Jonathan L. Gleason

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Utility of preoperative endometrial assessment in asymptomatic women undergoing hysterectomy for pelvic floor dysfunction.

Introduction and hypothesisUterine morcellation during laparoscopy for pelvic floor repair has prompted adoption of uterine screening tests by some surgeons. We report a case series of uterine malignancy incidentally diagnosed at the time of pelvic floor surgery.MethodsWe reviewed records from patients undergoing hysterectomy for pelvic organ prolapse (POP) and/or urinary incontinence (UI) from January 2004 to December 2009 and abstracted preoperative screening trends and final pathologic diagnoses.ResultsOf the 708 women in the study, 125 (18%) had preoperative endometrial biopsy (EB), 43 (6%) had pelvic ultrasound (US), and 21 (3%) had EB and US. Surgical route included vaginal (58%), abdominal (23%), and laparoscopic (18%). Most (97.1%) final pathologic diagnoses were benign. Five cancers (0.6%) were detected; four of these women had normal preoperative screening, including EB (2), US (1), or both tests (1).ConclusionsScreening with EB + US was found to be ineffective in our cohort of patients due to the low prevalence of undetected uterine cancer in asymptomatic women planning POP/UI surgery.

Incontinence outcomes in women undergoing primary and repeat midurethral sling procedures.

OBJECTIVE: To assess stress urinary incontinence (SUI) and other lower urinary tract symptom outcomes in women undergoing repeat midurethral sling procedures compared with those undergoing primary midurethral sling procedures. METHODS: Cure was defined as responses of “not at all” or “somewhat” to both questions of the SUI subscale of the Urogenital Distress Inventory-6; symptom effect was assessed using the Incontinence Impact Questionnaire-7. Multivariable models were created controlling for baseline Medical Epidemiologic and Social Aspects of Aging questionnaire urge score and Urogenital Distress Inventory-6 stress subscale score. RESULTS: One thousand three hundred sixteen patients had charts available for review: 135 of 1,316 (10.2%) had undergone prior midurethral sling procedures; 799 of 1,316 (61%) questionnaires were returned, with 92 from those having undergone prior midurethral sling procedures. Median follow-up time was 36.4 months with a range of 11.4–71.5 months. Cure rates were 71% (95% confidence interval [CI] 67.7–74.3%) in the primary midurethral sling group and 54% (95% CI 43.8–64.2%) in the repeat midurethral sling group (P<.001). Women undergoing repeat midurethral sling procedures experienced significantly greater improvement in symptom-specific quality of life (QOL) compared with those undergoing primary midurethral sling procedures (−28.87±37.6 compared with −18.42±32.73, P=.01). Multivariable analyses revealed that women in the repeat midurethral sling group had increased risk of SUI failure (odds ratio 1.7, 95% CI 1.1–2.8). CONCLUSION: Women undergoing repeat midurethral sling procedures had almost two times the odds of SUI treatment failure but greater improvement in symptom effect on QOL than did those undergoing a primary midurethral sling procedure. This information can help counsel patients regarding their expectations of repeat midurethral sling surgery for recurrent SUI . LEVEL OF EVIDENCE: II

Effect of hormonal contraception on the function of plasmacytoid dendritic cells and distribution of immune cell populations in the female reproductive tract

Objective:Epidemiological evidence suggests an association between the use of hormonal contraception and an increased risk of acquiring sexually transmitted diseases including HIV-1. We sought to elucidate the biological mechanisms underlying the effect of hormonal contraception on the immune system. Design:Cross-sectional study. Methods:To delineate the biological mechanisms underlying the effect of hormonal contraceptives on the immune system, we analyzed the functional capacity of circulating plasmacytoid dendritic cells (pDCs), the distribution of vaginal immune cell populations, and the systemic and genital levels of immune mediators in women using depot medroxyprogesterone acetate (DMPA), NuvaRing, or combined oral contraceptives (COC). Results:The use of DMPA or NuvaRing was associated with reduced capacity of circulating pDCs to produce interferon (IFN)-&agr; and tumor necrosis (TNF-&agr;) in response to TLR-9 stimulation. Systemic levels of IFN-&agr; and cervicovaginal fluid levels of IFN-&agr;, CXCL10, monocyte chemotactic protein-1, and granulocyte-colony stimulating factor were significantly lower in DMPA users compared to control volunteers not using hormonal contraception. The density of CD207+ Langerhans cells in the vaginal epithelium was reduced in NuvaRing and combined oral contraceptive users but not in DMPA users. Conclusions:The presented evidence suggests that the use of some types of hormonal contraception is associated with reduced functional capacity of circulating pDCs and altered immune environment in the female reproductive tract.

Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review.

OBJECTIVE: To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy. DATA SOURCES: MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries. METHODS OF STUDY SELECTION: Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14–0.7% compared with 0.02–0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04–1.92). Coronary heart disease (HR 1.26, 95% CI 1.04–1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27–2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results. CONCLUSION: Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.

Sling surgery for stress urinary incontinence in women: A systematic review and meta-analysis

Traditional treatment options in women with stress urinary incontinence (SUI) include Burch urethropexy or pubovaginal slings. These procedures have become much less popular and less frequently performed with the development and increased use of synthetic midurethral slings (MUSs). These trends in practice have not been associated with dramatic improvements in outcomes, however, and up to a third of women require repeat surgery. Therefore, it is important to understand the comparative effectiveness of competing surgical repair procedures. The primary aim of this systematic review and meta-analysis was to compare objective and subjective cure rates in adult women with SUI treated with different surgical procedures. A systematic review was performed using the MEDLINE and Cochrane Central Register for Controlled Trials databases to obtain English-language comparative studies, cohort studies, and systematic reviews published from 1990 through April 2013 comparing a sling procedure for SUI to another sling or to Burch urethropexy. For evaluation of outcomes, only peer-reviewed randomized controlled trials with at least 12 months of follow-up were included. The minimum requirement for meta-analysis was at least 3 randomized controlled trials that compared the same surgeries for the same outcome and provided adequate efficacy and adverse event data. A random-effects model meta-analysis was used to estimate pooled odds ratios (ORs). Comparison ofMUS vs Burch urethropexy (open or laparoscopic):Meta-analysis of objective cure showed no significant difference between these 2 procedures (OR, 1.18; 95% confidence interval [CI], 0.73–1.89). There was also no difference between these 2 surgeries for outcomes of subjective cure, quality of life, or sexual function. Either an MUS or Burch procedure can be used. The choice should be based on potential adverse events and planned concomitant surgeries. Comparison of pubovaginal sling vs Burch urethropexy: Because the evidence favored pubovaginal slings for both subjective and objective cure, the authors recommended use of pubovaginal slings to maximize cure outcomes. Comparison of pubovaginal slings vs MUS: Meta-analysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18–0.85). A meta-analysis for objective cure could not be performed because of inadequate data. Based on the subjective evidence for better cure, the authors recommended MUS. www.obgynsurvey.com | 586 Copyright

Survey of robotic surgery credentialing requirements for physicians completing OB/GYN residency.

STUDY OBJECTIVE To describe credentialing requirements for newly graduated resident physicians for robotic-assisted gynecologic surgery in Alabama. DESIGN Cross-sectional study (Canadian Task Force classification III). SETTING Hospitals in the state of Alabama in the United States. PARTICIPANTS Credentialing authorities at hospitals in Alabama that currently use robotic surgery in the field of gynecology. INTERVENTIONS Participants completed an online questionnaire about credentialing policies. MEASUREMENTS AND MAIN RESULTS Fifteen of 16 hospitals (94%) in Alabama that use robotic technology for gynecologic surgery participated in this survey. All hospitals had a credentialing policy for robotic surgery; however, only 9 of the 15 hospitals (60%) had a separate pathway for physicians with recent residency training. This pathway consisted of an attestation letter from a residency program director in all of the 9 hospitals, a robotic case list in 3 (33%), and proctored cases after residency in 2 (22%). Five hospitals (55%) required a certain number of hysterectomy procedures (median, 5; range, 2-10). CONCLUSION Robotic surgery credentialing requirements in Alabama vary. Validation of requirements in best practices for robotic surgery by graduating resident physicians is needed.

Sacral neuromodulation effects on periurethral sensation and urethral sphincter activity

To characterize the effect of sacral neuromodulation (SNM) on urethral neuromuscular function.

Effects of transvaginal repair of symptomatic rectocele on symptom-specific distress and impact on quality of life

To determine symptom‐specific distress and quality‐of‐life impact outcomes among women who had undergone transvaginal repair of symptomatic rectocele.

Characterization of colorectal symptoms in women with vesicovaginal fistulas

To characterize colorectal symptoms in women with a history of an obstetric vesicovaginal fistula (VVF).