Danielle Patterson

A retrospective multicenter study on outcomes after midurethral polypropylene sling revision for voiding dysfunction

Objectives: The purpose of this study was to determine outcomes of sling revision after midurethral sling (MUS) placement and whether timing of sling revision affected those outcomes. Materials and Methods: This is a multicenter study including patients who underwent MUS placement and subsequent sling revision secondary to voiding dysfunction. Diagnostic outcomes before and after sling revision were compared for all sling revision patients with complete data. Logistic regression analyses were performed to determine if revision timing predicted voiding dysfunction and stress incontinence. Results: One hundred seventy-five patients who met the study criteria had complete data. Overall, 70% (133) of MUS were retropubic and 30% (56) were obturator slings. Midurethral sling revision was accomplished by cutting (54%), excision (29%), and pulling down on the mesh (18%). Stress urinary incontinence (SUI) resolved in 38%, urinary tract infections (UTIs) in 69%, and overactive bladder (OAB) in 75%. In comparison, 21% experienced de novo SUI; 18%, de novo UTIs; and 12%, de novo OAB symptoms after revision. Voiding dysfunction resolved in 80%, however 10% experienced new voiding dysfunction symptoms. Retropubic slings displayed more voiding dysfunction, higher de novo/worsened OAB, and more UTIs after revision than obturator slings. Sling revision timing did not predict persistent voiding dysfunction but did predict SUI with earlier revision (≤2 weeks) resulting in less postrevision SUI when compared to revisions at 15-90 days or greater than 90 days. The method of sling revision (cut, excised, pulled down) did not predict SUI, OAB, or obstructive voiding symptoms. Conclusions: Sling revision resolves voiding dysfunction symptoms, UTIs and post-sling OAB symptoms in the majority of patients. Resolution of voiding dysfunction is independent of method and timing of revision; however earlier revision is associated with decreased postrevision SUI.

Risk factors leading to midurethral sling revision: a multicenter case-control study

Introduction and hypothesisTo determine risk factors for sling revision after midurethral sling (MUS) placement.MethodsThis multicenter case-control study included patients who underwent MUS placement and subsequent revision secondary to voiding dysfunction from January 1999–2007 from nine Urogynecology centers across the USA. Direct logistic regression analysis was used to determine which diagnostic variables predicted sling revision.ResultsOf the patients, 197 met the study criteria. Patient demographics, urodynamic findings, and operative differences did not increase the risk for sling revision. Risk factors for sling revision did include: pre-existing voiding symptoms (OR 2.76, 95% CI 1.32–5.79; p = 0.004) retropubic sling type (OR = 2.28, 95% CI 1.08–4.78; p = 0.04) and concurrent surgery (OR = 4.88, 95% CI 2.16–11.05; p < 0.001)ConclusionsThis study determined that pre-existing obstructive voiding symptoms, retropubic sling type, and concurrent surgery at the time of sling placement are risk factors for sling revision.

Patient-focused websites related to stress urinary incontinence and pelvic organ prolapse: a DISCERN quality analysis

Introduction and hypothesisThe quality of information related to pelvic floor disorders is varied and understudied. Using a validated instrument we evaluated the quality of selected websites addressing treatment options for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).MethodsEnglish-language, patient-focused professional, governmental, and consumer websites related to POP and SUI were identified using the International Urogynecology Association (IUGA) list of continence societies worldwide, search terms, and provider nomination. Websites were evaluated by 10 providers at an academic medical center, representing urogynecology (6), urology (3), and general gynecology (1). Quality assessment utilized the DISCERN instrument, a validated instrument consisting of 16 questions addressing the quality of consumer health information.ResultsWebsites of 13 organizations met inclusion criteria and were assessed, 12 relating to SUI and 8 to POP. The websites with the highest mean total DISCERN score for POP were those of the IUGA, the American Society of Colon and Rectal Surgeons, and the American Urogynecologic Association, and for SUI, the National Association For Continence, the American Urological Association, and the IUGA. High correlations were obtained for the total DISCERN score and the overall quality scores for POP (0.76) and SUI (0.82). The most commonly omitted components of the DISCERN instrument were a clear statement of the content objectives, references or sources of the content, and a discussion of what patients could expect if they opted for no intervention.ConclusionsAvailable English-language professional websites written to inform patients about management choices for SUI and POP miss key components of quality patient information.

Urinary Retention After Hysterectomy and Postoperative Analgesic Use

Objective This study aimed to determine risk factors, including postoperative analgesic use, for the development of postoperative urinary retention (PUR) after hysterectomy for routine gynecologic indications using a case-control study design. Methods Cases of PUR after hysterectomy were identified from billing data. Cases were those patients requiring recatheterization for inability to void. Controls were similarly identified and matched by age and date of surgery in a 3:1 control-to-case ratio. Chart review was performed to obtain demographic, medical, surgical, anesthetic, and medication data. Cumulative and interval doses of postoperative narcotic were recorded and converted into morphine equivalents. Crude odds ratios (ORs) were determined for potential risk factors for PUR using standard statistical analysis. Conditional logistic regression was used on multivariate models, including cumulative postoperative narcotic use, to determine adjusted ORs for risk factors. Results Twenty-six cases of PUR were matched with 78 controls. The cases had a higher body mass index (32 vs 28 kg/m2, P = 0.02), had a higher preoperative use of tricyclic antidepressants (TCA; 19.2% vs 1.3%, P = 0.004), were more likely to present preoperative urinary retention associated with fibroids (19.2% vs 0%, P < 0.01), and received a higher cumulative narcotic dose in the postoperative period (109 vs 73.6 mg, P < 0.001). In a multivariate model, preoperative TCA use (OR, 30.1; 95% confidence interval, 1.99–456; P = 0.01) and cumulative narcotic dose (OR, 2.54; 95% confidence interval, 1.44–4.56; P < 0.01) were significantly associated with PUR. Conclusions Postoperative urinary retention after hysterectomy is associated with higher postoperative narcotic dose, preoperative TCA use, and preoperative urinary retention.

Sling plication for recurrent stress urinary incontinence.

Objectives: Management of recurrent stress urinary incontinence (SUI) after synthetic mid-urethral sling placement is a challenging clinical dilemma. This case series describes a safe, minimally invasive treatment option for recurrent SUI after failure of the primary mid-urethral sling procedure. Methods: Twenty women with recurrent SUI after previous synthetic mid-urethral sling placement underwent plication of the sling with 2-0 polyester suture under intravenous sedation with an intra-operative cough stress test between December 2004 and December 2008. A retrospective chart review was performed to obtain pertinent preoperative and postoperative data. Results: Nine of the patients had prior retropubic synthetic mid-urethral slings. The other 11 women had transobturator mid-urethral slings, 10 of whom had slings via the outside-in approach and 1 had a single-incision mini-sling placed. The mean patient age was 59.8 years (range 38-83 years). Sling plication was performed at a median of 159.5 days after initial sling placement (range 26-2090 days). Overall 85% of patients had subjective improvement in SUI after sling plication with a median follow-up of 54.5 days (range 29-972 days). Those patients with prior retropubic slings had a 100% improvement rate compared to 72% improvement with prior obturator slings (P = 0.22). The subjective cure rate was 65%, 88% for the retropubic slings and 45% for the transobturator slings (P = 0.07). There were no complications. Conclusions: Midline plication of previously placed synthetic mid-urethral slings is a safe and effective method of treating recurrent SUI.

Cost-utility of routine endometrial evaluation before le fort colpocleisis

Introduction Routine preoperative evaluation of the endometrium before Le Fort colpocleisis is often recommended. There are no data, however, to support this practice. In select patients, it may not be a necessary addition to the preoperative evaluation of Le Fort colpocleisis. Methods A decision analysis model was created to compare uterine evaluation, by either endometrial (EM) biopsy or transvaginal ultrasound, to no evaluation for a hypothetical cohort of women undergoing Le Fort colpocleisis. We assumed the absence of risk factors for EM cancer. Probabilities and health outcome utilities were obtained from literature review. Medicare charges were used to estimate cost in 2012 US dollars. Cost-utility analysis was performed using US recommendations from a health plan perspective. Results At willingness-to-pay thresholds of

Cost utility of the treatment of stress urinary incontinence.

50,000 and

Determining health-related quality of life and health state utility values of urinary incontinence in women.

100,000, no evaluation is superior to both biopsy and ultrasound. At a 64% probability of cancer, biopsy is more cost-effective than no evaluation and ultrasound. Conclusions Compared to biopsy and ultrasound, in low-risk women, no EM evaluation before Le Fort colpocleisis demonstrates superior cost-utility.

Voiding Function After Midurethral Slings With and Without Local Anesthetic: Randomized Controlled Trial

Objective We sought to investigate the cost utility of nonsurgical versus surgical treatments for stress urinary incontinence (SUI). Methods A decision analysis model was created to compare nonsurgical and surgical treatment options for women with SUI. Decision paths included conservative management, pelvic floor physical therapy (pelvic floor muscle training [PFMT]), PFMT with electrical stimulation, incontinence pessary, and surgical treatment. A Markov model cohort analysis was performed with a cycle length of 1 year starting at age 45 years with a lifetime horizon. Probabilities, success rates, and utilities were obtained from the literature when available or by expert opinion. Cost-utility analysis was performed using US recommendations from a societal perspective. Cost data were obtained from Medicare reimbursement in 2012 US dollars. Results Incontinence pessary was the most cost-effective treatment option with a cost of

Risk factors for perineal lacerations in teen deliveries.

11,411 for 18.9 quality-adjusted life years. At a willingness to pay (WTP) threshold of