Predictors of vaginal mesh exposure after midurethral sling placement: a case–control study

Introduction and hypothesis

Female stress urinary incontinence is highly prevalent, and synthetic midurethral sling placement is the most common type of anti-incontinence surgery performed in the USA. We aimed to identify risk factors associated with surgery used to treated vaginal mesh exposure after midurethral sling placement for stress urinary incontinence.

Methods

We identified women who underwent anti-incontinence procedures from January 2002 through December 2012. Patients with vaginal mesh exposure undergoing surgical repair after midurethral sling placement were compared with a control group without mesh exposure in a 1:3 ratio. Patients with ObTape sling placement (Mentor Corporation) were excluded. Logistic regression models were used to evaluate associations between clinical risk factors and vaginal mesh exposure.

Results

Overall, 2,123 patients underwent primary sling placement, with 27 (1.3 %) having vaginal mesh exposure necessitating surgical repair. Patients with mesh exposure were more likely to have undergone previous bariatric surgery (P?=?0.008), hemoglobin <13 g/dL (P?=?0.006), premenopausal status (P?=?0.008), age <50 years (P?=?0.001), and the retropubic approach to sling placement (P?=?0.03). Multivariate analysis identified these risk factors: previous bariatric surgery (odds ratio [OR], 7.0; 95 % CI, 1.1–61.4), retropubic approach (OR, 5.7; 95 % CI, 1.1–107.0), preoperative hemoglobin <13 g/dL (OR, 2.8; 95 % CI, 1.1–7.5), and premenopausal status (OR, 2.6; 95 % CI, 1.0–7.3). Among postmenopausal patients, those with mesh exposure were significantly more likely to receive preoperative estrogen therapy (OR, 12.4; 95 % CI, 2.7–57.8).

Conclusions

Previous bariatric surgery, retropubic approach, premenopausal status, and lower preoperative hemoglobin were associated with a significantly increased risk of surgery for vaginal mesh exposure after midurethral sling placement. Recognizing these factors can improve preoperative patient counseling.

     

Long-term outcomes of TOT and TVT procedures for the treatment of female stress urinary incontinence: a systematic review and meta-analysis

Introduction and hypotheses

One of the most relevant topics in the field of pelvic floor dysfunction treatment is the long-term efficacy of surgical procedures, in particular, the use of prosthesis. Hence, a systematic review and meta-analysis was conducted to evaluate the long-term effectiveness and safety of midurethral sling (MUS) procedures for stress urinary incontinence (SUI), as reported in randomised controlled trials (RCTs) and non-randomised studies.

Methods

This systematic review is based on material searched and obtained via PubMed/Medline, Scopus, and the Cochrane Library between January 2000 and October 2016. Peer-reviewed, English-language journal articles evaluating the long-term (≥5 years) efficacy and safety of MUS in women affected by SUI were included.

Results

A total of 5,592 articles were found after the search, and excluding duplicate publications, 1,998 articles were available for the review process. Among these studies, 11 RCTs (0.6%) and 5 non-RCTs (0.3%) could be included in the qualitative and quantitative synthesis. Objective and subjective cumulative cure rates for retropubic technique (TVT) and transobturator tape (TOT; both out–in and in–out) were 61.6% (95% CI: 58.5–64.8%) and 76.5% (95% CI: 73.8–79.2%), and 64.4% (95% CI: 61.4–67.4%) and 81.3% (95% CI: 78.9–83.7%) respectively. When considering TOT using the out–in technique (TOT-OI) and TOT using the in–out technique (TVT-O) the objective and subjective cumulative cure rates were 57.2% (95% CI: 53.7–60.7%) and 81.6% (95% CI: 78.8–84.4%), and 68.8% (95% CI: 64.9–72.7%) and 81.3% (95% CI: 77.9–84.7%) respectively. Furthermore, this article demonstrates that both TVT and TOT are associated with similar long-term objectives (OR: 0.87 [95% CI: 0.49–1.53], I ²?=?67%, p?=?0.62) and subjective (OR: 0.84 [95% CI: 0.46–1.55], I ²?=?68%, p?=?0.58) cure rates. Similarly, no significant difference has been observed between TTOT-OI and TVT-O) in objective (OR: 3.03 [95% CI: 0.97–9.51], I ²?=?76%, p?=?0.06) and subjective (OR: 1.85 [95% CI: 0.40–8.48], I ²?=?88%, p?=?0.43) cure rates. In addition, this study also shows that there was no significant difference in the complication rates for all comparisons: TVT versus TOT (OR: 0.83 [95% CI: 0.54–1.28], I ²?=?0%, p?=?0.40), TOT-OI versus TVT-O (OR: 0.77 [95% CI: 0.17–3.46], I ²?=?86%, p?=?0.73).

Conclusions

Independent of the technique adopted, findings from this systematic review and meta-analysis suggest that the treatment of SUI with MUS might be similarly effective and safe at long-term follow-up.

     

A repeat mid-urethral sling as valuable treatment for persistent or recurrent stress urinary incontinence

Introduction and hypothesis

The value of a repeat mid-urethral sling (MUS) after a failed primary sling is not generally accepted. We hypothesize that repeat MUS can be performed with favorable results and acceptable complication rates.

Methods

We reviewed the medical records of 80 women (mean age 62?±?12.3 years) who underwent repeat MUS surgery from January 2000 to January 2009 at a single tertiary academic centre. Mean follow-up was 44.8 months (range 3–104). Three of these 80 patients were lost to follow-up. Twenty-six (33%) transobturator (TOT), 25 (31%) retropubic (TVT) and 16 (20%) minislings were placed as secondary slings. Thirteen slings (15%) were biological (Pelvicol?). In 4 patients (5%) a release of the primary sling was performed, and in 6 (7.5 %) the extruded sling fragment was totally excised prior to secondary sling placement.

Results

The overall subjective cure rate was 61.0%. Of the study group 74.0% reported subjective improvement. The amounts of pads reduced from a mean of 3.8 pads a day to a mean of 0.75 pads a day postoperatively. The objective cure rate was 63.5%. The incidence of de novo urgency was 8.2% (4 patients). When comparing different secondary sling types no difference was found in the overall continence rate, except for the biological sling. More than half (7 out of 13) of the patients from whom the secondary sling was a biological sling, were not satisfied (p?=?0.01). The subjective improvement rates in patients with recurrent or persistent stress urinary incontinence (SUI) were 68.2% and 75.0% respectively. This difference is not statistically significant (p?=?0.94). Excision versus release of the MUS showed a slightly higher satisfaction rate after excision, 84.6% and 74.0 % respectively (p?=?0.63).

Conclusions

Cure rates and improvement rates of a repeat MUS are favorable and complication rates are acceptable. It should be offered to patients with persistent or recurrent SUI after a failed primary sling, even after previous release or excision.     

Indications and risk factors for midurethral sling revision

Introduction and hypothesis

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement.

Methods

This was a case–control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data.

Results

Of 3,307 women who underwent sling placement, 89 (2.7 %, 95 % CI 1.9 – 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8 %), voiding dysfunction (42.7 %), recurrent urinary tract infection (20.2 %), mesh erosion (21.3 %), vaginal pain/dyspareunia (7.9 %), and groin pain (3.4 %). The median time from the index to the revision surgery was 7.8 months (2.3 – 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95 % CI 1.7 – 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95 % CI 1.4 – 4.5).

Conclusions

The rate of sling revision after midurethral sling placement was 2.7 %. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

     

Comparing the risk of urethrolysis for the treatment of voiding dysfunction between two retropubic mesh slings: a case-control study

Introduction and hypothesis

Long-term outcome data exist with Gynecare TVT? tension-free support for incontinence (TVT), yet few comparisons have been made to newer retropubic sling delivery systems, especially with regards to urethrolysis for postoperative voiding dysfunction. Our objective was to compare the odds of urethrolysis for the treatment of voiding dysfunction between two retropubic sling systems.

Methods

We performed a case–control study comparing the risk of urethrolysis between TVT versus the Bard ALIGN® Urethral Support System (Bard Align). We identified surgical procedures described as urethrolysis, sling revision, loosening, or lysis performed for the treatment of voiding dysfunction by urogynecologists at Duke University between January 2007 and June 2011. Slings placed at outside institutions were excluded. Controls were matched for both concomitant prolapse procedures and academic year.

Results

Of 818 total slings placed during the study period, there were 28 (3.4 %) urethrolysis cases, which were matched to 84 controls. Among urethrolysis cases, 6/28 (21.4 %) had received TVT, while 22/28 (78.6 %) had received Bard Align slings. Of the 84 matched controls, 30/84 (35.7 %) had undergone TVT and 54/84 (64.3 %) had undergone Bard Align. There was no significant difference in the odds of urethrolysis following the use of TVT or Bard Align [odds ratio (OR) 2.00, 95 % confidence interval (CI) 0.74–5.50]. In a conditional logistic regression model, which adjusted for age, body mass index, prior anti-incontinence or prolapse surgery, and postvoid residual, there remained no significant difference in odds of urethrolysis between the two sling types (OR 1.50, 95 % CI 0.42–5.33).

Conclusions

Despite different instrument designs, there was no significant difference in the risk of urethrolysis following TVT or Bard Align retropubic sling.     

Repeat versus primary slings in patients with intrinsic sphincter deficiency

Introduction and hypothesis

Our goal was to compare outcomes of repeat vs. primary synthetic slings in patients with stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD).

Materials and methods

We reviewed patients who underwent a sling for SUI with ISD from 2003 to 2010. The patients were divided into two groups according to whether they underwent primary or repeat sling. Surgical success was defined as no incontinence and no reintervention (i.e., urethral bulking) during follow-up. Statistical analysis included the unpaired t test, Wilcoxon rank sums test, chi-squared/Fisher’s exact tests, and logistic regression to identify risk factors associated with failure.

Results

Six hundred and thirty-seven patients with ISD underwent a sling procedure at our institution; 557 (87 %) a primary sling and 80 (13 %) a repeat sling. Patient demographics were similar. Preoperatively, patients with recurrent SUI reported more subjective bother. Mean follow-up was 66.5 weeks (24–374). Success was achieved in 81 % of primary compared with 55 % of repeat slings (p?<?0.0001). Repeat patients were 3.4 times more likely to fail surgery [odds ratio (OR)?=?3.43, 95 % confidence interval (CI) 2.1–5.6]. Additionally 30 % of the repeat group underwent urethral bulking postoperatively compared with 8.6 % in the primary group (OR?=?4.4, 95 % CI 2.5–7.7). Prior incontinence procedures, a positive supine stress test, and transobturator sling were independent risk factors for failure. Among the types of slings placed (transobturator, retropubic, tensioned pubovaginal), pubovaginal slings were most successful (OR?=?2.7, 95 % CI 1.4–5.2).

Conclusion

In women with ISD, repeat slings are associated with lower success rates compared with primary slings. Pubovaginal slings resulted in the highest success rate compared with both transobturator and retropubic slings.     

Predictors for persistent urodynamic stress incontinence following extensive pelvic reconstructive surgery with and without midurethral sling

Introduction and hypothesis

The objective of this study was to identify the predictors for persistent urodynamic stress incontinence (P-USI) in women following extensive pelvic reconstructive surgery (PRS) with and without midurethral sling (MUS).

Mmethods

A total of 1,017 women who underwent pelvic organ prolapse (POP) surgery from January 2005 to December 2013 in our institutions were analyzed. We included 349 USI women who had extensive PRS for POP stage III or more of whom 209 underwent concomitant MUS.

Results

Of the women who underwent extensive PRS without MUS, 64.3 % (90/140) developed P-USI compared to only 10.5 % (22/209) of those who had concomitant MUS. Those with concomitant MUS and PRS alone were at higher risk of developing P-USI if they had overt USI [odds ratio (OR) 2.2, 95 % confidence interval (CI) 1.3–4.0, p?=?0.014 and OR 4.7, 95 % CI 2.0–11.3, p?<?0.001, respectively], maximum urethral closure pressure (MUCP) of?<?60 cm H₂O (OR 5.0, 95 % CI 3.0–8.1, p?<?0.001 and OR 5.3, 95 % CI 2.7–10.4, p?<?0.001, respectively), and functional urethral length (FUL) of?<?2 cm (OR 5.4, 95 % CI 2.7–8.8, p?<?0.001 and OR 3.9, 95 % CI 2.4–6.9, p?<?0.001, respectively). Parity?≥?6 (OR 3.9, 95 % CI 1.7–5.2, p?<?0.001) and Prolift T (OR 3.1, 95 % CI 1.9–4, p?<?0.001) posed a higher risk of P-USI in those with concomitant surgery. Perigee and Avaulta A seemed to be protective against P-USI in those without MUS.

Conclusions

Overt USI with advanced POP together with low MUCP and FUL values have a higher risk of developing P-USI. Therefore, counseling these women is worthwhile while considering the type of mesh used.

     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

Which women develop urgency or urgency urinary incontinence following midurethral slings?

Introduction and hypothesis

De novo urgency has a negative impact on women after midurethral sling (MUS). We aimed to identify risk factors for de novo urgency (dU) and urgency urinary incontinence (dUUI) following MUS, using multivariate analysis.

Methods

We investigated 358 consecutive women with only stress urinary incontinence (SUI) [or urodynamic stress incontinence (USI)] and 598 women with both SUI (or USI) and urgency (but not UUI) who underwent MUS with a mean follow-up of 50 months. Women who developed dU or dUUI at long-term follow-up were compared to those who did not.

Results

dU occurred in 27.7 % (99/358) and dUUI occurred in 13.7 % (82/598) of women at long-term follow-up after midurethral sling. Intrinsic sphincter deficiency {odds ratio (OR) dU 3.94 [95 % confidence interval (CI) 1.50–10.38]; OR dUUI 2.5 (1.31–4.80)}, previous stress incontinence surgery [sling: OR dU 3.69 (1.45–9.37); colposuspension: OR dUUI 2.5 (1.23–5.07)], previous prolapse surgery [OR dU 2.45 (1.18–5.10)], preexisting detrusor overactivity [OR dU 1.99 (1.15–3.48); OR dUUI 1.85 (1.31–2.60)] increased the risk, whereas performing concomitant apical prolapse surgery [OR dU 0.5 (0.41–0.81); OR dUUI 0.29 (0.087–0.97)] significantly decreased the risk. Women are more likely to not recommend surgery when they experienced dU (18.2 vs 0.8 %, p?<?0.0001) or dUUI (20.7 vs 2.1 %, p?<?0.0001).

Conclusions

Urodynamic parameters, history of prior incontinence or prolapse surgery and concomitant apical prolapse operation were important predictors of dU or dUUI following MUS.     

Resection for Hilar Cholangiocarcinoma: Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Long-term Outcome

Introduction

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

Methods

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

Results

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR?=?0.03, 95 % CI 0–0.19, p?<?0.001), caudate lobe invasion (HR?=?6.33, 95 % CI 1.31–30.46, p?=?0.021), adjuvant gemcitabine-based chemotherapy (HR?=?0.38, 95 % CI 0.15–0.94, p?=?0.037), and the neutrophil-to-lymphocyte ratio (HR?=?0.78, 95 % CI 0.62–0.98, p?=?0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR?=?0.03, 95 % CI 0–0.22, p?<?0.001), caudate lobe invasion (HR?=?11.75, 95 % CI 1.65–83.33, p?=?0.014), and adjuvant gemcitabine-based chemotherapy (HR?=?0.19, 95 % CI 0.06–0.56, p?=?0.003).

Conclusions

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.     

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality,a Cohort of 191 Patients

Background

Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality.

Methods

All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality.

Results

A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo–Clavien >?2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA?>?2 (OR?=?2.75, 95% CI?=?1.07–7.62, p?=?0.037), multiorgan failure (MOF) (OR?=?5.22, 95% CI?=?2.11–13.5, p?=?0.0037), perioperative transfusion (OR?=?2.7, 95% CI?=?1.05–7.47, p?=?0.04) and upper GI origin (OR?=?3.55, 95% CI?=?1.32–9.56, p?=?0.013). Independent risk factors for morbidity were: MOF (OR?=?2.74, 95% CI?=?1.26–6.19, p?=?0.013), upper GI origin (OR?=?3.74, 95% CI?=?1.59–9.44, p?=?0.0034) and delayed extubation (OR?=?0.27, 95% CI?=?0.14–0.55, p?=?0.0027).

Conclusion

Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

     

What is the importance of “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture?

Summary

We investigated the importance, risk factors, and clinical course of the radiolucent “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture. Preoperative osteonecrosis and a lump cement pattern were the most important risk factors for the peri-cement halo phenomenon, and it was associated with vertebral recollapse.

Introduction

We observed a newly developed radiolucent area around the bone cement following vertebral augmentation for osteoporotic compression fractures. Here, we describe the importance of the peri-cement halo phenomenon, as well as any associated risk factors and long-term sequelae.

Methods

In total, 175 patients (202 treated vertebrae) were enrolled in this study. The treated vertebrae were subdivided into two groups: Group A (with halo, n?=?32) and Group B (without halo, n?=?170), and the groups were compared with respect to multiple preoperative (age, sex, BMD, preoperative osteonecrosis) and perioperative factors (operative approach: vertebroplasty or kyphoplasty; cement distribution pattern; cement leakage; cement volume), and postoperative results (VAS score, recollapse). Logistic regression analysis was used to evaluate the relationship between the incidence of the peri-cement halo and all of the parameters described above.

Results

Rates of osteonecrosis were also significantly higher in Group A than in Group B (62.5% vs. 31.2%, p?p?p?p?p?=?0.001), KP (OR?=?3.630; 95% CI?=?1.628–8.095; p?=?0.002), lump pattern (OR?=?13.870; 95% CI?=?2.907–66.188; p?=?0.001), and vertebral recollapse (OR?=?5.356; 95% CI?=?1.897–15.122; p?=?0.002) were significantly associated with peri-cement halo.

Conclusions

The peri-cement halo was found to be associated with vertebral recollapse, this sign likely represents a poor prognostic factor after vertebral augmentation for osteoporotic compression fractures.     

Incidence of successful voiding and predictors of early voiding dysfunction after retropubic sling

Introduction and hypothesis

There is a paucity of literature on resumption of normal voiding predictors after synthetic retropubic sling insertion and lack of a standardized method of determination. Our goals were to determine the incidence of a successful voiding trial; whether clinical, operative, or urodynamic variables predict discharge with a catheter; and incidence of later retention in those who were initially successful.

Methods

We performed an internal-review-board (IRB)-approved retrospective chart review of 229 consecutive patients who underwent retropubic sling (TVT, Boston Scientific, Natick, MA, USA)) from 2001 to 2010. Exclusions were concomitant surgery or cystotomy at the time of retropubic sling insertion. All participants underwent a voiding trial in recovery consisting of 300 cc sterile-water retrograde fill and were discharged home without a catheter after single void of at least 200 cc following catheter removal.

Results

Of 170 patients, 136 (80 %) passed the voiding trial the same day, with 165 (97 %) passing within 1 day. Factors associated with delayed voiding were age ≥65 years (p?<?0.05), presence of Valsalva voiding (p?<?0.01), lower body mass index (BMI) (p?<?0.05), and higher gravidity (p?<?0.05) and parity (p?<?0.01). Age ≥65 years [adjusted odds ratio (aOR) 3.72, 95 % confidence interval (CI) 1.40–9.90, p?<?0.01] and Valsalva voiding (aOR 3.89, 95 % CI 1.56–9.69, p?<?0.01) remained significant independent predictors in multivariate analysis.

Conclusions

The majority of patients with retropubic sling can be safely discharged home the same day without a catheter after retrograde fill. Women >65 years or Valsalva voiders had nearly four times the odds of being discharged with a catheter.

Summary

Most patients resume normal voiding within 24 h after retropubic sling insertion, but >65 years and Valsalva voiding are risk factors for voiding inability at discharge.

     

SHBG levels are associated with bone loss and vertebral fractures in patients with prostate cancer

Summary

Fractures are increased among prostate cancer patients. No data have been reported in patients with prostate cancer about the relation between serum sex hormone-binding globulin (SHBG) and bone metabolism. We found that SHBG levels were inversely related to bone mass and vertebral fractures in this population.

Introduction

Fractures are increased among prostate cancer patients, especially those on androgen deprivation therapy (ADT), but few data are available on the role of SHBG in their bone status. Our objective was to analyze the relation between serum SHBG and bone metabolism in prostate cancer patients.

Methods

This is a cross-sectional study including 91 subjects with prostate cancer (54 % with ADT). We measured serum levels of SHBG and sex steroids, bone mineral density (BMD) by dual-energy X-ray absorptiometry, and prevalent radiographic vertebral fractures.

Results

SHBG levels were inversely related to BMD (femoral neck: r?=??0.299, p?=?0.00; total hip: r?=??0.259, p?=?0.019). Subjects with osteoporosis had higher SHBG concentrations than patients without osteoporosis (60.97?±?39.56 vs 44.45?±?23.32 nmol/l, p?=?0.022). Patients with SHBG levels in the first quartile (>57.6 nmol/l) had an odds ratio (OR) for osteoporosis of 2.59 (95 % CI, 1.30–5.12; p?=?0.009) compared with patients with lower SHBG levels. In patients with SHBG >57.6 nmol/l, the OR for vertebral fractures was 2.34 (95 % CI, 1.15–4.78; p?=?0.034). The calculated OR was higher after adjustment for age (OR, 5.16; 95 % CI, 1.09–24.49; p?=?0.039), estrogens (OR, 6.45; 95 % CI, 1.44–28.95; p?=?0.023), and androgens (OR, 5.51; 95 % CI, 1.36–22.37; p?=?0.017).

Conclusions

In prostate cancer patients, SHBG levels were inversely related to bone mass and vertebral fractures. Determination of the serum SHBG level may constitute a useful and straightforward marker for predicting the severity of osteoporosis in these patients.     

Effect of anesthesia type on perioperative outcomes with a midurethral sling

Introduction and hypothesis

There is no consensus on the most appropriate type of anesthesia for placement of a midurethral sling. Our objective was to compare intra- and perioperative outcomes for this procedure performed under general anesthesia versus monitored anesthesia care.

Methods

Retrospective cohort analysis of women undergoing outpatient placement of synthetic retropubic midurethral sling under general anesthesia (n?=?141) or monitored anesthesia care (n?=?84). Patients undergoing concomitant procedures were excluded. Primary outcome was operating room time. Secondary outcomes included surgical and recovery times, cost, discharge home with a catheter, and postoperative pain and/or nausea.

Results

In the general anesthesia group, both operating room time (mean?±?SD, 67.6?±?13.3 min vs 56.9?±?11.8 min, p?<?0.001) and recovery room time (240.0?±?69.8 min vs 190.1?±?78.3 min, p?<?0.001) were longer, whereas there was no difference in surgical time (30.0?±?8.9 min vs 29.0?±?9.7 min, p?=?0.43). Cost was significantly higher in the general anesthesia group ($4,095?±?715 vs $3,877?±?777, p?=?0.03). There was no difference in rates of bladder perforation (6.4 % vs 11.9 %, p?=?0.33). Patients who underwent general anesthesia had higher rates of discharge with a catheter (27.0 % vs 15.8 %, p?=?0.04).

Conclusion

Monitored anesthesia care may offer significant benefits over general anesthesia in women undergoing retropubic midurethral sling, including shorter operating room and recovery times, lower costs, and less voiding dysfunction in the immediate postoperative period.

     

Prognostic Significance of Neuroendocrine Differentiation in Colorectal Adenocarcinoma After Radical Operation: a Meta-analysis

Background

The phenomenon of neuroendocrine differentiation has been observed in colorectal adenocarcinoma. However, the ability of neuroendocrine differentiation to predict the outcome of colorectal adenocarcinoma remains controversial.

Methods

We conducted an extensive search of research studies related to neuroendocrine differentiation using scientific databases, including the PubMed, Embase, OVID, BIOSIS Previews, and Cochrane Central Register of Controlled Trials (up to July, 2013), according to the established search terms. RevMan version 5.2 statistical program was used to analyze the data. An odds ratio (OR) with a 95 % confidence interval (CI) was used for the dichotomous data.

Results

Eleven studies with a total of 1,587 patients were included. Patients with neuroendocrine differentiation who underwent a radical operation had a lower 5-year survival rate (pooled OR 0.60, 95 % CI 0.37–0.97) compared with those without neuroendocrine differentiation, with evidence of moderate heterogeneity (I ²?=?37 %, p?=?0.10). A sensitivity analysis and meta-regression showed that the different classification criteria of neuroendocrine differentiation used in these studies were the main source of heterogeneity. When the strong positive rates of neuroendocrine differentiation indicators between the higher (stage III + IV) and the lower (stage I + II) clinical stages were compared, the pooled OR was 1.84 (703 patients; 95 % CI 0.98–3.43) without evidence of heterogeneity (I ²?=?0 %, p?=?0.89). However, comparisons between consecutive stages showed different ORs: stage II vs. I (203 patients; OR?=?0.52, 95 % CI 0.17–1.56), stage III vs. II (569 patients; OR?=?2.27, 95 % CI 1.03–4.98), and stage IV vs. III (375 patients; OR?=?1.81, 95 % CI 1.00–3.29).

Conclusion

The patients with strong positive indicators of neuroendocrine differentiation had a lower 5-year survival rate. The ability to detect neuroendocrine indicators using conventional methods could improve the prognosis judgment of colorectal adenocarcinoma.     

Is Resection Equivalent to Transplantation for Early Cirrhotic Patients with Hepatocellular Carcinoma? A Meta-Analysis

Background

Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question.

Study Design

This study performed a systematic review of the published literature between January 2000 and April 2012.

Results

Nine retrospective studies, totaling 2,279 patients (989 resected and 1,290 transplanted), met the selection criteria. Older patients with larger tumors and less severe cirrhosis were identified in the resection group. At 1?year, resection demonstrated significantly higher overall [odds ratio (OR)?=?1.54; 95?% confidence interval (CI), 1.19?C1.98; p?=?0.001], but equivalent disease-free survival (OR?=?0.93; 95?% CI, 0.53?C1.63; p?=?0.80). At 5?years, there was no difference in overall survival (OR?=?0.86; 95?% CI, 0.61?C1.21; p?=?0.38), but a higher disease-free survival in transplanted patients was observed (OR?=?0.39; 95?% CI, 0.24?C0.63; p?<?0.001). When limiting our analysis to studies conducted in an intent-to-treat fashion, there was no difference in 5?year overall survival (OR?=?1.18; 95?% CI, 0.92?C1.51; p?=?0.19), but a significantly higher disease-free survival (OR?=?0.76; 95?% CI, 0.57?C1.00; p?=?0.05) in transplanted patients. At 10?years, transplantation had higher overall and disease-free survival rates.

Conclusion

Liver transplantation in patients with HCC results in increased late disease-free and overall survival when compared with liver resection. Nonetheless, the benefit of liver transplantation is offset by higher short-term mortality, donor organ availability, and long transplant wait times associated with more patient deaths. Understanding these differences in survival is helpful in guiding treatment. However, a properly controlled prospective trial is needed to define how best to treat HCC patients who are candidates for either therapy.     

Early postoperative voiding dysfunction after insertion of retropubic midurethral tape

Introduction and hypothesis

A significant proportion of patients develop voiding dysfunction after midurethral tape (MUT) insertion, which reduces patient satisfaction. The study’s purpose was to identify predictive factors of voiding dysfunction after a retropubic MUT procedure.

Methods

This was a retrospective study of 100 patients who underwent only a retropubic MUT procedure between January 2010 and December 2011. Early voiding dysfunction was defined when patients required a Foley catheter within 48 h. Data including demographic information, urogenital symptoms, previous surgery, preoperative uroflowmetry and urodynamic parameters were analysed using SPSS v22. Univariate analysis of all demographic variables was performed; those significant at 10 % were entered into a multivariate logistic regression.

Results

Fourteen patients required Foley catheter insertion, with a median age of 58 years (26–83 years), median BMI 28 kg/m² (20–48 kg/m2), and median parity 2 (0–4). Univariate analysis revealed peak flow rate <15 ml/s (OR 3.79; 1.07, 13.4; p?=?0.046), bladder capacity (p?=?0.044), stress incontinence versus mixed or urge incontinence (p?=?0.064) and previous surgery (OR 4.39; 1.34, 14.41; p?=?0.015) to be associated with voiding dysfunction. Multivariate analysis showed only previous pelvic floor surgery to be independently associated (OR 3.76; 1.14, 12.23, p?=?0.029).

Conclusions

Only previous pelvic-floor surgery was found to be a strong predictive factor of voiding dysfunction. The rate of voiding dysfunction was similar to those of published data. Previous studies revealed different predictive factors. A larger cohort is needed to provide a definite answer. Those with previous surgery appear to be those most at risk and pre-surgical counselling for these women could be suggested.

     

Risk factors of microtia: A systematic review and meta-analysis

Background

The pathogenesis of microtia is still unclear. Various risk factors have been studied but they remain inconclusive. We conducted the first ever systematic review and meta-analysis to look for the association between microtia and various environmental risk factors.

Methods

Relevant case-control studies published between January 2000 to October 2014 were identified through a systematic search in PubMed and EMBASE. Reference lists from relevant review articles were also searched. Studies were included if they meet our selection criteria. Out of 1706 potential articles, 12 were included in the systematic review and 8 in the meta-analysis.

Results

Risk factors which showed significant positive association with microtia were: cold-like syndrome during pregnancy (OR?=?2.15; 95 % CI?=?1.36, 3.41, P?=?0.001); multiple gestation (OR?=?1.55; 95 % CI?=?1.05, 2.29, P?=?0.03); and gestational diabetes (OR?=?1.48; 95 % CI?=?1.04, 2.10, P?=?0.03). Risk factors which showed positive association but statistically insignificant were: threatened abortion (OR?=?1.22; 95 % CI?=?0.69, 2.15, P?=?0.50); smoking during pregnancy (OR?=?1.05; 95 % CI?=?0.63, 1.77, P?=?0.84); alcohol during pregnancy (OR?=?1.08; 95 % CI?=?0.65,1.80 P?=?0.77); urinary tract infection (OR?=?1.04; 95 % CI?=?0.59, 1.84, P?=?0.89); essential hypertension (OR?=?1.04; 95 % CI?=?0.74, 1.47, P?=?0.82); maternal diabetes (OR?=?3.98; 95 % CI?=?0.72, 21.96, P?=?0.11); respiratory tract infection (OR?=?1.26,95 % CI?=?0.84,1.88, P?=?0.26); chronic disease during pregnancy (OR?=?1.29,95 % CI?=?0.99,1.69, P?=?0.06); severe nausea/vomiting (OR?=?1.16; 95 % CI?=?0.66, 2.04, P?=?0.61); NSAIDs during pregnancy (OR?=?1.17, 95 % CI?=?0.61,2.22, P?=?0.64); antihypertensives during pregnancy (OR?=?1.84,95 % CI?=?0.94,3.62, P?=?0.08); and illegal drugs during pregnancy (OR?=?1.69; 95 % CI?=?0.65, 4.39, P?=?0.28). Reduced risk for microtia was found with these factors: folic acid (OR?=?0.55; 95 % CI?=?0.33, 0.92, P?=?0.02); advanced maternal age (OR?=?0.94; 95 % CI?=?0.79, 1.11, P?=?0.45); ampicillin during pregnancy (OR?=?0.80,95 % CI?=?0.50, 1.28, P?=?0.35); and metronidazole during pregnancy (OR?=?0.77,95 % CI?=?0.40, 1.48 P?=?0.44).

Conclusions

Our study indicates cold-like syndrome, multiple gestation, and gestational diabetes as significant risk factors for microtia; whereas folic acid consumption during pregnancy is shown to be a protective factor. Studies on risk factors for microtia are still very limited to establish the definitive risk factors. Further large-scale and multicentre studies are needed to clarify the role of key risk factors for the development of microtia.Level of Evidence: Level II, risk / prognostic study.

     

Comparison between the retropubic and transobturator approaches in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Objective

This study aimed to compare the effectiveness and complications between the retropubic and transobturator approaches for the treatment of female stress urinary incontinence (SUI) by conducting a systematic review.

Materials and Methods

We selected all randomized controlled trials (RCTs) that compared retropubic and transobturator sling placements for treatment of SUI. We estimated pooled odds ratios and 95% confidence intervals for intraoperative and postoperative outcomes and complications.

Results

Six hundred twelve studies that compared retropubic and transobturator approaches to midurethral sling placement were identified, of which 16 were included in our research. Our study was based on results from 2646 women. We performed a subgroup analysis to compare outcomes and complications between the two approaches. The evidence to support the superior approach that leads to better objective/subjective cure rate was insufficient. The transobturator approach was associated with lower risks of bladder perforation (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.09-0.32), retropubic/vaginal hematoma (OR 0.32, 95% CI 0.16-0.63), and long-term voiding dysfunction (OR 0.32, 95% CI 0.17-0.61). However, the risk of thigh/groin pain seemed higher in the transobturator group (OR 2.53, 95% CI 1.72-3.72). We found no statistically significant differences in the risks of other complications between the two approaches.

Conclusions

This meta-analysis shows analogical objective and subjective cure rates between the retropubic and transobturator approaches to midurethral sling placement. The transobturator approach was associated with lower risks of several complications. However, good-quality studies with long-term follow-ups are warranted for further research.