Catherine A. Matthews

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the “gold standard” procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.

Bladder Capacity is a Biomarker for a Bladder Centric versus Systemic Manifestation in Interstitial Cystitis/Bladder Pain Syndrome

Purpose: Interstitial cystitis/bladder pain syndrome presents a significant clinical challenge due to symptom heterogeneity and the myriad associated comorbid medical conditions. We recently reported that diminished bladder capacity may represent a specific interstitial cystitis/bladder pain syndrome subphenotype. The objective of this study was to investigate the relationship between anesthetic bladder capacity, and urological and nonurological clinical findings in a cohort of patients with interstitial cystitis/bladder pain syndrome who had undergone therapeutic urinary bladder hydrodistention. Materials and Methods: This is a retrospective chart review of prospectively collected data on women diagnosed with interstitial cystitis/bladder pain syndrome between 2011 and 2015 who underwent bladder hydrodistention. Assessments in each patient included a detailed history and physical examination, ICPI (Interstitial Cystitis Problem Index), ICSI (Interstitial Cystitis Symptom Index) and PUF (Pelvic Pain and Urgency/Frequency Patient Symptom Scale). Bladder capacity was determined during bladder hydrodistention with the patient under general anesthesia. Results: Mean age was 45.8 years and mean bladder capacity was 857 ml in the 110 enrolled patients. We found a significant inverse correlation between bladder capacity and scores on 3 gold standard interstitial cystitis/bladder pain syndrome metrics, including ICPI (p = 0.0014), ICSI (p = 0.0022) and PUF (p = 0.0009) as well as urination frequency (p = 0.0025). Women with higher bladder capacity were significantly more likely to report depression (p = 0.0059) and irritable bowel syndrome (p = 0.022). Conclusions: Low bladder capacity while under anesthesia was significantly associated with high symptom scores on 3 validated interstitial cystitis/bladder pain syndrome questionnaires as well as with urinary frequency. However, it was not associated with depression or other common systemic pain problems. These results suggest that low bladder capacity is a marker for a bladder centric manifestation of interstitial cystitis/bladder pain syndrome.

New Developments in Robotics and Single-site Gynecologic Surgery.

Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset

Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse.

Validation of an educational simulation model for vaginal hysterectomy training: a pilot study

Introduction and hypothesisThe Miya Model ™ (Miyazaki Enterprises, Winston-Salem, NC, USA) was designed as a realistic vaginal surgery simulation model. Our aim was to describe this model and present pilot data on validity and reliability of the model as an assessment tool of vaginal hysterectomy skills.MethodsWe video recorded ten obstetrics and gynecology residents (novice group) and ten practicing gynecologists (expert group) performing vaginal hysterectomy using the Miya model. Blood loss and time taken to complete the procedure were documented. Participants evaluated the model using a postsimulation survey. In addition, two experienced gynecologic surgeons independently evaluated video recordings of each participant’s performance using two previously validated global rating scales: Reznick’s Objective Structured Assessment of Technical Skill (OSATS) and Vaginal Surgical Skills Index (VSSI).ResultsMost participants (80% of novice and 100% of expert group) rated the model as effective or highly effective for vaginal hysterectomy training and assessment. Median time to procedure completion was significantly higher in the novice group, whereas median estimated blood loss was no different between groups. No significant differences were observed in the composite median OSATS or VSSI scores between groups. The interrater reliability indices for subscales and composite scores of the OSATS and VSSI were high and ranged from 0.79 to 0.90 and 0.77 to 0.93, respectively.ConclusionsWith further study, the Miya Model may be a useful tool for teaching and assessing vaginal surgical skills.

Physical Activity, BMI, and Risk of Fecal Incontinence in the Nurses’ Health Study

Background: Higher body mass index (BMI) and low physical activity have been associated with increased prevalence of fecal incontinence (FI) in cross‐sectional studies, but prospective studies examining the role of these factors are lacking. We sought to determine whether BMI and/or physical activity are associated with risk of FI among older women. Methods: We prospectively examined the association between BMI and physical activity and risk of FI in the Nurses’ Health Study among 51,708 women who were free of FI in 2008. We defined FI as at ≥1 liquid or solid FI episode/month during the past year reported in 2010 or 2012. We used Cox proportional hazards models to calculate multivariable‐adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for FI according to physical activity and BMI, adjusting for potential confounding factors. Results: During more than 175,000 person‐years of follow‐up, we documented 5954 cases of incident FI. Compared with women in the lowest activity category (<3 metabolic equivalent of task (MET)‐hrs/week), multivariable‐adjusted HRs for FI were 0.86 (95% CI 0.80–0.93) for women doing 3–8 MET‐hrs/week, 0.78 (95% CI 0.72–0.84) for 9–17 MET‐hrs/week, 0.76 (95% CI 0.69–0.83) for 18–26 MET‐hrs/week, and 0.75 (95% CI 0.70–0.81) for 27 + MET‐hrs/week (Ptrend = <0.0001). There was no association between BMI and risk of FI. Conclusions: Higher levels of physical activity were associated with a modest reduction (25%) in risk of incident FI among older women. These results support a potential role of ongoing physical activity in the neuromuscular health of the anorectal continence mechanism with aging. Translational impact: These results support a potential role of ongoing physical activity in the neuromuscular health of the anorectal continence mechanism with aging.

PD02-12 THE EFFECT OF RESIDENT INVOLVEMENT IN PELVIC PROLAPSE SURGERY: A RETROSPECTIVE STUDY FROM A NATIONWIDE INPATIENT SAMPLE

INTRODUCTION AND OBJECTIVES: We evaluated satisfaction, quality of life, and additional treatments after transvaginal (TV) and abdominal (ABD) pelvic organ prolapse (POP) repair. METHODS: Adult women enrolled in a prospective POP database were reviewed. Baseline and outcomes data one year after surgery were collected from medical records, validated Pelvic Floor Distress Inventory (PFDI), and mailed surveys, and analyzed with descriptive statistics, Fishers Exact, and two sample t tests. RESULTS: Two hundred twenty-two patients were identified from the database, of whom 147 (66%) had TV and 75 (34%) had ABD repair. TV patients were older (mean 64.1 vs. 59.7 years; p1⁄40.003) but no differences in BMI, race, marital status or other demographics were identified. Preoperative mean anterior (TV 2.7 vs. ABD 3.1; p1⁄40.003) and apical (TV 2.1 vs. ABD 3.1; p<0.001) POP grades were more severe in the ABD patients compared to the TV patients. Baseline PFDI scores however were similar between groups (TV 115.8 vs. ABD 111.6, p1⁄40.605). At one year PFDI scores were improved in both groups, though were significantly higher in the TV group (45.6 vs. 32.6; p1⁄40.032). Absolute score improvement from baseline to 1-year did not differ (TV -67.6 vs. ABD -76.1, p1⁄40.353). The majority of patients in both groups reported moderately or markedly improved overall symptoms (TV 79/101; 78% and ABD 51/59; 86% p1⁄40.199) and quality of life (80/101; 79% and 51/59; 87% p1⁄40.252). Similar proportions of patients in both groups (TV 52/109; 48% vs. ABD 21/62; 34%, p1⁄40.108) had additional POP treatments including pelvic floor physical therapy, medications, coping strategies, and surgical procedures. Specifically, there was no difference in rates of additional surgical treatments for prolapse between groups (TV 32/109; 29% vs. ABD 10/62; 11%, p1⁄40.053). Most TV and ABD patients were satisfied (68/101; 68% and 48/59; 81%, p1⁄40.055, respectively) and would recommend to a friend (85/99; 86% and 55/57; 96%, p1⁄40.052). CONCLUSIONS: This study suggests that although symptoms, satisfaction and quality of life improve after both TV and ABD prolapse repair, women seek additional treatments as early as the first year after POP repair.

Evaluation of the efficacy of postmortem human bladder tissue as a normal comparator for case-controlled gene expression studies in urology.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a poorly understood disease with no absolute diagnostic marker. A molecular‐based tool (biomarker) for IC/BPS diagnosis would have immediate clinical utility. We have generated a bank of bladder biopsy tissue from IC/BPS patients and require a control group for comparative gene expression studies. The objective of this pilot study was to investigate the feasibility of cadaveric bladder specimens as a viable source of control tissue.

The Effect of Resident Involvement in Pelvic Prolapse Surgery: A Retrospective Study From a Nationwide Inpatient Sample

Objective The primary aim of this study was to assess the effect of resident involvement on perioperative complication rates in pelvic organ prolapse surgery using the National Surgical Quality Improvement database. Methods All pelvic organ prolapse operations from 2006 to 2012 were identified and dichotomized by resident participation. Preoperative characteristics and 30-day perioperative outcomes were compared using &khgr;2 and Student t test. To control for nonrandomization of cases, propensity scores representing the probability of resident involvement as a function of a cases comorbidities were calculated. They were then divided into quartiles, and because of equal probabilities for the first and second quartiles, 3 groups were created (Q1/2, Q3, and Q4), followed by substratification and analysis. As a control, complications of transurethral resection of prostate and nephrectomy were dichotomized by resident involvement. Results We identified 2637 cases. Resident involvement was associated with increased postoperative urinary tract infections, perioperative complications, and procedure length. After stratification by propensity scoring, the following unique findings occurred in each group: in the first group, resident involvement was associated with increased rates of readmission, pulmonary embolism, and sepsis; in the second and third groups, resident involvement was associated with increased rates of superficial surgical site infection. Resident involvement in nephrectomy observed increased perioperative complications and procedural length. In prostate resection, increased procedure lengths and decreased postoperative length of stay were observed. Conclusions Resident involvement in pelvic organ prolapse surgery was associated with an increased risk of adverse outcomes. A similar effect was seen with nephrectomy but not with a more simple endoscopic urologic procedure.