Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence. METHODS: This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse. RESULTS: Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II. CONCLUSIONS: Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.

Pain and activity after vaginal reconstructive surgery for pelvic organ prolapse and stress urinary incontinence.

BACKGROUND: Little is known about short- and long-term pain and functional activity after surgery for pelvic organ prolapse. OBJECTIVE: The objectives of the study were to describe postoperative pain and functional activity after transvaginal native tissue reconstructive surgery with apical suspension and retropubic synthetic midurethral sling and to compare these outcomes between patients receiving 2 common transvaginal prolapse repairs, uterosacral ligament, and sacrospinous ligament vaginal vault suspension. STUDY DESIGN: This planned secondary analysis of a 2 × 2 factorial randomized trial included 374 women randomized to receive uterosacral (n = 188) or sacrospinous (n = 186) vaginal vault suspension to treat both stages 2-4 apical vaginal prolapse and stress urinary incontinence between 2008 and 2013 at 9 medical centers. Participants were also randomized to receive perioperative pelvic muscle therapy or usual care. All patients received transvaginal native tissue repairs and a midurethral sling. Participants completed the Surgical Pain Scales (0-10 numeric rating scales; higher scores = greater pain) and Activity Assessment Scale (0-100; higher score = higher activity) prior to surgery and at 2 weeks, 4-6 weeks, and 3 months postoperatively. The MOS 36-item Short-Form Health Survey was completed at baseline and 6, 12, and 24 months after surgery; the bodily pain, physical functioning, and role-physical subscales were used for this analysis (higher scores = less disability). Self-reported pain medication use was also collected. RESULTS: Before surgery, average pain at rest and during normal activity were (adjusted mean ± SE) 2.24 ± 0.23 and 2.76 ± 0.25; both increased slightly from baseline at 2 weeks (+0.65, P = .004, and +0.74, P = .007, respectively) and then decreased below baseline at 3 months (-0.87 and -1.14, respectively, P < .001), with no differences between surgical groups. Pain during exercise/strenuous activity and worst pain decreased below baseline levels at 4-6 weeks (-1.26, P = .014, and -0.95, P = .002) and 3 months (-1.97 and -1.50, P < .001) without differences between surgical groups. Functional activity as measured by the Activity Assessment Scale improved from baseline at 4-6 weeks (+9.24, P < .001) and 3 months (+13.79, P < .001). The MOS 36-item Short-Form Health Survey Bodily Pain, Physical Functioning, and Role-Physical Scales demonstrated significant improvements from baseline at 6, 12, and 24 months (24 months: +5.62, +5.79, and +4.72, respectively, P < .001 for each) with no differences between groups. Use of narcotic pain medications was reported by 14.3% of participants prior to surgery and 53.7% at 2 and 26.1% at 4-6 weeks postoperatively; thereafter use was similar to baseline rates until 24 months when it decreased to 6.8%. Use of nonnarcotic pain medication was reported by 48.1% of participants prior to surgery, 68.7% at 2 weeks, and similar to baseline at 3 months; thereafter use dropped steadily to 26.6% at 2 years. Uterosacral ligament suspension resulted in less new or worsening buttock pain than sacrospinous suspension at 4-6 weeks postoperatively (4.6% vs 10.5%, P = .043) but no difference in groin or thigh pain. CONCLUSION: Pain and functional activity improve for up to 2 years after native tissue reconstructive surgery with uterosacral or sacrospinous vaginal vault suspension and midurethral sling for stages 2-4 pelvic organ prolapse. On average, immediate postoperative pain is low and improves to below baseline levels by 4-6 weeks.

Effect of mesh width on apical support after sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: We evaluated the effect of polypropylene mesh width on vaginal apical support, mesh elongation, and mesh tensile strength for abdominal sacrocolpopexy. METHODS: Abdominal sacrocolpopexy was performed on ten cadavers using pieces of polypropylene mesh of width 1, 2, and 3 cm. Weights of 1, 2, 3, and 4 kg were sequentially applied to the vagina. The total distance moved by the vaginal apex, and the amount of stretch of the intervening mesh segment between the sacrum and the vagina were recorded for each width. The failure strengths of additional single and double layer sets of each width were also tested using a tensiometer. Data were analyzed with analysis of variance using a random effects model. RESULTS: The mean (standard error of the mean) maximum distance moved by the vaginal apex was 4.63 cm (0.37 cm) for the 1 cm mesh compared to 3.67 cm (0.26 cm) and 2.73 cm (0.14 cm) for the 2 and 3 cm meshes, respectively (P < 0.0001). The 1 cm width ruptured during testing in four of the ten cadavers. The results were similar for mesh elongation, with the 1 cm mesh stretching the most and the 3 cm mesh stretching the least. Mesh failure loads for double-layer mesh were 52.9 N (2.5 N), 124.4 N (2.7 N), and 201.2 N (4.5 N) for the 1, 2, and 3 cm meshes, respectively, and were higher than the failure loads for single mesh (P < 0.001). CONCLUSIONS: In a cadaver model, increasing mesh width is associated with better vaginal apical support, less mesh elongation, and higher failure loads. Mesh widths of 2-3 cm provide sufficient repair strength for sacrocolpopexy.

Proximity of uterosacral ligament suspension sutures and S3 sacral nerve to pelvic landmarks.

INTRODUCTION AND HYPOTHESIS: To describe the relationships between pelvic bony landmarks to points along the third sacral nerve and to uterosacral ligament suspension sutures. METHODS: Three transvaginal uterosacral ligament suspension sutures were placed bilaterally in unembalmed female human cadavers. The third sacral nerve was marked at the foramen (S3a) and at two additional points at 1-cm intervals along its course caudally (S3b, S3c). Three bony pelvic landmarks were identified and marked, including the ischial spine, pubic symphysis, and coccyx. Distances from each landmark to each suture and nerve point were measured. The distance from each landmark to each S3 nerve point was extended radially, encompassing an arbitrary zone in which sutures may be placed and thus where nerve injury may occur. Zones of potential nerve injury included: zone A (closest to the sacral nerve root), zone B, and zone C (closest to the landmark). Descriptive statistics were used and comparisons were made using Student's t test and ANOVA. RESULTS: Ten cadaver specimens were dissected. For the ischial spine, the distances to points S3a, S3b, and S3c were 6.3, 5.4, and 4.6 cm respectively. Approximately two thirds of the sutures were noted beyond zone C, indicating a potentially increased risk of nerve injury with suture placement in zones farthest from the ischial spine given their proximity to the sacral nerve. CONCLUSIONS: Using the ischial spine as a landmark, increased sacral nerve injury could result from suture placement beyond the mean distance of 4.6 cm from the ischial spine. The use of bony landmarks in avoiding sacral nerve injury may be as important as suture depth and angle of suture placement.

Effect of myogenic stem cells on the integrity and histomorphology of repaired transected external anal sphincter.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the effect of myogenic stem cells on histological properties and the volume of striated muscle of the external anal sphincter after transection and repair. METHODS: Histological analysis was performed on the external anal sphincters of 40 young female rats euthanized at 7 or 90 days after transection and repair and randomization to injection of either phosphate buffered solution (PBS) or myogenic stem cells (SC) at the transection site. Sphincter complexes, previously evaluated for neurophysiological function, were processed for histology and analyzed for possible disruption, amount of inflammation, and volume of striated muscle. The relationship between the muscular disruption and contractile force of sphincters was evaluated. RESULTS: Disruption was seen in 100 % of sphincters 7 days after repair for both SC and control animals. Eighty-nine percent of controls and 78% of SC-administered animals had intact sphincters at 90 days. Significant inflammatory infiltrate was seen in repaired anal sphincters for both the PBS and the SC groups at 7 days, and persisted at 90 days, with no difference between treatment groups. Striated muscle volume increased from 7 to 90 days for both control and SC-administered animals. Although there was no difference in volume between treatments, there was substantial temporal improvement in contractile force generation of the sphincters receiving SC compared with those receiving PBS. CONCLUSION: In this animal model, administration of myogenic stem cells to transected/repaired anal sphincters did not alter the amount of inflammation nor the volume of striated muscle, suggesting that stem cells might improve contractile function through other cellular processes.

Myogenic stem cell-laden hydrogel scaffold in wound healing of the disrupted external anal sphincter.

OBJECTIVE: To evaluate the effect of myogenic stem cell-laden hydrogel scaffold on contractile function and histomorphology of the external anal sphincter (EAS) after transection without repair. METHODS: Eighty female rats underwent anal sphincter transection without repair. After 2 weeks, animals were injected at the transection site with: nothing (non-repaired control, NRC group); a polyethylene glycol-based hydrogel matrix scaffold combined with phosphate-buffered saline (PBS/hydrogel group); a hydrogel matrix scaffold combined with myogenic stem cells (stem cell/hydrogel group): or type I collagen (collagen) group. 4 (n = 40) or 12 (n = 40) weeks later, the anal sphincter complexes were dissected out and analyzed for contractile function, disruption, and striated muscle volume. Time-matched unoperated controls (UOC) were utilized for each of the two time points (n = 20). RESULTS: After 4 weeks, maximal electrical field-stimulated (EFS) contractions were significantly decreased in all four non-repaired treatment groups compared with UOC. However, EFS-stimulated contractions, tetanic force generation, and twitch tension were improved in non-repaired EAS injected with stem cell/hydrogel group relative to the NRC, PBS/hydrogel, or collagen groups. NRC and sphincters injected with PBS/hydrogel deteriorated further by 12 weeks, while those receiving stem cell/hydrogel maintained improved contractile function at varying frequencies and voltages. Striated muscle volume increased from 4 to 12 weeks for PBS/hydrogel and stem cell/hydrogel animals. At 12 weeks, stem cell/hydrogel animals had greater sphincter striated muscle volumes compared with all other treatment groups. CONCLUSION: In this animal model, sustained improvement of contractile responses in non-repaired EAS treated with biogel scaffold and myogenic stem cells suggests that a biologically compatible matrix may facilitate stem cell survival, differentiation, or function leading to recovery of contractile function even after persistent disruption.

Unruptured second-trimester ovarian pregnancy.

Ovarian ectopic pregnancies are rare, with the majority diagnosed in the first trimester and often treated due to symptoms related to ovarian rupture. We report our experience with the diagnosis, management, and histologic evaluation of an unruptured second-trimester ovarian ectopic pregnancy. A 37-year-old woman presented with vague abdominal discomfort and irregular menses. Ultrasound detected a 16-week 4-day gestation with cardiac motion in the right adnexa and no evidence of an intrauterine pregnancy. Laparotomy with right salpingo-oophorectomy was performed, with removal of an unruptured pregnancy from the ovary. Although intraoperative examination and postoperative histopathologic evaluation demonstrated the classic Speigelberg criteria, it did not assist in the preoperative diagnosis, nor impact the treatment of the ovarian ectopic pregnancy in this case.

Effectiveness of blinding: sham suprapubic incisions in a randomized trial of retropubic midurethral sling in women undergoing vaginal prolapse surgery.

OBJECTIVE: This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial assessed whether treatment knowledge differed between randomized groups at 12 months and whether treatment success was affected by treatment perception. STUDY DESIGN: Sham suprapubic tension-free vaginal tape (TVT) incisions were made in the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial participants randomized to no-TVT. Primary surgical outcomes and maintenance of blinding was assessed at 12 months. Knowledge of treatment assignment was compared between groups, and the relationship with treatment success rates was assessed. RESULTS: Prior to the 12 month postoperative visit, only 4% of treated participants (13 of 336) formally reported unmasking. At 12 months, 94% of the randomized participants (315 of 336) provided treatment knowledge data. Sixteen TVT participants (10%) reported treatment knowledge; most (n = 15, 94%) were correct; 17 of the sham participants (11%) reported treatment knowledge; half (n = 8, 47%) were correct. Similar proportions of unmasked participants who reported no treatment knowledge correctly guessed/perceived treatment assignment (sham, 46 [33%] vs TVT, 44 [33%]). We did not detect significant differences in treatment success rates based on perception within and across received treatment groups (perceived sham vs TVT overall [P = .76]). Of those receiving TVT, more participants perceiving TVT had treatment success compared with those who perceived sham (84% vs 74%; P = .29). Among sham participants, more participants perceiving sham had success compared with those who perceived receiving TVT (65% vs 56%; P = .42). CONCLUSION: Sham surgical incisions effectively mask TVT randomization. These findings may help to inform future surgical trial designs.

Patient satisfaction following midurethral sling surgeries.

PURPOSE OF REVIEW: Patient-reported outcomes and satisfaction are recognized as being equally important as traditional objective measures of success following midurethral sling (MUS) procedures. The objective of this article is to review the success after MUSs in the context of patient satisfaction. RECENT FINDINGS: Patient satisfaction for both transobturator and retropubic MUSs at 2 years is high with rates up to 88%. Factors that positively influence satisfaction include improvement in quality of life and reduction in severity of symptoms. Satisfaction has been found to be negatively impacted by persistent stress incontinence, preoperative urinary urgency, mixed urinary incontinence, detrusor overactivity, and selected comorbidities such as diabetes. Factors, such as postoperative incomplete bladder emptying, irritative voiding, and complications after MUS surgery, can also influence satisfaction adversely. SUMMARY: Combining patient-reported outcome measures with customary objective measures offer a more comprehensive assessment of success. Even though the data are limited, the short-term and intermediate-term rates of satisfaction are promising for both transobturator and retropubic MUSs. Future studies should focus on further elucidating long-term predictors of satisfaction after MUS placement.

Estrogen alters remodeling of the vaginal wall after surgical injury in guinea pigs.

Loss of pelvic organ support (i.e., pelvic organ prolapse) is common in menopausal women. Surgical reconstruction of pelvic organ prolapse is plagued with high failure rates. The objective of this study was to determine the effects of estrogen on biomechanical properties, lysyl oxidase (LOX), collagen content, and histomorphology of the vagina with or without surgical injury. Nulliparous ovariectomized guinea pigs were treated systemically with either 50 µg/kg/day estradiol (E2,) or vehicle. After 2 wk, vaginal surgery was performed, and animals were treated with either beta-aminopropionitrile (BAPN, an irreversible LOX inhibitor), or vehicle to determine the role of LOX in recovery of the vaginal wall from injury with or without E2. Estradiol resulted in (i) significant growth, increased smooth muscle, and increased thickness of the vagina, (ii) increased distensibility without compromise of maximal force at failure, and (iii) increased total and cross-linked collagen. In the absence of E2, BAPN resulted in decreased collagen and vaginal wall strength in the area of the injury. In contrast, in E2-treated animals, increased distensibility, maximal forces, and total collagen were maintained despite BAPN. Interestingly, LOX mRNA was induced dramatically (9.5-fold) in the injured vagina with or without E2 at 4 days. By 21 days, however, LOX levels declined to near baseline in E2-deprived animals. LOX mRNA levels remained strikingly elevated (12-fold) at 21 days in the estrogenized vagina. The results suggest that prolonged E2 induced increases in LOX, and collagen cross-links may act to sustain a matrix environment that optimizes long-term surgical wound healing in the vagina.

Functional and anatomic comparison of 2 versus 3 suture placement for uterosacral ligament suspension: a cadaver study.

OBJECTIVE: The objective of the study was to compare the vaginal apex pullout distance using 2 vs 3 suspension sutures during transvaginal uterosacral ligament suspension (USLS) and to describe relationships to ipsilateral ureter and nerve structures. STUDY DESIGN: Eight fresh-frozen female cadavers were studied. After hysterectomy, a transvaginal USLS was performed with placement of 3 suspension sutures per side. The 2 most distal sutures on each ligament were tied. A screw-and-washer attachment was secured in the middle of the vaginal cuff and tied to a pulley system with surgical filament. Distal traction was applied with sequentially increasing weight loads. Distal migration of the vaginal apex from baseline with each weight load was recorded. The most proximal suspension suture was tied and the procedure repeated. Horizontal distances between each USLS suture to the ipsilateral ureter were measured. Three discrete points were marked on sacral nerves S1-S3, and the shortest distance between each point and each ipsilateral USLS suture was measured. Descriptive statistics and repeated-measures analysis of variance were performed. RESULTS: Application of each load resulted in greater migration distances for the 2 suture configuration when compared with 3 sutures (P < .05). Differences were greatest for the 3 kg load (mean ± SEM, 2.0 ± 0.2 vs 1.5 ± 0.1 cm, respectively). Distances to ipsilateral ureter between the 2 most cranial sutures were comparable (P > .05). The most cranial USLS suture was closest to sacral nerves S1-S3. CONCLUSION: In this cadaveric study, 3 USLS sutures provided more support to the vaginal apex than 2 sutures, although the absolute difference may not be clinically significant. The most cranial suture had the smallest distances to sacral nerves S1-S3.

Effect of repeat acute injury on contractile function of the external anal sphincter in an animal model.

INTRODUCTION AND HYPOTHESIS: Our aim was to estimate the physiologic effects of early repeat transection and repair on the contractile properties of the external anal sphincter (EAS) in a rat model. METHODS: Eighty young female rats underwent anal sphincter transection and repair. After 7 days, they were randomized to repeat sphincter transection (injury-injury, n = 40) or sham operation (injury-sham, n = 40). Thereafter, the anal sphincter complex was dissected, mounted, and analyzed for contractile function 7 days, 21 days, 3 months, or 6 months after the second operation. Contractile function was also determined in 40 age-matched unoperated controls (n = 10 for each time point). Statistical analysis was performed using analysis of variance (ANOVA) with Tukey-Kramer adjustment for multiple testing. P ≤ 0.05 was considered significant. RESULTS: Although single injury (injury-sham) resulted in modest compromise of sphincter function, repeat injury (injury-injury) resulted in profound impairment of twitch tension, maximal tetanic responses, and maximal electrical-field stimulation (EFS) induced-force generation at 7 days. After single injury, parameters of contractile function returned to baseline uninjured levels by 21 days. In contrast, sphincter function remained reduced 21 days after repeat injury. Contractile function of sphincters from both injury-sham and injury-injury animals were no longer impaired at 3 and 6 months. CONCLUSION: In this animal model, repeat injury and repair of the EAS 7 days after the initial injury resulted in prolonged compromise of EAS function compared with single injury. Nevertheless, contractile function of the double-injured sphincter fully recovered with time, resulting in no long-term impairment.

Utility of clinical parameters, cystourethroscopy, and magnetic resonance imaging in the preoperative diagnosis of urethral diverticula.

INTRODUCTION AND HYPOTHESIS: Our purpose was to assess the accuracy of history and physical, cystourethroscopy, and magnetic resonance imaging (MRI) in preoperative diagnosis of urethral diverticula. METHODS: This was a retrospective review of all patients who underwent surgical excision of periurethral masses between 1998 and 2009. Presenting symptoms and examination and cystourethroscopic findings were noted. A single pathologist reviewed all cases and provided the reference standard for the diagnosis of a diverticulum. A single radiologist reviewed all preoperative MRI studies. Sensitivities, specificities, and positive and negative predictive values (PPV, NPV) were determined. RESULTS: Diverticula were diagnosed in 36/60 (60 %) patients. Transurethral fluid expression on palpation and recurrent urinary tract infection (UTI) had high PPV. Sensitivity, specificity, PPV, and NPV, respectively, for cystourethroscopy were 33 %, 100 %, 100 %, and 42 %; for MRI, these were 100 %, 83 %, 92 %, and 100 %. CONCLUSION: These data reinforce the utility of transurethral fluid expression for preoperative evaluation of urethral diverticula. Additionally, MRI is an excellent adjunctive diagnostic tool and may assist in establishing the diagnosis when there is high clinical suspicion of a urethral diverticulum but nonconfirmatory findings on cystourethroscopy.

Sensory neuropathy following suspension of the vaginal apex to the proximal uterosacral ligaments.

INTRODUCTION AND HYPOTHESIS: Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients. METHODS: A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected. RESULTS: Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management. CONCLUSIONS: Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.

Urodynamic indices and pelvic organ prolapse quantification 3 months after vaginal delivery in primiparous women.

INTRODUCTION AND HYPOTHESIS: This study aims to describe multichannel urodynamic indices and pelvic organ prolapse quantification (POP-Q) in primiparous women 3 months after vaginal delivery. METHODS: This was a secondary analysis of a group of women who had been randomized to either coached or non-coached pushing during the second stage of labor. Primiparous women were evaluated with POP-Q examination and multichannel urodynamic testing 3 months after vaginal delivery. RESULTS: Of 128 women evaluated, the cumulative stage of prolapse was distributed as 4.7% stage 0, 39% stage I, 56% stage II, and none with stage III prolapse or greater. For the anterior compartment, most had stage II prolapse. Stage I prolapse predominated for both the central and posterior compartments. Of the women, 14.1% had urodynamic stress incontinence, 12.5% had detrusor overactivity, and 6% had both. CONCLUSIONS: In a predominantly Hispanic primiparous population, ICS POP-Q stage II prolapse of the vagina, urodynamic stress incontinence, and detrusor overactivity are common findings at a 3-month postpartum assessment.

Patient satisfaction with stress incontinence surgery.

AIMS: To identify predictors and correlates of patient satisfaction 24 months after Burch colpopexy or autologous fascial sling for treatment of stress urinary incontinence (SUI). METHODS: Participants were the 655 randomized subjects in the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Variables potentially associated with satisfaction were tested in bivariate analysis, including demographics, baseline clinical characteristics of incontinence, and outcomes on validated subjective and objective measures. Satisfaction with treatment was defined as a response of "completely satisfied" or "mostly satisfied" on the Patient Satisfaction Questionnaire (PSQ) at 24 months. Variables significantly related to satisfaction were entered into multivariable regression models to test their independent association with satisfaction. RESULTS: At 24 months post-surgery, 480 (73%) participants completed the PSQ. Mean (±SD) age of the sample was 52 (±10) years and 77% were white. Most (82%) were completely or mostly satisfied with their surgery related to urine leakage. In the final multivariable model, patient satisfaction was associated with greater reduction in SUI symptoms (from baseline to 24 months; OR = 1.17, 95% CI: 1.10, 1.24) and greater reductions in symptom distress (OR = 1.16; CI: 1.08, 1.24). Lower odds of satisfaction were associated with greater urge incontinence symptoms at baseline (OR = 0.09, CI: 0.04, 0.22), detrusor overactivity at 24 months (OR = 0.29, CI: 0.12, 0.69), and a positive stress test at 24 months (OR = 0.45, CI: 0.22, 0.91). CONCLUSIONS: Stress incontinent women who also have urge incontinence symptoms may benefit from additional preoperative counseling to set realistic expectations about potential surgical outcomes or proactive treatment of urge incontinence symptoms to minimize their post-operative impact.

Comparisons of Functional Apical Support After Sacral Hysteropexy Versus Sacral Colpopexy: A Cadaveric Study.

OBJECTIVES: Prolapse procedures with uterine preservation offer an alternative to colpopexy with hysterectomy. Few studies have examined the differences in anatomic or subjective outcomes following sacral hysteropexy versus sacral colpopexy with hysterectomy. This study sought to compare the ability of sacral hysteropexy and sacral colpopexy with hysterectomy to resist downward traction as an estimate of apical support in human cadavers. METHODS: Sacral hysteropexy was performed on unembalmed female cadavers. A metal bolt/washer was threaded through the uterine fundus, down the cervical canal. and out the vagina and fastened to a waxed surgical filament, which ran over a fixed pulley at the table's end. Successive weights were added to provide increasing loads on the uterine fundus, and the distances traversed by the fundus were recorded. The same process was repeated after completion of a total hysterectomy (with vaginal cuff closure) and subsequent sacral colpopexy in the same specimen. Data were analyzed using paired-sample t test and repeated-measures analysis of variance (Sigma Plot version 13.0), with P ≤ 0.05 considered statistically significant. RESULTS: Eight female cadavers were utilized. With the addition of each weight, the average distance traversed by the uterine fundus or vaginal cuff gradually increased. There were no statistical differences in the distances moved by the apex between sacral hysteropexy and total hysterectomy/sacral colpopexy. CONCLUSIONS: These results suggest that functional support provided by sacral hysteropexy and sacral colpopexy with hysterectomy may be similar. Further studies are needed to correlate these findings with patient satisfaction, which may vary despite similar anatomic results.

Effects of pregnancy, parturition, and anal sphincter transection on function of the external anal sphincter in an animal model.

OBJECTIVE: To estimate the effects of pregnancy, parturition, and anal sphincter laceration (with repair) on external anal sphincter morphology and neurophysiology and to define the time course of these effects after injury. METHODS: Within 4 hours of vaginal delivery, 80 rats underwent either sham or anal sphincter laceration with repair. After 3 days, 3 weeks, and 3 and 6 months (n=20 for each time point), animals were killed, and the anal sphincter complexes dissected and removed for neurophysiologic studies. Twitch tension, peak tetanic force, fatigue, and maximal electrical field-stimulated force generation were determined. Sphincters were then fixed and serially sectioned (5-micrometer thickness) at 100-micrometer intervals for histologic analysis. RESULTS: Maximal electrical field-stimulated force generation, maximal tetanic contraction, and twitch tension were decreased in the external anal sphincter 3 days after anal sphincter laceration with repair compared with sham-operated parturient rats (3.3 g compared with 11.6 g, 4.5 g compared with 14.5 g, and 0.6 g compared with 2.0 g, respectively, all P<.02). Increased fatigability of the sphincter muscle was observed in all newly parturient rats-sham and anal sphincter laceration with repair; recovery occurred in the shams by 3 months. A gradual recovery occurred in all these neurophysiologic measures, with no significant differences between anal sphincter laceration with repair and shams by 6 months postpartum. CONCLUSION: Repaired anal sphincter transection in periparturient animals results in short-term severe compromise of neurophysiologic function of the external anal sphincter. Over time, however, force generation recovers and approximates that of postpartum rats with intact anal sphincters.

Optimal location and orientation of suture placement in abdominal sacrocolpopexy.

OBJECTIVE: To estimate the strongest location and optimal orientation of suture placement in the anterior longitudinal ligament for abdominal sacrocolpopexy in female cadavers. METHODS: The anterior longitudinal ligament was exposed below the level of the aortic bifurcation in 23 unembalmed female cadavers. To the right of midline of the vertebral column, sutures were placed in a horizontal orientation into the ligament at the sacral promontory, 1 and 2 cm above (sacral promontory+1 and sacral promontory+2), and 1, 2, and 3 cm below (sacral promontory-1, sacral promontory-2 and sacral promontory-3). At these same locations, but to the left of midline, sutures were placed in a vertical orientation. Pull-out force and ligament thickness at each level of testing were measured. Data were analyzed using Student t test and repeated measures analysis of variance. RESULTS: Sutures (either horizontally or vertically placed) had greater pull-out strengths at or above, compared with those placed below, the level of the sacral promontory. At sacral promontory and sacral promontory+1, there were no differences in the pull-out strengths of the ligament when sutures were placed in either orientation. However, horizontally placed sutures had significantly greater pull-out strengths than vertically placed sutures at sacral promontory+2, sacral promontory-1 and sacral promontory-2. Ligament thickness decreased from 2 cm above (mean+/-standard error of the mean sacral promontory+2, 1.8+/-0.1 mm) to 3 cm below (sacral promontory-3, 1.3+/-0.1 mm) the sacral promontory. CONCLUSION: Sutures placed in the anterior longitudinal ligament at or above the sacral promontory are more secure than those placed below. Horizontally oriented sutures should be considered for mesh attachment below the sacral promontory because they are significantly stronger when compared with vertically placed sutures.

Contractile properties of the denervated external anal sphincter.

OBJECTIVE: The purpose of this study was to evaluate the effect of denervation on contractile properties of the external anal sphincter (EAS) of the female rat. STUDY DESIGN: Sham operation, pudendal nerve transection, pelvic neurectomy, or combined pudendal nerve transection/pelvic neurectomy was performed in young female rats. Contractile function of the EAS was determined after 2 weeks. RESULTS: Maximal force-generating capacity of the EAS was not impaired by bilateral pudendal denervation or pelvic neurectomy. Twitch tension, however, was decreased, and fatigability increased after pelvic neurectomy. Combined bilateral pudendal nerve-transection plus pelvic neurectomy resulted in compromised force-generating capacity, decreased twitch tension, and increased fatigability of the anal sphincter. CONCLUSION: Subtle changes in EAS function are detectable after pelvic neurectomy, but not pudendal denervation. In contrast, combination pudendal and pelvic neurectomy resulted in severe compromise of EAS function. These data suggest that EAS function is relatively preserved unless injury occurs to > 1 source of innervation.