RESUMO
INTRODUCTION AND HYPOTHESIS: Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission. METHODS: The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities. RESULTS: The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors. CONCLUSION: The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.
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Currículo , Grupos Focais , Ginecologia , Urologia , Ginecologia/educação , Urologia/educação , Humanos , Bolsas de Estudo , Sociedades Médicas , FemininoRESUMO
INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the differences in the incidence of peri-operative complications at the time of pelvic organ prolapse (POP) repair based on health care disparities such as race and socioeconomic status. METHODS: The National Inpatient Sample (NIS) database was queried using ICD-9/-10 codes for patients aged >18 years undergoing POP repair in 2008-2018. Demographic information, Elixhauser Comorbidity Index (ECI), insurance status, and peri-operative complications were extracted. Multivariate weighted logistic regression using the discharge weights from NIS were constructed on binary outcomes. Complications with at least 1% incidence were included in the analysis. RESULTS: A total of 172,483 POP repair patients were analyzed: 130,022 (75.4%) were white, 10,561 (6.1%) were Black, 21,915 (12.7%) were Hispanic, and 9,985 (5.8%) were of other races. Patients with Medicaid as well as Black, Hispanic, and other races had higher odds of developing postoperative complications such as urinary tract infections, sepsis, and acute renal failure (p value <0.001-0.02). These were also more common in smaller, rural hospitals and with patients with an annual income of $45,999 or less (p value <0.001-0.03). Black and Hispanic patients had lower odds of intraoperative complications such as hemorrhage (aOR 0.77, 95% CI 0.71-0.84; aOR 0.75, 95% CI 0.7-0.8 respectively) or abdominopelvic injury (aOR 0.86, 95% CI 0.81-0.92; aOR 0.93, 95% CI 0.79-0.88 respectively) compared with white patients. CONCLUSION: Nonwhite patients with lower socioeconomic status had increased postoperative complications and fewer intraoperative complications from POP surgery, whereas white patients with higher socioeconomic status had more intraoperative complications.
Assuntos
Disparidades em Assistência à Saúde , Prolapso de Órgão Pélvico , Humanos , Hispânico ou Latino , Complicações Intraoperatórias , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Baixo Nível Socioeconômico , Negro ou Afro-AmericanoRESUMO
INTRODUCTION AND HYPOTHESIS: The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans. METHODS: A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type. RESULTS: A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size. CONCLUSIONS: Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.
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Distúrbios do Assoalho Pélvico , Prolapso de Órgão Pélvico , Incontinência Urinária , Feminino , Humanos , Distúrbios do Assoalho Pélvico/complicações , Estudos Retrospectivos , Incontinência Urinária/complicações , Atenção à Saúde , Prolapso , Prolapso de Órgão Pélvico/complicações , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Women consider preservation of sexual activity and improvement of sexual function as important goals after pelvic organ prolapse surgery. This systematic review aimed to compare sexual activity and function before and after prolapse surgery among specific approaches to pelvic organ prolapse surgery including native tissue repairs, transvaginal synthetic mesh, biologic grafts, and sacrocolpopexy. DATA SOURCES: MEDLINE, Embase, and ClinicalTrials.gov databases were searched from inception to March 2021. STUDY ELIGIBILITY CRITERIA: Prospective comparative cohort and randomized studies of pelvic organ prolapse surgeries were included that reported the following specific sexual function outcomes: baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Notably, the following 4 comparisons were made: transvaginal synthetic mesh vs native tissue repairs, sacrocolpopexy vs native tissue repairs, transvaginal synthetic mesh vs sacrocolpopexy, and biologic graft vs native tissue repairs. METHODS: Studies were double screened for inclusion and extracted for population characteristics, sexual function outcomes, and methodological quality. Evidence profiles were generated for each surgery comparison by grading quality of evidence for each outcome across studies using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: Screening of 3651 abstracts was performed and identified 77 original studies. The overall quality of evidence was moderate to high. There were 26 studies comparing transvaginal synthetic mesh with native tissue repairs, 5 comparing sacrocolpopexy with native tissue repairs, 5 comparing transvaginal synthetic mesh with sacrocolpopexy, and 7 comparing biologic graft with native tissue repairs. For transvaginal synthetic mesh vs native tissue repairs, no statistical differences were found in baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, persistent dyspareunia, and de novo dyspareunia. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form change scores were not different between transvaginal synthetic mesh and native tissue repairs (net difference, -0.3; 95% confidence interval, -1.4 to 0.8). For sacrocolpopexy vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, de novo dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form score differences were not different. For biologic graft vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form changes were also not different. For transvaginal synthetic mesh vs sacrocolpopexy, there was no difference in sexual activity and sexual function score change. Based on 2 studies, postoperative total dyspareunia was more common in transvaginal synthetic mesh than sacrocolpopexy (27.5% vs 12.2%; odds ratio, 2.72; 95% confidence interval, 1.33-5.58). The prevalence of postoperative dyspareunia was lower than preoperative dyspareunia after all surgery types. CONCLUSION: Sexual function comparisons are most robust between transvaginal synthetic mesh and native tissue repairs and show similar prevalence of sexual activity, de novo dyspareunia, and sexual function scores. Total dyspareunia is higher after transvaginal synthetic mesh than sacrocolpopexy. Although sexual function data are sparse in the other comparisons, no other differences in sexual activity, dyspareunia, and sexual function score change were found.
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Dispareunia/etiologia , Procedimentos Cirúrgicos em Ginecologia , Prolapso de Órgão Pélvico/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Complicações Pós-Operatórias , Telas CirúrgicasRESUMO
INTRODUCTION AND HYPOTHESIS: Uterosacral ligament suspension surgery is commonly utilized to correct post-hysterectomy vaginal vault prolapse (VVP). Vaginal intraperitoneal uterosacral vault suspension (IUSVS) is a viable option, but intraperitoneal access can be challenging. An alternative approach is an extraperitoneal uterosacral vault suspension (EUSVS). The aim of our study was to compare surgical outcomes of IUSVS and EUSVS in patients with post-hysterectomy VVP. METHODS: Retrospective cohort study of women who underwent treatment of post-hysterectomy VVP with an IUSVS and EUSVS from May 2016 to January 2019 at our institution. The primary outcome was surgical success that was assessed by a composite outcome for surgical failure, defined as ANY of the following: (1) apical descent > 1/3 of the TVL or anterior or posterior vaginal wall beyond the hymen, (2) retreatment of prolapse, or (3) bothersome vaginal bulge symptoms with a positive response to either of two questions on the PFDI questionnaire. Secondary outcomes included EBL, operative time, duration of hospitalization, and perioperative complications. Two-sample t-tests and chi-square tests were used for the bivariate analysis. RESULTS: Eighty patients were included (36 IUSVS and 44 EUSVS) with a mean follow-up of 7 months. For our primary outcome, there was no difference in surgical success (IUSVS group 72.22% vs. EUSVS group 81.82%, p = 0.307). Operative time, duration of hospitalization, and EBL were significantly less in the EUSVS group than in the IUSVS group. CONCLUSIONS: EUSVS demonstrated similar short-term success compared to IUSVS for post-hysterectomy VVP, with shorter operative time, EBL, and length of stay.
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Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/etiologia , Prolapso de Órgão Pélvico/cirurgia , Estudos Retrospectivos , Suspensões , Resultado do Tratamento , Vagina/cirurgiaRESUMO
INTRODUCTION AND HYPOTHESIS: This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018. METHODS: The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes. RESULTS: We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12. CONCLUSION: Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery.
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Prolapso de Órgão Pélvico , Incontinência Urinária , Feminino , Humanos , Prolapso de Órgão Pélvico/cirurgia , Estudos Prospectivos , Comportamento Sexual , Inquéritos e Questionários , Vagina/cirurgiaRESUMO
AIMS: The aim is to assess whether subjects with diabetes mellitus (DM) have greater urinary retention and increased post-void residual volume (PVR) following mid-urethral sling (MUS) surgery. METHODS: This multi-center retrospective study included patients who underwent MUS (2012-2016). Baseline data included demographics, comorbidities, urinary symptoms, urodynamics data, PVR, and responses to validated questionnaires (UDI6 and IIQ7). Intraoperative data, postoperative voiding trial results, postop questionnaires, and complications were also noted. Patients with and without DM were compared. Significance was defined as P < .05. RESULTS: A total of 605 MUS were included, 538(89%) without DM and 67(11%) with DM, of which 69% were transobturator and 31% retropubic. No differences were seen in urinary retention and passing void trial(79% DM vs 81% non-DM; P = .72). Mean PVR at discharge was similar between groups (136 mL DM vs 139 mL non-DM; P = .922). There were no differences between groups in UDI6 and IIQ7 sum scores at baseline and 1 month. DM subjects reported more bother at baseline on certain UDI-6 and IIQ-7 items including frequent urination, leakage related to urgency, and feeling frustrated. At 3 months postop, all subjects demonstrated improvement in scores. Interestingly, patients with DM reported worse quality of life on the IIQ7 sum. CONCLUSIONS: Among subjects with well-controlled diabetes and more comorbidities who underwent MUS there were few differences in postoperative voiding dysfunction or PVR compared to nondiabetic women. DM patients were more bothered at baseline by urge-related symptoms. Quality of life following sling surgery appears to be worse in patients with DM at 3 months based on IIQ7. This data suggests that diabetic women with lower HbA1C can be counseled similarly to these complication rates and voiding dysfunction after MUS.
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Complicações do Diabetes , Slings Suburetrais , Incontinência Urinária/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do Tratamento , Bexiga Urinária/fisiopatologia , Incontinência Urinária/fisiopatologia , Urodinâmica , Procedimentos Cirúrgicos UrológicosRESUMO
INTRODUCTION AND HYPOTHESIS: The COVID-19 pandemic and the desire to "flatten the curve" of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic. METHODS: We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19. RESULTS: Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission. CONCLUSIONS: We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.
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Infecções por Coronavirus/prevenção & controle , Doenças Urogenitais Femininas/terapia , Ginecologia/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Telemedicina/métodos , Betacoronavirus , COVID-19 , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Feminino , Doenças Urogenitais Femininas/virologia , Humanos , Controle de Infecções/métodos , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , SARS-CoV-2RESUMO
This case presents the work-up and management of a spina bifida patient with recurrent prolapse. Four international experts also provide their evaluation of and approach to this complex case. According to the literature, little is known regarding the approach to the management of this specific patient population.
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Obesidade Mórbida/complicações , Prolapso de Órgão Pélvico/complicações , Prolapso de Órgão Pélvico/cirurgia , Disrafismo Espinal/complicações , Adulto , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Procedimentos de Cirurgia Plástica/métodos , Recidiva , Telas CirúrgicasRESUMO
INTRODUCTION AND HYPOTHESIS: We aimed to systematically review the literature on pelvic organ prolapse (POP) surgery with uterine preservation (hysteropexy). We hypothesized that different hysteropexy surgeries would have similar POP outcomes but varying adverse event (AE) rates. METHODS: MEDLINE, Cochrane, and clinicaltrials.gov databases were reviewed from inception to January 2018 for comparative (any size) and single-arm studies (n ≥ 50) involving hysteropexy. Studies were extracted for participant characteristics, interventions, comparators, outcomes, and AEs and assessed for methodological quality. RESULTS: We identified 99 eligible studies: 53 comparing hysteropexy to POP surgery with hysterectomy, 42 single-arm studies on hysteropexy, and four studies comparing stage ≥2 hysteropexy types. Data on POP outcomes were heterogeneous and usually from <3 years of follow-up. Repeat surgery prevalence for POP after hysteropexy varied widely (0-29%) but was similar among hysteropexy types. When comparing sacrohysteropexy routes, the laparoscopic approach had lower recurrent prolapse symptoms [odds ratio (OR) 0.18, 95% confidence interval (CI) 0.07-0.46), urinary retention (OR 0.05, 95% CI 0.003-0.83), and blood loss (difference -104 ml, 95% CI -145 to -63 ml) than open sacrohysteropexy. Laparoscopic sacrohysteropexy had longer operative times than vaginal mesh hysteropexy (difference 119 min, 95% CI 102-136 min). Most commonly reported AEs included mesh exposure (0-39%), urinary retention (0-80%), and sexual dysfunction (0-48%). CONCLUSIONS: Hysteropexies have a wide range of POP recurrence and AEs; little data exist directly comparing different hysteropexy types. Therefore, for women choosing uterine preservation, surgeons should counsel them on outcomes and risks particular to the specific hysteropexy type planned.
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Procedimentos Cirúrgicos em Ginecologia/métodos , Tratamentos com Preservação do Órgão/métodos , Prolapso de Órgão Pélvico/cirurgia , Útero/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Histerectomia , Duração da Cirurgia , Tratamentos com Preservação do Órgão/efeitos adversos , Tratamentos com Preservação do Órgão/instrumentação , Recidiva , Reoperação , Disfunções Sexuais Fisiológicas/etiologia , Telas Cirúrgicas/efeitos adversos , Retenção Urinária/etiologiaRESUMO
OBJECTIVE: We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines. DATA SOURCES: The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017. STUDY ELIGIBILITY CRITERIA: We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS: Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed. RESULTS: We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation. CONCLUSION: Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.
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Histerectomia/métodos , Tratamentos com Preservação do Órgão/métodos , Prolapso de Órgão Pélvico/cirurgia , Perda Sanguínea Cirúrgica , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Histerectomia Vaginal , Laparoscopia , Tempo de Internação , Duração da Cirurgia , Dor Pós-Operatória , Guias de Prática Clínica como Assunto , Qualidade de Vida , Procedimentos de Cirurgia Plástica/métodos , Recidiva , Reoperação , Telas Cirúrgicas , Resultado do Tratamento , Vagina/cirurgiaRESUMO
BACKGROUND: The American Congress of Obstetricians and Gynecologists recommends that "the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy," resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy. OBJECTIVE: The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms. STUDY DESIGN: This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow-up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and χ2 test when appropriate. Questionnaire scores were compared using paired t tests. RESULTS: Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5-5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5-22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001). CONCLUSION: Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible.
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Histerectomia Vaginal/métodos , Neoplasias Ovarianas/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Profiláticos/métodos , Salpingectomia/métodos , Adulto , Perda Sanguínea Cirúrgica , Estudos de Viabilidade , Feminino , Humanos , Leiomioma/cirurgia , Menorragia/cirurgia , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Neoplasias Uterinas/cirurgia , Prolapso Uterino/cirurgiaRESUMO
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.
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Informação de Saúde ao Consumidor/estatística & dados numéricos , Internet/estatística & dados numéricos , Distúrbios do Assoalho Pélvico , Rede Social , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Distúrbios do Assoalho Pélvico/cirurgia , Ferramenta de Busca/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos , Adulto JovemRESUMO
INTRODUCTION: To determine the significance of bladder trabeculations seen on preoperative cystoscopy prior to midurethral sling surgery with respect to lower urinary tract symptoms and sling outcomes. MATERIALS AND METHODS: This retrospective study included women with preoperative cystoscopy who underwent midurethral slings for urinary incontinence from 2006-2009. Cystoscopic findings of bladder trabeculations, as well as pre and postoperative urinary symptoms were recorded. Patients with and without bladder trabeculations were compared with respect to baseline characteristics, lower urinary tract symptoms, and sling outcomes. RESULTS: Of the 241 women included in the study, 14.9% had trabeculations on preoperative cystoscopy. At baseline, women with trabeculations were more likely to be older (64.8 years versus 57.8 years, p < 0.01), and have lower mean maximum cystometric capacity (341 mL +/- 136 versus 436 mL +/- 148, p < 0.01), compared to those without trabeculations. More women with trabeculations had mixed incontinence (p < 0.01) and less pure stress incontinence (p < 0.01) preoperatively. There was no difference between women with and without trabeculations with respect to pre and postoperative symptoms of urgency, frequency, and nocturia. Women with preoperative trabeculations were more likely to have preoperative treatment with anticholinergics (p = 0.02) and had a three times higher risk of postoperative sling failure (HR 2.95 [CI 1.11-7.85], p = 0.03). CONCLUSIONS: Preoperative cystoscopic bladder trabeculations are associated with significantly higher rate of midurethral sling failure. Trabeculations were not associated with pre or postoperative lower urinary tract symptoms.
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Músculo Liso/patologia , Falha de Prótese , Slings Suburetrais , Bexiga Urinária/patologia , Incontinência Urinária por Estresse/cirurgia , Incontinência Urinária de Urgência/cirurgia , Fatores Etários , Idoso , Antagonistas Colinérgicos/uso terapêutico , Cistoscopia , Feminino , Humanos , Hipertrofia/complicações , Pessoa de Meia-Idade , Tamanho do Órgão , Período Pré-Operatório , Estudos Retrospectivos , Slings Suburetrais/efeitos adversos , Resultado do Tratamento , Incontinência Urinária por Estresse/complicações , Incontinência Urinária de Urgência/complicaçõesRESUMO
IMPORTANCE: OnabotulinumtoxinA (BTX-A) is an effective treatment for overactive bladder (OAB), but few studies have been done to evaluate injection techniques. OBJECTIVE: The primary objective was to evaluate procedural discomfort between 2 commonly used injection techniques for BTX-A. STUDY DESIGN: This was a single-blinded, randomized clinical trial of women undergoing injection of 100 U BTX-A for idiopathic OAB. Patients were randomized to 5 mL/5 injection or 10 mL/10 injection groups. Bladder pain was assessed by a validated Numeric Pain Rating Scale. Overactive bladder symptoms were assessed with a standardized questionnaire (Overactive Bladder Questionnaire Short Form). Patient satisfaction, treatment efficacy, and adverse events were assessed at 30 days after procedure. RESULTS: One hundred eight patients were randomized to 52 in the 5 mL/5 injection arm and 56 in the 10 mL/10 injection arm. Mean procedural pain scores were 3.2 (±2.3) in the 5 mL/5 injection group versus 3.6 (±2.1) in the 10 mL/10 injection group (P = 0.21). No difference was found when categorizing pain scores into ordinal outcomes of low (P = 0.55), medium (P = 0.70), and high (P = 1.0) or a binary outcome of low (P = 0.55) versus medium + high (P = 0.55). Multivariate analyses did not effect statistical significance between the 2 groups for the ordinal outcome (odds ratio = 1.86; 95% confidence interval = 0.77 = 4.52; P = 0.17) or the binary outcome (odds ratio = 1.81; 95% confidence interval = 0.68-4.77; P = 0.28). No difference was observed between overall patient satisfaction, global impression of improvement, Overactive Bladder Questionnaire Short Form scores, or adverse outcomes. CONCLUSIONS: Procedural discomfort related to BTX-A injection for idiopathic OAB was not different between 2 injection protocols. Overall satisfaction was high for both groups, and there was no difference in symptom scores or adverse events.
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Toxinas Botulínicas Tipo A , Bexiga Urinária Hiperativa , Humanos , Feminino , Bexiga Urinária Hiperativa/tratamento farmacológico , Toxinas Botulínicas Tipo A/efeitos adversos , Resultado do Tratamento , Satisfação do Paciente , Dor Pélvica/induzido quimicamenteRESUMO
OBJECTIVE: To assess and compile the current level of evidence regarding successful surgical treatment of vesicovaginal fistulae and how these perioperative interventions affect anatomic, patient-centered, and adverse outcomes. DATA SOURCES: PubMed and EMBASE were searched from inception through September 9, 2022. METHODS OF STUDY SELECTION: This review included comparative studies (of any sample size) and single-group studies (1,000 or more participants) of primary or recurrent vesicovaginal fistula (ie, vesicovaginal fistula, urethrovaginal fistula, and bladder neck-vaginal fistula). We evaluated preintervention assessment or management, various techniques for intraoperative management, and postoperative management. Outcomes of interest included anatomic and objective outcomes (such as successful repair, fistula closure, urinary incontinence, recurrent fistula, perioperative complications) and subjective outcomes (such as voiding symptoms and quality of life). Abstracts and full-text articles were screened in duplicate, and study descriptions and findings were extracted into standardized extraction forms. Risk of bias was assessed independently by two investigators and adjudicated by a third. Study quality was summarized with standardized tools. We conducted random-effects model and restricted maximum-likelihood meta-analyses of relative risks when at least three studies compared similar interventions and reported similar outcome measures. TABULATION, INTEGRATION, AND RESULTS: Forty-six studies met the inclusion criteria. Studies were categorized into 11 domains: 1) preoperative assessment, 2) preoperative and postoperative physical therapy, 3) route of surgery, 4) incorporation of a flap, 5) trimming, 6) layered closure, 7) intraoperative antibiotics, 8) fibrin glue, 9) fascial sling, 10) postoperative Foley catheter duration, and 11) quality of life. Although the strength of the data is insufficient, preoperative phenazopyridine, physical therapy, layered closure, and intraoperative antibiotics seemed to improve the rate of successful fistula repair. Route of surgery (vaginal vs abdominal laparotomy) was determined primarily by surgeon preference and showed no difference in successful fistula repair. In addition, use of interpositional flaps, trimming fistula edges, fibrin glue, and fascial sling did not show significant improvement in rates of fistula cure. Overall, quality-of-life scores improved postoperatively regardless of route of repair and use of interpositional flaps. CONCLUSION: Our findings highlight the limited information available to guide evidence-based treatment of vesicovaginal fistula repair. Overall, high-quality evidence is lacking to provide guidelines; therefore, expert opinion remains the primary influence for fistula repair recommendations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021214948.
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Fístula Vesicovaginal , Feminino , Humanos , Antibacterianos , Adesivo Tecidual de Fibrina , Qualidade de Vida , Bexiga Urinária , Fístula Vesicovaginal/cirurgiaRESUMO
OBJECTIVE: To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. DATA SOURCES: PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. METHODS OF STUDY SELECTION: This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. TABULATION, INTEGRATION, AND RESULTS: The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. CONCLUSION: Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021233300.
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Histerectomia Vaginal , Histerectomia , Laparoscopia , Humanos , Feminino , Histerectomia Vaginal/métodos , Histerectomia Vaginal/efeitos adversos , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , Laparoscopia/métodos , Laparoscopia/efeitos adversos , Útero/cirurgia , Duração da Cirurgia , Doenças Uterinas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Salpingo-Ooforectomia/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. DATA SOURCES: We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. METHODS OF STUDY SELECTION: Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. TABULATION, INTEGRATION, AND RESULTS: The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. CONCLUSION: Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022327490.
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Procedimentos Cirúrgicos em Ginecologia , Vagina , Humanos , Feminino , Vagina/cirurgia , Procedimentos Cirúrgicos em Ginecologia/métodos , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Duração da Cirurgia , Histerectomia Vaginal/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Cirurgia Endoscópica por Orifício Natural/instrumentaçãoRESUMO
OBJECTIVE: To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES: PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION: In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION: Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022326255.
Assuntos
Índice de Massa Corporal , Obesidade , Prolapso de Órgão Pélvico , Humanos , Feminino , Obesidade/complicações , Obesidade/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Resultado do Tratamento , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologiaRESUMO
INTRODUCTION AND HYPOTHESIS: The objective was to determine the effect of uterine fibroid embolization (UFE) on lower urinary tract symptoms (LUTS) and quality of life (QoL). METHODS: This prospective study included women with symptomatic fibroids and LUTS who underwent UFE between March 2008 and May 2010. Subjects underwent pre-procedural pelvic magnetic resonance imaging (MRI) and completed the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Prolapse and Incontinence Sexual Questionnaire (PISQ-12), Uterine Fibroid Symptom Quality of Life questionnaire (UFS-QoL), and a standardized 48-h bladder diary at baseline and 3 months after the procedure. Patient Global Impression of Improvement (PGI-I) assessed post-procedural patient satisfaction. The primary outcome was subjective improvement in LUTS at 3 months, as measured by a decrease in UDI-6 score. Univariate analysis, paired t test and a stepwise regression analysis were appropriately conducted. RESULTS: Fifty-seven patients underwent UFE and completed bladder diaries and questionnaires. At 3 months after UFE, patients reported a significant decrease in UDI-6, IIQ-7, and UFS-QoL, indicating an improvement in urinary symptoms and QoL. Bladder diaries showed a significant reduction in daytime and night-time voids. No difference was found in incontinence episodes. Uterine volume, dominant fibroid size, fibroid location, and MRI-confirmed bladder compression did not affect the difference in UDI-6 scores. In a stepwise regression model, BMI had a significant impact on the change in UDI-6 score, with a decrease of 1.18 points for each 1 unit increase in BMI. CONCLUSION: Uterine fibroid embolization significantly improves LUTS and urinary-related QoL. Obesity seems to attenuate this effect.