AnnaMarie Connolly

Abdominal sacrocolpopexy: A comprehensive review

OBJECTIVE: To summarize published data about abdominal sacrocolpopexy and to highlight areas about which data are lacking. DATA SOURCES: We conducted a literature search on MEDLINE using Ovid and PubMed, from January,1966 to January, 2004, using search terms “sacropexy,” “sacrocolpopexy,” “sacral colpopexy,” “colpopexy,” “sacropexy,” “colposacropexy,” “abdominal sacrocolpopexy” “pelvic organ prolapse and surgery,” and “vaginal vault prolapse or surgery” and included articles with English-language abstracts. We examined reference lists of published articles to identify other articles not found on the electronic search. METHODS OF STUDY SELECTION: We examined all studies identified in our search that provided any outcome data on sacrocolpopexy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data. TABULATION, INTEGRATION, AND RESULTS: Follow-up duration for most studies ranged from 6 months to 3 years. The success rate, when defined as lack of apical prolapse postoperatively, ranged from 78–100% and when defined as no postoperative prolapse, from 58–100%. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range 0–18.2%) and 4.9% (range 1.2% to 30.9%), respectively. The overall rate of mesh erosion was 3.4% (70 of 2,178). Some reports found more mesh erosions when concomitant total hysterectomy was done, whereas other reports did not. There were no data to either support or refute the contentions that concomitant culdoplasty or paravaginal repair decreased the risk of failure. Most authors recommended burying the graft under the peritoneum to attempt to decrease the risk of bowel obstruction; despite this, the median rate (when reported) of small bowel obstruction requiring surgery was 1.1% (range 0.6% to 8.6%). Few studies rigorously assessed pelvic symptoms, bowel function, or sexual function. CONCLUSION: Sacrocolpopexy is a reliable procedure that effectively and consistently resolves vaginal vault prolapse. Patients should be counseled about the low, but present risk, of reoperation for prolapse, stress incontinence, and complications. Prospective trials are needed to understand the effect of sacrocolpopexy on functional outcomes.

Sexual Function 6 Months After First Delivery

OBJECTIVE: To explore the association of anal sphincter laceration and sexual function 6 months postpartum in the Childbirth and Pelvic Symptoms (CAPS) cohort. METHODS: The primary CAPS study, a prospective cohort study, was designed to estimate the postpartum prevalence and incidence of urinary and fecal incontinence. Three cohorts of new mothers (vaginal delivery with a third- or fourth-degree anal sphincter tear, vaginal delivery without a third- or fourth-degree anal sphincter tear, and cesarean delivery without labor) were compared at 6 months postpartum. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Short Form Questionnaire (PISQ-12). Urinary and fecal incontinence were assessed using the Medical Epidemiological and Social Aspects of Aging questionnaire and the Fecal Incontinence Severity Index, which is embedded within the Modified Manchester Health Questionnaire. RESULTS: Most women (459 [90%]) of those with partners reported sexual activity at the 6-month visit. Fewer women whose delivery was complicated by anal sphincter laceration reported sexual activity when compared with those who delivered vaginally without sphincter laceration (88 compared with 94%, P=.028). The mean PISQ-12 score (39±4) did not differ between delivery groups (P=.92). Pain (responses of “sometimes,” “usually,” or “always”) during sex affected one of three sexually active women (164 [36%]). CONCLUSION: At 6 months postpartum, primiparous women who delivered with anal sphincter laceration are less likely to report sexual activity. LEVEL OF EVIDENCE: II

Non-surgical management of stress urinary incontinence: ambulatory treatments for leakage associated with stress (ATLAS) trial.

Background Non-surgical treatment for stress urinary incontinence (SUI) is recommended as first-line therapy, yet few prospective studies and no randomized trials compare the most common non-surgical treatments for SUI. Purpose To present the design and methodology of the ambulatory treatments for leakage associated with stress (ATLAS) trial, a randomized clinical trial comparing three interventions for predominant SUI in women: intravaginal continence pessary; behavioral therapy (including pelvic floor muscle training and exercise and bladder control strategies); and a combination of the two treatments. Methods Treatment outcome measures, collected at 12 weeks and six and 12 months post randomization, include the Patient Global Impression of Improvement (PGI-I), the Stress Incontinence Scale of the Pelvic Floor Distress Inventory (PFDI), seven-day bladder diaries, Pelvic Floor Impact Questionnaire (PFIQ), Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ-12), Patient Satisfaction Questionnaire (PSQ) and the Medical Outcomes Study Short Form Health Survey (SF-36). Limitations The study design reduces most common biases, but some degree of selection bias may remain. Conclusion This trial will provide useful information to help counsel women with stress and mixed incontinence about the relative efficacy and satisfaction with pessary, behavioral therapy and both treatments combined.

Robotic versus vaginal urogynecologic surgery: a retrospective cohort study of perioperative complications in elderly women.

Objectives The primary objective was to compare perioperative complications after robotic surgery (RS) versus vaginal surgery (VS) for apical prolapse repair in elderly women. The secondary objectives were to (1) assess whether tools designed to predict surgical morbidity, the American Society of Anesthesiologists (ASA) class and the Charlson Comorbidity Index (CCI), are useful in the elderly urogynecologic population and (2) to classify complications during urogynecologic apical procedures using the Dindo classification system. Methods We reviewed medical records of women 65 years or older who underwent RS or VS between March 2006 and April 2011. Procedures included robotic sacrocolpopexy and sacrocervicopexy, vaginal uterosacral ligament suspension, sacrospinous ligament suspension, colpocleisis, and Uphold vaginal mesh placement. We assessed preoperative risks using ASA and CCI classification and complications using Dindo grade. Results There were 136 eligible cases (RS, 70; and VS, 66) during the 5-year study period. Women who underwent RS were younger (70 vs 74 years; P < 0.001). Vaginal surgery had more severe comorbidities as measured by the CCI (P = 0.012) but similar ASA profiles (P = 0.10). Robotic surgery had longer operative times (P < 0.001) but a lower estimated blood loss (P < 0.001). There were fewer postoperative complications in RS (P = 0.005). However, complication severity based on Dindo grade was similar between RS and VS, with most surgeries having no complications. Conclusions In the elderly women, RS was associated with fewer postoperative complications than VS. Overall, all procedures were associated with few complications, and either route may be reasonable in the elderly population.

Potential Risk Factors Associated With Subtypes of Uterine Leiomyomata

Objective: To compare potential risk factors for uterine leiomyomata (UL) subtypes among premenopausal African American and Caucasian women. Methods: This cross-sectional study included 986 premenopausal women, aged 35 to 49 years old, from the National Institute of Environmental Health Sciences (NIEHS) Uterine Fibroid Study (UFS). Uterine leiomyomata were subtyped as submucosal, intramural/subserosal, and diffuse, based on ultrasound examinations. Results: For both ethnic groups, age, age at menarche, body mass index, and current physical activity had similar associations across the 3 UL subtypes. Inverse associations with pregnancies after age 24 appeared to be stronger for the submucosal subtype. Current smoking was associated only with diffuse UL (adjusted odds ratio [aOR] = 1.97, 95% CI: 1.11, 3.51 in African Americans, aOR = 3.00, 95% CI: 1.07, 8.38 in Caucasians). Conclusions: Although the 2 focal UL subtypes had similar risk factor profiles, the diffuse UL subtype appeared to have a distinctive risk profile with regard to current smoking. Further study of the diffuse heterogeneity seen with uterine ultrasound is needed.

Get on your boots: Preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism

INTRODUCTION Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeons formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. METHODS We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. RESULTS A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). CONCLUSIONS Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

Severe separation of the pubic symphysis and prompt orthopedic surgical intervention

BACKGROUND: The incidence of pubic symphysis separation during delivery is 1 in 300 to 1 in 30,000 pregnancies, and it can cause a variety of problems such as pain, bladder dysfunction, and difficulty ambulating. There is no consensus on how to treat pregnancy-related pubic symphyseal separation. CASE: A patient, gravida 1 para 1, who underwent vacuum-assisted vaginal delivery was found to have a severe vaginal sidewall laceration and a 6.2-cm symphyseal disruption. The patient was treated with external fixation of an open book pelvis and physical therapy. She was discharged to home on postpartum day 4, voiding spontaneously and ambulatory with a walker. CONCLUSION: Aggressive treatment of severe pubic symphysis separation with external fixation resulted in early ability to ambulate, void, and care for self and baby.

Evaluation of Aa point and cotton-tipped swab test as predictors of urodynamic stress incontinence

OBJECTIVE: To compare the predictive abilities of the Aa point of the pelvic organ prolapse quantification examination and the cotton-tipped swab test straining angle to diagnose urodynamic stress incontinence. METHODS: A case-control study was conducted between June 1997 and February 2003. Cases were defined as patients with urodynamic stress incontinence (n = 352). Controls were patients who also underwent urodynamic testing but who did not have a diagnosis of urodynamic stress incontinence (n = 245). Independent variables were defined as Aa point, Aa point of 0 or greater, straining cotton-tipped swab angle, and straining cotton-tipped swab angle of 30° or greater. Logistic regression estimated the odds ratio of stress incontinence in women based on Aa values and cotton-tipped swab straining angle measurements, controlling for other variables commonly associated with stress incontinence. RESULTS: The mean (± standard deviation) age of the cases was 55.9 ± 13.4 and of controls was 55.3 ± 14.8, (P = .6). The median parity of the cases was 2 (range 0–10) and of controls, 2 (range 0–9) (P = .7). The Aa point was not associated with a diagnosis of stress incontinence (odds ratio 1.01, 95% confidence interval (CI) 0.83–1.23). The adjusted odds ratios of having an Aa value of 0 or greater was 0.49 (95% CI 0.26–0.92), and of having a cotton-tipped swab angle of 30° or greater was 3.1 (95% CI 1.09–5.07), in a model that adjusted for age, parity, race, and postmenopausal and hormonal replacement status. CONCLUSION: Aa point is not associated with a diagnosis of stress incontinence. However, a cotton-tipped swab angle of 30° or greater is positively associated with stress incontinence. LEVEL OF EVIDENCE: II-2

Effect of anticholinergic use for the treatment of overactive bladder on cognitive function in postmenopausal women.

BACKGROUND Overactive bladder (OAB) is a common condition affecting the elderly. The mainstay of treatment for OAB is medical therapy with anticholinergics. However, adverse events have been reported with this class of drugs, including cognitive changes. OBJECTIVE The objective of this study was to investigate the effect of an anticholinergic medication, trospium chloride, on cognitive function in postmenopausal women being treated for OAB. METHODS This was a prospective cohort study conducted at a urogynaecology clinic at one academic medical centre from January to December 2010, with 12-week follow-up after medication initiation. Women aged 55 years or older seeking treatment for OAB and opting for anticholinergic therapy were recruited. Baseline cognitive function was assessed via the Hopkins Verbal Learning Test-Revised Form (HVLT-R) [and its five subscales], the Orientation, Memory & Concentration (OMC) short form, and the Mini-Cog evaluation. After initiation of trospium chloride extended release, cognitive function was reassessed at Day 1, Week 1, Week 4 and Week 12. Bladder function was assessed via three condition-specific quality-of-life questionnaires. Secondary outcomes included change in bladder symptoms, correlation between cognitive and bladder symptoms, and overall medication compliance. The main outcome measure was change in HVLT-R score at Week 4 after medication initiation, compared with baseline (pre-medication) score. RESULTS Of 50 women enrolled, 35 completed the assessment. The average age was 70.4 years and 77.1% had previously taken anticholinergic medication for OAB. At enrollment 65.7% had severe overactive bladder and 71.4% had severe urge incontinence. Cognitive function showed an initial decline on Day 1 in HVLT-R total score (p = 0.037), HVLT-R Delayed Recognition subscale (p = 0.011) and HVLT-R Recognition Bias subscale (p = 0.01). At Week 1 the HVLT-R Learning subscale declined from baseline (p = 0.029). All HVLT-R scores normalized by Week 4. OMC remained stable throughout. The Mini-Cog nadired at a 90.9% pass rate at Week 4. OAB symptoms did not improve until Week 4, based on questionnaire scores (p < 0.05). CONCLUSION Cognitive function exhibited early changes after initiation of trospium chloride but normalized within 4 weeks. Cognitive changes occurred weeks prior to OAB symptom improvement. Surveillance for cognitive changes with anticholinergic use should be part of OAB management.

Uterine leiomyomata associated with self-reported stress urinary incontinence.

AIMS To investigate the association between the presence and characteristics of uterine leiomyomata (UL) and self-reported stress urinary incontinence (SUI). METHODS The study included 836 premenopausal participants (474 African American and 362 Caucasian) in the National Institute of Environmental Health Sciences (NIEHS) Uterine Fibroid Study. UL were characterized at baseline with ultrasound screening, and SUI was assessed at follow-up (after 4 years, on average). Linear risk models were used to estimate adjusted prevalence differences (aPD) and 95% confidence intervals (CI), controlling for age, ethnicity, body mass index (BMI), and number of deliveries. RESULTS Compared with women without UL, SUI prevalence was higher among women with any UL (aPD = 7.4%, 95% CI 0.4-14.3) and women with UL 2-4 cm (aPD = 9.6%, 95% CI 1.3-17.9). Marginally significant results were found for the presence of UL > or =4 cm and anterior UL > or =2 cm. CONCLUSIONS The observed 7% increase in prevalence of this common condition for women with UL is of clinical importance. Further research is needed before concluding that treatment for larger UL might enhance SUI treatment in some women.