Keisha A. Jones

Massive subcutaneous emphysema in robotic sacrocolpopexy

Robotic sacrocolpopexy may increase insufflation complications including massive subcutaneous emphysema.

Trends in inpatient prolapse procedures in the United States, 1979-2006.

OBJECTIVE We sought to describe national trends for inpatient procedures for pelvic organ prolapse from 1979-2006. STUDY DESIGN The National Hospital Discharge Survey was analyzed for patient and hospital demographics, as were International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedures codes from 1979-2006. Age-adjusted rates (AARs) per 1000 women were calculated using the 1990 US Census data. RESULTS There was a significantly decreasing trend in the AARs for inpatient prolapse procedures, from 2.93-1.52 per 1000 women from 1979-2006. AARs for hysterectomy decreased from 8.39-4.55 per 1000 women from 1979-2006. Over the study period, AARs remained at about the 1979 level among the women>or=52 years old (2.73-2.86; P=.075). In women<52 years old, AARs declined to less than one-third of the 1979 rate (3.03-0.84; P<.001). CONCLUSION AARs for inpatient procedures for prolapse in the United States remained stable for women aged>or=52 years from 1979-2006; rates declined by two-thirds for women aged<52 years.

Tensile properties of commonly used prolapse meshes.

Introduction and hypothesisTo improve our understanding of the differences in commonly used synthetic prolapse meshes, we compared four newer generation meshes to Gynecare PS™ using a tensile testing protocol. We hypothesize that the newer meshes have inferior biomechanical properties.MethodsMeshes were loaded to failure (n = 5 per group) generating load–elongation curves from which the stiffness, the load at failure, and the relative elongation were determined. Additional mesh samples (n = 3) underwent a cyclic loading protocol to measure permanent elongation in response to subfailure loading.ResultsWith the exception of Popmesh, which displayed uniform stiffness, other meshes were characterized by a bilinear behavior. Newer meshes were 70–90% less stiff than Gynecare™ (p < 0.05) and more readily deformed in response to uniaxial and cyclical loading (p < 0.001).ConclusionRelative to Gynecare™, the newer generation of prolapse meshes were significantly less stiff, with irreversible deformation at significantly lower loads.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures.

OBJECTIVES: To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a womans lifespan. METHODS: Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed. RESULTS: More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a womans lifetime. CONCLUSION: Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women. LEVEL OF EVIDENCE: III

Parity negatively impacts vaginal mechanical properties and collagen structure in rhesus macaques.

OBJECTIVE The purpose of this study was to determine the impact of parity on mechanical behavior of the vagina and to correlate these findings with alterations in collagen structure. STUDY DESIGN Mechanical properties of 5 nulliparous and 6 parous rhesus macaques were derived from uniaxial tensile tests. Collagen ratios and alignment were quantified by quantitative fluorescent microscopy and picrosirius red staining. Outcomes were compared by the Student t test or Mann Whitney U test (P < .05) and Spearmans rho for correlation coefficients. RESULTS Mechanical properties were inferior in a parous vs nulliparous vagina with decreased tangent modulus (P = .03), tensile strength (P < .001), and strain energy density (P = .006). Although no difference in collagen ratios (P = .26) were observed, collagen alignment decreased with parity (P = .06). Worsening pelvic organ support negatively correlated with decreasing collagen alignment (r(2) = -0.66) and mechanical properties (r(2) = -0.67). CONCLUSION Vaginal parity is associated with inferior tissue mechanics and loss of collagen alignment. Such behavior likely predisposes to the development of pelvic organ prolapse.

Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse.

OBJECTIVE: To compare the size of the genital hiatus in women wearing a pessary for pelvic organ prolapse after consistent pessary use, describe characteristics of patients who continue use, and assess change in pelvic floor symptoms. METHODS: This was an observational cohort study of 90 women seeking nonsurgical management of symptomatic prolapse. Our primary outcome was change in genital hiatus (in centimeters) after 3 months of consistent pessary use. Pelvic floor symptoms were assessed with the Pelvic Floor Distress Inventory. Change in genital hiatus measurements and Pelvic Floor Distress Inventory scores were assessed using a paired Student t test. Between-group differences were evaluated using the Student t, Mann Whitney U, and Fisher exact tests, where appropriate. Logistic regression was used to assess baseline characteristics predictive of continued pessary use. RESULTS: The average (±standard deviation) age of participants enrolled was 62.8 ±13.2 years. Median parity was 3, and 87.7% were postmenopausal. Forty-two (47%) continued pessary use at 3 months. After 2 weeks, there was a decrease in the size of the genital hiatus measured with strain from 4.8±1.6 cm to 4.1±1.2 cm, P<.001, which persisted at 3 months (3.9±1.1 cm, P<.001). The greatest change occurred with the Gellhorn pessary. Baseline Pelvic Organ Prolapse Quantification system point Aa was positively associated with continued pessary use at 3 months, and perineal body at rest was negatively associated. CONCLUSION: After 3 months of pessary use, genital hiatus size decreased significantly. Pessary use results in significant anatomic changes to the genital hiatus in patients with pelvic organ prolapse. LEVEL OF EVIDENCE: III

Retropubic and transobturator midurethral slings: a decision analysis to compare outcomes including efficacy and complications.

Introduction and hypothesisThe objective of this paper is to compare retropubic (RP) and transobturator (TO) midurethral slings using decision analysis techniques.MethodsA decision analysis was constructed including efficacy and complication data. Probability of complication-free surgery and overall utility were analyzed using two models: ALL (all 42 trials) and RCT (seven randomized controlled trials with higher quality data, but missing data on some complications).ResultsSurgery was complication-free more frequently with TO approach with 83.7% vs. 55.7% (ALL) and 70.9% vs. 62.8% (RCT). One-year overall utility favored TO in the ALL model (0.943 vs. 0.895). Conversely, the RCT model favored RP (0.936 vs. 0.910). These differences were both less than published minimally important differences (MID) for utilities. Multiple one-way sensitivity analyses confirmed robustness of results.ConclusionsThe difference between the two surgeries in both utility-based models was less than the MID. Therefore, the separate approaches are highly comparable with similar overall utility. Complications are more frequent with the retropubic approach.

Using lubricant for speculum insertion.

Speculum insertion can be associated with considerable discomfort during routine pelvic examination. Physiologically, vaginal entry requires lubrication. However, traditional teaching recommends, if anything, warm water only for lubrication, because lubricants are believed to interfere with Pap and infection tests. There is level I evidence that modest lubrication of the external surface of the speculum does not impair cytologic and infectious evaluation of the cervix. This should be reflected in contemporary teaching and guidelines.

Vaginal Evisceration During Pessary Fitting and Treatment With Immediate Colpocleisis

BACKGROUND: Complications from pessaries are rare and occur predominantly as a result of neglect and loss to follow-up. We report a case of vaginal evisceration at the time of pessary insertion, which was repaired with concomitant colpocleisis. CASE: An 82-year-old woman with stage IV pelvic organ prolapse (POP) presented for a routine pessary fitting, which resulted in vaginal evisceration and displacement of the pessary into the abdomen. She was treated successfully with immediate colpocleisis after transvaginal removal of the pessary and repair of the rupture site. CONCLUSION: Pessary insertion can result in vaginal evisceration. Both POP and vaginal rupture can be successfully treated with removal of the pessary, closure of the vaginal defect, and LeFort colpocleisis all in one session.

Pathophysiology of pelvic organ prolapse.

Pelvic organ prolapse (POP) has emerged as an important common and understudied healthcare problem; recently having been described as the “hidden epidemic.” By age 80, women in the United States have an 11% lifetime risk of undergoing surgery for prolapse or incontinence, with a 30% risk of reoperation over a period of 4 years. The United States census bureau projects that the number of women in America aged 65 years will double within the next 25 years to more than 40 million by the year 2030. To effect this healthcare epidemic, clinicians must gain a better understanding of the pathophysiology of POP. This will afford the development of improved prevention and treatment modalities for this condition. Pelvic organ support is provided by the vagina. The vagina, in turn, is supported by the physiologically complex interactions between the levator ani muscles (pubococcygeus, puborectalis, coccygeus, iliococcygeus), their fascial coverings, the vagina and its connective tissue attachments to the bony pelvis, including the uterosacral ligaments, the arcus tendinous fascia pelvis, the perineal body, and perineal membrane. The levator ani, providing a shelf-like structure at the inferior most portion of the pelvis, separate to allow passage of the urethra, vagina, and rectum. At rest, tonic contraction of the levator ani muscles provides support to pelvic organs, with their activity adjusting to variations in posture, increased vaginal distension, and intra-abdominal pressure. In the presence of normal support, the supportive connective tissues of the vagina pulled the vagina superiorly and back toward the sacrum placing the upper vagina at a nearly horizontal orientation over the levator ani muscles. Thus, with increases in intra-abdominal pressure, the upper vagina is compressed against the levator ani muscles and pelvic organ support is maintained. Damage to any component of vaginal connective tissue support changes the vaginal axis to a vertical position directly over the genital hiatus. Thus, with increases in intra-abdominal pressure, the vagina is no longer compressed against the levator muscles but is directed downward toward the genital hiatus, thereby predisposing to repetitive stretch and the development of POP. Damage to the vaginal support complex may result from genetic conditions that adversely affect muscle or nerves, injury to the vagina or its supportive tissues via direct trauma (eg, vaginal delivery, surgery, chronically increased intra-abdominal pressure), or indirectly as a result of age, menopause, obesity, and occupational factors. It is clear, however, that the etiology of prolapse is multifactorial and risk factors will vary from one individual to the other. Clinically, POP leads to derangements in bladder, bowel, and sexual function that effect quality of life (QOL), social interactions, and mental health. This review focuses on purported risk factors for POP derived from epidemiological studies. Our discussion includes predisposing, inciting, and promoting risk factors incurred by vaginal childbirth, obesity, age, menopausal status, as well as neurologic and musculoskeletal injury. In addition, we examine the effect of POP on QOL, urinary, gastrointestinal, and sexual function.