Pelvic Medicine Research Articles

Mesh-associated pain syndrome: predictors for continence and prolapse mesh removal surgery in a single centre

ObjectiveOver the last two decades one of the main surgical treatment for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) surgery was the insertion of non-absorbable mesh to restore continence and prolapse respectively. Over time complications arose including mesh-associated pain syndrome (MAPS), mesh exposure, mesh, erosion, chronic bladder/vaginal infections, and dyspareunia. Consequently, women chose surgical mesh removal to counter these problems. However, little is known about the demographics, medical co-morbidities, mesh types involved and the timing from mesh insertion to mesh removal. This retrospective study will look at which of these factors may be closely associated with mesh removal surgery.DesignRetrospective evaluation.SettingFemale Pelvic Medicine and Reconstructive Surgery (FPMRS) Clinic at University College London Hospitals NHS Foundation Trust.PopulationAll patients presenting to the FPMRS Clinic between June 2011 to December 2019, requesting mesh removal surgery with a history of MAPS and other mesh complications were included in this study.MethodsPatient demographics including age, ethnicity, obstetric history, and medical co-morbidities; type of mesh/anatomical route used; onset of symptoms; and time from insertion to removal were recorded.Main Outcome MeasuresDetermination of correlation coefficients between patient demographics, patient reported symptoms and mesh removal surgery.ResultsThree hundred and forty-five women with a history of MAPS were included in the study. Women in the 40–60 year old cohort accounted for 54.4% of mesh removal surgery; 54.8% had a BMI under 30 and almost 90% were Caucasian. 96.5% had had children, with over 77% having had a vaginal delivery. 91.9% of patients reported other health conditions including 18.8% with a concomitant history of mental health problems and 15.4% with a history of heart disease. Over 80% of women undergoing mesh removal surgery had a continence mesh (49% retropubic and 32% obturator continence mesh) removed, whereas 20% had an abdominal prolapse and/or vaginal prolapse mesh removed. The average time from mesh insertion to mesh removal was seven years, with the prevalence of mesh removal surgery averaging 85% (range 50–100%) depending on the comorbidity determined.ConclusionsAll women presented to the clinic with a history of MAPS and other comorbidities which may have influenced their decision to pursue mesh removal surgery. There were no specific predictors, other than chronic pain associated with mesh, determining which women underwent surgery, though those with continence mesh were more likely to do so.

A Tale of 102,726 Messages: Characterizing the Modern Urologist's Portal Message Burden After Common Urologic Surgeries.

We aimed to characterize patient portal messaging use after urologic surgery to identify administrative burden and evaluate postoperative clinical associations. Epic was queried for all urologic surgeries performed at the Mayo Clinic enterprise between 2019 and 2022. Data from the highest volume procedures were extracted including patient-generated portal messages to their provider and emergency department (ED) visits within 6 months of surgery. Factors associated with portal users and message volume, as well as the impact of portal use on risk of subsequent ED visit, were evaluated. We analyzed data from 23,621 urologic procedures, which generated 102,726 patient portal messages within 6 months of surgery. We found that 55% of our cohort sent at least 1 message. Stratifying by subspecialty, endourologic surgeries generated the fewest number of messages per surgery (3.83; SD, 8.76), whereas female pelvic medicine and reconstructive surgeries yielded the most (6.05; SD, 10.92). Younger age, female sex, and White race were associated with increased portal utilization. Multivariable time-to-event analysis revealed a 33% reduction in the risk of ED presentation within 90 days after surgery for patients using the patient portal compared with those who did not. While only half of patients sent portal messages after surgery, active users showed a 33% reduction in ED visits, suggesting its potential to reduce health care utilization. Encouraging broader portal adoption can improve outcomes. However, the message burden for urologists necessitates solutions. Resource allocation should prioritize strategies to help urologists manage messages while preserving the established clinical benefits.

Towards a minimum data set for the female stress urinary incontinence surgical literature: a collaborative work.

There has been a need for an acceptable common minimum data set in the scientific literature as regards the surgical treatment of female stress urinary incontinence (SUI). Such a data set, if widely adopted, would improve the quality of the literature and allow objective comparisons between and across interventions. The surgical treatment of female stress urinary incontinence has evolved considerably over the past few decades. The corresponding body of literature has grown exponentially describing the outcomes of hundreds of studies of these novel interventions. However, historically, the literature in this space has been of uneven quality. In order to improve the reporting of clinical studies, and ultimately patient outcomes, a standard minimum data set for trial design and publications was created by a collaborative group formed from leading scientific societies. The consensus document created from this novel collaboration between members of SUFU (Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction), AUGS (American Urogynecologic Society), and ICS (International Continence Society) provides clear guidance for the structure of clinical studies and reporting of results in the peer-reviewed literature. This has substantial potential ramifications for scientific journals, journal editors, peer reviewers, investigators, regulatory agencies, industry, clinicians, and patients.

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence (MP23)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence (MP23)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Overactive Bladder II (PD54)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Overactive Bladder II (PD54)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Overactive Bladder I (PD43)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Overactive Bladder I (PD43)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Basic Research & Pathophysiology (MP59)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Basic Research & Pathophysiology (MP59)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence (MP03)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence (MP03)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction (Excluding OAB) (MP75)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction (Excluding OAB) (MP75)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Pelvic Organ Prolapse and Reconstructive Surgery (Including Non-trauma Related Fistula and Urethral Diverticulum) (PD24)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Pelvic Organ Prolapse and Reconstructive Surgery (Including Non-trauma Related Fistula and Urethral Diverticulum) (PD24)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neuromodulation (PD59)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neuromodulation (PD59)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neurogenic Voiding Dysfunction (PD07)

Urodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neurogenic Voiding Dysfunction (PD07)

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.

Performance of chatGPT on female pelvic medicine and reconstructive surgery PROLOG exam

Performance of chatGPT on female pelvic medicine and reconstructive surgery PROLOG exam

The Future of Basic Science: Development of the Next Generation of Mechanistic Researchers in Female Pelvic Medicine.

The International Urogynecological Association (IUGA) brought together senior and junior members actively engaged in scholarly and educational activities for a consensus conference centered on developing a strategy for sustainable training of the next generation of mechanistic researchers in female pelvic medicine. Four a priori identified major foci were explored in a half-day virtual consensus conference. Participants included representatives from various countries and disciplines with diverse backgrounds-clinicians, physician-scientists, and basic scientists in the fields of urogynecology, biomechanical engineering, and molecular biology.Following a keynote address, each focus area was first tackled by a dedicated breakout group, led by the Chair(s) of the most relevant IUGA committees. The break-out sessions were followed by an iterative discussion among all attendees to identify mitigating strategies to address the shortage of mechanistic researchers in the field of female pelvic medicine. The major focus areas included: research priorities for IUGA basic science scholar program; viable strategies for sustainable basic science mentorship; core competencies in basic science training; and the challenges of conducting complex mechanistic experiments in low-resource countries. Key gaps in knowledge and core competencies that should be incorporated into fellowship/graduate training were identified, and existing training modalities were discussed. Recommendations were made for pragmatic approaches to increasing the exposure of trainees to learning tools to enable sustainable training of the next generation of basic science researchers in female pelvic medicine worldwide. The attendees presented multiple perspectives to gain consensus regarding critical areas of need for training future generations of mechanistic researchers. Recommendations for a sustainable Basic Science Scholar Program were developed using IUGA as a platform. The overarching goal of such a program is to ensure a successful bench-to-bedside-and-back circuit in Urogynecology and Pelvic Reconstructive Surgery, ultimately improving lives of millions of women worldwide through scientifically rational effective preventative and therapeutic interventions.

Current Approaches for the Diagnosis and Conservative Treatment of Stress Urinary Incontinence - A Guideline of Guidelines

Urologists utilize evidence-based guidelines organized by urological organizations in the management of stress urinary incontinence (SUI). The objective of this study is to provide guidance in the clinical management of stress urinary incontinence (SUI) by reviewing key guidelines. We conducted a medical literature analysis in the following databases: PubMed, Medline, Embase, National Guideline Clearinghouse, the National Institute for Health and Care Excellence, and Cochrane Library. We also manually searched the websites of the following international and national societies to identify relevant guidelines for inclusion in this review: the International Consultation on Incontinence, American College of Obstetrics and Gynecology, American Urogynecologic Society, American Urological Association/Society of Urodynamic, Female Pelvic Medicine and Urogenital Reconstruction, National Institute for Health and Care Excellence, European Association of Urology, and Canadian Urological Association. The recommendations in the guidelines are summarized in different areas, including the diagnostic standards of SUI, examination and evaluation methods, and conservative treatment methods. This ‘guideline of guidelines’ presents the similarities and differences between prominent authorities in the management of SUI.

Provider Practice Patterns Regarding Over-The-Counter Continence Devices.

Vaginal inserts and continence devices are recommended as a conservative treatment option for the management of stress urinary incontinence (SUI); however, practice patterns for recommendation and use of such devices are currently unknown. Our objectives were to better understand counseling patterns relating to over-the-counter (OTC) continence devices, to assess perceived barriers to recommending these devices, and to estimate clinician familiarity with three such devices currently available in the USA. In this cross-sectional study, an anonymous electronic survey was distributed to all Accreditation Council for Graduate Medical Education-accredited OB/GYN and Urology residency and Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellowship programs. A total of 326 survey responses were collected. Multivariate logistic regression was used to assess respondent characteristics associated with recommending OTC continence devices to patients. Sixty-four percent of respondents expressed familiarity with any OTC continence device. Of respondents who reported regular evaluation and treatment of women with SUI (n = 269), 60% reported ever recommending OTC devices for SUI. On multivariate regression, being a trainee and general OB/GYN provider were associated with being less likely to recommend OTC devices for SUI. Of respondents who did not regularly recommend OTC continence devices, reported barriers to doing so included a lack of training with these devices, leading to clinician discomfort (70%) and not remembering OTC devices as an option (15%). Given the low risk associated with patient use of these easily accessible devices, our study highlights barriers to clinician recommendation with the goal of increasing clinician awareness and consideration of OTC continence devices.

Post-prostatectomy incontinence: a guideline of guidelines.

To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI). The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018). In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well. This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

OCT angiography in the monitoring of vaginal health.

Fractional-pixel CO2 laser therapy shows promise for treating the genitourinary syndrome of menopause (GSM). Nevertheless, it remains controversial in the field of female pelvic medicine. This is due to the inherent difficulties in obtaining noninvasive biopsies to evaluate the treatment's efficacy and safety objectively. To address this challenge, we developed a noninvasive intravaginal optical coherence tomography (OCT)/OCT angiography (OCTA) endoscopic system, whose probe features a shape identical to the laser treatment probe. This system can provide high-resolution OCT images to identify the microstructure of vaginal tissue and visualize the vasculature network in vivo. We conducted clinical research on 25 post-menopausal patients with GSM. OCT/OCTA scans were acquired at four different locations of the vagina (distal anterior, distal posterior, proximal anterior, and proximal posterior) during the whole laser treatment session. A U-Net deep learning model was applied to segment the vaginal epithelium for assessing vaginal epithelial thickness (VET). Blood vessel density and VET were quantified to monitor the efficacy of fractional-pixel CO2 laser therapy. Statistical correlation analyses between these metrics and other clinical scores were conducted, validating the utility of our system. This OCT/OCTA endoscopic system has great potential to serve as a noninvasive biopsy tool in gynecological studies to screen, evaluate, and guide laser treatment for GSM.

Postoperative outcomes and urodynamic findings after continence mesh removal.

To analyze urodynamics findings and patient-reported outcomes after removal of a mid-urethral mesh because data regarding outcomes following mesh removal vary in different studies, and mesh removal itself may have risks. Women who were referred to the Female Pelvic Medicine and Reconstructive Surgery Department of University College London Hospital and underwent vaginal removal of a continence mesh between January 2014 and January 2020, were included. Patient clinical data and results of video-urodynamics investigations performed 4 months after mesh removal were collected and analyzed retrospectively. In all, 204 patients were included in the study. After mesh removal, 80.5% of patients reported recurrent stress urinary incontinence (SUI), 10.1% reported prolapse symptoms, 8% reported voiding dysfunction and 2.9% reported overactive bladder (OAB) symptoms. Video-urodynamics investigations confirmed the presence of SUI (67.6%), mixed urinary incontinence (14.3%), detrusor overactivity (DO) (6.8%) and voiding dysfunction in one patient. In two women a urethral stricture was described, and 10 women were deemed to have a significant cystocele. Recurrence of SUI was the most frequent finding after continence mesh removal, both symptomatically and objectively. Women seldom reported OAB symptoms, but urodynamics showed evidence of DO despite this. On the other hand, voiding dysfunction was often reported but less often proven on urodynamics.