Anna C. Frick

Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial.

OBJECTIVE: To compare conventional laparoscopic and robotic-assisted laparoscopic sacrocolpopexy for vaginal apex prolapse. METHODS: This single-center, blinded randomized trial included participants with stage 2–4 posthysterectomy vaginal prolapse. Participants were randomized to laparoscopic or robotic sacrocolpopexy. The primary outcome was total operative time from incision to closure. Secondary outcomes were postoperative pain, functional activity, bowel and bladder symptoms, quality of life, anatomic vaginal support, and cost from a health care system perspective. RESULTS: A total of 78 patients enrolled and were randomized (laparoscopic n=38; robotic n=40). Total operative time was significantly longer in the robotic group compared with the laparoscopic group (+67-minute difference; 95% confidence interval [CI] 43–89; P<.001). Anesthesia time, total time in the operating room, total sacrocolpopexy time, and total suturing time were all significantly longer in the robotic group. Participants in the robotic group also had significantly higher pain at rest and with activity during weeks 3 through 5 after surgery and required longer use of nonsteroidal anti-inflammatory drugs (median, 20 compared with 11 days, P<.005). The robotic group incurred greater cost than the laparoscopic group (mean difference +

Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse

1,936; 95% CI

Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse.

417–

Effect of Prior Cesarean Delivery on Risk of Second-Trimester Surgical Abortion Complications

3,454; P=.008). Both groups demonstrated significant improvement in vaginal support and functional outcomes 1 year after surgery with no differences between groups. CONCLUSION: Robotic-assisted sacrocolpopexy results in longer operating time and increased pain and cost compared with the conventional laparoscopic approach. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00551993. LEVEL OF EVIDENCE: I

Risk of deep venous thrombosis and pulmonary embolism in urogynecologic surgical patients

OBJECTIVE The aim of this study was to assess the risk of unanticipated abnormal gynecologic pathology at the time of reconstructive pelvic surgery to better understand risks of uterine conservation in the surgical treatment of uterovaginal prolapse. STUDY DESIGN This was a retrospective analysis of pathology findings at hysterectomy with reconstructive pelvic surgery over a 3.5-year period. RESULTS Seventeen of 644 patients had unanticipated premalignant or malignant uterine pathology (2.6%; 95% confidence interval, 1.7-4.2). Two (0.3%; 95% confidence interval, 0.09-1.1) had endometrial carcinoma. All cases of unanticipated disease were identified in postmenopausal women. CONCLUSION Premenopausal women with uterovaginal prolapse and normal bleeding patterns or with negative evaluation for abnormal uterine bleeding have a minimal risk of abnormal gynecologic pathology. In postmenopausal women without bleeding, the risk of unanticipated uterine pathology is 2.6% but may be reduced by preoperative endometrial evaluation. However, in women with a history of postmenopausal bleeding, even with a negative endometrial evaluation, we do not recommend uterine preservation at the time of prolapse surgery.

Laparoscopic management of incontinence and pelvic organ prolapse.

Objectives To investigate attitudes toward hysterectomy in women seeking care for pelvic organ prolapse. Methods Two hundred twenty women referred for evaluation of prolapse without evidence of previous hysterectomy were surveyed with the Pelvic Organ Prolapse Distress Inventory; the Control Preferences Scale; and questions regarding patients’ perception of the impact of hysterectomy on health, social life, and emotional well-being. Additional items presented hypothetical scenarios. Surveys were distributed in small batches until 100 responses were obtained from patients who met inclusion criteria. Results One hundred women with an intact uterus responded. Sixty percent indicated they would decline hysterectomy if presented with an equally efficacious alternative to a hysterectomy-based prolapse repair. The doctor’s opinion, risk of surgical complications, and risk of malignancy were the most important factors in surgical decision making. Conclusions Many women with prolapse prefer to retain their uterus at the time of surgery in the absence of a substantial benefit to hysterectomy. These findings should provide further impetus to investigate the efficacy of uterine-sparing procedures to help women make informed decisions regarding prolapse surgery.

Comparison of Responsiveness of Validated Outcome Measures After Surgery for Stress Urinary Incontinence

OBJECTIVE: To estimate second-trimester surgical abortion complication rates and to estimate the effect of past cesarean delivery on the risk of complications. METHODS: Demographic, medical, and operative data were collected prospectively between October 2004 and March 2007 in an academic, urban, U.S. abortion clinic. Complication and intervention rates were calculated. Multivariable logistic regression models were used to evaluate risk factors for a major complication, hemorrhage, cervical laceration, and atony. RESULTS: We included 2,973 second-trimester surgical abortions. Cervical laceration (3.3%), atony (2.6%), and hemorrhage (1.0%) were the most common complications. The rate of major complications (eg, transfusion, disseminated intravascular coagulation, and reoperation) was 1.3%. In multivariable logistic regression modeling, a history of two or more cesarean deliveries was the strongest predictor for having a major complication (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.4–15.8), while additional predictors included gestational age of 20 weeks or more (OR 4.4, 95% CI 2.0–11.4) and insufficient initial cervical preparation requiring further dilation (OR 2.6, 95% CI 1.2–5.4). CONCLUSION: Second-trimester surgical abortions were associated with a major complication rate of approximately 1%. A history of two or more cesarean deliveries was associated with a sevenfold increase in odds of major complication and was the strongest independent risk factor for a major complication. LEVEL OF EVIDENCE: III

Robotic-assisted laparoscopic management of ureteral endometriosis.

OBJECTIVE We sought to determine the incidence of symptomatic deep venous thrombosis and pulmonary embolism, collectively referred to as venous thromboembolic events (VTE), in patients undergoing urogynecologic surgery to guide development of a VTE prophylaxis policy for this patient population. STUDY DESIGN We conducted a retrospective analysis of VTE incidence among women undergoing urogynecologic surgery over a 3-year period. All patients wore sequential compression devices intraoperatively through hospital discharge. RESULTS Forty of 1104 patients (3.6%) undergoing urogynecologic surgery were evaluated with chest computed tomography, lower extremity ultrasound, or both for suspicion of VTE postoperatively. The overall rate of venous thromboembolism in this population was 0.3% (95% confidence interval, 0.1-0.8). CONCLUSION Most women undergoing incontinence and reconstructive pelvic surgery are at a low risk for VTE. Sequential compression devices appear to provide adequate VTE prophylaxis in this patient population.

Conventional Laparoscopic Versus Robotic-Assisted Laparoscopic Sacral Colpopexy: A Randomized Controlled Trial

Laparoscopy provides an enticing alternative for incontinence and pelvic floor procedures that would otherwise require a laparotomy or that would be difficult vaginally. Despite some data suggesting lower cure rates with the laparoscopic Burch when compared with the open approach or trans-vaginal tape, the safety and relative efficacy of the laparoscopic procedure support its continued use. Laparoscopic sacrocolpopexy seems to yield comparable outcomes when compared with the open approach and is associated with a shorter hospitalization. Although laparoscopic paravaginal defect, cystocele, and rectocele repairs are technically feasible and may have a role as a concomitant procedure, a vaginal approach is more appropriate for an isolated operation.

Conventional Laparoscopic versus Robotic-Assisted Laparoscopic Sacrocolpopexy: A Randomized Controlled Trial

PURPOSE We compared the responsiveness of several validated incontinence, pelvic floor and quality of life outcome measures in women undergoing surgery for stress urinary incontinence to assist investigators in selecting appropriate outcomes in future trials of stress urinary incontinence therapy. MATERIALS AND METHODS This is an ancillary analysis of data from a multicenter, randomized trial comparing tension-free vaginal tape and transobturator slings. All patients were asked to complete outcome measures at baseline and again 1 year postoperatively, including Incontinence Severity Index, Pelvic Floor Distress Inventory-Short Form 20, Pelvic Floor Impact Questionnaire-Short Form 7, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12, SF-12® and a 3-day bladder diary. They also completed the Patient Global Index of Improvement at 1 year. We assessed the responsiveness of each outcome measure by calculating a standardized response mean and performing receiver operator characteristics curve analysis. RESULTS Incontinence Severity Index, Pelvic Floor Distress Inventory-Short Form 20, Urinary Distress Inventory-Short Form, Pelvic Floor Impact Questionnaire-Short Form 7 and Urinary Impact Questionnaire-Short Form 7 showed excellent responsiveness (standardized response mean ≥1.0). Using receiver operator characteristics curve data the bladder diary had the greatest ability to discriminate patients who did vs did not improve (area under the curve 0.97). Incontinence Severity Index, Pelvic Floor Distress Inventory-Short Form 20 and Urinary Distress Inventory-Short Form also showed strong responsiveness according to these data (area under the curve greater than 0.7). CONCLUSIONS In this study of women undergoing mid urethral sling surgery for stress urinary incontinence the greatest responsiveness was noted on Incontinence Severity Index, Pelvic Floor Distress Inventory-Short Form 20, Urinary Distress Inventory-Short Form and bladder diary. Thus, they may be preferable as primary outcome measures in trials of stress urinary incontinence treatment.