Megan E. Tarr

A retrospective multicenter study on outcomes after midurethral polypropylene sling revision for voiding dysfunction

Objectives: The purpose of this study was to determine outcomes of sling revision after midurethral sling (MUS) placement and whether timing of sling revision affected those outcomes. Materials and Methods: This is a multicenter study including patients who underwent MUS placement and subsequent sling revision secondary to voiding dysfunction. Diagnostic outcomes before and after sling revision were compared for all sling revision patients with complete data. Logistic regression analyses were performed to determine if revision timing predicted voiding dysfunction and stress incontinence. Results: One hundred seventy-five patients who met the study criteria had complete data. Overall, 70% (133) of MUS were retropubic and 30% (56) were obturator slings. Midurethral sling revision was accomplished by cutting (54%), excision (29%), and pulling down on the mesh (18%). Stress urinary incontinence (SUI) resolved in 38%, urinary tract infections (UTIs) in 69%, and overactive bladder (OAB) in 75%. In comparison, 21% experienced de novo SUI; 18%, de novo UTIs; and 12%, de novo OAB symptoms after revision. Voiding dysfunction resolved in 80%, however 10% experienced new voiding dysfunction symptoms. Retropubic slings displayed more voiding dysfunction, higher de novo/worsened OAB, and more UTIs after revision than obturator slings. Sling revision timing did not predict persistent voiding dysfunction but did predict SUI with earlier revision (≤2 weeks) resulting in less postrevision SUI when compared to revisions at 15-90 days or greater than 90 days. The method of sling revision (cut, excised, pulled down) did not predict SUI, OAB, or obstructive voiding symptoms. Conclusions: Sling revision resolves voiding dysfunction symptoms, UTIs and post-sling OAB symptoms in the majority of patients. Resolution of voiding dysfunction is independent of method and timing of revision; however earlier revision is associated with decreased postrevision SUI.

Risk factors leading to midurethral sling revision: a multicenter case-control study

Introduction and hypothesisTo determine risk factors for sling revision after midurethral sling (MUS) placement.MethodsThis multicenter case-control study included patients who underwent MUS placement and subsequent revision secondary to voiding dysfunction from January 1999–2007 from nine Urogynecology centers across the USA. Direct logistic regression analysis was used to determine which diagnostic variables predicted sling revision.ResultsOf the patients, 197 met the study criteria. Patient demographics, urodynamic findings, and operative differences did not increase the risk for sling revision. Risk factors for sling revision did include: pre-existing voiding symptoms (OR 2.76, 95% CI 1.32–5.79; p = 0.004) retropubic sling type (OR = 2.28, 95% CI 1.08–4.78; p = 0.04) and concurrent surgery (OR = 4.88, 95% CI 2.16–11.05; p < 0.001)ConclusionsThis study determined that pre-existing obstructive voiding symptoms, retropubic sling type, and concurrent surgery at the time of sling placement are risk factors for sling revision.

Primary Ewing Sarcoma Presenting as a Vulvar Mass in an Adolescent: Case Report and Review of Literature

BACKGROUND Extraosseous Ewing sarcoma (ES) tumors presenting in the genitourinary tract are highly uncommon. Few cases of primary vulvar and vaginal cases of ES have been published. CASE A 15-year-old adolescent presented with a bothersome 5-cm mass located on her left labium minorum. Following excision, a diagnosis of a primary ES was made. The patient was treated with multiagent chemotherapy and was doing well 20 months after treatment completion. SUMMARY AND CONCLUSION Based on the few available case reports and our reported case, it appears that extraosseous ES arising in superficial sites such as the vulva have better prognosis and should be treated with complete excision and multiagent chemotherapy.

Robotic objective structured assessment of technical skills: a randomized multicenter dry laboratory training pilot study.

Study Objective The goal of this study was to determine if a robotic dry laboratory curriculum for gynecology and urology residents improved their basic robotic skills. Methods After the institution-specific institutional review board approval or exemption, 165 residents from 8 gynecology and/or urology programs were enrolled. Residents underwent standardized robotic orientation followed by dry laboratory testing on 4 unique robotic tasks. Residents were block randomized by program to unstructured or structured training programs. Regardless of group, residents were expected to practice for 15 minutes twice monthly over 7 months. Errors, time to completion, and objective structured assessment of technical skills global rating scores were recorded for each task before and after the training period. Statistics were calculated using the Student t tests, Pearson correlation, and analysis of variance with STATA systems (version 11.2). Results A total of 99 residents completed both the pretraining and posttraining testing. A mean of 4 (range, 0–15) 15-minute training sessions per resident was self-reported. The structured group had faster posttraining times on the transection task, although the unstructured group had higher posttraining scores on the knot-tying task. Conclusions Overall, the residents’ robotic skills improved after participating in a dry laboratory curriculum; however, robotic availability, duty hour restrictions, and clinical responsibilities limit the curriculum implementation.

Perioperative bowel habits of women undergoing gynecologic surgery: A pilot study

Objectives To describe perioperative bowel habits of women undergoing gynecologic surgery. Methods This prospective cohort study included women undergoing gynecologic surgery. Before surgery, participants completed the Bristol Stool Form Scale (BSFS), a validated instrument describing stool characteristics consistent with transit categories: slow (BSFS 1–2), normal (BSFS 3–5), and fast (BSFS 6–7). For 2 weeks after surgery, the participants recorded daily medications and bowel movements (BM), and completed BSFS. The &khgr;2 test, the Fisher exact test, analysis of variance, t tests, and ordinal regression were used. Results Preoperatively, most (70%) of 340 women had normal stool transit, with 15% having slow transit and 7% having fast transit. Complete postoperative data were available for 170 (50%). Mean ± SD time to first postoperative BM was 2.8 ± 1.4 days with transit classification: 48% normal, 32% slow, and 20% fast. Conclusions Most women had normal stool transit both preoperatively and postoperatively. Time to first BM was longer after open surgery by approximately 3 days.

Peri-urethral Injections

Peri-urethral bulking agents have evolved since the 1930s and remain a viable option for treatment of stress urinary incontinence (SUI) in selected patient populations. We review the history of urethral bulking and complication data from historically used bulking agents. We discuss success and complication data for agents currently available for urethral bulking in the USA. Additionally, we review troubleshooting and use instructions for each of these urethral bulking therapies.

Techniques for Robotic Urogynecology and Pelvic Reconstructive Surgery

Laparoscopic urethropexy was introduced in the early 1990s, and the first robot-assisted sacral colpopexy was reported in 2004. Over the past 10–15 years, laparoscopic and robot-assisted laparoscopic techniques have been applied to many prolapse and incontinence procedures. After the United States Food and Drug Administration approved its use in gynecologic surgery in 2005, the da Vinci Surgical System (Intuitive Surgical, Inc.; Sunnyvale, CA) gave gynecologic surgeons another minimally invasive option for surgeries that had been previously performed by laparotomy, vaginally, or by the traditional laparoscopic technique.