Heterogeneity in post-intervention prolapse and urinary outcome reporting: a one-year review of the International Urogynecology Journal

Protocol for a prospective multisite cohort study investigating hysterectomy versus uterine preservation for pelvic organ prolapse surgery: the HUPPS study

INTRODUCTION

Pelvic organ prolapse (POP) is the descent of pelvic organs into the vagina resulting in bulge symptoms and occurs in approximately 50% of women. Almost 20% of women will elect surgical correction of this condition by age 85. Removal of the uterus (hysterectomy) with concomitant vaginal vault suspension is a long-standing practice in POP surgery to address apical (uterine) prolapse. Yet, contemporary evidence on the merits of this approach relative to preservation of the uterus through suspension is needed to better inform surgical decision making by patients and their healthcare providers. The objective of this study is to evaluate POP-specific health outcomes and service utilisation of women electing uterine suspension compared with those electing hysterectomy and vaginal vault suspension for POP surgery up to 1-year postsurgery.

METHODS AND ANALYSIS

This is a prospective cohort study planning to enrol 321 adult women with stage ≥2 POP from multiple sites in Alberta, Canada. Following standardised counselling from study surgeons, participants self-select either a hysterectomy based or uterine preservation surgical group. Data are being collected through participant questionnaires, medical records and administrative data linkage at four time points spanning from the presurgical consultation to 1-year postsurgery. The primary outcome is anatomic failure to correct POP, and secondary outcomes include changes in positioning of pelvic structures, retreatment, subjective report of bulge symptoms, pelvic floor distress and impact, sexual function and health service use. Data will be analysed using inverse probability weighting of propensity scores and generalised linear models.

ETHICS AND DISSEMINATION

This study is approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB19-2134). Results will be disseminated via peer-reviewed publications, presentations at national and international conferences, and educational handouts for patients.

TRIAL REGISTRATION NUMBER

NCT04890951.

From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh

Beginning in the late 1990s, surgeons around the world widely adopted the transvaginal placement of permanent synthetic mesh for the treatment of several common pelvic floor disorders in women. By 2012 it had become the subject of extensive litigation, including one of the biggest mass-tort cases in U.S. history, with litigants reporting debilitating and unexpected complications. Based on qualitative research that includes interviews with surgeons, observations of medical conferences, and analysis of archival materials, we argue the adoption of transvaginal mesh cannot be fully explained without recognizing the role of mindlines, or collective moral-epistemological ways of knowing and acting responsibly. The adoption of mesh was anchored in a mindline focused on repairing anatomy. The harms that resulted from transvaginal mesh necessitated a shift to a focus on patient experience. We analyze the role of evidence-based medicine (EBM) in the re-organization of these surgeons' mindlines, showing that mindlines are not reducible to evidence as defined by EBM and that evidence thus defined facilitated the adoption of transvaginal mesh.

Multivariate network meta-analysis incorporating class effects

BACKGROUND

Network meta-analysis synthesises data from a number of clinical trials in order to assess the comparative efficacy of multiple healthcare interventions in similar patient populations. In situations where clinical trial data are heterogeneously reported i.e. data are missing for one or more outcomes of interest, synthesising such data can lead to disconnected networks of evidence, increased uncertainty, and potentially biased estimates which can have severe implications for decision-making. To overcome this issue, strength can be borrowed between outcomes of interest in multivariate network meta-analyses. Furthermore, in situations where there are relatively few trials informing each treatment comparison, there is a potential issue with the sparsity of data in the treatment networks, which can lead to substantial parameter uncertainty. A multivariate network meta-analysis approach can be further extended to borrow strength between interventions of the same class using hierarchical models.

METHODS

We extend the trivariate network meta-analysis model to incorporate the exchangeability between treatment effects belonging to the same class of intervention to increase precision in treatment effect estimates. We further incorporate a missing data framework to estimate uncertainty in trials that did not report measures of variability in order to maximise the use of all available information for healthcare decision-making. The methods are applied to a motivating dataset in overactive bladder syndrome. The outcomes of interest were mean change from baseline in incontinence, voiding and urgency episodes. All models were fitted using Bayesian Markov Chain Monte Carlo (MCMC) methods in WinBUGS.

RESULTS

All models (univariate, multivariate, and multivariate models incorporating class effects) produced similar point estimates for all treatment effects. Incorporating class effects in multivariate models often increased precision in treatment effect estimates.

CONCLUSIONS

Multivariate network meta-analysis incorporating class effects allowed for the comparison of all interventions across all outcome measures to ameliorate the potential impact of outcome reporting bias, and further borrowed strength between interventions belonging to the same class of treatment to increase the precision in treatment effect estimates for healthcare policy and decision-making.

Female Pelvic Medicine and Reconstructive Surgery challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium: managing complicated cases : Series 5: management of recurrent stress urinary incontinence after midurethral sling exposure

This case presents the work-up and management of a patient requesting surgical intervention for recurrent stress urinary incontinence after previous excision of a portion of her midurethral sling because of mesh exposure. Four international experts provide their approach to this complex case. There is little consensus regarding further surgery in a patient who has required mesh excision. Treatment by fascial sling was commonly considered and the literature review outlines the pros and cons of autologous fascia versus donor fascia for this specific case.

Urinary leakage during exercise: problematic activities, adaptive behaviors, and interest in treatment for physically active Canadian women

INTRODUCTION AND HYPOTHESIS

Urine loss during recreational exercise is problematic. We aimed to characterize which activities are most frequently reported as causing leakage for women, adaptive management mechanisms, and awareness and interest in treatment in a cohort of physically active women.

METHODS

We administered an anonymous questionnaire to 59 physically active women in Canada. Surveys were completed electronically or on paper. Demographic information was obtained. Questions about which specific activities caused leakage, adaptive behaviors to deal with urinary loss, and degree of bother were addressed, and knowledge and interest in therapies for leakage were queried.

RESULTS

Activities most likely to cause leakage were skipping, trampoline, jumping jacks, and running/jogging. To decrease leakage, 93.2% voided immediately before exercise, 62.7% reported voiding breaks, and some reported fluid restriction (37.3%). Leakage impacted activity level for 50% of women. Most often, activity intensity was decreased (90.3%) or specific activities avoided (80.7%). Pad use during exercise was common (49.2%). Interest in receiving treatment for urinary incontinence (UI) was high (88.1%) despite a large proportion (35.6%) not knowing of available treatments. Interest was highest for pelvic floor physiotherapy (84.6%), although interest in both pessary and surgical management (63.5% each) was significant.

CONCLUSIONS

Women experiencing UI during exercise report high-impact activities as most frequently causing loss. Adaptive behaviors are common. Physically active women are interested in treatment, and the high interest in pelvic physiotherapy presents a unique opportunity to link pelvic exercise with recreational exercise to meet both cardiovascular and continence needs in the physically active patient population.