Chi Chiung Grace Chen

Biologic grafts and synthetic meshes in pelvic reconstructive surgery.

Despite the lack of evidence, augmenting pelvic organ prolapse surgery with biologic graft or synthetic mesh is increasing. The objective of this review is to examine the available grafts and meshes and discuss the current data addressing the use of these implants in correction of apical, anterior, and posterior prolapse. Most of the studies are retrospective with few randomized controlled trials. There is level I evidence suggesting that repair of apical prolapse with abdominal sacral colpopexy using synthetic mesh results in improved outcomes. However, most of the data concerning graft or mesh incorporation in anterior or posterior repairs do not support augmentation with prosthesis.

Obesity is associated with increased prevalence and severity of pelvic floor disorders in women considering bariatric surgery

BACKGROUNDnAlthough an association between obesity and urinary incontinence (UI) has been reported, the association between obesity and other PFDs is less clear. The aim of this study was to determine the prevalence of pelvic floor disorders (PFDs), including stress urinary incontinence (SUI), urge urinary incontinence (UUI), pelvic organ prolapse (POP), and anal incontinence (AI), in obese women contemplating bariatric surgery compared with nonobese subjects at a tertiary care referral hospital.nnnMETHODSnFrom September 2006 to December 2007, obese women contemplating bariatric surgery and nonobese women from general gynecology clinic completed a validated screening questionnaire for PFDs, the Sandvik urinary incontinence severity index, and the Rockwood fecal incontinence severity index.nnnRESULTSnA total of 217 obese (mean body mass index of 50 +/- 10 kg/m(2)) and 210 nonobese controls (mean body mass index 23 +/- 3 kg/m(2)) were screened. The presence of any PFD occurred in 159 patients (75%) in the obese group compared with 89 nonobese patients (44%; P <.0001). More obese patients experienced SUI, UUI, and AI, but not POP. Obese patients also had more severe UI and AI. Obesity remained a significant risk factor for UI and AI, even after adjusting for baseline differences in demographics and medical conditions, with an adjusted odds ratio of 4.1 (95% confidence interval 2.3-7.8) and 2.1 (95% confidence interval 1.1-4.1), respectively.nnnCONCLUSIONnThe prevalence of PFDs, including SUI, UUI, and all forms of AI, was greater in the obese and morbidly obese women contemplating bariatric surgery. Obesity was also associated with an increased severity of UI and AI. Obesity appears to confer a fourfold and twofold increased risk of UI and AI, respectively.

The use of synthetic mesh in pelvic reconstructive surgery

The use of synthetic materials in pelvic reconstructive surgery is increasing. Abdominal sacral colpopexy with permanent, type I mesh is a durable and safe operation to treat apical prolapse. The incorporation of synthetic materials during surgery to correct anterior and posterior prolapse has variable anatomic results, with several studies demonstrating moderate rates of mesh-related complications. Procedural kits for vaginal placement of synthetic materials are becoming popular, though long-term outcome and safety data are lacking.

Risk factors that predict failure after vaginal repair of obstetric vesicovaginal fistulae.

OBJECTIVEnTo identify anatomic characteristics and method of bladder closure that predict failure after repair of obstetric vesicovaginal fistulae.nnnSTUDY DESIGNnA retrospective analysis of 1045 patients that underwent vaginal repair of vesicovaginal fistulae from January 2006 to December 2007 at the Addis Ababa Hamlin Fistula Hospital.nnnRESULTSnThe fistulae were midvaginal (26%), adjacent to ureteral orifice (22%), circumferential (6%), had urethral compromise (10%), or had a combination of different locations (17%). Most had fair or good residual bladder size (83%) and minimal or moderate vaginal scarring (85%). Closure was in 1 layer in 48% and 2 layers in 52% with 89% cure, 11% failure, and 17% urethral incontinence. Failures were significantly associated with complete or partial urethral destruction, severe vaginal scarring, small bladders, and circumferential involvement. The 1-layer fistula closure was associated with failure but not after excluding small bladders.nnnCONCLUSIONnRisk factors for failure include small bladder size, urethral destruction, circumferential involvement, and severe vaginal scarring.

Leak point pressure does not correlate with incontinence severity or bother in women undergoing surgery for urodynamic stress incontinence

The aim of this study was to correlate the lowest Valsalva or cough leak point pressure (LPP) with clinical measures of incontinence severity and quality of life in women with pure urodynamic stress incontinence (SUI). This is an analysis of the baseline data from a prospective, multicenter, randomized trial comparing the Monarc transobturator sling to the tension-free vaginal tape. One hundred fifty-five women with SUI underwent urodynamic evaluations including abdominal or vesical LPP determinations, and each completed the Sandvik Incontinence Severity Index, a 3-day voiding diary, and quality-of-life questionnaires. In patients with a LPP, there were no significant correlations between LPP and the above clinical measures of incontinence severity or condition-specific quality-of-life questionnaire scores. In this patient population with pure urodynamic SUI, LPP is not a useful urodynamic predictor of baseline SUI severity and its effects on quality of life.

Objective assessment of vaginal surgical skills

OBJECTIVEnTo develop and validate an instrument to assess surgical skills during vaginal surgery.nnnSTUDY DESIGNnTrainees from 2 institutions were directly assessed in the operating room by supervising surgeons while performing a vaginal hysterectomy using the new Vaginal Surgical Skills Index, global rating scale, and visual analogue scale. Trainees were assessed again by the same surgeons 4 weeks after the live surgery and by a blinded outside reviewer using a videotape of the case. Internal consistency, interrater and intrarater reliability, and construct validity were evaluated.nnnRESULTSnTwo hundred twelve evaluations were analyzed on 76 surgeries from 27 trainees. There was good internal consistency, interrater, and intrarater reliability. Vaginal Surgical Skills Index scores correlated with global rating score and visual analog scale scores. Increasing Vaginal Surgical Skills Index scores significantly correlated with year of training and surgical volume with an estimated increase in score of 0.3 per hysterectomy performed.nnnCONCLUSIONnThe Vaginal Surgical Skills Index is a feasible, reliable, and valid instrument to assess vaginal surgical skills.

Pudendal neuropathy involving the perforating cutaneous nerve after cystocele repair with graft

BACKGROUND: Pudendal neuropathy is a documented complication of sacrospinous ligament fixation, but it is infrequently reported with other types of gynecologic surgery. CASE: A woman developed neuropathic symptoms of the right vulva, perianal area, and gluteal fold after vaginal surgery with graft for anterior pelvic organ prolapse. Pudendal nerve entrapment with involvement of the perforating cutaneous nerve was suspected. Suture removal 1 year after the operation resulted in improved pain symptoms and sexual function. CONCLUSION: Pudendal nerve entrapment is one potential complication of anterior vaginal repair with biologic graft. Removal of sutures, even long after surgery, can result in clinically significant improvement in pain symptoms and sexual function in patients with pudendal nerve entrapment.

An update on the laparoscopic approach to urogynecology and pelvic reconstructive procedures.

Purpose of review To review the evidence behind laparoscopic pelvic organ prolapse and urinary incontinence repair. Recent findings A review of the recent literature continues to support the use of laparoscopy for colposuspension and sacral colpopexy as a viable alternative for open surgery. Polypropylene mid-urethral slings are comparable, if not better than laparoscopic Burch, though most data are short-term. The literature regarding other laparoscopic prolapse procedures, such as uterosacral ligament suspension, paravaginal defect repair, and rectocele repair is sparse. Summary Short-term studies support the use of laparoscopy in urogynecology and reconstructive pelvic surgery. However, longer term studies are needed to confirm these findings.