Bladder instillations vs onabotulinumtoxinA injection for interstitial cystitis/bladder pain syndrome: a randomized clinical trial.

BACKGROUND: Interstitial cystitis (IC)/bladder pain syndrome (BPS) is an unpleasant sensation related to the bladder with lower urinary tract symptoms lasting more than 6 weeks, unrelated to an otherwise identifiable cause. The etiology is likely multifactorial including urothelial abnormalities, neurogenic pain upregulation, and potentially bladder and vaginal microbiome alterations. Despite treatment effectiveness of both bladder instillations and intradetrusor onabotulinumtoxinA injection for this condition, a head-to-head comparison has not been performed. OBJECTIVE: To compare the efficacy of bladder instillations and intradetrusor onabotulinumtoxinA injection for treatment of IC/BPS. STUDY DESIGN: Patients with O'Leary-Sant (OLS) questionnaire scores of ≥6, meeting clinical criteria for IC/BPS, and desiring procedural management were randomized to bladder instillations or intradetrusor onabotulinumtoxinA injection. The primary outcome was the difference in OLS scores at 2 months posttreatment between groups. Secondary outcomes included evaluation of sexual function, physical/mental health status, pain, patient satisfaction, treatment perception, retreatment, and adverse event rates. RESULTS: Forty-seven patients were analyzed with 22 randomized to bladder instillations and 25 to onabotulinumtoxinA injection. There were no differences in demographic and clinical characteristics between groups. From baseline to 2 months posttreatment, there was a decrease in OLS subscales in all patients (Interstitial Cystitis Symptom Index [ICSI] -6.3 (confidence interval [CI] -8.54, -3.95), P<.0001; Interstitial Cystitis Problem Index [ICPI] -5.9 (CI -8.18, -3.57), P<.0001). At 2 months posttreatment, patients in the onabotulinumtoxinA group had significantly lower OLS scores compared to those in the bladder instillation group (ICSI 6.3±4.5 [onabotulinumtoxinA] vs 9.6±4.2 [instillation], P=.008; ICPI 5.9±5.1 [onabotulinumtoxinA] vs 8.3±4.0 [instillation], P=.048). The difference in OLS scores between groups did not persist at 6 to 9 months posttreatment. There were no statistically significant differences between baseline and posttreatment time points for the remaining questionnaires. Eight percent of patients who received onabotulinumtoxinA injection experienced urinary retention requiring self-catheterization. Patients who underwent onabotulinumtoxinA injection were significantly less likely to receive retreatment within 6 to 9 months compared to patients who received bladder instillations (relative risk 13.6; 95% CI, 1.92-96.6; P=.0002). There were no differences between groups regarding patient satisfaction, perception of treatment convenience, or willingness to undergo retreatment. CONCLUSION: Both onabotulinumtoxinA injection and bladder instillations are safe, effective treatments for patients with IC/BPS, with significant clinical improvement demonstrated at 2 months posttreatment. Our findings suggest that intradetrusor onabotulinumtoxinA injection is a more effective procedural treatment for this condition than bladder instillation therapy and associated with decreased rates of retreatment.

More With Less: Single-Incision Sling Insertion Techniques.

STUDY OBJECTIVE: To demonstrate reproducible procedures for efficient single-incision sling insertion and troubleshooting. DESIGN: Narrated video footage with stepwise demonstration of single-incision sling insertion technique with anchor system. SETTING: The mesh midurethral sling is a highly effective and safe procedure that is considered the gold standard for surgical treatment of stress urinary incontinence. Retropubic and transobturator approaches for midurethral slings have similar subjective cure rates with differing surgical risk profiles [1,2]. The retropubic route has a higher risk of injury to the bladder, nerves, and vascular structures, whereas the obturator approach carries a risk of groin or thigh pain [3-5]. Use of a single-incision sling decreases these risks and allows flexibility to perform the procedure without sedation or general anesthesia. Recent literature demonstrates similar subjective and objective success and safety of single-incision slings compared with both retropubic and transobturator approaches, although long-term data are forthcoming [5]. INTERVENTIONS: We demonstrate a stepwise approach for the insertion of a single-incision sling using a helical trocar. Easily reproducible procedures for setup and sling anchor management allow for efficient placement without assistance. In addition, we outline hand positioning, trocar management, and anchor deployment with troubleshooting techniques for potential placement difficulties. Finally, we review methods for sling tensioning to prevent complications such as voiding dysfunction and mesh or suture exposures. CONCLUSION: Given that single-incision slings are more likely to be performed under local anesthesia and are less invasive with decreased recovery time, it has the potential to become the preferred approach in the future. This video demonstrates clear and detailed steps to facilitate successful placement of the single-incision mesh midurethral sling.

Reduced versus standard intradetrusor OnabotulinumtoxinA injections for treatment of overactive bladder.

BACKGROUND: Intradetrusor onabotulinumtoxinA injection is an effective advanced treatment for overactive bladder. While the effective dosages have been well studied, very little data exist on treatment efficacy using differing injection techniques. The objective of this study was to determine whether the efficacy of a reduced injection technique of 5 injection sites was noninferior to the standard technique of 20 injection sites of intradetrusor onabotulinumtoxinA for treatment of overactive bladder. METHODS: In this randomized noninferiority trial, men and women seeking treatment of overactive bladder with intradetrusor onabotulinumtoxinA injections were randomized to receive 100 units administered via either a reduced injection technique of 5 injection sites or a standard injection technique of 20 injection sites. Subjects completed a series of standardized questionnaires at baseline and at 4-12 weeks postprocedure to determine symptom severity and treatment efficacy. The primary outcome was treatment efficacy as determined by Overactive Bladder Questionnaire-Short Form with a noninferiority margin of 15 points. Secondary outcomes were incidence of urinary tract infection and urinary retention requiring catheterization. RESULTS: Data from 77 subjects were available for analysis with 39 in the control arm (20 injections) and 38 in the study arm (5 injections). There was a significant improvement in both arms from baseline to follow-up in Overactive Bladder Questionnaire-Short Form and International Consultation on Incontinence Questionnaire scores (p < 0.001). Overall treatment success was 68% with no statistically significant difference between arms. A significant difference between arms was found on the Overactive Bladder Questionnaire-Short Form quality of life survey favoring the control arm (confidence interval [CI]: 0.36-20.5, p = 0.04). However, there were no significant differences between arms in the remaining validated questionnaires. The study arm did not demonstrate noninferiority to the control arm. Subjects in the study arm were significantly more likely to express a willingness to undergo the procedure again (odds ratio = 3.8, 95% CI: 1.42-10.67, p = 0.004). Adverse events did not differ between arms. CONCLUSIONS: A reduced injection technique for administration of intradetrusor onabotulinumtoxinA demonstrates similar efficacy to the standard injection technique but did not demonstrate noninferiority. Subjects preferred the reduced injection technique over the standard technique. A reduced injection technique is a safe and effective alternative to the standard technique.

Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial.

BACKGROUND: Pelvic reconstructive surgery may cause significant postoperative pain, especially with posterior colporrhaphy, contributing to a longer hospital stay and increased pain medication utilization. Regional blocks are being increasingly utilized in gynecologic surgery to improve postoperative pain and decrease opioid usage, yet preoperative pudendal blocks have not been used routinely during posterior colporrhaphy. OBJECTIVE: This study aimed to compare the effect of preoperative regional pudendal nerve block using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and 3. We hypothesized that there would be a reduction in vaginal pain scores for the study group vs the control group over the first 72 hours. STUDY DESIGN: This was a double-blinded, randomized controlled trial that included patients undergoing a posterior colporrhaphy, either independently or in conjunction with other vaginal or abdominal reconstructive procedures. Patients were block randomized to receive 20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study) or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before the start of surgery. Double blinding was achieved by covering four 5-mL syringes containing the randomized local anesthetic. After induction of anesthesia, a pudendal nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary outcomes included total analgesic medication usage through postoperative day 3, postoperative voiding and defecatory dysfunction, and impact of vaginal pain on quality of life factors. RESULTS: A total of 120 patients were enrolled (60 in each group). There were no significant differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined liposomal and bupivacaine group at all time points vs the plain bupivacaine group. Median pain scores for the study and control groups, respectively, were 0 (0-2) and 2 (0-4) for postoperative day 1 (P=.03), 2 (1-4) and 3 (2-5) for postoperative day 2 (P=.05), and 2 (1-4) and 3 (2-5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days 2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%, P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity). CONCLUSION: Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine provided more effective vaginal pain control than plain bupivacaine alone for reconstructive surgery that included posterior colporrhaphy. Given the statistically significant decrease in vaginal pain in the study group, this block may be considered as a potential adjunct for multimodal pain reduction in this patient population.

Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population.

We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.

Urethral Diverticulum Marsupialization With Modified Spence-Duckett Procedure.

OBJECTIVE: To demonstrate a modified approach to the Spence-Duckett procedure for treatment of a distal urethral diverticulum. A urethral diverticulum is an outpouching of urethral mucosa occurring in 2-5% of the population.1 They are thought to commonly arise due to chronic inflammation or infection of the peri-urethral glands.2,3 MATERIALS AND METHODS: We present a 37-year-old female with vaginal bulge, dyspareunia, and dysuria. On examination, she had a 2-centimeter tender mass abutting the distal urethra. Imaging such as ultrasound or magnetic resonance imaging is critical to map the location of the diverticula along the urethra and extent of urethral involvement as it can inform surgical technique. Diverticula are typically located postero-laterally at the mid- or distal urethra; however, they can be found at any location along the urethra.2,3 Care must be taken to avoid disruption of the continence mechanism at the mid-urethra to prevent incontinence after surgery. Magnetic resonance imaging revealed a 1.7 × 1.7 × 1.8 centimeter unilocular cystic structure at the left posteromedial distal urethra consistent with a urethral diverticulum. The patient desired surgical management. RESULTS: Spence and Duckett traditionally described insertion of one blade of the Metzenbaum scissors in the urethra with incision into the diverticulum and anterior vaginal wall followed by marsupialization.4 Given the small size of the diverticular ostium identified, we opted to make an incision using a scalpel from the ostium down the posterior aspect of the urethra and proximally to the anterior vaginal wall. We then excised the diverticular sac prior to marsupialization. At 6 weeks after surgery, she had full resolution of her symptoms without development of urinary incontinence. Pathologic examination is important because while rare, cancers can originate from urethral diverticula, with a prevalence of 6-9%.5 Pathology was consistent with urethral diverticulum and negative for dysplasia. CONCLUSION: While effective, the Spence-Duckett technique is described as a "generous meatotomy" with risks of urethral shortening. Our modified approach reduces these risks, resolves bothersome symptomatology, improves cosmesis, and minimizes risk of anatomic or functional urethral compromise.

Colpocleisis Techniques: An Open-and-shut Case for Advanced Pelvic Organ Prolapse.

OBJECTIVE: To highlight several advanced surgical techniques for all types of colpocleisis. Pelvic organ prolapse is a common condition that affects up to 40% of the postmenopausal female population.1,2 Particularly for women with advanced pelvic organ prolapse who no longer desire penetrative vaginal intercourse and with multiple medical comorbidities, the obliterative approach is preferred due to decreased anesthetic needs, operative time, and perioperative morbidity.3 Additionally, colpocleisis is associated with a greater than 95% long-term efficacy with low patient regret, high satisfaction, and improved body image.4,5 MATERIALS AND METHODS: The umbrella term of "colpocleisis" encompasses a uterine-sparing procedure, the LeFort colpocleisis, colpocleisis with hysterectomy, and posthysterectomy vaginal vault colpocleisis. We demonstrate the surgical steps of performing each type of colpocleisis as well as levator myorrhaphy and perineorrhaphy, which are typically included to reinforce the repair. RESULTS: To streamline the LeFort colpocleisis procedure, we demonstrate use of electrosurgery to mark out the epithelium and methods to create the lateral tunnels with LeFort colpocleisis with and without the use of a urinary catheter. We also present techniques that can be utilized across all types of colpocleisis including the push-spread technique for dissection, tissue retraction with Allis clamps and rubber bands on hemostat clamps to improve visualization, and approximation of the anterior and posterior vaginal muscularis to close existing space. Attention must be paid not to proceed past the level of the urethrovesical junction to avoid angulation of the urethra. We use an anatomic model to demonstrate appropriate suture placement during levator myorrhaphy to facilitate an adequate purchase of the levator ani muscles in order to adequately narrow the vaginal opening. Ultimately the goal of the colpocleisis procedure is a well-approximated, obliterated vagina, approximately 3 cm in depth and 1 cm in width. CONCLUSION: The skills demonstrated enable the surgeon to maximize efficiency and surgical outcomes for an effective obliterative procedure for advanced stage pelvic organ prolapse.

Sacrocolpopexy Techniques for the Savvy Surgeon.

Laparoscopic sacrocolpopexy (LSCP) can be challenging even for the experienced surgeon. Knowledge and adequate visualization of the sacral and pelvic anatomy is paramount to prevent potentially catastrophic intra-operative hemorrhage, nerve or ureteral injury, and to facilitate presacral dissection. We highlight several techniques to maximize surgical efficiency, optimize visualization of the sacral anatomy during presacral dissection, as well as a method to facilitate peritoneal closure over the mesh during LSCP. These techniques are generalizable, maximize surgical efficiency and safety, and can decrease frustration during LSCP.

Risk factors of lower urinary tract injury with laparoscopic sacrocolpopexy.

BACKGROUND: Lower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy. OBJECTIVE: The primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy. STUDY DESIGN: This was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios. RESULTS: A total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m2 (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48-160.38; P=.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05-23.19; P=.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21-8227; P=.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury. CONCLUSION: Although lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.

Suprapubic Versus Transurethral Catheterization: Perioperative Outcomes After Colpocleisis.

OBJECTIVES: Transient postoperative urinary retention occurs in approximately half of women after colpocleisis; however, the optimal strategy for postoperative catheter management is unclear. This study compared length of catheterization and postoperative complications after colpocleisis between planned suprapubic catheter placement and transurethral catheterization. METHODS: This is a retrospective cohort study including all women undergoing colpocleisis from January 2015 to December 2019 in a large female pelvic medicine and reconstructive surgery practice. Women undergoing planned placement of a suprapubic catheter intraoperatively during colpocleisis and women who were discharged with a transurethral catheter after failing an active voiding trial postoperatively after colpocleisis were included. Women with surgical complications requiring prolonged catheterization and those needing catheterization before surgery were excluded. Length of catheterization and postoperative complications were compared between groups. RESULTS: Two hundred fifty-eight women underwent colpocleisis during the study time frame and 170 were eligible for analysis: with 78 in the planned suprapubic catheter group and 92 in the transurethral catheter group. Length of catheterization with suprapubic catheter placement was significantly longer than transurethral catheter placement with median catheter days of 11 (95% confidence interval [CI], 10-14) versus 7 (95% CI, 6-7), which persisted after adjustment (HR, 2.61, 95% CI, 1.85-3.68, P < 0.001). No significant differences were found in overall complications or urinary tract infections. CONCLUSIONS: Suprapubic catheter placement at the time of colpocleisis is associated with increased length of catheterization postoperatively compared with transurethral catheter for management of postoperative urinary retention. These data can aid surgeons in preoperative counseling and shared decision making with patients.

Effects of Preoperative Gabapentin on Clinical Outcomes After Outpatient Midurethral Sling Placement.

OBJECTIVES: This study aimed to evaluate transient urinary retention in women undergoing outpatient midurethral sling placement who received preoperative gabapentin (treated) versus those who did not (untreated). Secondary outcomes included unexpected admission rates, analgesic usage, time to discharge, and pain. METHODS: This was a retrospective cohort study including women who underwent outpatient midurethral sling placement from 2015 to 2019. Exclusion criteria included suprapubic catheter placement, planned overnight admission, abnormal preoperative postvoid residual volume, and prolonged postoperative catheterization. Logistic regression was performed to evaluate gabapentin usage and urinary retention after adjusting for patient characteristics. RESULTS: Three hundred two women met the inclusion criteria, with 19.5% experiencing urinary retention after midurethral sling placement. Women older than 65 years were more likely to have urinary retention than those aged 18-65 years (29.8% vs 17.6%, P = 0.054). Of treated participants, 26% had urinary retention versus 18% of untreated participants (P = 0.162). Adjusting for age, parity, pain, operative time, blood loss, sling type, analgesic, scopolamine patch, or hemostatic agent use, treated participants had 72% higher odds of urinary retention (adjusted odds ratio, 1.72; 95% confidence interval, 0.88-3.38; P = 0.113). There was no difference in unexpected admission, analgesic usage, time to discharge, or pain between groups. CONCLUSIONS: One of 5 women had urinary retention after outpatient midurethral sling placement. Although no statistically significant difference was found in urinary retention between groups, the odds of urinary retention in the treated group were increased. Because there was no difference in pain, analgesic usage, or time to discharge between groups, investigation regarding gabapentin use for outpatient urogynecologic surgery is needed.

A stepwise approach to robotic assisted excision of a cesarean scar pregnancy.

OBJECTIVE: To develop a stepwise approach to robotic assisted excision of cesarean scar pregnancy (CSP) with metroplasty. METHODS: This illustrative video presentation demonstrating CSP, the criteria for ultrasound diagnosis, and a step-by-step approach for robotic assisted excision of CSP and multi-layer hysterotomy closure at a tertiary medical center. RESULTS: Robotic assisted resection is a safe and feasible method to treat cesarean scar ectopic pregnancies. Key ultrasonographic characteristics of CSP are highlighted to facilitate its diagnosis, thus allowing for early intervention with a minimally invasive surgical treatment as necessary. Our patient was a 30-year-old gravida 2 para 1 woman with a history of 1 prior-term low transverse cesarean delivery, who presented with vaginal bleeding in the first trimester and was ultimately diagnosed with CSP. After unsuccessful methotrexate therapy, the patient underwent an uncomplicated robotic assisted excision of her CSP and metroplasty in 2 layers using a stepwise approach: Step 1-Creation of a bladder flap; Step 2-Isolation and excision of CSP; Step 3-Hysterotomy closure in 2 layers; and Step 4-Hysteroscopy. CONCLUSION: When diagnosed late, cesarean scar ectopic pregnancy can cause a significant hemorrhage from rupture. Early radiologic diagnosis does not only indicate minimally invasive surgery as a treatment option but also assists with related surgical planning. This video demonstrates a stepwise approach to the robotic assisted excision of CSP with metroplasty. With these 4 simple steps, surgical procedure can be safe and efficient.