International Urogynecology Journal最新文献

Introduction and hypothesis: Patients with stage 3 or 4 pelvic organ prolapse (POP) may concurrently have hydronephrosis. Consequences of hydronephrosis, such as acute kidney injury and chronic kidney disease, have significant costs to patients and healthcare facilities. In this study, we evaluate the cost-effectiveness of renal ultrasound to screen for hydronephrosis in patients with stage 3 or 4 POP.

Methods: We designed a decision tree model comparing screening renal ultrasound versus usual care for patients with stage 3 or 4 POP. In the screening strategy, patients undergo ultrasound and subsequently proceed with pessary or surgery should they screen positive for hydronephrosis or proceed with expectant management, pessary, or surgery should they screen negative. In the non-screening strategy, patients choose treatment as they normally would and those with underlying hydronephrosis either continue to have hydronephrosis or have resolution of hydronephrosis. We modeled a time horizon of 5 years, with a 3% discount rate annually for future costs and quality-adjusted life-years (QALY). This was an IRB-exempt study.

Results: At a willingness to pay threshold of $150,000/QALY, renal ultrasound was cost-effective when the majority of patients who screen positive for hydronephrosis choose pessary instead of surgery. Screening renal ultrasound is cost-effective if less than 36.3% of patients with hydronephrosis choose surgery. At 5 years, screening renal ultrasound was cost-effective regardless of the prolapse treatment chosen by patients with hydronephrosis.

Conclusion: Routine renal ultrasound screening of patients with stage 3 or 4 POP is a cost-effective strategy to identify hydronephrosis and guide treatment that mitigates risk of permanent renal damage.

Introduction and hypothesis: Urinary tract endometriosis (UTE) commonly presents with urinary urgency, frequency, retention, and hesitancy. Although surgical excision consistently improves storage symptoms postoperatively, voiding dysfunction often persists due to interactions between clearing lesions, potential neural injury, and pelvic floor dysfunction. Understanding these mechanisms is vital for optimizing outcomes and minimizing long-term morbidity.

Methods: We conducted a structured narrative review on surgical management of endometriosis with urinary symptom predominance in PubMed, Scopus, and Cochrane. We thematically synthesized studies on surgical techniques, urinary outcomes, pelvic floor dysfunction, and adjunct neuromodulation to provide insight into current practices, mechanistic understanding, and new approaches.

Results: Initially, 928 studies were identified, 798 titles and abstracts were screened after elimination of duplicates, and 63 studies were included after full text screening. Continued improvements in storage symptoms were seen regardless of surgical approach (partial cystectomy, bladder shaving, ureteral procedures) but up to 50% of patients experienced persistent voiding dysfunction. This was due to potential neural injury, fibrosis, and hypertonicity of the pelvic floor. Although nerve-sparing techniques had less dysfunction, they did not eliminate it. Adjuncts, including pelvic floor physiotherapy and neuromodulation, were supported as novel therapies. Advanced imaging techniques might improve risk stratification prior to surgery but prospective level evidence is lacking.

Conclusions: The significant proportion of patients with voiding dysfunction after UTE surgery indicates a need for multi-disciplinary pathways. In addition to lesion excision, co-management with pelvic floor rehabilitation, advanced imaging, and neuromodulation may optimize recovery. There are important priorities for the future, including standardized urodynamic outcomes and prospective study designs.

Introduction and hypothesis: The objective of this study is to quantify baseline Anticholinergic Cognitive Burden (ACB) scores among women presenting to a urogynecology practice with overactive bladder (OAB) symptoms and to examine patient characteristics associated with higher baseline ACB scores.

Methods: This retrospective study included women 18 years of age and older presenting as a new patient for evaluation of OAB at an academic urogynecology practice in 2022. A total of 242 patients met the inclusion criteria. Patient baseline characteristics, including medications, were abstracted from the electronic medical record. ACB scores were assessed using a validated four-point scale. OAB treatment after the initial visit was also abstracted.

Results: The median ACB score was 1, with 37% of patients having a high-risk ACB score (≥3). Anticholinergics were prescribed to 3% of patients, with 71% of these having high-risk baseline ACB scores. Beta-3 agonists were prescribed to 15%, with 46% of these having high-risk baseline scores. Forty-three percent of patients prescribed beta-3 agonists did not initiate therapy owing to cost. High-risk ACB scores were associated with comorbidities such as hypertension, diabetes, anxiety, and depression. Patients with high-risk ACB scores were more likely to receive sacral neuromodulation.

Conclusions: Many women with OAB have high-risk baseline ACB scores. Although anticholinergics remain commonly prescribed, their cognitive risks necessitate careful patient assessment. Increasing use of safer alternatives such as beta-3 agonists and addressing cost barriers can improve OAB management. Future research should focus on reducing anticholinergic use and addressing inequity in treatment access.

Introduction and hypothesis: Vesicovaginal fistula (VVF) is a common genitourinary fistula, and most cases are treated by surgical repair. The deeper location of supratrigonal vesicovaginal fistulas requires specialized training and expertise to be successfully performed transvaginally. To determine the learning curve of transvaginal closure of supratrigonal VVF, which was performed by a single surgeon who had experienced only transabdominal or transvesical repair.

Methods: All VVF cases without other fistulas who underwent a transvaginal approach at our institute between November 2015 and April 2023 were retrospectively reviewed. Success was defined as no urine leak via the vagina by patient report and vaginal examination at the last follow-up.

Results: A total of 40 transvaginal closures in 35 VVF patients were analyzed. The average follow-up time was 2.6 ± 2.3 years, providing sufficient time to assess long-term surgical outcomes and the progression of the learning curve. The success rate after the first surgery was 82.9% (29 of 35 VVF patients), and the overall success rate was 97.5%. The success rate was significantly higher in cases 20 to 40 than in cases 1 to 10 (p = 0.018). There were no perioperative complications, including bleeding requiring blood transfusion and reoperation, and the postoperative complication was a urinary tract infection, which required intravenous antibiotics.

Conclusions: Transvaginal closure of supratrigonal VVF is another approach that has many advantages, but it requires a surgeon's experience and a learning curve. To achieve more than 80% success, a surgeon may need to perform a transvaginal approach on at least 20 of cases.

Introduction and hypothesis: Current research on pelvic floor disorders is constrained by fragmented disciplinary approaches, static anatomical views, and insufficient attention to biomechanical balance. This paper is aimed at constructing a novel theoretical framework for pelvic floor stress dysfunction disorders (PFSDs) by integrating philosophical and scientific methodologies.

Methods: Using First Principles thinking, we redefine PFSD as a disruption of dynamic biomechanical equilibrium centered on the concept of "force." Inductive and deductive reasoning are applied to critically evaluate existing theories (e.g., Three-Compartment, Hammock), while verification and falsification principles are employed to expose logical inconsistencies between etiology and treatment.

Results: The analysis reveals fundamental limitations in current theories, which fail to account for the dynamic and integrated nature of pelvic floor function. We propose physiological biomechanical reconstruction-rather than symptom-based repair-as the core therapeutic objective. Boundary-breaking innovation promotes a holistic understanding of pelvic floor synergy across disciplines.

Conclusions: This philosophically grounded framework shifts the focus from static anatomy to dynamic biomechanical balance, offering a logical basis for evidence-based PFSD management. It supports a transition from empirical to mechanism-driven approaches in both research and clinical practice.

Introduction and hypothesis: Episiotomy is among the most performed obstetrical procedure globally. While restrictive episiotomy is recommended, patients may be reluctant to consent. TikTok, a rapidly growing video platform, is a popular patient resource to obtain health information on episiotomy. This study aimed to evaluate the information quality and degree of misinformation contained in TikTok videos about episiotomy and examine the relationship between user engagement and misinformation.

Methods: In this cross-sectional study, we identified the top videos with keyword "episiotomy" on the Canadian TikTok app. Three reviewers scored videos using the DISCERN instrument for health information quality and a 5-point Likert scale for misinformation. We evaluated correlation between user engagement and misinformation and narrator credentials and misinformation using the Pearson correlation coefficient.

Results: Forty-seven videos met the inclusion criteria. The median video length was 57 s (IQR 15-89). Most videos were oriented towards education (59.6%) and narrated by healthcare providers (36.2%) or patients (25.5%). Many videos (71.74%) contained low quality information (DISCERN score < 3), and 36.17% of videos contained misinformation (misinformation rating Likert score > 3). There was no significant correlation between engagement and misinformation (r = 0.06, p = 0.68) nor between narrator credentials and misinformation (r = 0.17, p = 0.29).

Conclusions: Low-quality health information and misinformation about episiotomy are prevalent on TikTok. Neither user engagement nor narrator credentials showed a significant correlation with misinformation. Patient education about potential misinformation on these platforms and development of evidence-based resources about episiotomy are essential to support informed decision-making.

Introduction and hypothesis: Although the association between the prolonged second stage of labour and obstetrical anal sphincter injury (OASI) risk has been established, the contribution of the duration of the active phase (time spent pushing) remains unclear. This study was aimed at estimating the association between the duration of the active phase of the second stage of labour and OASI risk among nulliparous pregnant persons.

Methods: We conducted a population-based, retrospective cohort study of nulliparous pregnant persons who gave birth to a singleton, non-anomalous, vertex foetus at ≥ 37 weeks' gestational age from 2017 to 2021. Poisson regression models adjusting for confounders were developed to estimate the risk ratio (RR) with 95% confidence intervals (CI) for the association between duration of the active phase, and total duration of the second stage, of labour and OASI.

Results: Of 4963 persons, 471 (9.5%) cohort members sustained an OASI (8.7% third-degree and 0.8% fourth-degree). An active phase ≥ 120 min was associated with a 92% higher risk of OASI compared with 30 to < 60 min (RR 1.92, 95% CI 1.51-2.45). When stratified by mode of delivery, RRs estimated for this association were attenuated (spontaneous: 0.92, 95% CI 0.56-1.53; vacuum: 1.37, 95% CI 0.77-2.45; forceps: 0.85, 95% CI 0.63-1.15). When total duration of the second stage was considered, a duration ≥ 120 min was associated with a 59% increased risk of OASI compared with 30 to < 60 min (1.59, 95% CI 1.17-2.16).

Conclusion: Increasing duration of the active phase of the second stage of labour is associated with an increased risk of OASI.

Context: Stress and urgency urinary incontinence (UI) significantly impact the quality of life of women worldwide. The complexity of treatment options calls for robust decision support tools to guide informed, patient-centered care.

Aim: This scoping review maps best practices in the development, implementation, use, evaluation, and reported outcomes of patient decision aids (PDAs) for adult women with stress and/or urgency urinary incontinence.

Method: Complementary literature searches (2000-2024) were conducted between March 2023 and May 2024 using scientific databases and gray literature. The first focused on general PDA, the second on PDAs specific for women with stress and/or urgency UI. Selected documents were analyzed using standardized extraction grids; inter-rater agreement ensured validity.

Results: Fourteen literature reviews and six studies specifically about PDAs for women with stress and/or urgency UI were selected. PDAs were reported to improve patient knowledge, reduce decisional conflict, and support shared decision-making. Key facilitators of PDA development and implementation include involving patients and healthcare professionals, adapting tools for diverse needs, clinician training, clear guidelines, regular updates, and multiformat accessibility. Barriers include time constraints, limited access, comprehension difficulties, individual preferences, media influence, and organizational challenges. Addressing these factors through tailored design, improved access, and targeted training is important for successful adoption and implementation of PDAs in this context.

Conclusion: PDAs represent a valuable tool for supporting decision-making for women with stress and/or urgency UI. Future research should address long-term outcomes, cost-effectiveness, and strategies to tailor PDAs to diverse patient needs, ultimately enhancing patient-centered care and adoption in practice.

Introduction and hypothesis: Stress urinary incontinence is a common condition that significantly affects women's quality of life. Minimally invasive mid-urethral slings are the gold standard treatment, offering high cure rates and low complication risks. Although rare, mesh exposure can cause debilitating pain, making prevention essential. Infection may contribute to mesh exposure, but evidence supporting prophylactic antibiotic use is limited. We hypothesized that a single perioperative dose of antibiotics reduces the risk of mesh exposure and that exposure rates differ between retropubic (R-MUS) and transobturator (tO-MUS) sling approaches.

Methods: We included Danish women undergoing primary mid-urethral sling surgery from 2010 to 2018 using nationwide registry data. Cox's regressions were used to assess the risk of mesh exposure by perioperative antibiotic use and sling type.

Results: Among 6706 women, 3991 underwent R-MUS and 2715 tO-MUS, hereof 34 (0.9%) and 53 (2.0%), respectively, experienced mesh exposures; 5178 (77.2%) received perioperative antibiotics, 82% in the R-MUS and 70% in the tO-MUS group. Mesh exposure occurred in 30 (1.6%) patients with antibiotics vs. 23 (2.9%) without. Perioperative antibiotics reduced mesh exposure in the tO-MUS group (adjusted hazard ratio (aHR) 0.5 [95% confidence interval (CI) 0.3-0.9])), whereas the pooled R-MUS/tO-MUS analysis was nonsignificant (aHR 0.77 [95% CI 0.45-1.32]). In the R-MUS group, the effect remained inconclusive due to low precision. R-MUS was associated with a significantly lower risk of mesh exposure compared to tO-MUS (aHR 0.5 [95% CI 0.3-0.7]).

Conclusion: Perioperative antibiotics were linked to reduced mesh exposure after tO-MUS. R-MUS had a lower mesh exposure risk than tO-MUS.