Urogynecology (Hagerstown, Md.)最新文献

Importance: Restrictive physical activity after pelvic reconstructive surgery is recommended, although the optimal duration and intensity are not standardized.

Objective: This systematic review and meta-analysis aimed to evaluate the existing literature comparing clinical outcomes for liberal postoperative physical activity versus standard of care, defined as restricted postoperative physical activity, after pelvic reconstructive surgery.

Study design: PubMed, CENTRAL, Scopus, Web of Science, and CINAHL databases were searched for observational and randomized studies comparing liberal postoperative physical activity and standard of care in women undergoing pelvic reconstructive surgery, reporting anatomic and functional outcomes. Statistical analysis was performed using RevMan software, presenting results as mean difference (MD) or odds ratio in a random-effects model, with 95% confidence intervals (CIs).

Results: Five randomized trials, representing total n = 434, were included, with 2 studies on sling surgical procedures and 3 on prolapse surgical procedures. Data from 3 studies suggest no significant difference between liberal and standard postoperative instructions in surgical outcomes, measured by Point Ba from POP-Q assessment tool, up to 3 months follow-up (MD, -0.04; 95% CI, -0.16 to 0.07; P = 0.49). Disease-specific symptom distress, measured by Pelvic Floor Distress Inventory-20, favored the liberal approach (MD, -10.09; 95% CI, -18.33 to -1.86; P = 0.02). Other domains, including Urinary Distress Inventory-6, also showed significant improvements with liberal postoperative activities (MD, -4.29; 95% CI, -7.84 to -0.74; P = 0.02).

Conclusions: Patients with liberal postoperative physical activity recommendations in prolapse repair surgical procedures had similar short-term anatomic outcomes compared with standard restrictions, with more favorable outcomes in disease-specific symptom relief and quality of life.

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: Urinary tract infection (UTI) is the most common complication of intradetrusor onabotulinumtoxinA (BTX-A) injection. Despite this, there are no evidence-based guidelines on antibiotic prophylaxis.

Objectives: Our primary aim was to determine whether antibiotic prophylaxis decreased symptomatic, culture-proven UTI rates within 6 weeks of intradetrusor BTX-A injection. Our secondary aims were to determine if there are differences between antibiotic regimens and to identify risk factors for developing a UTI.

Study design: This was a prospective, observational multicenter cohort study of female patients receiving BTX-A for idiopathic overactive bladder. We compared patients who received antibiotics (nitrofurantoin or trimethoprim-sulfamethoxazole) to those who did not. To detect a 15% difference in UTI rates between groups (80% power, alpha = 0.05), 270 participants were needed.

Results: A total of 282 participants ultimately received BTX-A and were included in the analysis. One hundred eighty-one (62.6%) were in the antibiotic cohort and 101 (35.8%) were in the no-antibiotic cohort. The overall rate of symptomatic, culture-proven UTI was 12.1%, and there was no difference between the antibiotic and no-antibiotic cohort (10.6% vs 14.9%, respectively; P = 0.29). On multivariable logistic regression, UTI was associated with older age (adjusted odds ratio [aOR], 1.07; 95% CI, 1.02-1.11), BTX-A dose of 200 units (aOR, 4.24; 95% CI, 1.45-12.35), and self-catheterization (aOR, 26.0; 95% CI, 3.62-186.5). The odds of symptomatic UTI were lower among postmenopausal participants (aOR, 0.13; 95% CI, 0.02-0.68) and participants in the Northeast United States (aOR, 0.23; 95% CI, 0.08-0.72).

Conclusions: Our study did not find a lower rate of symptomatic, culture-proven UTI among participants who took antibiotics compared with those who did not.

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: 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: The Accreditation Council for Graduate Medical Education (ACGME) has aimed to increase diversity among the physician workforce. Prospective applicants utilize websites to identify programs that share a commitment to equity and inclusion. Published statements of Diversity, Equity, and Inclusion (DEI) demonstrate a fellowship program's recognition of the importance of improving diversity in health care and medical education.

Objective: The aim of the study was to assess the utilization of DEI statements published on urogynecology and reconstructive pelvic surgery (URPS) fellowship program websites.

Study design: All ACGME accredited URPS fellowship websites in July 2023 were reviewed for presence of a DEI statement as a primary outcome. Website content was then compared across geographical regions (Northeast, Mid-Atlantic, Midwest, South, and West).

Results: Seventy-two URPS programs had a dedicated website for review. Nine (12.5%) URPS programs had a published diversity statement. There were no statistical differences in the presence of a statement in URPS fellowships based on core-surgical speciality or geographic region.

Conclusions: A majority of URPS programs lack a DEI statement (87.5%) demonstrating an area for improvement. With an increasingly diverse patient population, the recruitment of a diverse pool of physician applicants is more crucial than ever. By advocating for transparency, URPS fellowship programs can foster an environment that nurtures a physician workforce better equipped to provide culturally inclusive health care.

Importance: Studies characterizing pain and pain management following obstetric anal sphincter injury (OASI) are limited.

Objectives: Our primary objective was to analyze time to pain resolution following OASI. Secondary objectives included analyzing pain severity, location, triggers, and patterns of pain medication use.

Study design: This was a prospective cohort study of patients with OASIs seen in a postpartum care clinic at a tertiary referral center between 2017 and 2022. We analyzed data on pain resolution, visual analog scale pain scores, pain triggers, pain location, and pain medications.

Results: A total of 362 patients were included in this study. In the Kaplan-Meier estimator, 58.5% of patients showed resolution of pain by 3 months following their initial postpartum care clinic visit, and 73.3% showed resolution of pain by 6 months. The median months to pain resolution was 2.2 (95% confidence interval: 1.6-3.0) for patients with third-degree lacerations and 2.3 (95% confidence interval: 1.6-6.8) for patients with fourth-degree lacerations. Visual analog scale scores showed the most improvement in the first 2 months. Common pain triggers included sitting and bowel movements in the first few months, as well as intercourse during later recovery. Pain location varied over time; bilateral pain in the levator ani muscles and obturator internus were most prevalent at each time point. Pain appeared to be predominantly managed by acetaminophen and ibuprofen.

Conclusions: Half of patients who experience OASI will have pain resolution by 2-3 months postpartum. Most patients will have resolution of their pain by 6 months postpartum.

Importance: Overactive bladder is a distressing syndrome that significantly affects quality of life. Transcutaneous tibial nerve stimulation (TTNS) has been proposed as a home-based, patient-centered therapy that could improve access to treatment for this condition.

Objective: We aimed to determine the efficacy of 12 weeks of TTNS versus sham therapy in reducing symptomatic bother in ambulatory women with urgency urinary incontinence.

Study design: This was a double-masked, sham-controlled randomized trial. The primary outcome was the change in Overactive Bladder Questionnaire scores. Secondary outcomes included those with 50% or greater reduction in urgency incontinence episodes on 3-day voiding diaries and Patient Global Impression of Improvement.

Results: One hundred women were randomized (65 intervention, 35 sham) and included in analysis. Both groups experienced clinically meaningful improvement in Overactive Bladder Questionnaire scores postintervention from baseline, which was not significant between groups (symptom severity: intervention -19.5 ± 20.2 vs sham -19.4 ± 20.4, P = 1.0; health-related quality of life -16.6 ± 18.5 vs -13.8 ± 16.8, P = 0.5). In the TTNS group, 58.8% of women achieved 50% or greater reduction in urgency incontinence episodes versus 41.7% of women in the sham group (P = 0.2), and 25% versus 18% were "much" or "very much improved" (P = 0.2). A sensitivity analysis confirmed these findings.

Conclusions: Clinically meaningful reductions in overactive bladder symptoms were observed in both TTNS and sham therapy without significant differences between groups; however, a trend toward greater reduction in incontinence episodes and overall impression of improvement was noted in the active treatment. The therapeutic benefit from regularly connecting with a clinician should be considered when developing new therapies.

Importance: Vaginal fibroblast function is altered in people with pelvic organ prolapse. Thus, it is important to study vaginal fibroblasts to better understand the pathophysiology of prolapse.

Objective: This study aimed to compare 3 culturing methods of primary vaginal fibroblasts.

Study design: This was an in vitro study. Patients who were undergoing surgery for vaginal prolapse were recruited. Excess vaginal epithelial tissue that would have otherwise been discarded was collected. The vaginal fibroblasts from each participant were cultured via (1) 3-hour digest, (2) coverslip, and (3) gelatin-coat methods. Differences in the efficiency of cell isolation, expression of known fibroblast-associated genes, and cellular function were compared between the 3 methods using one-way analysis of variance and Tukey test for post hoc pairwise comparisons (P < 0.05).

Results: Five patients with pelvic organ prolapse were recruited. Fibroblasts cultured via the 3-hour digest method became confluent within 3-5 days in a 100-mm dish compared to 2-3 weeks in a 6-well dish for the coverslip and gelatin-coat methods. Cells from all culture methods expressed similar amounts of vimentin and α smooth muscle actin. There were no significant differences in morphology; gene expression levels of MMP1, MMP2, ACTA2, COL1A1, COL3A1, and LOXL1 on qPCR; cell viability; proliferation; and migration between the 3 culturing methods.

Conclusion: Culturing primary vaginal fibroblasts via the 3-hour digest, coverslip, and gelatin-coat methods similarly resulted in reliable primary vaginal fibroblast growth and function.

Importance: Sacral neuromodulation (SNM) requires removal for infectious complications in 3-11%.

Objective: The objective of this study was to examine the effect of preoperative antibiotic choice on all-cause SNM device removal rates.

Study design: This was a retrospective cohort analysis, using the Health Facts Database, representing more than 750 hospitals. We included female patients undergoing SNM implantation from 2010 to 2018. Univariate and multivariate logistic regression identified factors associated with removal. Thirty-five comorbidities were evaluated. Those with P < 0.2 on univariate analysis were included in the multivariate analysis. We decided a priori to include prophylactic antibiotic choice in the final model.

Results: Of 1,433 patients, 170 (11.9%) had device removal. Patients were 63.0 ± 14.9 years old, predominantly Caucasian (90.0%), treated in urban hospitals (94.1%), and married (54.2%). A total of 11.8% were obese, and 18.0% smoked. Those in the removal cohort were more likely from the Northeastern United States; 52.3% received first-gen cephalosporins (CPSN), 7.4% second- or third-generation CPSNs, 9.1% vancomycin, 13.4% aminoglycosides, 4.6% clindamycin, and 13.3% fluoroquinolones. Compared to vancomycin, more removals were associated with first-generation CPSNs (odds ratio [OR] = 3.1, 95% confidence interval [1.4, 6.8]); clindamycin (OR = 3.2, [1.2, 8.4]); second/third-generation CPSNs (OR = 3.1, [1.3, 7.6]); and aminoglycosides (OR = 3.1, [1.3, 7.4]). Additionally, patients treated in the Northeast were more likely to undergo removal (OR = 1.9, [1.0, 3.7]).

Conclusions: Vancomycin as a prophylactic antibiotic was associated with fewer device removals compared to most antibiotics in this retrospective cohort analysis. While prospective trials could confirm this benefit, low removal rates may make this impractical.