Paul M. Yandell

Antibiotic prophylaxis for urinary tract infection after midurethral sling: a randomized controlled trial.

Objective Because of the reported high percentage of bladder infections after placement of a midurethral sling (8.9%–34%), this study was undertaken to determine if a 3-day postoperative course of a urinary antibiotic would significantly lower the incidence of urinary tract infection (UTI) among treated women. Methods Women who were planning outpatient vaginal surgery for stress incontinence were enrolled, after informed consent, and randomized to receive placebo or nitrofurantoin (100 mg 2 times a day) for 3 days after surgery. Research subjects and investigators were blinded to the randomization. Women were observed for signs and symptoms of UTI until 6 weeks after surgery. Sample size was calculated to have 80% power to detect a 15% difference in the primary outcome (&agr; = 0.05). The primary outcome was analyzed using a &khgr;2 analysis. Results Data were analyzed from 149 subjects (placebo, n = 75; drug, n = 74). Overall, 37 women (24.8%) were diagnosed with a UTI during the study period. The incidence of postoperative UTI was significantly lower in the treatment arm (17.6%) then in the placebo arm (32%; P = 0.04). Conclusions A short (3-day) course of nitrofurantoin after outpatient sling surgery significantly reduces the incidence of postoperative bladder infection in the first 6 weeks after sling surgery. (clinicaltrials.gov registration number: NCT00734968).

A randomized comparison of bupivacaine versus saline during placement of tension-free vaginal tape.

Objectives To compare postoperative urinary retention and pain control when bupivacaine versus saline for hydrodissection is used while placing tension-free vaginal tape midurethral slings. Methods A prospective, randomized, double-blind trial was performed after institutional review board approval. Sixty women were randomized to receive bupivacaine or saline for hydrodissection. Subjects and research team were blinded to subject assignments. Group characteristics were compared using the Student t test, the &khgr;2 test, and the Mann-Whitney U test. Proportions of subjects with a successful postoperative voiding trial along with measurements of postoperative pain and analgesic use were compared using similar appropriate tests. The study was powered to detect differences in voiding trial success from an estimated 58% to greater than 90% with P < 0.05 and 0.8 power using 25 subjects per group. Results Thirty patients were allocated to each group. One subject in the saline-only group was excluded. Group characteristics were not different. After surgery, pain medication use (20/30 vs 25/29 for bupivacaine vs saline only; P = 0.08), pain scores (36 ± 22 vs 31 ± 24; P = 0.49), and successful voiding trials did not differ (14/30 vs 19/29; P = 0.14), whereas postvoid residuals did differ (225 ± 180 mL vs 140 ± 147 mL; P = 0.043). Conclusions Bupivacaine was not seen to improve immediate postoperative pain after placement of a tension-free vaginal tape. It did not increase the risk of failing a postoperative voiding trial. Without an obvious benefit, the use of an additional medicine is not supported. We suggest saline alone be used for hydrodissection.

Recognition and management of nerve entrapment pain after uterosacral ligament suspension.

OBJECTIVE: To estimate the incidence, risk factors, and characteristics of neuropathic pain related to nerve entrapment after uterosacral ligament suspension. METHOD: A review of patients who underwent uterosacral ligament suspension from January 2007 to August 2011 was performed. Patients with neuropathic pain attributable to nerve entrapment from uterosacral ligament suspensory suture placement were identified. Factors including surgeons dominant hand, side of pain, onset of pain, day of suture removal, number of sutures placed and removed, patient age, and body mass index (BMI) were collected. Follow-up of patients with neuropathic pain was performed at postoperative visits and by telephone contact. RESULT: Eight (1.6%) of 515 patients had neuropathic pain requiring suture removal from the affected side. The postoperative pain was recognized after discontinuation of intravenous narcotics on postoperative day 1. Patients reported their pain improved after removal of all sutures on the affected side. Patients with neuropathic pain did not differ from those without in regard to age, BMI, and preoperative prolapse stage, or in the number of sutures placed. None of the eight had recurrent pelvic organ prolapse (POP), with a median follow-up of 5 months. CONCLUSION: Eight patients (1.6%) had postoperative neuropathic pain that resolved after all sutures were removed on the affected side. The removal of sutures was not associated with recurrent POP in the short-term. LEVEL OF EVIDENCE: II

Perineal Body Length and Perineal Lacerations During Delivery in Primigravid Patients

This study assessed the relation between perineal body length and the risk of perineal laceration extending into the anal sphincter during vaginal delivery in primigravid patients at an institution with a low utilization of episiotomy. This was a prospective study of primigravid patients in active labor. Primigravid women with singleton pregnancies who were in the first stage of labor at 37 weeks gestation or greater were recruited, and the admitting physician measured the length of the perineal body. The degree of perineal laceration and other delivery characteristics were recorded. Data were analyzed using univariate analyses, receiver-operator curve analyses, and multiple logistic regression for factors associated with increased severity of vaginal lacerations. The perineal body length, duration of second stage of labor, type of delivery, and patient age were associated (P < 0.1) with third- and fourth-degree (severe) perineal lacerations in primigravid women using receiver-operator curve analysis. Using logistic regression, only the duration of second stage of labor and length of the perineal body were significant (P < 0.04) predictors of third- and fourth-degree lacerations, with odds ratios of 32 (1.3 to 807 as 95% CI) and 24 (1.3 to 456), respectively. Both a perineal body length of ≤3.5 cm and a duration of second stage of labor >99 minutes were associated with an increased risk of third- and fourth-degree lacerations in primigravid patients.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension.

Objectives To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS). Methods A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status. Results During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses. Conclusions In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Incidence of Bladder Injury During Retropubic Midurethral Sling Placement After Prior Burch Colpopexy.

Objectives To elucidate if prior Burch changes the risk of bladder injury or rates of voiding dysfunction and continence in the immediate postoperative period when undergoing retropubic midurethral sling (MUS) placement. Methods In this retrospective case control, charts were selected by Current Procedural Terminology codes for MUS placement. Women undergoing retropubic MUS placement with history of Burch urethropexy were considered. For every case, 2 age-matched and parity-matched controls without prior Burch were selected. Results In total, 538 charts were reviewed from 2010 to 2014. Twenty cases were found. There was a difference (P = 0.023) in trocar penetration of the bladder. Twenty-five percent (5/20) of women with prior Burch had a 9-fold (odds ratio [OR], 9.0; 95% confidence interval [CI], 1.0–82) higher chance of bladder penetration compared with women without prior retropubic surgery as calculated with Mantel-Haenszel paired test. Women with prior Burch had more success passing their voiding trials (OR, 7.5; 95% CI, 1.1–49.2). At 6 weeks, there was no difference in voiding dysfunction. Cure of stress incontinence at 6 weeks occurred more in controls than cases (P = 0.044) with match pairs manifesting an OR of 0.20 and 95% CI of 0.04–1.1. Discussion This study shows a significant increase risk of trocar penetration of the bladder during retropubic MUS placement in women with a history of Burch urethropexy. Despite this, MUS placement was successful in all women. Women with prior surgery were much more likely to pass their voiding trials. There was no difference in voiding dysfunction at 6 weeks between the 2 groups. Conclusions This indicates that though bladder penetration with a trocar is more common in the setting of previous retropubic surgery, it does not impact a womans short-term intraoperative or postoperative course.

Nausea and vomiting after placement of tension-free vaginal tape sling.

BACKGROUND: Minimally invasive surgical procedures such as tension-free vaginal tape sling should not imply that a minimal preoperative evaluation is all that is required. CASE: A 52-year-old multiparous perimenopausal woman presented with postoperative nausea, vomiting, and vague abdominal–pelvic discomfort after placement of tension-free vaginal tape. The final diagnosis was invasive molar pregnancy. CONCLUSION: This case raises the awareness of the rare diagnosis of gestational trophoblastic disease in perimenopausal women and emphasizes the importance of a complete preoperative evaluation in those scheduled to undergo minimally invasive procedures.