Patient perspectives in adverse event reporting after vaginal apical prolapse surgery

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.

Minimally invasive approach to pelvic organ prolapse: a review

Uterovaginal prolapse, vaginal vault prolapse, and rectal prolapse are pelvic floor support problems that have been traditionally addressed through abdominal, vaginal or perineal approaches. Over the past decade, minimally invasive approaches to these procedures have been reported and refined. We discuss both laparoscopic and robotic techniques for repair of uterovaginal prolapse, vaginal vault prolapse, and rectal prolapse. In addition, we summarize currently available success and complication data associated with each technique.

Vaginal rugae: measurement and significance

OBJECTIVE

To devise a validated measure of vaginal rugae and assess the relationships between vaginal rugae and important clinical parameters.

METHODS

Two techniques of assessing vaginal rugae were developed and their inter-/intra-observer variability assessed. Examination variability was assessed using intraclass correlation and by way of an analysis of the absolute difference between the two rugal quantitations. After validating the assessment technique, the rugal quantitations of 88 women were compared to clinical parameters such as age, estrogen status, stage of prolapse, parity, history of anterior vaginal wall surgery, and body mass index. Linear regression analysis was used to assess the relationships between vaginal rugae score and these clinical parameters.

RESULTS

The mean age and body mass index of the subjects were 56 years (standard deviation (SD) +/- 13.8 years) and 30.4 kg/m2 (SD +/- 7.5 kg/m2), respectively. The median parity was 2 (range 0-11). A history of anterior vaginal wall surgery was present in 29% of subjects and 46% were estrogen-deficient. Scores for the two techniques to quantitate vaginal rugae were normally distributed. Both techniques demonstrated satisfactory interexaminer reliability. Increasing age and deficient estrogen status were found to be independent predictors of less vaginal rugae.

CONCLUSIONS

Vaginal rugae can be reliably quantitated. Loss of vaginal rugae is associated with estrogen deficiency and advancing age.

Reliability and Agreement of Urodynamics Interpretations in a Female Pelvic Medicine Center

OBJECTIVE

To estimate the reliability and interobserver consistency of urodynamic interpretations of female bladder and urethral function.

METHODS

Three urogynecologists and three female urologists at a tertiary care medical center reviewed masked, abstracted clinical and urodynamic information from 100 charts, selected for adequate completeness from a consecutive series of 135 women referred for urodynamic testing. For each of the 100 cases, the reviewers assigned International Continence Society filling and voiding phase diagnoses, and overall clinical diagnoses. Raw agreement proportions and weighted kappa chance-corrected agreement statistics (kappa) were used jointly to describe both reliability and interobserver agreement. Reliability was estimated from duplicate reviews, masked and separated by at least 4 months, of each case by each physician. Interobserver agreement was estimated from comparisons of all pairs of responses from different physicians.

RESULTS

For clinical diagnosis of stress incontinence (present, absent, indeterminate), the within- and across-physician weighted kappa's were, respectively, 0.78 and 0.68. Corresponding results were 0.40 and 0.13 for detrusor overactivity without incontinence, 0.58 and 0.38 for detrusor overactivity with incontinence, and 0.51 and 0.26 for voiding dysfunction. Standard errors of each kappa were between 0.023 and 0.043.

CONCLUSION

In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of kappa-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses.

Clinical evaluation of anterior vaginal wall support defects: interexaminer and intraexaminer reliability

OBJECTIVE

The purpose of this study was to determine the interobserver and intraobserver reliability of the clinical examination of anterior vaginal wall support defects.

STUDY DESIGN

Sixty-three patients with at least stage II anterior vaginal wall prolapse were prospectively evaluated with a standardized examination to detect anterior vaginal wall support defects. Interobserver reliability was assessed with a duplicate examination performed by a blinded second examiner. Intraobserver reliability was assessed with a second examination performed at least 3 weeks later by 1 of the original 2 examiners. Examination reliability for the 4 types of defects (central, right lateral, left lateral, and superior) was evaluated with the kappa statistic.

RESULTS

The inter- and intraexaminer reliability of the clinical examination for central, superior, and right and left paravaginal defects was poor; all kappas were less than 0.50. Overall interexaminer agreement was 42% with a kappa of 0.16 (95% CI, 0-0.32). Overall intraexaminer agreement was 46% with a kappa of 0.16 (95% CI, 0-0.45). Reliability was noted to improve with increasing stage of prolapse.

CONCLUSION

The clinical examination of anterior vaginal wall support defects displays poor interexaminer and intraexaminer agreement.

Outcome of sphincteroplasty combined with surgery for urinary incontinence and pelvic organ prolapse

PURPOSE

This is the first reported prospective study comparing outcome and cost in patients undergoing sphincteroplasty for anal incontinence vs. sphincteroplasty performed in combination with one or more procedures for urinary incontinence and/or pelvic organ prolapse.

METHODS

We analyzed 44 patients with fecal incontinence who underwent anal sphincter repair alone (20 patients) or in combination with procedures for urinary incontinence or pelvic organ prolapse (24 patients). Information regarding risk factors for fecal incontinence, the degree of incontinence, and the extent that incontinence limited social, physical, and sexual activity was prospectively obtained from questionnaires. Clinic chart reviews and follow-up telephone interviews provided additional data. A cohort of case-matched patients who underwent only urogynecologic procedures was compared retrospectively for operative time, hospital cost, length of stay, and postoperative complications.

RESULTS

There were no major complications in any group. The functional outcomes, physical, social, and sexual activity were similar in all three groups. Twenty-two of 24 patients who underwent the combined procedures were glad that they had both procedures concomitantly.

CONCLUSION

Combination pelvic floor surgery provides good outcomes and is cost effective. This approach should be offered to women with concurrent problems of fecal and urinary incontinence and/or pelvic organ prolapse.

Laparoscopic surgery for enterocele, vaginal apex prolapse and rectocele

Laparoscopy has been applied to all aspects of gynecologic surgery, but few investigators have reported the repair of vaginal apex prolapse, enterocele and rectocele via the laparoscopic route. This article reviews the indications, anatomy, operative technique, clinical results and complications of laparoscopic culdeplasty, enterocele repair, posterior repair, sacral colpopexy and vaginal vault-uterosacral ligament suspension.

Laparoscopic surgery for genuine stress incontinence

Laparoscopic Burch colposuspension has rapidly become one of the primary surgical treatment options for genuine stress incontinence. The procedure has been modified by some investigators because of technical difficulty with laparoscopic suturing, but should be identical to the conventional open Burch procedure. This article reviews the indications, operative technique, clinical results, complications and learning curve for laparoscopic retropubic surgical procedures.

Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy

OBJECTIVE

We compared operative time, length of hospital stay, postoperative recovery, return to work, and costs for women undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy.

STUDY DESIGN

A prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy (n = 24) versus abdominal hysterectomy (n = 24) was carried out in a tertiary care setting. The main outcome variables were operative time, length of hospital stay, and return to work. Secondary outcomes were postoperative pain and return to normal activity as determined by weekly visual analog scales and daily diary. Hospital costs were calculated.

RESULTS

The laparoscopically assisted vaginal hysterectomy group had longer operative times (median and quartiles, laparoscopically assisted vaginal hysterectomy 180 [139, 225] minutes vs abdominal hysterectomy 130 [97, 155] minutes), lower requirements for postoperative intravenous analgesia (patient-controlled analgesia pump, median and quartiles: laparoscopically assisted vaginal hysterectomy 22.1 [15.9, 23.5] hours, abdominal hysterectomy 36.7 [26.2, 45.0] hours), shorter length of hospital stay (median and quartiles, laparoscopically assisted vaginal hysterectomy 1.5 [1.0, 2.3] days, abdominal hysterectomy 2.5 [1.5, 2.5] days), and quicker return to work (Kaplan-Meier analysis, P =.03). Both procedures had similar hospital costs (P =.21).

CONCLUSION

Laparoscopically assisted vaginal hysterectomy appears to allow patients a more rapid postoperative recovery and an earlier return to work with hospital costs similar to those of abdominal hysterectomy.

Staple pull-out strength in an animal model of Cooper's ligament

STUDY OBJECTIVE

To understand the effect of staple number, orientation, and configuration on pull-out strength in an animal model of Cooper's ligament, and compare it with force to knot failure or suture breakage.

DESIGN

Comparative study (Canadian Task Force classification I).

SETTING

Ethicon Endo-Surgery Institute, Cincinnati, Ohio.

SUBJECTS

Fibrous connective tissues from bovine ischia were the tissue model.

INTERVENTION

Specimens were fixed in a cement-plaster compound and mounted in a tensiometer. Endoscopic staples were used to hold a loop of 0-braided polyester suture to the tissue.

MEASUREMENTS AND MAIN RESULTS

The suture loop was pulled perpendicularly away from tissue at a constant rate of 2.1 mm/second and peak force to staple pull-out was recorded. Two staple orientations and four staple configurations were studied. Tests were applied in a factorial arrangement. Ten-millimeter stitches of 0-braided polyester suture in the model were also tested. Maximum force to staple pull-out depended on staple number, orientation, and configuration. Peak force required to remove two staples was significantly higher than that to remove one. Spacing between two staples was less important. Pull-out strength was significantly higher when staples were placed parallel to tissue fibers. Stitches placed perpendicular to fibers failed at the knot or by suture breakage with a mean force approximately two times the peak force to remove two staples.

CONCLUSION

Two staples placed 2 to 5 mm apart parallel to tissue fibers resulted in the greatest pull-out strength of studied configurations.

Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction

OBJECTIVE

Our purpose was to evaluate the efficacy and consequences of sacrospinous ligament suspension and pelvic reconstruction.

STUDY DESIGN

Patients who underwent sacrospinous ligament suspension between 1978 and 1991 were evaluated from follow-up visits, telephone interviews, questionnaires, and chart reviews. Before and after operation, vaginal support was graded in three segments. Postoperative visceral and sexual function was evaluated.

RESULTS

Mean length of follow-up for 243 patients was 73.6 months. Of these, 102 (42.0%) had a support defect in at least one segment; anterior, posterior, and apical defects were found in 91 (37.4%), 33 (13.6%), and 20 (8.2%) patients, respectively. A clinically significant defect was defined as a symptomatic first-degree or any second-or third-degree prolapse. Defect-free survival rates at 1, 5, and 10 years were 88.3%, 79.7%, and 51.9%, respectively. Eleven patients (4.5%) underwent subsequent pelvic reconstruction.

CONCLUSION

Sacrospinous ligament suspension and pelvic reconstruction are effective for vaginal apex support, but vaginal prolapse recurs with time, most commonly in the anterior segment.

Evaluation of the endocervical Cytobrush and Cervex-Brush in pregnant women

OBJECTIVE

To compare, in pregnant women, the endocervical cell yield of the Cytobrush Cell Collector and the Cervex-Brush Cell Sampler with the standard cotton swab, and to determine the incidence of serious adverse events associated with the collection techniques.

METHODS

In a randomized, controlled clinical trial, 352 pregnant women undergoing initial obstetric evaluation were randomly assigned to either the cotton swab and modified Ayers spatula, Cytobrush and modified Ayers spatula, or Cervex-Brush. The cytopathology laboratory, blinded to the Papanicolaou smear method, screened the smears using the Bethesda System guidelines. Statistical analyses were performed using the Pearson chi 2 and analysis of variance tests.

RESULTS

There was an increased detection of endocervical cells in pregnant patients with both the Cytobrush and modified Ayers spatula (90.7%) and the Cervex-Brush (83.3%) methods, compared with the cotton swab and modified Ayers spatula (70.8%) (P = .0001 and P = .0233, respectively). There was no statistically significant difference between the Cytobrush-spatula and Cervex-Brush groups (P = .0956). Although there were more bloody Papanicolaou smears in the study groups, this was neither clinically nor statistically significant because all the samples were interpretable and repeat samples due to bloody specimens were not required. There were no serious adverse events associated with the study group methods.

CONCLUSION

Performance of Papanicolaou smears using the Cytobrush and modified Ayers spatula and with the Cervex-Brush improved Papanicolaou smear adequacy as compared with the cotton swab and modified Ayers spatula. Despite an increased incidence of spotting following collection, these techniques were not associated with an increase in serious adverse events. Based on the cost per item and a clinically significant increase in endocervical cell yield, we recommend the Cytobrush and modified Ayers spatula for cytologic screening in pregnant women.