Ja-Hong Kim

Is robotic sacrocolpopexy a marketing gimmick or a technological advancement

Purpose of review Robot-assisted laparoscopic sacrocolpopexy (RALS) is a new surgical technique for the treatment of symptomatic vaginal vault prolapse that is rapidly gaining popularity among both urologists and gynecologists. This article will summarize the available published data to assess the potential advantages and disadvantages of this new procedure and its current role in female pelvic floor reconstruction. Recent findings The literature on RALS is limited mainly to single-institution retrospective studies, which suggest minimal morbidity, technical feasibility, and short-term efficacy comparable to open abdominal sacrocolpopexy. What remains uncertain is whether this approach will be superior to the other established minimally invasive transvaginal and laparoscopic approaches in terms of subjective and objective outcomes and quality of life. Other relevant issues, such as overall cost-effectiveness and extended application for multicompartment defects and uterine-sparing procedures, remain largely unexplored. Summary The use of RALS will likely continue to expand secondary to increased access and the popularity of the robotic apparatus among both surgeons and patients. Well designed large randomized multicenter comparative studies based on validated measurement instruments are needed to evaluate its advantage over conventional approaches, including open abdominal sacrocolpopexy and various transvaginal and laparoscopic techniques.

Validating the Incontinence Symptom Severity Index: A Self-Assessment Instrument for Voiding Symptom Severity in Women

PURPOSE Most voiding symptom self-assessment instruments assess either symptom bother or effect on quality of life. The Incontinence Symptom Severity Index is an instrument for self-assessment of severity of female urinary storage and voiding symptoms, rather than symptom bother or effects of symptoms on quality of life. We assessed the validity of the Incontinence Symptom Severity Index for female voiding symptom self-assessment. MATERIALS AND METHODS The Incontinence Symptom Severity Index assesses 8 symptom domains, including emptying, urgency, urge incontinence, nocturia, daytime frequency, stress incontinence, leakage with physical activity and pad use. Three separate cohorts of women with a mean age of 59, 60 and 63 years, respectively, who underwent evaluation for urinary complaints associated with incontinence and vaginal prolapse were analyzed. Internal consistency was assessed via item-total correlations and Cronbachs alpha. Concurrent validity against the Urogenital Distress Inventory and Pelvic Floor Distress Inventory-Short Form were studied by correlating similar symptom domains of the Incontinence Symptom Severity Index with both instruments. We assessed criterion validity by comparison with the objective measures of post-void residual urine, voiding logs and self-reported pad use. Response to change was assessed by comparing pretreatment and posttreatment Incontinence Symptom Severity Index scores. RESULTS Significant item total correlations were seen for each Incontinence Symptom Severity Index item and Cronbachs alpha was 0.69. All Incontinence Symptom Severity Index items significantly correlated with similar items of the Urogenital Distress Inventory and Pelvic Floor Distress Inventory-Short Form. Significant posttreatment reductions were also observed for all 8 Incontinence Symptom Severity Index items. Progressively higher post-void residual urine was noted for the 4 severity scores of Incontinence Symptom Severity Index item 1 (emptying) (p = 0.07). Incontinence Symptom Severity Index items 3 (nocturia) and 4 (daytime frequency) showed significantly increasing nighttime and daytime voids with worsening severity scores for each (p <0.0001 and <0.0041, respectively). Incontinence Symptom Severity Index items 5 to 8 (stress incontinence, urge incontinence, leakage with activity and pad use) showed significantly increasing trends in mean daily pad use (p <0.0001, 0.022, <0.0001 and <0.0001, respectively) among the 4 severity scores for each. CONCLUSIONS The Incontinence Symptom Severity Index demonstrates good reliability and validity. It is a useful instrument for assessment of female incontinence and voiding symptom severity in clinical and research settings.

Comparison of Times to Ureteral Efflux after Administration of Sodium Fluorescein and Phenazopyridine

Purpose: There is currently a national shortage of indigo carmine. In efforts to identify the most efficient aid for visualizing ureteral efflux intraoperatively we investigated the time to excretion of phenazopyridine vs a newly identified alternative, sodium fluorescein. Materials and Methods: We analyzed prospectively collected data on a cohort of women who underwent pelvic reconstructive surgery in 2015. Per provider preference patterns a number of patients were administered 200 mg phenazopyridine orally with a sip of water 1 hour prior to the start of operative time. Other patients were given 0.5 ml 10% sodium fluorescein intravenously in the operating room. In all cases time was measured between the administration of the agent and the visualization of color changes consistent with agent efflux in an indwelling catheter, which was placed at the start of the operation. Differences in excretion times between the groups were compared with the Wilcoxon rank sum test. Results: Seven women received phenazopyridine and 5 received sodium fluorescein. Mean excretion time was significantly longer in the phenazopyridine group compared to the sodium fluorescein group (81.9 vs 5.1 minutes, p = 0.0057). Median excretion time for phenazopyridine was 70 minutes (range 59 to 127) and for sodium fluorescein it was 5 minutes (range 3 to 9). Conclusions: Sodium fluorescein is excreted significantly faster in the operating room compared to phenazopyridine. Depending on the cost of these agents at an institution, in addition to the desire to decrease operative time, this may impact practice patterns and agent selection.

Lack of uniformity among United States recommendations for diagnosis and management of acute, uncomplicated cystitis

Introduction and hypothesisAcute, uncomplicated cystitis is one of the most common bacterial infections seen in clinical practice. Quality improvement and antibiotic stewardship efforts to optimize cystitis management rely on clinicians managing patients in a manner recommended by experts and guidelines. However, it is unclear if recent recommendations for cystitis from experts and guidelines from US medical societies that provide recommendations are well aligned.MethodsWe examined recommendations and guidelines for acute, symptomatic cystitis in women published in US medical societies’ journals from January 1, 2008, to December 31, 2016, within the fields of family medicine, obstetrics and gynecology, internal medicine, female pelvic medicine and reconstructive surgery, and infectious diseases.ResultsAll recommendations endorsed the use of symptoms and urine dipstick to diagnose cystitis. Some societies did not recommend urine dipstick in patients with recurrent urinary tract infection (UTI), classic UTI symptoms, or a lack of underlying conditions or competing diagnoses. All endorsed nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as first-line agents. Some guidelines classified fluoroquinolones as second- or third-line, while others considered them first-line treatment for UTI. Avoiding use of amoxicillin and ampicillin, antibiotic agents with high prevalence of resistance in the US, was recommended by some societies.ConclusionsUS recommendations differed in their approach to the treatment of acute, uncomplicated cystitis. Lack of uniformity likely contributes to clinical management variance for patients with UTI and hampers quality improvement and antibiotic stewardship efforts aimed at promoting optimal management. Our findings emphasize the need for more consistent recommendations for cystitis management.

Complete Excision of Sacrocolpopexy Mesh With Autologous Fascia Sacrocolpopexy

OBJECTIVE To evaluate the safety and short-term efficacy of complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy. METHODS A retrospective cohort study of patients undergoing complete sacrocolpopexy mesh excision and concomitant autologous fascia sacrocolpopexy from March 2013 to September 2016 was conducted. The primary objective was assessment of perioperative outcomes including complications within 60 days of surgery. The secondary outcome measure was surgical success defined as no need for retreatment by either surgery for apical prolapse or pessary. RESULTS Nineteen patients were identified. Median patient age was 56 years old (range 35-78). Median time from mesh placement to surgical excision was 4.5 years (0-13). Indications for mesh excision included refractory pelvic pain in 18 patients (95%), symptomatic mesh exposure in 8 patients (42%), and bilateral ureteral obstruction with ureterovaginal fistula in 1 patient (5%). Median operative time, estimated blood loss, and length of hospital stay were 228 minutes (133-362), 200 mL (50-1000), and 5 days (2-9), respectively. The rate of minor and major complications within 60 days was 36.8% and 5.3%, respectively. There were no cases of bladder or bowel injury. At a median follow-up of 9.9 months (2.4-39) no patient required secondary surgery for apical vaginal prolapse or retreatment with pessary. CONCLUSION Complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy can be accomplished safely with a low rate of major complications. These are short-term findings and longer follow-up of anatomic and functional outcomes is needed.

Robotic Sacrocolpopexy—Is It the Treatment of Choice for Advanced Apical Pelvic Organ Prolapse?

Purpose of ReviewPelvic organ prolapse (POP) is a highly prevalent condition among women that, although non-life threatening, can significantly impact daily activities and quality of life (QOL). Sacrocolpopexy (SC) has been touted by many as the “gold standard,” citing superior anatomic success rates compared to transvaginal approaches for apical prolapse repair. In line with current trends throughout the surgical field, robotic-assisted laparoscopic sacrocolpopexy (RSC) has rapidly gained popularity. This review will present the most contemporary evidence examining RSC and discuss whether it has met criteria to qualify as the “treatment of choice” for advanced apical vaginal prolapse.Recent FindingsRecent findings support the superior durability of SC for apical prolapse repair compared to native tissue vaginal approaches. Recent evidence demonstrates that anatomic outcomes of minimally invasive sacrocolpopexy, including RSC, are no different than those of traditional ASC. Low quality evidence suggests lower rates of dyspareunia with SC compared to vaginal repairs. RSC may be cost-effective when compared to ASC. When compared to LSC, however, RSC is more expensive and associated with longer operating times.SummaryRSC is an excellent option for many women who desire the most durable option for definitive repair of advanced apical POP.

1346 TRANSLABIAL ULTRASONOGRAPHY OF SUBURETHRAL SLINGS IN PATIENTS WITH RECURRENT URINARY INCONTINENCE AFTER SYNTHETIC SLING PLACEMENT

INTRODUCTION AND OBJECTIVES: Treatment for stress urinary incontinence using suburethral slings fails in 10–20% of surgeries. The underlying pathophysiology is not fully understood. In this study, we use translabial ultrasonography (US) to evaluate sling type, position, and morphology in patients after suburethral sling placement. We hypothesize that sling position and morphological changes have an impact on sling failure. METHODS: In this retrospective observational study, 51 consecutive patients were evaluated with translabial US for type, position, and morphology of suburethral slings between 2009 and 2010. Axial, coronal, and sagittal planes were obtained using a curvilinear 4-9mHz transducer. The patients were stratified, by cough test and bother scores, into patients with recurrent incontinence (n 33) and continent patients (n 18). Student’s t-test was performed for statistical evaluation comparing sling type, position, and morphology in both groups after suburethral sling procedures. RESULTS: By evaluating the sling type, translabial US revealed a similar number of patients in the incontinent and continent group treated with a transobturator (45% vs. 56%) or retropubic sling (55% vs. 44%), respectively. Comparing the position of suburethral slings in incontinent and continent patients with translabial US reveals that more patients in the incontinence group were found with slings located at the proximal urethra (48% vs. 16%, p 0.0123), less patients in the incontinence group were found with slings at the midurethra (39% vs. 67%, p 0.0323), and a similar number of patients in both groups were found with slings at the distal urethra (12% vs. 17%), respectively. Only incontinent patients presented with urethra or bladder perforation (6%). Morphologically, slings were significantly more folded in the incontinent group than in the continent population (73% vs. 6%, p 0.0016). CONCLUSIONS: In this study, we have shown that US can distinguish transobturator and retropubic slings and determine sling position. The type of sling does not seem to have an impact on recurrent UI, whereas the position, close to the bladder neck and/or folding of the sling, might be related to recurrent incontinence. Because it is the only diagnostic tool to determine the type of sling, locate the sling position, and follow up on its morphology, translabial US helps to elucidate the pathophysiology responsible for sling failure.

URETHROVAGINAL FISTULA REPAIR WITH MARTIUS FLAP

Synopsis of Video Technique: Indigo carmine is injected through the urethral catheter to visualize the fistulous opening. A small 10F catheter is inserted through fistula (in some cases dilation with sounds is needed to allow passage). An inverted U incision is made on the anterior vaginal wall, including the fistula tract in the incision. Dissection of the U flap proximally toward the bladder ensures easy coverage of the fistula after repair and dissection of the distal and lateral vaginal walls assists with tension free closure. A horizontal incision is made in the periurethral fascia and fascial flaps are dissected on the proximal and distal sides of the fistula. The fistula tract is not excised; it is closed vertically in a running fashion after removal of the fistula catheter. A second layer of closure, taking deep bites to incorporate urothelium, is performed. A watertight closure is confirmed with injection of indigo carmine. The periurethral fascia is closed horizontally. A Martius flap is harvested in the standard fashion and used to cover the repair. The U shaped vaginal wall flap is advanced over the Martius flap for closure.

SUPRAMEATAL URETHROLYSIS WITH MARTIUS FLAP

Synopsis of Video Technique: A semicircular incision is made between the urethral meatus and clitoris. The dissection is directed toward the periostium of the pubic symphysis 2 cm above the urethra. Bovey cautery is used to dissect the subcutaneous tissue directly on top of the pubic bone. A Heney retractor is placed superiorly to expose the pubic bone and a curved mayo with curved tip pointing up is passed directly under the bone to enter the retropubic space. Careful dissection frees the bladder from the pubis and lysis of adhesions with removal of residual mesh, if present, is performed. The urethra and bladder are dissected until completely free in the retropubic space. A Martius flap is harvested from the labia in the standard fashion and passed into the suprameatal area to cover the bladder and urethra. The subcutaneous tissues are then re-approximated over the Martius flap and the vaginal skin is closed in an interrupted fashion.

QUALITY-OF-CARE INDICATORS FOR WOMEN WITH OVERACTIVE BLADDER: A SYSTEMATIC REVIEW OF THE LITERATURE

INTRODUCTION AND OBJECTIVE: Overactive bladder (OAB) is highly prevalent in the general population and has a strong impact on all measures of quality of life. Unfortunately, there are identifiable variations in the awareness and implementation of guidelines for the diagnosis and management of OAB. The goal of this study was to conduct a systematic literature review to identify potential indicators of quality of care for women with overactive bladder symptoms. METHODS: We first conducted semi-structured interviews with experts in the field of urinary incontinence in order to identify potential candidate quality-of-care indicators. We then searched MEDLINE and the Cochrane database to identify English-language articles published between 1997 and 2008 that focused on evaluation, diagnosis, and management of overactive bladder in women. We conducted supplementary searches at guidelines.gov to identify national and international clinical practice guidelines for urge incontinence/overactive bladder. Additional articles were obtained by reviewing the references of previously identified articles. We then synthesized the evidence by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) classification. RESULTS: We used more than 30 combinations of search terms relevant to each quality indicator to identify peer-reviewed articles addressing evaluation, diagnosis, examination, and treatment of overactive bladder. We screened 2,127 titles to find 380 relevant abstracts and reviewed the full articles. We identified 34 quality indicators for OAB management through literature reviews and interviews with leading specialists. These candidate indicators address four general domains of care: evaluation, physical examination, diagnostic work-up and treatment. CONCLUSIONS: While the literature includes moderate to strong evidence regarding behavioral and pharmacologic management of OAB, there is a dearth of high-quality studies that address the appropriate diagnostic evaluation of OAB. Instead, recommendations for the proper evaluation and work-up of OAB derive primarily from general practice guidelines and review articles. Further development of quality-of care indicators will allow for large-scale measurement of the quality of care provided to women with OAB, with the ultimate goal of implementing quality improvement programs.