Melinda G. Abernethy

Symptom resolution after operative management of complications from transvaginal mesh.

OBJECTIVE: Complications from transvaginal mesh placed for prolapse often require operative management. The aim of this study is to describe the outcomes of vaginal mesh removal. METHODS: A retrospective review of all patients having surgery by the urogynecology group in the department of obstetrics and gynecology at our institution for a complication of transvaginal mesh placed for prolapse was performed. Demographics, presenting symptoms, surgical procedures, and postoperative symptoms were abstracted. Comparative statistics were performed using the &khgr;2 or Fisher’s exact test with significance at P<.05. RESULTS: Between January 2008 and April 2012, 90 patients had surgery for complications related to vaginal mesh and 84 had follow-up data. The most common presenting signs and symptoms were: mesh exposure, 62% (n=56); pain, 64% (n=58); and dyspareunia, 48% (n=43). During operative management, mesh erosion was encountered unexpectedly in a second area of the vagina in 5% (n=4), in the bladder in 1% (n=1), and in the bowel in 2% (n=2). After vaginal mesh removal, 51% (n=43) had resolution of all presenting symptoms. Mesh exposure was treated successfully in 95% of patients, whereas pain was only successfully treated in 51% of patients. CONCLUSION: Removal of vaginal mesh is helpful in relieving symptoms of presentation. Patients can be reassured that exposed mesh can almost always be successfully managed surgically, but pain and dyspareunia are only resolved completely in half of patients. LEVEL OF EVIDENCE: III

Long-Term Patient Satisfaction With Michigan Four-Wall Sacrospinous Ligament Suspension for Prolapse

OBJECTIVE: To describe patient satisfaction after Michigan four-wall sacrospinous ligament suspension for prolapse and identify factors associated with satisfaction. METHODS: Four hundred fifty-three patients were asked to rate their satisfaction with surgery and complete validated quality-of-life instruments. Postoperative support was extracted from the medical record and assessed when possible. Factors independently associated with patients who were “highly satisfied” were identified with multivariable logistic regression. RESULTS: Sixty-two percent (242/392) reported how satisfied they were 8.0±1.7 years later. Fifty-seven percent had failed prior prolapse surgery, and 56% had a preoperative prolapse 4 cm or greater beyond the hymen. Ninety percent were satisfied; 76% were “completely” or “very” satisfied and they were considered “highly satisfied” for analysis. Fourteen percent reporting being “moderately” satisfied and they were considered among those “less satisfied.” Women with lower scores on the postoperative Pelvic Floor Distress Inventory-20 were more likely to be “highly satisfied.” Postoperative anatomic data were available for 67% (162/242) and vaginal support was observed at or above the hymen in 86%. Women with preoperative Baden Walker grade 3 or 4 prolapse were more likely than those with grade 2 prolapse to be “highly satisfied.” Women with advanced postoperative prolapse (grade 3 or 4) were less likely and those with grade 2 support were as likely to be “highly satisfied” as those with grade 0 or 1 support. CONCLUSION: The Michigan four-wall sacrospinous ligament suspension is an anatomically effective approach to vault suspension with a high rate of long-term patient satisfaction. Postoperative vaginal support at the hymen does not negatively affect patient satisfaction. LEVEL OF EVIDENCE: III

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.

Where do we place the sacrocolpopexy stitch?- A magnetic resonance imaging investigation

Objectives Sacrocolpopexy presacral sutures are placed at or slightly above the sacral promontory without knowledge of the location of intervertebral discs. We used magnetic resonance imaging to assess the anatomic relationship of the sacral promontory to intervertebral discs. Methods We reviewed spinal magnetic resonance images of women imaged at Loyola University Medical Center between January 2010 and February 2012. Sagittal T1 fluid-attenuated inversion recovery sequence images of the lumbosacral spine were used to identify the promontory as the most prominent point where S1 intersected with the superior anatomic structures. All measurements were obtained at the midline of the spinal cord. Results The mean age of 73 study subjects was 59 years (range, 22–89 years). The promontory was an intervertebral disc in many women (53 [73%]); the remaining images confirmed a nondisc promontory at the superior aspect of S1 in 20 patients (27%). The distance between the promontory and the next bony structure (L5) was 13 mm (25th-75th interquartile range, 11–16). In women without disc at the promontory, the median distance between the promontory and the base of L5 disc was 1.29 mm (interquartile range, 1.1–2.2). The mean height of the disc was 13.3 mm (4.4–20.6 mm). Age was not associated with the most prominent structure (P = 0.2), nor was it correlated to disc height (P = 0.27, r = 0.13) or distance to L5 (P = 0.75, r = 0.04). Conclusions Given the high proportion of women with an intervertebral disc at the promontory, suture placement strategies that avoid this location may avoid-reduce disc-related sequelae after sacrocolpopexy.

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.

Prevalence of cognitive impairment in older women with pelvic floor disorders

Introduction and hypothesisThis study aimed to determine the prevalence of mild cognitive impairment (MCI) and early dementia among women >55 years seeking care for pelvic floor disorders (PFDs) and to describe the impact of cognitive impairment on condition-specific quality of life (QoL). We hypothesized that the prevalence of MCI would be at least 15% among this population.MethodsThis was a cross-sectional study of English-speaking women >55 years presenting for evaluation of PFDs. We assessed baseline demographics and administered the Short Test of Mental Status (STMS) to screen for cognitive impairment. We predicted a sample of 196 would be needed for a precision of ±5% of the estimated sample prevalence in participants with PFDs. Chi-square tests were used to compare categorical variables and Student’s t tests and analysis of variance (ANOVA) for continuous variables. Multivariate regression analysis was used to assess for any independent association with cognitive impairment and condition-specific QoL.ResultsBetween July 2013 and July 2014, 211 participants were enrolled. The prevalence of MCI and early dementia were 15% [95% confidence interval (CI) 10.9–20.6; n = 32)] and 17% (95% CI 11.9–22.1; n = 36], respectively. Patients with MCI and early dementia had higher Patient Heath Questionnaire scores indicating greater depressive symptoms (p = 0.006) and higher overall Pelvic Floor Impact Questionnaire scores indicating worse condition-specific QoL (p = 0.008).ConclusionMCI and early dementia were prevalent in our population seeking care for PFDs. Women with cognitive impairment experienced worse condition-specific QoL.

Longitudinal changes in pelvic floor muscle strength among parous women

BACKGROUND: There is limited knowledge of the effects of time on change in pelvic floor muscle strength after childbirth. OBJECTIVE: The objectives of this study were to estimate the change in pelvic floor muscle strength in parous women over time and to identify maternal and obstetric characteristics associated with the rate of change. STUDY DESIGN: This is an institutional review board‐approved prospective cohort study of parous women. Participants were recruited 5–10 years after first delivery and followed annually. Pelvic floor muscle strength (peak pressure with voluntary contraction) was measured at 2 annual visits approximately 4 years apart with the use of a perineometer. We calculated the change in peak pressures, which were standardized per 5‐year interval. Linear regression was used to identify maternal and obstetric characteristics that are associated with the rate of change in peak pressure. The obstetric variable of greatest interest was delivery group. Participants were classified into 3 delivery groups (considering all deliveries for each multiparous woman). Delivery categories included cesarean only, at least 1 vaginal birth but no forceps‐assisted deliveries, and at least 1 forceps‐assisted vaginal birth. Statistical analysis was completed with statistical software. RESULTS: Five hundred forty‐three participants completed 2 perineometer measurements with a median 4 years between measures (interquartile range, 3.1–4.8). At initial measurement, women were, on average, 40 years old and 8 years from first delivery. Initial strength was higher in participants who delivered all their children by cesarean (38.5 cm H2O) as compared with women with any vaginal non‐forceps delivery (26.0 cm H2O) or vaginal forceps delivery (13.5 cm H2O; P<.001). There was a strong correlation between the first and second perineometry measurement (r=0.84). Median change in pelvic floor muscle strength was small at 1.2 cm H2O per 5 years (interquartile range, –5.6, 9.9 cm H2O). In multivariable analysis, women who delivered by cesarean only demonstrated almost no change in strength over 5 years (0.2 increase cm H2O per 5 years); those who experienced at least 1 vaginal or vacuum delivery increased strength (4.8 cm H2O per 5 years) as did women with at least 1 forceps delivery (5.0 cm H2O per 5 years). Additionally, obese women had a significant reduction in strength (–3.1 cm H2O per 5 years) compared with normal weight participants (0.2 cm H2O per 5 years). CONCLUSION: Among parous women, pelvic muscle strength increased minimally over time with an average change of 1.2 cm H2O per 5 years; change in strength was associated with mode of delivery and obesity.

Laparoscopic and Robotic Skills Are Transferable in a Simulation Setting

Study Objective: To assess the transferability of skills from robotic to laparoscopic simulators and vice versa among simulation naive participants. Design: Randomized single-blinded controlled trial. Setting: Johns Hopkins Bayview Surgical Simulation Center. Patients: Forty medical students with limited prior laparoscopic and robotic simulation experience. Intervention: Participants completed a baseline practice on a robotic pegboard transfer task (dV -Trainer, Mimic, Seattle, WA) and a laparoscopic peg transfer task (Fundamentals of Laparoscopic Surgery [FLS], VT Medical Inc., Waltham, MA). Skills were evaluated using validated objective and subjective measures (global rating scales (GRS)) by two blinded expert surgeons. Participants were then randomized to practice on either of the above robotic(N=20) or laparoscopic(N=20) task. After practice, participants were again evaluated performing both tasks. Measurements and Main Results: At baseline, there were no significant differences in objective measures or composite GRS scores on both the robotic and laparoscopic tasks between the two groups. Participants in the laparoscopic practice group completed the final laparoscopic task faster (100 vs. 158 sec, p\.003) and with higher percent improvement in GRS scores (67.5% vs. 27%, p\0.001) compared to the robotic practice group. The robotic practice group performed the robotic task faster (71 vs. 120 sec, p\0.001) and more efficiently (economy of motion p\0.001), with higher percent improvement in GRS scores (77% vs. 29%, p\0.001) compared to the laparoscopic practice group. Participants who practiced laparoscopically did improve their robotic performance with an increase in mean GRS scores of 15 to 20 but this was not statistically significant (p=0.091). Participants who practiced robotically did significantly improve their laparoscopic performance with an increase in mean GRS scores of 15 to 19(p=0.02). Conclusion: Medical students significantly improved their performances following practice on either robotic or laparoscopic simulators. Skills learned on either platform appears to be transferable; however, the amount of improvement was still significantly less than practice on the respective platforms.

Does Side Make a Difference? Anatomical Differences Between the Left and Right Ureter.

Objectives Seventy to eighty percent of iatrogenic ureteral injuries involve the left ureter. We sought to evaluate potential anatomical differences between the left and right ureters that may contribute to this discrepancy. Methods A retrospective image review was undertaken of women who underwent computed tomography urograms between 2012 and 2013. The distance to the ureters from the midline was measured at the level of the sacral promontory (S1) and the cervix. Cervical deviation from the midline was measured, and distance between the cervix and ureters was calculated. The anterior-posterior distance between ureters was also measured. Results Ninety-five computed tomography urograms were analyzed. The mean age was 56 years (range, 23–92 years). Mean cervical deviation was 2.9 mm left of the midline (P = 0.028). The left ureter was 4.2 mm more lateral than the right at S1 and 2.7 mm more lateral at the cervix (P = 0.000 and 0.001). There was no significant difference when accounting for cervical deviation (P = 0.220). The left ureter was 1.9 mm more anterior than the right at the cervix (P = 0.012). Age, body mass index, and ethnicity did not affect the ureteral position. Conclusions Based on midline measurements, the left ureter courses 2 to 4 mm more lateral and anterior than does the right ureter. The cervix is also positioned 2 to 4 mm to the left side, and as a result, the ureters are actually symmetric to the cervix. Although seemingly small, 2 to 4 mm is the width range of a Heaney clamp. These anatomic differences may be a contributing factor to the increase in ureteral injuries on the left side compared with the right.