International Urogynecology Journal最新文献

Introduction and hypothesis: Few data exist on the impact of immunosuppression on perioperative outcomes in women undergoing sacrocolpopexy. The objective of this study was to compare differences in 30-day perioperative morbidity in immunocompromised versus non-immunocompromised women undergoing sacrocolpopexy (SCP). We hypothesize that compared with the non-immunocompromised group, immunocompromised women undergoing SCP experience worse composite 30-day postoperative outcomes.

Methods: Retrospective cohort of female patients aged 18 years or older who underwent sacrocolpopexy from 2012 to 2017. Current procedural terminology (CPT) codes 57280 and 57425 identified sacrocolpopexy in the American College of Surgeons-National Surgical Quality Improvement Project database. The primary exposure was a binary indicator of immunocompromised status, and the primary outcome was a composite indicator of readmission, reoperation, or a severe adverse event 30 days after surgery. Marginal standardization, a G-computation method, was used to estimate risk ratios (RR) and 95% confidence intervals (CI) representing the association between exposure and outcome.

Results: A total of 13,505 women underwent SCP between 2012 and 2017. Of those, 2,625 (19.4%) had an indicator of immunocompromised status, with diabetes and smoking being most common. The risk of the composite adverse outcome in immunocompromised women was 7.3% versus 4.6% in non-immunocompromised women. After adjusting for age, race, ethnicity, and body mass index, immunocompromised women experienced 54% increased relative risk of an adverse outcome, compared with non-immunocompromised women (RR = 1.54; 95% CI: 1.31, 1.82).

Conclusions: Immunocompromised status, most commonly caused by diabetes and smoking, increases the risk of readmission, reoperation, and a severe adverse event within 30 days of sacrocolpopexy.

Introduction and hypothesis: Vaginal pessaries are the mainstay of the non-surgical management of pelvic organ prolapse (POP). A flexible silicone irregular hexagonal (SIH) pessary was developed based on the results of a prior vaginal case study. We hypothesised that the SIH pessary would have a higher rate of retention and self-management than the polyvinyl chloride (PVC) pessary.

Methods: This was a prospective non-blinded, randomised controlled trial with institutional review board approval. Eligible participants were randomised and fitted with the assigned pessary. They were reviewed 1 week, 6 months and 1 year after the initial pessary fitting. Participants who returned for follow-up completed the study questionnaires. The primary outcome was success, defined as continued use of the allocated pessary at 6 months. Secondary outcomes included the ability to perform pessary self-care, treatment satisfaction and pessary-related complications. Statistical tests were performed with alpha or statistical significance defined as a p value of ≤ 0.05, two-tailed.

Results: A total of 104 participants were randomised, with 52 subjects in each arm. Primary outcome data were analysed using per protocol analysis. Continuing pessary usage at 6 months was 68.1% for the PVC pessary group and 65.1% for the SIH group, with no statistically significant differences between the two groups (p = 0.765). Subjects with SIH were more likely to perform pessary self-care. There were no significant differences in subjects' satisfaction, quality-of-life scores or treatment complications between groups.

Conclusions: The pessary continuation rate between the SIH and the PVC pessary groups was similar at 6 months. Participants with an SIH pessary were more likely to self-manage.

Introduction and hypothesis: The objective was to determine if mid-urethral sling (MUS) tensioning with a Mayo Scissor as a sub-urethral spacer compared with a Babcock clamp holding a loop of tape under the urethra results in differences in patient-reported outcomes and rates of repeat surgery over a 5-year follow-up.

Methods: Follow-up 5 years after a randomized clinical trial, utilizing primary data collection linked to administrative health data, was carried out to create a longitudinal cohort. The primary outcome was participant-reported bothersome SUI symptoms, as defined by the Urogenital Distress Inventory (UDI-6) questionnaire. Secondary outcomes included participant-reported bothersome overactive bladder (OAB) scores, median scores of three validated urinary symptom questionnaires, and rates of subsequent surgery determined through patient report and administrative data.

Results: Two hundred and sixty (81.8%) of the original study participants provided participant-reported data at 5 years. Administrative data linkage was completed for all of the original participants (n = 318). Demographic characteristics remained similar in the two groups at the 5-year follow-up mark. No differences existed in the primary outcome of reported bothersome SUI symptoms (30.8% Scissors vs 26.8% Babcock, p = 0.559), proportion of participants with bothersome OAB, the median scores of three validated bladder questionnaires, or in rates and cumulative incidence of recurrent MUS surgery or surgical revision of mesh-related complications.

Conclusion: Both the Scissor and Babcock tensioning techniques provided comparable outcomes at 5 years post-MUS surgery. The information from this study allows surgeons to better decide which technique to adopt in their practice, providing confidence in longer-term cure and safety.

Introduction and hypothesis: Changes in the expression of type III collagen have been linked to women's predisposition to pelvic organ prolapse (POP); however, the findings of prior studies have been conflicting. This study was aimed at investigating whether changes in the type III collagen gene expression levels occur in POP development.

Methods: A systematic review and meta-analysis were conducted on research articles that evaluated type III collagen gene expression levels in patients with POP compared with those without the condition. The articles, published between January 2000 and February 2024, were obtained from PubMed, ScienceDirect, Semantic Scholar, and EBSCO databases. Data were analyzed using fixed-effect models, and the pooled standardized mean difference (SMD) was calculated. Cochrane's Review Manager 5.4 was used for the analysis. The aggregated SMD with 95% confidence interval (CI) regarding type III collagen gene expression levels relative to POP development was the main outcome measure. Results with p < 0.05 were considered statistically significant.

Results: Six studies were included in our analysis, comprising 229 POP cases and 139 non-POP cases. Our meta-analysis indicated that patients with POP had higher type III collagen gene expression levels than those without POP (SMD = 0.32; 95% CI: 0.07 to 0.56; p = 0.01).

Conclusion: The results of this study provide evidence that a higher type III collagen gene expression levels is significantly associated with POP.

Introduction and hypothesis: Pregnancy and childbirth predispose to pelvic floor dysfunction (PFD), coinciding with functional and anatomical changes in the pelvic floor. To some extent, these can be assessed by transperineal ultrasound (TPUS), yet the correlation between ultrasound findings and symptoms has not been well elucidated. We hypothesised that pregnant women with PFD would show different findings at TPUS.

Methods: This is a planned secondary analysis of a prospective cohort study. Pregnant women were asked to fill out standardised questionnaires on PFD and undergo TPUS at 12-14 weeks and 28-32 weeks of gestation. We compared bladder neck descent, urethral rotation, retrovesical angle, pelvic organ descent, genital hiatus dimensions and the presence of anal sphincter defects between women with and those without PFD using t test and Fisher's exact test. Linear mixed-effects models were used to assess the correlation between TPUS findings and PFD severity. As this is a secondary subgroup analysis of participants who underwent TPUS, no sample size was determined upfront.

Results: At Valsalva, women with urinary incontinence had more pronounced bladder neck descent (p = 0.02) and urethral rotation (p < 0.01), as well as wider retrovesical angles (p = 0.04) and larger genital hiatus areas (p < 0.01). After controlling for age, BMI and parity, the retrovesical angle was the only persistent predictor of urinary incontinence. No correlation was observed between any TPUS marker and symptoms of either prolapse or anorectal dysfunction.

Conclusions: In pregnant women, symptoms of urinary incontinence, but not of prolapse and anorectal dysfunction, are associated with differences in pelvic floor anatomy at TPUS.

Introduction and hypothesis: Challenges in intracorporeal knot tying can be addressed with extracorporeal slip knots, simplifying the process of tying and managing tissue tension using a knot pusher. However, existing extracorporeal knot techniques are difficult owing to their complexity, the finesse required with thin yarns, and extensive training needs. We developed a new laparoscopic extracorporeal slip knot technique that can be used with a conventional needle driver or standard clamps, offering the advantages of being cost-effective and easy to learn.

Methods: The technique involves passing the active strand over another loop and securing it with the nondominant hand. A Kelly clamp is then wound around both loops three times in a tornado-like motion, passing the instrument over the active loop and under the passive one, and grasping the active strand. The passive strand is pulled to approximate the knot to the tissue and is tightened by the tension of the passive strand.

Results: This method has proven effective in various laparoscopic procedures such as sacrocolpopexy, colposuspension, pectopexy, myomectomy, and hysterectomy, facilitating surgeries without complications.

Conclusions: The tornado knot technique is a feasible and safely locked sliding extracorporeal knot that can be easily learned, especially by surgeons who are accustomed to open surgery.

Introduction and hypothesis: Concurrent pelvic organ and rectal prolapse have an incidence of 38%. Dynamic pelvic magnetic resonance imaging (MRI) is the modality of choice for workup. We discuss dynamic pelvic MRI indications, interpretation, and clinical application to pelvic floor disorders.

Methods: The pubococcygeal line (PCL) extends from the pubic symphysis to the last coccygeal joint. The "H line" demonstrates the levator hiatus size, drawn from the inferior pubic symphysis to the posterior rectal wall at the anorectal junction. The "M line" represents vertical descent of the levator hiatus and extends perpendicularly from the PCL to the posterior aspect of the H line. With rectovaginal fascial defects, the small bowel, the peritoneum, and the sigmoid colon can prolapse. Posterior compartment abnormalities include rectocele, rectal prolapse, and descending perineal syndrome. Pelvic MRI can evaluate functional disorders such as anismus, where the anorectal angle is narrowed and associated with lack of pelvic floor descent and incomplete evacuation.

Conclusions: Particularly for patients with concurrent urogynecological and colorectal complaints, previous pelvic reconstructive surgery, or when clinical symptomatology does not correlate with physical examination, dynamic pelvic MRI can impact management. It is critical for pelvic reconstructive surgeons to be familiar with this imaging modality to counsel patients and interpret radiographic findings.