Dena White

Levator ani deficiency and pelvic organ prolapse severity.

OBJECTIVE: To estimate whether levator ani deficiency severity is a predictor of clinically significant pelvic organ prolapse (POP) and to determine whether there is a levator ani deficiency threshold above which POP occurs. METHODS: Two-hundred twenty three-dimensional ultrasound scans performed on urogynecologic clinic patients were reviewed, and each levator ani muscle subdivision was individually scored (0=no defect, 1=50% or less defect, 2=more than 50% defect, 3=total absence of the muscle) on each side. A levator ani deficiency score was calculated and categorized as mild (score 0–6), moderate (score 7–12), and severe (score more than 13). Clinically significant prolapse was defined as stage 2 or higher. RESULTS: The mean age was 56.50 (standard deviation ±15.58) and median parity was 2 (range 0–6). A mild positive correlation was demonstrated between levator ani deficiency category and prolapse stage (rs=0.44; P<.001). Score distribution significantly differed by prolapse stage (P<.001). No patients with stage 3 prolapse had a levator ani score less than 6, and no patients with stage 4 prolapse had a levator ani score less than 9. In patients with prolapse, those with moderate levator ani deficiency had 3.2 times the odds of POP compared with patients with a minimal defect; those with severe levator ani deficiency had 6.4 times the odds of prolapse than those with minimal deficiency. CONCLUSIONS: Levator ani deficiency severity is associated with clinically significant prolapse. LEVEL OF EVIDENCE: II

Outcomes of abdominal and minimally invasive sacrocolpopexy: a retrospective cohort study.

Objective To compare perioperative and postoperative surgical outcomes between and among open and minimally invasive sacrocolpopexies (MISCs). Methods We performed a multicenter retrospective cohort study comparing abdominal sacrocolpopexy (ASC) and MISC from January 1999 to December 2010. Results A total of 1124 subjects underwent sacrocolpopexy, with 589 ASCs and 535 MISCs. Within the MISC group, 273 were laparoscopic (LSC) and 262 were robotic (RSC). Abdominal sacrocolpopexy was associated with greater overall complication rate compared with MISC (20.0% vs 12.7%; P = 0.001). After controlling for difference in length of follow-up, there was no significant difference in the rate of anatomical failure between the ASC and MISC groups. The MISC group had shorter hospitalization, less blood loss, but longer operative times compared with the ASC group. When comparing LSC to RSC, there was no difference in anatomic failures (7.7% vs 6.9%; P = 0.74). However, LSC was associated with more complications compared with RSC (18% vs 7%; P < 0.02). In addition, LSC had higher blood loss, less operative time, and shorter hospital stay compared with RSC. Conclusion Although anatomic results are similar, ASC is associated with a higher rate of complications compared with MISC.

Incidence of Unanticipated Uterine Pathology at the Time of Minimally Invasive Abdominal Sacrocolpopexy

STUDY OBJECTIVE To determine the incidence of unanticipated uterine pathologic findings in women undergoing hysterectomy concomitant with minimally invasive sacrocolpopexy. DESIGN Retrospective case series (Canadian Task Force classification III). SETTING Four institutions in the United States. PATIENTS Women undergoing laparoscopic or robotically assisted sacrocolpopexy with hysterectomy. INTERVENTIONS Concurrent hysterectomy and minimally invasive sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS We measured the incidence of clinically important uterine disease at minimally invasive sacrocolpopexy. A total of 324 women underwent concurrent hysterectomy and minimally invasive sacrocolpopexy. Their mean age was 56.1 years, and body mass index was 26.9 kg/m(2). Sixty-four percent were postmenopausal. Only 3 patients (0.92%) had abnormal uterine pathologic findings. No significant differences were noted in age, body mass index, or parity between the women with normal and abnormal uterine pathologic findings. None of the 3 women reported abnormal uterine bleeding before surgery. All lesions were premalignant and focal. No invasive carcinomas were identified. No patients required further follow-up or treatment of abnormal pathologic findings. CONCLUSION The risk of unanticipated uterine pathologic findings during minimally invasive sacrocolpopexy to treat pelvic organ prolapse is low.

Age effects on pelvic floor symptoms in a cohort of nulliparous patients.

Objectives This study aimed to investigate the effects of age on pelvic floor symptoms (PFSs) in nulliparous women. Methods Eighty community-dwelling nulliparous women, aged 21 to 70 years, were recruited. Pelvic floor support was assessed with pelvic organ prolapse quantification system. Participants completed the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 and health status with the Short-Form Health Survey. The correlation between age and questionnaire scores was evaluated using Pearson coefficient. Logistic regression assessed predictors associated with PFS. Results Participants had a median age of 47 years, average body mass index of 28.3 kg/m2, and most were white; 52.5% were healthy and 30% were postmenopausal. The most common stage of prolapse was stage I. Age was associated with slightly higher Pelvic Floor Distress Inventory-20 scores (r = 0.41, P = 0.002), corresponding to more bothersome PFS, and lower Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 scores, corresponding to worsening sexual function with advancing age (r = −0.41, P = 0.0012). There was no association between age and overall Pelvic Floor Impact Questionnaire scores (P = 0.12). For symptomatic patients, logistic regression showed age to be associated with increased odds of having PFS [odds ratio (OR), 1.881; 95% confidence interval (CI), 1.216–2.91]. Menopausal status was not associated with increased odds of reporting symptoms (OR, 3.05; 95% CI, 0.80–11.62). When age and age by menopause were incorporated in the model, age remained a significant predictor of having PFS (OR, 1.78; 95% CI, 1.13–2.78). Conclusions In this population of community-dwelling nulliparous women, age was associated with worsening sexual function and slightly increased odds of reporting symptoms of pelvic floor disorders.

Is a new high-resolution probe better than the standard probe for 3D anal sphincter and levator ani imaging?

The aim of our study was to determine the accuracy of a new three-dimensional (3D) endoluminal ultrasound probe in assessing the levator ani muscle and anal sphincter complex. A total of 85 patients who had undergone concurrent 3D endovaginal (EVUS) and 3D endoanal (EAUS) ultrasound with both the standard BK 2052 probe and the new high-definition BK 8838 probes were included. For EVUS volumes, the levator ani deficiency (LAD) scores were calculated for each probe. For the EAUS volumes, any defects in the external anal sphincter (EAS) and the internal anal sphincter (IAS) visualized with each probe were recorded. The 3D volumes were evaluated in a blinded fashion. Appropriate statistics were utilized to assess absolute agreements between each pair of imaging modalities. The mean age of the patient population was 59 years (SD ± 10.76), the mean body mass index (BMI) was 28.36 (SD ± 5.99), and the median parity was 2 (range 1, 7). In all, 93% of the patients were Caucasian, 31% had stage 0 or 1 prolapse, while 59% had stage 2 prolapse. The mean total LAD score obtained on EVUS with the standard and the new probes were 11.49 (SD ± 4.94) and 11.53 (SD ± 5.01), respectively, p = 0.3778. Among the 53 patients who had EAUS with both probes, exact agreement for visualization of EAS and IAS for the standard and the new probes was 83% and 98%, respectively. Both transducers can be used for endovaginal imaging of the levator ani muscles interchangeably. Both transducers can be used for endoanal imaging of anal sphincter complex interchangeably.

Association Between Raynaudʼs Phenomenon and Pregnancy Complications [266]

INTRODUCTION: Raynauds phenomenon is caused by vasospasm of the small muscular arteries of the digits. Given this, we hypothesize that pregnant patients with Raynauds phenomenon experience higher rates of hypertensive disorders and other pregnancy complications associated with placental insufficiency. Consequently, patients may have higher rates of emergent deliveries and poor neonatal outcomes. Anecdotal data support these theories; however, the objective data are lacking. The aim of our study is to elucidate the rates of pregnancy complications in patients with Raynauds phenomenon. METHODS: An institutional review board-approved survey was published online with a link to it on the Raynauds Association web site and their Facebook page. The survey includes 32 questions regarding Raynauds phenomenon and pregnancy complications. All females with Raynauds phenomenon were eligible for the survey. Mean and standard deviations were calculated and compared with averages of national data of pregnancy complications using Pearson &khgr;2 tests. RESULTS: Results (n=110) show that participants experienced infertility at high rates (26%). Twenty one percent reported having hypertensive disorders. Thirty-two percent report having had at least one cesarean delivery and 25% report having had an emergency cesarean delivery. Five percent of participants report having had an abruption with some of their pregnancies. Twenty-seven percent reported preterm deliveries. Seven percent reported three or more miscarriages. Thirty-two percent reported some or all of their neonates were admitted to the neonatal intensive care unit. Two percent of patients report having a pregnancy result in a perinatal death. CONCLUSION: Patients with Raynauds phenomenon appear to be at increased risk for vascular complications during pregnancy such as hypertensive disorders, emergent deliveries, and poor neonatal outcomes. Obstetric providers should be aware of their increased risk and manage pregnancies accordingly.