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Menefee SA, Richter HE, Myers D, Moalli P, Weidner AC, Harvie HS, Rahn DD, Meriwether KV, Paraiso MFR, Whitworth R, Mazloomdoost D, Thomas S. Apical Suspension Repair for Vaginal Vault Prolapse: A Randomized Clinical Trial. JAMA Surg 2024:2819032. [PMID: 38776067 PMCID: PMC11112501 DOI: 10.1001/jamasurg.2024.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/01/2024] [Indexed: 05/25/2024]
Abstract
Importance The optimal surgical repair of vaginal vault prolapse after hysterectomy remains undetermined. Objective To compare the efficacy and safety of 3 surgical approaches for vaginal vault prolapse after hysterectomy. Design, Setting, and Participants This was a multisite, 3-arm, superiority and noninferiority randomized clinical trial. Outcomes were assessed biannually up to 60 months, until the last participant reached 36 months of follow-up. Settings included 9 clinical sites in the US National Institute of Child Health and Human Development (NICHD) Pelvic Floor Disorders Network. Between February 2016 and April 2019, women with symptomatic vaginal vault prolapse after hysterectomy who desired surgical correction were randomized. Data were analyzed from November 2022 to January 2023. Interventions Mesh-augmented (either abdominally [sacrocolpopexy] or through a vaginal incision [transvaginal mesh]) vs transvaginal native tissue repair. Main Outcomes and Measures The primary outcome was time until composite treatment failure (including retreatment for prolapse, prolapse beyond the hymen, or prolapse symptoms) evaluated with survival models. Secondary outcomes included patient-reported symptom-specific results, objective measures, and adverse events. Results Of 376 randomized participants (mean [SD] age, 66.1 [8.7] years), 360 (96%) had surgery, and 296 (82%) completed follow-up. Adjusted 36-month failure incidence was 28% (95% CI, 20%-37%) for sacrocolpopexy, 29% (95% CI, 21%-38%) for transvaginal mesh, and 43% (95% CI, 35%-53%) for native tissue repair. Sacrocolpopexy was found to be superior to native tissue repair (adjusted hazard ratio [aHR], 0.57; 99% CI, 0.33-0.98; P = .01). Transvaginal mesh was not statistically superior to native tissue after adjustment for multiple comparisons (aHR, 0.60; 99% CI, 0.34-1.03; P = .02) but was noninferior to sacrocolpopexy (aHR, 1.05; 97% CI, 0-1.65; P = .01). All 3 surgeries resulted in sustained benefits in subjective outcomes. Mesh exposure rates were low (4 of 120 [3%] for sacrocolpopexy and 6 of 115 [5%] for transvaginal mesh) as were the rates of dyspareunia. Conclusions and Relevance Among participants undergoing apical repair for vaginal vault prolapse, sacrocolpopexy and transvaginal mesh resulted in similar composite failure rates at study completion; both had lower failure rates than native tissue repair, although only sacrocolpopexy met a statistically significant difference. Low rates of mesh complications and adverse events corroborated the overall safety of each approach. Trial Registration ClinicalTrials.gov Identifier: NCT02676973.
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Affiliation(s)
- Shawn A. Menefee
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, California
| | - Holly E. Richter
- Division of Urogynecology and Pelvic Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
| | - Deborah Myers
- The Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Pamela Moalli
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Research Institute, 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
| | - Heidi S. Harvie
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David D. Rahn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Kate V. Meriwether
- The Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque
| | - Marie Fidela R. Paraiso
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ryan Whitworth
- RTI International, Research Triangle Park, North Carolina
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Sonia Thomas
- RTI International, Research Triangle Park, North Carolina
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Ross JH, Yao M, Wallace SL, Paraiso MFR, Vogler SA, Propst K, Ferrando CA. Patient Outcomes After Robotic Ventral Rectopexy With Sacrocolpopexy. Urogynecology (Phila) 2024; 30:425-432. [PMID: 37737838 DOI: 10.1097/spv.0000000000001412] [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] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
IMPORTANCE As few studies exist examining postoperative functional outcomes in patients undergoing robotic sacrocolpopexy and ventral rectopexy, results from this study can help guide surgeons in counseling patients on their outcomes. OBJECTIVE The aim of the study was to evaluate functional outcomes and overall postoperative satisfaction as measured by the Pelvic Floor Disability Index 20 (PFDI-20), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and Patient Global Impression of Improvement Scale (PGI-I) in patients who underwent combined robotic ventral rectopexy and sacrocolpopexy for concomitant pelvic organ prolapse (POP) and rectal prolapse or intussusception (RP/I). METHODS This was a retrospective cohort and survey study of patients with combined POP and RP/I who underwent the previously mentioned surgical repair between January 2018 and July 2021. Each patient was contacted to participate in a survey evaluating postoperative symptoms related bother, sexual function, and overall satisfaction using the PFDI-20, PISQ-12, and PGI-I. RESULTS A total of 107 patients met study inclusion criteria with 67 patients completing the surveys. The mean age and body mass index were 63.7 ± 11.5 years and 25.0 ± 5.4, respectively. Of the patients, 19% had a prior RP repair and 23% had a prior POP repair. Rectal prolapse or intussusception recurrence was reported in 10.4% of patients and objective POP recurrence was found in 7.5% of patients. Sixty-seven patients (62%) completed the surveys. The median time to survey follow-up was 18 (8.8-51.8) months. At the time of survey, the mean PFDI-20 score was 95.7 ± 53.7. The mean PISQ-12 score for all patients was 32.8 ± 7.2 and the median PGI-I score was 2.0 (interquartile range, 1.0-3.0). CONCLUSIONS In this cohort of patients who underwent a combined robotic ventral rectopexy and sacrocolpopexy, patient-reported postoperative symptom bother was low, sexual function was high, and their overall condition was much improved.
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Affiliation(s)
- James H Ross
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic
| | - Shannon L Wallace
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Marie Fidela R Paraiso
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Sarah A Vogler
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Port St Lucie
| | - Katie Propst
- Urogynecology and Reconstructive Pelvic Surgery, Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Cecile A Ferrando
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
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Yuan AS, Propst KA, Ross JH, Wallace SL, Paraiso MFR, Park AJ, Chapman GC, Ferrando CA. Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial. Am J Obstet Gynecol 2024; 230:340.e1-340.e13. [PMID: 37863158 DOI: 10.1016/j.ajog.2023.10.027] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/01/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Opioids are routinely prescribed for postoperative pain control after gynecologic surgery with growing evidence showing that most prescribed opioids go unused. Restrictive opioid prescribing has been implemented in other surgical specialties to combat the risk for opioid misuse and diversion. The impact of this practice in the urogynecologic patient population is unknown. OBJECTIVE This study aimed to determine if a restrictive opioid prescription protocol is noninferior to routine opioid prescribing in terms of patient satisfaction with pain control after minor and major surgeries for prolapse and incontinence. STUDY DESIGN This was a single-center, randomized, noninferiority trial of opioid-naïve patients who underwent minor (eg, colporrhaphy or mid-urethral sling) or major (eg, vaginal or minimally invasive abdominal prolapse repair) urogynecologic surgery. Patients were excluded if they had contraindications to all multimodal analgesia and if they scored ≥30 on the Pain Catastrophizing Scale. Subjects were randomized on the day of surgery to the standard opioid prescription protocol (wherein patients routinely received an opioid prescription upon discharge [ie, 3-10 tablets of 5 mg oxycodone]) or to the restrictive protocol (no opioid prescription unless the patient requested one). All patients received multimodal pain medications. Participants and caregivers were not blinded. Subjects were asked to record their pain medication use and pain levels for 7 days. The primary outcome was satisfaction with pain control reported at the 6-week postoperative visit. We hypothesized that patient satisfaction with the restrictive protocol would be noninferior to those randomized to the standard protocol. The noninferiority margin was 15 percentage points. Pain level scores, opioid usage, opioid prescription refills, and healthcare use were secondary outcomes assessed for superiority. RESULTS A total of 133 patients were randomized, and 127 (64 in the standard arm and 63 in the restrictive arm) completed the primary outcome evaluation and were included in the analysis. There were no statistically significant differences between the study groups, and this remained after adjusting for the surgery type. Major urogynecologic surgery was performed in 73.6% of the study population, and minor surgery was performed in 26.4% of the population. Same-day discharge occurred for 87.6% of all subjects. Patient satisfaction was 92.2% in the standard protocol arm and 92.1% in the restrictive protocol arm (difference, -0.1%; P=.004), which met the criterion for noninferiority. No opioid usage in the first 7 days after hospital discharge was reported by 48.4% of the patients in the standard protocol arm and by 70.8% in the restrictive protocol arm (P=.009). Opioid prescription refills occurred in 8.5% of patients with no difference between the study groups (9.4% in the standard arm vs 6.7% in the restrictive arm; P=.661). No difference was seen in the rate of telephone calls and urgent visits for pain control between the study arms. CONCLUSION Among women who underwent minor and major surgery for prolapse and incontinence, patient satisfaction rates were noninferior after restrictive opioid prescribing when compared with routine opioid prescribing.
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Affiliation(s)
- Angela S Yuan
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Katie A Propst
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - James H Ross
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Shannon L Wallace
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Amy J Park
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Graham C Chapman
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Lua-Mailland LL, Stanley EE, Yao M, Paraiso MFR, Wallace SL, Ferrando CA. Healthcare Resource Utilization Following Minimally Invasive Sacrocolpopexy: Impact of Concomitant Rectopexy. Int Urogynecol J 2024:10.1007/s00192-024-05748-w. [PMID: 38416154 DOI: 10.1007/s00192-024-05748-w] [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: 12/01/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Combined surgical procedures with sacrocolpopexy (SCP) and rectopexy (RP) are more commonly being performed for treatment of multicompartment pelvic organ prolapse. This study aimed to compare healthcare resource utilization (HRU) within 6 weeks following combined surgery (SCP-RP) versus SCP alone (SCP-only). We hypothesized that concomitant RP does not impact HRU. METHODS A retrospective cohort study of patients who underwent minimally invasive SCP from 2017 to 2022 was conducted at a tertiary referral center. Patients were grouped based on the performance of concomitant RP. HRU was defined as a composite of unscheduled office visits, emergency department visits, and readmissions before the 6-week postoperative visit. HRU was compared in the SCP-RP and SCP-only groups. Multivariable regression analysis was performed to identify factors associated with HRU. RESULTS There were 144 patients in the SCP-RP group and 405 patients in the SCP-only group. Patient characteristics were similar between the two groups, with the following exceptions: the SCP-RP group was older, more likely to have comorbid conditions, and live >60 miles from the hospital. Of the 549 patients, 183 (33.3%) had ≥1 HRU encounter within 6 weeks after surgery. However, there was no difference between the SCP-RP and SCP-only groups in composite HRU (34.0% vs 33.1%, p = 0.84). The most common reasons for HRU were pain, urinary tract infection symptoms, and wound issues. Concomitant mid-urethral sling was associated with a two-fold increased risk of HRU after surgery. CONCLUSIONS One in 3 patients undergoing minimally invasive SCP had at least one unanticipated encounter within 6 weeks after surgery. Concomitant RP was not associated with increased postoperative HRU.
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Affiliation(s)
- Lannah L Lua-Mailland
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics and Gynecology Institute, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA.
| | - Elizabeth E Stanley
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics and Gynecology Institute, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Meng Yao
- Department of Quantitative Health Sciences, Section of Biostatistics, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics and Gynecology Institute, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Shannon L Wallace
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics and Gynecology Institute, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Cecile A Ferrando
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics and Gynecology Institute, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
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Chang OH, Yao M, Ferrando CA, Paraiso MFR, Propst K. Changes in sexual function over 12 months after native-tissue vaginal pelvic organ prolapse surgery with and without hysterectomy. Sex Med 2023; 11:qfad006. [PMID: 36936899 PMCID: PMC10018253 DOI: 10.1093/sexmed/qfad006] [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: 11/08/2022] [Revised: 01/23/2023] [Accepted: 02/07/2023] [Indexed: 03/18/2023] Open
Abstract
Background There is a need to determine how preoperative sexual activity, uterine preservation, and hysterectomy affect sexual function after pelvic organ prolapse surgery. Aim (1) To determine changes in sexual function in women, stratified by preoperative sexual activity status, after native-tissue pelvic organ prolapse surgery. (2) To examine the impact of hysterectomy and uterine preservation on sexual function. (3) To determine predictors for postoperative dyspareunia. Methods This was a planned secondary analysis of a prospective cohort study. Sexual function was evaluated preoperatively and 6 and 12 months postoperatively. Sexual function was compared between those who had a hysterectomy and those who had uterine-preserving prolapse surgery. A logistic regression analysis was performed to assess predictors for dyspareunia. Outcomes Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire. Results At 12 months, 59 patients underwent surgery and were followed up (hysterectomy [n = 28, 47.5%] vs no hysterectomy [n = 31, 52.5%]; sexually active [n = 26, 44.1%] vs non-sexually active [n = 33, 55.9%]). Of those who did not undergo a hysterectomy, 17 (54.8%) had a uterine-preserving procedure. At 12 months, sexually active patients had significant improvement in sexual function (mean ± SD, 0.37 ± 0.43; P = .005), while non-sexually active patients reported significant improvement in satisfaction of sex life (P = .04) and not feeling sexually inferior (P = .003) or angry (P = .03) because of prolapse. No variables were associated with dyspareunia on bivariate analysis. Clinical Implications It did not appear that either uterine preservation or hysterectomy had any impact on sexual function. There was a 10% increase in people who were sexually active after surgery. Strengths and Limitations The major strength of our study is the use of a condition-specific validated questionnaire intended for sexually active and non-sexually active women. We interpreted our results utilizing a validated minimal clinically important difference score to provide interpretation of our results with statistical and clinical significance. The limitation of our study is that it was a secondary analysis that was not powered for these specific outcomes. Conclusion At 12 months, for patients who were sexually active preoperatively, there was a clinically meaningful improvement in sexual function after native-tissue pelvic organ prolapse surgery. Non-sexually active women reported improvement in satisfaction of sex life. There was no difference in the sexual function of patients undergoing uterine preservation or posthysterectomy colpopexy when compared with those with concurrent hysterectomy, though this sample size was small.
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Affiliation(s)
- Olivia H Chang
- Corresponding author: Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States.
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Katie Propst
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States
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Chang OH, Yao M, Ferrando CA, Paraiso MFR, Propst K. Determining the Ideal Intraoperative Resting Genital Hiatus Size-Balancing Surgical and Functional Outcomes. Female Pelvic Med Reconstr Surg 2022; 28:649-657. [PMID: 35830588 DOI: 10.1097/spv.0000000000001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE The intraoperative resting genital hiatus (GH) size can be surgically modified but its relationship to prolapse recurrence is unclear. OBJECTIVES The objective of this study was to identify the optimal intraoperative resting GH size as it relates to prolapse recurrence and functional outcomes at 1 year. STUDY DESIGN This prospective cohort study was conducted at 2 hospitals from 2019 to 2021. Intraoperative measurements of the resting GH, perineal body, and total vaginal length were collected. The composite primary outcome consisted of anatomic recurrence, subjective recurrence, and/or conservative or surgical retreatment at 1 year. Comparisons of anatomic, functional, and sexual outcomes were compared between patients stratified by the optimal intraoperative GH size identified by receiver operating characteristic curve analysis. RESULTS Sixty-eight patients (median age of 63 years) underwent surgery, with 59 (86.8%) presenting for follow-up at 1 year. Based on the 13 patients (22%) with composite recurrence, receiver operating characteristic curve analysis demonstrated an intraoperative resting GH size of 3 cm, had 76.9% sensitivity (confidence interval [CI], 54-99.8%), and 34.8% specificity (CI, 21.0-48.5%) for composite recurrence at 1 year (area under curve = 0.61). Nineteen patients had an intraoperative GH less than 3 cm (32.2%) and 40 had a GH of 3 cm or greater (67.8%). The intraoperative resting GH size was significantly larger in patients with prolapse beyond the hymen at 1 year (4 cm [3.0, 4.0]) compared with those with prolapse at or proximal to the hymen (3.0 cm [2.5, 3.5], P = 0.009). CONCLUSIONS Intraoperative GH size may not reliably predict composite prolapse recurrence at 1 year, although there was an association between intraoperative resting GH size with prolapse beyond the hymen.
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Affiliation(s)
- Olivia H Chang
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Cecile A Ferrando
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Marie Fidela R Paraiso
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Katie Propst
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
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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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Ross JH, Vogler SA, Paraiso MFR. Combined Robotic Ventral Rectopexy and Sacrocolpopexy- a Single Institution Approach. J Minim Invasive Gynecol 2021. [DOI: 10.1016/j.jmig.2021.09.464] [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: 11/24/2022]
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Hickman LC, Tran MC, Paraiso MFR, Walters MD, Ferrando CA. Intermediate term outcomes after transvaginal uterine-preserving surgery in women with uterovaginal prolapse. Int Urogynecol J 2021; 33:2005-2012. [PMID: 34586437 PMCID: PMC8479721 DOI: 10.1007/s00192-021-04987-5] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/24/2021] [Indexed: 12/02/2022]
Abstract
Introduction and hypothesis There is growing interest in and performance of uterine-preserving prolapse repairs. We hypothesized that there would be no difference in pelvic organ prolapse (POP) recurrence 2 years following transvaginal uterosacral ligament hysteropexy (USLH) and sacrospinous ligament hysteropexy (SSLH). Methods This is a retrospective cohort study with a cross-sectional survey of women who underwent transvaginal uterine-preserving POP surgery from May 2016 to December 2017. Patients were included if they underwent either USLH or SSLH. POP recurrence was defined as a composite of subjective symptoms and/or retreatment. A cross-sectional survey was used to assess pelvic floor symptoms and patient satisfaction. Results A total of 47 women met the criteria. Mean age was 52.8 ± 12.5 years, and all had a preoperative POP-Q stage of 2 (55.3%) or 3 (44.7%). Thirty (63.8%) underwent SSLH and 17 (36.2%) underwent USLH. There were no differences in patient characteristics or perioperative data. There was no difference in composite recurrence (26.7% [8] vs 23.5% [4]) and retreatment (6.7% [2] vs 0%) retrospectively between SSLH and USLH groups at 22.6 months. Survey response rate was 80.9% (38) with a response time of 30.7 (28.0–36.6) months. The majority of patients (84.2%) reported POP symptom improvement, and both groups reported great satisfaction (89.5%). In respondents, 13.2% (5) reported subjective recurrence and 5.3% (2) underwent retreatment, with no differences between hysteropexy types. There were no differences in other pelvic floor symptoms. Conclusions Although 1 in 4 women experienced subjective POP recurrence after transvaginal uterine-preserving prolapse repair and <5% underwent retreatment at 2 years, our results must be interpreted with caution given our small sample size. No differences in outcomes were identified between hysteropexy types; however, additional studies should be performed to confirm these findings. Both hysteropexy approaches were associated with great patient satisfaction. Supplementary Information The online version contains supplementary material available at 10.1007/s00192-021-04987-5
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Affiliation(s)
- Lisa C Hickman
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. .,Division of Female Pelvic Medicine and Reconstructive Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Room 504, OH, 43210, Columbus, USA.
| | - Misha C Tran
- University of Chicago School of Medicine, Chicago, IL, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark D Walters
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cecile A Ferrando
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Ferrando CA, Paraiso MFR. A prospective randomized trial comparing Restorelle® Y mesh and flat mesh for laparoscopic and robotic-assisted laparoscopic sacrocolpopexy: 24-month outcomes. Int Urogynecol J 2021; 32:1565-1570. [PMID: 33471144 DOI: 10.1007/s00192-020-04657-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 10/14/2020] [Accepted: 12/14/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare prolapse recurrence and the incidence of mesh exposure between Restorelle® Y mesh and dual flat mesh. METHODS A randomized trial of women undergoing laparoscopic (LSC) or robotic (RSC) sacrocolpopexy for post-hysterectomy vaginal prolapse. Subjects were randomized to either Y mesh or dual flat mesh. Subjects underwent a pelvic examination with POP-Q and evaluation of any mesh exposure, and the PFDI-20 was administered at 6, 12 and 24 months postoperatively. Subjective recurrence was defined by symptomatic vaginal bulge. All subjects underwent pelvic examination with POP-Q at 6, 12 and 24 months. Objective recurrence was defined by descent of the apex > 1/3 into the vaginal canal, anterior or posterior vaginal descent beyond the hymen, or retreatment for prolapse. RESULTS Sixty-two patients were enrolled, and 59 patients were implanted with mesh: 30 Y mesh (17 LSC, 13 RSC) and 29 flat mesh (18 LSC, 11 RSC). There were no differences in patient characteristics between the groups. At 24 months, data were available for 44 (74.5%) patients. There were no mesh exposures for all subjects. PFDI-20 scores improved significantly for all subjects with no differences in mean improvement by mesh configuration. There were no differences in subjective and objective recurrence rates between the groups. Four patients (9.1%) complained of subjective vaginal bulge symptoms while nine (20.5%) patients had an objective recurrence (77.8% [7] examination only and 22.2% [2] reoperation). There were no apical recurrences. Of those patients who had a recurrence on examination only (n = 7), 85.7% (6) were asymptomatic. CONCLUSIONS At 24 months, there were no differences in subjective outcomes and prolapse recurrence in patients who underwent sacrocolpopexy with the Restorelle® Y mesh versus dual flat mesh. One in five patients experienced an objective recurrence; however, there were no apical recurrences and the majority were asymptomatic.
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Affiliation(s)
- Cecile A Ferrando
- Center for Urogynecology & Reconstructive Surgery, Subspecialty Care for Women's Health, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA. .,, Cleveland, USA.
| | - Marie Fidela R Paraiso
- Center for Urogynecology & Reconstructive Surgery, Subspecialty Care for Women's Health, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Chang OH, Davidson ERW, Thomas TN, Paraiso MFR, Ferrando CA. Correction to: Does concurrent posterior repair for an asymptomatic rectocele reduce the risk of surgical failure in patients undergoing sacrocolpopexy? Int Urogynecol J 2020; 32:233. [PMID: 33108488 DOI: 10.1007/s00192-020-04584-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Olivia H Chang
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA.
| | - Emily R W Davidson
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA
| | - Tonya N Thomas
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA
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Paraiso MFR, Brown J, Abrão MS, Dionisi H, Rosenfield RB, Lee TTM, Lemos N. Surgical and Clinical Reactivation for Elective Procedures during the COVID-19 Era: A Global Perspective. J Minim Invasive Gynecol 2020; 27:1188-1195. [PMID: 32446972 PMCID: PMC7242200 DOI: 10.1016/j.jmig.2020.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Marie Fidela R Paraiso
- Department of Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio (Dr. Paraiso).
| | - Jubilee Brown
- Department of Obstetrics and Gynecology and Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (Dr. Brown)
| | - Mauricio S Abrão
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo and Department of Obstetrics and Gynecology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil (Dr. Abrão)
| | | | | | - Ted T M Lee
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee Women's Hospital, Pittsburgh, Pennsylvania (Dr. Lee)
| | - Nucelio Lemos
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario (Dr Lemos)
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Chang OH, Davidson ERW, Thomas TN, Paraiso MFR, Ferrando CA. Does concurrent posterior repair for an asymptomatic rectocele reduce the risk of surgical failure in patients undergoing sacrocolpopexy? Int Urogynecol J 2020; 31:2075-2080. [DOI: 10.1007/s00192-020-04268-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
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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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Chang OH, Paraiso MFR. Reply. Am J Obstet Gynecol 2019; 221:292-293. [PMID: 31279445 DOI: 10.1016/j.ajog.2019.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/10/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Olivia H Chang
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, OH.
| | - Marie Fidela R Paraiso
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, OH
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Davidson ERW, Thomas TN, Lampert EJ, Paraiso MFR, Ferrando CA. Route of hysterectomy during minimally invasive sacrocolpopexy does not affect postoperative outcomes. Int Urogynecol J 2018; 30:649-655. [DOI: 10.1007/s00192-018-3790-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/03/2018] [Indexed: 11/29/2022]
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Gurland B, E Carvalho MEC, Ridgeway B, Paraiso MFR, Hull T, Zutshi M. Should we offer ventral rectopexy to patients with recurrent external rectal prolapse? Int J Colorectal Dis 2017; 32:1561-1567. [PMID: 28785819 DOI: 10.1007/s00384-017-2858-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described. PURPOSE The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs. DESIGN This study is a prospective cohort study. METHODS IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015. MAIN OUTCOME MEASURES Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method. RESULTS A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03). CONCLUSIONS VR is a better option for patients undergoing primary rectal prolapse repair.
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Affiliation(s)
- Brooke Gurland
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | - Beri Ridgeway
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Cleveland Clinic, Gynecology and Women's Health Institute, Cleveland, OH, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Cleveland Clinic, Gynecology and Women's Health Institute, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Massarat Zutshi
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Abstract
Hysterectomy is one of the most commonly performed surgeries worldwide. Indication for hysterectomy is most often benign, which includes conditions such as prolapse, abnormal uterine bleeding, fibroids and pelvic pain. A broad range of surgical approaches exists for hysterectomy, ranging from open to minimally invasive techniques. Under this minimally invasive umbrella, the following techniques are included: vaginal hysterectomy, laparoscopic hysterectomy, and variations of those two techniques, such as laparoscopic-assisted vaginal hysterectomy, robotic-assisted hysterectomy, laparo-endoscopic single-site laparoscopic hysterectomy, mini-laparoscopic hysterectomy, and natural orifice transluminal endoscopic surgery hysterectomy. As hysterectomy is being performed increasingly via a minimally invasive route, it is important that gynecologists are familiar with the established as well as emerging techniques for minimally invasive hysterectomy (MIH). Surgical planning is a complex process, which requires an in depth and informed conversation between a patient and her physician. Patient preferences, surgeon skill and indication for surgery all should be taken into consideration when determining the most appropriate surgical approach. This article will review the different routes of MIH. Perioperative considerations will be discussed, as will the advantages and disadvantages of each minimally invasive approach.
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Affiliation(s)
- C Emi Bretschneider
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA -
| | - Karl Jallad
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Siff LN, Unger CA, Jelovsek JE, Paraiso MFR, Ridgeway BM, Barber MD. Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates. Am J Obstet Gynecol 2016; 215:74.e1-6. [PMID: 26875949 DOI: 10.1016/j.ajog.2016.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/19/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intravenous indigo carmine has routinely been used to confirm ureteral patency after urogynecologic surgery. Recent discontinuation of the dye has altered clinical practice. In the absence of indigo carmine, we have used 10% dextrose in sterile water (D10) as cystoscopic fluid to evaluate ureteral patency. Glucosuria has been associated with urinary tract infection (UTI) in vivo and significantly enhanced bacterial growth in vitro. The concern is that the use of D10 would mimic a state of glucosuria albeit transient and increase the risk of postoperative UTI. OBJECTIVES The objectives of this study were to compare the rates of postoperative UTI and lower urinary tract (LUT) injuries between patients who underwent instillation of D10 vs normal saline at the time of intraoperative cystoscopy after urogynecological surgery. STUDY DESIGN This was a retrospective cohort study of all women who underwent cystoscopic evaluation of ureteral patency at the time of urogynecological surgery from May through December 2014 at a tertiary care referral center. We compared patients who received D10 cystoscopy fluid vs those who used normal saline. Outcomes included UTI and diagnosis of ureteral or LUT injuries. UTI was diagnosed according to Centers for Disease Control and Prevention guidelines by symptoms alone, urine dipstick, urinalysis, or urine culture. Descriptive statistics compared the rates of UTI between the 2 groups, and a multivariable model was fit to the data to control for potential confounders and significant baseline differences between the groups. RESULTS A total of 303 women were included. D10 was used in 113 cases and normal saline (NS) was used in 190. The rate of UTI was higher in the D10 group than the NS group: 47.8% (95% confidence interval [CI], 38.3-57.4) vs 25.9% (95% CI, 19.8-32.8, P < .001). After adjusting for age, pelvic organ prolapse stage, use of perioperative estrogen, days of postoperative catheterization, menopausal status, diabetes mellitus, and history of recurrent UTI, the UTI rate remained significantly higher with the use of D10 (adjusted odds ratio, 3.4 [95% CI, 1.6-7.5], P = .002) compared with NS. Overall, 3 cases of transient ureteral kinking (1.0%) and one cystotomy (0.3%) were identified intraoperatively. However, ureteral and LUT injuries were not different between groups. No unidentified injuries presented postoperatively. CONCLUSION Although the use of D10 cystoscopy fluid has been successful in identifying ureteral patency in the absence of indigo carmine, it is associated with an increased rate of postoperative UTI compared with NS.
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Hill AJ, Siff L, Vasavada SP, Paraiso MFR. Surgical excision of urethral prolapse. Int Urogynecol J 2016; 27:1601-3. [DOI: 10.1007/s00192-016-3021-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/05/2016] [Indexed: 11/28/2022]
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Jallad K, Barber MD, Ridgeway B, Paraiso MFR, Unger CA. The effect of surgical start time in patients undergoing minimally invasive sacrocolpopexy. Int Urogynecol J 2016; 27:1535-9. [DOI: 10.1007/s00192-016-2994-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 02/22/2016] [Indexed: 11/30/2022]
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Unger CA, Walters MD, Ridgeway B, Jelovsek JE, Barber MD, Paraiso MFR. Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse. Am J Obstet Gynecol 2015; 212:603.e1-7. [PMID: 25434838 DOI: 10.1016/j.ajog.2014.11.034] [Citation(s) in RCA: 31] [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: 08/19/2014] [Revised: 11/01/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We sought to describe perioperative and postoperative adverse events associated with uterosacral colpopexy, to describe the rate of recurrent pelvic organ prolapse (POP) associated with uterosacral colpopexy, and to determine whether surgeon technique and suture choice are associated with these rates. STUDY DESIGN This was a retrospective chart review of women who underwent uterosacral colpopexy for POP from January 2006 through December 2011 at a single tertiary care center. The electronic medical record was queried for demographic, intraoperative, and postoperative data. Strict definitions were used for all clinically relevant adverse events. Recurrent POP was defined as the following: symptomatic vaginal bulge, prolapse to or beyond the hymen, or any retreatment for POP. RESULTS In all, 983 subjects met study inclusion criteria. The overall adverse event rate was 31.2% (95% confidence interval [CI], 29.2-38.6), which included 20.3% (95% CI, 17.9-23.6) of subjects with postoperative urinary tract infections. Of all adverse events, 3.4% were attributed to a preexisting medical condition, while all other events were ascribed to the surgical intervention. Vaginal hysterectomy, age, and operative time were not significantly associated with any adverse event. The intraoperative bladder injury rate was 1% (95% CI, 0.6-1.9) and there were no intraoperative ureteral injuries; 4.5% (95% CI, 3.4-6.0) of cases were complicated by ureteral kinking requiring suture removal. The rates of pulmonary and cardiac complications were 2.3% (95% CI, 1.6-3.5) and 0.8% (95% CI, 0.4-1.6); and the rates of postoperative ileus and small bowel obstruction were 0.1% (95% CI, 0.02-0.6) and 0.8% (95% CI, 0.4-1.6). The composite recurrent POP rate was 14.4% (95% CI, 12.4-16.8): 10.6% (95% CI, 8.8-12.7) of patients experienced vaginal bulge symptoms, 11% (95% CI, 9.2-13.1) presented with prolapse to or beyond the hymen, and 3.4% (95% CI, 2.4-4.7) required retreatment. Number and type of suture used were not associated with a higher rate of recurrence. Of the subjects who required unilateral removal of sutures to resolve ureteral kinking, 63.6% did not undergo suture replacement; this was not associated with a higher rate of POP recurrence. CONCLUSION Perioperative and postoperative complication rates associated with severe morbidity after uterosacral colpopexy appear to be low. Uterosacral colpopexy remains a safe option for the treatment of vaginal vault prolapse.
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Hill AJ, Paraiso MFR. Resolution of Chronic Vulvar Pruritus With Replacement of a Neuromodulation Device. J Minim Invasive Gynecol 2015; 22:889-91. [PMID: 25757813 DOI: 10.1016/j.jmig.2015.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
Vulvar pruritus is typically associated with fungal, bacterial, and/or dermatological conditions that routinely resolve with the use of topical medications. Pruritus rarely becomes chronic in nature without a definable pathological diagnosis. However, when this occurs, management is difficult and has limited treatment options. Few cases have reported resolution of vulvar pain or discomfort with sacral neuromodulation implantation. We report a case in which a patient experienced chronic vulvar pruritus that was refractory to medical treatments and did not have a pathological diagnosis. A neurological etiology was suspected, and upon replacement of the patient's sacral neuromodulation device, complete resolution of the vulvar symptoms occurred.
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Affiliation(s)
- Audra Jolyn Hill
- Obstetrics/Gynecology and Women's Health Institute, Division of Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Marie Fidela R Paraiso
- Obstetrics/Gynecology and Women's Health Institute, Division of Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Unger CA, Paraiso MFR, Jelovsek JE, Barber MD, Ridgeway B. Perioperative adverse events after minimally invasive abdominal sacrocolpopexy. Am J Obstet Gynecol 2014; 211:547.e1-8. [PMID: 25088866 DOI: 10.1016/j.ajog.2014.07.054] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [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: 12/20/2013] [Revised: 04/26/2014] [Accepted: 07/30/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our first objective was to compare peri- and postoperative adverse events between robotic-assisted laparoscopic sacrocolpopexy (RSC) and conventional laparoscopic sacrocolpopexy (LSC) in a cohort of women who underwent these procedures at a tertiary care center. Our second objective was to explore whether hysterectomy and rectopexy at the time of sacrocolpopexy were associated with these adverse events. STUDY DESIGN This was a retrospective cohort study of women who underwent either RSC or LSC with or without concomitant hysterectomy and/or rectopexy from 2006-2012. Once patients were identified as either having undergone RSC or LSC, the electronic medical record was queried for demographic, peri-, and postoperative data. RESULTS Four hundred six women met study inclusion criteria. Mean age and body mass index of all the women were 58 ± 10 years and 27.9 ± 4.9 kg/m(2). The women who underwent RSC were older (60 ± 9 vs 57 ± 10 years, respectively; P = .009) and more likely to be postmenopausal (90.9% vs 79.1%, respectively; P = .05). RSC cases were associated with a higher intraoperative bladder injury rate (3.3% vs 0.4%, respectively; P = .04), a higher rate of estimated blood loss of ≥500 mL (2.5% vs 0, respectively; P = .01), and reoperation rate for pelvic organ prolapse (4.9% vs 1.1%, respectively; P = .02) compared with LSC. Concomitant rectopexy was associated with a higher risk of transfusion (2.8% vs 0.3%, respectively; P = .04), pelvic/abdominal abscess formation (11.1% vs 0.8%, respectively; P < .001), and osteomyelitis (5.6% vs 0, respectively; P < .001). The mesh erosion rate for all the women was 2.7% and was not statistically different between LSC and RSC and for patients who underwent concomitant hysterectomy and those who did not. CONCLUSION Peri- and postoperative outcomes after RSC and LSC are favorable, with few adverse outcomes. RSC is associated with a higher rate of bladder injury, estimated blood loss ≥500 mL, and reoperation for recurrent pelvic organ prolapse; otherwise, the rate of adverse events is similar between the 2 modalities. Concomitant rectopexy is associated with a higher rate of postoperative abscess and osteomyelitis complications.
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Affiliation(s)
- Cecile A Unger
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - John E Jelovsek
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew D Barber
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Beri Ridgeway
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Paraiso MFR. Robotic-assisted laparoscopic surgery for hysterectomy and pelvic organ prolapse repair. Fertil Steril 2014; 102:933-8. [DOI: 10.1016/j.fertnstert.2014.08.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/05/2014] [Accepted: 08/07/2014] [Indexed: 11/30/2022]
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Solomon ER, Muffly TM, Hull T, Paraiso MFR. Laparoscopic repair of recurrent lateral enterocele and rectocele. Int Urogynecol J 2014; 26:145-6. [PMID: 25224146 DOI: 10.1007/s00192-014-2465-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 06/19/2014] [Indexed: 11/26/2022]
Abstract
It is difficult to determine what types of procedures should be attempted in patients who have recurrent prolapse. We present a case of recurrent lateral enterocele and rectocele after the patient had undergone multiple surgeries for pelvic organ prolapse (POP), including a vaginal hysterectomy, bladder-neck suspension, anterior colporrhaphy, site-specific rectocele repair, apical mesh implant, iliococcygeus vault suspension, and transobturator suburethral sling procedure. With recurrence, the patient underwent robot-assisted laparoscopic sacral colpopexy, tension-free vaginal tape transobturator sling insertion, rectocele repair, and perineorrhaphy with cystoscopy. She then presented with defecatory outlet obstruction and constipation and subsequently was treated with a stapled transanal rectal resection. The patient returned with continued defecatory dysfunction and a recurrent lateral enterocele and rectocele. The recurrence was treated laparoscopically using a lightweight polypropylene mesh. The postoperative period was uneventful. Two years later, the patient reported decreased defecatory symptoms and no further symptomatic prolapse.
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Affiliation(s)
- Ellen R Solomon
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Surgery, Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01199, USA,
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Abstract
Pelvic organ prolapse is a vaginal protrusion of female pelvic organs. It has high prevalence worldwide and represents a great burden to the economy. The pathophysiology of pelvic organ prolapse is multifactorial and includes genetic predisposition, aberrant connective tissue, obesity, advancing age, vaginal delivery and other risk factors. Owing to the long course prior to patients becoming symptomatic and ethical questions surrounding human studies, animal models are necessary and useful. These models can mimic different human characteristics - histological, anatomical or hormonal, but none present all of the characteristics at the same time. Major animal models include knockout mice, rats, sheep, rabbits and nonhuman primates. In this article we discuss different animal models and their utility for investigating the natural progression of pelvic organ prolapse pathophysiology and novel treatment approaches.
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Affiliation(s)
- Bruna M Couri
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue ND20 Cleveland, OH 44195, USA
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Paraiso MFR, Ridgeway B, Park AJ, Jelovsek JE, Barber MD, Falcone T, Einarsson JI. Reply: To PMID 23395927. Am J Obstet Gynecol 2013; 209:594-5. [PMID: 23871949 DOI: 10.1016/j.ajog.2013.07.009] [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] [Received: 06/28/2013] [Accepted: 07/10/2013] [Indexed: 10/26/2022]
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Kow N, Paraiso MFR. Robotic Approach to Pelvic Floor Disorders. Curr Surg Rep 2013. [DOI: 10.1007/s40137-013-0011-4] [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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Brubaker L, Litman HJ, Rickey L, Dyer KY, Markland AD, Sirls L, Norton P, Casiano E, Paraiso MFR, Ghetti C, Rahn DD, Kusek JW. Surgical preparation: are patients "ready" for stress urinary incontinence surgery? Int Urogynecol J 2013; 25:41-6. [PMID: 23912506 DOI: 10.1007/s00192-013-2184-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 06/27/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life. METHODS The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ). RESULTS Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008). CONCLUSIONS Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.
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Affiliation(s)
- L Brubaker
- Departments of OG and Urology, Loyola University Chicago, Stritch School of Medicine, 2160 South First Avenue, Maywood, Chicago, IL, 60153, USA,
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Paraiso MFR, Ridgeway B, Park AJ, Jelovsek JE, Barber MD, Falcone T, Einarsson JI. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol 2013; 208:368.e1-7. [PMID: 23395927 DOI: 10.1016/j.ajog.2013.02.008] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/23/2013] [Accepted: 02/04/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The purpose of this study was to compare operative time and intra- and postoperative complications between total laparoscopic hysterectomy and robotic-assisted total laparoscopic hysterectomy. STUDY DESIGN This study was a blinded, prospective randomized controlled trial conducted at 2 institutions. Subjects consisted of women who planned laparoscopic hysterectomy for benign indications. Preoperative randomization to total laparoscopic hysterectomy or robotic-assisted total laparoscopic hysterectomy was stratified by surgeon and uterine size (> or ≤12 weeks). Validated questionnaires, activity assessment scales, and visual analogue scales were administered at baseline and during follow-up evaluation. RESULTS Sixty-two women gave consent and were enrolled and randomly assigned; 53 women underwent surgery (laparoscopic, 27 women; robot-assisted, 26 women). There were no demographic differences between groups. Compared with laparoscopic hysterectomy, total case time (skin incision to skin closure) was significantly longer in the robot-assisted group (mean difference, +77 minutes; 95% confidence interval, 33-121; P < .001] as was total operating room time (entry into operating room to exit; mean difference, +72 minutes; 95% confidence interval, 14-130; P = .016). Mean docking time was 6 ± 4 minutes. There were no significant differences between groups in estimated blood loss, pre- and postoperative hematocrit change, and length of stay. There were very few complications, with no difference in individual complication types or total complications between groups. Postoperative pain and return to daily activities were no different between groups. CONCLUSION Although laparoscopic and robotic-assisted hysterectomies are safe approaches to hysterectomy, robotic-assisted hysterectomy requires a significantly longer operative time.
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Visco AG, Brubaker L, Richter HE, Nygaard I, Paraiso MFR, Menefee SA, Schaffer J, Lowder J, Khandwala S, Sirls L, Spino C, Nolen TL, Wallace D, Meikle SF. Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. N Engl J Med 2012; 367:1803-13. [PMID: 23036134 PMCID: PMC3543828 DOI: 10.1056/nejmoa1208872] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [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: 12/26/2022]
Abstract
BACKGROUND Anticholinergic medications and onabotulinumtoxinA are used to treat urgency urinary incontinence, but data directly comparing the two types of therapy are needed. METHODS We performed a double-blind, double-placebo-controlled, randomized trial involving women with idiopathic urgency urinary incontinence who had five or more episodes of urgency urinary incontinence per 3-day period, as recorded in a diary. For a 6-month period, participants were randomly assigned to daily oral anticholinergic medication (solifenacin, 5 mg initially, with possible escalation to 10 mg and, if necessary, subsequent switch to trospium XR, 60 mg) plus one intradetrusor injection of saline or one intradetrusor injection of 100 U of onabotulinumtoxinA plus daily oral placebo. The primary outcome was the reduction from baseline in mean episodes of urgency urinary incontinence per day over the 6-month period, as recorded in 3-day diaries submitted monthly. Secondary outcomes included complete resolution of urgency urinary incontinence, quality of life, use of catheters, and adverse events. RESULTS Of 249 women who underwent randomization, 247 were treated, and 241 had data available for the primary outcome analyses. The mean reduction in episodes of urgency urinary incontinence per day over the course of 6 months, from a baseline average of 5.0 per day, was 3.4 in the anticholinergic group and 3.3 in the onabotulinumtoxinA group (P=0.81). Complete resolution of urgency urinary incontinence was reported by 13% and 27% of the women, respectively (P=0.003). Quality of life improved in both groups, without significant between-group differences. The anticholinergic group had a higher rate of dry mouth (46% vs. 31%, P=0.02) but lower rates of catheter use at 2 months (0% vs. 5%, P=0.01) and urinary tract infections (13% vs. 33%, P<0.001). CONCLUSIONS Oral anticholinergic therapy and onabotulinumtoxinA by injection were associated with similar reductions in the frequency of daily episodes of urgency urinary incontinence. The group receiving onabotulinumtoxinA was less likely to have dry mouth and more likely to have complete resolution of urgency urinary incontinence but had higher rates of transient urinary retention and urinary tract infections. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health; ClinicalTrials.gov number, NCT01166438.).
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Affiliation(s)
- Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27707, USA.
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Jeppson PC, Paraiso MFR, Jelovsek JE, Barber MD. Accuracy of the digital anal examination in women with fecal incontinence. Int Urogynecol J 2011; 23:765-8. [PMID: 22057427 DOI: 10.1007/s00192-011-1590-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 10/17/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI). METHODS Seventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects. RESULTS Anal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95-1.16) and -likelihood ratio of 0.6 (95% CI, 0.2-1.24) for detecting a complete EAS defect on endoanal US. CONCLUSION DRE has poor specificity for detecting anal sphincter defects seen on endoanal US.
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Affiliation(s)
- Peter C Jeppson
- Obstetrics, Gynecology, & Women's Health Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Ridgeway B, Barber MD, Walters MD, Paraiso MFR, Jelovsek JE. Perioperative Gastrointestinal Complications After Abdominal and Intraperitoneal Vaginal Surgery for Pelvic Organ Prolapse. J Gynecol Surg 2011. [DOI: 10.1089/gyn.2010.0076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Reddy J, Barber MD, Walters MD, Paraiso MFR, Jelovsek JE. Lower abdominal and pelvic pain with advanced pelvic organ prolapse: a case-control study. Am J Obstet Gynecol 2011; 204:537.e1-5. [PMID: 21345412 DOI: 10.1016/j.ajog.2011.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/16/2010] [Accepted: 01/13/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP). STUDY DESIGN This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support. RESULTS Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7-20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6-3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3-4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8-4.1). CONCLUSION Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.
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Affiliation(s)
- Jhansi Reddy
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, OH, USA
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Solomon ER, Frick AC, Paraiso MFR, Barber MD. Risk of deep venous thrombosis and pulmonary embolism in urogynecologic surgical patients. Am J Obstet Gynecol 2010; 203:510.e1-4. [PMID: 20800214 DOI: 10.1016/j.ajog.2010.07.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/16/2010] [Accepted: 07/20/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We sought to determine the incidence of symptomatic deep venous thrombosis and pulmonary embolism, collectively referred to as venous thromboembolic events (VTE), in patients undergoing urogynecologic surgery to guide development of a VTE prophylaxis policy for this patient population. STUDY DESIGN We conducted a retrospective analysis of VTE incidence among women undergoing urogynecologic surgery over a 3-year period. All patients wore sequential compression devices intraoperatively through hospital discharge. RESULTS Forty of 1104 patients (3.6%) undergoing urogynecologic surgery were evaluated with chest computed tomography, lower extremity ultrasound, or both for suspicion of VTE postoperatively. The overall rate of venous thromboembolism in this population was 0.3% (95% confidence interval, 0.1-0.8). CONCLUSION Most women undergoing incontinence and reconstructive pelvic surgery are at a low risk for VTE. Sequential compression devices appear to provide adequate VTE prophylaxis in this patient population.
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Muffly TM, Diwadkar GB, Paraiso MFR. Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy. Int Urogynecol J 2010; 21:1569-71. [PMID: 20532751 DOI: 10.1007/s00192-010-1187-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 05/16/2010] [Indexed: 10/19/2022]
Abstract
We report on the transabdominal resection of infected lumbosacral bone, synthetic mesh, and sinus tract following sacral colpopexy. A 45-year-old nulliparous patient who had undergone transvaginal mesh followed by robot-assisted sacral colpopexy presented with increasing back pain and foul-smelling vaginal drainage. An epidural abscess required surgical intervention, including diskectomy, sacral debridement, and mesh removal to drain the abscess and vaginal sinus tract. Recognized complications of open prolapse procedures also manifest following minimally invasive approaches. Osteomyelitis of the sacral promontory following sacral colpopexy may require gynecologic and neurosurgical management.
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Affiliation(s)
- Tyler M Muffly
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Reddy J, Paraiso MFR. Primary stress urinary incontinence: what to do and why. Rev Obstet Gynecol 2010; 3:150-155. [PMID: 21364846 PMCID: PMC3046739] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine on effort, exertion, sneezing, or coughing. SUI is the most common cause of urinary incontinence in younger women and the second most common cause in older women. Surgery offers high cure rates and is considered by many to be the first-line therapy for uncomplicated SUI in women. Currently, a variety of surgical procedures are available to treat symptomatic SUI. This article reviews the process of choosing a primary surgical procedure for women with SUI.
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Affiliation(s)
- Jhansi Reddy
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic Cleveland, OH
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Park AJ, Paraiso MFR. Surgical management of uterine prolapse. Minerva Ginecol 2008; 60:493-507. [PMID: 18981977] [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] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The surgical management of uterine prolapse requires an apical suspension procedure, with or without uterine removal. Options in the surgical treatment of uterine prolapse encompass the open, laparoscopic, or vaginal approaches. Vaginal apical suspension procedures include the uterosacral vaginal vault suspension, sacrospinous ligament fixation, iliococcygeus fascia suspension, and the McCall or Mayo culdoplasty. The abdominal sacral colpopexy may be performed via laparotomy or laparoscopy. Uterine preservation techniques include the Manchester procedure, sacrospinous hysteropexy, laparoscopic sacral hysteropexy and laparoscopic uterosacral vault suspension. Most of the data for subjective and objective outcomes for these prolapse procedures are from uncontrolled retrospective case series. Currently there is no definitive gold standard procedure to favor a particular route in the treatment of uterine prolapse. Thus, the optimal procedure to treat uterine prolapse depends on the specific defects that are present, as well as considerations such as the patient's age, comorbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, as well as the skill and comfort level of the surgeon with the particular surgery.
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Affiliation(s)
- A J Park
- Section of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
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Barber MD, Kleeman S, Karram MM, Paraiso MFR, Ellerkmann M, Vasavada S, Walters MD. Risk factors associated with failure 1 year after retropubic or transobturator midurethral slings. Am J Obstet Gynecol 2008; 199:666.e1-7. [PMID: 19084098 DOI: 10.1016/j.ajog.2008.07.050] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 05/19/2008] [Accepted: 07/21/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of the study was to identify predictors of recurrent urinary incontinence (UI) 1 year after treatment with tension-free vaginal tape (TVT) and transobturator tape (TOT). STUDY DESIGN One hundred sixty-two women with urodynamic stress urinary incontinence (SUI) were included in a clinical trial comparing TVT with TOT with at least 1 year of follow-up were included in this analysis. Potential clinical and urodynamic predictors for development of "any recurrent UI" or "recurrent SUI" 1 year after surgery were evaluated using logistic regression models. RESULTS Subjects who received concurrent prolapse surgery and those taking anticholinergic medications preoperatively were more likely to develop any recurrent UI. Increasing age was independently associated with recurrent SUI. Risk factors were similar for TVT and TOT for both definitions of treatment failure. CONCLUSION Concurrent prolapse surgery and preoperative anticholinergic medication use are associated with increased risk of developing recurrent UI 1 year after TVT or TOT. Increasing age is specifically associated with the recurrence of SUI symptoms.
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Ridgeway B, Walters MD, Paraiso MFR, Barber MD, McAchran SE, Goldman HB, Jelovsek JE. Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits. Am J Obstet Gynecol 2008; 199:703.e1-7. [PMID: 18845292 DOI: 10.1016/j.ajog.2008.07.055] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 05/13/2008] [Accepted: 07/21/2008] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the complications, treatments, and outcomes in patients choosing to undergo removal of mesh previously placed with a mesh procedural kit. STUDY DESIGN This was a retrospective review of all patients who underwent surgical removal of transvaginal mesh for mesh-related complications during a 3-year period at Cleveland Clinic. At last follow-up, patients reported degree of pain, level of improvement, sexual activity, and continued symptoms. RESULTS Nineteen patients underwent removal of mesh during the study period. Indications for removal included chronic pain (6/19), dyspareunia (6/19), recurrent pelvic organ prolapse (8/19), mesh erosion (12/19), and vesicovaginal fistula (3/19), with most patients (16/19) citing more than 1 reason. There were few complications related to the mesh removal. Most patients reported significant relief of symptoms. CONCLUSION Mesh removal can be technically difficult but appears to be safe with few complications and high relief of symptoms, although some symptoms can persist.
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Affiliation(s)
- Beri Ridgeway
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Paraiso MFR, Menefee S, Schaffer J, Varner E, Fitzgerald MP. Investigation of Surgical Procedures for Pelvic Organ Prolapse–The Mesh Dilemma. J Minim Invasive Gynecol 2008; 15:521-2. [DOI: 10.1016/j.jmig.2008.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/09/2008] [Accepted: 05/17/2008] [Indexed: 10/21/2022]
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Stanford EJ, Paraiso MFR. A comprehensive review of suburethral sling procedure complications. J Minim Invasive Gynecol 2008; 15:132-45. [PMID: 18312981 DOI: 10.1016/j.jmig.2007.11.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2007] [Revised: 11/17/2007] [Accepted: 11/21/2007] [Indexed: 10/22/2022]
Abstract
The study objective was to review the existing literature regarding complications of anti-incontinence sling procedures. PubMed listings using keywords related to slings and associated complications with no date or language restrictions through May 2007 and the Manufacturer and User Facility Device Experience Database were searched for specific device- and procedure-related complications. Where no information was available, published abstracts were cited. Published reports of complications for all types of anti-incontinence sling procedures are analyzed and reported. Sling-related complications are multiple but can be summarized from studies on 13737 cumulative patients as involving: voiding dysfunction (8 studies, 881 patients, 16.3% average overall incidence [OI]); detrusor overactivity (20 studies, 1950 patients, 15.4% OI); urinary retention (14 studies, 943 patients, 14.2% OI); erosion/extrusion (19 studies, 2197 patients, 6.03% OI); impact on quality of life-dyspareunia (2 studies, 175 patients, 4.3% OI); infections-most often urinary tract infections but severe infections such as abscess are reported (19 studies, 1487 patients, 5.5% OI); hematoma-most often pelvic or vaginal (4 studies, 3691 patients, 2% OI); pain (6 studies, 597 patients, 7.3% OI); abdominal and pelvic organ injury-bladder, urethra, vagina, and intestines (10 studies, 1816 patients, 3.3% OI); systemic complications-deep vein thrombosis, sepsis (case reports); and death (case reports). Cure rates for all slings are as follows: subjective (16 studies, 1541 patients, 95% OI, range 63%-99%), objective (15 studies, 1203 patients, 82% OI, range 51%-97%), and failure (8 studies, 599 patients, 11.5% OI, range 4%-37%). It is likely that sling-related complications are under-reported in the published medical literature and in the Manufacturer and User Facility Device Experience Database. This review reports on the incidence of known complications for all types of slings. Some complications are common to all sling techniques; however, with development of minimally invasive slings, device-related complications are reported and compared.
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Jelovsek JE, Barber MD, Karram MM, Walters MD, Paraiso MFR. Randomised trial of laparoscopic Burch colposuspension versus tension-free vaginal tape: long-term follow up. BJOG 2007; 115:219-25; discussion 225. [DOI: 10.1111/j.1471-0528.2007.01592.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [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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Chen CCG, Gustilo-Ashby AM, Jelovsek JE, Paraiso MFR. Anatomic relationships of the tension-free vaginal mesh trocars. Am J Obstet Gynecol 2007; 197:666.e1-6. [PMID: 18060974 DOI: 10.1016/j.ajog.2007.08.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Revised: 05/11/2007] [Accepted: 08/27/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective of the study was to describe the distances between the major anatomic structures to the path of the tension-free vaginal mesh (TVM) trocars. STUDY DESIGN Four anterior transobturator and 2 posterior ischiorectal TVM trocars were inserted bilaterally into 8 fresh frozen cadavers. Dissections were performed and mean distances (95% confidence interval) were measured between the closest points along the trocar's path and significant anatomic structures. RESULTS The mean distances between both anterior transobturator trocars and the medial branch of the obturator vessels were 0.8 cm (range, 0.6 to 1.0) and 0.7 cm (range, 0.4 to 1.1), and bladder were 0.7 cm (range, 0.5 to 0.9) and 1.3 cm (range, 0.8 to 1.9), respectively. The mean distances between the posterior trocar and the rectum and inferior rectal vessels were 0.8 cm (range, 0.6 to 1.0) and 0.9 cm (range, 0.7 to 1.1), respectively. CONCLUSION The bladder and medial branch of the obturator vessel may be at risk of injury during the passage of the anterior trocars, whereas the rectum and inferior rectal vessels may be at risk during the passage of the posterior trocar.
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Abstract
BACKGROUND In the United States, vesico-vaginal fistula formation is most commonly associated with prior gynecologic surgery, and only rarely with severe pressure necrosis. CASE A 16-year-old girl presented with continuous urinary leakage and malodorous discharge. Examination revealed an incarcerated plastic cup in the vagina with a 5 cm vesico-vaginal fistula at the bladder neck. After trans-vaginal repair, the patient underwent full recovery with an intact continence mechanism. CONCLUSION Evaluation of unusual urinary symptoms in an adolescent should include pelvic examination and/or imaging. An undisclosed vaginal foreign body is a rare, but well described entity, contributing to vesico-vaginal fistula formation.
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Affiliation(s)
- Nazema Y Siddiqui
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Abstract
Despite the lack of evidence, augmenting pelvic organ prolapse surgery with biologic graft or synthetic mesh is increasing. The objective of this review is to examine the available grafts and meshes and discuss the current data addressing the use of these implants in correction of apical, anterior, and posterior prolapse. Most of the studies are retrospective with few randomized controlled trials. There is level I evidence suggesting that repair of apical prolapse with abdominal sacral colpopexy using synthetic mesh results in improved outcomes. However, most of the data concerning graft or mesh incorporation in anterior or posterior repairs do not support augmentation with prosthesis.
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Chen CCG, Collins SA, Rodgers AK, Paraiso MFR, Walters MD, Barber MD. Perioperative complications in obese women vs normal-weight women who undergo vaginal surgery. Am J Obstet Gynecol 2007; 197:98.e1-8. [PMID: 17618776 DOI: 10.1016/j.ajog.2007.03.055] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 03/13/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the incidence of perioperative complications in obese and normal-weight patients who undergo vaginal urogynecologic surgery. STUDY DESIGN A retrospective cohort analysis was conducted for obese patients (body mass index, > or = 30 kg/m2) who underwent vaginal surgery and who were matched with patients with normal body mass indices (> 18.5 kg/m2 but < 30 kg/m2) by surgical procedures. Demographic information, comorbidities, and perioperative (< or = 6 weeks) complications were documented. Logistic regression analysis was used to compare the incidence of perioperative complications and to adjust for baseline differences. RESULTS Seven hundred forty-two patients underwent vaginal surgery during the study period; 235 women were considered to have obese body mass indices. We matched 194 of these patients with normal-weight control subjects. There was no statistical difference in the proportion of subjects who had at least 1 perioperative complication (20% [obese] vs 15% [nonobese]). However, obese subjects were more likely to have an operative site infection (adjusted odds ratio, 5.5; [95% CI, 1.7-24.7]; P = .01). CONCLUSION The overall perioperative complication rate in obese and nonobese women is low, with obesity as an independent risk factor for the development of operative site infections.
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Affiliation(s)
- Chi Chiung Grace Chen
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Gynecology and Obstetrics, Cleveland Clinic, Cleveland, OH, USA
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Gustilo-Ashby AM, Paraiso MFR, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007; 197:76.e1-5. [PMID: 17618766 DOI: 10.1016/j.ajog.2007.02.045] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Revised: 01/06/2007] [Accepted: 02/27/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze change in bowel function and its relationship to vaginal anatomy 1 year after rectocele repair and pelvic reconstruction in a randomized trial of 3 techniques of rectocele repair. STUDY DESIGN The study is an ancillary analysis of data from a randomized trial of 3 techniques of rectocele repair: posterior colporrhaphy, site-specific repair, and site-specific repair with Fortagen graft augmentation. Pelvic examination and validated questionnaires were obtained at baseline, 6 months, and 1 year after surgery. Bowel symptoms included straining, splinting, incomplete emptying, painful defecation, fecal urgency, and fecal incontinence. Logistic regression was used to identify predictors of bothersome postoperative symptoms. RESULTS One hundred six women with Stage > or = 2 POP, which included a rectocele, were enrolled in the study. Ninety-nine underwent prolapse surgery that included a rectocele repair and completed at least 1 follow-up visit. Ninety-six percent of subjects underwent concomitant prolapse surgery. No differences in change in bowel symptoms were noted between treatment groups. On average, all bowel symptoms evaluated were significantly improved 1 year after surgery. The development of new "bothersome" bowel symptoms after surgery was uncommon (11%). After controlling for age, treatment group, comorbidities, and preoperative bowel symptoms, corrected postoperative vaginal support (Stage 0/1) was associated with a reduced risk of postoperative straining (adj. OR 0.17 95% CI 0.03 to 0.9) and feeling of incomplete emptying (adj. OR 0.1 95% CI 0.01 to 0.52). Normal support of the posterior vaginal wall (Bp < or = -2) was associated with a reduced risk of bothersome incomplete emptying (OR 0.08 95% CI 0.004 to 0.58) but not with other symptoms. CONCLUSION Resolution or improvement in bowel symptoms can be expected in the majority of women after rectocele repair and pelvic reconstruction. While all symptoms improved after surgery, a reduction in bothersome postoperative straining and incomplete emptying were specifically associated with cure of posterior vaginal wall prolapse.
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Affiliation(s)
- A Marcus Gustilo-Ashby
- Section of Urogynecology and Reconstructive Pelvic Surgery, Division of Surgery, Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Ridgeway B, Barber MD, Walters MD, Paraiso MFR. Small bowel obstruction after vaginal vault suspension: a series of three cases. Int Urogynecol J 2007; 18:1237-41. [PMID: 17387418 DOI: 10.1007/s00192-007-0346-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 02/26/2007] [Indexed: 10/23/2022]
Abstract
Surgical correction of pelvic organ prolapse is increasingly common. The vaginal approach is often favored secondary to its limited peritoneal cavity access and low complication rates. A thorough review of the literature revealed no previous reports of primary vaginal reconstructive surgery leading to small bowel obstruction (SBO). Three patients who underwent transvaginal hysterectomy, uterosacral ligament vaginal vault suspension, and other reconstructive procedures subsequently suffered from SBO. All patients failed conservative management and required surgery. All were treated with laparoscopy initially, but two patients required laparotomy to correct iatrogenic enterotomies. The complication of SBO should be considered in the post vaginal surgery patient with abdominal pain. Though laparoscopic surgery can be considered, our experience has been discouraging. Candidate selection is critical and care should be taken to avoid enterotomy.
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Affiliation(s)
- Beri Ridgeway
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A81, Cleveland, OH 44195, USA.
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