Emily L. Whitcomb

Natural orifice surgery: initial clinical experience

BackgroundNatural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience.MethodsUnder an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance.ResultsNine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred.ConclusionThe limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.

Does weight loss improve incontinence in moderately obese women

Abstract: The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (þSD) baseline BMI of 38.3 (þ10.1) kg/m2 and 13 (þ10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (þ6.2) kg/m2 (P<0.03). Among women achieving a weight loss of ≥5%, 6/6 had ≥50% reduction in incontinence frequency compared to 1 in 4 women with <5% weight loss (P<0.03). Incontinence episodes decreased to 8 (þ10) per week following weight reduction (P<0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.

Prevalence and degree of bother from pelvic floor disorders in obese women.

We aimed to determine the prevalence and bother from pelvic floor disorders (PFD) by obesity severity, hypothesizing that both would increase with higher degrees of obesity. We performed a secondary analysis of 1,155 females enrolled in an epidemiologic study that used a validated questionnaire to identify PFD. Prevalence and degree of bother were compared across three obesity groups. Logistic regression assessed the contribution of degree of obesity to the odds of having PFD. Prevalence of any PFD was highest in morbidly (57%) and severely (53%) obese compared to obese women (44%). Regression models demonstrated higher prevalence of pelvic organ prolapse, overactive bladder, stress urinary incontinence, and any PFD in morbidly compared to obese women and higher prevalence of stress urinary incontinence in severely obese compared to obese women. Degree of bother did not vary by degree of obesity. Prevalence of PFD increases with higher degrees of obesity.

Racial Differences in Pelvic Organ Prolapse

OBJECTIVE: To compare the estimated prevalence of, risk factors for, and level of bother associated with subjectively reported and objectively measured pelvic organ prolapse in a racially diverse cohort. METHODS: The Reproductive Risks for Incontinence Study at Kaiser 2 is a population-based cohort study of 2,270 middle-aged and older women. Symptomatic prolapse was self-reported, and bother was assessed on a five-point scale. In 1,137 women, prolapse was measured with the Pelvic Organ Prolapse Quantification (POP-Q) system. Multivariable logistic regression analysis was used to identify the independent association of prolapse and race while controlling for risk factors. RESULTS: The participants’ mean (standard deviation) age was 55 (9) years, and 44% were white, 20% were African American, 18% were Asian American, and 18% were Latina or other race. Seventy-four women (3%) reported symptomatic prolapse. In multivariable analysis, the risk of symptomatic prolapse was higher in white (prevalence ratio 5.35, 95% confidence interval [CI] 1.89–15.12) and Latina (prevalence ratio 4.89, 95% CI 1.64–14.58) compared with African-American women. Race was not associated with report of moderate to severe bother. Degree of prolapse by POP-Q stage was similar across all racial groups; however, the risk of the leading edge of prolapse at or beyond the hymen was higher in white (prevalence ratio 1.40, 95% CI 1.02–1.92) compared with African-American women. CONCLUSION: Compared with African-American women, Latina and white women had four to five times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse with leading edge of prolapse at or beyond the hymen. LEVEL OF EVIDENCE: II

The Impact of Obesity on Urinary Incontinence Symptoms, Severity, Urodynamic Characteristics and Quality of Life

PURPOSE We compared urinary incontinence severity measures and the impact of stress urinary incontinence in normal, overweight and obese women. MATERIALS AND METHODS Baseline characteristics of subjects in the SISTEr (655) and the TOMUS (597) were analyzed. Body mass index was defined as normal (less than 25 kg/m(2)), overweight (25 to less than 30 kg/m(2)) and obese (30 kg/m(2) or greater). Independent urinary incontinence severity measures included a 3-day diary including incontinence episode frequency, Urogenital Distress Inventory scores and Valsalva leak point pressure from urodynamic testing. Impact was measured using the Incontinence Impact Questionnaire. Multivariable regression models were fit for each severity measure (Urogenital Distress Inventory, incontinence episode frequency, Valsalva leak point pressure and Incontinence Impact Questionnaire) on weight category. Covariates included age, race, diabetes and variables significantly associated with body mass index on bivariate analysis. RESULTS Mean age (SD) of participants was 51.9 (10.3) in SISTEr and 52.9 (11.0) in TOMUS. In each trial 45% of subjects were obese. In SISTEr multivariable regression analyses showed that higher weight category was independently associated with higher mean Urogenital Distress Inventory score (p = 0.003), incontinence episode frequency (p <0.0001), Valsalva leak point pressure (p = 0.003) and Incontinence Impact Questionnaire score (p = 0.0004). In TOMUS higher weight category was not associated with Urogenital Distress Inventory score (p = 0.24) but was associated with higher incontinence episode frequency (p = 0.0003), Valsalva leak point pressure (p = 0.0006) and Incontinence Impact Questionnaire score (p <0.0001). CONCLUSIONS Obese women undergoing surgery for stress urinary incontinence report more incontinence episodes, more symptom distress and worse quality of life despite better measure of urethral function (higher Valsalva leak point pressure) on urodynamics.

Sexual function before and after nonsurgical treatment of stress urinary incontinence

Objectives: (1) To describe sexual function in women seeking treatment of stress urinary incontinence (SUI), (2) to compare the impact on sexual function of 3 SUI treatments, and (3) to investigate whether nonsurgical treatment of SUI is associated with improved sexual function. Methods: Women with SUI were randomized to continence pessary, behavioral therapy (pelvic floor muscle training and continence strategies), or combination therapy. Sexual function was assessed at baseline and 3 months using short forms of the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire and the Personal Experiences Questionnaire. Successful treatment of SUI was assessed with a patient global impression of improvement. Analysis of variance was used to compare scores between groups. Results: At baseline, sexual function was worse among women with mixed incontinence compared with those with pure SUI. After therapy, successful treatment of SUI was associated with greater improvement in the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire score (2.26 ± 3.24 vs 0.48 ± 3.76, P = 0.0007), greater improvement in incontinence with sexual activity (0.45 ± 0.84 vs 0.01 ± 0.71, P = 0.0002), and greater reduction in restriction in sexual activity related to fear of incontinence (0.32 ± 0.76 vs −0.06 ± 0.78, P = 0.0008). Among those successfully treated for SUI, improvement in continence during sexual activity was greater in both the combined therapy group (P = 0.019) and the behavioral group (P = 0.02) compared with the pessary group. Conclusions: Successful nonsurgical treatment of SUI is associated with improvements in incontinence-specific measures of sexual function. Behavioral therapy may be preferred to pessary for treatment of SUI among women whose incontinence interferes with sexual function.

Effect of weight loss on urinary incontinence in women

Background The purpose of this research was review the epidemiology of the association of obesity and urinary incontinence, and to summarize the published data on the effect of weight loss on urinary incontinence. Methods A literature review of the association between urinary incontinence and overweight/obesity in women was performed. Case series and clinical trials reporting the effect of surgical, behavioral, and/or pharmacological weight loss on urinary incontinence are summarized. Results Epidemiological studies demonstrate that obesity is a strong and independent risk factor for prevalent and incident urinary incontinence. There is a clear dose-response effect of weight on urinary incontinence, with each 5-unit increase in body mass index associated with a 20%–70% increase in risk of urinary incontinence. The maximum effect of weight on urinary incontinence has an odds ratio of 4–5. The odds of incident urinary incontinence over 5–10 years increase by approximately 30%–60% for each 5-unit increase in body mass index. There appears to be a stronger association between increasing weight and prevalent and incident stress incontinence (including mixed incontinence) than for urge incontinence. Weight loss studies indicate that both surgical and nonsurgical weight loss leads to significant improvements in prevalence, frequency, and/or symptoms of urinary incontinence. Conclusion Epidemiological studies document overweight and obesity as important risk factors for urinary incontinence. Weight loss by both surgical and more conservative approaches is effective in reducing urinary incontinence symptoms and should be strongly considered as a first line treatment for overweight and obese women with urinary incontinence.

Urinary frequency in community-dwelling women: What is normal?

OBJECTIVE The objective of the study was to assess urinary frequency in community-dwelling women. STUDY DESIGN Voiding habits were assessed in 4061 women 25-84 years of age using survey responses from the Epidemiology of Prolapse and Incontinence Questionnaire. Bother related to daytime and nighttime frequency was assessed with 100-mm visual analog scales and compared using t tests and analysis of variance. RESULTS Median daytime frequency was every 3-4 hours. Urinary frequency every 2 hours or more occurred in 27% and was more bothersome than every 3-4 hours or less (51.7 +/- 30.1 mm vs 23.6 +/- 23.7 mm; P < .001). Nocturia was reported in 72%, whereas 33% had 2 or more voids per night. Bother increased with increasing nighttime frequency (27.3 +/- 26.3 for 1 time vs 57.3 +/- 28.5 for > or = 2 times; P < .001). CONCLUSION Bothersome urinary frequency is common and occurs when frequency is at least every 2 hours by day and more than once per night.

Effects of concomitant surgeries during midurethral slings (MUS) on postoperative complications, voiding dysfunction, continence outcomes, and urodynamic variables.

OBJECTIVE To determine whether concomitant surgeries affected outcomes in a randomized trial comparing retropubic midurethral sling (MUS) vs transobturator MUS. METHODS Subjects (n = 597) were stratified into 4 groups based on type of concomitant surgeries: group I had anterior/apical with or without posterior repairs (n = 79, 13%); group II had posterior repairs or perineorrhaphy only (n = 38, 6%); group III had nonprolapse procedures (n = 34, 6%); and group IV had no concomitant surgeries (n = 446, 75%). Complication rates, voiding dysfunction, objective and subjective surgical failure rates, and changes in urodynamic values (postop minus preop) were assessed and compared in these 4 groups. RESULTS There were no differences in complications, voiding dysfunction, and subjective failure outcomes between these 4 groups. Group I had lower odds ratio of objective surgical failure compared with group IV (OR 0.38, 95% CI 0.18-0.81, P = .05). The OR of failure of all patients undergoing concomitant surgeries (groups I-III) was lower than group IV (OR 0.57, 95% CI 0.35-0.95, P = .03). The change in Pdet@Qmax (from pressure-flow) was significantly higher in group III vs IV (P = .01). The change in Q(max.) (from uroflowmetry) was significantly less in groups I and II vs group IV (P = .046 and .04, respectively). CONCLUSION Concomitant surgeries did not increase complications. Subjects who underwent certain concomitant surgeries had lower failure rates than those undergoing slings only. These data support safety and efficacy of performing concomitant surgery at the time of MUS.

Repeat midurethral sling compared with urethral bulking for recurrent stress urinary incontinence.

OBJECTIVE: To compare the effectiveness and safety of repeat midurethral sling with urethral bulking after failed midurethral sling. METHODS: This is a retrospective cohort study of patients within Kaiser Permanente Southern California Medical Group who underwent a midurethral sling for stress urinary incontinence (SUI) from 2008 to 2011 and subsequently had either a midurethral sling or urethral bulking for recurrent SUI. Current Procedural Terminology codes were used to identify patients and electronic medical records were queried for individual patient information. Our primary outcome was either subjective failure defined by SUI or objective failure defined as a positive cough stress test, urodynamic stress incontinence, or retreatment for SUI. Secondary outcomes included perioperative complications and adverse events. RESULTS: Of 6,914 midurethral slings performed, 165 patients underwent a repeat procedure for recurrent SUI, including 98 midurethral slings and 67 urethral bulking. Of the 165 patients who underwent repeat procedures, there were 11 failures (11.2%) in the midurethral sling group and 26 failures (38.8%) in the urethral bulking group (P=.004). There were no differences in perioperative complications or adverse events between the groups. In multivariable logistic regression, risk of failure was significantly higher in those undergoing urethral bulking compared with those undergoing midurethral sling (odds ratio 3.49, 95% confidence interval 1.34–9.09, P=.01). CONCLUSIONS: In a managed care population, urethral bulking was associated with higher risk of failure than repeat midurethral sling after primary midurethral sling failure with no differences in perioperative complications or adverse events. LEVEL OF EVIDENCE: II