Gynecologic surgeons have traditionally restricted the physical activity of postoperative patients. Minimally invasive surgery and enhanced recovery after surgery programs have contributed to ...decreased hospital stays and more expeditious recovery. In this narrative review, we review the current state of postoperative activity restrictions in gynecology and other specialties, the purported risks and potential benefits of postoperative activity, the available evidence to refute or support activity in the postoperative activity, and, finally, the potential benefit of added activity in the postoperative period.
To investigate differences in the urinary microbiome and cytokine levels between women with and without interstitial cystitis and to correlate differences with scores on standardized symptom severity ...scales and depression and anxiety screening tools.
Our cross-sectional study compared women presenting to a pelvic floor clinic and diagnosed with interstitial cystitis over a 6-month period with age-matched women in a control group from the same institution. Participants provided a catheterized urine sample and completed symptom severity, quality-of-life, depression, and anxiety screening questionnaires. Urinary microbiomes generated through bacterial ribosomal RNA sequencing and cytokine levels were analyzed using a standard immunoassay. Nonparametric analyses were used for all comparisons.
Participants with interstitial cystitis reported more disability, bothersome urinary symptoms, genitourinary pain, and sexual dysfunction and scored higher on depression and anxiety screens compared with women in the control group. The urine of participants with interstitial cystitis contained fewer distinct operational taxonomic units (2 median range 2-7, interquartile range 1 compared with 3.5 median, range 2-22, interquartile range 5.25, P=.015) and was less likely to contain Lactobacillus acidophilus (1/14 7% compared with 7/18 39%, P=.05) compared with women in the control group. L acidophilus was associated with less severe scores on the Interstitial Cystitis Symptoms Index (1 median, range 0-17, interquartile range 5 compared with 10 median, range 0-14, interquartile range 11, P=.005) and the Genitourinary Pain Index (0 median, range 0-42, interquartile range 22 compared with 22.5 median, range 0-40, interquartile range 28, P=.03). Participants with interstitial cystitis demonstrated higher levels of macrophage-derived chemokine (13.32 median, range 8.93-17.05, interquartile range 15.86 compared with 0 median, range 8.93-22.67, interquartile range 10.35, P=.037) and interleukin-4 (1.95 median, range 1.31-997, interquartile range 11.84 compared with 1.17 median, range 0.44-3.26, interquartile range 1.51, P=.029). There was a positive correlation between interleukin-4 and more severe scores on the Interstitial Cystitis Symptoms Index (r=0.406, P=.013). No associations between the presence of lactobacillus species and cytokine levels were observed.
The urinary microbiome of participants with interstitial cystitis was less diverse, less likely to contain Lactobacillus species, and associated with higher levels of proinflammatory cytokines. It is unknown whether this represents causality and whether the effect of alterations to the urinary microbiome is mediated through an inflammatory response.
Sacrocolpopexy is the gold standard for the surgical management of apical prolapse. Over the years, surgical advancements have transformed the procedure from a laparotomy with a hospital stay of ...several days to a minimally invasive approach with a much shorter hospital stay. One recent innovation has the potential to transform minimally invasive sacrocolpopexy.INTRODUCTION AND HYPOTHESISSacrocolpopexy is the gold standard for the surgical management of apical prolapse. Over the years, surgical advancements have transformed the procedure from a laparotomy with a hospital stay of several days to a minimally invasive approach with a much shorter hospital stay. One recent innovation has the potential to transform minimally invasive sacrocolpopexy.The da Vinci single-port robotic platform has allowed urological procedures to generate improved recovery, pain control, and cosmesis, with no differences in complications rates.METHODSThe da Vinci single-port robotic platform has allowed urological procedures to generate improved recovery, pain control, and cosmesis, with no differences in complications rates.Although the data with respect to sacrocolpopexy are more limited owing to the novelty of this application, the results appear to be similar to those of urological procedures such as prostatectomy.RESULTSAlthough the data with respect to sacrocolpopexy are more limited owing to the novelty of this application, the results appear to be similar to those of urological procedures such as prostatectomy.We present our surgical technique for completing single-port robotic sacrocolpopexy, with and without a hysterectomy, as well as a review of the relevant literature.CONCLUSIONSWe present our surgical technique for completing single-port robotic sacrocolpopexy, with and without a hysterectomy, as well as a review of the relevant literature.
Women undergoing surgery for apical pelvic organ prolapse have several medically sound options for specific surgical approaches.INTRODUCTION AND HYPOTHESISWomen undergoing surgery for apical pelvic ...organ prolapse have several medically sound options for specific surgical approaches.We review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit.METHODSWe review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit.We emphasize the importance of collaboration between patients and surgeons in surgical decision-making.RESULTSWe emphasize the importance of collaboration between patients and surgeons in surgical decision-making.All medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.CONCLUSIONAll medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.
Introduction and hypothesis
To describe and compare urethral neuromuscular function using concentric needle electromyography (CNEMG) and urodynamic (UDS) parameters between stress incontinent (SUI) ...and urge incontinent (UUI) women.
Methods
Incontinent women were recruited from a urogynecology clinic if they answered “sometimes” or “always” to one of the items on the Medical, Epidemiologic, and Social Aspects of Aging questionnaire. Participants were categorized by MESA scores into stress (SUI) or urgency (UUI) incontinence groups. Participants underwent CNEMG of the striated urethral sphincter at three insertion sites using Medtronic multiple motor unit action potential analysis. UDS was performed with Laborie microtip catheters: urethral pressure profiles were obtained at baseline and 300 ml. Data were analyzed in SPSS. Continuous variables were compared with independent t-test or Mann-Whitney U, categorical variables with chi-square test. A logistic regression was performed to control for variables found to be significant on univariate analysis.
Results
Fifty-six women (37 SUI, 19 UUI) with mean ± SD age of 53 ± 13 years participated. At baseline, patients with SUI were younger, more likely to be premenopausal and had lower BMIs. There were no differences in urethral EMG or UDS parameters between UUI and SUI women except lower maximum cystometric capacity in women with UUI. When controlling for age, BMI and MCC on logistic regression, there remained no differences between SUI and UUI groups on EMG or UDS parameters.
Conclusions
Women with UUI and DO show similar evidence of denervation-reinnervation injury to the striated urethral sphincter muscle as women with SUI.
Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational ...studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period.
This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database.
This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses.
In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3–19) and varied significantly based on type of injury (P<.01) with ureteral obstruction (6; interquartile range, 2–16) recognized earlier than ureteral fistula (12; interquartile range, 7–21) and bladder fistula (14; interquartile range, 4–23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21–3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16–3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26–3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders.
Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period.
To assess the relationship between prescribed postoperative activity recommendations (liberal compared with restricted) after reconstructive prolapse surgery and patient satisfaction and pelvic floor ...symptoms.
In our multicenter, randomized, double-blind clinical trial, women undergoing reconstructive prolapse surgery were randomized to liberal compared with restricted postoperative activity recommendations. Liberal recommendations instructed women to resume postoperative activity at the woman's own pace with no restrictions on lifting or high-impact activities. Conversely, restricted recommendations instructed women to avoid heavy lifting or strenuous exercise for 3 months. The primary outcome, patient satisfaction, was assessed on a 5-point Likert scale at 3 months postoperatively with the question, "How satisfied are you with the result of your prolapse surgery?" Secondary outcomes included anatomic outcomes and pelvic floor symptoms.
From September 2014 to December 2015, 130 women were screened and 108 were randomized. Ultimately, 95 were allocated to study intervention (n=45 liberal, n=50 restricted) and completed the primary outcome. Baseline characteristics (including pelvic organ prolapse quantification stage and demographics) and surgical intervention did not differ between groups. Most women underwent a minimally invasive sacrocolpopexy (58) followed by vaginal suspension (27) or vaginal closure procedures (nine). Rates of satisfaction were similarly high in the liberal and restricted recommendations groups (98% compared with 94%, odds ratio 0.36 0.036-3.55, P=.619). Anatomic outcomes did not differ between groups; however, fewer pelvic floor symptoms were reported in the liberal group.
Satisfaction was equally high 3 months after prolapse surgery in women who were instructed to liberally resume activities compared with those instructed to restrict postoperative activities. Women who liberally resumed their activities reported fewer prolapse and urinary symptoms and had similar short-term anatomic outcomes suggesting that allowing women to resume their normal activities postoperatively may result in improved pelvic floor outcomes.
ClinicalTrials.gov, www.clinicaltrials.gov, NCT02138487.
Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small ...intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts.
Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed.
Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion.
We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated.
IV.
Retrospective Study.
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