Female Pelvic Medicine and Reconstructive Surgery最新文献

Objective: The objective of this study was to evaluate the relationship between vaginal mesh exposure and vaginal bacterial community composition.

Methods: Vaginal swab samples were collected from 13 women undergoing excision of vaginal mesh with vaginal mesh exposure. Samples were collected at the midvagina, site of exposure, and underneath the vaginal epithelium at the exposure. Control samples were collected vaginally during 15 new patient examinations. For all samples, we extracted genomic DNA and polymerase chain reaction amplified and sequenced the 16S rRNA gene V4 region. We tested for differences in the microbiota among control and exposure samples with PERMANOVA tests of beta diversity measures (Morisita-Horn dissimilarity) and Wilcoxon rank sum tests of Lactobacillus distribution.

Results: Vaginal bacterial communities in both control and case groups were divided into 2 primary community types, one characterized by Lactobacillus dominance (>50% of community) and the other by low Lactobacillus and a high diversity of vaginal anaerobes. In 10 of 13 case women, bacterial communities were highly similar between the 3 vaginal sites (adonis R2 = 0.86, P = 0.0099). In the 3 women with community divergence, all 3 were characterized by decreased Lactobacillus abundance at the exposure site. Overall, Lactobacillus abundance was lower at the site of mesh exposure and under the epithelium than in the experimental control (W = 137, P = 0.072, r = 0.41; W = 146, P = 0.025, r = 0.50). Common putative pathogenic mesh colonizing bacteria were common (in 51 of 54 samples), but generally not abundant (median relative abundance = 0.014%).

Conclusions: In vaginal mesh exposure cases, a woman is more likely to have a diverse, non-Lactobacillus-dominant community.

Objective: The objective of this study was to validate a Spanish version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ).

Methods: Validation and reliability testing of the Spanish version of the PIKQ was conducted in 2 phases. In the first phase, a translation-back-translation method by 6 bilingual researchers was utilized to generate a final Spanish translation. In the second phase, bilingual women were randomized to complete the Spanish or English version first, followed by the alternate language. Agreement between individual items from English and Spanish versions was assessed by percent agreement and κ statistics. Intraclass correlation coefficients compared overall PIKQ scores and pelvic organ prolapse (POP) and urinary incontinence (UI) subscores. To establish test-retest reliability, we calculated Pearson correlation coefficients. In order to have a precision of 10% for 90% agreement, so that the lower 95% confidence interval would not be less than 80% agreement, 50 bilingual participants were required.

Results: Fifty-seven bilingual women were randomized and completed both versions of the PIKQ. Individual items showed 74%-97% agreement, good to excellent agreement (κ = 0.6-0.89) for 9 items and moderate agreement (κ = 0.4-0.59) for 14 items between English and Spanish PIKQ versions. Intraclass correlation coefficients of the overall score and POP and UI subscores showed excellent agreement (intraclass correlation coefficient = 0.81-0.91). Pearson correlation coefficients between initial and repeat Spanish scores were high: overall (r = 0.87) and for POP (r = 0.81) and UI subscores (r = 0.77).

Conclusions: A valid and reliable Spanish version of the PIKQ has been developed to assess patient knowledge about UI and POP.

Objective: The aim of the study was to evaluate the mean appointment wait time for a new patient visit at outpatient female pelvic medicine and reconstructive surgery (FPMRS) offices for U.S. women with the common and nonemergent concern of uterine prolapse.

Methods: The American Urogynecologic Society "Find a Provider" tool was used to generate a list of FPMRS offices across the United States. Each of the 427 unique listed offices was called. The caller asked for the soonest appointment available for her mother, in whom uterine prolapse was recently diagnosed. Data for each office were collected, including date of the earliest appointment, FPMRS physician demographics, and office demographics. Mean appointment wait time was calculated.

Results: Four hundred twenty-seven FPMRS offices were called in 46 states plus the District of Columbia. The mean appointment wait time was 23.1 business days for an appointment (standard deviation, 19 business days). The appointment wait time was 6 days longer when seeing a female FPMRS physician compared with a male FPMRS physician (mean, 26 business days vs 20 business days, P < 0.02). There was no difference in wait time by day of the week called.

Conclusions: Wait times are a measure of access to care within the health care system. Shorter wait times are associated with increased patient satisfaction. Typically, a woman with uterine prolapse can expect to wait at least 4 weeks for a new patient appointment with an FPMRS board-certified physician listed on the American Urogynecologic Society website. The first available appointment is more often with a male physician. A patient can expect to wait 6 days longer to see a female FPMRS physician. As mean wait times across outpatient specialties continue to increase, FPMRS offices should strive to keep wait times at a minimum to allow women timely access to care.

Objective: Our objective was to determine if there is a difference in anxiety during urodynamics in women given lavender aromatherapy (lavender) versus placebo.

Methods: This was a randomized, controlled trial of women scheduled for urodynamic testing with baseline anxiety. Participants rated their anxiety and pain immediately before the examination and then were randomized to lavender or placebo. Anxiety and pain were assessed immediately after catheter placement and 15 minutes after termination of the study.

Results: Data for 40 women who received lavender and 38 women who received placebo were available for analysis. Decrease in anxiety from baseline to catheter placement (-2 vs -0.5, P = 0.01) and 15 minutes post procedure was significantly greater in the lavender group. Postprocedure anxiety was lower in the lavender group compared with controls (0 vs 0.5, P = 0.001). No differences were seen in pain.

Conclusions: Lavender aromatherapy reduces anxiety during urodynamics.

Objective: The aim of the study was to assess whether home biofeedback is noninferior to supervised pelvic floor physical therapy (PFPT) for the treatment of stress urinary incontinence (SUI) in women.

Methods: The study used a randomized controlled noninferiority trial to compare a home biofeedback device with PFPT. Women older than 18 years with SUI and no history of a prior incontinence surgery or PFPT were eligible. Forty-two participants were required to determine noninferiority for the primary outcome, improvement in quality of life as measured by the International Consultation on Incontinence Questionnaire Short Form. The noninferiority margin was 4 points. Secondary outcomes included sexual function, overactive bladder symptoms, and patient impression of improvement.

Results: From June 2018 to October 2019, 54 women with SUI were recruited (27 biofeedback, 27 PFPT) and 43 (21 biofeedback, 22 PFPT) completed follow-up. The groups had comparable baseline characteristics. For the primary outcome of change in mean International Consultation on Incontinence Questionnaire-Short Form scores (where lower scores indicate less incontinence), home biofeedback was found to be noninferior to PFPT with a mean decrease from baseline of -3.95 (95% confidence interval [CI] = -2.21 to -5.70) in the home biofeedback group versus -4.73 (95% CI = -3.21 to -6.25) and -3.95 (95% CI = -2.21 to -5.70) in the PFPT group (P = 0.009). The PFPT group showed more improvement in overactive bladder symptoms, but not in incontinence severity without difference in sexual function.

Conclusions: Home biofeedback was noninferior to PFPT for the primary treatment of SUI in women at 3 months. These results support the use of personal biofeedback devices for the treatment of SUI.Clinical Trial Registration: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT03443687.

Objectives: The aim of the study was to evaluate the effect of hysterectomy on the risk of complications from transvaginal pelvic organ prolapse surgery with mesh.

Methods: We conducted a retrospective cohort study between October 2010 and December 2017. Transvaginal mesh surgery was performed in patients with symptomatic anterior and/or apical prolapse (Pelvic Organ Prolapse Quantification ≥ stage 2). The primary outcome was rate of severe surgical complications based on the Clavien-Dindo classification (defined as grade ≥3), and the secondary outcome was the anatomical success at the last postoperative follow-up visit.

Results: Three hundred and ninety-six patients were included, 289 of these patients underwent anterior sacrospinous fixation with uterine preservation, 50 had a previous hysterectomy and 57 underwent a concomitant hysterectomy. The median follow-up was 12 months (interquartile range, 7 months). The rate of severe complications was 2.1%, 6.0%, and 5.3% in the uterine preservation group, previous hysterectomy group, and concomitant hysterectomy group, respectively (P = 0.2). The operative time was significantly higher in the concomitant hysterectomy group, and the mesh exposure rate was significantly higher in the previous hysterectomy group. The overall recurrence rate was 7.6%, with no differences between the study groups.

Conclusions: Concomitant and previous hysterectomy did not appear to increase the severe complication rate or anatomical failure after transvaginal mesh surgery. However, a history of hysterectomy appears to be a risk factor for vaginal mesh exposure. This must be considered in the choice between prosthetic and autologous management options for the treatment of posthysterectomy vault prolapse.

Objectives: This study aimed to assess the subjective and objective cystoscopy skills of gynecology residents before and after implementation of a comprehensive simulation curriculum.

Methods: Residents in an obstetrics/gynecology program at a single academic institution participated in a 6-week cystoscopy simulation course. Residents attended an initial orientation and didactic presentation, and then weekly 20- to 30-minute training sessions using a water balloon model and a virtual reality simulator. Pretesting and posttesting were performed, including (1) subjective self-assessments, (2) a written quiz, and (3) objective structured assessment of technical skills. Paired t test was used to assess the differences in residents' objective assessment scores before and after simulation training.

Results: A total of 16 residents were recruited. Residents reported significant subjective improvements in comfort, confidence, and proficiency in performing cystoscopy after completing the curriculum. Their overall objective assessment improved, including written quiz scores (mean score, 49% vs 78%; P < 0.001), efficiency in cystoscope assembly (means score, 0 vs 4; P < 0.001), overall bladder survey score (56% vs 86%, P < 0.001), and global rating score (mean score, 15 vs 24; P < 0.001). Residents tended to prefer the water-balloon model compared with the virtual reality simulator (75% vs 25%).

Conclusions: Obstetrics/gynecology residents demonstrated significant improvements in subjective and objective measures of skill after completion of a 6-week cystoscopy simulation training course using a combination of low- and high-fidelity models. Although universal cystoscopy at the time of hysterectomy for benign indications remains controversial, cystoscopy simulation should remain an important part of resident training.

Objectives: This study aimed to determine if there are differences in (1) surgical procedures performed for pelvic organ prolapse (POP) and (2) rates of adverse events between racial groups.

Methods: We conducted a retrospective cohort study of women 18 years and older who underwent POP surgery using the 2005-2015 American College of Surgeons National Surgical Quality Improvement Program database. Race was categorized as Black, White, Hispanic, and other minority. Pelvic organ prolapse procedures were organized into 4 groups: (1) hysterectomy without concurrent POP procedures, (2) vaginal wall repair(s) only without apical suspension, (3) apical suspension with or without vaginal wall repair(s), and (4) obliterative procedures. Patient characteristics and rates of adverse events were noted. A multivariable logistic regression model was used to assess the association between patient race and surgical procedures performed for POP.

Results: We identified 48,005 women who met the inclusion criteria. Most women who underwent POP surgery were White (79.6% [n = 38,191]). Although only contributing to 4.7% (2,299) of the cohort, Black women experienced higher complication rates compared with White women (10.7% [246] for Black vs 8.9% [3,417] for White women, P < 0.01). Hispanic and other minority women were less likely to undergo an apical suspension than White women (adjusted odds ratios [aORs], 0.79 [0.75-0.84] for Hispanic women and 0.78 [0.71-0.86] for other minority women; P < 0.001 for both). Obliterative procedures were more likely to be performed in Black, in Hispanic, and especially in other minority women (aORs, 1.53 [1.20-1.92] for Black, 1.33 [1.12-1.58] for Hispanic, and 3.67 [3.04-4.42] for other minority women; P < 0.001 for all).

Conclusions: Racial differences exist among women who undergo POP surgery.