Body image in the Pelvic Organ Prolapse Questionnaire: development and validation.

OBJECTIVE: The purpose of this study was to develop and validate a prolapse-specific body image questionnaire. STUDY DESIGN: Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability. RESULTS: Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbach's α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high. CONCLUSION: We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.

Changes in prolapse surgery trends relative to FDA notifications regarding vaginal mesh.

INTRODUCTION AND HYPOTHESIS: In 2008 and 2011, the US Food and Drug Administration (FDA) released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native tissue repairs would increase. METHODS: Operative reports were reviewed for all prolapse repairs performed from 2008 to 2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of two FDA notifications. We used linear regression to analyze surgical trends and chi-square for demographic comparisons. RESULTS: One thousand two hundred and eleven women underwent 1,385 prolapse procedures. Mean age was 64 ± 12, and 70 % had stage III prolapse. Vaginal mesh procedures declined over time (p = 0.001), comprising 27 % of repairs in early 2008, 15 % at the first FDA notification, 5 % by the second FDA notification, and 2 % at the end of 2011. The percentage of native tissue anterior/posterior repairs (p < 0.001) and apical suspensions (p = 0.007) increased, whereas colpocleisis remained constant (p = 0.475). Despite an overall decrease in open sacral colpopexies (p < 0.001), an initial increase was seen around the first FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter (p < 0.001). All sacral colpopexies combined as a group declined over time (p = 0.011). CONCLUSIONS: Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing two FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native tissue repairs and minimally invasive sacral colpopexies.

Managing mesh exposure following vaginal prolapse repair: a decision analysis comparing conservative versus surgical treatment.

INTRODUCTION AND HYPOTHESIS: A decision analysis model was developed comparing conservative and surgical treatments in the management of synthetic mesh exposure following vaginal prolapse repair. We hypothesized that surgical excision would be favored. METHODS: A Markov decision analysis model compared initial management with conservative versus surgical treatment allowing for the complexities of multiple attempts at conservative management and/or surgical mesh excision. Model assumptions were obtained from published literature or through surrogate values and expert consensus when not available in published resources. Transitions were made between Markov states at 6-week intervals and overall utility was compared over 2 years. Multiple one-way sensitivity analyses were performed. RESULTS: Initial surgical excision was favored, with an average yearly quality adjusted life year (QALY) value of 0.947 compared to 0.939 for conservative treatment. This difference is less than the published minimally important difference (MID) for utility values. One-way sensitivity analyses revealed that surgical excision is favored when the probability of being healed with conservative therapy is less than 80 % (base case 57.1 %) and when the probability of being healed from surgery is greater than 78 % (base case 93.2 %). Few thresholds confirmed model robustness. CONCLUSIONS: While our model favored surgical excision over conservative treatment in the initial management of mesh exposure following vaginal prolapse repair with synthetic mesh, the difference in QALYs between strategies was less than the MID. Therefore the strategies are likely similar overall. Individual patient characteristics may ultimately drive clinical decision-making for this surgical complication.

The Emotional Burden of Pelvic Organ Prolapse in Women Seeking Treatment: A Qualitative Study.

OBJECTIVE: We aimed to qualitatively describe the emotional burden experienced by women seeking treatment for prolapse. We hypothesized that the condition of prolapse would have an impact on women's emotional well-being. METHODS: Women with stage II or greater symptomatic prolapse participated in focus groups or individual phone interviews. A trained facilitator conducted semi-structured focus groups and interviews. These were audio-taped and transcribed. Two authors coded transcripts and identified themes using an "editing" approach. The codebook was amended until no new major themes emerged from the data. RESULTS: Forty-four women participated (25 in focus groups and 19 in phone interviews). Mean (SD) age of women was 60 (10) years and mean (SD) prolapse leading edge was 3 (2) cm. Analysis revealed the following 3 main themes: (1) emotions associated with the condition of prolapse (minimal emotions, annoyance, irritation, frustration, anger, sadness, anxiety, depression), (2) communicating emotions related to prolapse (to friends, family, healthcare providers), and (3) emotions relating to treatment (both positive and negative effects). CONCLUSIONS: Prolapse significantly impacts women's emotional health and subjective well-being. An improved understanding of women's emotional experiences of prolapse may help providers better meet patients' needs.

Regional differences in rat vaginal smooth muscle contractility and morphology.

The objective of this study was to define the regional differences in rat vaginal smooth muscle contractility and morphology. We evaluated circumferential segments from the proximal, middle, and distal rat vagina (n = 21) in vitro. Contractile responses to carbachol, phenylephrine, potassium chloride, and electrical field stimulation (EFS) were measured. Immunohistochemical analyses were also performed. The dose-response curves for carbachol- and phenylephrine-dependent contractions were different in the distal (P = .05, P = .04) compared to the proximal/middle regions. Adjusted for region-dependent changes in contractility, the distal vagina generated lower force in response to carbachol and higher force in response to phenylephrine. There was less force with increasing EFS frequency in the distal (P = .03), compared to the proximal/middle regions. Cholinergic versus adrenergic nerves were more frequent in the proximal region (P = .03). In summary, the results indicate that functional and morphological differences in smooth muscle and nerve fibers of the distal versus proximal/middle regions of the vagina exist.

Teaching techniques in the operating room: the importance of perceptual motor teaching.

PURPOSE: To identify sucessful teaching techniques in the operating room environment through examining the teaching of the midurethral sling (MUS) surgery. METHOD: The authors distributed questionnaires with open-ended questions about teaching and learning MUS to 5 urogynecology attendings and 16 obstetrics-gynecology residents in spring 2010. In an effort to identify qualities of an effective sling teacher, the authors used grounded theory to determine common themes and to code participant responses for examples. RESULTS: Of 21 potential respondents, 14 (67%) returned questionnaires. The authors analyzed these and identified seven commonalities among effective sling teachers: they (1) emphasize anatomical landmarks (as determined by 64 total comments); (2) use perceptual-motor teaching (PMT; 38 comments); (3) encourage repetition (28); (4) promote early independence (34); (5) demonstrate confident competence (23); (6) maintain a calm demeanor in the operating room (20); and (7) exhibit a willingness to accept responsibility for mistakes and consequences (9). The second-most common attribute, using PMT, requires the teaching attending to emphasize the motor and tactile aspects of operating and involves incorporating not only what learners see but also what they feel. CONCLUSIONS: The authors report seven qualities or techniques fundamental to good teaching practice in a high-stress, high-technology surgical environment, and they have identified the use of PMT, which to their knowledge has not been previously described. Teachers and learners in this study characterized PMT, which is likely generalizable to surgical procedures other than the MUS, as important. Future research should focus on exploring this technique in other surgeries.

Use of composite grafts in abdominal sacrocolpopexy.

OBJECTIVE: : The ideal graft material for pelvic reconstructive surgery remains undetermined. The purpose of this study was to present data on novel composite biologic/synthetic grafts during use in abdominal sacrocolpopexy. METHODS: : A case series of 90 patients undergoing abdominal sacrocolpopexy with composite biologic/synthetic grafts was conducted. The primary outcome was graft erosion. Assuming a 3% risk of reoperation for mesh erosion, the number needed to treat with a composite graft in order to avoid erosion risk from a synthetic-only graft was calculated. The cost of a composite graft was compared to reoperation costs for mesh erosion of a synthetic-only graft. RESULTS: : Zero patients (N = 90) undergoing abdominal sacrocolpopexy with a composite biologic/synthetic graft experienced graft erosion. Based on existing data, thirty-three patients would need to be treated with a composite graft to avoid one mesh erosion from a synthetic-only graft. If a $500 composite graft is used, the cost of reoperation performed abdominally is higher. CONCLUSIONS: : This study introduces a novel biologic/synthetic composite graft that offers the advantage of low erosion risk during use in abdominal sacrocolpopexy. Combined grafts may also be cost-effective. Future research should focus on exploring the role of these durable, yet low erosion risk grafts to potentially promote improved safety for our patients and cost savings for society.