Faculty Bibliography

The objective of this review is to discuss the main goals of pelvic organ prolapse repair. Pelvic organ prolapse symptoms are variable, and prolapse degree does not necessarily correlate with perceived symptoms or other associated conditions including urinary, defecatory, and sexual dysfunction. Treatment for pelvic organ prolapse is based upon symptom bother and patient expectations. There are various surgical approaches to treat pelvic organ prolapse; however, there is no standardized definition of cure or success. Physician goals of pelvic surgery to correct prolapse include restoration of anatomy, resolution of patient symptoms, avoidance of complications and attainment of patient goals. However, patient's expectations may differ, and discussing preoperative goals and setting realistic expectations prior to treatment may guide surgical therapy and improve patient satisfaction.

Abstract Background and Purpose: The aim of this study was to describe the surgical technique and report the safety and feasibility of robotic-assisted laparoscopic sacrohysteropexy, a uterine sparing procedure to correct pelvic organ prolapse (POP). Hysterectomy at the time of POP surgery has yet to be proven to improve the durability of repair. Nevertheless, the leading indication for hysterectomy in postmenopausal women is POP. Patients and Methods: We reviewed the medical records of a consecutive case series of uterine sparing prolapse repair procedures from 2005 to 2011. Fifteen women were identified. Procedures utilized a type I polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip that was inserted through the broad ligaments to include the anterior uterocervical junction. Results: Objective success was defined as Baden Walker grade 0 uterine prolapse and subjective success was defined as no complaint of vaginal bulge or pressure. The mean age of women was 51.8 years (28-64 years). No intraoperative complications were noted. The mean operating time was 159.4 minutes (130-201 minutes) and mean estimated blood loss was 35 mL (0-100 mL). The mean length of stay was 1.6 days (1-4 days) and mean length of follow-up was 10.8 months. Uterine prolapse improved in all 15 patients. Objective success was 93% (14/15) and subjective success was 80% (12/15). Conclusion: Robotic-assisted laparoscopic sacrohysteropexy was found to be a safe and feasible surgical treatment option for POP patients who desire uterine preservation.

PURPOSE: We determined the usefulness of urodynamics in patients with obstruction secondary to anti-incontinence surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of all procedures performed from January 2001 to June 2011 to relieve obstruction due to anti-incontinence surgery. Patients were excluded from study if they underwent prior procedures to relieve obstruction, followup data were missing or a neurological disorder was present. Patients were grouped into categories before intervention, including urodynamics diagnostic of obstruction vs nondiagnostic urodynamics vs no urodynamics testing. We also separated patients with predominantly storage symptoms and those with incomplete emptying. RESULTS: A total of 71 women were included in analysis. Of 54 women who presented with increased post-void residual urine volume 33 (61%) were diagnosed with obstruction on urodynamics, urodynamics was not diagnostic in 4 (7.4%) and 17 (32%) did not undergo urodynamics preoperatively. All 18 patients with predominantly storage symptoms underwent urodynamics. In patients with incomplete emptying there was no difference between the groups in storage or voiding symptom improvement, overall cure or success according to whether diagnostic urodynamics were or were not done. Of patients with storage symptoms who underwent urodynamics those without evidence of detrusor overactivity had significantly greater storage symptom improvement than those with detrusor overactivity (85.7% vs 53.8%, p = 0.02). CONCLUSIONS: When voiding symptoms or urinary retention is the primary indication for intervention after anti-incontinence surgery, urodynamic findings are not predictive of outcomes after intervention to relieve obstruction. If storage symptoms are the main indication for intervention, urodynamics may be valuable for patient counseling.

OBJECTIVES: To define the urodynamic study findings among women with insensible urinary incontinence. METHODS: Women complaining of insensible incontinence who underwent urodynamics at our center were identified. Coexisting symptoms of stress incontinence, urgency incontinence and/or mixed incontinence were recorded. The primary outcome was the urodynamic study finding. Urodynamic stress incontinence, detrusor overactivity incontinence, combination of both or neither (no incontinence) were the possible diagnoses. RESULTS: A total of 58% of patients had insensible incontinence alone and 42% had insensible incontinence combined with other urinary incontinence symptoms. Of the patients with insensible incontinence alone, 37% had no incontinence on urodynamics, whereas urodynamic stress incontinence was diagnosed in 52%. Isolated urodynamic stress incontinence was found in 73% of patients with insensible and stress incontinence symptoms. In patients with insensible plus urgency incontinence, isolated detrusor overactivity incontinence and detrusor overactivity incontinence with urodynamic stress incontinence were found in the same percentage of women (40% each). In patients with symptoms including stress urinary incontinence, stress incontinence was the predominant urodynamic finding. CONCLUSIONS: In patients who have incontinence symptoms in addition to insensible incontinence, these symptoms are highly predictive of urodynamic findings. In particular, women with insensible incontinence, concomitant stress incontinence symptoms are most predictive of urodynamic findings (i.e. urodynamic stress urinary incontinence). In contrast, where insensible incontinence represents the only symptom, urodynamic findings vary widely, with a significant proportion having non-diagnostic studies.

OBJECTIVES: To characterize the symptoms and urodynamic findings of anatomical bladder outlet obstruction (AO) and functional bladder outlet obstruction (FO) in women and to determine if future endeavors at defining bladder outlet obstruction in women can group these entities together. METHODS: Retrospective review of all videourodynamic studies was performed on women from March 2003 to July 2009. Women with diagnosis of obstruction were categorized based on the cause of obstruction into 2 groups: AO and FO. Demographic data, symptoms, and urodynamic findings were compared between the 2 groups. RESULTS: One hundred fifty-seven women were identified of which 86 (54.8%) were classified as having AO and 71 (45.2%) were classified as having FO. There were no differences in symptoms between the 2 groups. There was no difference (P=0.5789) in the mean detrusor pressure at maximum flow rate Qmax between AO (38.9 cm H20) and FO (41.0 cm H20). There was a difference in the Qmax between AO and FO (10.6 [0-41.7] and 7.4 [0-35.7] mL/s, respectively; P=0.0044), but there was considerable overlap between the values in these 2 groups. CONCLUSIONS: Anatomical bladder outlet obstruction and FO have similar urodynamic voiding pressure findings, but Qmax was statistically significantly lower in AO. However, there is a large overlap in the Qmax values between the 2 groups. Therefore, future studies that attempt to characterize bladder outlet obstruction in women need not exclude either group.

Objectives: To report the safety and feasibility of robotic abdominal sacrohysteropexy and the associated short term outcomes. Methods: We reviewed the medical records of a consecutive series of robotic uterine sparing procedures from 8/2005-6/2011. 15 women were identified. All procedures utilized a polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip inserted through the broad ligaments to include the anterior uterocervical junction. Complications were classified as intraoperative and early postoperative, which was considered within one month following surgery. Objective success was defined as grade 0 uterine prolapse on the Baden- Walker system. Subjective success was defined as no complaint of vaginal bulge or pressure. Results: The mean age was 51.8 (28-64) years and mean follow-up was 10.8 months. 13 women were parous, 8 women were postmenopausal. Mean BMI was 23.6 (18.6-29.9) kg/m2. Mean operating time was 159.4 (130-201) minutes, mean estimated blood loss was 35 (0-100) ml, and mean length of stay was 1.6 (1-4) days. Anti-incontinence procedures were performed in 53% of women (8/15) and concomitant transvaginal prolapse repair procedures were performed in 33% of women (5/15). No intra-operative complications were noted. Early postoperative complications occurred in 3 cases: 2 patients with wound infection (treated with oral antibiotics) and 1 patient with nausea/vomiting (resolved within 3 days following procedure) and urinary retention (concomitant TVT-O procedure). All patients presented with complaint of vaginal bulge or pressure. Subjective success was achieved in 80% of patients (12/15). Objectively uterine prolapse improved in all patients (15/15) by mean grade of 2.9, cystocele improved in 77% of patients (10/13) by 2.1, and rectocele improved in 80% of patients (8/10) by 2.4. Although 100% objective success was initially obtained, there was one case of recurrent uterine prolapse (grade 2) at 4 months following procedure. This patient was not overly symptomatic and did not require surgical treatment. Conclusions: Robotic abdominal sacrohysteropexy was found to be a safe and feasible surgical treatment option for POP patients who desire uterine preservation. With short-term follow up we found good success but long term follow-up is needed. (Table Presented)

Objectives: Over the last decade, the mid-urethral sling has become the new gold standard in the management of stress urinary incontinence because of its high success rate and minimally invasive nature. However, postoperative management has not kept pace with the modernization of sling surgery. Currently, there are no standardized postoperative instructions after a sling procedure with or without prolapse repair. The purpose of our study was to better understand the variation of postoperative recommendations given to patients following these procedures and to determine practice patterns among female pelvic medicine specialists across the United States. Methods: With IRB approval, attendants at the 2012 Annual Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) were randomly approached. Physician members of SUFU, AUGS, and the ICS, were asked to respond to two open-ended questions: "What is your usual plan of postoperative restriction after sling?" and "What is your usual plan of postoperative restriction after sling with prolapse repair?" Qualitative data analysis was performed to analyze the data. Results: The survey was completed by 62 surgeons. For sling repairs, four categories of restrictions emerged. These included restriction on sudden increases in intra-abdominal pressure (i.e. lifting, straining from constipation, coughing), limits on exaggerated movements (i.e. exercise, stretching), prevention of suture line trauma (i.e. vaginal penetration, bathing, soaking) and overall patient safety/well being (i.e. no driving, antimicrobial prophylaxis). Clinicians had varied times (0 days, 2 weeks, 4 weeks, 6 weeks) and intensity (i.e. weight, vigor of exercise) for postoperative restrictions. The question pertaining to concurrent prolapse resulted in the same themes. Interestingly, 62.9% of respondents had the same restriction regardless of a concurrent prolapse repair. Of those that differed, the major theme was that restriction was advised for a longer duration of time and in some cases the restriction intensity. No scientific evidence was cited during the interviews, but restrictions were admittedly based on experience (personal and institutional), presumed mechanism of repair, and theoretical risk. Conclusions: Despite the wide use of sling insertions with or without prolapse repairs, postoperative recommendations vary greatly amongst physicians. Most doctors have set arbitrary restrictions that limit several aspects of patient recovery. Further studies are required to establish common postoperative recommendation plans based on evidence based medicine rather than on individual preferences