Caroline Foust-Wright

Clinical application of IUGA/ICS classification system for mesh erosion

Our aim was to assess the usability of the IUGA/ICS classification system for mesh erosion in a tertiary clinical practice and to determine if assigned classification is associated with patient symptoms, treatment, and outcome.

Development of a core set of outcome measures for OAB treatment

Introduction and hypothesisStandardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).MethodsThe International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.ResultsThe standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.ConclusionsThe standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

Hormone Modulation of Toll-Like Receptor 5 in Cultured Human Bladder Epithelial Cells

AIM The effect of hormone levels on the stimulation of Toll-like receptor 5 (TLR5) in the bladder is unknown. We aimed to study the effect of estradiol and progesterone on TLR5 expression and function in human bladder epithelial cells. METHODS After growing to near confluence, T24 human urinary bladder (HUB) cells were incubated in hormone-free (HF) media for 72 hours. Human urinary bladder cells were then incubated in (1) HF media, (2) estradiol media, (3) progesterone media, or (4) media containing estradiol and progesterone at physiologic concentrations. Following flagellin exposure, cells and media were collected. Toll-like receptor 5 expression and stimulated cytokine release were analyzed using enzyme-linked immunosorbent assays. Results were normalized with cellular protein assays. A TLR5 antagonist was used to confirm that stimulation from flagellin was mediated by TLR5 signaling. RESULTS Cultured HUB cells express TLR5 protein. Estradiol and progesterone environments suppress TLR5 expression compared to HF environment. The function of TLR5 was measured by interleukin 6 (IL-6) and monocyte chemoattractant protein 1 production after flagellin exposure. Interleukin 6 production was 75% higher in the estradiol than progesterone environment. The progesterone environment produced IL-6 levels twice that observed in HF and combined estrogen-progesterone environments. Interestingly, higher TLR5 expression was associated with lower IL-6 production. CONCLUSION Our study demonstrated that TLR5 expression and functional activity as measured by IL-6 are modulated by hormones. The increase in TLR5-associated IL-6 may play a role in increasing the rate of symptomatic urinary tract infection. Likewise, low TLR5 functional activity may dampen the response of the innate immune system, thereby lessening the likelihood of a symptomatic bladder infection.Aim: The effect of hormone levels on the stimulation of Toll-like receptor 5 (TLR5) in the bladder is unknown. We aimed to study the effect of estradiol and progesterone on TLR5 expression and function in human bladder epithelial cells. Methods: After growing to near confluence, T24 human urinary bladder (HUB) cells were incubated in hormone-free (HF) media for 72 hours. Human urinary bladder cells were then incubated in (1) HF media, (2) estradiol media, (3) progesterone media, or (4) media containing estradiol and progesterone at physiologic concentrations. Following flagellin exposure, cells and media were collected. Toll-like receptor 5 expression and stimulated cytokine release were analyzed using enzyme-linked immunosorbent assays. Results were normalized with cellular protein assays. A TLR5 antagonist was used to confirm that stimulation from flagellin was mediated by TLR5 signaling. Results: Cultured HUB cells express TLR5 protein. Estradiol and progesterone environments suppress TLR5 expression compared to HF environment. The function of TLR5 was measured by interleukin 6 (IL-6) and monocyte chemoattractant protein 1 production after flagellin exposure. Interleukin 6 production was 75% higher in the estradiol than progesterone environment. The progesterone environment produced IL-6 levels twice that observed in HF and combined estrogen–progesterone environments. Interestingly, higher TLR5 expression was associated with lower IL-6 production. Conclusion: Our study demonstrated that TLR5 expression and functional activity as measured by IL-6 are modulated by hormones. The increase in TLR5-associated IL-6 may play a role in increasing the rate of symptomatic urinary tract infection. Likewise, low TLR5 functional activity may dampen the response of the innate immune system, thereby lessening the likelihood of a symptomatic bladder infection.

Transitioning to Blunt Suture Needles in Obstetric Operating Rooms: Results From a Quality Improvement Project [2G]

INTRODUCTION: Our objective was to identify impact of transition to blunt-tip suture needles in obstetric procedures on incidence of needlestick injuries (NSI) in obstetric residents and attendings. METHODS: All OBGYN residents and attending physicians in a tertiary care hospital were surveyed regarding NSI. Following this, suture needles in obstetric operating rooms were changed to blunt needles. A one-year follow-up survey was then sent. RESULTS: Prior to introduction of blunt needles, 28% of attendings had at least one NSI in previous year. Eight needlesticks were sustained in the year preceding transition to blunt needles versus 1 in the year following transition (P=.05) in attendings. Prior to their introduction, greater than 70% of attendings believed blunt needles would reduce NSI; following introduction, only 29% still felt this to be true, despite the actual reduction in NSI occurrence among attendings (P less than .01 for change). Of the responding residents, 61% had sustained at least 1 NSI in the preceding year in the initial query; 50% sustained at least 1 NSI following the introduction to blunt suture needles. At the 1-year follow-up survey, a total of 10 NSI were recalled, with a reporting rate of 50%. CONCLUSION: The introduction of blunt suture needles was associated with a decrease in total recalled needlestick injuries sustained by residents and attendings. The decrease was most notable among the attending physicians, despite their perception that blunt needles were not safer. Blunt needles are an acceptable alternative to the sharp suture needles and thus should be utilized wherever feasible.

Quality Measures for Prolapse Management

Quality measure development has become increasingly important over the past few years, and there have been many attempts to increase the scientific literature on the subject. Measurement of quality is now an integral part of the healthcare system. This review considers recently recommended quality metrics for prolapse management, subdividing these into structural, process, and outcome metrics. The Quality in Prolapse Surgery (QuIPS) project, Choosing Wisely® campaign by the American Board of Internal Medicine (ABIM), quality measures proposed by AUGS, and the 2012 joint report from IUGA and International Continence Society (ICS) are included this review. Evaluation of adherence to quality metrics is also discussed.

Predictors for Voiding Trial Failure after Minimally Invasive Sacrocolpopexy

Introduction: Catheter associated urinary tract infections (CAUTIs) due to indwelling catheters pose a serious health and financial burden in the US. Patients who undergo reconstructive pelvic surgery experience postoperative voiding dysfunction at a significant rate, requiring prolonged catheterization. The preoperative identification of patients at highest risk of failing a backfill trial of void (TOV) would allow for selected instruction in self-catheterization techniques and minimize the prevalence in dwelling catheters. Objective: To identify predictors for voiding trial failure after minimally-invasive (laparoscopic or robot-assisted) sacrocolpopexy for surgical correction of prolapse in patients who did not undergo a concomitant urinary anti-incontinence procedure. Methods: All subjects undergoing minimally-invasive sacrocolpopexy without concomitant anti-incontinence surgery from October 2006 to July 2010 at our institution were included. Patient characteristics including basic demographics, medical and surgical history, operative characteristics, and baseline preoperative urodynamic testing were included. The data was analyzed with logistic regression for continuous variables and Pearson chi-squared test for dichotomous variables (Stata IC-13). Results: 56 subjects were identified. Of those, 5 subjects (8.9%) failed a postoperative voiding trial. No significant association between examined variables and failure of trial of void were observed. Concomitant vaginal surgery approached significance with a p-value of 0.058. Conclusion:The percentage of subjects that failed a voiding trail was comparable to that described in the minimally invasive literature. Providers should educate all patients undergoing minimally invasive sacrocolpopexy as to self-catheterization techniques given the inability to identify preoperative risk factors.

Levatorplasty for Symptomatic Posterior Prolapse due to Recurrent Malignant Ascites.

Background Although infrequently described, massive ascites due to malignancy contributes to symptomatic pelvic organ prolapse. Case A 73-year-old woman with recurrent ovarian cancer and massive ascites underwent a levatorplasty for repair of posterior prolapse after failing conservative management. Conclusions Management of patient with cancer with prolapse is complex. Patients with cancer with ascites also have pelvic organ prolapse, in addition to other, better described sequelae of increased intra-abdominal pressure. These patients should be treated specifically for prolapse, with therapy, including type of surgery, chosen with special consideration of their underlying disease.

Confidence in repair of obstetric anal sphincter injuries and objective assessment in obstetricians

Objective: To describe attending obstetricians’ self-reported confidence to recognize and repair Obstetric Anal Sphincter Injuries (OASIS), assess knowledge of anatomy and risk factors for OASIS and evaluate the need for a protocol. Study design: A questionnaire was distributed to attending obstetricians at seven major medical centers. The survey was divided into categories including demographics, self-reported confidence at recognition of OASIS, self–reported competence at OASIS repair, questions on anatomy and risk factors for OASIS and need for a protocol for OASIS repair. Results: We collected 82 questionnaires for a response rate of 40.2 percent. Twenty-two (26.8%) and 59 (72%) survey respondents were respectively mostly confident or very confident and only one (1.2%) was somewhat confident at OASIS recognition. Thirty-two (39%) participants felt mostly competent, and 47 (57.3%) felt very competent at OASIS repairs. Percentage of correct answers to the objective questions on anatomy and risk factors ranged from 45.1 to 58.5. Overall performance in objective questions did not differ by self-reported competence in repair of higher order lacerations (p=0.09). Conclusions: Our study shows that self-reported confidence in detecting OASIS and competence in repair of OASIS does not correlate with knowledge of anatomy and risk factors of OASIS.