Urogynecology (Hagerstown, Md.)最新文献

Importance: Previous work identified racial disparities in access to fecal incontinence (FI) treatments. However, less is known about patient perspectives of these barriers.

Objectives: This study assessed differences in FI symptom severity and treatment utilization between Black and White patients.

Study design: This mixed-methods assessment studied adult non-Hispanic Black and White women treated for FI who either did not respond to medical therapy nor received sacral neuromodulation or did not follow up after medical therapy. Structured interviews queried patients about treatments offered and symptom severity.

Results: Of the 118 patients in the retrospective evaluation, 59 (50%, 24 Black and 35 White) were interviewed. Black patients were more likely than White patients to report occasional, weekly, or daily solid and stool incontinence (75.0% vs 48.6%, P = 0.042; 87.5% vs 51.4%, P = 0.004, respectively) and flatal incontinence (83.3% vs 62.9%, P = 0.088).Of those prescribed fiber supplements and antidiarrheal medications, Black patients were less likely to report symptom improvement (25.0% vs 70.0%, P = 0.013; 57.1% vs 87.5%, P = 0.092, respectively, for each medication type) and ongoing regimen adherence (25.0% vs 63.3%, P = 0.013; 28.6% vs 87.5%, P = 0.035, respectively).Black patients were more likely to report impairment in daily functioning secondary to FI (83.3% vs 57.1%, P = 0.034) and were more likely to seek a follow-up visit with a health care professional that performs sacral neuromodulation (79.2% vs 28.6%, P < 0.001).

Conclusions: Black patients were more likely to have severe symptoms and poorer treatment outcomes and desire future follow-up, highlighting the importance of addressing racial differences in patient preferences in FI management strategies.

Importance: This is the first systematic review on female sexual dysfunction (FSD) in patients who sustained obstetric anal sphincter injury (OASI).

Objective: The aim of the study was to characterize FSD following OASI.

Study design: Between January and April 2024, we conducted a literature search of studies that explored outcomes of FSD following OASI, reporting on rates of dyspareunia and/or using questionnaires that measured female sexual function.

Results: Fourteen studies with 1,907 OASI patients met inclusion criteria. Rates of dyspareunia in the first year after OASI ranged from 27% to 35% with only 40%-57% of women having resumed sexual activity at 3 months postpartum. The Female Sexual Function Index (FSFI) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were the most utilized questionnaires. Using the FSFI, the range of FSD was 47%-81% among patients with OASI. The FSFI subdomain scores (maximum 6) for desire and arousal had the least improvement with time, ranging from 1.3-2.1 at 2 months to 3-3.1 at 4 months. Pain, lubrication, and orgasm domains showed greater improvement with time, ranging from 1.4-1.6 at 2 months and up to 3.5-3.8 at 4 months. Five studies used the PISQ-12 with mean scores of 34.1-39 (range 0-48), 3 of which included a non-OASI control group and found similar PISQ-12 scores between groups. Physical therapy did not significantly impact FSD.

Conclusions: One-third of patients with OASI experience dyspareunia in the first year postpartum, 1in 2 patients do not resume intercourse at 3 months postpartum, and FSD, measured by the FSFI, may be present in 80% of women with OASI at 3 months postpartum.

Importance: Racial/ethnic and socioeconomic disparities have been observed in the mode of pelvic organ prolapse surgery. Some of the disparities may be attributed to differences in access to care and advanced surgical technology across the United States, although this is difficult to study.

Objective: We aimed to investigate whether racial/ethnic or socioeconomic disparities in a mode of prolapse surgery exist in a managed care setting, where differences in access are minimized.

Study design: This was a retrospective cohort study of patients who underwent apical pelvic organ prolapse surgery within Kaiser Permanente Southern California facilities between 2014 and 2017. We conducted bivariate tests to examine the associations between patient characteristics and multivariate logistic regression to predict the odds of having obliterative and native tissue repair surgical procedures by race and income.

Results: The analytic sample consisted of 2,798 patients who underwent prolapse surgery. Hispanic/Latina, Non-Hispanic White, Non-Hispanic Black, Asian, and "other" race represented 51.1%, 37.0%, 5.7%, 5.3%, and 0.8% of the sample, respectively. Median household income varied by racial groups. After adjusting for patient characteristics and regional factors, we did not find significant differences in apical prolapse surgery mode by race/ethnicity or income level.

Conclusions: Within this managed care setting, no disparities in mode of apical prolapse surgery were observed by race/ethnicity or income level when regional and patient-level confounders were controlled for, such as prolapse stage and comorbidities. This may suggest that a significant driver of racial/ethnic disparities observed in prolapse surgery may be attributed to structural level factors.

Importance: Currently, there are no validated training models for cystoscopy with ureteral stent placement.

Objectives: The objectives of this study were to develop and validate a novel endoscopic simulation model for training in ureteral stent placement.

Study design: A low-cost, low-fidelity training model was developed to simulate ureteral stent placement. Recruited participants were divided into 3 groups: novices (postgraduate year 3/4 gynecology residents), advanced learners (urogynecology and reconstructive pelvic surgery fellows), and experts (urology residents, urogynecology faculty, and urology faculty). Construct validity was measured using de-identified video-recorded performances on the model, which were evaluated by 2 expert reviewers using validated scales (Global Operative Assessment of Laparoscopic Skills [GOALS], Global Rating Scale [GRS]) and procedure-specific metrics.

Results: The model was created using a hollow Styrofoam sphere, plastic tubing from a retropubic sling, and a silicone pacifier. Thirty-six surgeons were assessed performing the procedure using the model with cystoscopic equipment. The experts (n = 12) performed significantly better than the advanced learners (n = 17) and novices (n = 7) in total scores (max 75, median [IQR]: 75 [75-75], 61 [56.5-68.5], 45 [43-46], respectively; P < 0.001) and within each individual scale domain. Increasing experience with ureteral stent placement had a significant correlation ( P < 0.001) with better performance on the model. A minimum total passing score of 63 was established. On post simulation assessment, most participants "agreed" or "strongly agreed" that the model closely approximates the feel of ureteral stent placement.

Conclusion: This ureteral stenting simulation model is easy to construct, affordable, and reproducible. The model is valid and reliable for practicing the procedure in preparation for live surgery.

Importance: Electrosurgical vessel sealing devices for vaginal hysterectomy have demonstrated reduced postoperative pain. This modality, however, has not been evaluated in patients undergoing vaginal hysterectomy with pelvic reconstruction.

Objective: The aim of the study was to describe postoperative pain levels utilizing the LigaSure vessel sealing device for vaginal hysterectomy in patients undergoing major reconstructive surgery.

Study design: In this single-blinded, randomized controlled trial, participants were randomized to vaginal hysterectomy utilizing the LigaSure vessel sealing device versus standard clamping and suturing techniques. Following hysterectomy, all participants underwent major vaginal reconstruction, including apical suspension via high uterosacral ligament fixation. The primary outcome was postoperative pain on a 100-mm visual analog scale 3-6 hours after surgery. Secondary outcomes included hysterectomy operative time, blood loss, pain scores and narcotic use on days 1, 3, 5, and 2 weeks after surgery.

Results: A total of 95 participants were randomized: 48 (50.5%) in the intervention arm and 47 (49.5%) in the control arm. Between 3 and 6 hours postoperatively, there was no difference in overall pain scores (49 vs 50.5). Groups also had similar hysterectomy operative times (40.5 minutes vs 38 minutes) and blood loss (100 mL vs 100 mL). Pain scores and narcotic use on postoperative days 1, 3, 5, and 2 weeks were not different.

Conclusions: While vessel sealing devices may reduce pain after vaginal hysterectomy alone, these benefits were not detected following concomitant major pelvic reconstruction. Similar operative times and blood loss between groups may be due to the expertise of the surgical subspecialist and not the device itself.

Importance: Limited evidence exists on the effect of combined native tissue vaginal prolapse repair with midurethral sling on urgency urinary incontinence (UUI) symptoms.

Objectives: This study aimed to evaluate the effect of combined native tissue vaginal prolapse repair with midurethral sling on UUI symptoms at 12 months postoperatively and identify risk factors for persistent UUI.

Study design: This secondary analysis utilized data from a randomized trial comparing retropubic versus single-incision slings in women undergoing treatment of stress incontinence and vaginal prolapse with native tissue vaginal repair and midurethral sling. Responses to Question 16 of the Pelvic Floor Distress Inventory-20 were grouped into no and mild UUI (0, 1) versus moderate and severe UUI (2, 3, 4), and associations between UUI symptoms and patient and surgical characteristics were explored.

Results: At baseline, 196/254 (77%) reported at least moderate UUI bother, whereas 58 (23%) had no bother. At 12 months postoperatively, persistent, resolved and de novo UUI were 41%, 59%, and 11%, respectively. At baseline, higher body mass index (odds ratio [OR], 1.08 95% CI, 1.02-1.14; P = 0.005) and symptomatic SUI (OR, 4.76; 95% CI, 2.53-9.01; P < 0.001) were associated with UUI. At 12 months, age (OR, 1.18, 95% CI, 1.04-1.35; P = 0.012) and Charlson Comorbidity Index (OR, 1.21; 95% CI, 1.00-1.45; P = 0.049) were associated with UUI. Colpocleisis was the only significant protective factor for the presence of UUI at 12 months (OR, 0.35; 95% CI, 0.13-0.97; P = 0.043).

Conclusion: At 12 months postoperatively, almost 60% saw resolution of baseline UUI symptoms, especially those undergoing colpocleisis.

Importance: Obesity is a risk factor for pelvic organ prolapse (POP) and independently associated with perioperative complications following prolapse surgery. Although weight loss surgery (WLS) may lead to weight loss and mitigate obesity-related comorbidities, it is associated with chronic malabsorption, which may also lead to increased perioperative complications. There have been no studies evaluating the impact of prior WLS on POP surgery outcomes.

Objective: This study aimed to describe the effect of WLS on complications after POP surgery.

Study design: We performed a retrospective cohort study of patients with obesity who underwent POP surgery and compared outcomes between those with and without a prior history of WLS. Data were procured from the Premier U.S. National Database between January 2000 and March 2020.

Results: Of 22,905 surgical procedures performed for POP, 542 (2.2%) previously underwent WLS with a median of 30 months between procedures (IQR, 15-51). The WLS group had higher rates of postoperative mesh erosion at 3 months (3.0% vs 1.5%, P = 0.0079) and 12 months (3.1% vs 1.8%, P = 0.04) and had higher hematoma incidence (1.7% vs 0.68%, P = 0.014). After adjusting for covariates, WLS was not associated with increased probability of infectious (OR, 0.94; 95% CI, 0.67-1.27) or noninfectious morbidity (OR, 1.06; 95% CI, 0.59-1.75). Rates of recurrent prolapse resulting in surgery were similar between groups (1.7% vs 1.3%, P = 0.56), and time interval between WLS and POP surgical procedures did not affect rates of complications.

Conclusion: WLS does not appear to increase the risk of perioperative complications following surgery for POP.

Importance: Use of the publicly available Large Language Model, Chat Generative Pre-trained Transformer (ChatGPT 3.5; OpenAI, 2022), is growing in health care despite varying accuracies.

Objective: The aim of this study was to assess the accuracy and readability of ChatGPT's responses to questions encompassing surgical informed consent in urogynecology.

Study design: Five fellowship-trained urogynecology attending physicians and 1 reconstructive female urologist evaluated ChatGPT's responses to questions about 4 surgical procedures: (1) retropubic midurethral sling, (2) total vaginal hysterectomy, (3) uterosacral ligament suspension, and (4) sacrocolpopexy. Questions involved procedure descriptions, risks/benefits/alternatives, and additional resources. Responses were rated using the DISCERN tool, a 4-point accuracy scale, and the Flesch-Kinkaid Grade Level score.

Results: The median DISCERN tool overall rating was 3 (interquartile range [IQR], 3-4), indicating a moderate rating ("potentially important but not serious shortcomings"). Retropubic midurethral sling received the highest overall score (median, 4; IQR, 3-4), and uterosacral ligament suspension received the lowest (median, 3; IQR, 3-3). Using the 4-point accuracy scale, 44.0% of responses received a score of 4 ("correct and adequate"), 22.6% received a score of 3 ("correct but insufficient"), 29.8% received a score of 2 ("accurate and misleading information together"), and 3.6% received a score of 1 ("wrong or irrelevant answer"). ChatGPT performance was poor for discussion of benefits and alternatives for all surgical procedures, with some responses being inaccurate. The mean Flesch-Kinkaid Grade Level score for all responses was 17.5 (SD, 2.1), corresponding to a postgraduate reading level.

Conclusions: Overall, ChatGPT generated accurate responses to questions about surgical informed consent. However, it produced clearly false portions of responses, highlighting the need for a careful review of responses by qualified health care professionals.

Importance: Pelvic organ prolapse recurrence following native tissue repair occurs with composite failure rates of 9-19% within 12 months, predominantly involving apical/anterior compartments. Objective The objective of this study was to develop a novel vaginal orthosis (NVO) device prototype through an iterative design process based on investigator and user feedback.

Study design: The NVO was designed based on pelvic floor biomechanical principles to mitigate unopposed intra-abdominal pressure of the anterior vagina by absorbing and redirecting intra-abdominal forces to the levator ani and tailored to accommodate postoperative vaginal caliber and axis. Prototypes were fabricated by 3D-printing negative molds, cast, and cured with medical-grade biocompatible silicone. Ten healthy volunteers were recruited to provide qualitative feedback for iterative design refinement (phase 0).

Results: Through an iterative engineering design process, initial concepts were refined to align with the natural, resting H-shape of the vagina. Key features included a distal self-retaining feature, posterior curvature, proximal taper, and apical/anterior contact areas for support. A more rigid material to withstand intra-abdominal forces without folding was required; therefore, Shore A60 (medium soft) instead of A40 (soft) silicone was used. Based on participant feedback, the NVO retaining feature width range was reduced (47.5-63 mm to 45-50 mm) to decrease pressure on lateral vaginal walls and levator ani distally maintaining self-retaining function. Updates to the fitting and education process also provided increased descriptive instructions for insertion and removal.

Conclusions: A novel vaginal orthosis was designed specifically tailored to facilitate wound healing using an orthomedical model, improving the design through iterative feedback.