Michelle M. Takase-Sanchez

Obliterative Surgery for the Treatment of Pelvic Organ Prolapse: A Patient Survey on Reasons for Surgery Selection and Postoperative Decision Regret and Satisfaction.

Objectives To identify patient-reported reasons for selecting obliterative surgery for the purpose of predicting decision regret and satisfaction. Methods We created a deidentified database of patients who underwent an obliterative procedure for prolapse from 2006 to 2013. Patients were excluded if they declined study participation, were deceased, or had dementia. Participants completed a survey regarding reasons for selecting obliterative surgery and a modified version of validated questionnaires on decision regret (Decision Regret Scale-Pelvic Floor Disorder) and satisfaction (Satisfaction with Decision Scale-Pelvic Floor Disorder). Parsimonious multivariate linear regression models were constructed to determine if any of the reasons given for choosing obliterative surgery were independent predictors of decision regret and satisfaction after controlling for significant sociodemographic, clinical, and surgical outcome data identified by bivariate analysis. Results Seventy-seven women completed the surveys. “To follow my doctors recommendations” and “no longer sexually active,” and/or “did not plan to be” as reasons for selecting obliterative surgery made the most difference; however, these reasons were not identified as independent predictors of decision regret or satisfaction after controlling for confounders. The regret linear regression models identified preoperative sexual activity rather than the patient-reported reason “no longer sexually active and/or did not plan to be,” as the only independent predictor of more decision regret after obliterative surgery (B coefficient 1.68, P < 0.01). The satisfaction linear regression models identified reoperation for any reason as an independent predictor of lower satisfaction (&bgr;, −0.24; P = 0.04) and the patient-reported reason for choosing obliterative surgery “not interested in pessary” as a predictor of higher satisfaction (&bgr;, 0.30, P = 0.01). Conclusions This study advances our knowledge about the obliterative surgical decision making process. Behavioral and educational interventions directed at improving patient and physician communications concerning the dynamics of sexual health issues in an aging population will likely decrease regret when obliterative surgery is chosen. Minimizing reoperation after obliterative surgery through increased experience, knowledge, and improved surgical skills and patient validation when pessary is declined will likely improve satisfaction when obliterative surgery is chosen.

Minimally Invasive Pelvic Reconstructive Surgery: A Literature Review of Laparoscopic Surgery for Pelvic Organ Prolapse

Pelvic reconstructive surgery for pelvic organ prolapse includes transvaginal, open, laparoscopic, and robotic-assisted approaches. Laparoscopy has established a significant role in minimally invasive surgery across surgical disciplines. In pelvic surgery, although the vaginal approach may offer the most native route to a minimally invasive technique, advances in gynecologic laparoscopy have reported advantages over traditional routes maintaining safety, efficacy, and high patient satisfaction. Majority of current data is limited to descriptive case series and retrospective data that nonetheless continue to support the laparoscopic approach as a reasonably safe alternative to open and vaginal approaches. Few prospective, clinical trials have compared the safety, efficacy, and cost-effectiveness of various approaches and surgical techniques highlighting challenges in the utility of robotic-assistance and vaginal graft placement. This literature review provides a summary of important historical and current data in regards to surgical technique and clinical outcomes of advanced pelvic laparoscopy for pelvic organ prolapse.

Characteristics Associated with Successful Fitting of a Vaginal Bowel Control System for Fecal Incontinence

Objectives We previously showed that management with a novel vaginal bowel control system was efficacious in women with moderate to severe fecal incontinence. The objective of this secondary analysis was to evaluate the clinical characteristics associated with device-fitting success. Methods This is a secondary analysis of an institutional review board-approved, multicenter, prospective, open-label clinical study of women aged 19 to 75 years with 4 or more episodes of fecal incontinence recorded on a 2-week baseline bowel diary. Those successfully fitted with the vaginal bowel control device entered a 1-month treatment period, and efficacy was assessed with a repeat bowel diary. Demographic data, medical and surgical history, and pelvic examination findings were compared across women with successful and unsuccessful completion of the fitting period. Multivariate logistic regression analysis was performed. Results Six clinical sites in the United States recruited from August 2012 through October 2013. Overall, 110 women underwent attempted fitting, of which 61 (55.5%) of 110 were successful and entered the treatment portion of the study. Multivariate logistic regression analysis revealed that previous prolapse surgery (P = 0.007) and shorter vaginal length (P = 0.041) were independently associated with unsuccessful fitting. Women who have not undergone previous prolapse surgery had 4.7 times the odds (95% confidence interval [CI], 1.53-14.53) of a successful fit. In addition, for every additional centimeter of vaginal length, women had 1.49 times the odds (95% CI, 1.02-2.17) of a successful fit. Conclusions Shorter vaginal length and previous prolapse surgery were associated with an increased risk of fitting failure. These findings may be used to inform patients regarding their expectation of successful fitting.