Margaret Mueller

Outcomes in 450 Women After Minimally Invasive Abdominal Sacrocolpopexy for Pelvic Organ Prolapse.

Objective To report outcomes and complications in approximately 450 women who underwent isolated minimally invasive abdominal sacrocolpopexy (ASC) for the management of pelvic organ prolapse (POP). Material and Methods We retrospectively reviewed the electronic medical records of women who underwent minimally invasive ASC (laparoscopic ASC [LASC] or robotic ASC [RASC]) for symptomatic POP at Loyola University Chicago Medical Center from 2007 to 2012. Polypropylene mesh was used and the decision to reperitonealize the mesh was left to surgeon discretion. Data collected included demographics, Pelvic Floor Distress Inventory questionnaire, intraoperative and postoperative details, and POP quantification. Results Four hundred twenty-eight women underwent minimally invasive ASC—232 LASC and 226 RASC. Most women (86%) did not undergo reperitonealization of the mesh. Median follow-up was 13 weeks (range, 2–268 weeks) for complications and 13 weeks (range, 2–104 weeks) for anatomic outcomes. Postoperatively, 88.6% of women had stage 0/I, 10.7% had stage II, and 2 women had stage III POP. Twelve (2.6%) underwent reoperation, 6 for POP (3 posterior repairs, 2 repeat ASC, 1 perineorrhaphy) and 6 for bowel complications. Fourteen women had postoperative bowel complications; half of which resolved with conservative treatment. There were no differences between anatomic and functional outcomes or bowel complications between LASC and RASC. Reoperation rates for bowel complications in women who underwent reperitonealization of the mesh were similar to those who did not (1.5% vs 1.0%, P = 0.86). Conclusions Minimally invasive ASC without concomitant vaginal repair is an effective and safe procedure for the surgical management of POP with low rates of reoperation and complications.

Colpocleisis: a safe, minimally invasive option for pelvic organ prolapse.

Objective This study aimed to describe the morbidity and mortality associated with colpocleisis and factors associated with improved outcomes. Methods We used University HealthSystem Consortium database, which included inpatient data from US hospitals. We included all women who underwent colpocleisis from 2002 to 2012. Centers were categorized geographically and by annual case volume. Cases were grouped by age and provider specialty. Outcome and readmission data from participating hospitals were compared between groups by analysis of variance and Tukey statistics. Average length of stay (LOS), intensive care unit (ICU) admission rate, complication rate, mortality rate, and readmission rate were calculated for each hospital and compared. Results Colpocleisis procedures (4776) were performed at 145 US medical centers. Forty-three percent of procedures were done on women older than 80 years, 52% on women 60 to 79 years, 3% on women 40 to 59 years, and 0.9% on women 20 to 39 years. Overall, rates of complications, ICU admission, and mortality were low with average rates of 6.82%, 2.80%, and 0.15%, respectively. High-volume centers had lower ICU admission and complications rates as well as a shorter LOS. Younger women had higher ICU admission and complication rates as well longer LOS. Stratification by provider specialty demonstrated higher ICU admission rates among cases performed by urologists as compared to cases performed by urogynecologists and general obstetrician-gynecologists. Complication rates were also higher among obstetrician-gynecologists and urologists as compared to urogynecologists. Length of stay was significantly longer when colpocleisis was performed by urologists rather than a urogynecologists. Conclusions Colpocleisis is a safe minimally invasive procedure and outcomes are influenced by provider specialty and hospital volume.

Venous thromboembolism in reconstructive pelvic surgery

OBJECTIVE We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS). STUDY DESIGN Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables. RESULTS In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037). CONCLUSION The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

Changing Referral Patterns to Urogynecology

Objective The study aims to identify sources of and changes in referral patterns for pelvic floor disorders. Methods All new patient visits to urogynecology at our institution between January 2010 and December 2015 were identified. Patient demographics, referral source, insurance type, and visit diagnoses using ICD-9 codes were abstracted. ICD-9 codes were grouped into 18 urogynecologic diagnoses. Data were analyzed using SPSS (Version 20; Chicago, IL). Results Five thousand seven hundred ninety-nine new patient visits were included in the analysis. The mean age was 54 ± 17 years and 59% were Caucasian. Forty-four percent were referred by obstetrician/gynecologists (OB/GYNs), 32% by primary care providers (PCPs), 14% by self-referral, and 9% by other specialties. New patient visits increased overall by 280% over 6 years; self- and PCP referrals increased by 480% and 320%, respectively. In comparison, OB/GYN referrals increased by only 229%. Patients diagnosed with prolapse and stress incontinence were more likely to be referred by an OB/GYN (P < 0.001), whereas PCPs were more likely to refer for urinary tract infections (P < 0.005) and urgency urinary incontinence (P < 0.001) than OB/GYNs. Conclusions Demand for pelvic floor specialists is growing quickly, with PCP and self-referrals outpacing referrals from obstetrician-gynecologists to tertiary care urogynecology practices.

Trachelectomy: Removal of cervical stump following supracervical hysterectomy

Cervical stump extirpation (trachelectomy) is the removal of the cervix following supracervical hysterectomy. Subtotal or supracervical hysterectomy is an alternative to total hysterectomy (removal of uterine fundus and cervix) in women undergoing hysterectomy for many benign indications. There are several benefits to supracervical hysterectomy including reduced complications, shorter hospital stay, and faster resumption of activity; in addition, mesh complications are reduced when hysterectomy is done in conjunction with an abdominal sacrocolopexy. However, women considering supracervical hysterectomy should be counseled regarding risks of cervical retention, including need for cervical screening according to current guidelines, as well as the potential need for future surgery to remove the cervical stump. With increases in minimally invasive surgical techniques, many women will elect to undergo supracervical hysterectomy: therefore, it is likely that most gynecologists will encounter patients that require trachelectomy. In this chapter, we will review the indications for trachelectomy, advantages and disadvantages of different routes of access for trachelectomy, as well as complications associated with removing the cervix following subtotal hysterectomy.

Anal penetrative intercourse as a risk factor for fecal incontinence

Objective The aim of the study is to investigate the relationship between anal penetrative intercourse (API) and pelvic floor symptoms, specifically, anal incontinence (AI). Methods This was an institutional review board–approved, cross-sectional, e-mail survey of women enrolled in the Illinois Womens Health Registry. Participants were anonymously queried about their sexual practices and the effects of these on bowel and bladder symptoms. Urinary symptoms were assessed using the urogenital distress inventory-6 and bowel symptoms with the fecal incontinence severity index (FISI). Results One thousand three women (mean age of 46 ± 15 years) completed the survey. Eighty percent were white, 56% were married, and 99% reported ever being sexually active. Thirty-two percent had API at least once, and 12% considered it “part of their sexual practice.” Sixty percent of the cohort reported a bothersome urinary symptom on the urogenital distress inventory-6, 70% reported AI on the FISI, and 15% reported fecal incontinence. Of women who engaged in API, 18% reported it changed their stool consistency, and 10% reported it caused AI. Having engaged in API within the last month was correlated with higher FISI scores (P = 0.05) and with fecal incontinence on the FISI (28.3% vs 14.4%; P = 0.01; odds ratio, 2.48). In addition, API was more commonly practiced among women who reported that vaginal intercourse caused dyspareunia (17% vs 12%, P = 0.05) or changes in bladder symptoms such as urgency or dysuria (44% vs 30%, P < 0.001). Conclusions Self-reported AI and FI (as measured by the FISI scores) are higher in women who have had API, and frequency of API may be important in determining the risk of bowel symptoms.

74: Fibroids and urinary symptoms study (FUSS)

(+/346.8). One hundred sixty-two patients (95.8%) were discharged to home within one day or less. Final pathological diagnosis was benign in 99.4% of the cases. Uterine leiomyoma was the most common final pathology diagnosis. Occult malignancy was identified in one patient. There were no conversions to an open approach, no instances of containment bag tear or gross spillage during the manual tissue extraction process, and no complications related to the tissue extraction technique. CONCLUSION: Contained extracorporeal manual tissue extraction through an extended umbilical incision is a safe and feasible technique in women undergoing laparoscopic hysterectomy and laparoscopic myomectomy.

Anal Sphincter Injuries After Operative Vaginal Versus Spontaneous Delivery-Is There a Difference in Postpartum Symptoms?

Objective The aim of this study was to determine whether there is a difference in pelvic floor symptoms between women who had obstetric anal sphincter injuries (OASIS) after an operative vaginal delivery versus those who had OASIS after a spontaneous delivery. Methods This was a secondary analysis of a prospective cohort study of women who sustained OASIS. Women were evaluated at 1 week postpartum and again at 12 weeks; at both of these visits, they completed a battery of validated questionnaires including a visual analog scale for pain, Patient Health Questionnaire 9 depression inventory, Fecal Incontinence Severity Index, Urogenital Distress Inventory 6, and Incontinence Impact Questionnaire 7. Results Two hundred sixty-eight women with OASIS were included in this analysis (194 operative vaginal, 74 spontaneous). Ninety-one percent of those with operative vaginal delivery had a forceps-assisted delivery. After multivariate regression, operative OASIS was independently associated with greater Urogenital Distress Inventory 6 scores (P = 0.02), Fecal Incontinence Severity Index scores (P = 0.04), and visual analog scale pain scores (P = 0.03) and higher rates of urgency urinary incontinence (P = 0.04), stress urinary incontinence (P = 0.02), and anal incontinence (P = 0.04) at 1 week postpartum. At 3 months postpartum, symptoms were no different between the groups. Conclusions Women who sustain OASIS secondary to operative vaginal delivery report more bothersome urinary symptoms and higher rates of anal incontinence immediately postpartum as compared with women with OASIS secondary to spontaneous delivery. These differences may resolve by 3 months postpartum.