Javier Pizarro-Berdichevsky

Robotic Female Pelvic Floor Reconstruction: A Review

As the surgical correction of pelvic organ prolapse has continued to evolve, robotic-assisted abdominal sacrocolpopexy (RASC) has gained increasing popularity. Studies have shown equivalent subjective and objective outcomes compared with the gold standard abdominal sacrocolpopexy. Additionally, this approach is associated with a shorter hospital stay and less cost than the traditional open procedure. Although there is a learning curve associated with RASC, the basic principles of the procedure are the same. Herein, we discuss the robotic techniques for repair of pelvic organ prolapse as well as discuss the currently available literature regarding RASC.

Evaluation and Management of Pelvic Organ Prolapse in Elderly Women.

Pelvic organ prolapse is a common disease in elderly patients. The most important symptom is vaginal bulge (bulge sensation or the sensation of something coming down through the vaginal introitus). This symptom is not different than in the general population. Diagnosis can be confirmed using just vaginal examinations to identify the presence of protrusion beyond the hymen, and is not different than in the general population. Different treatment options are available, including observation, nonsurgical, and surgical techniques. Pessaries and colpocleisis are the treatment options used more often in elderly patients than in the general population.

Real-Time Changes in Brain Activity during Sacral Neuromodulation for Overactive Bladder

Purpose: We performed functional magnetic resonance imaging to identify changes in brain activity during sacral neuromodulation in women with overactive bladder who were responsive to therapy. Materials and Methods: Women recruited into the study had nonneurogenic refractory overactive bladder, responded to sacral neuromodulation and had had a stable program for at least 3 months with no subsequent overactive bladder treatment. Enrolled patients completed validated symptom and quality of life instruments before functional magnetic resonance imaging. Stimulus settings were recorded, devices were switched off for a 5‐day washout and instruments were repeated. Three functional magnetic resonance imaging scans with simultaneous sacral neuromodulation stimulation were performed below, at and above stimulus sensory threshold using a block design. This yielded brain activity maps represented by changes in blood oxygenation level dependence. A total of 5 stimulator off and 4 stimulator on cycles of 42 seconds each were imaged. Group analysis was done using a single voxel p value of 0.05 with a false‐positive error of 0.05 on cluster analysis. Results: Six of the 13 patients enrolled completed functional magnetic resonance imaging. Median age was 52 years (range 36 to 64). Urinary symptoms and voiding diary data worsened with washout. Overall brain activation generally progressed with increasing stimulation amplitude. However, activation of the right inferior frontal gyrus remained stable while deactivation of the pons and the periacqueductal gray matter only occurred with subsensory stimulation. Sensory stimulation activated the insula but deactivated the medial and superior parietal lobes. Suprasensory stimulation activated multiple structures and the expected S3 somatosensory region. All devices had normal impedance after functional magnetic resonance imaging. Conclusions: Functional magnetic resonance imaging confirmed that sacral neuromodulation influences brain activity in women with overactive bladder who responded to therapy. These changes varied with stimulus intensity.

Impact of Age and Comorbidities on Use of Sacral Neuromodulation

Purpose: We investigated the influence of patient age on sacral nerve stimulation trial outcomes, device implantation and treatment durability. Materials and Methods: We analyzed a database of all sacral nerve stimulation procedures performed between 2012 and 2014 at a high volume institution for associations of patient age with sacral nerve stimulation indication, trial stimulation success, device revision and device explantation. Results: In a cohort of 356 patients those with nonobstructive urinary retention and urgency‐frequency were younger than patients with urgency urinary incontinence. Trial stimulation success did not differ by age in stage 1 and percutaneous nerve evaluation trials (p = 0.51 and 0.84, respectively). Logistic regression identified greater odds of trial success in females compared to males (OR 2.97, 95% CI 1.32–6.04, p = 0.009) and for urgency urinary incontinence compared to urgency‐frequency (OR 3.02, 95% CI 1.39–6.50, p = 0.006). In analyzed patients there were 119 surgical revisions, including battery replacement, and 53 explantations. Age was associated with a decreased risk of revision with 3% lower odds per each additional year of age (OR 0.97, 95% CI 0.95–0.98, p <0.0001). While age did not influence explantation, for each body mass index unit there was a 5% decrease in the odds of explantation (OR 0.95, 95% CI 0.91–0.98). Conclusions: In contrast to previous studies, older patients experienced no difference in the sacral nerve stimulation response in stimulation trials and no difference in the implantation rate. Furthermore, age was modestly protective against device revision. This suggests that age alone should not negatively predict sacral nerve stimulation responses.

Sacral Neuromodulation Implant Infection: Risk Factors and Prevention

Device infection is one of the most common complications of sacral nerve stimulator placement and occurs in approximately 3–10% of cases. Infection is a serious complication, as it often requires complete explantation of the device. Not much is known regarding risk factors for and methods of preventing infection in sacral nerve stimulation. Multiple risk factors have been linked to device infection including prolonged percutaneous testing and choice of preoperative antibiotic. Methods of infection prevention have also been studied recently, including antibiotic-impregnated collage and type of skin preparation. This review will discuss the recent literature identifying risk factors and means of preventing infection in sacral nerve stimulation. Finally, we will outline a protocol we have enacted at our institution which has resulted in an incidence of infection of 1.6%.

Association between pelvic floor disorder symptoms and QoL scores with depressive symptoms among pelvic organ prolapse patients

There is no consensus on the relationship between depressive symptoms (DS) and pelvic organ prolapse (POP) symptoms and quality of life (QoL). Our hypothesis was that women with DS and POP have worse symptoms and QoL than those without DS and POP.

Validation of the Spanish-language version of the Prolapse Quality of Life Questionnaire in Chilean women

Introduction and hypothesisThe Prolapse Quality of Life (P-QOL) questionnaire is a specific health-related quality of life (HRQL) instrument to assess the impact of POP on women. It has been validated in English-speaking women and to date has been translated into several other languages. However, currently there is no Spanish translation of the P-QOL questionnaire. The aim of this study was to translate the P-QOL questionnaire into Spanish and to assess its feasibility, validity, and reliability.MethodsFollowing a forward- and back-translation of the original English P-QOL questionnaire into Spanish language, the translated questionnaire was reviewed by a group of patients as well as an expert panel to assess its comprehensibility. In this cross-sectional study women with POP symptoms were recruited from a tertiary referral teaching hospital. Women were defined as symptomatic if they report feeling a lump/bulge/pressure in the vagina. The Spanish translated P-QOL questionnaire was self-administered to all women. Reliability, content, and construct validity were evaluated using the Cronbach’s alpha coefficient, ANOVA, and Spearman’s correlation tests.ResultsOne hundred and twenty-eight women were studied. There were no missing items. The Cronbach’s alpha ranged from 0.626 to 0.866 across domains, demonstrating the good reliability of the Spanish P-QOL. The severity of symptoms was related to the worst quality of life, but the severity of POP was not related to poorer QoL.ConclusionsThe Spanish translated version of the P-QOL is a reliable, consistent and valid instrument to assess symptom severity and QoL impact in Chilean women with POP.

Labhardt’s colpoperineocleisis: subjective results of an alternative treatment for genital prolapse in patients who are not sexually active—2-year follow-up

Introduction and hypothesisGenital prolapse affects up to 50xa0% of multiparous women and has an impact on quality of life (QoL) for many. Vaginal obliterative techniques are relevant in older patients who are not sexually active. We performed Labhardt’s colpoperineocleisis in such patients. The objective was the evaluation of subjective outcomes of this technique using PGI-I.MethodsRetrospective cohort analysis of patients. We performed a bivariate, multivariate analysis, and survival curves for subjective improvement.ResultsSeventy-four cases were analyzed. Average age of the patients was 72xa0years, median parity 4, 95.9xa0% POP-Q stage III or IV, anterior leading edge defect in 61.1xa0%. Operating time: 54xa0min, estimated blood loss 70xa0ml, no intraoperative complications, 12 patients had protocol deviations with changes in the recommended type of suture. Median hospital stay was 2xa0days and average follow-up 24.9xa0months. There was 13.5xa0% anatomical recurrence, 3 of which (30xa0%) were in patients with protocol deviations. 1.9xa0% developed clinically significant de novo stress urinary incontinence (SUI). PGI-I: 64 (86xa0%) reported subjective improvement and 10 did not. In the subjective improvement group, 98.4xa0% reported being very much or much better. In the non-subjective improvement group 80xa0% reported that they were the same as before surgery and 20xa0% were worse. In bivariate analysis anatomical recurrence showed significance and persisted after multivariate analysis with an OR of 8322 for subjective failure.ConclusionLabhardt’s colpoperineocleisis is a safe technique with good subjective results. It has few complications, an acceptable recurrence rate, and a low rate of de novo SUI. It may be important to use the #0 or #1 polydioxanone sutures, as these are associated with better outcomes in this series. Comparative studies with other obliterative techniques are needed.

Can Lumbosacral Magnetic Resonance Imaging be Performed Safely in Patients with a Sacral Neuromodulation Device? An In Vivo Prospective Study

Purpose We sought to determine the safety of sacral neuromodulation in patients during lumbosacral 1.5 Tesla magnetic resonance imaging. Materials and Methods We prospectively recruited patients with a sacral neuromodulation implant who required lumbosacral 1.5 Tesla magnetic resonance imaging. Before imaging the patients completed validated urinary symptom questionnaires and a survey regarding the usual sacral neuromodulation sensation. The implantable pulse generator was interrogated, and impedances, battery life and stimulus amplitude sensory thresholds were assessed before and after magnetic resonance imaging. Devices were switched off before the patient entered the scanner. Patients were monitored during the study and magnetic resonance imaging related adverse events questionnaires were completed after imaging. Validated questionnaires were repeated 1 month after magnetic resonance imaging to assess for changes in sacral neuromodulation therapeutic efficacy. Results A total of 11 patients were enrolled in the study. Lower back pain, which was noted by 6 of the 11 patients (55%), was the most common indication for imaging. Immediately after magnetic resonance imaging only 1 patient reported mild discomfort during imaging at the site of the implantable pulse generator. This discomfort was present only during the scan and not afterward. Two patients reported warmth at the implantable pulse generator site during the scan, which was also present only during scanning. Patients did not report any other adverse events. There were no major changes in impedance or battery life after magnetic resonance imaging. Stimulus amplitude sensory thresholds and stimulation localization were unchanged. Validated questionnaires 1 month after imaging did not show worsening scores compared to scores before imaging. Conclusions No significant adverse events occurred in patients implanted with a Medtronic InterStim™ II device who underwent a 1.5 Tesla lumbosacral magnetic resonance imaging scan. Therapeutic efficacy of sacral neuromodulation was unchanged 1 month after imaging.

Surgeons’ views on sling tensioning during surgery for female stress urinary incontinence

Introduction and hypothesisLittle is known regarding the use of various techniques for sling tensioning. Our objective was to determine which techniques are most commonly used by surgeons and surgeons’ views on sling tensioning.MethodsAn Internet-based survey designed to assess the use of various tensioning evaluation methods, different sling tensioning techniques, and views and beliefs regarding the importance of tensioning was sent to members of major sub-specialty professional organizations. The responses were analyzed using descriptive statistics, and univariate and multivariate logistic analyses were performed to assess the effect of various surgeon characteristics on operative techniques.ResultsA total of 596 surgeons (63% gynecologists, 37% urologists) from 56 different countries were included in the analysis. Over 30% of respondents reported performing >50 sling operations/year. Use of objective intraoperative tension evaluation methods was 15.6, 7.8, and 1.9% for intraoperative stress tests, cystoscopic evaluation of urethral coaptation, or Q-tip tests respectively. Sixty-three percent indicated that they tension retropubic transvaginal tape (RP) and transobturator tape (TOT) slings similarly, whereas 26.2% place more tension on TOT than RP slings and 10.4% place more tension on RP than TOT slings. Those with fellowship training were 66% more likely to utilize leak point pressure results to inform the degree of tensioning (OR 1.66, CI 1.04–2.66).ConclusionsOur results indicate that there is a wide degree of variation in technique among surgeons. Prospective studies assessing the utility of various techniques could provide more evidence-based approaches to midurethral sling surgery and potentially improve quality and patient outcomes.