Midurethral Sling Placement Research Articles

An update on surgical management for stress urinary incontinence.

Stress urinary incontinence (SUI) is a common condition for which women often opt for surgical management. Synthetic midurethral slings (MUS) have been the dominant treatment for decades. Single-incision slings (SIS) have been introduced to lower the morbidity associated with trocar passage during MUS placement. Urethral bulking has been used less frequently owing to its lower cure rates. New data have recently emerged in support of single-incision slings (SIS) and urethral bulking with Bulkamid polyacrylamide hydrogel (PAHG). Several studies with a follow-up ≥10 years have shown stable efficacy and complication rates of retropubic (RMUS) and transobturator (TMUS) midurethral slings over time. SIS products show equivalent efficacy to traditional TMUS and RMUS at up to 3 years of follow-up and can be placed under local anesthesia. While urethral bulking with PAHG results in lower cure rates compared to slings, satisfaction rates are high and responders have sustained improvement at 7 years follow-up. All three types of available slings, TMUS, RMUS, and SIS, are now considered appropriate surgical options for the treatment of SUI. Although the absence of comparative data precludes a formal recommendation for one injectable over another, urethral bulking with PAHG has favorable long-term results and an excellent safety profile.

No mess with mesh; vaginal natural orifice transluminal endoscopic surgery (vNOTES) autologous posterior rectus fascia mesh for vaginal urinary incontinence procedures

Urinary incontinence affects 25–45 % of women with the gold standard surgical approach being placement of mid-urethral synthetic slings; tension-free vaginal tape (TVT) and trans-obturator tape (TOT). Due to the controversies regarding vaginal mesh the last decade, an increasing demand has evolved for incontinence treatment without vaginal synthetic mesh. The short term results of autologous rectus fascia sling for TOT surgery have shown similar success rates compared to those after the use of synthetic mesh, but the harvesting of the mesh is less minimally invasive and is associated with longer surgical time.vNOTES is a combination of a vaginal entrance to the abdomen and endoscopy via the vagina.The aim with the video is to show a new surgical technique with a fully vaginal, scarless vNOTES approach for harvesting the posterior rectus fascia for TVT and TOT procedures.

(110) THE SURGICAL ANATOMY OF CLITORAL INNERVATION: A REVIEW OF THE CURRENT MEDICAL LITERATURE

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

Midurethral Sling With Concomitant Sacrocolpopexy: Does the Sequence Matter? A Retrospective Cohort Study

The objective is to determine if the timing of midurethral sling (MUS) placement has an impact on the recurrence rate of stress urinary incontinence. We conducted a retrospective cohort study of patients who underwent robot sacrocolpopexy (RSC) with MUS placement at a large community hospital. Our data demonstrated that there was no significant difference in stress urinary incontinence recurrence when the MUS was placed before or after the RSC (15% vs. 11%, P = 0.41, respectively). We concluded that physician preference may dictate surgical approach to sequence of retropubic MUS placement at the time of RSC.

Assessment of Urinary Dysfunction After Midurethral Sling Placement: A Comparison of Two Voiding Trial Methods

Study objectiveTemporary urinary retention after midurethral sling (MUS) surgery requiring indwelling catheter or self-catheterization usage is common. Different methods for assessment of immediate postoperative urinary retention have been described. The aim of this study was to compare postoperative voiding trial (VT) success following active versus passive voiding trial in women undergoing MUS surgery.Design: Comparative retrospective cohort study. SettingFemale pelvic medicine and reconstructive surgery practice at a university affiliated tertiary medical center. PatientsPatients with stress urinary incontinence who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients under the age of 18, combined cases with other surgical services, planned laparotomy, patients with history of urinary retention and patients for whom their VT was performed on postoperative day 1. The cohort was divided into two groups: 1) patients who underwent an active retrofill of their bladder using a Foley catheter; 2) patients who were allowed to have a spontaneous void. Interventionsnone. Measurements and main resultsTwo hundred and eighty-five patients met the inclusion criteria for the study. Of these subjects, 94 underwent an active voiding trial and 191 underwent a passive voiding trial. There were no statistically significant differences in immediate postoperative urinary retention (30.8% vs. 29.3%, p=0.79) or time from surgery end to voiding trial (233.0 ± 167.6 minutes vs. 203.1 ± 147.8 minutes, p=0.13) between groups. Urinary retention, as defined by a failed voiding trial, increased from 10% to 29.3% when MUS placement was accompanied by concomitant prolapse repair procedure. Multivariate logistic regression analysis revealed that undergoing a combined anterior and posterior colporrhaphy (OR 5.13, p <0.001) as well as undergoing an apical prolapse procedure (OR 2.75, p=0.004) were independently associated with immediate postoperative urinary retention while increased BMI (OR 0.89, p<0.001) lowered likelihood of retention. ConclusionThe method used to assess immediate postoperative urinary retention did not affect VT success. Concomitant combined anterior and posterior colporrhaphy and apical suspension were correlated with greater likelihood of VT failure while increased BMI decreased odds of retention.

Risk Factors for De Novo Overactive Bladder After Midurethral Sling

(Abstracted from Urogynecology 2024;30:59–64 The standard surgical treatment for stress urinary incontinence is midurethral sling (MUS) placement, due to its excellent efficacy, minimally invasive approach, and low overall rates of complication. However, development of de novo overactive bladder (OAB) symptoms is a known complication of anti-incontinence procedures and previously described as occurring in 5%–32% after fascial sling or Burch urethropexy.

Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience

ABSTRACT Duration, intensity, and management of pain and discomfort may all be affected by experience, personality, and medical and psychosocial comorbidities. A negative cognitive-affective response to actual or anticipated pain, which impacts the pain experience, is called pain catastrophizing. The scale utilized for identifying individuals who magnify, feel helpless to manage, anticipate, or ruminate on pain is known as the Pain Catastrophizing Scale (PCS) and is composed of a 13-question validated measure and 3 subscales. The scale's score ranges from 0 to 52, where scores of 30 and greater indicate pain catastrophizing (30 points is the 75th percentile for PCS score distribution in patients with chronic pain). Pain catastrophizing is associated with increased pain severity, pain persistence, and opioid consumption following surgery, as well as poorer response to endometriosis treatments. Approximately 300,000 prolapse surgical procedures are performed in the United States annually, and because little is known about pain catastrophizing on perioperative pain, pelvic floor symptom distress/impact, and voiding trial (VT) performance following urogynecologic surgery, the authors' primary aim was to assess baseline pain catastrophizing on preoperative pelvic floor symptom impact and distress. The secondary aims included assessing the impact of pain catastrophizing on voiding function and postoperative pain following pelvic floor surgery. The patients for this prospective cohort study included self-identifying female patients undergoing surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse from March 2020 to December 2021. Inclusion came following completion of appropriate surveys and subsequent surgery. Exclusion was merited through surgery for reasons besides SUI or prolapse. At the baseline patient visit, a PCS score of 30 or greater was defined as pain catastrophizing. The initial visit also included recording data such as body mass index, age, benzodiazepine use, chronic opioid use, anxiety and depression diagnoses, postoperative prolapse stage, bothersome urgency urinary incontinence, and preoperative postvoid residual volume. Charts were used for abstracting surgical data, such as operative time, estimated blood loss, type of pelvic reconstructive surgery performed, and midurethral sling placement. Surgeries were all performed by fellowship-trained reconstructive pelvic surgery providers. Postanesthesia care unit (PACU) nurses and clinic staff were masked to preoperative PCS scores obtained in the PACU and postoperative clinic visits. A standardized void trial was performed. Of 320 participants in this cohort, 46 had a pain catastrophizing score of ≥30. Mean age was 60.0 ± 12.8 years. Bivariate analysis indicated that the pain catastrophizing group had higher average body mass index and greater preoperative use of benzodiazepines. Variants such as SUI rates, urgency urinary incontinence, or prolapse stage had no significant differences between groups, yet preoperative pelvic floor symptom distress and impact scores were clinically and statistically significantly higher in the catastrophizing group. Higher PACU pain scores were associated with pain catastrophizing, but not first postoperative VT failure. A significant association between pain catastrophizing and symptom distress remained following multivariable analysis, as well as a relationship between high PCS scores and symptom impact. All quality-of-life subscales maintained the significant associations. This study, although unique in describing pain catastrophizing in this setting, includes various limitations such as its single-institutional nature, which may limit external generalizability. Furthermore, generalizability may also be limited for those electing nonsurgical management, as the study selected for women choosing surgery. Study strengths include its large number of patients cared for by fellowship-trained providers in a similar manner with uniform surgical practice and timing of measures for assessing pelvic pain and pelvic floor symptoms. Also, a relatively standard VT method was utilized. Although further investigation is warranted for describing pain catastrophizing and its role with pelvic floor symptoms and pain postoperatively, the results of this study support other investigative findings, which indicate the importance of understanding pain catastrophizing and its potential effect on patients undergoing pelvic floor surgery. Future studies around this relationship can potentially enable health care providers to tailor perioperative care for individuals with pain catastrophizing.

Evaluation of Outcomes Between the Top-down Versus the Bottom-up Approach for Retropubic Midurethral Sling

Introduction and hypothesisRetropubic midurethral sling (MUS) placement is the gold standard for the treatment of stress urinary incontinence in the USA. The procedure can be approached from either a top-down or a bottom-up direction, but there is a paucity of contemporary data regarding outcomes between these approaches. The aim of this study was to provide updated clinical outcomes data.MethodsThis was a retrospective cohort study of women undergoing the retropubic MUS procedure alone or at the time of pelvic organ prolapse repair between 2010 and 2020 at a single academic medical center. The electronic medical record was used to extract demographic data, operative approach, and perioperative complications. The primary outcome was a composite incidence of any perioperative complication.ResultsOf the 309 patients analyzed, 140 (45.3%) underwent top-down and 169 (54.7%) underwent bottom-up retropubic MUS placement. Patients undergoing top-down MUS placement were more likely to be older (mean age 58 vs 54, p=0.02), have a history of diabetes mellitus (20% vs 8.9%, p=0.004), and have had a prior hysterectomy (27% vs 16%, p=0.02). They were less likely to have a concurrent anterior (p<0.001) or posterior repair (p<0.001). Patients undergoing the top-down procedure were less likely to experience sling exposure (p=0.02); complications in the two groups were otherwise similar.ConclusionsThe top-down approach to retropubic MUS placement was associated with lower rates of mesh erosion in this population of patients. Neither approach is associated with an increased overall risk of complications or de novo overactive bladder symptoms.

(265) The Surgical Anatomy of Clitoral Innervation: A Review of the Current Medical Literature

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. Fourteen papers discussed both somatic and autonomic innervation to the clitoris. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

More With Less: Single-Incision Sling Insertion Techniques

To demonstrate reproducible procedures for efficient single-incision sling insertion and troubleshooting. Narrated video footage with stepwise demonstration of single-incision sling insertion technique with anchor system. The mesh midurethral sling is a highly effective and safe procedure that is considered the gold standard for surgical treatment of stress urinary incontinence. Retropubic and transobturator approaches for midurethral slings have similar subjective cure rates with differing surgical risk profiles [1,2]. The retropubic route has a higher risk of injury to the bladder, nerves, and vascular structures, whereas the obturator approach carries a risk of groin or thigh pain [3-5]. Use of a single-incision sling decreases these risks and allows flexibility to perform the procedure without sedation or general anesthesia. Recent literature demonstrates similar subjective and objective success and safety of single-incision slings compared with both retropubic and transobturator approaches, although long-term data are forthcoming [5]. We demonstrate a stepwise approach for the insertion of a single-incision sling using a helical trocar. Easily reproducible procedures for setup and sling anchor management allow for efficient placement without assistance. In addition, we outline hand positioning, trocar management, and anchor deployment with troubleshooting techniques for potential placement difficulties. Finally, we review methods for sling tensioning to prevent complications such as voiding dysfunction and mesh or suture exposures. Given that single-incision slings are more likely to be performed under local anesthesia and are less invasive with decreased recovery time, it has the potential to become the preferred approach in the future. This video demonstrates clear and detailed steps to facilitate successful placement of the single-incision mesh midurethral sling.

Persistent and De Novo Stress Urinary Incontinence After Minimally Invasive Sacrocolpopexy.

Data on stress urinary incontinence (SUI) after minimally invasive sacrocolpopexy (SCP) with or without midurethral sling placement are limited. The aim of the study was to determine the incidence of SUI after minimally invasive sacrocolpopexy. This was a secondary analysis of 2 randomized clinical trials of participants undergoing SCP. Participants completed symptom assessment and urodynamic testing. Participants underwent SCP with or without midurethral sling placement. Preoperatively, participants were defined as having symptomatic SUI, occult SUI, or no SUI. Participants completed the Pelvic Floor Distress Inventory-20 at 6 and 12 months postoperatively and were categorized as having persistent SUI in the setting of symptomatic or occult SUI or de novo SUI. Eighty-one participants were included. Sixty-one participants met inclusion criteria for the persistent SUI analysis: 42 participants with symptomatic SUI and 19 participants with occult SUI. There were 20 participants in the de novo SUI group. The overall incidence of persistent SUI was 26.2% (95% confidence interval [CI], 15.8%-39.1%) with 33.3% (95% CI, 19.6%-49.6%) of symptomatic and 10.5% (95% CI, 1.5%-33.1%) of occult participants. Bothersome symptoms were defined as "moderately" or "quite a bit" bothered postoperatively. Of participants with symptomatic SUI, 14.3% participants were bothered and no participants underwent retreatment. No patient with occult SUI was bothered; however, 1 patient underwent retreatment. The incidence of de novo SUI was 45% (95% CI, 23.1%-68.5%). No patient in the de novo SUI group was bothered or underwent SUI treatment. Approximately 1 in 4 participants reported persistent SUI. Almost 50% reported de novo SUI. However, few participants were bothered or underwent treatment.

Efficacy of botulinum toxin in the management of refractory de novo overactive bladder symptoms in women after midurethral sling placement: retrospective, single center study.

This study aimed o evaluate the efficacy of onabotulinumtoxin A (onaBTX-A) intradetrusor injections in women with refractory de novo overactive bladder (OAB) following midurethral sling (MUS) placement. A retrospective single-center study was conducted. We screened 372 women who underwent MUS surgery between August 2009 and January 2022. 54/372 women diagnosed with pharmacologically refractory de novo OAB following MUS were evaluated using cystoscopy and urodynamics, and after tape erosion and obstructive voiding were excluded, they received onaBTX-A therapy. Outcomes were the reduction of self-reported OAB symptoms and leakage episodes, improvement of validated OAB scores and adverse events of the procedure after a follow-up of 3, 6, and 12 months. Successful results were reported in 81%, 68%, and 43% at 3, 6 and 12 months respectively. Postoperatively, median voiding frequency and median nocturia episodes were significantly improved in 70% and 77% of women, respectively, with a decrease in daily number of voids (-4.1, p = 0.0001) and nocturia episodes (-2.2, p = 0.005). At 3 months, 80% of women reported an >25% reduction in urgency severity and episodes following injection. The median number of pads used was significantly reduced after injection (-2 pads; p = 0.03). Repeat injections of onaBTX-A were performed in 61% of patients after a median of 11 months. Intravesical onaBTX-A injections are clinically effective at 3- and 6-month follow-up for the treatment of refractory de novo OAB after MUS placement. Over 60% of the patients opted for retreatment with onaBTX-A due to a high level of satisfaction.

Is antibiotic prophylaxis generally safe and effective in surgical and nonsurgical scenarios? Evidence from an umbrella review of randomized controlled trials.

The authors aimed to comprehensively evaluate the efficacy and safety of antibiotic prophylaxis through surgical and nonsurgical scenarios and assess the strength of evidence. The authors performed an umbrella review of meta-analyses of randomized controlled trials (RCTs). An evidence map was created to summarize the absolute benefits of antibiotic prophylaxis in each scenario and certainty of evidence. Seventy-five meta-analyses proved eligible with 725 RCTs and 78 clinical scenarios in surgical and medical prophylaxis. Of 119 health outcomes, 67 (56.3%) showed statistically significant benefits, 34 of which were supported by convincing or highly suggestive evidence from RCTs. For surgeries, antibiotic prophylaxis may minimize infection occurrences in most surgeries except Mohs surgery, simple hand surgery, herniorrhaphy surgery, hepatectomy, thyroid surgery, rhinoplasty, stented distal hypospadias repair, midurethral sling placement, endoscopic sinus surgery, and transurethral resection of bladder tumors with only low to very low certainty evidence. For nonsurgery invasive procedures, only low to very low certainty evidence showed benefits of antibiotic prophylaxis for cystoscopy, postoperative urinary catheterization, and urodynamic study. For medical prophylaxis, antibiotic prophylaxis showed greater benefits in nonemergency scenarios, in which patients were mainly with weakened immune systems, or at risk of recurrent chronic infections. Antibiotics prophylaxis may increase antibiotic resistance or other adverse events in most scenarios and reached significance in cystoscopy, afebrile neutropenia following chemotherapy and hematopoietic stem cell transplantation. Antibiotic prophylaxis in surgical and nonsurgical scenarios is generally effective and seems independent of surgical cleanliness and urgency of diseases. Its safety is not well determined due to lack of available data. Nevertheless, the low quality of current evidence limits the external validity of these findings, necessitating clinicians to judiciously assess indications, balancing low infection rates with antibiotic-related side effects.

Impact of Sling at Time of Prolapse Surgery on Overactive Bladder.

Prolapse surgery and sling surgery both lead to improvement in overactive bladder. However, less is known regarding how slings performed concurrently with less is know about how overactive bladder symptoms change in patients having prolapse surgery with a sling compared to prolapse surgery without a sling. The primary aim was to compare change in postoperative overactive bladder symptoms in patients with preoperative overactive bladder who underwent sling placement versus no sling with prolapse surgery. This was a secondary analysis of a cohort study evaluating overactive bladder in patients undergoing prolapse surgery. Sling procedures were performed concomitantly for treatment or prevention of stress incontinence. Baseline and 3-month follow-up urinary symptoms were assessed with the Overactive Bladder Questionnaire Short Form (OAB-q SF) and Urinary Distress Inventory-6 (UDI-6). Of patients with overactive bladder, 26 (40.0%) underwent midurethral sling (MUS) placement and 39 (60.0%) no sling. Preoperative OAB-q SF bother (score [SD], 46.8 [20.2] vs 40.2 [22.1]; P = 0.23) was similar between groups, but UDI-6 scores (59.2 [28.8] vs 43.8 [29.1]; P = 0.04) were higher in the sling group. At 3 months, the change (improvement) in OABq-SF bother (-16.9 [24.1] vs -22.4 [23.0]; P = 0.36), OABq-SF health-related quality of life (22.8 [28.6] vs 22.9 [23.9]; P = 0.99), and UDI-6 (-38.8 [32.9] vs -34.0 [27.8]; P = 0.53) were similar in the MUS and no MUS groups. Patients with prolapse and overactive bladder undergoing prolapse surgery with a sling had similar improvements in OAB-q SF bother scores compared with those who did not have a sling.

Trans-labial or introital ultrasounds for midurethral slings.

Stress urinary incontinence is common in adult women. The use of introital or trans-labial ultrasound can help the surgeon (urologist or gynecologist) to better assess the type of incontinence the patient presents in order to guide him in the management of the patient. Often, surgical treatment with a mid-urethral sling (MSU) placement can be chosen in case of failure of non-invasive therapies (such as local estrogen or physical therapy) and if the clinical examination shows an urethral hypermobility. The use of ultrasound can help in this choice. Although rare, complications of MSU can sometimes cause disabling symptoms and be difficult to diagnose. Introital or trans-labial ltrasound can help diagnose them. The objective of this work was to describe the realization of ultrasound of stress urinary incontinence before or after the placement of a MSU, in order to make their realization easier for young surgeons which can use them in current practice.

Cost Effectiveness of Concurrent Midurethral Sling at the Time of Prolapse Repair: Results From a Randomized Controlled Trial

ABSTRACT After pelvic reconstructive surgery for pelvic organ prolapse, postoperative stress urinary incontinence (SUI) commonly occurs, which leads many women to choose to have a midurethral sling placed at the time of surgery, even in cases without symptomatic preoperative urinary incontinence. Approximately 27.3% of women with a sling had de novo SUI despite this intervention. Full evaluation of the societal and economic implications brought by a midurethral sling placement attempting to prevent postoperative de novo SUI at the time of a pelvic reconstructive surgery have yet to be evaluated. This study aimed to evaluate the 1-year cost-effectiveness of a midurethral sling in the prevention of SUI at the time of prolapse surgery. This assessment was a randomized controlled trial based on patient resource utilization and patient-reported effectiveness. Study data were obtained via the OPUS randomized clinical trial, which was performed through the Pelvic Floor Disorders Network (a cooperative agreement network sponsored through the National Institute of Child Health and Human Development). A total of 337 women with anterior vaginal prolapse and without SUI symptoms set to undergo treatment from May 2007 to January 2011 were included in the study. Patients were randomly assigned to receive either sham incisions or a midurethral sling during vaginal prolapse surgery. Follow-up occurred at 3, 6, and 12 months postsurgery, with surveys, physical examinations, and medical history. Cost data were collected, and overall health utility in quality-adjusted life-years (QALYs) was calculated. Secondary outcomes were urinary incontinence-specific quality of life and cases of urinary incontinence, as defined by bothersome incontinence symptoms and positive cough stress tests. Initial surgical procedures and subsequent urinary incontinence-related health care were all used for recording health care sector costs. Total costs for study participants were collected via health care resource utilization data, including office visits, additional surgical procedures, and related procedures. The incremental cost-effectiveness ratio was the difference between the sham incision and midurethral sling groups in mean cost, divided by difference in mean QALYs. Data for health care resource utilization were collected during the trial period. Questionnaires at baseline, 3, 6, 9, and 12 months were used to collect other costs. At 1 year, one-way sensitivity analysis was performed for assessing the varying effectiveness of midurethral slings at 1 year, by noting the urinary incontinence-associated patient costs and by using varied QALY for the sling group. Results were taken from a study population of 337 women who underwent randomization to be included in the analysis of cost-effectiveness. No great variance of characteristics existed between groups. One year after surgery, a lower rate of urinary incontinence existed for those in the midurethral sling group. Notably, QALYs were not statistically different between midurethral sling and sham incision groups at baseline, but at 12 months, there was an improvement in both the UDI stress subscale and an overall reduction in the Incontinence Severity Index for the midurethral sling group. In conclusion, although prophylactic midurethral sling placements during vaginal prolapse surgery does reduce the rate of de novo SUI, based on this analysis of date from the OPUS trial, it is not a cost-effective intervention. The decision to place a sling in this setting is often driven by cost savings on the patient side, whereas midurethral sling health care costs are higher than when sling is not done.

Cost-Utility Analysis of Midurethral Sling Timing Among Women Undergoing Prolapse Surgery.

There are no guidelines regarding the ideal timing of midurethral sling (MUS) placement following prolapse repair. The objective of this study was to estimate the cost-utility of concomitant MUS versus staged MUS among women undergoing apical suspension surgery for pelvic organ prolapse. Cost-utility modeling using a decision analysis tree compared concomitant MUS with staged MUS over a 1-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER). Six scenarios were modeled to estimate cost-utilities for women with preoperative overt, occult, or no stress urinary incontinence (SUI) who underwent either minimally invasive sacrocolpopexy or vaginal native tissue apical suspension. Possible complications of de novo overactive bladder, urinary retention requiring sling lysis, mesh exposure, and persistent SUI were included. Costs from a third-party payer perspective were derived from Medicare 2022 reimbursements. One-way sensitivity analyses were performed. Among women without preoperative SUI, staged MUS was the dominant strategy for both surgical routes with higher utility and lower costs. For women with either occult or overt SUI undergoing sacrocolpopexy or vaginal repair, concomitant MUS was cost-effective (ICER = $21,114-$96,536 per quality-adjusted life-year). Therefore, concomitant MUS is preferred for patients with preoperative SUI as higher costs were offset by higher effectiveness. One-way sensitivity analyses demonstrated that ICERs were most affected by probability of cure following MUS. A staged MUS procedure is the dominant strategy for women undergoing apical prolapse repair without preoperative SUI. In women with either overt or occult SUI, the ICER was below the willingness-to-pay threshold of $100,000 per quality-adjusted life-year, suggesting that concomitant MUS surgery is cost-effective.

MP19-17 SPECIALTY-SPECIFIC TRENDS IN THE SURGICAL MANAGEMENT OF APICAL PELVIC ORGAN PROLAPSE POST VAGINAL MESH

You have accessJournal of UrologyCME1 Apr 2023MP19-17 SPECIALTY-SPECIFIC TRENDS IN THE SURGICAL MANAGEMENT OF APICAL PELVIC ORGAN PROLAPSE POST VAGINAL MESH Rahul Dutta, Gopal Badlani, and Catherine Matthews Rahul DuttaRahul Dutta More articles by this author , Gopal BadlaniGopal Badlani More articles by this author , and Catherine MatthewsCatherine Matthews More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Since transvaginal mesh (VM) for apical pelvic organ prolapse (APOP) repair was labeled “high-risk” in 2016 and subsequently banned in 2019 by the US Food and Drug Administration, remaining surgical treatment options include abdominal mesh-augmented sacrocolpopexy (AS) via laparoscopic (LAS) and open (OAS) approaches and vaginal native tissue apical suspension (VN). Our aim was to determine trends in APOP procedures post VM and whether differences existed between urologists and gynecologists. METHODS: Between 2011-2020, the National Surgical Quality Improvement Program (NSQIP) database was queried for AS, VM, and VN performed by both urologists and gynecologists. Trends in surgical approach were analyzed. RESULTS: 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) were included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with higher ASA score (32% vs 25% ASA III) with a higher prevalence of diabetes, chronic obstructive pulmonary disease, and bleeding disorders (p<0.05). Mean BMI was 28 and did not vary by specialty. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists (p<0.0001). VM utilization has decreased over time for both urologists (p=0.0242) and gynecologists (p=0.0001); a trend towards increasing AS (p=0.1646) in urologists and VN (p=0.0913) in gynecologists has concurrently occurred. Both specialties have increasingly favored LAS over OAS (p<0.0001). Operating room times did not vary for AS (p=0.1719) and were slightly higher for urologists in VM (111 vs 106 min, p=0.0432) and VN (118 vs 111 min, p<0.0001). Concurrent mid-urethral mesh sling placement occurred in 29% of cases overall; this has remained unchanged over time for urologists (p=0.8348) and decreased (p=0.0003) for gynecologists. CONCLUSIONS: Significant differences in the surgical approach to apical prolapse repair procedures and concomitant mid-urethral mesh slings exist between specialties. Urologists tend to operate on more medically complex and older patients with APOP and continue to demonstrate a strong preference for mesh-augmented repairs compared to transvaginal native tissue repairs. Minimally-invasive sacrocolpopexy is being more frequently performed by both specialties treating APOP. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e272 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rahul Dutta More articles by this author Gopal Badlani More articles by this author Catherine Matthews More articles by this author Expand All Advertisement PDF downloadLoading ...

Retreatment of Stress Urinary Incontinence After Midurethral Sling With Prior Urethral Bulking.

There is limited current literature regarding the retreatment of stress urinary incontinence (SUI) after midurethral sling (MUS) placement with prior urethral bulking. The objective was to evaluate the retreatment and perioperative complications of MUS placement with prior urethral bulking compared with MUS placement without prior urethral bulking. This was a retrospective cohort study of patients within the Southern California Permanente Medical Group who underwent MUS placement from January 2009 to December 2020. Patients who underwent prior urethral bulking were compared with a control group without prior urethral bulking in a 1:1 ratio matched by age and MUS procedure date. The primary outcome was the retreatment of SUI after MUS placement with prior urethral bulking. Secondary outcomes were perioperative complications. Regression models were used to evaluate associations between retreatment and perioperative complications while controlling for confounding variables. Eighty-five patients who underwent MUS placement with prior urethral bulking were identified and matched with 85 control patients who underwent MUS placement without prior urethral bulking. Patients who underwent MUS placement without prior urethral bulking were more likely to have concomitant surgery. Linear regression analysis controlling for the effect of concomitant surgery revealed no difference in estimated blood loss and operative time between the 2 groups. In logistic regression analysis, there was no difference in the retreatment rate and perioperative complications between groups. We found that the unique treatment combination of MUS placement with prior urethral bulking for recurrent SUI seems to have a similar retreatment rate and perioperative complications as MUS placement without prior urethral bulking.

8776 Perioperative Outcomes of Robotic Versus Open Midline Specimen Extraction Fascial Site Closure

<h3>Study Objective</h3> Laparoscopic sacrocolpopexy (SCP) is typically performed to repair advanced stage pelvic organ prolapse. Surgeons often opt to perform a supracervical hysterectomy (SCH) rather than total during combination SCP to avoid mesh erosions/infections. Tissue extraction is accomplished by extending a midline port site and may be closed by either a traditionally open or intra-abdominal robotic technique. This study aims to evaluate the outcomes of these two closures. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Academic-affiliated community hospital. <h3>Patients or Participants</h3> All patients (n=183) undergoing a robotic-assisted SCH, SCP, and midurethral sling placement by a single urogynecologist in which the uterus was extracted from an extended midline port between January 2021 and March 2022 were included in this study. <h3>Interventions</h3> Cases (n=105) of extraction sites closed via an intra-abdominal robotic approach were compared to controls (n=78) of a traditional open approach. <h3>Measurements and Main Results</h3> Casesand controls had similar operative times (251 vs 258 mins, p=0.35). Cases required less pain medication use in morphine milligram equivalents (MME) during the hospital stay (12.1 vs 18.4 MME, P<0.05). Body mass index (BMI) averages were also greater amongst cases (28.3 vs 26.3 kg/m², p<0.05). No difference was observed in other demographic data including age, race, and comorbid medical conditions. No statistical difference was noted comparing returns to the emergency department or hospital readmissions between groups. <h3>Conclusion</h3> Robotic and open fascial closure after tissue extraction requires similar operative times. Robotic closure has decreased pain requirements with similar complication profiles and was performed on patients with greater BMI reflecting surgeon bias for its use in obese patients. Surgeons should consider intra-abdominal robotic closure especially when patient body habitus makes secure fascial closure from an open approach more challenging.