Evaluation of Transvaginal Uterosacral Ligament Hysteropexy vs. Uterosacral Ligament Suspension with Hysterectomy: A Retrospective Comparison Study with Two Year Outcomes

Introduction: Pelvic organ prolapse affects many women with an 12.6% lifetime risk of requiring surgical intervention. There has been growing interest in the efficacy of uterine preservation for uterovaginal prolapse. Many studies to date have evaluated sacrospinous hysteropexy and sacral hysteropexy as surgical options for uterine preservation techniques for the correction of uterovaginal prolapse. There is paucity in the data regarding uterosacral ligament hysteropexy (USLH). The objective of this study was to evaluate the two year outcomes of utererosacral ligament hysteropexy in comparison to uterosacral ligament suspension with hysterectomy in terms of operative data, anatomical efficacy and patient satisfaction. Methods: A retrospective chart review was performed on patients that underwent a high uterosacral hysteropexy or uterosacral ligament suspension with hysterectomy between 2013 and 2016 by a single provider. Patient demographics, baseline and follow-up POP-Q exam, operative data and patient satisfaction scores were evaluated with descriptive statistics. Results: The USLH group included 14 patients and the hysterectomy group included 13 patients. Please see Table 1 for patient demographic information. Mean estimated blood loss was 75.4 cc for the USLH and 209.6 cc for the hysterectomy group (p=0.001). 64% of the USLH group followed up at 21.6 months or later while only 46.2% of the hysterectomy group followed up at more than 22.3 months. At this follow-up point, 8/9 in the USLH group had stage 2 or less prolapse and 6/6 had stage 2 or less prolapse in the hysterectomy group. Reoperation was required in 2/14 in the USLH group with these patients having preoperative stage 3 and 4 prolapse. The mean Pelvic Floor Distress Inventory 20 (PFDI-20) questionnaire scores showed no statistical significance between the patients that followed up at this time interval. Conclusion: Transvaginal uterosacral ligament hysteropexy appears to provide comparable results to uterosacral ligament suspension with hysterectomy. Though this study was limited by its small sample size and limited patient follow-up, there is evidence that results are durable at 2 years for those that do not have high grade preoperative prolapse

Evaluation of Transvaginal Uterosacral Ligament Hysteropexy vs. Uterosacral Ligament Suspension with Hysterectomy: A Retrospective Comparison Study with Two Year Outcomes

Introduction: Pelvic organ prolapse affects many women with an 12.6% lifetime risk of requiring surgical intervention. There has been growing interest in the efficacy of uterine preservation for uterovaginal prolapse. Many studies to date have evaluated sacrospinous hysteropexy and sacral hysteropexy as surgical options for uterine preservation techniques for the correction of uterovaginal prolapse. There is paucity in the data regarding uterosacral ligament hysteropexy (USLH). The objective of this study was to evaluate the two year outcomes of utererosacral ligament hysteropexy in comparison to uterosacral ligament suspension with hysterectomy in terms of operative data, anatomical efficacy and patient satisfaction. Methods: A retrospective chart review was performed on patients that underwent a high uterosacral hysteropexy or uterosacral ligament suspension with hysterectomy between 2013 and 2016 by a single provider. Patient demographics, baseline and follow-up POP-Q exam, operative data and patient satisfaction scores were evaluated with descriptive statistics. Results: The USLH group included 14 patients and the hysterectomy group included 13 patients. Please see Table 1 for patient demographic information. Mean estimated blood loss was 75.4 cc for the USLH and 209.6 cc for the hysterectomy group (p=0.001). 64% of the USLH group followed up at 21.6 months or later while only 46.2% of the hysterectomy group followed up at more than 22.3 months. At this follow-up point, 8/9 in the USLH group had stage 2 or less prolapse and 6/6 had stage 2 or less prolapse in the hysterectomy group. Reoperation was required in 2/14 in the USLH group with these patients having preoperative stage 3 and 4 prolapse. The mean Pelvic Floor Distress Inventory 20 (PFDI-20) questionnaire scores showed no statistical significance between the patients that followed up at this time interval. Conclusion: Transvaginal uterosacral ligament hysteropexy appears to provide comparable results to uterosacral ligament suspension with hysterectomy. Though this study was limited by its small sample size and limited patient follow-up, there is evidence that results are durable at 2 years for those that do not have high grade preoperative prolapse

Relationship Between Pelvic Organ Prolapse and Metabolic Syndrome

Introduction: The prevalence of pelvic organ prolapse (POP) has been increasing with the increase in the proportion of elderly patients. Metabolic Syndrome (MS) is a constellation of signs that are associated with insulin resistance and increased risk of cardiovascular disease. It also increases in prevalence with increasing age. In this study we sought to find if an association exists between MS and POP in the U.S population. Methods: Patients were recruited from our urogynecology and female urology clinics. All the patients were referred to our clinics with various pelvic floor complaints. After written informed consent, a waist circumference was measured and recorded. The remaining MS criteria were collected from the chart including, blood pressure, fasting blood glucose; if not available glycated Hemoglobin; triglycerides, and high density lipoprotein. Other variables collected include age, gravity, parity, number of vaginal deliveries, body mass index, and history of previous pelvic organ prolapse surgery. A pelvic organ prolapse quantification was performed as part of our routine examination. Results: A total of 142 patients were recruited. 138 were included in our analysis. The average age was 69 (±10.6). Metabolic Syndrome was not significantly associated with POP (OR: 0.827, 95% CI 0.421-1.625). None of the MS subcategories were significantly associated with POP after controlling for other confounders such as age and number of vaginal deliveries. Age was significantly associated with POP (p = 0.009). Body mass index, gravity, parity or number of vaginal deliveries were not independently associated with POP. Conclusion: MS was not associated with POP. Only age was significantly associated with the development of pelvic organ prolapse

Relationship between pelvic organ prolapse and metabolic syndrome

Introduction: The prevalence of pelvic organ prolapse (POP) has been increasing with the increase in the proportion of elderly patients. Metabolic Syndrome (MS) is a constellation of signs that are associated with insulin resistance and increased risk of cardiovascular disease. It also increases in prevalence with increasing age. In this study we sought to find if an association exists between MS and POP in the U.S population. Methods: Patients were recruited from our urogynecology and female urology clinics. All the patients were referred to our clinics with various pelvic floor complaints. After written informed consent, a waist circumference was measured and recorded. The remaining MS criteria were collected from the chart including, blood pressure, fasting blood glucose; if not available glycated Hemoglobin; triglycerides, and high density lipoprotein. Other variables collected include age, gravity, parity, number of vaginal deliveries, body mass index, and history of previous pelvic organ prolapse surgery. A pelvic organ prolapse quantification was performed as part of our routine examination. Results: A total of 142 patients were recruited. 138 were included in our analysis. The average age was 69 (±10.6). Metabolic Syndrome was not significantly associated with POP (OR: 0.827, 95% CI 0.421-1.625). None of the MS subcategories were significantly associated with POP after controlling for other confounders such as age and number of vaginal deliveries. Age was significantly associated with POP (p = 0.009). Body mass index, gravity, parity or number of vaginal deliveries were not independently associated with POP. Conclusion: MS was not associated with POP. Only age was significantly associated with the development of pelvic organ prolapse

Propofol-Related Infusion Syndrome in the Peripartum Period.

Background Propofol is a widely known, commonly used drug. Complications can occur with the use of this drug, including propofol-related infusion syndrome (PRIS). PRIS, in the obstetric population, has not been documented; however, we report a case of a patient who developed PRIS after an emergent cesarean delivery of a preterm infant. Case Study A 35-year-old multigravida woman presented complaining of leakage of fluid and decreased fetal movement. Her pregnancy was complicated by methadone maintenance therapy due to a history of opioid abuse. Complications after admission for prolonged monitoring and a prolonged fetal heart tone deceleration was noted with no recovery despite intrauterine resuscitation. An emergent cesarean delivery was performed using general anesthesia and endotracheal intubation after which she developed aspiration pneumonia. She was admitted to the intensive care unit and reintubation and sedation were required secondary to respiratory distress. Sedation was achieved using propofol infusion. She subsequently developed changes in her electrocardiogram, an increase of her serum creatinine, creatinine protein kinase, lipase, amylase, and triglycerides, making the diagnosis of PRIS. Conclusion PRIS should be included in the differential diagnosis of intubated or postoperative patients in the obstetric population. Keywords: PRIS, infusion syndrome, pregnancy, obstetric

Quality of life outcomes in peri-urethral calcium hydroxylapatite injection.

INTRODUCTION AND HYPOTHESIS: Peri-urethral calcium hydroxylapatite injection is an established treatment for patients with stress urinary incontinence. Information is limited regarding calcium hydroxylapatite treatment and quality of life (QOL) outcomes. We hypothesize that patients might improve QOL after peri-urethral calcium hydroxylapatite injection, which was reflected in validated questionnaires. METHODS: The peri-urethral calcium hydroxylapatite injection billing code was used to identify patients who underwent injection from 2011-2013. Female patients who completed the American Urological Association Symptom Score (AUASS), the AUASS QOL and Michigan Incontinence Symptom Index (M-ISI), and the bother score (M-ISI bother), or pad count at baseline and follow-up were included. Change in questionnaire scores and pads were assessed using the paired t test. RESULTS: Sixty patients underwent 1 (30), 2 (63) or 3 (7 %) peri-urethral calcium hydroxylapatite injections performed by a single surgeon. Thirty-seven patients provided questionnaires and 38 provided pad counts, all with a mean age of 75 years. The overall AUASS, AUASS QOL, and overall M-ISI scores improved in 67.6, 54.8, and 61.3 % respectively (4.5 ± 7.9, 1.3 ± 1.7 and 5.5 ± 8.6 respectively). The M-ISI bother score improved in 44.8 % with a mean improvement of 0.5 ± 2.9, but did not reach significance. There was a 1.7 ± 3.7 decrease in the mean number of pads used daily after the procedure (p = 0.006) and 19 % experienced transient urinary retention. CONCLUSIONS: Peri-urethral calcium hydroxylapatite injections can improve urinary QOL scores in patients with initial and recurrent stress urinary incontinence. This short-term retrospective analysis suggests that larger long-term studies focusing on QOL outcomes are needed to evaluate the effect of peri-urethral calcium hydroxylapatite has on incontinence-specific QOL

Effect of morbid obesity on mid-urethral sling effecacy for the management of stress urinary incontinence.

Objectives: Mid-urethral slings (MUS) are the most widely accepted and studied minimally invasive procedure for the management of stress urinary incontinence (SUI) (1). However, studies have suggested decrease in efficacy of MUS procedures in the obese patients (2). In our urban population, we are encountering an increasing number of morbidly obese patients (BMI≥40) presenting with stress urinary incontinence interested in surgical management. The aim of our study was to assess the success rate of MUS in the morbidly obese patients. Our secondary outcome was to assess difference in complication rates between patients with BMI≥40 and \u3c40. Methods: This is a retrospective chart review. We collected data on all patients that have undergone a sling procedure between 2008-2015 in our health system. Failure was defined as reported SUI symptoms or treatment for SUI. Variables collected were BMI, smoking status, comorbidities, peri-operative complications (within 24hrs), short term (within 30days) and long term complications (\u3e30days) and the follow-up time. Analyses included ANOVA, Chi-square test, logistic, Kaplan Meier method and Cox regression. Results: We identified 565 patients, 130 were eliminated as they underwent a sling procedure other than MUS and for follow-up time \u3c6 months. 435 were included in our analysis, 49 patients were morbidly obese (mean=44.9 +/-5.07), 164 with BMI of 30-39 (mean=33.6 +/-2.63), 123 with BMI of 25-29.9 (mean= 27.4 +/-1.13) and 99 with BMI ≤25 (mean=23 +/-1.68). Our mean follow-up time was 52 months. There was no difference in failure rate between normal weight, overweight and class 1 and 2 obesity groups even after controlling for potential confounders such as diabetes mellitus (DM), smoking status, or chronic obstructive pulmonary disease (COPD) (p=0.18). Morbid obesity (BMI\u3e40) was associated with increased risk of failure when compared to the normal weight category (p=0.04, OR: 2.38, CI:1.05-5.39). COPD independently was associated with an increased risk of failure, odds ratio p=0.05, OR=1.72, CI=0.98-2.95). BMI category was not a significant predictor of peri-operative, short-term post-operative or long-term post-operative complications (p=0.33, p=0.16 and p=0.15 respectively) and also after controlling for other comorbidities as potential confounders. Conclusions: BMI has significant impact on MUS failure in the morbidly obese patients when compared to the normal weight category. This effect was not seen in overweight and Class 1 and 2 obesity categories. COPD independently and after stratification based on BMI category was associated with a higher failure rate and recurrence of stress urinary incontinence

Effect of Morbid Obesity on Midurethral Sling Efficacy for the Management of Stress Urinary Incontinence.

OBJECTIVES: The aim of our study was to assess midurethral sling (MUS) failure rate in the morbidly obese (body mass index [BMI] ≥40 kg/m) population as compared with normal-weight individuals. Our secondary objective was to assess the difference in complication rates. METHODS: This is a retrospective cohort study. We included all patients who underwent a synthetic MUS procedure from January 1, 2008, to December 31, 2015, in our health system. Failure was defined as reported stress urinary incontinence symptoms or treatment for stress urinary incontinence. Variables collected were BMI; smoking status; comorbidities; perioperative (≤24 hours), short-term (≤30 days), and long-term (\u3e30 days) complications; and follow-up time. Statistics include analysis of variance, χ test, logistic regression, Kaplan-Meier method, and Cox regression. RESULTS: There were 431 patients included in our analysis. Forty-nine patients were in class 3 with a BMI mean of 44.9 ± 5.07 kg/m. Median follow-up time was 52 months (range, 6-119 months). Class 3 obesity (BMI ≥40 kg/m) was the only group that had an increased risk of failure when compared with the normal-weight group (P = 0.03; odds ratio, 2.47; 95% confidence interval, 1.09-5.59). Obesity was not a significant predictor of perioperative, short-term, or long-term postoperative complications (P = 0.19, P = 0.28, and P = 0.089, respectively) after controlling for other comorbidities. CONCLUSIONS: Patients in the class 3 obesity group who are treated with an MUS are 2 times as likely to fail when compared with those in the normal-weight category on long-term follow-up with similar low complication rates