Brent A. Parnell

Robotic vs abdominal sacrocolpopexy: 44-month pelvic floor outcomes.

OBJECTIVE To evaluate longer-term clinical outcomes after robotic vs abdominal sacrocolpopexy for the treatment of advanced pelvic organ prolapse (POP). MATERIAL AND METHODS This was a retrospective cohort assessment of women undergoing either robotic or abdominal sacrocolpopexy between March 2006 and October 2007. Pelvic floor support was measured using Pelvic Organ Prolapse Quantification (POP-Q) examination, and pelvic floor function was assessed via validated questionnaires, including the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). RESULTS The analysis included 51 subjects: 23 robotic and 28 abdominal. Mean time since surgery was 44.2 ± 6.4 months. Postoperative POP-Q improved similarly from baseline in both the robotic and abdominal groups: C (-8 vs -7), Aa (-2.5 vs -2.25), Ap (-2 vs -2) (all P >.05 based on route of surgery). Pelvic floor function also improved similarly in both groups: PFDI-20 (61.0 vs 54.7), PFIQ-7 (19.1 vs 15.7), with high sexual function PISQ-12 (35.1 vs 33.1) (all P >.05 based on route of surgery). Two mesh exposures occurred in each group for a rate of 8% and 7%, respectively. CONCLUSION Robotic sacrocolpopexy demonstrates similar long-term outcomes compared with abdominal sacrocolpopexy. The robotic approach offers an effective treatment alternative to abdominal sacrocolpopexy for the lasting treatment of advanced POP.

Pelvic Floor Function Before and After Robotic Sacrocolpopexy: One-Year Outcomes

STUDY OBJECTIVE Estimate pelvic floor function and support 1 year after robotic sacrocolpopexy. DESIGN Prospective cohort analysis of women undergoing robotic sacrocolpopexy for correction of advanced pelvic organ prolapse (Canadian Task Force Classification III). Primary outcome was pelvic floor function. Secondary outcomes included anatomic support and long-term surgical failures and complications. SETTING One university hospital in the southeastern United States. PATIENTS Primarily postmenopausal women (mean age 60) with advanced pelvic organ prolapse. INTERVENTIONS All subjects underwent robotic sacrocolpopexy during the study period. Subjects then underwent 1-year postoperative assessment of pelvic floor function via validated condition-specific quality of life questionnaires and assessment of pelvic floor support, long-term surgical failures, and complications via physical examination. MEASUREMENTS AND MAIN RESULTS From November 2007 to April 2009, there were 28 subjects, 25 of whom (89.3%) were evaluated. Mean time since surgery was 14.8 months. Pelvic floor function remained significantly improved over preoperative baseline: PFDI-20 (117 vs 38, p <.001), PFIQ-7 (60 vs 10, p = .001), with stable high sexual function: PISQ-12 (34 vs. 36, p = .17), and improved pelvic support on POP-Q: Ba (+3 vs -2, p = .001), Bp (+0.5 vs -1, p = .092), C (+2.25 vs -8, p = .001). Anatomic cure for vault prolapse was 100% at 1 year. There were two mesh exposures and two subsequent prolapse surgeries. CONCLUSION Robotic sacrocolpopexy demonstrates durable improvement in pelvic floor function and support, with high sexual function and reasonable failure and complication rates 1 year after surgery.

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.

Diagnostic accuracy of retrograde and spontaneous voiding trials for postoperative voiding dysfunction: a randomized controlled trial.

OBJECTIVE: To compare the diagnostic accuracy of two voiding trial methods to predict postoperative voiding dysfunction. METHODS: Women undergoing operations for urinary incontinence, prolapse, or both urinary incontinence and prolapse from November 2009 and March 2010 were randomized into one of two groups: retrograde or spontaneous. All patients underwent both techniques of voiding trials with randomization determining order. RESULTS: Fifty women were randomized to 25 per group. Failure rates were 62% for retrograde and 84% for spontaneous. Women who failed both had 12.6±14.4 days of retention compared with 2.5±2.1 days for those who failed only one method (P=.004). The retrograde method had 94.4% sensitivity and 58.1% specificity to detect postoperative voiding dysfunction lasting at least 7 days compared with the spontaneous method with 100% sensitivity and 25.8% specificity. Positive and negative predictive values for the retrograde method were 56.7% and 94.7%, respectively, compared with the spontaneous method with 43.9% and 100%. Retrograde was preferred by patients (51.1% compared with 44.4%) regardless of randomization. CONCLUSION: The retrograde method is more accurate in evaluating postoperative voiding dysfunction, although both tests had a low positive predictive value. A longer period of retention was seen with failure of both methods. Retrograde was preferred by patients and provides an efficient alternative to the spontaneous method of voiding trial. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01091844. LEVEL OF EVIDENCE: I

The effect of sacral neuromodulation on pudendal nerve function and female sexual function.

To quantify changes in pudendal nerve function with sacral neuromodulation (SNM). To understand the relationship of pudendal nerve function to SNM treatment response for overactive bladder. To assess the relationship between female sexual function and pudendal nerve function after SNM.

Genitofemoral and perineal neuralgia after transobturator midurethral sling.

BACKGROUND: Midurethral slings successfully treat stress urinary incontinence through a minimally invasive vaginal approach. Postoperative pain related to sling placement can occur and poses both diagnostic and treatment dilemmas. CASE: Four years after transobturator midurethral sling placement, the patient presented with complaints of left labial pain and dyspareunia since surgery. Using sensory mapping and a nerve stimulator, the problem was identified in the distribution of the genitofemoral nerve. Conservative therapy with a centrally acting neuromodulatory drug and nerve block relieved the pain. CONCLUSION: Postsling neuralgia diagnosis using sensory mapping and a nerve stimulator aids in indentifying the nerve involved and in successful conservative treatment with a nerve block.

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.

Robot-assisted techniques and outcomes in the realm of pelvic reconstructive surgery.

Robotic-assisted surgery for the treatment of pelvic organ prolapse continues to grow in popularity as more surgeons adopt this technology. Encompassing all of the benefits of laparoscopic surgery, robotic-assisted techniques allow more surgeons the ability to perform complex tasks such as meticulous deep pelvic dissection and extensive suturing without having to resort to laparotomy. This chapter reviews the techniques involved in the robotic approach to pelvic reconstructive surgery and discusses the currently available information focusing on the outcomes of this procedure.

Obstetric sphincter injury interacts with diarrhea and urgency to increase the risk of fecal incontinence in women with irritable bowel syndrome.

Objectives This study aimed to confirm that fecal urgency and diarrhea are independent risk factors for fecal incontinence (FI), to identify obstetrical risk factors associated with FI in women with irritable bowel syndrome, and to determine whether obstetric anal sphincter injuries interact with diarrhea or urgency to explain the occurrence of FI. Methods The study is a supplement to a diary study of bowel symptoms in 164 female patients with irritable bowel syndrome. Subjects completed daily bowel symptom diaries for 90 consecutive days and rated each bowel movement for stool consistency and presence of urgency, pain, and FI. All female participants from the parent study were invited to complete a telephone-administered 33-item bowel symptom and obstetric history questionnaire, which included the fecal incontinence severity index. Results Of the 164 women in the parent study, 115 (70.1%) completed the interview. Seventy-four (45.1%) reported FI on their diary including 34 (29.6%) who reported at least 1 episode per month, 112 (97.4%) reported episodes of urgency, and 106 (92.2%) reported episodes of diarrhea. The mean fecal incontinence severity index score was 13.9 (9.7). On multivariable analysis, FI was significantly associated with parity (P = 0.007), operative abdominal delivery (P = 0.049), obstetrical sphincter lacerations (P = 0.007), fecal urgency (P = 0.005), diarrhea (P = 0.008), and hysterectomy (P = 0.004), but was not associated with episiotomy, pelvic organ prolapse, or urinary incontinence. The synergistic interactions of obstetric anal sphincter laceration with urgency (P = 0.002) and diarrhea (P = 0.004) were significant risk factors for FI. Conclusions Fecal urgency and diarrhea are independent risk factors for FI, and they interact with obstetric anal sphincter laceration to amplify the risk of FI.

Diagnostic accuracy of visual urethral mobility exam versus Q-Tip test: a randomized crossover trial

OBJECTIVE The objective of the study was to compare the diagnostic accuracy of a visual urethral mobility examination (VUME) with a Q-Tip test in the assessment of urethral hypermobility. STUDY DESIGN Subjects were randomized to a VUME or Q-Tip test first, followed by the alternate assessment. Outcomes included hypermobile, not hypermobile, or indeterminate. Hypermobility was defined as 30° or greater from the horizontal. Pain perception and test preference were assessed. RESULTS For the 54 subjects, 61.1% demonstrated hypermobility on VUME vs 72.2% on the Q-Tip test (P = .39). Assessment of hypermobility was correlated between the 2 tools (ρ = 0.47, P = .001). Positive and negative predictive value, sensitivity, and specificity for VUME were 88%, 56%, 78%, and 71%, respectively, with a Q-Tip test as the reference standard. Mean pain score on visual analog scale was 0.72 for VUME and 3.15 for Q-tip test (P < .001). VUME was preferred by 83% of subjects. CONCLUSION VUME is a diagnostic alternative to the Q-Tip test for the assessment of urethral hypermobility and is preferred by subjects.