Urogynecology (Hagerstown, Md.)最新文献

Importance: Single-incision slings (SIS) offer a minimally invasive option for treating stress urinary incontinence (SUI), aiming to reduce operative time, postoperative pain, and recovery compared to traditional slings. Their growing use underscores the importance of understanding their effectiveness, safety profile, and long-term outcomes to ensure optimal patient care.

Objective: The objective was to update current evidence on the safety, efficacy, and economic impact of SISs for the treatment of SUI in women.

Study design: A structured literature review was conducted using PubMed, Cochrane Library, and the U.S. Food and Drug Administration (FDA) 522 Postmarket Surveillance Studies Database up to December 2024. Inclusion criteria were randomized controlled trials, prospective observational studies, meta-analyses and the FDA summary addressing SIS outcomes. Key metrics included objective and subjective cure rates, complications, and economic evaluations.

Results: A total of 28 publications were reviewed since the most recent Cochrane review in 2023. Overall, high subjective (73.3% to 94.2%) and objective cure rates (61.5% to 94%) continue to be reported for SISs with operative times of 10.7 to 20.4 min and low adverse events of mesh complications (0% to 14.2%), reintervention procedures (0% to 16.3%) and de novo urgency urinary incontinence (0% to 15%) up to 36 months. Economic analyses revealed short-term cost savings for SISs, particularly in outpatient settings under local anesthesia, though cost-effectiveness over longer periods remains uncertain due to potential retreatment and/or complications.

Conclusions: Single-incision slings offer a minimally invasive option for SUI with comparable efficacy to full-length midurethral slings, with rare perioperative complications and short operative times. Long-term outcomes on complications and durability are needed. Future studies are needed to guide clinical decision making, particularly regarding longer-term complications and cost-effectiveness.

Importance: Antimuscarinic medications are widely used for overactive bladder (OAB). Recent studies linking antimuscarinics to dementia and cognitive impairment (DCI) have raised concerns about long-term antimuscarinic use for OAB management.

Objectives: We sought to investigate the incidence of DCI among patients with OAB and whether DCI incidence is associated with antimuscarinic use.

Study design: We conducted a retrospective cohort study of women aged 55 years or older with OAB, without a preexisting DCI diagnosis, within a managed health care system with at least 10 years of follow-up. Participants were divided into 2 groups: antimuscarinic users and nonusers for OAB. We calculated each participant's total antimuscarinic burden and identified incident DCI using International Classification of Diseases codes. We used bivariate analysis to identify factors associated with DCI and multivariate logistic regression to assess the association between antimuscarinic use and DCI.

Results: Of the 16,249 women included, 7,141 (44%) received antimuscarinics for OAB and 1,200 (7.4%) were diagnosed with DCI. Compared with those without DCI, women with DCI were older, less likely to be white, had more comorbidities, were more likely to use antimuscarinics, and had higher mean anticholinergic burden scores. Age at OAB diagnosis (OR: 1.13, CI: 1.12-1.14, P <0.001), diabetes (OR: 1.43, CI: 1.22-1.68, P <0.001), and bladder antimuscarinic use (OR: 1.27, CI: 1.12-1.44, P <0.001) were associated with incident DCI using multivariate analysis.

Conclusions: Among women with OAB, DCI is associated with bladder antimuscarinic use and with higher cumulative exposure to antimuscarinics. This association persists after controlling for age and comorbidities.

Importance: When treating pelvic organ prolapse (POP) through surgery, age may factor into joint decision making for surgeons and patients.

Objective: The objective of this study was to determine if 30-day perioperative outcomes after POP surgery vary by age.

Study design: This was a retrospective cohort study of women who underwent surgery for POP using the 2011-2022 American College of Surgeons National Surgical Quality Improvement Program database. Composite rates of adverse events were categorized as major complications (deep/organ space surgical site infection [SSI], reintubation, renal failure, wound dehiscence, pulmonary embolism, cardiac arrest, myocardial infarction, deep vein thrombosis, sepsis, septic shock, return to operating room, stroke, and death) or minor complications (pneumonia, blood transfusion, superficial SSI, or urinary tract infection). Multivariate logistic regression models were used to assess the association between patient age and perioperative complications after adjusting for relevant variables. Interaction models were created to determine if age modulates the effect of procedure type (apical, nonapical, obliterative prolapse surgery) or concomitant hysterectomy on risk of complications.

Results: We included 133,058 women (aged 18-59 years, n=60,659, 45.6%; aged 60-69 years, n=37,818, 28.4%; aged 70-79 years, n=27,598, 20.7%; aged 80 years and older, n=6,983, 5.2%) who underwent POP surgical procedures. On multivariate logistic regression, relative to patients younger than 60 years, age groups 60-69 years and 70-79 years had significantly lower rates of major complications (60-69 years: adjusted odds ratio [aOR]=0.68 [0.62-0.74]; 70-79 years: aOR=0.71 [0.64-0.78]) and patients older than 80 years had similar rates of major complications (aOR=0.98 [0.86-1.12]). In the patients younger than 60 years, the addition of a hysterectomy to a prolapse procedure carried a slightly increased risk of major complications (aOR=1.19, 95% CI=1.06-1.32). No other group carried an increased risk of major complications when adding a hysterectomy or performing an apical or obliterative repair.

Conclusion: This study shows a low risk of complications after POP procedures, even in patients older than 80 years.

Importance: Due to the lack of data comparing transvesical (TV) and extravesical (EV) techniques for uterovesical fistulas (UVFs), specifically comparing surgical success rates, intraoperative complications, and postoperative effect on urinary bladder (UB) capacity, we designed our study.

Objectives: This study compares laparoscopic TV versus EV repair of UVFs in terms of surgical success, intraoperative complications, postoperative UB capacity, and overactive bladder (OAB) symptoms.

Study design: A retrospective observational cohort study was conducted from January 1, 2020 to January 1, 2025, upon patients aged 18 years and older who underwent laparoscopic UVF repair at Ain Shams University Hospital, Cairo, Egypt. Data were collected through a chart review of routinely administered perioperative assessments, including the Overactive Bladder 8-Question Awareness Tool (OAB-V8) and a 3-day voiding diary.

Results: Patient demographic characteristics were similar in both groups. Success rates were similar between cohorts. One hysterectomy was performed in the EV group due to intraoperative bleeding. The EV approach had a higher complication rate than the TV group (P=0.014). The TV approach was associated with a significantly greater reduction in UB capacity compared with the EV approach (97.73±15.39 mL vs. 37.50±22.39 mL, respectively, P=0.001). Concurrently, the TV group demonstrated a significantly higher increase in OAB-V8 scores than the EV group (6.70±0.82 vs. 1.36±0.50, respectively, P=0.001).

Conclusion: Both techniques demonstrated efficacy in repairing fistulas. However, the EV approach offered superior functional outcomes, with significantly better preservation of UB capacity and a lower incidence of postoperative OAB symptoms. In contrast, the TV approach may remain preferable in younger patients or those seeking uterine preservation, as it enables precise dissection and repair while minimizing risk to uterine integrity.

Importance: A lack of data on the time course of recovery following pelvic organ prolapse surgery limits evidence-based counseling.

Objectives: The objective of this study was to define the time course of recovery following vaginal native tissue prolapse repair and identify factors affecting recovery. We hypothesized that half of the patients would return to baseline activity by 6 weeks.

Study design: This was a secondary analysis of a previously published randomized controlled trial of perioperative pain control for women ≥18 years undergoing vaginal native tissue prolapse repair under general anesthesia and an enhanced recovery after surgery protocol. The Activities Assessment Scale was used to quantify perioperative functional status. Our primary outcome was the proportion of participants returning to baseline activity at 1,2, 6, and 12 weeks postoperatively. Secondary outcomes included factors associated with recovery.

Results: Sixty-five participants (aged: 69.1±10.2 years) undergoing vaginal apical prolapse procedures were included. More than half (52.3%) returned to their baseline activity by 1 week postoperatively, with 69.2%, 84.1%, and 93.6% returning to baseline activity by 2, 6, and 12 weeks, respectively. On final multivariable analysis, chronic obstructive pulmonary disease [OR: 0.02 (95% CI, 0.001-0.43), P<0.05], total intraoperative morphine equivalents [OR: 0.89 (95% CI, 0.80-0.98), P<0.05], and total postanesthesia care unit phase 2 morphine equivalents [OR: 0.72 (95% CI, 0.52-0.99), P<0.05] were negatively associated with 6-week recovery.

Conclusions: In women undergoing apical vaginal prolapse repair, >50% recovered baseline functional activity by 1 week, and >80% recovered by 6 weeks.

Importance: Unidirectional barbed suture may decrease suture time for vaginal mesh attachment in robotic sacrocolpopexy.

Objective: The objective of this study was to evaluate if absorbable unidirectional barbed suture decreases vaginal mesh attachment time compared with nonbarbed suture.

Study design: This single-blind, randomized trial of women undergoing robotic sacrocolpopexy for ≥stage 2 symptomatic pelvic organ prolapse assessed if absorbable unidirectional barbed suture resulted in a 50% faster vaginal mesh attachment compared with interrupted nonbarbed suture. Surgeon-reported ease of mesh attachment, appearance of mesh, and global satisfaction with each suture type was assessed with a 10-point Likert scale (1 worst, 10 best). Six-month patient-centered outcomes were assessed.

Results: In total, 52 participants were randomized, with 25 in the barbed suture group and 27 in the nonbarbed suture group. Vaginal mesh attachment was faster for barbed suture (13.2 vs. 19.7 min, P <0.01). However, this did not reach the primary outcome of a 50% decrease in suture time. When stratified by level of training, barbed suture remained significantly faster for resident and fellow surgeons but not for attending surgeons. Surgeons rated barbed suture higher than nonbarbed suture for ease of suture use and global satisfaction, with similar mesh appearance ratings. Total operative time was similar between groups (186.1 vs. 180.9 min, P =0.62). Six-month patient-centered outcomes were similar between groups.

Conclusions: Unidirectional barbed suture decreased mesh attachment time compared with nonbarbed suture, especially for novice surgeons. Surgeon satisfaction was higher for barbed suture, and there was a similar improvement in all patient-centered outcomes at 6 months.

Importance: Despite evidence emphasizing the necessity of routine care for women with pelvic organ prolapse (POP) using pessaries, the frequency of follow-up is unclear.

Objective: The aim of this study was to compare the presence of complications in women with POP using vaginal pessaries with cleaning and gynecological examination every 3 or 6 months.

Study design: This pilot study was a randomized clinical trial of women with advanced POP using a ring pessary. The women were randomized into 2 groups ("3-month group" and a "6-month group") that returned for evaluation by a health care professional that monitored the vagina, removed the pessary, cleaned it, and reinserted it. Sociodemographic and clinical data were collected. During their follow-up, the women answered a questionnaire regarding the presence of vaginal symptoms and had a physical examination and vaginal sampling for microbiological analysis.

Results: A total of 38 women were randomized into 2 groups: the 3-month group (n = 18) and the 6-month group (n = 20). Baseline characteristics of the groups were similar except for age, which was 70.7 (±7.4) years in the 3-month group and 74.7 (±6.6) years in the 6-month group ( P  = 0.022). Regarding physical examination, after 12 months of follow-up, 4 women in each group presented erosions or ulcers in each group, but without difference ( P  = 1). The presence of bacterial vaginosis was more frequent in the group with cleaning every 6 months ( P  = 0.026).

Conclusions: The prevalence of ulcerations was similar in both groups with cleaning every 3 or 6 months, but the group with cleaning every 6 months showed a higher prevalence of bacterial vaginosis.

Importance: The effect of vaginal bacteria on wound healing is an evolving area of study. Bacterial vaginosis (BV), characterized by an overgrowth of anaerobic bacteria, is linked to increased surgical site infections after pelvic surgery. While BV-associated microbes are known to impair epithelial repair, their effects on fibroblasts, which are crucial for wound healing and prolapse recurrence after pelvic organ prolapsesurgery, are unclear. Understanding these interactions can deepen knowledge of vaginal tissue remodeling.

Objective: This study aimed to compare the effects of BV-associated bacteria and commensal lactobacilli on fibroblast cell number and function, using estradiol as a positive control.

Study design: Fibroblasts were isolated from vaginal wall biopsies of 9 participants undergoing pelvic organ prolapse surgery. Cells were co-cultured in media alone, media containing estradiol, and media with cell-free supernatants (CFS) from Lactobacillus crispatus, Lactobacillus iners , and Gardnerella vaginalis . Intact cell number was assessed using an lactate dehydrogenase assay at 0, 24, and 48 hours, and ELISA measured IL-6, type I collagen, and fibronectin levels.

Results: Fibroblasts exposed to G vaginalis CFS showed significantly reduced cell number and type I collagen production, with increased fibronectin levels. Cell-free supernatants from L crispatus and L iners did not affect fibroblast proliferation. While some donor cells showed an increase in cell number with estradiol, the change was inconsistent and not statistically significant. IL-6 levels showed a nonsignificant increase with any bacterial CFS.

Conclusions: G vaginalis significantly impairs fibroblast cell number and type I collagen production, suggesting BV-associated microbes may alter fibroblast function, emphasizing the vaginal microbiome's role in outcomes.

Importance: A vaginal pessary is a highly effective treatment for patients with pelvic organ prolapse (POP). Patient views of pessaries and how their beliefs affect whether they choose pessary treatment is unknown.

Objective: Our objective of this study was to describe the knowledge, understanding, and patient concerns regarding pessary use for POP management.

Study design: We performed a qualitative study of women presenting with POP who were counseled about pessary use at their initial urogynecology visit. Participants completed interviews, which were recorded, de-identified, and transcribed. Transcriptions were coded for major themes by 2 independent researchers.

Results: Twenty patients with an average age of 63 ± 8.5 years participated. Most identified as sexually active (60%) and the majority had a high school education or less (80%). Thematic saturation was reached with themes of "Failure", "Convenience," "Self-Image," "Sexual Relations," "Cleanliness/Hygiene," "Physical Barriers," "Knowledge Deficits," and "Discomfort." Many patients not only viewed a pessary as a less invasive alternative to surgery but also considered it a temporary treatment. Many patients disliked the idea of having a "foreign body" in place and felt it may affect their hygiene. Although most patients believed it would alleviate their POP symptoms, many had concerns about sexual intercourse, discomfort, and fear that it may fall out. Most participants who were not sexually active thought a pessary would increase their sexual confidence.

Conclusions: Patient opinions about pessaries are often negative with preconceived notions surrounding utilization. Focused counseling addressing concerns and fears may improve a patient's comfort with a pessary as their choice of treatment modality.