of mesh detachment from the cervix/vagina, the anterior longitudinal ligament, or disruption/stretching of the mesh. Our case series demonstrates that abdominal re-exploration is feasible and valuable in these rare cases.

Evaluation of the histological and biomechanical properties of poly-4-hydroxybutyrate scaffold for pelvic organ prolapse, compared with polypropylene mesh in a rabbit model.

INTRODUCTION AND HYPOTHESIS: Poly-4-hydroxybutyrate (P4HB) is a biopolymer produced by Escherichia coli K12 bacteria. P4HB is fully resorbed in vivo by 18-24 months post-implantation. The aim of this study is to evaluate P4HB in the rabbit abdomen and vagina to determine that the biomechanical and histological properties are similar to the standard polypropylene mesh. Our hypothesis is that the histological and biomechanical properties of a fully absorbable graft will be similar to a lightweight polypropylene (PP) mesh when implanted in rabbit vagina and abdomen. METHODS: Sixteen (n = 16) female New Zealand White (retired breeder) rabbits were equally divided between two time points (3 and 9 months). A total of 17 rabbits were used owing to one death secondary to suspected cardiomyopathy. P4HB scaffold and PP mesh were subcutaneously and peri-vaginally implanted into the rabbit abdomen and vagina respectively. All rabbits had both posterior and anterior vaginal implants, and half of the rabbits had four abdominal implants in addition to the vaginal implants. The abdominal implants were 4.5 cm long × 1.5 cm wide whereas the vaginal implants were 1.5 cm long × 0.5 cm wide. At 3 and 9 months, gross necropsy was performed and samples were obtained, sectioned, stained and evaluated via histological analysis. Specimens were assessed for host inflammatory response, neovascularization, elastin content, and collagen deposition/maturation. Specimens were also biomechanically evaluated via uniaxial tensile test to determine the stiffness, ultimate tensile strength and load at ultimate tensile strength of the device/tissue composite. RESULTS: No abdominal mesh exposures were noted. A comparable number of asymptomatic partial vaginal exposures were observed at 3 months (P4HB: n = 3; PP: n = 2) and 9 months (P4HB: n = 3; PP: n = 2) respectively. Histological analysis of specimens showed comparable results in the P4HB and PP groups at 3 and 9 months post-implantation. Although no acute inflammation was seen, chronic inflammation was demonstrated in all specimens. Elastic fibers were present in the 3-month vaginal PP and P4HB specimens, but were not seen again. There was an increase in type I/III collagen noted over time. Biomechanical evaluation of the vaginal mesh tissue complex showed ultimate tensile strength was not significantly different between P4HB and PP groups at 3 (P = 0.625) and 9 months (P = 0.250) respectively. CONCLUSIONS: P4HB scaffold may represent a fully absorbable alternative to permanent mesh for pelvic organ prolapse (POP) repair.

Rates of Pessary Self-Care and the Characteristics of Patients Who Perform it.

OBJECTIVE: The aims of this study were to determine the percentage of patients who opt to undergo pessary self-care versus those who return to the office for care and to identify any differences in the characteristics between the 2 groups. METHODS: This study is a retrospective chart review conducted at a tertiary care center. Demographic data; details regarding pessary use; body weight; pelvic organ prolapse stage; and medical, surgical, and obstetrical histories were evaluated. Variables were compared between groups of patients using the t test, Wilcoxon rank sum test, χ2 test, and Fisher exact test. RESULTS: The rate of patients choosing to perform pessary self-care was 31%. The patients in the self-care group were significantly younger (65.0 vs 75.0 years, P < 0.001). Those who were performing self-care were more likely to be premenopausal (6.9% vs 1.5%, P = 0.003), have a lower stage of pelvic organ prolapse (61.3% vs 42.1%, P < 0.001), and more likely to be sexually active (40.5% vs 9.6%, P < 0.001). Those not performing self-care had higher rates of vaginal bleeding (26.0% vs 16.4%, P = 0.012) and erosion (23.5% vs 9.9%, P < 0.001). Self-care patients predominantly used the ring with support pessary, whereas those in the non-self-care group were mostly using the Gellhorn. CONCLUSIONS: Only one third of patients who use a pessary chose to perform self-care. Patients who use self-care are younger, premenopausal, sexually active, and have lower degrees of prolapse. These data can help educate patients on the characteristics more often seen in those choosing self-care. This study highlights the importance of further exploring pessary care preferences and using this information for counseling.

The effect of collection method on urinalysis results in women with pelvic organ prolapse.

Midstream clean catch and catheterized urine specimens were obtained for each patient and samples were compared by microscopic urinalysis. The results of this study demonstrate that a midstream clean catch does not yield accurate urinalysis results in women with advanced urogenital prolapse.

Effect of prior hysterectomy on the anterior and posterior vaginal compartments of women presenting with pelvic organ prolapse.

OBJECTIVE: To describe the effects of hysterectomy on the anterior and posterior vaginal compartments and specific pelvic organ prolapsed quantification (POP-Q) data points. METHODS: In a retrospective case-control study, data were analyzed from patients presenting at a urogynecologic center in Manhasset, USA, with urogenital prolapse between January 1, 2008, and December 31, 2010. Patients who underwent hysterectomy for indications not including prolapse were compared with age- and parity-matched women without prior hysterectomy. POP-Q points were measured and converted to stages for each vaginal compartment. The t test, Wilcoxon rank sum, and Fisher exact tests were used to compare normally distributed variables, nonparametric data, and categoric variables, respectively. RESULTS: Seventy-one patients who underwent prior hysterectomy were matched to 71 patients with intact uteri. Women with prior hysterectomy had significantly greater prolapse at POP-Q point Bp and worse overall posterior compartment prolapse compared with those without prior hysterectomy. Women who underwent hysterectomy were more likely to have stage 2 or greater prolapse (OR 2.6, 95% CI, 1.3-5.2; P=0.01). CONCLUSION: When matched for age and parity, women with prior hysterectomy had significantly greater posterior compartment prolapse compared with those without. Prior hysterectomy had no significant effect on the anterior vaginal compartment.