Christine A. LaSala

Porcine subintestinal submucosal graft augmentation for rectocele repair: a randomized controlled trial.

OBJECTIVE: To estimate the effect of porcine subintestinal submucosal graft augmentation on improving anatomic and subjective rectocele repair outcomes compared with native tissue repair. METHODS: We conducted a randomized controlled trial at two sites, including women with at least stage 2 symptomatic rectocele. Anatomic and subjective outcomes (vaginal bulge and defecatory) were collected 12 months postoperatively, including blinded Pelvic Organ Prolapse Quantification (POP-Q) examinations. Anatomic failure was defined as points Ap or Bp −1 or greater on POP-Q. Subjective failure was defined as no improvement or worsening of symptoms. We estimated number needed to treat and adjusted odds ratios (ORs). Assuming graft use is associated with 93% anatomic success, 63 women per group would be needed to detect a 20% difference at &agr;=.05 and &bgr;=.20. RESULTS: One hundred sixty women were randomized; 137 had 12-month anatomic data (67 graft; 70 control). There was no difference in anatomic failure (12% compared with 9%, P=.5), vaginal bulge symptom failure (3% compared with 7%, P=.4, number needed to treat=26) or defecatory symptom failure (44% compared with 45%, P=.9, number needed to treat=91) for graft compared with control, respectively. Both groups reported improvement in vaginal bulge and defecatory symptoms (P<.05 for all). On multiple logistic regression, graft use was not associated with a decreased odds of anatomic failure (adjusted OR 1.36, 95% confidence interval [CI] 0.44–4.25), vaginal bulge symptoms (adjusted OR 0.46, 95% CI 0.08–2.68), or defecatory symptoms (adjusted OR 0.98, 95% CI 0.48–2.03). CONCLUSION: Although rectocele repair by either approach is associated with improved symptoms, subintestinal submucosal graft augmentation was not superior to native tissue for anatomic or subjective outcomes at 12 months. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00321867. LEVEL OF EVIDENCE: I

The Effect of Posterior Wall Support Defects on Urodynamic Indices in Stress Urinary Incontinence

Objective To determine if posterior vaginal wall defects affect urodynamic indices and mask stress urinary incontinence. Methods Ninety women with grade 0, 1, 2, or 3 posterior wall defects were evaluated prospectively by complete urodynamics to assess their urinary complaints. None had severe anterior or apical support defects. Urethral pressure profilometry and cough stress test were performed with the posterior wall in the unretracted position and then with the posterior wall retracted using a split speculum. Analysis of covariance was used to compare adjusted mean differences in maximum urethral closure pressure, functional urethral length, and units of leakage volume during the cough stress test in the unretracted and retracted positions among the posterior wall grade groups. Results In women with grade 3 posterior wall defects, there were significant changes from the unretracted to the retracted position in maximum urethral closure pressure of −7.0 cm H2O, (99% confidence interval [CI] −12.4, −1.6), functional urethral length of −0.3 cm (99% CI −0.5, −0.1), and leak volume units of +0.7 (99% CI 0.4, 1.0) during the cough stress test. There were four women with grade 3 posterior wall defects who demonstrated potential stress incontinence when their posterior wall was retracted. Conclusion A grade 3 posterior wall defect may artificially raise maximum urethral closure pressure, increase functional urethral length, and mask urinary stress incontinence during a cough stress test. Women with grade 3 posterior wall defects should be tested with the posterior wall retracted during urodynamic evaluation.

Impact of pessary use on prolapse symptoms, quality of life, and body image

OBJECTIVE We sought to evaluate whether use of a vaginal pessary would change body image, bother symptoms, and quality of life in women with pelvic organ prolapse. STUDY DESIGN Women presenting for pessary insertion completed the short forms of Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire, and Body Image Scale. After successful pessary insertion and use for at least 3 months, subjects completed the surveys again. Scores were compared with a paired t test. RESULTS A total of 75 subjects were enrolled and follow-up responses were available for 54 subjects for analysis. Body Image Scale scores showed a significant decrease (6.1-3.4; P<.001), indicating an improvement in these womens perception of themselves, as did Pelvic Floor Distress Inventory-20 scores (81.34-45.83; P<.001) and Pelvic Floor Impact Questionnaire scores (50.32-17.98; P=.003). CONCLUSION The use of a pessary for 3 months reduces bother symptoms and improves both quality of life and perception of body image in women.

Occurrence of postoperative hematomas after prolapse repair using a mesh augmentation system

BACKGROUND: Mesh-augmented repair kits are increasingly being used for anterior compartment defect repair and can be associated with complications. CASES: Two cases are presented of postoperative pelvic hematomas confirmed on computerized tomography scan after anterior repair with a mesh-augmented anterior vaginal prolapse repair system. Both resolved without requiring drainage, although one patient did require a blood transfusion, and the other required intravenous antibiotics to treat an infected hematoma. CONCLUSION: Significant complications may arise from this new technology. Further studies are needed to determine whether the benefits of this technology outweigh its risk of use.

Resident education and training in urogynecology and pelvic reconstructive surgery: a survey

The aim of the study is to assess satisfaction with urogynecology education among obstetrics and gynecology residents. An Internet-based survey was designed to obtain a cross-sectional sample of third- and fourth-year residents. Didactic and surgical training as well as perceived surgical competency were assessed. Responses were received from 205 residents for this convenience sample. Nearly half (46%) of the respondents were unsatisfied with urogynecology resident education. There was no significant difference between respondents from academic programs and community programs with regard to overall satisfaction, the opportunity to work with the presence of a fellowship-trained urogynecologist or having a dedicated urogynecology rotation. Respondents were more satisfied with their education if they did a urogynecology rotation or worked with a fellowship-trained urogynecologist. Female pelvic medicine and reconstructive surgery fellows were involved in the education of 23.9% of the respondents. Most respondents indicated comfort performing cystoscopy, anterior and posterior repairs, and McCall’s culdoplasty following graduation. Overall, respondents indicated that residency training in urogynecology is less and later than desired, although they did feel competent at some urogynecologic surgeries.

Pessary use and impact on quality of life and body image.

Objectives: The objective of the study was to determine if vaginal pessaries improve symptoms of prolapse and body image in women with pelvic organ prolapse. Our hypothesis was that pessary use would improve prolapse-related symptoms and body image up to 1 year. Methods: Women presenting for pessary insertion completed questionnaires regarding pelvic floor-related symptoms and body image with successful pessary insertion and after 6 to 12 months of continued pessary use. Scores were compared with a paired t test. Results: Forty-three subjects had complete data for analysis. Scores on both prolapse-related and body image questionnaires showed improvements at 6 months (P < 0.001) and 12 months (P < 0.010). Younger women and those with prior prolapse surgery were less likely to continue to use a pessary past 3 to 6 months. Stage of prolapse, body mass index, and scores on symptom questionnaires did not correlate with likelihood of continued pessary use versus surgery. Conclusions: The use of a pessary for more than 12 months improves symptoms of prolapse and self perception of body image.

Anterior vaginal wall prolapse and voiding dysfunction in urogynecology patients

We investigated whether women with and without anterior vaginal wall prolapse have voiding differences. Women (n = 109) who presented to a urogynecology practice were categorized into two groups based on anterior vaginal wall prolapse: stages 0 and 1 and stages 2, 3, and 4. Women with prolapse were older than the women without prolapse but the groups were otherwise similar demographically. There was a higher rate of activity-related urine loss and use of wetness protection amongst women without prolapse. There was no significant difference for urgency symptoms or urge incontinence. Urodynamic testing found no significant differences for maximal flow rate or maximal urethral closing pressures. Postvoid residual volume and detrusor overactivity were not different but approached significance. Anterior vaginal wall prolapse of stage 2 or greater was not associated with urge incontinence or voiding function in this population. Women without prolapse were more likely to report stress incontinence.

Use of a beef tongue model and instructional video for teaching residents fourth-degree laceration repair

Introduction and hypothesisThis study seeks to compare the utility of the beef tongue model versus an instructional video in teaching obstetric and gynecology residents how to repair a fourth-degree laceration.MethodsTwenty-seven residents were randomized to participate in a workshop with a beef tongue model or assigned to watch an instructional video on repair of fourth-degree lacerations and read a chapter on the repair. All subjects were tested with a pre- and postintervention written test. These scores were compared with paired t test at 0.05 significance level.ResultsResidents with no prior experience in fourth-degree laceration repairs showed an improvement in knowledge (49.5% versus 64.1%, p < 0.001) on written exams about the repairs.ConclusionsAn instructional video or beef tongue model and textbook chapter on fourth-degree laceration repair can improve skills in repair of a fourth-degree laceration among residents with no experience in these repairs.

Complex sacral abscess 8 years after abdominal sacral colpopexy.

BACKGROUND: Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period. CASE: A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh. CONCLUSION: Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial

OBJECTIVE The objective of the study was to compare time to first bowel movement (BM) after surgery in subjects randomized to placebo or senna with docusate. STUDY DESIGN Ninety-six subjects completed a baseline 7-day bowel diary before and after surgery. After pelvic reconstructive surgery, the subjects were randomized to either placebo (n=45) or senna (8.6 mg) with docusate (50 mg) (n=48). Time to first BM and postoperative use of magnesium citrate were compared. RESULTS There was a significant difference in the time to first BM in those receiving senna with docusate vs placebo (3.00+/-1.50 vs 4.05+/-1.50 days; P<.002). More subjects in the placebo group needed to use magnesium citrate to initiate a bowel movement (43.6% vs 7.0%; P<.001). CONCLUSION The use of senna with docusate decreases time to first BM in those undergoing pelvic reconstructive surgery compared with placebo. Subjects using senna with docusate are also significantly less likely to use magnesium citrate.