Minita Patel

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy.

Impact of pessary use on prolapse symptoms, quality of life, and body image

OBJECTIVE We sought to evaluate whether use of a vaginal pessary would change body image, bother symptoms, and quality of life in women with pelvic organ prolapse. STUDY DESIGN Women presenting for pessary insertion completed the short forms of Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire, and Body Image Scale. After successful pessary insertion and use for at least 3 months, subjects completed the surveys again. Scores were compared with a paired t test. RESULTS A total of 75 subjects were enrolled and follow-up responses were available for 54 subjects for analysis. Body Image Scale scores showed a significant decrease (6.1-3.4; P<.001), indicating an improvement in these womens perception of themselves, as did Pelvic Floor Distress Inventory-20 scores (81.34-45.83; P<.001) and Pelvic Floor Impact Questionnaire scores (50.32-17.98; P=.003). CONCLUSION The use of a pessary for 3 months reduces bother symptoms and improves both quality of life and perception of body image in women.

Pessary use and impact on quality of life and body image.

Objectives: The objective of the study was to determine if vaginal pessaries improve symptoms of prolapse and body image in women with pelvic organ prolapse. Our hypothesis was that pessary use would improve prolapse-related symptoms and body image up to 1 year. Methods: Women presenting for pessary insertion completed questionnaires regarding pelvic floor-related symptoms and body image with successful pessary insertion and after 6 to 12 months of continued pessary use. Scores were compared with a paired t test. Results: Forty-three subjects had complete data for analysis. Scores on both prolapse-related and body image questionnaires showed improvements at 6 months (P < 0.001) and 12 months (P < 0.010). Younger women and those with prior prolapse surgery were less likely to continue to use a pessary past 3 to 6 months. Stage of prolapse, body mass index, and scores on symptom questionnaires did not correlate with likelihood of continued pessary use versus surgery. Conclusions: The use of a pessary for more than 12 months improves symptoms of prolapse and self perception of body image.

Use of a beef tongue model and instructional video for teaching residents fourth-degree laceration repair

Introduction and hypothesisThis study seeks to compare the utility of the beef tongue model versus an instructional video in teaching obstetric and gynecology residents how to repair a fourth-degree laceration.MethodsTwenty-seven residents were randomized to participate in a workshop with a beef tongue model or assigned to watch an instructional video on repair of fourth-degree lacerations and read a chapter on the repair. All subjects were tested with a pre- and postintervention written test. These scores were compared with paired t test at 0.05 significance level.ResultsResidents with no prior experience in fourth-degree laceration repairs showed an improvement in knowledge (49.5% versus 64.1%, p < 0.001) on written exams about the repairs.ConclusionsAn instructional video or beef tongue model and textbook chapter on fourth-degree laceration repair can improve skills in repair of a fourth-degree laceration among residents with no experience in these repairs.

Sling surgery for stress urinary incontinence in women: A systematic review and meta-analysis

Traditional treatment options in women with stress urinary incontinence (SUI) include Burch urethropexy or pubovaginal slings. These procedures have become much less popular and less frequently performed with the development and increased use of synthetic midurethral slings (MUSs). These trends in practice have not been associated with dramatic improvements in outcomes, however, and up to a third of women require repeat surgery. Therefore, it is important to understand the comparative effectiveness of competing surgical repair procedures. The primary aim of this systematic review and meta-analysis was to compare objective and subjective cure rates in adult women with SUI treated with different surgical procedures. A systematic review was performed using the MEDLINE and Cochrane Central Register for Controlled Trials databases to obtain English-language comparative studies, cohort studies, and systematic reviews published from 1990 through April 2013 comparing a sling procedure for SUI to another sling or to Burch urethropexy. For evaluation of outcomes, only peer-reviewed randomized controlled trials with at least 12 months of follow-up were included. The minimum requirement for meta-analysis was at least 3 randomized controlled trials that compared the same surgeries for the same outcome and provided adequate efficacy and adverse event data. A random-effects model meta-analysis was used to estimate pooled odds ratios (ORs). Comparison ofMUS vs Burch urethropexy (open or laparoscopic):Meta-analysis of objective cure showed no significant difference between these 2 procedures (OR, 1.18; 95% confidence interval [CI], 0.73–1.89). There was also no difference between these 2 surgeries for outcomes of subjective cure, quality of life, or sexual function. Either an MUS or Burch procedure can be used. The choice should be based on potential adverse events and planned concomitant surgeries. Comparison of pubovaginal sling vs Burch urethropexy: Because the evidence favored pubovaginal slings for both subjective and objective cure, the authors recommended use of pubovaginal slings to maximize cure outcomes. Comparison of pubovaginal slings vs MUS: Meta-analysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18–0.85). A meta-analysis for objective cure could not be performed because of inadequate data. Based on the subjective evidence for better cure, the authors recommended MUS. www.obgynsurvey.com | 586 Copyright

The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial

OBJECTIVE The objective of the study was to compare time to first bowel movement (BM) after surgery in subjects randomized to placebo or senna with docusate. STUDY DESIGN Ninety-six subjects completed a baseline 7-day bowel diary before and after surgery. After pelvic reconstructive surgery, the subjects were randomized to either placebo (n=45) or senna (8.6 mg) with docusate (50 mg) (n=48). Time to first BM and postoperative use of magnesium citrate were compared. RESULTS There was a significant difference in the time to first BM in those receiving senna with docusate vs placebo (3.00+/-1.50 vs 4.05+/-1.50 days; P<.002). More subjects in the placebo group needed to use magnesium citrate to initiate a bowel movement (43.6% vs 7.0%; P<.001). CONCLUSION The use of senna with docusate decreases time to first BM in those undergoing pelvic reconstructive surgery compared with placebo. Subjects using senna with docusate are also significantly less likely to use magnesium citrate.

Is Burch or mid-urethral sling better with abdominal sacral colpopexy?

Introduction and hypothesisThis study aims to compare the post-operative rates of stress urinary incontinence (SUI) after abdominal sacral colpopexy (ASC) with either Burch or mid-urethral sling, tension-free vaginal tape (TVT), or no anti-incontinence procedure. The null hypothesis was there would be no difference in SUI among groups.MethodsA cohort of women who had undergone ASC (n = 150) either alone or with an anti-continence procedure were analyzed to determine the rates of post-operative SUI. Statistically significant differences were evaluated with a Student’s t-test.ResultsA total of 150 subjects were evaluated, with 115 having SUI preoperatively. Post-operatively, 10% (15/150) of all subjects had SUI. Subjects with preoperative SUI who had a Burch were more likely to have post-operative SUI than those who had a TVT (10 versus 0, p = 0.007).ConclusionsBurch and TVT procedures improve SUI symptoms in patients undergoing ASC. Mid-urethral slings performed with ASC have lower rates of post-operative SUI.

The impact of pessary use on bowel symptoms: one-year outcomes.

Objectives The literature states that patients with pelvic organ prolapse have a higher prevalence of bothersome bowel symptoms and that surgical correction of prolapse may improve bowel function. There is limited knowledge regarding the impact of pessary use on bowel function in patients with prolapse. The aim of this study was to evaluate if there is a change in bowel symptoms in patients with prolapse treated with a vaginal pessary. Methods Women who presented for pessary insertion completed the validated questionnaires on the bowel symptom severity and on the effect of bowel symptoms on the quality of life at baseline and again at 12 months of continuous pessary use. Inferential statistics comprised Student t test for evaluating differences in continuous Gaussian data between groups and paired t tests were used to evaluate differences among subjects between the baseline and 12 months of use. Results One hundred four women participated in the original study, and 43 had complete data for analysis. Women who completed 12 months of pessary use reported significant improvements in both bowel-related symptoms and bowel-related quality of life (95% confidence interval of the difference 1.6–11.4 and 2.0–14.0, respectively). Patients who completed the 12-month follow-up were significantly older and more likely to have stage 3 or 4 prolapse than noncompleters, but there were no differences in body mass index, race, history of prior prolapse surgery, or menopause status. Conclusions In women with prolapse, the use of a pessary is associated with a decrease in complaints related to bowel symptoms.

Abdominal extraperitoneal excision of a foreign body in the pararectal space.

Permanent suture material and synthetic grafts can be used as part of pelvic organ prolapse surgery. These materials are often attached to the sacrospinous ligament or passed in retroperitoneal spaces. There is a risk for erosion and granulation tissue formation with any of these materials. Typically, this is managed through a transvaginal incision.We present a case of a postmenopausal woman with persistent granulation tissue and a sinus tract from a braided polyester (Ethibond) suture placed in the right sacrospinous ligament fixation. After failing several attempts at treating this granulation tissue through a vaginal incision, we managed this via an abdominal retroperitoneal approach.