Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery.

BACKGROUND: Nationally, there is increasing concern regarding the volume of opioid medications prescribed postoperatively and the rate of prescription opioid-related adverse events. In evaluation of this, several reports have identified significant variability in postoperative opioid-prescribing patterns, including quantities exceeding patient's needs, especially after minor surgical procedures. However, data regarding patient's postoperative opioids needs following surgery for pelvic organ prolapse are sparse. OBJECTIVE: To design procedure-specific opioid-prescribing recommendations for pelvic organ prolapse surgeries and evaluate their impact on opioid stewardship. STUDY DESIGN: We prospectively evaluated opioid-prescribing patterns, patient use, medication refills, and patient satisfaction in women undergoing prolapse surgery (ie, vaginal, abdominal, or robotic) during an 8-month time period. Two cohorts of women, stratified by whether they had surgery before or after implementation of procedure-specific opioid-prescribing recommendations, were evaluated. Postoperative opioid usage (assessed via pill count), medication refills, and satisfaction with pain management after hospital dismissal were evaluated by telephone call 2 weeks after surgery. Postoperative opioid prescribing and use were recorded after conversion to oral morphine equivalents. RESULTS: Overall, 96 women were included, 57 in the initial baseline cohort, and 39 following implementation of the prescribing recommendations. In the initial cohort, 32.8% of the prescribed oral morphine equivalents (3607/11,007 mg) were consumed. Following implementation of the prescribing recommendations, median oral morphine equivalents prescribed decreased from 200 mg oral morphine equivalents (interquartile range 150, 225) to 112.5 mg oral morphine equivalents (interquartile range 22.5, 112.5; P<.0001). The total oral morphine equivalents prescribed decreased by 45% when compared with the volume that would have been prescribed before implementing the recommendations. The amount of leftover opioids per patient significantly decreased as well (P<.0001). Pain medication refills increased after the intervention (18% vs 3.5%; P=.03), whereas satisfaction scores were similar in both cohorts (P=.87). CONCLUSIONS: By using procedure-specific opioid prescribing recommendations, we decreased the number of opioids prescribed at hospital dismissal by roughly one half. Decreased opioid prescribing did not adversely impact patient satisfaction.

Randomized controlled trial of silver-alloy-impregnated suprapubic catheters versus standard suprapubic catheters in assessing urinary tract infection rates in urogynecology patients.

INTRODUCTION AND HYPOTHESIS: Catheter-associated urinary tract infections (UTI) are the most common health-care-related infections. We aimed to compare the UTI rate among women undergoing urogynecological procedures with a silver-alloy suprapubic catheter (SPC) and a standard SPC, and identify the risk factors predisposing patients to UTI. METHODS: Patients who were to undergo placement of an SPC as part of pelvic organ prolapse surgery were enrolled between 1 August 2011 and 30 August 2017, and randomized to either standard SPC or silver-alloy SPC. Follow-up was performed at a postoperative visit or via a phone call at 6 weeks. The primary outcome was UTI. RESULTS: Of the 288 patients who were randomized, 127 with standard SPC and 137 with silver-alloy SPC were included in the analysis. Twenty-nine out of 123 women with standard SPC (23.6%) and 24 out of 131 (18.3%) with silver-alloy SPC were diagnosed with UTI within 6 weeks postoperatively (p = 0.30). In univariate analysis, non-white race (odds ratio [OR] 5.36, 95% CI 1.16-24.73) and diabetes (OR 2.80, 95% CI 1.26-6.23) were associated with increased risk of UTI. On multivariate analysis, only diabetes remained an independent risk factor. Comparisons between groups were evaluated using two-sample t test for age, Chi-squared tests for diabetes, and Wilcoxon rank sum test for all other variables. CONCLUSION: There was only a 5% difference in 6-week UTI rates between those who received standard vs silver-alloy SPC; the study was not powered to detect such a small difference. Diabetes was identified as a risk factor for SPC-associated UTI in women undergoing pelvic reconstructive surgeries.

Long-term outcomes and predictors of failure after surgery for stage IV apical pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of prolapse recurrence. METHODS: The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan-Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence. RESULTS: Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p < 0.001) and less likely to have a prior hysterectomy (39.7 vs 86.4%; p < 0.001) or prior apical prolapse repair (8.2 38.6%; p < 0.001). Median follow-up was 4.3 years [interquartile range (IQR) 1.1-7.7]. Survival free of recurrence was similar between USLS and sacrocolpopexy (p = 0.43), with 5-year rates of 88.7 and 97.6%, respectively. Younger age [adjusted hazard ratio (aHR) 1.55, 95% confidence interval (CI) 1.12-2.13; p = 0.008] and prior hysterectomy (aHR 2.8, 95% CI 1.39-5.64; p = 0.004) were associated with the risk of prolapse recurrence, whereas type of surgery approached statistical significance (aHR 2.76, 95% CI 0.80-9.60; p = 0.11). CONCLUSIONS: Younger age and history of prior hysterectomy were associated with an increased risk of recurrent prolapse symptoms. Notably, excellent survival free of prolapse recurrence were obtained with both surgical techniques.

Evaluation of the local carcinogenic potential of mesh used in the treatment of female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: To evaluate the carcinogenic potential of implanted synthetic mesh midurethral slings in the treatment of female stress urinary incontinence. METHODS: We identified female patients undergoing implantation of mesh materials for stress urinary incontinence at our institution from 1 January 2002 to 31 December 2012. This was accomplished by querying the medical records for CPT code 57288 ("sling operation for stress incontinence") and a subsequent chart review to identify patients who underwent synthetic mesh sling placement. Medical records were then evaluated for the documentation of bladder, urethral, vaginal, cervical, uterine or ovarian cancers via the International Classification of Disease (ninth edition) coding. A chart review of patients with a cancer diagnosis was performed for verification of the diagnosis and evaluation of the temporal relationship with sling placement. RESULTS: During the study period, 2,474 patients underwent polypropylene midurethral sling placement. The median age was 57 years (IQR 47, 69) and the median follow-up was 60 months (IQR 23.3, 94.9). Overall, 51 patients also had a cancer diagnosis (8 bladder cancers, 7 vaginal malignancies, 8 ovarian carcinomas, 26 endometrial cancers, 2 cervical malignancies); however, only 2 cancers (0.08 %, 2 out of 2,474) developed following sling placement (a vaginal melanoma 3 years after sling placement and an ovarian tumor 1 year after sling placement). No cases of sarcoma formation, bladder, urethral or squamous cell carcinomas were identified. CONCLUSIONS: With a median follow-up of 5 years after synthetic midurethral sling placement, development of pelvic malignancy was rare (0.08 %) and unlikely to be secondary to foreign body reaction from the implanted material.

Assessing the learning curve of robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The aim was to evaluate the learning curve of robotic sacrocolpopexy, adjusted for surgical risk. METHODS: The charts of 145 robotic sacrocolpopexies performed by urogynecologists at Mayo Clinic, Rochester, MN, USA, from 2007 to 2013, were reviewed. Outcomes of interest included operative time, intraoperative complications, and postoperative complications with a Clavien-Dindo grade 2 or higher. Risk-adjusted cumulative summation analysis was performed by comparing a calculated complication risk score with observed patient outcomes, and then cumulatively recalculating the rate of expected vs observed complications after each procedure. Proficiency was defined as the point at which the surgeon's complication rates were better than expected, given the patient's risk factors. RESULTS: The median operative time decreased significantly, from 5.3 to 3.6 h, during the 7-year period, and plateaued after the first 60 cases. A higher ASA classification was associated with an increased risk of intraoperative complications (p = 0.02), and a higher Charlson comorbidity index was associated with an increased risk of intraoperative or postoperative complications (p = 0.01). In risk-adjusted CUSUM analyses, accounting for these factors, and for body-mass index and vaginal parity, proficiency was identified at 55 cases for intraoperative complications and 84 cases for intraoperative or postoperative complications. CONCLUSIONS: Operative time plateaued after the first 60 cases, whereas complication rates continued to decrease beyond this. Proficiency, as determined by a risk-adjusted CUSUM analysis for complication rates, was achieved after approximately 84 cases. Evaluation of postoperative complications in addition to intraoperative complications, in a risk-adjusted model, is critical in depicting the surgical learning curve.

Perioperative complications of robotic sacrocolpopexy for post-hysterectomy vaginal vault prolapse.

INTRODUCTION AND HYPOTHESIS: Open abdominal sacrocolpopexy has been the preferred treatment for post-hysterectomy vaginal vault prolapse. In light of the rise in popularity of less invasive robotic sacrocolpopexy, our objective was to compare perioperative complications of robotic vs open sacrocolpopexy. METHODS: This was a single-institution, retrospective cohort study of robotic and open sacrocolpopexies. Robotic sacrocolpopexies performed between 1 January 2007 and 31 December 2009 were compared with open cases performed between 1 January 2002 and 31 December 2006. Baseline and intraoperative variables of the groups were compared. Complications were compared univariately and in a multivariable logistic regression model to adjust for prior transabdominal surgery. RESULTS: A total of 50 robotic and 87 open sacrocolpopexies were analyzed. Baseline characteristics were similar, but patients in the open group had more prior transabdominal surgeries. The robotically assisted group had decreased estimated blood loss (median, 100 mL vs 150 mL; P = 0.002) and hospital stay (median, 2 days vs 3 days; P < 0.001), but increased operative time (median, 4.6 vs 2.9 h; P < 0.001), cystotomy (10.0 % [5 out of 50] vs 1.1 % [1 out of 87]; P = 0.02), and vaginotomy (24.0 % [12 out of 50] vs 5.7 % [5 out of 87]; P = 0.003). Two patients in the robotically assisted group had postoperative hernia. There were no differences in rates of ureteral or bowel injury, urinary tract infection, ileus, bowel obstruction, or overall complications. CONCLUSIONS: Overall complication rates of robotic and open sacrocolpopexy were not significantly different. The robotically assisted group experienced shorter hospital stay but increased operative times and increased incidence of cystotomy and vaginotomy, possibly reflecting the learning curve of robotic sacrocolpopexy.

Incidence of female urethral diverticulum: a population-based analysis and literature review.

INTRODUCTION AND HYPOTHESIS: Urethral diverticulum (UD) is a protrusion of the urethra through the periurethral fascia. We aimed to determine the population-based incidence of female UD. METHODS: Using the records-linkage system of the Rochester Epidemiology Project (REP), we identified women 18 years and older with a new diagnosis of UD in Olmsted County, Minnesota, USA, from 1 January 1980, through 31 December 2011. We also identified cases meeting the same criteria diagnosed at Mayo Clinic, regardless of county of residency. Incidence rates were calculated and trends for changes in incidence over time were tested. We conducted a systematic search of the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases from inception through 30 March 2013, to identify published reports of UD incidence or prevalence. RESULTS: We identified 164 incidence cases, including 26 women residing in Olmsted County. Age-adjusted annual incidence of UD in Olmsted County was 17.9 per 1,000,000 women (<0.02 %) per year (95 % CI, 10.9-24.9). We observed a trend toward increased incidence during the past 3 decades (P = 0.03). In our literature review, only 7 studies included an estimate of incidence or prevalence of UD; these estimates ranged from 6.4 per 1,000,000 per year (<0.01 %) having surgical intervention related to UD to a 4.7 % rate of UD diagnosed in asymptomatic women admitted for gynecological or obstetric issues. CONCLUSIONS: In this population-based study, female UD was a rare disease, affecting fewer than 20 per 1,000,000 women (<0.02 %) per year.

A cohort study comparing a single-incision sling with a retropubic midurethral sling.

INTRODUCTION AND HYPOTHESIS: Despite established comparable efficacy between retropubic midurethral (RMUS) and transobturator slings, there are conflicting data regarding single-incision mini-slings (SIMS). This study tests the null hypothesis that the MiniArc® Single-Incision Sling is equivalent to the ALIGN® Urethral Support System for treatment of stress urinary incontinence (SUI). METHODS: Women who underwent a sling for SUI from 1 January 2008 through 31 December 2009 were identified (N = 324). A follow-up survey was mailed. Primary outcomes were treatment failure, defined as International Consultation on Incontinence Questionnaire (ICIQ) score >0 or additional anti-incontinence procedure, and stress-specific incontinence (SSI). Secondary outcomes included Patient Global Impression of Severity and Improvement (PGI-SI), satisfaction, de novo urge, and complications. RESULTS: The study included 202 women who returned the survey. The SIMS group had higher body mass index (BMI) (30.7 ± 6.5 vs 28.9 ± 6.0 kg/m(2), P = 0.052) and shorter follow-up (18.6 ± 11.5 vs 22.9 ± 14.6 months, P = 0.019). Treatment failure was higher in SIMS compared with RMUS (76.3 % vs 64.2 %) with adjusted odds ratio of 1.84 (95 % CI, 1.0, 3.5). The SIMS group was more likely to have postoperative SSI, with adjusted OR of 2.4 (95 % CI; 1.3-4.5). The RMUS group reported more improvement and satisfaction. Incidence of de novo urge and complications were similar between groups. Reoperation for mesh erosion was more likely in the RMUS group, while the SIMS had a higher reoperation rate for SUI. CONCLUSIONS: Compared with retropubic ALIGN® Slings, MiniArc® Single-Incision Slings are less effective, with more postoperative incontinence, less patient-reported improvement, satisfaction, and higher reoperation rates for SUI.

Abdominal and robotic sacrocolpopexy costs following implementation of enhanced recovery after surgery.

OBJECTIVE: To compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway. METHODS: The present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost-to-charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30. RESULTS: For the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331-$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P = 0.754), 30-day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P = 0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P = 0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001). CONCLUSIONS: Decreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.

Ureteral injury during vaginal mesh excision: role of prevention and treatment options.

Vaginal mesh kits are increasingly used in vaginal prolapse repair. Mesh erosion, infection, and pain may necessitate removal, which can lead to urinary tract injury. We describe 2 cases of ureteral injury at the time of mesh excision. Surgeons must recognize the possibility of ureteral injury and treatment modalities available.

A three-incision approach to treat persistent vaginal exposure and sinus tract formation related to ObTape mesh insertion.

Mentor Corporation's ObTape has been associated with considerable morbidity. An unacceptably high exposure rate has been noted, and in some cases, multiple procedures may be necessary for complete mesh removal. We evaluated a patient who had prior ObTape placement complicated with persistent vaginal discharge and granulation tissue formation related to persistent mesh exposure (3Bc-T2-S2) followed by sinus tract formation (6Cd-T3-S3) according to the International Urogynecological Association Classification. We performed a three-incision approach (abdominal, vaginal, and groin) for the complete removal of the retained portion of the transobturator tape. This three-incision technique represents a viable option for removal of transobturator tape causing persistent clinical issues.

A three-incision approach to treat persistent vaginal exposure and sinus tract formation related to ObTape mesh insertion.

Mentor Corporation's ObTape has been associated with considerable morbidity. An unacceptably high exposure rate has been noted, and in some cases, multiple procedures may be necessary for complete mesh removal.We evaluated a patient who had prior ObTape placement complicated with persistent vaginal discharge and granulation tissue formation related to persistent mesh exposure (3Bc-T2-S2) followed by sinus tract formation (6Cd-T3-S3) according to the International Urogynecological Association Classification. We performed a three-incision approach (abdominal, vaginal, and groin) for the complete removal of the retained portion of the transobturator tape. This three-incision technique represents a viable option for removal of transobturator tape causing persistent clinical issues.

Comparison of outcomes between pessary use and surgery for symptomatic pelvic organ prolapse: A prospective self-controlled study.

PURPOSE: We compared the degree of pelvic floor symptom improvement between pessary use and prolapse surgery. MATERIALS AND METHODS: Pessary-naïve women who elected prolapse surgery were enrolled and used a pessary preoperatively (for ≥7 days and ≤30 days). Pelvic floor symptoms were assessed at baseline, after pessary use, and at 3 months postoperatively. The primary outcome was concordance in the degree of symptoms improvement between pessary use and surgery, as assessed by Patient Global Impression of Improvement (PGI-I). Secondary outcomes were related to prolapse specific symptoms on validated questionnaires (POPDI-6, PFIQ-7). The McNemar test was used for comparisons of discordant pairs for comparisons of the PGI-I ratings after pessary use and surgery. RESULTS: Sixty-one participants were enrolled (March 2016 through April 2019) and 58 patients used a pessary. Mean±standard deviation age was 60.7±10.7 years; 24.1% had prior hysterectomy, and 13.8% had prior prolapse surgery. While both treatments demonstrated symptomatic improvement, concordance in the degree of overall improvement on the PGI-I score was poor (n=40); responses significantly favored more improvement postoperatively (p<0.001). Pessary use and surgery were associated with significant improvements in prolapse symptoms from baseline on POPDI-6 (both p<0.001) and POPIQ-7 (pessary, p=0.002; surgery, p<0.001). The degree of improvement was larger postoperatively compared to post-pessary use on POPDI-6 (p<0.001) and PFIQ-7 (p=0.004). CONCLUSIONS: Both pessary use and surgery significantly improved pelvic floor symptoms from baseline. However, concordance in degrees of improvement between these treatments was poor, with more favorable outcomes after surgery for prolapse symptoms.

Preoperative and postoperative predictors of satisfaction after surgical treatment of stress urinary incontinence.

OBJECTIVE: The purpose of this study was to assess which preoperative and postoperative variables correlated with satisfaction after surgical treatment of urinary incontinence. STUDY DESIGN: We conducted a retrospective cohort study of 371 women who underwent rectus fascial or midurethral sling procedure. Satisfaction was defined as a questionnaire response of "completely satisfied." Incontinence symptoms were based on responses to validated questionnaires. Associations between preoperative and postoperative variables and satisfaction were assessed with the use of logistic regression models. RESULTS: Increasing patient age (odds ratio [OR], 0.8; P = .002), body mass index (OR, 0.8; P = .003), and an autologous rectus fascial sling (compared with a midurethral sling; OR, 0.5; P = .003) were associated with decreased odds of satisfaction in a multivariate model. Furthermore, patients who required urethrolysis or had severe lower-urinary tract symptoms were significantly less likely to report satisfaction. CONCLUSION: Increasing age, body mass index, and type of operation were associated with decreased odds of satisfaction.

Changes in vaginal anatomy and sexual function after vaginal surgery.

INTRODUCTION AND HYPOTHESIS: The study's objectives were to determine changes in vaginal length and caliber after vaginal surgery and to correlate changes with sexual function. METHODS: This prospective study measured vaginal length and caliber before and immediately after vaginal surgery and at 5- to 8-week follow-up. A sexual function questionnaire was administered preoperatively and 6 months postoperatively. RESULTS: Ninety-two women were enrolled (mean age, 64 years); 44 (47.8%) were sexually active. The most common procedure was Mayo-McCall culdoplasty in 85 women (92.4%). Fourteen (15.2%) had intentional vaginal shortening and narrowing (coning). Mean vaginal length changed from 10.4 cm preoperatively to 8.7 cm at 5- to 8-week follow-up in women not having coning. Mean vaginal caliber changed from 3.2 to 2.8 cm. Preoperative and postoperative sexual function questionnaire scores did not correlate with vaginal measurements. CONCLUSIONS: Vaginal shortening and narrowing occurred after vaginal surgery; sexual function was unchanged.

Does concomitant prolapse repair at the time of midurethral sling affect recurrent rates of incontinence?

INTRODUCTION AND HYPOTHESIS: We compared outcomes after midurethral sling (MUS) with and without concomitant repair for prolapse. METHODS: Women who underwent MUS with or without concomitant repair for prolapse completed a follow-up survey. Outcomes were assessed with validated questionnaires and medical record review. Kaplan-Meier, Cox proportional hazards regression, and logistic regression models were used for analysis. RESULTS: Of 317 women, 281 (89%) responded to the survey. During a median follow-up of 2.7 years, survival free of "any" incontinence (Incontinence Severity Index score, >0) was similar in both groups (adjusted hazard ratio, 1.07; P = 0.77). Women with concomitant repair for advanced prolapse tended to be more bothered by frequent urination (adjusted odds ratio, 1.78; P = 0.08) and more likely to require urethrolysis (odds ratio, 6.11; P = 0.04) than those without concomitant pelvic floor repair. CONCLUSIONS: Prolapse repairs concomitant with MUS did not affect incontinence recurrence. However, repairs may cause increased lower urinary tract symptoms.

Medium-term comparison of continence rates after rectus fascia or midurethral sling placement.

OBJECTIVE: The purpose of this study was to compare continence rates after placement of rectus fascia or midurethral slings. STUDY DESIGN: We performed a retrospective cohort study of 242 women who underwent rectus fascia (n = 79) or midurethral (n = 163) sling procedures to treat urinary incontinence. Outcome was based on responses to validated questionnaires and need for interim treatment for incontinence. Survival free of incontinence was estimated using the Kaplan-Meier method. Associations between patient factors and survival free of incontinence were evaluated by fitting Cox proportional hazards models. RESULTS: Women with rectus fascia slings were more likely to report any leakage of urine (P = .04) and were 13 times more likely to require urethrolysis (P < .001) than patients with midurethral slings. Patient satisfaction was lower in the rectus fascia sling group compared with the midurethral sling group (P = .01). CONCLUSION: Midurethral slings appear to be more effective than rectus fascia slings and are less likely to cause postoperative voiding complications.

Can Urodynamic Parameters Predict Sling Revision for Voiding Dysfunction in Women Undergoing Synthetic Midurethral Sling Placement?

OBJECTIVE: The objective of the study was to evaluate the utility of urodynamic studies performed before primary midurethral sling placement for stress urinary incontinence in predicting the need for subsequent sling release for voiding dysfunction. METHODS: The health records of women managed with primary synthetic midurethral sling placement at Mayo Clinic (Rochester, MN) from January 1, 2002, to December 31, 2012, were reviewed. The primary outcome was surgical sling release for postoperative voiding dysfunction (ie, prolonged retention, elevated postvoid residual volumes with new voiding symptoms, or de novo onset or worsening of overactive bladder symptoms). Logistic regression models were used to evaluate associations between potential clinical risk factors and the primary outcome. RESULTS: Overall, 1629 women underwent primary synthetic midurethral sling placement during the study time frame, including 1081 patients (66%) who underwent a preoperative multichannel urodynamic evaluation. A sling release for voiding dysfunction was performed for 51 patients (3.1%) at a median of 1.9 months postoperatively (interquartile range, 1.3-9.3 months). Patients undergoing sling release were significantly more likely to have had retropubic sling placement (P = 0.003) and concomitant prolapse surgery (P = 0.005). On univariate analysis, no urodynamic parameters were associated with the risk of sling release; evaluated parameters included peak flow rate (P = 0.20), postvoid residual volume (P = 0.37), voiding without detrusor contraction (P = 0.96), and detrusor pressure at maximal flow (P = 0.23). CONCLUSIONS: Sling release for voiding dysfunction was rare in our cohort. No urodynamic parameters were associated with the risk of sling release.

Reoperation for Urinary Incontinence After Retropubic and Transobturator Sling Procedures.

OBJECTIVE: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures. METHODS: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure. RESULTS: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups. CONCLUSION: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.

Re-operation rates after permanent sacral nerve stimulation for refractory voiding dysfunction in women.

OBJECTIVES: To describe the development of screening tests and to identify re-operation rates after the permanent implant phase, and its characteristics, of the Interstim (Medtronic, Inc., Minneapolis, MI, USA) device for sacral nerve stimulation (SNS). PATIENTS AND METHODS: We retrospectively reviewed the charts of women who had SNS between January 1998 and December 2005; their demographic, clinical and surgical information was abstracted. Descriptive statistics, chi-square and analysis of variance were used to compare the results. RESULTS: In all, 95 patients had 105 test procedures; 30 peripheral nerve evaluation (PNE) and 75 staged tined leads. Response rates were lower in the PNE than in the tined lead (40% vs 67%, P = 0.01). The indication for SNS was associated with the response rate, with urinary retention having the highest response (71%, P = 0.01). For the 55 implanted devices, there were 18 revisions (33%) and eight explants (15%). The main reasons for revision or explants were loss of efficacy (16/26) and pain at the implant site (six of 26). The median (range) time to intervention after implantation was 17 (1.2-75.0) months, and this was significantly associated with the indication. Revisions due to pain at the implant site were within the first year, and re-operations due to loss of efficacy after 1-2 years, whereas battery replacement was required on average 4 years after initial implantation. CONCLUSIONS: This study confirms the higher response rates of the tined-lead staged technique over PNE. Unobstructive urinary retention had the highest response rates. The reason for revision appeared to be largely predicted by the length of time since implantation.