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Sung VW, Menefee S, Richter HE, Moalli PA, Andy U, Weidner A, Rahn DD, Paraiso MF, Jeney SE, Mazloomdoost D, Gilbert J, Whitworth R, Thomas S. Patient perspectives in adverse event reporting after vaginal apical prolapse surgery. Am J Obstet Gynecol 2024:S0002-9378(24)00569-6. [PMID: 38710268 DOI: 10.1016/j.ajog.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/10/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Many clinical trials use systematic methodology to monitor adverse events (AE) and determine grade (severity), expectedness, and relatedness to treatments as determined by clinicians. However, patient perspective in the process remains lacking. OBJECTIVES To compare clinician versus patient grading of AE severity in a urogynecologic surgical trial. Secondary objectives were to estimate the association between patient grading of AEs with decision-making and quality of life outcomes and to determine if patient perspective changes over time. STUDY DESIGN This was a planned supplementary study, "Patient-Perspectives in Adverse Event Reporting" (PPAR), to a randomized trial comparing 3 surgical approaches to vaginal apical prolapse. In the parent trial, AEs experienced by patients were collected per a standardized protocol every 6 months where clinicians graded AE severity (mild, moderate, severe/life threatening). In this sub-study, we obtained additional longitudinal patient perspectives for 19 predetermined "PPAR AEs". Patients provided their own severity grading (mild, moderate, severe/very severe/ life threatening) at initial assessment and at 12 and 36 months postoperatively. Clinicians and patients were masked to each other's reporting. The primary outcome was the interrater agreement (kappa statistic, κ) for AE severity between the initial clinician and patient assessment, combining patient grades of mild and moderate. Association between AE severity and the Decision-Regret Scale (DRS), Satisfaction with Decision Scale (SDS), the Short-Form Health Survey-12 (SF-12), and Patient-Global Impression of Improvement (PGI-I) scores were assessed utilizing Spearman's correlation coefficient (ρ) for continuous scales, Mantel-Haenszel chi-squared test for PGI-I, and T-tests or chi-squared tests comparing assessments of severe vs other grades. To describe patient perspective changes over time, the intra-observer agreement was estimated for AE severity grade over time using weighted kappa-coefficients. RESULTS Of 360 patients randomized, 219 (61%) experienced a total of 527 PPAR AEs (91% moderate and 9% severe/life threatening by clinician grading). Mean patient age was 67 years, 87% were White, and 12% Hispanic. Of patients reporting any PPAR event, the most common were urinary tract infection (61%), de novo urgency urinary incontinence (35%), stress urinary incontinence (22%), and fecal incontinence (13%). Overall agreement between clinician and participant grading of severity was poor (κ=0.24 (95%CI 0.14, 0.34). Of 414 AEs clinicians graded as moderate, patients graded 120 (29%) mild, and 80 (19%) severe. Of 39 AEs graded severe by clinicians, patients graded 15 (38%) mild or moderate. Initial patient grading of the most severe reported AE was mildly correlated with worse DRS (ρ=0.2, p=0.01), SF-12 (ρ=-0.24, p<0.01) and PGI-I (p<0.01). There was no association between AE severity and SDS. Patients with an initial grading of "severe" had more regret, lower quality of life, and poorer global impressions of health than those whose worst severity grade was mild (p<0.05). Agreement between the patients' initial severity and later timepoints was fair at 12 months (κ=0.48 (95% CI 0.39, 0.58)) and 36 months (κ=0.45 (95% CI 0.37, 0.53)). CONCLUSIONS Clinician and patient perceptions of AE severity are discordant. Worse severity from the patient perspective was associated with patient-centered outcomes. Including the patient perspective provides additional information for evaluating surgical procedures.
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Affiliation(s)
- Vivian W Sung
- Department of Obstetrics & Gynecology, Division of Urogynecology, Alpert Medical School of Brown University, Providence, RI, United States.
| | - Shawn Menefee
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, CA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Pamela A Moalli
- Department of Obstetrics & Gynecology, Division of Urogynecology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Uduak Andy
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Alison Weidner
- Department of Obstetrics & Gynecology, Division of Urogynecology & Reconstructive Pelvic Surgery, Duke University, Durham, NC, United States
| | - David D Rahn
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Marie F Paraiso
- Center for Urogynecology & Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Sarah E Jeney
- Department of Obstetrics & Gynecology, Division of Urogynecology, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Harvie HS, Richter HE, Sung VW, Chermansky CJ, Menefee SA, Rahn DD, Amundsen CL, Arya LA, Huitema C, Mazloomdoost D, Thomas S. Trial Design for Mixed Urinary Incontinence: Midurethral Sling Versus Botulinum Toxin A. Urogynecology (Phila) 2024; 30:478-488. [PMID: 38212101 PMCID: PMC11058039 DOI: 10.1097/spv.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
IMPORTANCE Mixed urinary incontinence (MUI) is common and can be challenging to manage. OBJECTIVES We present the protocol design and rationale of a trial comparing the efficacy of 2 procedures for the treatment of women with MUI refractory to oral treatment. The Midurethral sling versus Botulinum toxin A ( MUSA) trial compares the efficacy of intradetrusor injection of 100 U of onabotulinimtoxinA (an office-based procedure directed at the urgency component) versus midurethral sling (MUS) placement (a surgical procedure directed at the stress component). STUDY DESIGN The MUSA is a multicenter, randomized trial of women with MUI electing to undergo procedural treatment for MUI at 7 clinical centers in the NICHD Pelvic Floor Disorders Network. Participants are randomized to either onabotulinumtoxinA 100 U or MUS. OnabotulinimtoxinA recipients may receive an additional injection between 3 and 6 months. Participants may receive additional treatment (including crossover to the alternative study intervention) between 6 and 12 months. The primary outcome is change from baseline in Urogenital Distress Inventory (UDI) at 6 months. Secondary outcomes include change in UDI at 3 and 12 months, irritative and stress subscores of the UDI, urinary incontinence episodes, predictors of poor treatment response, quality of life and global impression outcomes, adverse events, use of additional treatments, and cost effectiveness. RESULTS Recruitment and randomization of 150 participants is complete and participants are currently in the follow-up phase. CONCLUSIONS This trial will provide information to guide care for women with MUI refractory to oral treatment who seek surgical treatment with either onabotulinumtoxinA or MUS.
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Affiliation(s)
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University/Women and Infants Hospital, Providence, RI
| | | | - Shawn A Menefee
- Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, CA
| | - David D Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern, TX
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham
| | - Lily A Arya
- From the Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania
| | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Andy UU, Iriondo-Perez J, Carper B, Richter HE, Dyer KY, Florian-Rodriguez M, Napoe GS, Myers D, O'Shea M, Mazloomdoost D, Gantz MG. Dietary Intake and Symptom Severity in Women with Fecal Incontinence. Int Urogynecol J 2024:10.1007/s00192-024-05776-6. [PMID: 38656362 DOI: 10.1007/s00192-024-05776-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/04/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The goal of this study was to determine whether dietary fat/fiber intake was associated with fecal incontinence (FI) severity. METHODS Planned supplemental analysis of a randomized clinical trial evaluating the impact of 12-week treatment with percutaneous tibial nerve stimulation versus sham in reducing FI severity in women. All subjects completed a food screener questionnaire at baseline. FI severity was measured using the seven-item validated St. Mark's (Vaizey) FI severity scale. Participants also completed a 7-day bowel diary capturing the number of FI-free days, FI events, and bowel movements per week. Spearman's correlations were calculated between dietary, St. Mark's score, and bowel diary measures. RESULTS One hundred and eighty-six women were included in this analysis. Mean calories from fats were 32% (interquartile range [IQR] 30-35%). Mean dietary fiber intake was 13.9 ± 4.3 g. The percentage of calories from fats was at the higher end of recommended values, whereas fiber intake was lower than recommended for adult women (recommended values: calories from fat 20-35% and 22-28 g of fiber/day). There was no correlation between St. Mark's score and fat intake (r = 0.11, p = 0.14) or dietary fiber intake (r = -0.01, p = 0.90). There was a weak negative correlation between the number of FI-free days and total fat intake (r = -0.20, p = 0.008). Other correlations between dietary fat/fiber intake and bowel diary measures were negligible or nonsignificant. CONCLUSION Overall, in women with moderate to severe FI, there was no association between FI severity and dietary fat/fiber intake. Weak associations between FI frequency and fat intake may suggest a role for dietary assessment in the evaluation of women with FI.
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Affiliation(s)
- Uduak U Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3737 Market Street, 12Th Floor, Philadelphia, PA, 19104, USA.
| | - Jeniffer Iriondo-Perez
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, Durham, NC, USA
| | - Benjamin Carper
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, Durham, NC, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keisha Y Dyer
- Department of Obstetrics and Gynecology Kaiser Permanente, San Diego, CA, USA
| | - Maria Florian-Rodriguez
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G Sarah Napoe
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Deborah Myers
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Michele O'Shea
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Marie G Gantz
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, Durham, NC, USA
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Meyer I, Iriondo-Perez J, Dyer KY, Sung V, Ackenbom MF, Florian-Rodriguez M, Kim E, Mazloomdoost D, Carper B, Gantz MG. Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence. Int Urogynecol J 2024; 35:545-551. [PMID: 38206340 PMCID: PMC11023758 DOI: 10.1007/s00192-023-05711-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/28/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Despite growing interest in a mobile-app bowel diary to assess fecal incontinence (FI) symptoms, data are limited regarding the correlation between mobile-app diary and questionnaire-based outcomes. The primary aim is to determine whether percentage reduction in FI episodes (FIEs)/week recorded on a mobile-app diary correlates with changes in scores of validated FI-symptom measures from baseline to 12 weeks in women with FI undergoing percutaneous tibial nerve stimulation (PTNS) versus sham. METHODS This is a planned secondary analysis of a multicenter randomized trial in which women with FI underwent PTNS or sham. FIEs were collected using a mobile-app diary at baseline and after 12 weekly sessions. FI-symptom-validated measures included St. Mark's, Accidental Bowel Leakage Evaluation, FI Severity Index (FISI), Colorectal Anal Distress Inventory, Colorectal Anal Impact Questionnaire, FI Quality of Life, Patient Global Impression of Improvement (PGI-I), and Patient Global Symptom Control (PGSC) rating. Spearman's correlation coefficient (ρ) was computed between %-reduction in FIEs/week and change in questionnaire scores from baseline to 12 weeks. Significance was set at 0.005 to account for multiple comparisons. RESULTS Baseline characteristics of 163 women (109 PTNS, 54 sham) include mean age 63.4±11.6, 81% white, body mass index 29.4±6.6 kg/m2, 4% previous FI surgeries, 6.6±5.5 FIEs/week, and St. Mark's score 17.4±2.6. A significant correlation was demonstrated between %-reduction in FIEs/week and all questionnaires (p<0.005). A moderate-strength correlation (|ρ|>0.4) was observed for St. Mark's (ρ=0.48), FISI (ρ=0.46), PGI-I (ρ=0.51), and PGSC (ρ=-0.43). CONCLUSIONS In women with FI randomized to PTNS versus sham, a moderate correlation was noted between FIEs measured via mobile-app diary and FI-symptom-validated questionnaire scores.
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Affiliation(s)
- Isuzu Meyer
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | | | - Vivian Sung
- Alpert Medical School of Brown University, University/Women & Infants Hospital, Providence, RI, USA
| | - Mary F Ackenbom
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Edward Kim
- Department of Obstetrics & Gynecology, Division of Urogynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Marie G Gantz
- RTI International, Research for the NICHD Pelvic Floor Disorders Network, Triangle Park, NC, USA
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Bowen ST, Moalli PA, Abramowitch SD, Luchristt DH, Meyer I, Rardin CR, Harvie HS, Hahn ME, Mazloomdoost D, Iyer P, Carper B, Gantz MG. Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study. BJOG 2024; 131:267-277. [PMID: 37522240 PMCID: PMC10828105 DOI: 10.1111/1471-0528.17620] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/10/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery. DESIGN Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study. SETTING Eight clinical sites in the US Pelvic Floor Disorders Network. POPULATION OR SAMPLE Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015. METHODS The MRI (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI-based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three-dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position. MAIN OUTCOME MEASURES Vaginal angulation (upper, lower and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid-vagina) at rest. RESULTS Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid-vagina (p = 0.01) at rest than women with successful surgery. CONCLUSIONS Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.
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Affiliation(s)
- Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Magee Women's Research Institute, Pittsburgh, Pennsylvania, USA
| | - Steven D Abramowitch
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Douglas H Luchristt
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles R Rardin
- Division of Urogynecology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Heidi S Harvie
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael E Hahn
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Pooja Iyer
- Biostatistics Division, PPD Incorporated, San Francisco, California, USA
| | - Benjamin Carper
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, USA
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, USA
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Borello-France D, Newman DK, Markland AD, Propst K, Jelovsek JE, Cichowski S, Gantz MG, Balgobin S, Jakus-Waldman S, Korbly N, Mazloomdoost D, Burgio KL. Adherence to Perioperative Behavioral Therapy With Pelvic Floor Muscle Training in Women Receiving Vaginal Reconstructive Surgery for Pelvic Organ Prolapse. Phys Ther 2023; 103:pzad059. [PMID: 37318279 PMCID: PMC10476875 DOI: 10.1093/ptj/pzad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 02/05/2023] [Accepted: 06/13/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The objective of this study was to describe adherence to behavioral and pelvic floor muscle training in women undergoing vaginal reconstructive surgery for organ prolapse and to examine whether adherence was associated with 24-month outcomes. METHODS Participants were women ≥18 years of age, with vaginal bulge and stress urinary incontinence symptoms, planning to undergo vaginal reconstructive surgery for stages 2 to 4 vaginal or uterine prolapse. They were randomized to either sacrospinous ligament fixation or uterosacral ligament suspension and to perioperative behavioral and pelvic floor muscle training or usual care. Measurements included anatomic failure, pelvic floor muscle strength, participant-reported symptoms, and perceived improvement. Analyses compared women with lower versus higher adherence. RESULTS Forty-eight percent of women performed pelvic floor muscle exercises (PFMEs) daily at the 4- to 6-week visit. Only 33% performed the prescribed number of muscle contractions. At 8 weeks, 37% performed PFMEs daily, and 28% performed the prescribed number of contractions. No significant relationships were found between adherence and 24-month outcomes. CONCLUSION Adherence to a behavioral intervention was low following vaginal reconstructive surgery for pelvic organ prolapse. The degree of adherence to perioperative training did not appear to influence 24-month outcomes in women undergoing vaginal prolapse surgery. IMPACT This study contributes to the understanding of participant adherence to PFMEs and the impact that participant adherence has on outcomes at 2, 4 to 6, 8, and 12 weeks and 24 months postoperatively. It is important to educate women to follow up with their therapist or physician to report new or unresolved pelvic symptoms.
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Affiliation(s)
- Diane Borello-France
- Department of OB/GYN, Magee-Womens Hospital, Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Diane K Newman
- Division of Urology, Penn Center for Continence and Pelvic Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alayne D Markland
- Department of Medicine, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center at the Birmingham VA Health Care System, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katie Propst
- Department of Obstetrics & Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - J Eric Jelovsek
- Department of Obstetrics & Gynecology, Duke University, Durham, North Carolina, USA
| | - Sara Cichowski
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Marie G Gantz
- Department of Biostatistics and Epidemiology, RTI International, Triangle Park, North Carolina, USA
| | - Sunil Balgobin
- Department of Obstetrics & Gynecology, University of Texas Southwestern, Dallas, Texas, USA
| | - Sharon Jakus-Waldman
- Department of Obstetrics, Gynecology and Urogynecology, Kaiser Permanente, Downey, California, USA
| | - Nicole Korbly
- Department of Obstetrics & Gynecology, Brown University, Providence, Rhode Island, USA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Kathryn L Burgio
- Department of Medicine, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center at the Birmingham VA Health Care System, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Gill BC, Thomas S, Barden L, Jelovsek JE, Meyer I, Chermansky C, Komesu YM, Menefee S, Myers D, Smith A, Mazloomdoost D, Amundsen CL. Intraoperative Predictors of Sacral Neuromodulation Implantation and Treatment Response: Results From the ROSETTA Trial. J Urol 2023; 210:331-340. [PMID: 37126070 PMCID: PMC10523414 DOI: 10.1097/ju.0000000000003498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
PURPOSE We determined the utility of intraoperative data in predicting sacral neuromodulation outcomes in urgency urinary incontinence. MATERIALS AND METHODS Intraoperative details of sacral neuromodulation stage 1 were recorded during the prospective, randomized, multicenter ROSETTA trial, including responsive electrodes, amplitudes, and response strengths (motor and sensory Likert scales). Stage 2 implant was performed for stage 1 success on 3-day diary with 24-month follow-up. An intraoperative amplitude response score for each electrode was calculated ranging from 0 (no response) to 99.5 (maximum response, 0.5 V). Predictors for stage 1 success and improvement at 24 months were identified by stepwise logistic regression confirmed with least absolute shrinkage and selection operator and stepwise linear regression. RESULTS Intraoperative data from 161 women showed 139 (86%) had stage 1 success, which was not associated with number of electrodes generating an intraoperative motor and/or sensory response, average amplitude at responsive electrodes, or minimum amplitude-producing responses. However, relative to other electrodes, a best amplitude response score for bellows at electrode 3 was associated with stage 1 failure, a lower reduction in daily urgency urinary incontinence episodes during stage 1, and most strongly predicted stage 1 outcome in logistic modeling. At 24 months, those who had electrode 3 intraoperative sensory response had lower mean reduction in daily urgency urinary incontinence episodes than those who had no response. CONCLUSIONS Specific parameters routinely assessed intraoperatively during stage 1 sacral neuromodulation for urgency urinary incontinence show limited utility in predicting both acute and long-term outcomes. However, lead position as it relates to the trajectory of the sacral nerve root appears to be important.
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Affiliation(s)
| | - Sonia Thomas
- RTI International, Research Triangle Park, North Carolina
| | - Lindsey Barden
- RTI International, Research Triangle Park, North Carolina
| | | | - Isuzu Meyer
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Shawn Menefee
- University of California San Diego, San Diego, California
| | | | - Ariana Smith
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Luchristt D, Carper B, Balgobin S, Meyer I, Myers D, Mazloomdoost D, Gantz M, Andy U, Zyczynski HM, Lukacz ES. Characteristics associated with subjective and objective measures of treatment success in women undergoing percutaneous tibial nerve stimulation vs sham for accidental bowel leakage. Int Urogynecol J 2023; 34:1715-1723. [PMID: 36705728 PMCID: PMC10372194 DOI: 10.1007/s00192-022-05431-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/25/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION AND HYPOTHESIS In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial. METHODS This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Mark's score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p<0.2 for each definition and interaction terms assessed differential effects of PTNS vs sham. RESULTS Of 166 women randomized, 160 provided data for at least one success definition. Overall, success rates were 65% (102 out of 158), 57% (90 out of 158), and 46% (73 out of 158) for ≥3-, ≥4-, and ≥5-point St Mark's reduction respectively; 43% (68 out of 157) for PGI-I; and 48% (70 out of 145) for ≥50% FIEs. Of those providing data for all definitions of success, 77% (109 out of 142) met one success criterion, 43% (61 out of 142) two, and 29% (41 out of 142) all three success criteria. No reliable or consistent factors were associated with improved outcomes with PTNS over sham regardless of definition. CONCLUSIONS Despite exploring diverse success outcomes, no subgroups of women with ABL differentially responded to PTNS over sham. Success results varied widely across subjective and objective definitions. Further investigation of ABL treatment success definitions that consistently and accurately capture patient symptom burden and improvement are needed.
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Affiliation(s)
| | | | | | - Isuzu Meyer
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Deborah Myers
- Brown University, Women's & Infants Hospital, Providence, RI, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Marie Gantz
- RTI International, Research, Triangle Park, NC, USA
| | - Uduak Andy
- University of Pennsylvania, Philadelphia, PA, USA
| | - Halina M Zyczynski
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Gill BC, Thomas S, Barden L, Jelovsek JE, Meyer I, Chermansky C, Komesu YM, Menefee S, Myers D, Smith A, Mazloomdoost D, Amundsen CL. Reply by Authors. J Urol 2023:101097JU000000000000349802. [PMID: 37211805 DOI: 10.1097/ju.0000000000003498.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
| | - Sonia Thomas
- RTI International, Research Triangle Park, North Carolina
| | - Lindsey Barden
- RTI International, Research Triangle Park, North Carolina
| | | | - Isuzu Meyer
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Shawn Menefee
- University of California San Diego, San Diego, California
| | | | - Ariana Smith
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Bradley MS, Sridhar A, Ferrante K, Andy UU, Visco AG, Florian-Rodriguez ME, Myers D, Varner E, Mazloomdoost D, Gantz MG. Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension. Urogynecology (Phila) 2023; 29:479-488. [PMID: 36701331 PMCID: PMC10132998 DOI: 10.1097/spv.0000000000001309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The impact of a persistently enlarged genital hiatus (GH) after vaginal hysterectomy with uterosacral ligament suspension on prolapse outcomes is currently unclear. OBJECTIVES This secondary analysis of the Study of Uterine Prolapse Procedures Randomized trial was conducted among participants who underwent vaginal hysterectomy with uterosacral ligament suspension. We hypothesized that women with a persistently enlarged GH size would have a higher proportion of prolapse recurrence. STUDY DESIGN Women who underwent vaginal hysterectomy with uterosacral ligament suspension as part of the Study of Uterine Prolapse Procedures Randomized trial (NCT01802281) were divided into 3 groups based on change in their preoperative to 4- to 6-week postoperative GH measurements: (1) persistently enlarged GH, 2) improved GH, or (3) stably normal GH. Baseline characteristics and 2-year surgical outcomes were compared across groups. A logistic regression model for composite surgical failure controlling for advanced anterior wall prolapse and GH group was fitted. RESULTS This secondary analysis included 81 women. The proportion with composite surgical failure was significantly higher among those with a persistently enlarged GH (50%) compared with a stably normal GH (12%) with an unadjusted risk difference of 38% (95% confidence interval, 4%-68%). When adjusted for advanced prolapse in the anterior compartment at baseline, the odds of composite surgical failure was 6 times higher in the persistently enlarged GH group compared with the stably normal group (95% confidence interval, 1.0-37.5; P = 0.06). CONCLUSION A persistently enlarged GH after vaginal hysterectomy with uterosacral ligament suspension for pelvic organ prolapse may be a risk factor for recurrent prolapse.
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Affiliation(s)
- Megan S Bradley
- From Obstetrics & Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Kimberly Ferrante
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, CA
| | - Uduak U Andy
- Obstetrics & Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | | | - Deborah Myers
- Obstetrics & Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Edward Varner
- Obstetrics & Gynecology, University of Alabama School of Medicine, Birmingham, AL
| | - Donna Mazloomdoost
- Gynecologic Health and Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) National Institutes of Health (NIH), Bethesda, MD
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
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11
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Meriwether K, Krashin J, Kim-Fine S, Ablove T, Dale L, Orejuela F, Mazloomdoost D, Beckham A, Probst K, Crisp C, Winkelman W, Florian-Rodriguez M, Grimes C, Turk J, Ollendorff A, Ros S, Chang O, Horvath S, Iglesia C. Trainee opinions regarding the effect of the dobbs v. jackson women’s health organization supreme court decision on obstetrics and gynecology training. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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Napoe GS, Luchristt D, Sridhar A, Ellington D, Ridgeway B, Mazloomdoost D, Sung V, Ninivaggio C, Harvie H, Santiago-Lastra Y, Gantz MG, Zyczynski HM. Reoperation for prolapse recurrence after sacrospinous mesh hysteropexy: characteristics of women choosing retreatment. Int Urogynecol J 2023; 34:255-261. [PMID: 36449027 PMCID: PMC9839581 DOI: 10.1007/s00192-022-05411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/31/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Factors that contribute to reoperation and surgical approaches for the management of recurrent uterovaginal prolapse after vaginal mesh hysteropexy (mesh hysteropexy) are unknown. We aimed to describe surgical management of pelvic organ prolapse recurrence after vaginal mesh hysteropexy, and patient characteristics in those who chose reoperation. METHODS This is a descriptive analysis of women who experienced treatment failure within 5 years of mesh hysteropexy in a multi-site randomized trial. The composite definition of treatment failure included retreatment (pessary or reoperation), prolapse beyond the hymen, or bothersome prolapse symptoms. Characteristics of those pursuing and not pursuing repeat prolapse surgery, measures of prolapse, and symptom severity are described. RESULTS Over 5-year follow up, 31/91 (34%) of the hysteropexy group met treatment failure criteria. All seven women who pursued reoperation reported bothersome prolapse symptoms; six were anatomic failures. Most seeking reoperation were early treatment failures; six (86%) by the 12-month visit and all by the 18-month visit. Compared to those electing expectant management, those pursuing reoperation had more apical prolapse, POP-Q point C median (IQR) -5.5 (-6.0, -4.0) cm versus +1.0 (-1.0, 3.0) cm respectively. Hysterectomy was performed in 6/7 reoperations (three vaginal, three endoscopic), with apical suspension in 5/6 hysterectomies. One participant with posterior compartment prolapse underwent transvaginal enterocele plication, uterosacral ligament suspension with posterior colpoperineorrhaphy. At a mean surgical follow-up of 34.3 (15.8) months, all women remained without anatomic or symptomatic failure. CONCLUSIONS When recurrent prolapse after mesh hysteropexy occurred, most women did not choose reoperation. Those who pursued surgery experienced more significant apical prolapse and were universally symptomatic. CLINICAL TRIAL IDENTIFICATION NUMBER NCT01802281.
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Affiliation(s)
- Gnankang Sarah Napoe
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA.
| | - Douglas Luchristt
- RTI International, Biostatics and Epidemiology Division, Research Triangle Park, Durham, NC, USA
| | - Amaanti Sridhar
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Ellington
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beri Ridgeway
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Donna Mazloomdoost
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Vivian Sung
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA
| | - Cara Ninivaggio
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Heidi Harvie
- Department of Urology, University of California - San Diego Health, La Jolla, CA, USA
| | | | - Marie G Gantz
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Halina M Zyczynski
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
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Richter HE, Sridhar A, Nager CW, Komesu YM, Harvie HS, Zyczynski HM, Rardin C, Visco A, Mazloomdoost D, Thomas S. Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol 2023; 228:63.e1-63.e16. [PMID: 35931131 PMCID: PMC9790026 DOI: 10.1016/j.ajog.2022.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/19/2022] [Accepted: 07/26/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery in the Vaginal hysterectomy with Native Tissue Vault Suspension vs Sacrospinous Hysteropexy with Graft Suspension (Study for Uterine Prolapse Procedures Randomized Trial) trial, sacrospinous hysteropexy with graft (hysteropexy) resulted in a lower composite surgical failure rate than vaginal hysterectomy with uterosacral suspension over 5 years. OBJECTIVE This study aimed to identify factors associated with the rate of surgical failure over 5 years among women undergoing sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral suspension for uterovaginal prolapse. STUDY DESIGN This planned secondary analysis of a comparative effectiveness trial of 2 transvaginal apical suspensions (NCT01802281) defined surgical failure as either retreatment of prolapse, recurrence of prolapse beyond the hymen, or bothersome prolapse symptoms. Baseline clinical and sociodemographic factors for eligible participants receiving the randomized surgery (N=173) were compared across categories of failure (≤1 year, >1 year, and no failure) with rank-based tests. Factors with adequate prevalence and clinical relevance were assessed for minimally adjusted bivariate associations using piecewise exponential survival models adjusting for randomized apical repair and clinical site. The multivariable model included factors with bivariate P<.2, additional clinically important variables, apical repair, and clinical site. Backward selection determined final retained risk factors (P<.1) with statistical significance evaluated by Bonferroni correction (P<.005). Final factors were assessed for interaction with type of apical repair at P<.1. Association is presented by adjusted hazard ratios and further illustrated by categorization of risk factors. RESULTS In the final multivariable model, body mass index (increase of 5 kg/m2: adjusted hazard ratio, 1.7; 95% confidence interval, 1.3-2.2; P<.001) and duration of prolapse symptoms (increase of 1 year: adjusted hazard ratio, 1.1; 95% confidence interval, 1.0-1.1; P<.005) were associated with composite surgical failure, where rates of failure were 2.9 and 1.8 times higher in women with obesity and women who are overweight than women who have normal weight and women who are underweight (95% confidence intervals, 1.5-5.8 and 0.9-3.5) and 3.0 times higher in women experiencing >5 years prolapse symptoms than women experiencing ≤5 years prolapse symptoms (95% confidence interval, 1.8-5.0). Sacrospinous hysteropexy with graft had a lower rate of failure than hysterectomy with uterosacral suspension (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-1.0; P=.05). The interaction between symptom duration and apical repair (P=.07) indicated that failure was less likely after hysteropexy than hysterectomy for those with ≤5 years symptom duration (adjusted hazard ratio, 0.5; 95% confidence interval, 0.2-0.9), but not for those with >5 years symptom duration (adjusted hazard ratio, 1.0; 95% confidence interval 0.5-2.1). CONCLUSION Obesity and duration of prolapse symptoms have been determined as risk factors associated with surgical failure over 5 years from transvaginal prolapse repair, regardless of approach. Providers and patients should consider these modifiable risk factors when discussing treatment plans for bothersome prolapse.
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Affiliation(s)
- Holly E Richter
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.
| | | | | | | | | | - Halina M Zyczynski
- University of Pittsburgh, Magee-Women's Research Institute, Pittsburgh, PA
| | | | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Zyczynski HM, Richter HE, Sung VW, Lukacz ES, Arya LA, Rahn DD, Visco AG, Mazloomdoost D, Carper B, Gantz MG. Percutaneous Tibial Nerve Stimulation vs Sham Stimulation for Fecal Incontinence in Women: NeurOmodulaTion for Accidental Bowel Leakage Randomized Clinical Trial. Am J Gastroenterol 2022; 117:654-667. [PMID: 35354778 PMCID: PMC8988447 DOI: 10.14309/ajg.0000000000001605] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To determine whether percutaneous tibial nerve stimulation (PTNS) is superior to sham stimulation for the treatment of fecal incontinence (FI) in women refractory to first-line treatments. METHODS Women aged 18 years or older with ≥3 months of moderate-to-severe FI that persisted after a 4-week run-in phase were randomized 2:1 (PTNS:sham stimulation) to 12 weekly 30-minute sessions in this multicenter, single-masked, controlled superiority trial. The primary outcome was change from baseline FI severity measured by St. Mark score after 12 weeks of treatment (range 0-24; minimal important difference, 3-5 points). The secondary outcomes included electronic bowel diary events and quality of life. The groups were compared using an adjusted general linear mixed model. RESULTS Of 199 women who entered the run-in period, 166 (of 170 eligible) were randomized, (111 in PTNS group and 55 in sham group); the mean (SD) age was 63.6 (11.6) years; baseline St. Mark score was 17.4 (2.7); and recording was 6.6 (5.5) FI episodes per week. There was no difference in improvement from baseline in St. Mark scores in the PTNS group when compared with the sham group (-5.3 vs -3.9 points, adjusted difference [95% confidence interval] -1.3 [-2.8 to 0.2]). The groups did not differ in reduction in weekly FI episodes (-2.1 vs -1.9 episodes, adjusted difference [95% confidence interval] -0.26 [-1.85 to 1.33]). Condition-specific quality of life measures did not indicate a benefit of PTNS over sham stimulation. Serious adverse events occurred in 4% of each group. DISCUSSION Although symptom reduction after 12 weeks of PTNS met a threshold of clinical importance, it did not differ from sham stimulation. These data do not support the use of PTNS as conducted for the treatment of FI in women.
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Affiliation(s)
- Halina M. Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh/ Magee-Womens Research Institute, Pittsburgh, PA
| | - Holly E. Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Vivian W. Sung
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women’s & Infants Hospital, Providence, RI
| | - Emily S. Lukacz
- Department of Obstetrics, Gynecology & Reproductive Sciences, UC San Diego Health, San Diego, CA
| | - Lily A. Arya
- Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, PA
| | - David D. Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anthony G. Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Benjamin Carper
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
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Giugale L, Sridhar A, Ferrante KL, Komesu YM, Meyer I, Smith AL, Myers D, Visco AG, Paraiso MFR, Mazloomdoost D, Gantz M, Zyczynski HM. Long-term Urinary Outcomes After Transvaginal Uterovaginal Prolapse Repair With and Without Concomitant Midurethral Slings. Female Pelvic Med Reconstr Surg 2022; 28:142-148. [PMID: 35272320 PMCID: PMC8928054 DOI: 10.1097/spv.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Many health care providers place concomitant midurethral slings during pelvic organ prolapse repair, yet growing evidence supports staged midurethral sling placement. OBJECTIVES The aim of this study was to compare urinary function after transvaginal uterovaginal prolapse repair with and without midurethral sling. STUDY DESIGN Secondary analysis of the Study of Uterine Prolapse Procedures Randomized Trial (hysterectomy with uterosacral ligament suspension vs mesh hysteropexy). Our primary outcome was Urinary Distress Inventory score (UDI-6) through 5 years compared between women with and without a concomitant sling within prolapse repair arms. Sling effect was adjusted for select clinical variables and interaction terms (α = .05). RESULTS The sling group included 90 women (43 hysteropexy, 47 hysterectomy), and the no-sling group included 93 women (48 hysteropexy, 45 hysterectomy). At baseline, the sling group reported more bothersome stress (66% vs 36%, P < 0.001) and urgency incontinence (69% vs 48%, P = 0.007). For hysteropexy, there were no significant long-term differences in UDI-6 scores or bothersome urine leakage between sling groups. For hysterectomy, women with sling had better UDI-6 scores across time points (adjusted mean difference, -5.1; 95% confidence interval [CI], -9.9 to -0.2); bothersome stress and urgency leakage were less common in the sling group (stress adjusted odds ratio, 0.1 [95% CI, 0.0-0.4]; urge adjusted odds ratio, 0.5 [95% CI, 0.2-1.0]). Treatment for stress incontinence over 5 years was similar in the sling (7.9%) versus no-sling (7.6%) groups. CONCLUSIONS Five-year urinary outcomes of concomitant midurethral sling may vary by type of transvaginal prolapse surgery, with possible benefit of midurethral sling at the time of vaginal hysterectomy with apical suspension but not after mesh hysteropexy.
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Affiliation(s)
- Lauren Giugale
- University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh PA
| | | | | | | | - Isuzu Meyer
- University of Alabama at Birmingham, Birmingham AL
| | - Ariana L. Smith
- Department of Surgery, Division of Urology, University of Pennsylvania Philadelphia PA
| | - Deborah Myers
- Brown University/Women & Infants Hospital, Providence RI
| | | | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| | - Marie Gantz
- RTI International, Research Triangle Park NC
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Yurteri-Kaplan L, Winkelman W, Carter-Brooks C, Donnellan N, Mazloomdoost D, Lozo S, Rogers R, Grimes C. Has the quality of sgs research improved over the years? Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Napoe G, Sridhar A, Luchristt D, Ridgeway B, Ellington D, Sung V, Ninivaggio C, Harvie H, Santiago-lastra Y, Mazloomdoost D, Gantz M, Zyczynski H. Clinical and procedure characteristics of women electing surgical management for recurrent prolapse after sacrospinous hysteropexy with mesh graft. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.12.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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DiCarlo-Meacham A, Mazloomdoost D. Vaginal mesh hysteropexy: a review. Curr Opin Obstet Gynecol 2021; 33:463-468. [PMID: 34747883 DOI: 10.1097/gco.0000000000000748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pelvic organ prolapse surgery is performed via native tissue or graft augmented repair. Graft augmentation with synthetic mesh was introduced to improve long-term surgical outcomes compared with vaginal native tissue repairs. Vaginal hysteropexy has recently become increasingly popular due to patient preference and an improved morbidity profile over hysterectomy, while maintaining comparable efficacy. As long-term outcomes remain unanswered, mesh augmentation to vaginal hysteropexy has sought to improve efficacy while minimizing complications. RECENT FINDINGS Recent studies have demonstrated superiority of vaginal mesh hysteropexy to vaginal hysterectomy with native tissue vault suspension. Short-term follow-up of vaginal mesh hysteropexy has also demonstrated lower blood loss and operative time with improved vaginal length compared with hysterectomy. Mesh exposure rates across studies were low and comparable to those of abdominally placed prolapse mesh. SUMMARY Vaginal mesh hysteropexy is a comparably well tolerated and effective surgical treatment option for women with uterovaginal prolapse. Although vaginal mesh kits are not commercially available, this procedure may be a viable treatment option in select patients.
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Affiliation(s)
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health, Bethesda, Maryland, USA
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19
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Harvie HS, Sung VW, Neuwahl SJ, Honeycutt AA, Meyer I, Chermansky CJ, Menefee S, Hendrickson WK, Dunivan GC, Mazloomdoost D, Bass SJ, Gantz MG. Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial. Am J Obstet Gynecol 2021; 225:651.e1-651.e26. [PMID: 34242627 DOI: 10.1016/j.ajog.2021.06.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking. OBJECTIVE Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed. STUDY DESIGN This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile. RESULTS The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years. CONCLUSION Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.
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Affiliation(s)
- Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Women and Infants Hospital, the Warren Alpert Medical School of Brown University, Providence, RI
| | - Simon J Neuwahl
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
| | - Amanda A Honeycutt
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
| | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Shawn Menefee
- Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, CA
| | | | - Gena C Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Sarah J Bass
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
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Jelovsek JE, Gantz MG, Lukacz ES, Zyczynski HM, Sridhar A, Kery C, Chew R, Harvie HS, Dunivan G, Schaffer J, Sung V, Varner RE, Mazloomdoost D, Barber MD. Subgroups of failure after surgery for pelvic organ prolapse and associations with quality of life outcomes: a longitudinal cluster analysis. Am J Obstet Gynecol 2021; 225:504.e1-504.e22. [PMID: 34157280 PMCID: PMC8578254 DOI: 10.1016/j.ajog.2021.06.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment outcomes after pelvic organ prolapse surgery are often presented as dichotomous "success or failure" based on anatomic and symptom criteria. However, clinical experience suggests that some women with outcome "failures" are asymptomatic and perceive their surgery to be successful and that other women have anatomic resolution but continue to report symptoms. Characterizing failure types could be a useful step to clarify definitions of success, understand mechanisms of failure, and identify individuals who may benefit from specific therapies. OBJECTIVE This study aimed to identify clusters of women with similar failure patterns over time and assess associations among clusters and the Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, Patient Global Impression of Improvement, patient satisfaction item questionnaire, and quality-adjusted life-year. STUDY DESIGN Outcomes were evaluated for up to 5 years in a cohort of participants (N=709) with stage ≥2 pelvic organ prolapse who underwent surgical pelvic organ prolapse repair and had sufficient follow-up in 1 of 4 multicenter surgical trials conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Surgical success was defined as a composite measure requiring anatomic success (Pelvic Organ Prolapse Quantification system points Ba, Bp, and C of ≤0), subjective success (absence of bothersome vaginal bulge symptoms), and absence of retreatment for pelvic organ prolapse. Participants who experienced surgical failure and attended ≥4 visits from baseline to 60 months after surgery were longitudinally clustered, accounting for similar trajectories in Ba, Bp, and C and degree of vaginal bulge bother; moreover, missing data were imputed. Participants with surgical success were grouped into a separate cluster. RESULTS Surgical failure was reported in 276 of 709 women (39%) included in the analysis. Failures clustered into the following 4 mutually exclusive subgroups: (1) asymptomatic intermittent anterior wall failures, (2) symptomatic intermittent anterior wall failures, (3) asymptomatic intermittent anterior and posterior wall failures, and (4) symptomatic all-compartment failures. Each cluster had different bulge symptoms, anatomy, and retreatment associations with quality of life outcomes. Asymptomatic intermittent anterior wall failures (n=150) were similar to surgical successes with Ba values that averaged around -1 cm but fluctuated between anatomic success (Ba≤0) and failure (Ba>0) over time. Symptomatic intermittent anterior wall failures (n=82) were anatomically similar to asymptomatic intermittent anterior failures, but women in this cluster persistently reported bothersome bulge symptoms and the lowest quality of life, Short-Form Six-Dimension health index scores, and perceived success. Women with asymptomatic intermittent anterior and posterior wall failures (n=28) had the most severe preoperative pelvic organ prolapse but the lowest symptomatic failure rate and retreatment rate. Participants with symptomatic all-compartment failures (n=16) had symptomatic and anatomic failure early after surgery and the highest retreatment of any cluster. CONCLUSION In particular, the following 4 clusters of pelvic organ prolapse surgical failure were identified in participants up to 5 years after pelvic organ prolapse surgery: asymptomatic intermittent anterior wall failures, symptomatic intermittent anterior wall failures, asymptomatic intermittent anterior and posterior wall failures, and symptomatic all-compartment failures. These groups provide granularity about the nature of surgical failures after pelvic organ prolapse surgery. Future work is planned for predicting these distinct outcomes using patient characteristics that can be used for counseling women individually.
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Affiliation(s)
- J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, NC
| | - Emily S Lukacz
- Department of Obstetrics and Gynecology, University of California San Diego, San Diego, CA
| | - Halina M Zyczynski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, NC
| | - Caroline Kery
- Division for Statistical and Data Sciences, Research Triangle Institute International, Research Triangle Park, NC
| | - Rob Chew
- Division for Statistical and Data Sciences, Research Triangle Institute International, Research Triangle Park, NC
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Gena Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - Joseph Schaffer
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vivian Sung
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, the Warren Alpert Medical School, Brown University, Providence, RI
| | - R Ed Varner
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Matthew D Barber
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
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21
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Bowen ST, Moalli PA, Abramowitch SD, Lockhart ME, Weidner AC, Ferrando CA, Nager CW, Richter HE, Rardin CR, Komesu YM, Harvie HS, Mazloomdoost D, Sridhar A, Gantz MG. Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria. Am J Obstet Gynecol 2021; 225:506.e1-506.e28. [PMID: 34087229 PMCID: PMC8578187 DOI: 10.1016/j.ajog.2021.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/13/2021] [Accepted: 05/26/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies. OBJECTIVE This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse. STUDY DESIGN This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging-based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests. RESULTS Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, -12 mm; 95% confidence interval, -19 to -6) and perineal body (difference, -7 mm; 95% confidence interval, -11 to -4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8-16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7-15). CONCLUSION The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.
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Affiliation(s)
- Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Magee-Womens Research Institute, Pittsburgh, PA.
| | | | - Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Charles W Nager
- Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego Health, San Diego, CA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Charles R Rardin
- Division of Urogyneology, Alpert Medical School of Brown University, Providence, RI
| | - Yuko M Komesu
- University of New Mexico, University of New Mexico, Albuquerque, NM
| | - Heidi S Harvie
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
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22
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Rogers RG, Meyer I, Smith AL, Ackenbom M, Barden L, Korbly N, Mazloomdoost D, Thomas S, Nager C. Improved body image after uterovaginal prolapse surgery with or without hysterectomy. Int Urogynecol J 2021; 33:115-122. [PMID: 34432089 DOI: 10.1007/s00192-021-04954-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/15/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to compare body image and sexual activity and function changes up to 3 years after sacrospinous ligament fixation with graft hysteropexy or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy). METHODS This was a planned secondary analysis of a multi-center randomized trial of women undergoing prolapse repair with mesh hysteropexy versus hysterectomy. Women were masked to intervention. The modified Body Image Scale (BIS), sexual activity status, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) scores were reported at baseline and 1.5, 6, 12, 18, 24, and 36 months after surgery. We compared mean BIS and PISQ-IR scores, the proportion of women whose BIS scores met a distribution-based estimate of the minimally important difference (MID), and sexual activity status. Comparisons were analyzed with linear and logistic repeated measures models adjusted for site, intervention, visit, and intervention by visit interaction. RESULTS Eighty-eight women underwent mesh hysteropexy; 87 underwent hysterectomy. Women were similar with regard to baseline characteristics, mean age 65.9 ± 7.3 years, and most had stage III or IV prolapse (81%). Baseline mean BIS scores were not significantly different, improved in both groups by 1.5 months, and were sustained through 36 months with no differences between groups (all p > 0.05). The estimated BIS MID was 3; and by 36 months, more women in the mesh hysteropexy group achieved the MID than in the hysterectomy group (62% vs 44%, p = 0.04). The makeup of the sexually active cohort changed throughout the study, making function comparisons difficult. CONCLUSIONS Body image improves following prolapse surgery whether or not hysterectomy is performed or transvaginal mesh is used at the time of repair; sexual activity status changes over time following prolapse surgery.
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Affiliation(s)
- Rebecca G Rogers
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA. .,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA.
| | - Isuzu Meyer
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Ariana L Smith
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Mary Ackenbom
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Lindsey Barden
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Nicole Korbly
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Donna Mazloomdoost
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Sonia Thomas
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
| | - Charles Nager
- Albany Medical College, Albany NY and University of New Mexico, Albuquerque, NM, USA.,, 391 Myrtle Avenue, Suite 200, Albany, NY, 12208, USA
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23
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Hill AJ, Balgobin S, Mishra K, Jeppson PC, Wheeler T, Mazloomdoost D, Anand M, Ninivaggio C, Hamner J, Bochenska K, Mama ST, Balk EM, Corton MM, Delancey J. Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review. Am J Obstet Gynecol 2021; 225:169.e1-169.e16. [PMID: 33705749 DOI: 10.1016/j.ajog.2021.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise. OBJECTIVE Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to "Terminologia Anatomica," the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding. STUDY DESIGN From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review. RESULTS Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. "Terminologia Anatomica" has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication. CONCLUSION This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.
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24
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Erekson E, Menefee S, Whitworth RE, Amundsen CL, Arya LA, Komesu YM, Ferrando CA, Zyczynski HM, Sung VW, Rahn DD, Tan-Kim J, Mazloomdoost D, Gantz MG, Richter HE. The Design of a Prospective Trial to Evaluate the Role of Preoperative Frailty Assessment in Older Women Undergoing Surgery for the Treatment of Pelvic Organ Prolapse: The FASt Supplemental Trial. Female Pelvic Med Reconstr Surg 2021; 27:e106-e111. [PMID: 32217922 PMCID: PMC7381379 DOI: 10.1097/spv.0000000000000833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We present the rationale for and the design of a prospective trial to evaluate the role of preoperative frailty and mobility assessments in older women undergoing surgery for the treatment of pelvic organ prolapse (POP) as a planned prospective supplemental trial to the ASPIRe (Apical Suspension Repair for Vault Prolapse In a Three-Arm Randomized Trial Design) trial. The Frailty ASPIRe Study (FASt) examines the impact of preoperative frailty and mobility on surgical outcomes in older women (≥65 years) participating in the ASPIRe trial. The primary objective of FASt is to determine the impact of preoperative age, multimorbidity, frailty, and decreased mobility on postoperative outcomes in older women (≥65 years old) undergoing surgery for POP. METHODS The selection of the preoperative assessments, primary outcome measures, and participant inclusion is described. Frailty and mobility measurements will be collected at the preoperative visit and include the 6 Robinson frailty measurements and the Timed Up and Go mobility test. The main outcome measure in the FASt supplemental study will be moderate to severe postoperative adverse events according to the Clavien-Dindo Severity Classification. CONCLUSIONS This trial will assess impact of preoperative age, multimorbidity, frailty, and decreased mobility on postoperative outcomes in older women (≥65 years old) undergoing surgical procedures for the correction of apical POP. Information from this trial may help both primary care providers and surgeons better advise/inform women on their individual risks of surgical complications and provide more comprehensive postoperative care to women at highest risk of complications.
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Affiliation(s)
- Elisabeth Erekson
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Shawn Menefee
- University of California, San Diego, and Kaiser Permanente, San Diego, CA
| | | | | | - Lily A Arya
- University of Pennsylvania, Philadelphia, PA
| | - Yuko M Komesu
- University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Cecile A Ferrando
- Department of Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Halina M Zyczynski
- The Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA
| | - Vivian W Sung
- Alpert Medical School of Brown University, Providence, RI
| | - David D Rahn
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Jasmine Tan-Kim
- University of California, San Diego, and Kaiser Permanente, San Diego, CA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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25
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Samimi G, Sathyamoorthy N, Tingen CM, Mazloomdoost D, Conroy J, Heckman-Stoddard B, Halvorson LM. Report of the National Cancer Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development-sponsored workshop: gynecology and women's health-benign conditions and cancer. Am J Obstet Gynecol 2020; 223:796-808. [PMID: 32835714 DOI: 10.1016/j.ajog.2020.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/31/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
The Division of Cancer Prevention and the Division of Cancer Biology at the National Cancer Institute and the Gynecologic Health and Disease Branch in the National Institute of Child Health and Human Development organized a workshop in April 2019 to explore current insights into the progression of gynecologic cancers from benign conditions. Working groups were formed based on 3 gynecologic disease types: (1) Endometriosis or Endometrial Cancer and Endometrial-Associated Ovarian Cancer, (2) Uterine Fibroids (Leiomyoma) or Leiomyosarcoma, and (3) Adenomyosis or Adenocarcinoma. In this report, we highlight the key questions and current challenges that emerged from the working group discussions and present potential research opportunities that may advance our understanding of the progression of gynecologic benign conditions to cancer.
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Zyczynski HM, Richter HE, Sung VW, Arya LA, Lukacz ES, Visco AG, Rahn DD, Carper B, Mazloomdoost D, Gantz MG. Performance, acceptability, and validation of a phone application bowel diary. Neurourol Urodyn 2020; 39:2480-2489. [PMID: 32960998 DOI: 10.1002/nau.24520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/07/2020] [Indexed: 12/11/2022]
Abstract
AIMS To assess performance, acceptability, external validity, and reliability of a phone application electronic bowel diary (PFDN Bowel eDiary). METHODS Women reporting refractory accidental bowel leakage (ABL) were enrolled in a randomized, crossover trial evaluating paper versus eDiary documentation of bowel movements (BM) and fecal incontinence episodes (FIE). Events were characterized by the presence or absence of urgency and Bristol stool scale consistency. The eDiary entries were date/time stamped and prompted by twice-daily phone notifications. Women were randomized to complete up to three consecutive 14-day diaries in two sequences. Diary events were compared between formats using the Pearson correlation. System usability scale (SUS) assessed eDiary usability. The eDiary test-retest reliability was assessed with intraclass correlations (ICCs). RESULTS Paired diary data were available from 60/69 (87%) women 63.8 ± 9.8 years old with mean 13.2 BM per week and 6.5 FIE per week (nearly half with urgency). Among those providing diaries, adherence did not differ by paper or eDiary (93.3% vs. 95.0%). Notifications prompted 29.6% of eDiary entries, improving adherence from 70% to 95%. Paper and eDiaries were moderate to-strongly correlated for BMs per week (r = .61), urgency BMs per week (r = .76), FIE per week (r = .66), urgency FIE per week (r = .72). Test-retest reliability was good (ICC = .81 BMs per week, .79 urgency BMs per week, .74 FIE per week, and .62 urgency FIE per week). The mean SUS score was high, 82.3 ± 17.5 (range, 0-100) with 91.4% rating it easy to use, and 75.9% preferring the eDiary over paper. CONCLUSION The PFDN Bowel eDiary correlated well with paper diary was considered easy to use, preferred to paper diaries, had high rates of confirmed real-time diary completion that obviated staff data entry.
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Affiliation(s)
- Halina M Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh/Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women's and Infants Hospital, Providence, Rhode Island, USA
| | - Lily A Arya
- Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, UC San Diego Health Care System, San Diego, California, USA
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - David D Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, Texas, USA
| | - Benjamin Carper
- Biostatistics and Epidemiology Division, RTI International, Durham, NC, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Durham, NC, USA
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Moalli PA, Bowen ST, Abramowitch SD, Lockhart ME, Ham M, Hahn M, Weidner AC, Richter HE, Rardin CR, Komesu YM, Harvie HS, Ridgeway BM, Mazloomdoost D, Shaffer A, Gantz MG. Methods for the defining mechanisms of anterior vaginal wall descent (DEMAND) study. Int Urogynecol J 2020; 32:809-818. [PMID: 32870340 PMCID: PMC7917148 DOI: 10.1007/s00192-020-04511-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The protocol and analysis methods for the Defining Mechanisms of Anterior Vaginal Wall Descent (DEMAND) study are presented. DEMAND was designed to identify mechanisms and contributors of prolapse recurrence after two transvaginal apical suspension procedures for uterovaginal prolapse. METHODS DEMAND is a supplementary cohort study of a clinical trial in which women with uterovaginal prolapse randomized to (1) vaginal hysterectomy with uterosacral ligament suspension or (2) vaginal mesh hysteropexy underwent pelvic magnetic resonance imaging (MRI) at 30-42 months post-surgery. Standardized protocols have been developed to systematize MRI examinations across multiple sites and to improve reliability of MRI measurements. Anatomical failure, based on MRI, is defined as prolapse beyond the hymen. Anatomic measures from co-registered rest, maximal strain, and post-strain rest (recovery) sequences are obtained from the "true mid-sagittal" plane defined by a 3D pelvic coordinate system. The primary outcome is the mechanism of failure (apical descent versus anterior vaginal wall elongation). Secondary outcomes include displacement of the vaginal apex and perineal body and elongation of the anterior wall, posterior wall, perimeter, and introitus of the vagina between (1) rest and strain and (2) rest and recovery. RESULTS Recruitment and MRI trials of 94 participants were completed by May 2018. CONCLUSIONS Methods papers which detail studies designed to evaluate anatomic outcomes of prolapse surgeries are few. We describe a systematic, standardized approach to define and quantitatively assess mechanisms of anatomic failure following prolapse repair. This study will provide a better understanding of how apical prolapse repairs fail anatomically.
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Affiliation(s)
- Pamela A Moalli
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee Women's Research Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Division of Urogynecology and Reconstructive Pelvic Surgery, Magee Women's Research Institute, Magee Women's Hospital of the University of Pittsburgh, 204 Craft Avenue, A320, Pittsburgh, PA, 15213, USA.
| | - Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Ham
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, Durham, NC, USA
| | - Michael Hahn
- Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego Health, San Diego, CA, USA
| | | | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Heidi S Harvie
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Beri M Ridgeway
- Division of Urogynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Amanda Shaffer
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, Durham, NC, USA
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, Durham, NC, USA
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Andy UU, Jelovsek JE, Carper B, Meyer I, Dyer KY, Rogers RG, Mazloomdoost D, Korbly NB, Sassani JC, Gantz MG. Impact of treatment for fecal incontinence on constipation symptoms. Am J Obstet Gynecol 2020; 222:590.e1-590.e8. [PMID: 31765640 DOI: 10.1016/j.ajog.2019.11.1256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/17/2019] [Accepted: 11/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. STUDY DESIGN This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. RESULTS At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). CONCLUSION Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.
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Affiliation(s)
- Uduak U Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | | | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Keisha Y Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA
| | - Rebecca G Rogers
- Department of Women's Health, Dell Medical School, University of Texas at Austin. Austin, TX; University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Nicole B Korbly
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Jessica C Sassani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA
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Meyer I, Whitworth RE, Lukacz ES, Smith AL, Sung VW, Visco AG, Ackenbom MF, Wai CY, Mazloomdoost D, Gantz MG, Richter HE. Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence. Int Urogynecol J 2020; 31:2155-2164. [PMID: 32146521 DOI: 10.1007/s00192-020-04271-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/18/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence. METHODS This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse. RESULTS Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II. CONCLUSIONS Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35249, USA.
| | - Ryan E Whitworth
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, University of California-San Diego Health Systems, San Diego, CA, USA
| | - Ariana L Smith
- Department of Surgery, Division of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Vivian W Sung
- Division of Urogynecology and Reconstructive Pelvic Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Anthony G Visco
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Mary F Ackenbom
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifford Y Wai
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Marie G Gantz
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC, USA
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35249, USA
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Rogers R, Ackenbom M, Barden L, Korbly N, Meyer I, Mazloomdoost D, Smith A, Thomas S, Nager C. 35: Body image improves among women undergoing prolapse repair regardless of whether or not hysterectomy is performed or transvaginal mesh is used. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.12.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Komesu YM, Dinwiddie DL, Richter HE, Lukacz ES, Sung VW, Siddiqui NY, Zyczynski HM, Ridgeway B, Rogers RG, Arya LA, Mazloomdoost D, Levy J, Carper B, Gantz MG. Defining the relationship between vaginal and urinary microbiomes. Am J Obstet Gynecol 2020; 222:154.e1-154.e10. [PMID: 31421123 DOI: 10.1016/j.ajog.2019.08.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/24/2019] [Accepted: 08/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although the vaginal and urinary microbiomes have been increasingly well-characterized in health and disease, few have described the relationship between these neighboring environments. Elucidating this relationship has implications for understanding how manipulation of the vaginal microbiome may affect the urinary microbiome and treatment of common urinary conditions. OBJECTIVE To describe the relationship between urinary and vaginal microbiomes using 16S rRNA gene sequencing. We hypothesized that the composition of the urinary and vaginal microbiomes would be significantly associated, with similarities in predominant taxa. STUDY DESIGN This multicenter study collected vaginal swabs and catheterized urine samples from 186 women with mixed urinary incontinence enrolled in a parent study and 84 similarly aged controls. Investigators decided a priori that if vaginal and/or urinary microbiomes differed between continent and incontinent women, the groups would be analyzed separately; if similar, samples from continent and incontinent women would be pooled and analyzed together. A central laboratory sequenced variable regions 1-3 (v1-3) and characterized bacteria to the genus level. Operational taxonomic unit abundance was described for paired vaginal and urine samples. Pearson's correlation characterized the relationship between individual operational taxonomic units of paired samples. Canonical correlation analysis evaluated the association between clinical variables (including mixed urinary incontinence and control status) and vaginal and urinary operational taxonomic units, using the Canonical correlation analysis function in the Vegan package (R version 3.5). Linear discriminant analysis effect size was used to find taxa that discriminated between vaginal and urinary samples. RESULTS Urinary and vaginal samples were collected from 212 women (mean age 53±11 years) and results from 197 paired samples were available for analysis. As operational taxonomic units in mixed urinary incontinence and control samples were related in canonical correlation analysis and since taxa did not discriminate between mixed urinary incontinence or controls in either vagina or urine, mixed urinary incontinence and control samples were pooled for further analysis. Canonical correlation analysis of vaginal and urinary samples indicated that that 60 of the 100 most abundant operational taxonomic units in the samples largely overlapped. Lactobacillus was the most abundant genus in both urine and vagina (contributing on average 53% to an individual's urine sample and 64% to an individual's vaginal sample) (Pearson correlation r=0.53). Although less abundant than Lactobacillus, other bacteria with high Pearson correlation coefficients also commonly found in vagina and urine included: Gardnerella (r=0.70), Prevotella (r=0.64), and Ureaplasma (r=0.50). Linear discriminant analysis effect size analysis identified Tepidimonas and Flavobacterium as bacteria that distinguished the urinary environment for both mixed urinary incontinence and controls as these bacteria were absent in the vagina (Tepidimonas effect size 2.38, P<.001, Flavobacterium effect size 2.15, P<.001). Although Lactobacillus was the most abundant bacteria in both urine and vagina, it was more abundant in the vagina (linear discriminant analysis effect size effect size 2.72, P<.001). CONCLUSION Significant associations between vaginal and urinary microbiomes were demonstrated, with Lactobacillus being predominant in both urine and vagina. Abundance of other bacteria also correlated highly between the vagina and urine. This inter-relatedness has implications for studying manipulation of the urogenital microbiome in treating conditions such as urgency urinary incontinence and urinary tract infections.
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Nager CW, Visco AG, Richter HE, Rardin CR, Rogers RG, Harvie HS, Zyczynski HM, Paraiso MFR, Mazloomdoost D, Grey S, Sridhar A, Wallace D. Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial. JAMA 2019; 322:1054-1065. [PMID: 31529008 PMCID: PMC6749543 DOI: 10.1001/jama.2019.12812] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Transvaginal mesh hysteropexy is an alternative option. OBJECTIVE To compare the efficacy and adverse events of vaginal hysterectomy with suture apical suspension and transvaginal mesh hysteropexy. DESIGN, SETTING, PARTICIPANTS At 9 clinical sites in the US Pelvic Floor Disorders Network, 183 postmenopausal women with symptomatic uterovaginal prolapse were enrolled in a randomized superiority clinical trial between April 2013 and February 2015. The study was designed for primary analysis when the last randomized participant reached 3 years of follow-up in February 2018. INTERVENTIONS Ninety-three women were randomized to undergo vaginal mesh hysteropexy and 90 were randomized to undergo vaginal hysterectomy with uterosacral ligament suspension. MAIN OUTCOMES AND MEASURES The primary treatment failure composite outcome (re-treatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival models. Secondary outcomes included operative outcomes and adverse events, and were evaluated with longitudinal models or contingency tables as appropriate. RESULTS A total of 183 participants (mean age, 66 years) were randomized, 175 were included in the trial, and 169 (97%) completed the 3-year follow-up. The primary outcome was not significantly different among women who underwent hysteropexy vs hysterectomy through 48 months (adjusted hazard ratio, 0.62 [95% CI, 0.38-1.02]; P = .06; 36-month adjusted failure incidence, 26% vs 38%). Mean (SD) operative time was lower in the hysteropexy group vs the hysterectomy group (111.5 [39.7] min vs 156.7 [43.9] min; difference, -45.2 [95% CI, -57.7 to -32.7]; P = <.001). Adverse events in the hysteropexy vs hysterectomy groups included mesh exposure (8% vs 0%), ureteral kinking managed intraoperatively (0% vs 7%), granulation tissue after 12 weeks (1% vs 11%), and suture exposure after 12 weeks (3% vs 21%). CONCLUSIONS AND RELEVANCE Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, vaginal mesh hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension did not result in a significantly lower rate of the composite prolapse outcome after 3 years. However, imprecision in study results precludes a definitive conclusion, and further research is needed to assess whether vaginal mesh hysteropexy is more effective than vaginal hysterectomy with uterosacral ligament suspension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01802281.
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Affiliation(s)
- Charles W. Nager
- Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego Health, San Diego, California
| | | | | | | | - Rebecca G. Rogers
- University of New Mexico, Albuquerque
- Dell Medical School, University of Texas at Austin
| | | | - Halina M. Zyczynski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Scott Grey
- Research Triangle International, Research Triangle Park, North Carolina
| | - Amaanti Sridhar
- Research Triangle International, Research Triangle Park, North Carolina
| | - Dennis Wallace
- Research Triangle International, Research Triangle Park, North Carolina
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Sung VW, Borello-France D, Newman DK, Richter HE, Lukacz ES, Moalli P, Weidner AC, Smith AL, Dunivan G, Ridgeway B, Nguyen JN, Mazloomdoost D, Carper B, Gantz MG. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial. JAMA 2019; 322:1066-1076. [PMID: 31529007 PMCID: PMC6749544 DOI: 10.1001/jama.2019.12467] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking. OBJECTIVE To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017. INTERVENTIONS Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207). MAIN OUTCOMES AND MEASURES The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms. RESULTS Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only). CONCLUSIONS AND RELEVANCE Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01959347.
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Affiliation(s)
- Vivian W. Sung
- The Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Diane Borello-France
- Department of Physical Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania
| | - Diane K. Newman
- The Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Holly E. Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Emily S. Lukacz
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, La Jolla
| | - Pamela Moalli
- Women’s Center for Bladder and Pelvic Health, Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alison C. Weidner
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Ariana L. Smith
- The Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia
| | - Gena Dunivan
- The Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque
| | - Beri Ridgeway
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - John N. Nguyen
- The Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, Kaiser Permanente, Downey, California
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Benjamin Carper
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Marie G. Gantz
- Social, Statistical, & Environmental Sciences, RTI International, Research Triangle Park, North Carolina
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Brubaker L, Jelovsek JE, Lukacz ES, Balgobin S, Ballard A, Weidner AC, Gantz MG, Whitworth R, Mazloomdoost D. Recruitment and retention: A randomized controlled trial of video-enhanced versus standard consent processes within the E-OPTIMAL study. Clin Trials 2019; 16:481-489. [PMID: 31347384 DOI: 10.1177/1740774519865541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS In this study, we compared two research consent techniques: a standardized video plus usual consent and usual consent alone. METHODS Individuals who completed 24-month outcomes (completers) in the Operations and Pelvic Muscle Training in the Management of Apical Support Loss study were invited to participate in an extended, longitudinal follow-up study (extended Operations and Pelvic Muscle Training in the Management of Apical Support Loss). Potential participants who were (1) able to provide consent and (2) not in long-term care facilities were randomized 1:1 to a standardized video detailing the importance of long-term follow-up studies of pelvic floor disorders followed by the usual institutional consent process versus the usual consent process alone. Randomization, stratified by site, used randomly permuted blocks. The primary outcome was the proportion of participants who enrolled in the extended study and completed data collection events 5 years after surgery. Secondary outcomes included the proportion enrolled in the extended study, completion of follow-up at each study year, completion of data collection points, completion of in-person visits, and completion of quality of life calls. Motivation and barriers to enrollment (study-level and personal-level) and satisfaction with the study consent process were measured by questionnaire prior to recruitment into extended Operations and Pelvic Muscle Training in the Management of Apical Support Loss. Groups were compared using an intention-to-treat principle, using unadjusted Student's t-test (continuous) and chi-square or Fisher's exact (categorical) test. A sample size of 340 (170/group) was estimated to detect a 15% difference in enrollment and study completion between groups with p < 0.05. RESULTS Of the 327 Operations and Pelvic Muscle Training in the Management of Apical Support Loss completers, 305 were randomized to the consent process study (153 video vs 152 no video). Groups were similar in demographics, surgical treatment, and outcomes. The overall rate of extended study enrollment was high, without significant differences between groups (video 92.8% vs no video 94.1%, p = 0.65). There were no significant differences in the primary outcome (video 79.1% vs no video 75.7%, p = 0.47) or in any secondary outcomes. Being "very satisfied" overall with study information (97.7% vs 88.5%, p = 0.01); "strong agreement" for feeling informed about the study (81.3% vs 70.8%, p = 0.06), understanding the study purpose (83.6% vs 71.0%, p = 0.02), nature and extent (82.8% vs 70.2%, p = 0.02), and potential societal benefits (82.8% vs 67.9%, p = 0.01); and research coordinator/study nurse relationship being "very important" (72.7% vs 63.4%, p = 0.03) were better in the video compared to the no video consent group. CONCLUSION The extended study had high enrollment; most participants completed most study tasks during the 3-year observational extension, regardless of the use of video to augment research consent. The video was associated with a higher proportion of participants reporting improved study understanding and relationship with study personnel.
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Affiliation(s)
- Linda Brubaker
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Emily S Lukacz
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Sunil Balgobin
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alicia Ballard
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alison C Weidner
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | | | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Harvie HS, Honeycutt AA, Neuwahl SJ, Barber MD, Richter HE, Visco AG, Sung VW, Shepherd JP, Rogers RG, Jakus-Waldman S, Mazloomdoost D. Responsiveness and minimally important difference of SF-6D and EQ-5D utility scores for the treatment of pelvic organ prolapse. Am J Obstet Gynecol 2019; 220:265.e1-265.e11. [PMID: 30471259 DOI: 10.1016/j.ajog.2018.11.1094] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 11/03/2018] [Accepted: 11/15/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Utility preference scores are standardized, generic, health-related quality of life (HRQOL) measures that quantify disease severity and burden and summarize morbidity on a scale from 0 (death) to 1 (optimal health). Utility scores are widely used to measure HRQOL and in cost-effectiveness research. OBJECTIVE To determine the responsiveness, validity properties, and minimal important difference (MID) of utility scores, as measured by the Short Form 6D (SF-6D) and EuroQol (EQ-5D), in women undergoing surgery for pelvic organ prolapse (POP). MATERIALS AND METHODS This study combined data from 4 large, U.S., multicenter surgical trials enrolling 1321 women with pelvic organ prolapse. We collected condition-specific quality of life data using the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). A subset of women completed the SF6D; women in 2 trials also completed the EQ5D. Mean utility scores were compared from baseline to 12 months after surgery. Responsiveness was assessed using effect size (ES) and standardized response mean (SRM). Validity properties were assessed by (1) comparing changes in utility scores at 12 months between surgical successes and failures as defined in each study, and (2) correlating changes in utility scores with changes in the PFDI and PFIQ. MID was estimated using both anchor-based (SF-36 general health global rating scale "somewhat better" vs "no change") and distribution-based methods. RESULTS The mean SF-6D score improved 0.050, from 0.705 ± 0.126 at baseline to 0.761 ± 0.131 at 12 months (P < .01). The mean EQ-5D score improved 0.060, from 0.810 ± 0.15 at baseline to 0.868 ± 0.15 at 12 months (P < .01). The ES (0.13-0.61) and SRM (0.13-0.57) were in the small-to-moderate range, demonstrating the responsiveness of the SF-6D and EQ-5D similar to other conditions. SF-6D and EQ-5D scores improved more for prolapse reconstructive surgical successes than for failures. The SF-6D and EQ-5D scores correlated with each other (r = 0.41; n = 645) and with condition-specific instruments. Correlations with the PFDI and PFIQ and their prolapse subscales were in the low to moderate range (r = 0.09-0.38), similar to other studies. Using the anchor-based method, the MID was 0.026 for SF-6D and 0.025 for EQ-5D, within the range of MIDs reported in other populations and for other conditions. These findings were supported by distribution-based estimates. CONCLUSION The SF-6D and EQ-5D have good validity properties and are responsive, preference-based, utility and general HRQOL measures for women undergoing surgical treatment for prolapse. The MIDs for SF-6D and EQ-5D are similar and within the range found for other medical conditions.
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Affiliation(s)
- Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
| | | | - Simon J Neuwahl
- Clinical Research Network Coordination, RTI, Research Triangle Park, NC
| | - Matthew D Barber
- Department of Obstetrics and Gynecology, Cleveland, Cleveland, OH
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Brown, Providence, RI
| | - Jonathan P Shepherd
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca G Rogers
- Department of Obstetrics and Gynecology, University of New Mexico and Department of Women's Health, Dell Medical School, University of Texas, Austin, TX
| | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Meyer I, Richter H, Whitworth R, Lukacz E, Smith A, Sung V, Ackenbom M, Visco A, Wai C, Mazloomdoost D, Gantz M. 04: Transvaginal apical approaches for advanced pelvic organ prolapse. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sutkin G, Zyczynski H, Sridhar A, Jelovsek J, Rardin C, Mazloomdoost D, Rahn D, Nguyen J, Andy U, Meyer I, Gantz M. 03: Posterior repair does not affect the success of transvaginal repair of apical prolapse. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2019.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dunivan GC, Sussman AL, Jelovsek JE, Sung V, Andy UU, Ballard A, Jakus-Waldman S, Amundsen CL, Chermansky CJ, Bann CM, Mazloomdoost D, Rogers RG. Gaining the patient perspective on pelvic floor disorders' surgical adverse events. Am J Obstet Gynecol 2019; 220:185.e1-185.e10. [PMID: 30612960 DOI: 10.1016/j.ajog.2018.10.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Institute for Healthcare Improvement defines an adverse event as an unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization or that results in death. The majority of research has focused on adverse events from the provider's perspective. OBJECTIVE The objective of this qualitative study was to describe patient perceptions on adverse events following surgery for pelvic floor disorders. STUDY DESIGN Women representing the following 3 separate surgical populations participated in focus groups: (1) preoperative (women <12 weeks prior to surgery); (2) short-term postoperative (women up to 12 weeks after surgery); and (3) long-term postoperative (women 1-5 years after surgery). Deidentified transcripts of audio recordings were coded and analyzed with NVivo 10 software to identify themes, concepts, and adverse events. Women were asked to rank patient-identified and surgeon-identified adverse events in order of perceived severity. RESULTS Eighty-one women participated in 12 focus groups. Group demographics were similar between groups, and all groups shared similar perspectives regarding surgical expectations. Women commonly reported an unclear understanding of their surgery and categorized adverse events such as incontinence, constipation, nocturia, and lack of improvement in sexual function as very severe, ranking these comparably with intensive care unit admissions or other major surgical complications. Women also expressed a sense of personal failure and shame if symptoms recurred. CONCLUSION Women consider functional outcomes such as incontinence, sexual dysfunction, and recurrence of symptoms as severe adverse events and rate them as similar in severity to intensive care unit admissions and death.
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Komesu YM, Richter HE, Carper B, Dinwiddie DL, Lukacz ES, Siddiqui NY, Sung VW, Zyczynski HM, Ridgeway B, Rogers RG, Arya LA, Mazloomdoost D, Gantz MG. The urinary microbiome in women with mixed urinary incontinence compared to similarly aged controls. Int Urogynecol J 2018; 29:1785-1795. [PMID: 29909556 PMCID: PMC6295358 DOI: 10.1007/s00192-018-3683-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/28/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION & HYPOTHESIS Previous studies have suggested that women with urinary incontinence have an altered urinary microbiome. We hypothesized that the microbiome in women with mixed urinary incontinence (MUI) differed from controls and tested this hypothesis using bacterial gene sequencing techniques. METHODS This multicenter study compared the urinary microbiome in women with MUI and similarly aged controls. Catheterized urine samples were obtained; v4-6 regions of the 16S rRNA gene were sequenced to identify bacteria. Bacterial predominance (> 50% of an individual's genera) was compared between MUI and controls. Bacterial sequences were categorized into "community types" using Dirichlet multinomial mixture (DMM) methods. Generalized linear mixed models predicted MUI/control status based on clinical characteristics and community type. Post-hoc analyses were performed in women < 51 and ≥ 51 years. Sample size estimates required 200 samples to detect a 20% difference in Lactobacillus predominance with P < 0.05. RESULTS Of 212 samples, 97.6% were analyzed (123 MUI/84 controls, mean age 53 ± 11 years). Overall Lactobacillus predominance did not differ between MUI and controls (45/123 = 36.6% vs. 36/84 = 42.9%, P = 0.36). DMM analyses revealed six community types; communities differed by age (P = 0.001). A High-Lactobacillus (89.2% Lactobacillus) community had a greater proportion of controls (19/84 = 22.6%, MUI 11/123 = 8.9%). Overall, bacterial community types did not differ in MUI and controls. However, post-hoc analysis of women < 51 years found that bacterial community types distinguished MUI from controls (P = 0.041); Moderate-Lactobacillus (aOR 7.78, CI 1.85-32.62) and Mixed (aOR 7.10, CI 1.32-38.10) community types were associated with MUI. Community types did not differentiate MUI and controls in women ≥ 51 years (P = 0.94). CONCLUSIONS Women with MUI and controls did not differ in overall Lactobacillus predominance. In younger women, urinary bacterial community types differentiated MUI from controls.
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Affiliation(s)
- Yuko M Komesu
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA.
| | - Holly E Richter
- Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin Carper
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, NC, USA
| | - Darrell L Dinwiddie
- Pediatrics and Clinical Translational Science Center, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, University of California San Diego, San Diego, CA, USA
| | | | - Vivian W Sung
- Obstetrics & Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Halina M Zyczynski
- Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Beri Ridgeway
- Obstetrics & Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca G Rogers
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA
- Obstetrics & Gynecology, Dell Medical School University of Texas Austin, Austin, TX, USA
| | - Lily A Arya
- Obstetrics & Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Donna Mazloomdoost
- Gynecologic Health and Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) National Institutes of Health (NIH), Bethesda, MD, USA
| | - Marie G Gantz
- Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, NC, USA
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Norton JM, Bradley CS, Brady SS, Brubaker L, Gossett D, Henderson JP, Mazloomdoost D, Musil CM, Rovner E, Bavendam T. Individualizing Urinary Incontinence Treatment: Research Needs Identified at NIDDK Workshop. J Urol 2018; 199:1405-1407. [DOI: 10.1016/j.juro.2017.11.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Jenna M. Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Catherine S. Bradley
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Sonya S. Brady
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Linda Brubaker
- Departments of Obstetrics & Gynecology and Urology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Daniel Gossett
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jeffrey P. Henderson
- Center for Women's Infectious Diseases Research, Division of Infectious Diseases, and Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Donna Mazloomdoost
- Gynecologic Health and Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Carol M. Musil
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Eric Rovner
- Department of Urology, Medical University of South Carolina, Charleston, South Carolina
| | - Tamara Bavendam
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Mazloomdoost D, Pauls RN, Crisp CC. Reply. Am J Obstet Gynecol 2018. [PMID: 29530671 DOI: 10.1016/j.ajog.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mazloomdoost D, Pauls RN, Hennen EN, Yeung JY, Smith BC, Kleeman SD, Crisp CC. Liposomal bupivacaine decreases pain following retropubic sling placement: a randomized placebo-controlled trial. Am J Obstet Gynecol 2017; 217:598.e1-598.e11. [PMID: 28694151 DOI: 10.1016/j.ajog.2017.07.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/09/2017] [Accepted: 07/01/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively. OBJECTIVE The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement. STUDY DESIGN This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed "current level of pain"; the evening items queried "current level of pain," "most intense pain today," "average pain today with activity," and "average pain today with rest." Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed. RESULTS One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m2. Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m2; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted. CONCLUSION Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful.
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Mazloomdoost D, Pauls R, Hennen E, Yeung J, Smith B, Kleeman S, Crisp C. 14: Impact of liposomal bupivacaine on pain following retropubic midurethral sling placement: A randomized placebo-controlled trial. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.12.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mazloomdoost D, Kanter G, Chan RC, Deveaneau N, Wyman AM, Von Bargen EC, Chaudhry Z, Elshatanoufy S, Miranne JM, Chu CM, Pauls RN, Arya LA, Antosh DD. Social networking and Internet use among pelvic floor patients: a multicenter survey. Am J Obstet Gynecol 2016; 215:654.e1-654.e10. [PMID: 27319368 DOI: 10.1016/j.ajog.2016.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 05/28/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Internet resources are becoming increasingly important for patients seeking medical knowledge. It is imperative to understand patient use and preferences for using the Internet and social networking websites to optimize patient education. OBJECTIVES The purpose of this study was to evaluate social networking and Internet use among women with pelvic floor complaints to seek information for their conditions as well as describe the likelihood, preferences, and predictors of website usage. STUDY DESIGN This was a cross-sectional, multicenter study of women presenting to clinical practices of 10 female pelvic medicine and reconstructive surgery fellowship programs across the United States, affiliated with the Fellows' Pelvic Research Network. New female patients presenting with pelvic floor complaints, including urinary incontinence, pelvic organ prolapse, and fecal incontinence were eligible. Participants completed a 24 item questionnaire designed by the authors to assess demographic information, general Internet use, preferences regarding social networking websites, referral patterns, and resources utilized to learn about their pelvic floor complaints. Internet use was quantified as high (≥4 times/wk), moderate (2-3 times/wk), or minimal (≤1 time/wk). Means were used for normally distributed data and medians for data not meeting this assumption. Fisher's exact and χ2 tests were used to evaluate the associations between variables and Internet use. RESULTS A total of 282 surveys were analyzed. The majority of participants, 83.3%, were white. The mean age was 55.8 years old. Referrals to urogynecology practices were most frequently from obstetrician/gynecologists (39.9%) and primary care providers (27.8%). Subjects were well distributed geographically, with the largest representation from the South (38.0%). Almost one third (29.9%) were most bothered by prolapse complaints, 22.0% by urgency urinary incontinence, 20.9% by stress urinary incontinence, 14.9% by urgency/frequency symptoms, and 4.1% by fecal incontinence. The majority, 75.0%, described high Internet use, whereas 8.5% moderately and 4.8% minimally used the Internet. Women most often used the Internet for personal motivations including medical research (76.4%), and 42.6% reported Google to be their primary search engine. Despite this, only 4.9% primarily used the Internet to learn about their pelvic floor condition, more commonly consulting an obstetrician-gynecologist for this information (39.4%). The majority (74.1%) held a social networking account, and 45.9% visited these daily. Nearly half, 41.7%, expressed the desire to use social networking websites to learn about their condition. Women <65 years old were significantly more likely to have high Internet use (83.4% vs 68.8%, P = .018) and to desire using social networking websites to learn about their pelvic floor complaint (P = .008). The presenting complaint was not associated with Internet use (P = .905) or the desire to use social networking websites to learn about pelvic floor disorders (P = .201). CONCLUSION Women presenting to urogynecology practices have high Internet use and a desire to learn about their conditions via social networking websites. Despite this, obstetrician-gynecologists remain a common resource for information. Nonetheless, urogynecology practices and national organizations would likely benefit from increasing their Internet resources for patient education in pelvic floor disorders, though patients should be made aware of available resources.
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Mazloomdoost D, Westermann L, Mutema G, Crisp C, Kleeman S, Pauls R. 39: Detailed histologic anatomy of the urethra in female cadaveric dissection. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2016.01.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mazloomdoost D, Crisp CC, Westermann LB, Benbouajili JM, Kleeman SD, Pauls RN. Survey of male perceptions regarding the vulva. Am J Obstet Gynecol 2015; 213:731.e1-9. [PMID: 26032042 DOI: 10.1016/j.ajog.2015.05.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 04/27/2015] [Accepted: 05/28/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The purpose of this study was to characterize male preferences of vulvar appearance, their awareness of labiaplasty, and their knowledge of genital anatomy. STUDY DESIGN Men 18-80 years old were recruited via emails sent by an Internet provider to participate in a 27-question web-based survey. The questionnaire included images and queried demographics, men's familiarity with vulvar anatomy, preferences regarding labial appearance, and awareness of labiaplasty. Two deployments to >150,000 email addresses were sent. Demographic data were described using frequencies for categoric variables and mean measures of central tendency for continuous variables. Logistic regression models were used to analyze associations between demographics and responses. RESULTS Two thousand four hundred three men responded to the survey. After excluding incomplete and ineligible surveys, 1847 surveys were analyzed. The median age of respondents was 55 years. The majority was white (87%), married (68%), employed (69%), and had completed high school or beyond (97%). One-third of the respondents lived in the South, with the other regions nearly equally represented. A significant majority, 95%, reported having been sexually active with women, and 86% felt comfortable labeling the vulvar anatomy. With regard to preferences, more respondents considered smaller labia attractive compared to large labia; yet 36% of the men remained neutral. Men also showed a preference for partially or completely groomed genitals compared to natural hair pattern. Whereas 51% of participants believed the appearance of a woman's labia influenced their desire to engage in sexual activity, 60% denied it affected sexual pleasure. Only 42% of men were familiar with labiaplasty, and 75% of all respondents would not encourage a female partner to change her genital appearance. Multivariable analysis revealed younger age to be associated with preferences for small labia and complete genital hair removal, as well as familiarity with labiaplasty. CONCLUSION In this national survey, men demonstrated familiarity with the female anatomy, but many did not feel it impacted sexual desire or pleasure. Moreover, the majority lacked strong preferences for a specific vulvar appearance and would not encourage a female partner to alter her genital appearance surgically.
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Affiliation(s)
- Donna Mazloomdoost
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, TriHealth/Good Samaritan Hospital, Cincinnati, OH.
| | - Catrina C Crisp
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, TriHealth/Good Samaritan Hospital, Cincinnati, OH
| | - Lauren B Westermann
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, TriHealth/Good Samaritan Hospital, Cincinnati, OH
| | | | - Steven D Kleeman
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, TriHealth/Good Samaritan Hospital, Cincinnati, OH
| | - Rachel N Pauls
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, TriHealth/Good Samaritan Hospital, Cincinnati, OH
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Westermann L, Crisp C, Oakley S, Mazloomdoost D, Kleeman S, Benbouajili J, Pauls R. Attitudes Regarding Labial Hypertrophy: A Survey of SGS and NASPAG Members. J Minim Invasive Gynecol 2015. [DOI: 10.1016/j.jmig.2014.12.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pauls R, Crisp C, Oakley S, Westermann L, Mazloomdoost D, Kleeman S, Ghodsi V, Estanol M. Effects of Preoperative Dexamethasone on Postoperative Quality of Recovery following Vaginal Reconstructive Surgery: A Randomized Controlled Trial. J Minim Invasive Gynecol 2015. [DOI: 10.1016/j.jmig.2014.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mazloomdoost D, Crisp C, Westermann L, Kleeman S, Benbouajili J, Pauls R. What Do Men Really Want? A Survey of Male Perceptions Regarding the Vulva. J Minim Invasive Gynecol 2015. [DOI: 10.1016/j.jmig.2014.12.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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