Eman A. Elkadry

Cardiac dysfunction in twin-twin transfusion syndrome: a prospective, longitudinal study.

Objective To use serial echocardiography to evaluate prospectively the cardiac dysfunction in twin-twin transfusion syndrome and determine its clinical course and outcome. Methods Twin pregnancies presenting in the second trimester with sonographic evidence of twin-twin transfusion syndrome were managed with therapeutic reduction amniocenteses. Gestational age at diagnosis and delivery, number of amniocenteses performed, volume of amniotic fluid withdrawn, placentation, birth weight, hemoglobin at delivery, and perinatal outcome were recorded. Serial fetal echocardiography was carried out in a single tertiary center. Echocardiographic assessments included cardiac anatomy, chamber size, cardiothoracic ratio, interventricular septal thickness, ventricular systolic function, and the presence and severity of atrioventricular valve regurgitation. Postnatal echocardiograms were obtained on the surviving twins. Results Twelve cases of twin-twin transfusion syndrome were evaluated with serial echocardiography. Evidence of cardiac dysfunction was present prenatally in 10 recipient twins. All of the donor twins had normal fetal echocardiographic assessments. The most common abnormalities detected prenatally in recipient twins were decreased ventricular function, tricuspid regurgitation, and cardiac chamber enlargement. A deterioration of cardiac function was observed in seven recipient twins with increasing gestational age. Four of the eight surviving recipient twins had persistent postnatal echocardiographic abnormalities on follow-up examinations after the first 28 days of life. Conclusion Prenatal cardiac dysfunction is common in recipient twins and can be transient, progressive, or persistent beyond the neonatal period.

Botulinum Toxin Type A (botox) for Refractory Myofascial Pelvic Pain

Objective To assess intralevator botulinum toxin type A (Botox) injections for refractory myofascial pelvic pain with short tight pelvic floor. Methods Retrospective cohort study of all women with intralevator Botox injection (100–300 Units) from 2005 through 2010 for refractory myofascial pelvic pain. Primary outcomes were self-reported pain on palpation and symptom improvement. Secondary outcomes included postinjection complications and a second injection. Pain was assessed during digital palpation of the pelvic floor muscles using a scale of 0 to 10, with 10 being the worst possible pain. Follow-up occurred at less than 6 weeks after injection and again at 6 weeks or more. Data are presented as median (interquartile range) or proportion. Results Thirty-one patients met eligibility criteria; 2 patients were lostto follow-up and excluded. The median age was 55.0 years (38.0–62.0 years). Before Botox injection, the median pain score was 9.5 (8.0–10.0). Twenty-nine patients (93.5%) returned for the first follow-up visit; 79.3% reported improvement in pain, whereas 20.7% reported no improvement. The median pain with levator palpation was significantly lower than before injection (P<0.0001). Eighteen women (58.0%) had a second follow-up visit with a median pain score that remained lower than before injection (P<0.0001). Fifteen (51.7%) women elected to have a second Botox injection; the median time to the second injection was 4.0 months (3.0–7.0 months). Three (10.3%) women developed de novo urinary retention, 2 patients (6.9%) reported fecal incontinence, and 3 patients (10.3%) reported constipation and/or rectal pain; all adverse effects resolved spontaneously. Conclusions Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few self-limiting adverse effects.

TVT-Secur (Hammock) versus TVT-Obturator: a randomized trial of suburethral sling operative procedures.

Objectives This study aimed to compare TVT-Secur (TVT-S) and TVT-Obturator (TVT-O) suburethral slings for treatment of stress urinary incontinence (SUI). Methods This was a single-center, nonblinded, randomized trial of women with SUI who were randomized to TVT-S or TVT-O from May 2007 to April 2009. The primary outcome, SUI on cough stress test (CST), and quality-of-life and symptom questionnaires (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) were assessed at 12 weeks and 1 year. Results Forty-three women were randomized to TVT-S and 44 to TVT-O. There were no differences in median baseline PFDI-20 and PFIQ-7. Twenty-two (52.4%) of 42 participants randomized to TVT-S had a positive CST result at evaluation after 12 weeks or 1 year, whereas 4 (9.1%) of the 44 in the TVT-O group had a positive CST result. The intent-to-treat analysis showed that the risk of a positive CST result was 6 times higher after TVT-S than TVT-O (risk ratio, 6.0; 95% confidence interval [CI], 2.3–16.0). Among women not lost to follow-up, the risk ratio for a positive CST result after TVT-S compared with TVT-O was 17.9 (95% CI, 2.5–128.0) at 12 weeks and 3.5 (95% CI, 1.1–11.0) at 1 year. Both TVT-S and TVT-O resulted in improved quality of life and symptoms at 12 weeks. There was no difference between the groups for PFDI-20 (P = 0.40) or PFIQ-7 (P = 0.43). A similar pattern was seen at 1 year (P = 0.85 and P = 0.36). Conclusions The TVT-S seems to have a higher risk of positive postoperative CST result; however, the procedures result in similar improvements in quality of life and symptoms.

Musculoskeletal pain in gynecologic surgeons.

OBJECTIVE To describe the prevalence of musculoskeletal pain and symptoms in gynecologic surgeons. DESIGN Prospective cross-sectional survey study (Canadian Task Force classification II-2). SETTING Virtual. All study participants were contacted and participated via electronic means. PARTICIPANTS Gynecologic surgeons. INTERVENTIONS An anonymous, web-based survey was distributed to gynecologic surgeons via electronic newsletters and direct E-mail. MEASUREMENTS AND MAIN RESULTS There were 495 respondents with complete data. When respondents were queried about their musculoskeletal symptoms in the past 12 months, they reported a high prevalence of lower back (75.6%) and neck (72.9%) pain and a slightly lower prevalence of shoulder (66.6%), upper back (61.6%), and wrist/hand (60.9%) pain. Many respondents believed that performing surgery caused or worsened the pain, ranging from 76.3% to 82.7% in these five anatomic regions. Women are at an approximately twofold risk of pain, with adjusted odds ratios (OR) of 1.88 (95% confidence interval [CI], 1.1-3.2; p = .02) in the lower back region, OR 2.6 (95% CI, 1.4-4.8; p = .002) in the upper back, and OR 2.9 (95% CI, 1.8-4.6; p = .001) in the wrist/hand region. CONCLUSION Musculoskeletal symptoms are highly prevalent among gynecologic surgeons. Female sex is associated with approximately twofold risk of reported pain in commonly assessed anatomic regions.

Use of synthetic mesh in pelvic reconstructive surgery: a survey of attitudes and practice patterns of urogynecologists

This study surveyed attitudes and practice patterns of urogynecologists regarding the use of synthetic mesh in pelvic reconstructive surgery. A web-based survey was administered to members of the American Urogynecologic Society. The survey evaluated the use of the mesh for sacrocolpopexy, suburethral sling, and vaginal pelvic reconstructive surgery. The survey had a 30.5% response rate. One hundred one (39%) respondents were women, and 158 (61%) were men. One hundred forty-seven (56.8%) participated in fellowship training. Two hundred forty-seven (99.5%) currently perform procedures using synthetic mesh, including 93% who perform sacrocolpopexy and 93% who perform suburethral slings. In a logistic regression model including gender, fellowship training, and practice setting, male surgeons and those who had not undergone fellowship training were more likely to use the mesh than those who were fellowship trained. Respondents use the mesh most commonly when performing sacrocolpopexies and suburethral slings. The use of the mesh for anterior and posterior colporrhaphy is less common.

Association of body mass index with hip and thigh pain following transobturator midurethral sling placement

OBJECTIVE We sought to investigate the incidence of hip and proximal lower extremity pain following transobturator midurethral sling and evaluate the association between pain and body mass index (BMI). STUDY DESIGN This was a retrospective cohort study of all transobturator midurethral sling procedures from July 2008 through June 2009. The primary outcome was postoperative hip or proximal lower extremity pain. RESULTS Four urogynecologists performed 226 procedures. The incidence of postoperative hip or proximal lower extremity pain was 15.5%. Women of normal BMI had a higher risk of developing pain than obese women (risk ratio, 2.51; 95% confidence interval, 1.01-6.22). While not statistically significant, overweight women were twice as likely as obese women to develop the primary outcome (risk ratio, 1.99; 95% confidence interval, 0.79-4.99). CONCLUSION Women of normal BMI have an increased risk of hip and proximal lower extremity pain following transobturator midurethral sling compared with obese women.

Do patient goals vary with stage of prolapse

OBJECTIVES To assess the relationship between stage of pelvic organ prolapse and self-expressed patient goals at initial urogynecologic evaluation. STUDY DESIGN From February to December of 2010, women presenting for evaluation of pelvic floor disorders were asked to identify up to 5 goals for treatment. Charts were reviewed for demographics. Patients were grouped according to stage of prolapse and goals were grouped into 9 categories. RESULTS Two hundred twenty-six women completed the questionnaire. Relief of urinary symptoms were the most commonly stated goal regardless of prolapse stage, pelvic organ prolapse quantitative-0 (59%), pelvic organ prolapse quantitative-I (78%), pelvic organ prolapse quantitative-II (55%), and pelvic organ prolapse quantitative-III (58%). Lifestyle, daily activity, and sexual function goals were the second, third, and fourth most common goals in all stages, respectively. CONCLUSION Resolution of urinary symptoms, ability to perform daily activities, and sexual function goals are at least as important as resolution of prolapse symptoms and may be the reason for seeking care.

Do symptoms of voiding dysfunction predict urinary retention

Objectives We assessed the relationship between symptoms of voiding dysfunction and elevated postvoid urinary residual (PVR). Methods Cross-sectional study of women presenting for initial evaluation from February through July 2011. Charts were reviewed for demographics, voiding dysfunction symptoms, and examination findings. Urinary retention was defined as PVR of 100 ml or more. Data are presented as median (interquartile range) or proportion; test characteristics are reported with 95% confidence intervals. Results Of 641 eligible women, 57 women (8.9%) had urinary retention. Of these, 32 women (56.1%) had at least one symptom of voiding dysfunction, most commonly, sensation of incomplete emptying (30.1%). Sensitivity and positive predictive values of voiding dysfunction symptoms were low. Of 254 women reporting voiding symptoms, most (87.5%) had PVR of less than 100 ml and were significantly more likely to have other pelvic floor symptoms and findings. Conclusions Patients’ symptoms do not predict urinary retention. Postvoid urinary residual should be measured, and other causes of voiding dysfunction symptoms should be considered.

Assessment of women with defecatory dysfunction and manual splinting using dynamic pelvic floor magnetic resonance imaging.

Objective This study aimed to describe magnetic resonance imaging (MRI) findings in women with defecatory dysfunction who perform manual splinting. Methods This is a retrospective study of 29 patients from a single urogynecology center who presented with complaints of defecatory dysfunction and who reported manual splinting to assist with bowel movements. Patients were scheduled for an MRI study with a novel “splinting” protocol to evaluate the effects of their manual splinting on the pelvic floor. The protocol involved asking patients to splint during the MRI, as they normally would when trying to defecate. The goal was to evaluate any change in pelvic anatomy and compensation for an anatomic defect that could potentially lead to their defecatory dysfunction. Magnetic resonance images of the pelvis were obtained at rest, with pelvic floor contraction, with Valsalva, and during manual splinting. These images were then reviewed by radiologists who evaluated various parameters, including anorectal angle, levator ani muscle integrity, and the presence of rectocele, cystocele, apical prolapse, and enterocele. The external and internal anal sphincters were also evaluated for continuity. Results From September 2008 to October 2010, 29 women reported defecatory dysfunction and the need for manual splinting. Their mean (SD) age was 55.2 (10.5) years. Magnetic resonance images showed a rectocele in 86.2% of the study group, cystocele in 75.9%, enterocele in 10.3%, and a defect of the levator ani muscles in 17.2%. Twenty-one (72.4%) women had more than 1 of these defects. In addition, 27.6% had an anorectal angle less than 90 degrees or greater than 105 degrees. Patients in the study group splinted in the vagina (58.6%), on the perineum (31.0%), or on the buttock (10.3%). In all but 1 woman (96.6%), splinting improved or completely corrected the identified defect(s) as evidenced with MRI. Among those who used vaginal splinting, 52.9% of defects were corrected and 47.1% were improved. Perineal splinting corrected 55.6% and improved 33.3% of cases and was ineffective in 11.1% of cases, whereas buttock splinting corrected 33.3% and improved 66.7% of cases. Conclusions Most women in our study group who used manual splinting to assist in defecation are compensating for a pelvic floor defect that can be detected on MRI. Magnetic resonance imaging of the pelvis may help elucidate the etiology of the defecatory dysfunction in some women and may assist pelvic reconstructive surgeons in planning surgical correction of pelvic floor defects. Magnetic resonance imaging may also identify defects in the pelvic floor that are, at the present time, not amenable to surgical correction.

Pelvic Floor Physical Therapy as Primary Treatment of Pelvic Floor Disorders With Urinary Urgency and Frequency-Predominant Symptoms.

Objective To assess the efficacy of pelvic floor physical therapy (PFPT) as primary treatment of urinary urgency and frequency symptoms Methods We conducted a prospective cohort study of women with urinary urgency and frequency symptoms. Participants underwent PFPT once or twice per week for 10 weeks. Symptom improvement was assessed by validated questionnaires (Pelvic Floor Distress Inventory-Short Form 20 and Patient Global Impression of Improvement), voiding diaries, and subjective measures. Results Fifty-seven participants enrolled; 21 (36.8%) withdrew or completed less than 5 weeks of PFPT. Thirty-one (54.4%) of the remaining 36 participants completed 10 weeks of PFPT. The mean age of the study group (n = 36) was 48.9 ± 15.0 years. The primary diagnoses were overactive bladder syndrome (n = 24, 66.7%) and painful bladder syndrome (n = 12, 33.3%). Women attended a median of 14.0 (interquartile range [IQR], 8.0–16.0) PFPT visits over a median of 11.9 weeks (IQR, 10.0–18.1). At baseline, the median Pelvic Floor Distress Inventory-Short Form 20 score was 79.2 (IQR, 53.1–122.9), and decreased to 50.0 (IQR, 25.0–88.5; P < 0.001) after PFPT; the urinary and prolapse symptom subscales both decreased significantly. Participants reported a decrease from a median of 10.0 voids per day to 8.0 (P < 0.001). On the Patient Global Impression of Improvement, 62.5% of women reported that they were “much better” or “very much better.” Conclusions The PFPT with myofasical release techniques improves urinary symptoms while avoiding medications and more invasive therapies. The high dropout rates suggest that motivation or logistic factors may play a significant role in the utilization and success of this treatment option.