International Urogynecology Journal最新文献

Introduction and hypothesis: To explore whether concurrent midurethral sling surgery (MUS) is necessary for pelvic organ prolapse (POP) patients with simple anatomical stress urinary incontinence (SUI) undergoing laparoscopic lateral abdominal wall suspension (LLS).

Methods: A multicenter prospective cohort study enrolled 200 eligible patients (stage Ⅱ + apical/anterior POP with SUI) from 2022-2024, divided into LLS + MUS (n = 100) and LLS alone (n = 100), with 40 healthy controls. Outcomes included urodynamic tests, ISI, POP-Q, MRI, and PGI-I at baseline, 3 months, and 1 year.

Results: 170 patients (85%) completed 1-year follow-up. LLS + MUS group had higher SUI cure rate (85.3% vs 50.9%, P < 0.05) but more complications (urinary tract infection:17.6% vs 5.9%; urinary retention:8.8% vs 0%; dyspareunia:35.3% vs 15.7%; mesh exposure:14.7% vs 2%, all P < 0.05). LLS alone group showed higher satisfaction (86.3% vs 67.6%, P < 0.05). POP anatomical reduction rates were similar between groups (P > 0.05).

Conclusions: For apical/anterior POP with SUI, LLS alone is preferred, with delayed MUS if needed, reducing complications and improving satisfaction.

Introduction and hypothesis: Postoperative bleeding is a recognized, potentially life-threatening complication after pelvic surgery. This case describes the management of such an event using laparoscopic techniques following vaginal hysterectomy for pelvic organ prolapse (POP), highlighting the importance of early detection and intervention, even with altered postoperative anatomy.

Methods: A 63-year-old woman underwent a vaginal hysterectomy, apical support with McCall culdoplasty, bilateral salpingo-oophorectomy (BSO), anterior and posterior colporrhaphy (APC), and a trans-obturator tape (TOT) procedure for POP. Evaluation before surgery was performed using the Pelvic Organ Prolapse Quantification system: Ba +2 cm, C +4 cm, Bp +1 cm, TVL 11 cm. On postoperative day 1, she reported severe abdominal pain; blood work showed a drop in her hemoglobin levels, and imaging confirmed intra-abdominal bleeding. Despite receiving two units of packed red blood cells, her hemoglobin continued to decline, necessitating exploratory laparoscopy. In this case, the laparoscopic approach improved visualization while allowing for precise identification and management of the bleeding source. The observed vaginal cuff hematoma was drained, the retroperitoneum was accessed bilaterally using the white line of Toldt as an anatomical landmark to develop the avascular spaces; then, the ureters were identified, and hemostasis was achieved by coagulating the infundibulopelvic ligaments and clipping the uterine arteries.

Results: The patient received two additional units of blood during surgery and experienced no additional events in the postoperative recovery time. She remained hemodynamically stable with no further complications.

Conclusions: Laparoscopic intervention for postoperative hemorrhage after vaginal hysterectomy is a safe and effective approach. Early detection and prompt management of intra-abdominal bleeding can prevent additional morbidity. Identifying and securely closing the uterine arteries are crucial for controlling bleeding, especially when anatomical changes from previous surgery are present.

Introduction: Stress urinary incontinence (SUI) imposes a high healthcare burden and significantly affects quality of life and daily functioning. While midurethral slings remain the standard surgical treatment, periurethral bulking with polyacrylamide hydrogel (PAHG) is increasingly utilized. Existing studies focus on PAHG success, and have been limited by small sample sizes and short follow-up. This study aimed to assess PAHG failure risk, time to failure, and the likelihood of repeat injections, while identifying associated risk factors.

Hypothesis: Periurethral injection with PAHG for SUI in a complex patient cohort, will have a significant failure rate within 24 months, with a mean time to failure under 2 years and a high rate of repeat SUI surgery.

Methods: We conducted a retrospective review of all SUI patients who underwent PAHG injection at a single center from January 1, 2014, to August 31, 2020. We defined subjective PAHG failure as patient-reported recurrent SUI symptoms.

Results: Among the 256 patients who underwent PAHG injection during the study period, 35.9% (N = 92) experienced PAHG failure within 2 years (mean time to failure 9.061 months (SD 11.60 months)). Repeat PAHG injection was performed in 12% (N = 30), while 15% (N = 38) underwent other incontinence surgery. Multivariable analysis did not show any factors associated with increased risk of PAHG failure.

Conclusions: Polyacrylamide hydrogel for SUI, in medically and surgically complex patients, has similar failure rates and mean time to failure, as in uncomplicated patients.

Introduction and hypothesis: The objective was to develop a retrieval-augmented ChatGPT model grounded in evidence-based patient education materials and compare its performance against the standard ChatGPT model in responding to common urogynecology patient questions in this pilot study.

Methods: We developed a retrieval-augmented ChatGPT-4.0 model that prioritized content from International Urogynecological Association patient information leaflets. Ten commonly asked patient questions were submitted to both the standard and retrieval-augmented models. Six board-certified urogynecologists evaluated responses using the validated Quality Analysis of Medical Artificial Intelligence (QAMAI) tool, which assesses accuracy, clarity, relevance, completeness, usefulness, and sources. Total and domain-specific QAMAI scores were compared using the Wilcoxon signed-rank test, and a sensitivity analysis was performed, excluding the unblinded Source domain.

Results: The retrieval-augmented model demonstrated significantly higher total QAMAI scores than the standard model (median 22 [interquartile range, IQR, 19-25] vs 16 [IQR 13-18], p < 0.01) and outperformed the standard model in all six domains. In the sensitivity analysis, the retrieval-augmented model maintained significantly higher performance (18 [IQR 16-20] vs 14.5 [IQR 11-17], p < 0.01). Clinician raters preferred the retrieval-augmented model in 81% of responses.

Conclusions: Grounding AI tools in vetted patient education materials significantly improved the quality of ChatGPT-generated responses in urogynecology. Retrieval-augmented models offer a promising approach to enhance patient education and promote patient-centered care.

Introduction and hypothesis: To evaluate in-hospital analgesic use patterns for pelvic organ prolapse (POP) repair and identify predictors of higher opioid prescribing using a large, national patient administrative database.

Methods: This retrospective cohort study used a large, national administrative database (2010-2022) to identify women undergoing vaginal non-apical (NAR), vaginal apical (VAR), laparoscopic apical (LAR), or robotic apical (RAR) repairs. Opioid doses were converted to morphine milligram equivalents (MME). The primary outcome was total opioid, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAID) use. Secondary outcomes included differences in analgesic doses by surgical approach, predictors of higher POD-0 opioid use, postoperative 30-day readmission/emergency room (ER) visit rate, and the relationship between opioid use and 30-day readmission/ER visits.

Results: Among 102,329 procedures, median POD-0 opioid dose was lowest in NAR (77.5 MME) (p < 0.001). NSAID and acetaminophen use was more common with minimally invasive approaches. Concurrent hysterectomy was the strongest predictor of higher POD-0 opioid use (exp(β) = 1.41, p < 0.001), along with adhesiolysis (exp(β) = 1.26, p < 0.001), bladder injury repair (exp(β) = 1.24, p < 0.001), anti-incontinence procedures (exp(β) = 1.05, p < 0.001), noncommercial insurance (exp(β) = 1.04, p = 0.002), and large hospital size (exp(β) = 1.09, p = 0.037). Older age (exp(β) = 0.87 per decade, p < 0.001), high Elixhauser comorbidity index (exp(β) = 0.9, p < 0.001), and NAR (exp(β) = 0.93, p < 0.001) were associated with lower opioid use. Receiving > 90 MME on POD-0 was linked to higher 30-day readmission/ER visit rates (8.3% vs 5.6%; p < 0.001, respectively).

Conclusions: Apical repair techniques did not show significant differences in predicting higher opioid use. Concurrent hysterectomy was the strongest predictor of higher opioid use. Higher opioid doses on POD-0 were associated with increased 30-day readmission/ER rates.