Erinn M. Myers

Vaginal versus robotic hysterectomy and concomitant pelvic support surgery: a comparison of postoperative vaginal length and sexual function.

STUDY OBJECTIVE To compare the change from pre- to postoperative total vaginal length (TVL) in women who underwent either a total vaginal hysterectomy (TVH) with uterosacral ligament suspension (USLS) or a robotic hysterectomy (RH) with colpopexy (SCP). Secondary objectives included comparing sexual function, pelvic floor function, and prolapse recurrence between routes of surgery. DESIGN This was a retrospective cohort study (Canadian Task Force classification II-2). SETTING This was conducted at 1 tertiary academic medical center over a 2-year period. PATIENTS Women who underwent either TVH/USLS or RH/SCP. INTERVENTIONS Baseline and postoperative POP-Q Pelvic Organ Prolapse Quantification exams were recorded as well as postoperative validated questionnaires. Twenty-nine subjects were needed in each group to detect a 1.5-cm difference in TVL. MEASUREMENTS AND MAIN RESULTS There were 38 TVH/USLS and 46 RH/SCP participants. RHs were either total (28/46 [61%]) or supracervical (18/46 [39%]). The mean postoperative follow-up was 9.5 ± 3.1 months. For the primary outcome, women in the TVH/USLS group had a decrease in TVL, whereas women in the RH/SCP group had an increase in TVL (-0.6 ± 1.0 cm vs 0.5 ± 0.8 cm, p < .001). Among sexually active women (55/84, 65.5%), there was no difference in postoperative sexual function between groups based on Pelvic Organ Prolapse/Urinary incontinence Sexual Function Questionnaire short form scores, with good sexual function in both groups (32.6 ± 6.2 TVH/USLS vs 35.1 ± 7.3 RH/SCP, p = .22). Although both groups showed good postoperative apical support, the TVH/USLS group had a slightly lower mean C point compared with the RH/SCP group (-6.8 ± 1.2 vs -7.7 ± 1.8, p = .02). Both groups showed good postoperative pelvic floor function, with no difference in mean postoperative Pelvic Organ Prolapse Distress Inventory scores (42.2 ± 45.4 vs 52.7 ± 46.6, p = .44). Recurrent prolapse (defined as any prolapse at or beyond the hymen) was not different between groups (13.2% for TVH/USLS vs 6.5% for RH/SCP, p = .46). CONCLUSION Vaginal length decreased after vaginal hysterectomy with pelvic support surgery compared with RH with pelvic support surgery, with no differences in postoperative sexual function or pelvic floor function between groups.

Estimating the early impact of the FDA safety communication on the use of surgical mesh.

Objectives To estimate the early impact of the July 2011 Food and Drug Administration Safety Communication on the practice patterns of gynecologic surgeons using surgical mesh to manage pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Methods A cross-sectional study was performed by administering a mesh usage questionnaire to physician attendees at the opening session of the American Association of Gynecologic Laparoscopists Global Congress of Minimally Invasive Gynecology in November 2011. Results Of the 827 physicians attending the opening session of the conference, 281 (34%) completed the questionnaire, 202 (72%) of whom reported performing surgery for POP and/or SUI. The respondents were attending physicians (83.4%) with at least 10 years of experience (65.7%), 136 (71.1%) identifying themselves as General Gynecology, 29 (17.3%) as Urogynecology, 13 (7.1%) as Minimally Invasive Gynecologic Surgery, and 3 (1.8%) as Urology. When compared with generalists, specialists were more likely to use mesh for abdominal (86% vs 56.3%, P < 0.001) and vaginal (65.9% vs 37.2%, P = 0.001) POP repair. Specialists reported using mesh for the anterior compartment (50% vs 28.3%, P = 0.01) and the posterior compartment (36.4% vs 12.5%, P = 0.001), and total vaginal mesh kits (13.6% vs 1.7%, P = 0.005). Respondents reported an increase in mesh use for primary abdominal POP repair (82 vs 92, P = 0.013) and a decrease in mesh use for recurrent vaginal POP repair (99 vs 75, P < 0.001), with more surgeons opting against mesh for recurrent POP (49 vs 74, P < 0.001). For patient counseling, 53.7% reported changing their methods. Conclusions In a self-selected sample of pelvic surgeons, we noted that the 2011 FDA Safety Communication had an impact, with changes in mesh usage and counseling patterns.

Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest

Objectives This study aimed to compare the prevalence and severity of pelvic floor symptoms and sexual function at 1 year postpartum in women who underwent either operative vaginal delivery (OVD) or cesarean delivery (CD) for second-stage arrest. Methods In this cohort study, women with second-stage arrest in their first pregnancy who delivered between January 2009 and May 2011 at 2 different institutions were identified by an obstetric database using International Classification of Diseases, Ninth Revision, codes. Validated questionnaires evaluating pelvic floor symptoms and sexual function were administered. Subjects were dichotomized into those who underwent an OVD or a CD. Additional analyses by intent-to-treat and stratification of vacuum versus forceps operative deliveries were performed. Results Of the 109 women who completed the 1-year postpartum symptom questionnaires, 53 (48.6%) had a successful OVD, 20 (18.3%) failed OVD and underwent CD, and 36 (33%) underwent CD only. There were no differences between those who had a successful OVD and those who underwent a CD in either pelvic floor function or sexual function, but bulge symptoms were more common in the OVD group (7.5% vs 0, P = 0.05). When analyzed by intent-to-treat (planned OVD vs planned CD), pelvic floor symptoms remained similar between groups. However, those in the planned CD group reported higher orgasm and overall sexual satisfaction scores. Conclusions In this sample of primiparous women with second-stage arrest, mode of delivery did not significantly impact pelvic floor function 1 year after delivery, except for bulge symptoms in the OVD group and sexual satisfaction in the planned CD group.

Short-term mesh exposure after robotic sacrocolpopexy with and without concomitant hysterectomy.

Objectives The primary objective of this study was to compare the short-term rate of mesh exposure after a robotic sacrocolpopexy (RSCP) compared with those after RSCP with a concomitant hysterectomy. Secondary objectives included a comparison of mesh exposure from total hysterectomies (TH) versus supracervical hysterectomies (SCH) and determination of risk factors for mesh exposure. Methods This was a retrospective cohort study of women who underwent RSCP between January 2009 and December 2011 at one academic center. The primary outcome was mesh exposure at 6 weeks postoperation. Subjects were divided into two groups: those with concomitant hysterectomy and those with RSCP alone. The hysterectomy group was subdivided into TH versus SCH. Mesh exposures and mesh revision procedures were identified using International Classification of Diseases-9 and CPT codes, respectively, and confirmed by chart review. Results There were 230 eligible women who underwent RSCP during the study period and were followed up at a 6-week postoperative visit; 118 (51.7%) had RSCP only and 112 (48.7%) had a concomitant hysterectomy. Of those who underwent hysterectomy, 79 patients (70.5%) had TH and 33 (29.5%) had SCH. There were nine (3.9%) mesh exposures attributed to RSCP. The difference between the RSCP + hysterectomy group and the RSCP-only group was 2.7% versus 5.1% (P = 0.50). The 2.7% of mesh exposures in the hysterectomy group were associated with TH and none with SCH, but this difference was not significant (P = 0.55). Conclusions Although mesh exposure with RSCP is low, serious morbidity can be associated with mesh use and appropriate preoperative counseling is critical.

Robotic sacrocolpopexy performance and cumulative summation analysis.

Objectives This study aimed to apply Cumulative Summation (CUSUM) analysis as a tool to monitor robotic sacrocolpopexy (RSCP) proficiency over time. Methods A retrospective analysis of all women who underwent RSCP between September of 2008 and December of 2011 at the University of North Carolina at Chapel Hill. The performance for 2 attending surgeons was analyzed sequentially over time. Intraoperative complications such as genitourinary or gastrointestinal tract injury, conversion to laparotomy, pulmonary embolus, hemorrhage, and blood transfusion, were identified by International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. A successful outcome was defined as no intraoperative complications. The target value of success was set at less than 10% complications. CUSUM analysis was then sequentially applied to all RSCP cases for 2 attending surgeons. Results Over 27 months, 169 RSCPs were performed. The first surgeon performed 107 RSCPs and the second surgeon performed 62 RSCPs with 8 (7.4%) and 3 (4.9%) intraoperative complications, respectively. Total complications included 7 (4.1%) cystotomies, 2 (1.2%) vaginal lacerations, 1 (0.6%) blood transfusion, and 1 (0.6%) bowel perforation. A CUSUM graph was created for each surgeon. Conclusions CUSUM analysis was successfully applied to monitor RSCP proficiency. Such testing of individual successive procedural outcomes with CUSUM may offer an objective tool to aid in physician self-assessment.

Internet Use Among Urogynecology Patients in North Carolina.

Objectives Given limited information regarding digital technology use among patients, we sought to evaluate Internet use among younger (<65 years) as compared to older (≥65 years) women and to assess factors associated with Internet use. Methods We administered an anonymous questionnaire on digital technology use to English-speaking women who presented to our Urogynecology practice during a 1-month period. The questionnaire assessed the following sociodemographics: age, race, education, income, and insurance status. For our primary outcome, we assessed Internet use among younger versus older women. We also conducted a logistic regression analysis to evaluate the association of age with Internet use, while adjusting for potential confounders. Results A total of 556 women presented during the study period. Among these women, 506 completed the survey, for a 91% response rate. There were 282 (55.7%) younger women and 222 (43.9%) older women. Most of the younger and older cohorts were white (77% vs 86.5%, P = 0.02). Younger women were more educated (79.8% vs 59.5% ≥ college education; P < 0.0001) and had a higher income (58.3% vs 39.8% ≥

Implementation of a standardized digital rectal exam to improve the accuracy of rectocele diagnosis

50,000; P < 0.0001). For our primary outcome, younger women were significantly more likely to use the Internet (93.8% vs 66.3%, P < 0.001). In a logistic regression model which adjusted for age, race, education, and income, younger women remained significantly more likely to use the Internet (odds ratio, 6.6; 95% CI, 3.4-13.0). Conclusions Although women younger than 65 years reported greater Internet use when compared to women 65 years or older, most of older women also used the Internet.

Overlapping sphincteroplasty and posterior repair

Introduction and hypothesisThe standardized evaluation of posterior compartment prolapse using the Pelvic Organ Prolapse Quantification (POP-Q) system is limited. The primary objective of this study is to develop and validate the interexaminer reliability of a new system for assessing the posterior vaginal wall for the presence of a rectocele.MethodsThis was a cross-sectional study of women presenting to an academic urogynecology clinic. Subjects underwent a routine pelvic examination that included a standard POP-Q followed by two Standardized Digital Rectal Exams (SDRE) by two different providers, each blinded to the other’s results. The SDRE measures the distance from the leading edge of a posterior bulge to the hymen with a finger in the distal rectum - first visually and then an actual measured distance using a marked cotton swab (Q-tip measurement). Correlations between examiners for the SDRE and the POP-Q were analyzed using Pearsons correlation coefficient (ρ).ResultsEight attending and fellow urogynecologists examined 50 subjects. Mean age was 57.3 years, mean BMI 30.9 kg/m2, with an overall median POP-Q stage 2 (range 0–3), and median posterior POP-Q stage 1 (range 0–3). Overall, 54 % of women had a noteworthy rectocele by typical digital rectal exam. Interexaminer correlations with SDRE for both the visual assessment (ρ = 0.697, p < 0.0001) and the Q-tip measurement (ρ = 0.767, p = p < 0.001) were strong. The intraexaminer visual assessment and the Q-tip measurement were highly correlated (ρ = 0.934, p = <0.001).ConclusionThis standardized rectal examination provides a consistent method for the reporting of distal rectoceles that can lend additional information to the POP-Q exam.

Differences in recurrent prolapse at 1 year after total vs supracervical hysterectomy and robotic sacrocolpopexy

Introduction and hypothesisKnowledge of how to anatomically reconstruct extensive posterior-compartment defects is variable among gynecologists. The objective of this video is to demonstrate an effective technique of overlapping sphincteroplasty and posterior repair.MethodsIn this video, a scripted storyboard was constructed that outlines the key surgical steps of a comprehensive posterior compartment repair: (1) surgical incision that permits access to posterior compartment and perineal body, (2) dissection of the rectovaginal space up to the level of the cervix, (3) plication of the rectovaginal muscularis, (4) repair of internal and external anal sphincters, and (5) reconstruction of the perineal body. Using a combination of graphic illustrations and live video footage, tips on repair are highlighted.ResultsThe goals at the end of repair are to: (1) have improved vaginal caliber, (2) increase rectal tone along the entire posterior vaginal wall, (3) have the posterior vaginal wall at a perpendicular plane to the perineal body, (4) reform the hymenal ring, and (5) not have an overly elongated perineal body.ConclusionThis video provides a step-by-step guide on how to perform an overlapping sphincteroplasty and posterior repair.