Meadow M. Good

Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse

OBJECTIVE The purpose of this study was to describe patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse symptoms and to describe predictors of preference for uterine preservation. STUDY DESIGN This multicenter, cross-sectional study evaluated patient preferences for uterine preservation vs hysterectomy in women with prolapse symptoms who were being examined for initial urogynecologic evaluation. Before meeting the physician, the women completed a questionnaire that asked them to indicate their prolapse treatment preference (uterine preservation vs hysterectomy) for scenarios in which the efficacy of treatment varied. Patient characteristics that were associated with preferences were determined, and predictors for uterine preservation preference were identified with multivariable logistic regression. RESULTS Two hundred thirteen women participated. Assuming outcomes were equal between hysterectomy and uterine preservation, 36% of the women preferred uterine preservation; 20% of the women preferred hysterectomy, and 44% of the women had no strong preference. If uterine preservation was superior, 46% of the women preferred uterine preservation, and 11% of the women preferred hysterectomy. If hysterectomy was superior, 21% of the women still preferred uterine preservation, despite inferior efficacy. On multivariable logistic regression, women in the South had decreased odds of preferring uterine preservation compared with women in the Northeast (odds ratio [OR], 0.17; 95% CI, 0.05-0.66). Women with at least some college education (OR, 2.87; 95% CI, 1.08-7.62) and those who believed that the uterus is important for their sense of self (OR, 28.2; 95% CI, 5.00-158.7) had increased odds for preferring uterine preservation. CONCLUSION A higher proportion of women with prolapse symptoms who were examined for urogynecologic evaluation preferred uterine preservation, compared with hysterectomy. Geographic region, education level, and belief that the uterus is important for a sense of self were predictors of preference for uterine preservation.

Methamphetamine use during pregnancy: maternal and neonatal implications.

OBJECTIVE: To report the demographic characteristics and clinical morbidity of methamphetamine-exposed pregnancies compared with control patients in a tertiary care, urban, academic medical center. METHODS: A single-site chart review from 2000 to 2006 was conducted. International Classification of Diseases, 9th Revision code 648.3x was used to identify potential study participants. Specific inclusion criteria required either a positive urine drug screen for methamphetamine use or by patient statement of methamphetamine use during pregnancy. Data from 276 identified patients were then compared with the 34,055 in the general obstetric population during the same period for various demographic factors and perinatal outcomes. RESULTS: Two hundred seventy-six patients responsible for 273 live births were identified between 2000 and 2006. Factors that were significantly associated with methamphetamine use were age younger than 20 years (9% methamphetamine compared with 16% control patients), non-Hispanic white ethnicity (55% compared with 71%), married (12% compared with 46%), preterm delivery (52% compared with 17%), low Apgar scores (6% compared with 1–2%), cesarean delivery (29% compared with 23%), and neonatal mortality (4% compared with 1%). Additionally, the maternal demographic characteristics suggested that these women were more likely to be unemployed, use other abusive substances, and have higher rates of domestic violence and adoption when compared with the control population. CONCLUSION: Methamphetamine use in pregnancy is complicated by more morbid maternal and neonatal outcomes when compared with the general obstetric population. Because the patients in this study were in a variety of ways demographically distinct, attempts to identify these patients early and intervene in an effort to improve pregnancy-related outcomes appears possible and warranted. LEVEL OF EVIDENCE: II

Effects of Preoperative Local Estrogen in Postmenopausal Women With Prolapse: A Randomized Trial

CONTEXT Pelvic organ prolapse (POP) increases in prevalence with age; recurrence after surgical repair is common. OBJECTIVE The objective of the study was to determine the effects of local estrogen treatment on connective tissue synthesis and breakdown in the vaginal wall of postmenopausal women planning surgical repair of POP. DESIGN This was a randomized trial. SETTING The study was conducted at an academic tertiary medical center. PATIENTS OR OTHER PARTICIPANTS Postmenopausal women with a uterus and symptomatic anterior and/or apical prolapse at stage 2 or greater participated in the study. INTERVENTION Estrogen (Premarin) or placebo cream for 6 weeks preoperatively was the intervention. MAIN OUTCOME MEASURES Full-thickness anterior apical vaginal wall biopsies were obtained at the time of hysterectomy and analyzed for mucosa and muscularis thickness, connective tissue synthesis, and degradation. Serum levels of estrone and 17β-estradiol were analyzed at baseline and the day of surgery using highly sensitive liquid chromatography-tandem mass spectrometry. RESULTS Fifteen women per group (n = 30 total) were randomized; 13 per group underwent surgery. Among drug-adherent participants (n = 8 estrogen, n = 13 placebo), epithelial and muscularis thickness was increased 1.8- and 2.7-fold (P = .002 and P =.088, respectively) by estrogen. Collagen types 1α1 and 1α2 mRNA increased 6.0- and 1.8-fold in the vaginal muscularis (P < .05 for both); collagen type Ia protein increased 9-fold in the muscularis (P = .012), whereas collagen III was not changed significantly. MMP-12 (human macrophage elastase) mRNA was suppressed in the vaginal mucosa from estrogen-treated participants (P = .011), and matrix metalloprotease-9 activity was decreased 6-fold in the mucosa and 4-fold in the muscularis (P = .02). Consistent with menopausal norms, serum estrone and 17β-estradiol were low and did not differ among the two groups. CONCLUSIONS Vaginal estrogen application for 6 weeks preoperatively increased synthesis of mature collagen, decreased degradative enzyme activity, and increased thickness of the vaginal wall, suggesting this intervention improves both the substrate for suture placement at the time of surgical repair and maintenance of connective tissue integrity of the pelvic floor.

Preventing L5-S1 discitis associated with sacrocolpopexy.

OBJECTIVE: To further characterize the anatomy of the fifth lumbar to first sacral (L5–S1) disc space and to provide anatomic landmarks that can be used to predict the locations of the disc, sacral promontory, and surrounding structures during sacrocolpopexy. METHODS: The lumbosacral anatomy was examined in 25 female cadavers and 100 computed tomography (CT) studies. Measurements were obtained using the midpoint of the sacral promontory as a reference. Data were analyzed using Pearson &khgr;2, unpaired Students t test, and analysis of covariance. RESULTS: The average height of the L5–S1 disc was 1.8±0.3 cm (range 1.3–2.8 cm) in cadavers and 1.4±0.4 cm (0.3–2.3) on CT (P<.001). The average angle of descent between the anterior surfaces of L5 and S1 was 60.5±9 degrees (39.5–80.5 degrees) in cadavers and 65.3±8 degrees (42.6–88.6 degrees) on CT (P=.016). The average shortest distance between the S1 foramina was 3.4±0.4 cm in cadavers and 3.0±0.4 cm on CT (P<.001). The average height of the first sacral vertebra (S1) was 3.0±0.2 cm in cadavers and 3.0±0.3 on CT (P=.269). CONCLUSION: In the supine position, the most prominent structure in the presacral space is the L5–S1 disc, which extends approximately 1.5 cm cephalad to the “true” sacral promontory. During sacrocolpopexy, awareness of a 60-degree average drop between the anterior surfaces of L5 and S1 vertebra should assist with intraoperative localization of the sacral promontory and avoidance of the L5–S1 disc. The first sacral nerve can be expected approximately 3 cm from the upper surface of the sacrum and 1.5 cm from the midline. LEVEL OF EVIDENCE: II

Vascular and ureteral anatomy relative to the midsacral promontory

OBJECTIVE The objective of the study was to further characterize the vascular and ureteral anatomy relative to the midsacral promontory, a landmark often used during sacrocolpopexy, and suggest strategies to avoid complications. STUDY DESIGN Distances between the right ureter, aortic bifurcation, and iliac vessels to the midsacral promontory were examined in 25 unembalmed female cadavers and 100 computed tomography (CT) studies. Data were analyzed using Pearson χ(2), unpaired Student t test, and analysis of covariance. RESULTS The average distance between the midsacral promontory and right ureter was 2.7 cm (range, 1.6-3.8 cm) in cadavers and 2.9 cm (range, 1.7-5.0 cm) on CT (P = .209). The closest cephalad vessel to the promontory was the left common iliac vein, the average distance being 2.7 cm (range, 0.95-4.75 cm) in cadavers and 3.0 cm (range, 1.0-6.1 cm) on CT (P = .289). The closest vessel to the right of the promontory was the internal iliac artery, with the average distance of 2.5 cm (range, 1.4-3.9 cm) in cadavers and 2.2 cm (range, 1.2-3.9 cm) on CT (P = .015). The average distance from the promontory to the aortic bifurcation was 5.3 cm (range, 2.8-9.7 cm) in cadavers and 6.6 cm (range, 3.1-10.1 cm) on CT (P < .001). The average distance from the aortic bifurcation to the inferior margin of the left common iliac vein was 2.3 cm (range, 1.2-3.9 cm) in cadavers and 3.5 cm (range, 1.7-5.6 cm) on CT (P < .001). CONCLUSION The right ureter, right common iliac artery, and left common iliac vein are found within 3 cm from the midsacral promontory. A thorough understanding of the extensive variability in vascular and ureteral anatomy relative to the midsacral promontory should help avoid serious intraoperative complications during sacrocolpopexy.

Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms.

OBJECTIVE The objective of the study was to describe the basic knowledge about prolapse and attitudes regarding the uterus in women seeking care for prolapse symptoms. STUDY DESIGN This was a cross-sectional study of English-speaking women presenting with prolapse symptoms. Patients completed a self-administered questionnaire that included 5 prolapse-related knowledge items and 6 benefit-of-uterus attitude items; higher scores indicated greater knowledge or more positive perception of the uterus. The data were analyzed using descriptive statistics and multiple linear regression. RESULTS A total of 213 women were included. The overall mean knowledge score was 2.2 ± 1.1 (range, 0-5); 44% of the items were answered correctly. Participants correctly responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises (34.3%) were prolapse treatment options. Prior evaluation by a female pelvic medicine and reconstructive surgery specialist (beta = 0.57, P = .001) and higher education (beta = 0.3, P = .07) was associated with a higher mean knowledge score. For attitude items, the overall mean score was 15.1 (4.7; range, 6-30). A total of 47.4% disagreed with the statement that the uterus is important for sex. The majority disagreed with the statement that the uterus is important for a sense of self (60.1%); that hysterectomy would make me feel less feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%). Previous consultation with a female pelvic medicine and reconstructive surgery specialist was associated with a higher mean benefit of uterus score (beta = 1.82, P = .01). CONCLUSION Prolapse-related knowledge is low in women seeking care for prolapse symptoms. The majority do not believe the uterus is important for body image or sexuality and do not believe that hysterectomy will negatively affect their sex lives.

Surgical Knot Integrity: Effect of Suture Type and Caliber, and Level of Residency Training

OBJECTIVE To evaluate if suture type and caliber or level of residency training affects strength and mode of failure of surgical knots. DESIGN All residents in an obstetrics and gynecology training program were invited to tie knots on a bench model using 2 calibers (0 and 3-0) of 2 types of surgical suture (polyglactin 910 and polydioxanone). The failure load, mode of failure, and loop lengths of the knots were determined. SETTING University of Texas Southwestern Medical Center, Dallas, Texas. PARTICIPANTS Physicians enrolled in the University of Texas Southwestern Medical Center Obstetrics and Gynecology residency training program. RESULTS Seventy-one of 73 residents participated. Knots tied with 0-caliber sutures had a higher mean failure load than those tied with 3-0 caliber sutures. For each type and caliber of suture, there were no differences in failure load between each level of residency training. However, senior residents tied knots with shorter loop lengths and had a lower proportion of knots that unraveled or slipped. CONCLUSIONS Even though there were no differences in failure loads, senior residents tied tighter and more secure knots than their junior counterparts.

Thermosensitive hydrogels deliver bioactive protein to the vaginal wall.

The pathophysiology and natural history of pelvic organ prolapse (POP) are poorly understood. Consequently, our approaches to treatment of POP are limited. Alterations in the extracellular matrix components of pelvic support ligaments and vaginal tissue, including collagen and elastin, have been associated with the development of POP in animals and women. Prior studies have shown the protease MMP-9, a key player of ECM degradation, is upregulated in vaginal tissues from both mice and women with POP. On the other hand, fibulin-5, an elastogenic organizer, has been found to inhibit MMP-9 in the vaginal wall. Hence, we hypothesized that prolonged release of fibulin-5 may delay progression of POP. To test the hypothesis, oligo (ethylene glycol)-based thermosensitive hydrogels were fabricated, characterized and then used to deliver fibulin-5 to the vaginal wall and inhibit MMP-9 activity. The results indicate that hydrogels are cell and tissue compatible. The hydrogels also prolong the ½ life of fibulin-5 in cultured vaginal fibroblasts and in the vaginal wall in vivo. Finally, fibulin-5-containing hydrogels resulted in incorporation of fibulin-5 into the vaginal matrix and inhibition of MMP-9 for several weeks after injection. These results support the idea of fibulin-5 releasing hydrogel being developed as a new treatment for POP.