Lekha S. Hota

TVT-Secur (Hammock) versus TVT-Obturator: a randomized trial of suburethral sling operative procedures.

Objectives This study aimed to compare TVT-Secur (TVT-S) and TVT-Obturator (TVT-O) suburethral slings for treatment of stress urinary incontinence (SUI). Methods This was a single-center, nonblinded, randomized trial of women with SUI who were randomized to TVT-S or TVT-O from May 2007 to April 2009. The primary outcome, SUI on cough stress test (CST), and quality-of-life and symptom questionnaires (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) were assessed at 12 weeks and 1 year. Results Forty-three women were randomized to TVT-S and 44 to TVT-O. There were no differences in median baseline PFDI-20 and PFIQ-7. Twenty-two (52.4%) of 42 participants randomized to TVT-S had a positive CST result at evaluation after 12 weeks or 1 year, whereas 4 (9.1%) of the 44 in the TVT-O group had a positive CST result. The intent-to-treat analysis showed that the risk of a positive CST result was 6 times higher after TVT-S than TVT-O (risk ratio, 6.0; 95% confidence interval [CI], 2.3–16.0). Among women not lost to follow-up, the risk ratio for a positive CST result after TVT-S compared with TVT-O was 17.9 (95% CI, 2.5–128.0) at 12 weeks and 3.5 (95% CI, 1.1–11.0) at 1 year. Both TVT-S and TVT-O resulted in improved quality of life and symptoms at 12 weeks. There was no difference between the groups for PFDI-20 (P = 0.40) or PFIQ-7 (P = 0.43). A similar pattern was seen at 1 year (P = 0.85 and P = 0.36). Conclusions The TVT-S seems to have a higher risk of positive postoperative CST result; however, the procedures result in similar improvements in quality of life and symptoms.

Use of synthetic mesh in pelvic reconstructive surgery: a survey of attitudes and practice patterns of urogynecologists

This study surveyed attitudes and practice patterns of urogynecologists regarding the use of synthetic mesh in pelvic reconstructive surgery. A web-based survey was administered to members of the American Urogynecologic Society. The survey evaluated the use of the mesh for sacrocolpopexy, suburethral sling, and vaginal pelvic reconstructive surgery. The survey had a 30.5% response rate. One hundred one (39%) respondents were women, and 158 (61%) were men. One hundred forty-seven (56.8%) participated in fellowship training. Two hundred forty-seven (99.5%) currently perform procedures using synthetic mesh, including 93% who perform sacrocolpopexy and 93% who perform suburethral slings. In a logistic regression model including gender, fellowship training, and practice setting, male surgeons and those who had not undergone fellowship training were more likely to use the mesh than those who were fellowship trained. Respondents use the mesh most commonly when performing sacrocolpopexies and suburethral slings. The use of the mesh for anterior and posterior colporrhaphy is less common.

Association of body mass index with hip and thigh pain following transobturator midurethral sling placement

OBJECTIVE We sought to investigate the incidence of hip and proximal lower extremity pain following transobturator midurethral sling and evaluate the association between pain and body mass index (BMI). STUDY DESIGN This was a retrospective cohort study of all transobturator midurethral sling procedures from July 2008 through June 2009. The primary outcome was postoperative hip or proximal lower extremity pain. RESULTS Four urogynecologists performed 226 procedures. The incidence of postoperative hip or proximal lower extremity pain was 15.5%. Women of normal BMI had a higher risk of developing pain than obese women (risk ratio, 2.51; 95% confidence interval, 1.01-6.22). While not statistically significant, overweight women were twice as likely as obese women to develop the primary outcome (risk ratio, 1.99; 95% confidence interval, 0.79-4.99). CONCLUSION Women of normal BMI have an increased risk of hip and proximal lower extremity pain following transobturator midurethral sling compared with obese women.

Underlying Factors Contributing to the Delay in Patients Seeking Care for Pelvic Floor Dysfunction

Objective: To investigate barriers and variables associated with the delay in seeking urogynecologic care by women with pelvic floor dysfunction. Methods: Cross sectional study of 300 new patients presenting for outpatient evaluation of pelvic floor dysfunction from August 2011 through March 2012. Patients were mailed a survey prior to initial visit. Delay in seeking care was defined as 12 months or more from symptom manifestation, persistence or recurrence after prior intervention, or being informed about the condition to time of visit. Data are presented as proportion or mean (±standard deviation). Comparisons were made using chi-square and t tests. Results: Two hundred and thirty one (77.0%) surveys were returned. Mean age was 55.9 years (± 17.4). Majority (91.3%) were Caucasian, 57.4% sexually active, and 96.1% saw a health care provider annually. Commonly reported causes were child birth (32.6%) and aging (23.4%). Delay was seen in 140 women (61.4%). Of these, 81 (57.9%) had been previously asked about symptoms by their primary care provider. The most common reason reported for delay was “Did not have time to care for myself” (19.8%). There was no statistically significant difference in level of education (p=0.86), annual health care visits (p=0.74), and sexual activity (p=0.28) between women with and without delay. However, women who delayed seeking care were more likely to report increased symptom severity (p=0.005) and to have been asked about symptoms (p=0.01). Conclusion: There is significant delay in seeking care with an urogynecologist. Additional resources are needed to promote patient and primary care provider awareness.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial

Objective To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. Methods We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. Results One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P⩽0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0–4.0) days. Conclusions Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE I

56: Tensioning of retropubic suburethral slings with Babcock versus Kelly clamp

McCall’s uterosacral ligament cuff suspensions, and 6 concurrent posterior repairs (PR). Twenty-three additional posterior repairs, 2 vaginal para vaginal repairs (VPVR), and 2 bilateral sacrospinous ligament colpopexies (SSLC). Preoperative POP-Q scores measuring level 1 and level 2 support ranged from -2 to +6. POP-Q scores obtained 1 to 60 months (median 1⁄4 46) postoperatively revealed durable global level 1 and 2 support with most at -3 scores. Two anatomical failures to anterior or apical -1 scores, but only 1 symptomatic case needed reoperation. No significant surgical or product complications were identified. CONCLUSION: Secondary to procurement inconsistencies associated with synthetic and cadaveric products, and the risk of erosion, fibrosis, retraction, or dyspareunia with synthetic materials, our preliminary data shows that Matristem xenografts offers a safe and efficacious alternative in the surgical repair of level 1 and 2 POP.