Stephanie Pickett

The Significant Morbidity of Removing Pelvic Mesh From Multiple Vaginal Compartments

OBJECTIVE: To investigate perioperative complications of mesh removal performed in the operating room from a single-site, tertiary care center with a large volume of referrals for mesh removal and to compare the morbidity associated with single-compartment mesh removal compared with removal from multiple vaginal compartments. METHODS: A retrospective review was performed on all patients who underwent mesh removal from January 2008 to April 2014. Patients were identified based on Current Procedural Terminology codes for removal of vaginal mesh or sling. Summary statistics were calculated for the patient population. Complications were compared between single-compartment mesh removal surgery and multicompartment mesh removal surgery. A P value of <.05 was considered significant for all analyses. RESULTS: During a 75-month period, a total of 398 procedures were performed for the removal of vaginally placed mesh. A total of 326 (82%) patients underwent single-compartment surgery, 48 (12%) underwent multicompartment surgery, and in 26 (6%), the type of surgery was unclear. The indications for mesh removal included: pain (63%), dyspareunia (57%), mesh exposure (54%), and voiding dysfunction (39%). The mean length of mesh removed was 4 cm (standard deviation±2.8). Those with multicompartment surgery had approximately three times higher estimated blood loss compared with single-compartment surgery (P<.001). The odds of blood transfusion after multicompartment surgery were more than nine times higher than the odds of transfusion after a single-compartment surgery (odds ratio 9.7, 95% confidence interval 2.1–44.6; P<.01). CONCLUSION: Bleeding complications are higher with concomitant removal of mesh from multiple vaginal compartments. LEVEL OF EVIDENCE: III

Increasing Age Is a Risk Factor for Decreased Postpartum Pelvic Floor Strength

Objectives This study aimed to determine factors associated with decreased pelvic floor strength (PFS) after the first vaginal delivery (VD) in a cohort of low-risk women. Methods This is a secondary analysis of a prospective study examining the risk of pelvic floor injury in a cohort of primiparous women. All recruited participants underwent an examination, three-dimensional ultrasound and measurement of PFS in the third trimester and repeated at 4 weeks to 6 months postpartum using a perineometer. Results There were 84 women recruited for the study, and 70 completed the postpartum assessment. Average age was 28.4 years (standard deviation, 4.8). There were 46 (66%) subjects with a VD and 24 (34%) with a cesarean delivery who labored. Decreased PFS was observed more frequently in the VD group compared with the cesarean delivery group (68% vs 42%, P = 0.03). In modified Poisson regression models controlling for mode of delivery and time of postpartum assessment, women who were aged 25 to 29 years (risk ratio = 2.80, 95% confidence interval, 1.03–7.57) and 30 years and older (risk ratio = 2.53, 95% confidence interval, 0.93–6.86) were over 2.5 times more likely to have decreased postpartum PFS compared with women younger than 25 years. Conclusions In this population, women aged 25 years and older were more than twice as likely to have a decrease in postpartum PFS.

Characteristics of Providers Performing Urogynecologic Procedures on Medicare Patients 2012–2014

Objective To analyze the characteristics of providers performing stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures in the United States. Methods The Centers for Medicare Services public database, released for years 2012 through 2014, was queried for SUI-related and POP-related Healthcare Common Procedure Coding System. Providers were categorized as Female Pelvic Medicine and Reconstructive Surgery (FPMRS) providers and non-FPMRS providers, using a list of FPMRS board-certified providers compiled through the American Board of Medical Subspecialties website. Other physician specialties that submitted SUI and POP procedures claims were tabulated. Results Six hundred twenty-nine FPMRS and 833 non-FPMRS providers submitted claims for SUI and POP procedures. The SUI procedures claims had the following provider specialty distribution: obstetrics and gynecology (OB/GYN)—FPMRS, 46.7%; urology, 26.3%; OB/GYN, 12.2%; and urology—FPMRS, 13.9%, with the remaining 0.9% being performed by other specialties. The POP procedures had the following specialty distribution: OB/GYN—FPMRS, 63.4%; OB/GYN, 16.7%; urology, 8.3%; and urology—FPMRS, 7.1%, with the remaining 4.5% being performed by other specialties. Provider distribution was compared between transvaginal mesh and sling insertion procedures to transvaginal mesh and sling removal procedures. The FPMRS providers claimed 63.6% of sling and transvaginal mesh insertion procedures and performed 84.9% of mesh and sling removal procedures. Conclusions Medicare reimbursement data provides a unique insight into the distribution of provider specialties performing SUI-related and POP-related procedures in the Medicare population. The OB/GYN-FPMRS providers submitted the majority of claims for SUI and POP procedures from 2012 to 2014. The FPMRS providers are also performing the majority of mesh removal procedures.

Neuroanatomy of the Female Pelvis

The neuroanatomy of the pelvis is a complex system with many interactive pathways that is not completely understood yet. The advancement of technology in the basic sciences and imaging continues to allow improved understanding in this area. This chapter serves as an overview of basic neurology as well as a look into the innervation of the musculature related to pelvic floor support and continence mechanisms.