ABSTRACTS ORAL PRESENTATION 1 Vascular Anatomy of the Presacral Space in Unembalmed Female Cadavers C. K. Wieslander, D. D. Rahn, S. I. Marinis, C. Y. Wai, J. I. Schaffer, and M. M. Corton OBGYN, University of Texas Southwestern Medical Center at Dallas, Dallas, TX Objectives: To characterize the vascular anatomy of the female presacral space and to correlate these findings to the abdominal sacrocolpopexy. Materials and Methods: The vascular boundaries and contents of the presacral space were dissected in 32 unembalmed female cadavers. Distances from the midline of the sacral promontory (MSP) to the closest cephalad and lateral vessels, aortic bifurcation, middle sacral artery and vein, and presacral venous anastomosis were recorded. All middle sacral and venous anastomotic vessels greater or equal to one millimeter were included. Results: Thirty Caucasian and two African American cadaver specimens with a mean BMI of 20.7 kg/m2 (11.8 –33.3 kg/m2) were dissected. In 97% of cadavers, the left common iliac vein was the closest cephalad vessel, with a mean distance of 27.5 mm (9.0 –51.5 mm) from the MSP. The closest vessel lateral to the MSP was also the left common iliac vein (41%), followed by the right internal iliac artery (24%). The average distance from the MSP to the closest lateral major vessel was 24.3 mm (13.0 –34.5 mm). The average distance from the MSP to the aortic bifurcation was 55.5 mm (26.0 – 89.5 mm). The average distance from the MSP to the caudal venous anastomosis was 30.3 mm (4.0 – 86.0 mm). A middle sacral artery was present in 100% of cadavers. The average width of this vessel was 1.7 mm (1.0 –3.0 mm). In the majority of cadavers (60%), the middle sacral artery was found to the left of the MSP. It was noted to the right of the MSP in 37% of specimens, and crossing the midline in 3% of specimens. The average distance of the middle sacral artery from the MSP was 5.0 mm (0 –15.0 mm). A middle sacral vein was not identified in 10% of cadavers; two vessels were noted in 10% of specimens. The mean width of the middle sacral vein was 1.7 mm (0.8 –3.8 mm). This vessel was more frequently noted to the right (45%) than to the left (38%) of the MSP. It crossed the midline in 7% of cadavers. The average distance of the middle sacral vein from the MSP was 6.7 mm (0 –16.5 mm). Conclusion: Anatomic location of the vascular boundaries and contents of the presacral space in reference to the MSP is highly variable. The left common iliac vein was the closest major vessel identified cephalad to the MSP. It is possible that vasodilation of veins from increased volume status and body temperature in the living patient may further reduce the distance of this vessel from the sacral promontory. In addition, identification of veins by palpation is more difficult than that of the arteries and hemorrhage from venous bleeding is more cumbersome to control. Understanding the proximity of the left common iliac vein to the MSP, an area exposed during an abdominal sacrocolpopexy, is essential to avoid injury to this vessel. Middle sacral vessels are variably found on either side of the MSP and vascular anastomosis between the middle and lateral sacral veins are frequently found within 3 cm caudal to the upper border of the sacral promontory. Therefore, careful dissection of the presacral space and good exposure of the anterior longitudinal ligament of the sacrum should minimize potentially life threatening vascular complications. Key Words: sacrocolpopexy, anatomy, presacral space, vascular injury Disclosure - Grant/Research Support, Speaker Bureau: Joseph I. Schaffer, Eli Lilly, Yamanouchi/GlaxoSmith/Klein; none: Cecilia K. Wieslander, none, David D. Rahn, none, Spyridon I. Marinis, none, Marlene M. Corton, none, Clifford Y. Wai, none. ORAL PRESENTATION 2 A Randomized Trial Comparing Methods of Vaginal Cuff Closure at Vaginal Hysterectomy and the Effect on Vaginal Length B. J. Vassallo1, C. Culpepper2, J. L. Segal3, M. D. Moen1, and M. B. Noone1 1Obstetrics and Gynecology, University of Illinois at Chicago/ Illinois Urogynecology, Park Ridge, IL; 2Obstetrics and Gynecology, Southview Hospital, Dayton, OH; 3Obstetrics and Gynecology, St. Barnabas Medical Center, Livingston, NJ Objectives: To compare the effect of horizontal versus vertical closure of the vaginal cuff during vaginal hysterectomy on vaginal length. Materials and Methods: Forty-three women were randomized to horizontal (n ⫽ 23) or vertical (n ⫽ 20) vaginal cuff closure during vaginal hysterectomy at a community hospital. The primary outcome of vaginal length before and after surgery was compared by the Student t test and the Paired t test. Results: Pre-operatively, mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 ⫾ 1.23 cm vs 8.28 ⫾ 1.39 cm, respectively; p ⫽ 0.21). Post-operatively, the groups statistically differed (6.63 ⫾ 1.02 cm vs 7.93 ⫾ 1.18 cm, p ⬍ 0.001). The mean change in vaginal length was ⫺1.13 ⫾ 1.15 cm and ⫺0.35 ⫾ 0.91 cm, respectively, (p ⫽ 0.01). Within group comparisons revealed a statistical difference between pre vs post mean vaginal length in the horizontal group (7.76 ⫾ 1.23 cm vs 6.63 ⫾ 1.02 cm; p ⬍ 0.001) and no difference within the vertical group (8.28 ⫾ 1.39 cm vs 7.93 ⫾ 1.18 cm; p ⫽ 0.11). Conclusion: Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length. Key Words: vaginal surgery, vaginal hysterectomy, vaginal length Disclosure - Consultant: B. Vassallo, Gynecare, Inc., M. Moen, Gynecare, Inc. ORAL PRESENTATION 3 Sensory Nerve Injury After Uterosacral Ligament Suspension M. Flynn1, C. Amundsen2, and A. Weidner2 1Obstetrics and gynecology, University of Rochester, Rochester, NY; 2Obstetrics and Gynecology, Duke University Medical center, Durham, NC Objectives: Uterosacral ligament suspension is a technique commonly performed to suspend the prolapsed vaginal apex. This review describes our experience with the clinical presentation and management of lower extremity sensory nerve symptoms in several subjects after uterosacral ligament suspension. Materials and Methods: Hospital and office medical records from our two institutions were reviewed from Jan 2002–August 2005 and all subjects who underwent uterosacral ligament suspension through a vaginal approach were identified. Records were reviewed and subjects with symptoms of buttock and posterior thigh pain during the 6 week postoperative period were identified. Detailed clinical information was abstracted from the charts of these subjects. Preoperative, intraoperative and postoperative findings were reviewed. Results: Of 169 uterosacral ligament suspensions, we identified 7 subjects with lower extremity pain. Age ranged from 42 to 70 years. Two subjects had a preoperative history of back pain and one of these also had a history of sciatic pain requiring steroid injections. Concurrent procedures included 6 vaginal hysterectomies, 5 anterior repairs, 4 posterior repairs, 2 slings and 1 bilateral salpingo-oophorectomy. All procedures were performed with subjects in high lithotomy position using padded Allen stirrups. Sutures were placed through the both uterosacral ligaments at the level of the ischial spine. Within 24 hours of the surgical procedure, all subjects experienced similar, substantial sharp buttock pain and numbness that radiated down the center of the Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 65 posterior thigh to the popliteal fossa. Five subjects had pain only in the right thigh, one subject only in the left thigh and one subject in both. Six of seven subjects experienced exacerbation of the pain with walking, standing, or sitting. Neurologic exam documented in six of seven subjects showed no motor deficits and confirmed decreased sensation over the involved dermatome. Pelvic exams were nonspecific in 4 subjects; however, in the other 3 subjects the pain was exacerbated by pulling on the ipsilateral uterosacral suture. In these subjects, the ipsilateral uterosacral ligament suture was removed within 2 days of surgery. These subjects had immediate subjective reduction in their pain and complete resolution of pain by 6 weeks, although the numbness persisted beyond 6 weeks. The remaining 4 subjects were treated with gabapentin and narcotics. Three had resolution of their pain by 12–14 weeks postoperatively and the last subject’s pain resolved gradually by 6 months. Conclusion: Women undergoing uterosacral ligament suspension are at risk of developing postoperative pain and numbness in a sciatic distribution. These symptoms appear to be related to placement of uterosacral ligament sutures and may be relieved either by prompt removal of the ipsilateral uterosacral ligament suture or with prolonged medical therapy. 6.6 and was significantly correlated with depression as measured by the PHQ (r ⫽ ⫺0.52, p ⫽ 0.0002). The PISQ-12 and FISI scores did not correlate and PISQ-12 scores were similar among the three continence groups. None of the individual PISQ-12 items including pain with intercourse or fear of incontinence during intercourse (either urine or stool) were different among the continence groups. Of women who underwent an “overlapping” sphincteroplasty 24% reported that they “always” or “usually” felt pain during intercourse compared to 4% of those having an “end-to-end” sphincteroplasty (p ⫽ 0.04). Conclusion: Sexual function as measured by PISQ-12 is not associated with type or severity of anal incontinence. Dyspareunia was more common after an “overlapping” than an “end-to-end” sphincteroplasty. Anal continence rates five years after anal sphincteroplasty are disappointing but similar to previously reported series. 75% of patients have incontinence of liquid or solid stool and these symptoms have a significant impact on physical function and quality of life. Key Words: sexual function, anal sphincteroplasty, quality of life, anal incontinence Disclosure - Nothing to disclose. Key Words: vaginal prolapse, postoperative pain, nerve injury Disclosure - research grant: Cindy Amundsen, Life-Tech, Inc, Cindy Amundsen, American Medical Systems, Cindy Amundsen, NDI Medical, Cindy Amundsen, Pfizer; consultant: Cindy Amundsen, Allergan. ORAL PRESENTATION 4 Sexual Function, Quality of Life, and Severity of Anal Incontinence Following Anal Sphincteroplasty E. R. Trowbridge, D. M. Morgan, J. O. Delancey, and D. E. Fenner Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI Objectives: To determine the severity of anal incontinence and its impact on quality of life and sexual function in women following anal sphincteroplasty. Materials and Methods: 84 women who underwent anal sphincteroplasty during the years 1993–2004 were mailed validated survey instruments to evaluate health-related quality of life. Questionnaires included the Fecal Incontinence Severity Index (FISI), the Colorectal Anal Impact Questionnaire (CRAIQ), Patient Health Questionnaire (PHQ) to screen for depression with higher scores in each scale reflecting worse disease or impact severity. Also included were the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionaire-12 (PISQ-12) and the Medical Outcomes Study Short Form (SF-12) with higher scores reflecting better function. Demographic and perioperative data were obtained from patient charts. Statistical analysis was performed with chi-square, paired t-tests, ANOVA or Pearson’s correlations. Results: 59 patients responded to the survey (response rate ⫽ 70%). Mean age was 48.1 ⫾ 11.5 years and mean length of follow-up was 5.6 ⫾ 3.0 years. Mean FISI score (0 –57) was 23 ⫾ 15.7, with 6 (11%) women being totally continent (group 1), 8 (15%) being incontinent of flatus only (group 2), and 45 (75%) being incontinent of liquid, solid stool or both (group 3). Analysis of medical co-morbidities showed that women with irritable bowel syndrome had a higher mean FISI score compared to women without irritable bowel syndrome (28.2 ⫾ 15.3 vs. 19.3 ⫾ 14.7, p ⫽ 0.04). FISI score correlated with CRAIQ score (r ⫽ 0.66, p ⬍ 0.0001) and the physical scale of the SF-12 (r ⫽ ⫺0.39, p ⫽ 0.005). The FISI score did not correlate with age, length of follow-up, age at the time of surgery, or procedure type (“end-to-end” vs. “overlapping”). 46 women were sexually active (78%). Sexually active women were younger than those who were not sexually active (45.9 ⫾ 10.6 vs. 56.5 ⫾ 11.5 years; p ⫽ 0.002), but they were not different with respect to BMI, FISI score, or procedure type (“end-to-end” vs. “overlapping”). Mean PISQ-12 score was 34.1 ⫾ 66 ORAL PRESENTATION 5 The Decision to Perform Lymphadenectomy in Advanced Stage Ovarian Cancer: Room for Improvement W. Cliby, G. D. Aletti, and K. Podratz Obstetrics and Gynecology, Mayo Clinic, Rochester, MN Objectives: There is limited objective data supporting or refuting the value of lymphadenectomy in patients with advanced stage ovarian cancer. As a result, no clear guidelines exist for the intra-operative management of lymph nodes. This lack of standardization can result in wide differences in surgical practice without sound reason for these differences. To better understand the factors that are important in the decision to perform lymph node assessment (LNA) in ovarian cancer we undertook this study. Materials and Methods: All consecutive patients with Stage IIIC or IV epithelial ovarian cancer were included during the 5 year period 1994 –1998. Patients who were upstaged to IIIC solely by virtue of lymphatic involvement were excluded as LNA is clearly recommended in the staging of presumably early ovarian cancer. Records were reviewed for specific procedures performed, pathology and overall survival (OS). Simple statistics, univariate and multivariable analysis was performed. Results: 215 patients met inclusion criteria and had sufficient information available from the operative notes to determine the type of LNA performed. Only 89/215 (41.4%) had LNA performed. The subtypes of LNA assessment performed were: 58/89 (65%) underwent complete pelvic (Pe) and para-aortic (Pa) lymphadenectomy (LND) and the remaining 31 (35%) underwent a more limited lymph node sampling (LNS). To first determine the importance of LNA in outcomes, we considered overall survival for the subgroup of patients undergoing LNA. In this group, the performance of radical surgery, LND (vs. LNS) and low RD were all important in univariate analysis. However, only residual disease (RD) was an independent predictor of overall survival. We then determined which factors correlated with the decision to perform LNA. We observed that although multiple factors were significantly correlated with the decision to perform LNA in univariate analysis, only surgeon (p ⬍ 0.001), low RD (p ⫽ 0.004), ASA1/2 (p ⫽ 0.002), and carcinomatosis (p ⫽ 0.01) were important in multivariable analysis. Further, if LNA was performed, the decision to do LND vs. LNS was independently associated with surgeon (p ⬍ 0.001), low RD (p ⫽ 0.002) and patient age ⬍65 (0.003). In all, surgeon preference appeared to be the most important factor for whether LNA, and extent of LNA. Finally, when considering survival of the subgroup undergoing LNA, we observed a significantly shorter survival for those with lymphatic involvement. However, when Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 considering only those with positive lymph nodes, we observed no survival benefit for those undergoing LND relative to LNS: the only independent predictor of survival was RD. Conclusion: The decision to perform LNA in advanced stage ovarian cancer in our series appears based on several intuitively logical factors: low RD, ASA status of the patient. However, the most important factor was individual surgeon preference. We believe the role of LNA and the recommendations for LNA are poorly defined for advanced ovarian cancer. This area represents an opportunity for standardization and improvement in surgical practice of gynecologic oncology. Key Words: surgery, ovarian cancer, lymphadenectomy Disclosure - Nothing to disclose. ORAL PRESENTATION 6 Is Intraoperative Frozen Section Analysis of Pelvic Lymph Nodes Accurate After Neoadjuvant Chemotherapy in Patients With Cervical Cancer? A. A. Bader1, K. F. Tamussino1, G. Pristauz1, F. Moinfar2, and R. Winter1 1Department of Obstetrics/Gynecology, Medical University of Graz, Graz, Austria; 2Department of Pathology, Medical University of Graz, Graz, Austria Objectives: Intraoperative frozen section examination of pelvic lymph nodes is frequently used to tailor the extent of lymphadenectomy or select individual treatment strategies in patients with cervical cancer, some of whom may have received neoadjuvant chemotherapy (NACT). NACT can cause necrosis, fibrosis, or keratinization of tumor deposits in extirpated lymph nodes and it is unclear whether intraoperative frozen section analysis of extirpated nodes is accurate after NACT. We analyzed the accuracy of frozen section examination of pelvic lymph nodes in patients after NACT. Materials and Methods: We reviewed 134 patients with invasive cervical cancer who underwent surgery including systematic pelvic lymphadenectomy with intraoperative frozen section examination of pelvic lymph nodes. Results of frozen section examination were related to definitive histology and compared between patient groups of NACT and primary surgery. Results: A total of 1670 pelvic lymph nodes were evaluated intraoperatively by frozen section examination and 6689 pelvic lymph nodes were analyzed by final histopathology. We observed 9 false negative cases out of 53 patients with positive lymph nodes (false negative rate 16.9%). After NACT, two false negative diagnoses out of twelve patients with node metastases were recorded (false negative rate 16.7%) (table). No false positive cases were noted. TABLE 1. Accuracy of Frozen Section Examination as a Diagnostic Test for Predicting the Final Node Status in Patients After NACT and Primary Surgery of 134 Patients With Cervical Cancer, Oral Presentation 6 True-positive True-negative False-negative Sensitivity Specificity Positive predictive value Negative predictive value NACT (No. of Patients) Primary Surgery (No. of Patients) 10 9 2 83% 100% 100% 34 72 7 83% 100% 100% 82% 91% Conclusion: NACT does not appear to compromise the diagnostic accuracy of intraoperative frozen section examination of pelvic lymph nodes in patients with cervical cancer. Key Words: cervical cancer, lymph nodes, frozen section, neoadjuvant chemotherapy Disclosure - Nothing to disclose. ORAL PRESENTATION 7 Clinical Anatomy and Surgical Skills Training (CASST) K. Kenton1,2, S. Graziano1, E. Mueller2,1, L. Oldham3, and F. Turner4 1 Obstetrics and Gynecology, Loyola University Medical Center, Maywood, IL; 2Urology, Loyola University Medical Center, Maywood, IL; 3Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL; 4Obstetrics and Gynecology, Illinois Masonic Medical Center, Chicago, IL Objectives: Resident surgical training is increasingly challenging due to limited work hours, decreased surgical volume, and increasing clinical demands of academic faculty. Innovative, cost effective programs must be developed to teach junior residents anatomy and basic surgical skill (SS). The aim of this program was to develop multicenter, multidisciplinary anatomy and SS training program for junior residents in Ob/Gyn and urology. Materials and Methods: We administered a needs assessment on knowledge of basic SS and clinical anatomy to junior residents from 4residency training programs in Chicago. We then developed 5, 3-hour workshops, including didactics, SS laboratories, and cadaver dissections to teach basic SS and anatomy. A program budget was developed for a single residency program with 6 juniors and compared to the budget for 4 residencies. Faculty included physicians from gynecology and urology from 3 different academic medical centers. A pre-test was given prior to the first session to assess baseline knowledge. The same test will be administered at the conclusion of the 5th session and at the end of the academic year to help determine short and long term program retention. The needs assessment and some pretest results are presented here. SPSS (Vesion 13) was used for data entry and analysis. Chi-square test of association was used for nominal data. Data were considered significant at the .05 level. Results: Thirty-two residents participated in the program. The perresident cost of the program with 4 participating sites was approximately $800 for models, cadavers, surgical instruments and supplies. When only 1 site with 6 residents was used, the per-resident cost increased to approximately $1700. Ninety-three percent of participants preferred hands-on surgical models or cadavers to didactic lectures. 100% of participants agreed or strongly agreed that they would benefit from more formal training in basic SS before entering the operating room, and 86% thought that prosected cadavers would increase their knowledge of anatomy. Over half of residents thought their knowledge and/or skills in all areas surveyed (except knot tying) were marginal or poor. A significantly higher percentage of R2s felt their knot tying skills were excellent or adequate (p ⫽ .009). Urology residents were significantly more likely to report that their knowledge of pelvic anatomy and hysterectomy was poor compared to gynecology residents (p ⫽ .001 and p ⫽ .012, respectively). On pretest assessment 27% could correctly identify 3 branches of the pudendal nerve and 40% accurately described differences between 1st4th degree perineal lacerations. Only 10% knew the 3 most common sites of ureteral injury during hysterectomy, while another 33% could name 2 sites. 50% selected an appropriate suture type to close fascia, subcutaneous tissues and skin. Conclusion: We have developed a unique multicenter, multidisciplinary program to train junior residents in clinical anatomy and Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 67 surgical skills. By including multiple centers and disciplines, we were able to reduce costs to individual programs and maximize faculty teaching time and effort. Objective outcomes of the program will be assessed at 2 time points to assess short and long term program efficacy. ORAL PRESENTATION 9 The Expectations of Surgical Patients: Are We Talking the Same Language? Disclosure - Grant/Research: Kim Kenton, Allergan, Pfizer, Q Med, Life-Tech, Astellas, Elizabeth Mueller, Allergan, Astellas. V. T. Mallett1, L. Brubaker2, L. Hammontree5, A. Stoddard3, L. Hall6, D. Borello-France4, S. Tennstedt2, for the Urinary Incontinence Treatment Network7 1Obstetrics and Gynecology, University of Tennessee, Memphis, TN; 2Obstetrics and Gynecology, Loyola University, Chicago, IL; 3New England Research Institute, Boston, MA; 4 Obstetrics and Gynecology, McGee Women’s Hospital University of Pittsburgh, Pittsburgh, PA; 5University of Alabama, Birmingham, AL; 6 University of California San Diego, San Diego, CA; 7NIDDK, National Institute of Health, Bethesda, MD ORAL PRESENTATION 8 Is Trans-Obturator Tape as Effective as Tension-Free Vaginal Tape in Patients With a Borderline Maximal Urethral Closure Pressure? Objectives: To assess patient expectations of surgical outcome following standardized pre-surgical video presentation of surgical procedures in a randomized trial comparing pubovaginal sling (PVS) and Burch colposuspension. Key Words: surgical education, sugical skills, clinical anatomy J. Miller1, S. M. Botros1, M. N. Akl2, R. P. Goldberg1, and P. K. Sand1 1 Division of Urogynecology, Evanston Continence Center, Northwestern University, Evanston, IL; 2Department of Obstetrics & Gynecology, Hurley Medical Center, Michigan State University, Flint, MI Objectives: Few clinical studies compare the trans-obturator tape (TOT) with the tension-free vaginal tape (TVT) and none address whether routine preoperative evaluation of urethral function is warranted. Most TOT failures happen in patients with maximum urethral closure pressure (MUCP) ⱕ40 cm H2O (Guerette, et al. Int Urogyn J 2005 16(S2): S120 关abstract兴 ). The purpose of this study was to compare TOT to TVT in that population. Materials and Methods: Retrospective cohort analysis of fourteenweek outcomes in 145 subjects (TOT ⫽ 85; TVT ⫽ 60). All patients had routine urodynamics including urethral pressure profiles preoperatively and fourteen weeks after surgery. All patients had routine cystoscopy at the time of surgery. Outcome variables included urodynamic stress incontinence (USI), subjective stress incontinence, bladder perforations estimated blood loss, and other intraoperative complications. Patients with preoperative MUCP ⱕ42 and ⬎42 cm H2O were included in separate sub-analyses of USI outcomes. A new cutpoint was used because initial subanalysis with a cutpoint of 40 cm H2O failed to show significance. Student’s T-test compared mean baseline characteristics and follow-up times. Pearson ␹2-tests of statistical significance and relative risks (RR) were calculated for outcomes. Results: Patients in the TOT and TVT groups did not differ significantly in baseline characteristics or follow-up time. In subanalysis of patients with a pre-operative MUCP ⱕ42 cm H2O, USI persisted in 7/44 (16%) patients with TOT and in 1/37 (3%) patients with TVT (RR 5.89; 1.02–33.90, 95% CI). In patients with MUCP ⬎42 cm H2O, USI persisted in 1/41 (2%) patients with TOT and in 1/23 (4%) patients with TVT (RR 0.57; 0.04 – 8.44, 95% CI). Overall, USI persisted in 8/85 (10%) patients with TOT and 2/60 (3%) patients with TVT (RR 2.85; 0.67–12.07, 95% CI). Subjective complaint of any stress incontinence after surgery was absent in 52/60 (87%) patients with TVT and 74/85 (87%) patients with TOT (RR 0.97; 0.94 –1.01, 95% CI). There was one bladder perforation (2%) with TVT and none with TOT (p ⫽ 0.41); other intraoperative complications including estimated blood loss also were similar between groups. Conclusion: In patients with a MUCP ⱕ42 cm H2O, the TOT is nearly six times more likely to fail than TVT. Long-term follow-up and randomized controlled trials are needed. Key Words: stress incontinence, transobturator tape, tension-free vaginal tape, maximal urethral closure pressure, urethral pressure profile, surgery Disclosure - Advisor: Peter Sand, Novasys; Investigator: Peter Sand, Mentor; Investigator, Advisor, Lecturer: Peter Sand, Alza/OrthoMcNeil, Peter Sand, American Medical Systems, Peter Sand, Indevus Pharmaceuticals, Peter Sand, Astellas. 68 Materials and Methods: Participants were randomized to Burch or PVS in an NIH sponsored multi-center trial. Prior to surgery, trial participants watched a video explaining, purpose, risks and benefits as well as the likelihood for eliminating stress incontinence. Preoperatively, a validated questionnaire was used to assess expectations for the effects of surgery on UI-related symptom relief, resolution of current limitations in activity, and change in emotions. The domains were examined on a 5 point Likert-type scale. The expectation score was computed as the average of expectations (0 –5) for the resolution of symptoms, limitations or negative emotions reported. Type and severity of incontinence were assessed preoperatively using the Medical, Epidemiologic and Social Aspects of Aging (MESA) questionnaire, Urinary Distress Inventory (UDI), incontinence impact questionnaire (IIQ), baseline health measures and urodynamic parameters. Bivariate and multivariable associations with expectation were explored using logistic regression analysis. Results: The study included 650 eligible randomized women (age 27– 81; mean:51.9). Mean and median expectation scores were 4.4 of 5 and 87% of women had a score ⬎4. Because the scores were highly skewed, women were categorized by score ⬎4 (higher expectations) and ⬍4 (lower expectations). Symptoms were recorded first followed by expected resolution of the symptom. The most frequent symptoms were urine leakage (98%) followed by embarrassment (88%). Frequency, reduced physical activity, and urgency were reported by 74%, 72%, and 70% respectively. Limitations on sexual and social activities were reported by less than 44%. Expectation for near or complete improvement was most frequent for urine leakage (98%). Of the 70% of patients reporting urgency, 92% had an expectation of the symptom becoming much better or completely better. Moreover, of the 74% reporting frequency, 83% expected substantial symptom relief. There was no association between expectation and IIQ, urodynamics and baseline health measures. Women who reported a greater impact of their incontinence on the UDI stress subscale had higher expectations. Among women with lower expectations (score less than 4), mean baseline UDI-stress score was 71.8 while among women with high expectations the mean was 79.3 (p ⬍ 0.01). Conclusion: Patients’ expectation for the outcome of anti-stress incontinence surgery is uniformly high. Even with standard counseling about expected outcome and benefits of the two procedures patients have expectation regarding resolution of irritative symptoms that are unrealistic and may ultimately impact patient satisfaction. Key Words: surgery, incontinence, patient expectation, patient satisfaction Disclosure - grant: Veronica T. Mallett, Watson, Yamanouchi, Gynecare, Linda Brubaker, Liley pharmaceuticals. Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 ORAL PRESENTATION 10 Bowel Symptoms in Women Planning Surgery for Pelvic Organ Prolapse C. S. Bradley, and ... for the Pelvic Floor Disorders Network University of Iowa Carver College of Medicine, Iowa City, IA Objectives: Bowel symptoms are common and often attributed to pelvic organ prolapse (POP). Our objective was to correlate bowel symptoms and level of vaginal descent in women with prolapse. Materials and Methods: This analysis used baseline data from the Colpopexy and Urinary Reduction Efforts (CARE) study, a randomized trial of sacrocolpopexy with or without Burch colposuspension in stress continent women with Stages II – IV POP. Participants completed validated questionnaires, including the Colorectal-anal Distress Inventory (CRADI) and the Colorectal-anal Impact Questionnaire (CRAIQ) and underwent Pelvic Organ Prolapse Quantification (POP-Q). POP-Q points Bp, Ba and C assessed descent of the posterior, anterior and apical vagina, respectively. Subject characteristics were compared between prolapse stages using the chisquare test. Results: The CARE trial enrolled 322 women with mean age 61.3 ⫾ 10.2 years and median parity of 3. POP-Q stages included II (n ⫽ 44, 13.7%), III (n ⫽ 217, 67.4%) and IV (n ⫽ 61, 18.9%). Posterior repair had been performed in 71 women (22.0%). When examining individual symptom questions on the CRADI, women with Stages III and IV prolapse tended to have similar levels of symptoms, while women with Stage II prolapse were more symptomatic. (Table) Summary scores for the CRADI (Stage II, median score 58.3; Stage III, score 47.6; and Stage IV, score 48.0; p ⫽ 0.08) and CRAIQ (Stage II, median score 112.6; Stage III, score 102.3; and Stage IV, score 108.0; p ⫽ 0.09) showed a similar pattern. Conclusion: In conclusion, although bowel symptoms are common in women planning sacrocolpopexy, these symptoms and focused questionnaire scores do not have a linear association with the stage of prolapse in the posterior or other pelvic compartments. We suggest that the CRADI, CRAIQ and POP-Q examination measure complementary, different and not necessarily related aspects of pelvic organ prolapse. Key Words: POP-Q, pelvic organ prolapse, bowel dysfunction, anorectal symptoms Disclosure - Grant/Research Support: Catherine Bradley, Astellas; Speaker Bureau: Catherine Bradley, Pfizer. TABLE 1. Oral Presentation 10 Symptoms Splinting Straining Incomplete emptying Stage II N ⴝ 44 Stage III N ⴝ 217 Stage IV N ⴝ 61 19 (44.2%) 23 (53.5%) 25 (59.5%) 53 (25.1%) 72 (34.1%) 88 (41.9%) 17 (28.3%) 18 (30.0%) 26 (43.3%) ORAL PRESENTATION 11 Posterior Vaginal Wall Prolapse Does Not Correlate With Fecal Symptoms or Objective Measurements of Anorectal Function G. Da Silva, B. Gurland, A. Sleemi, and G. Levy Maimonides Medical Center, Brooklyn, NY Objectives: The purpose of this study is to evaluate the relationship between the degree of posterior vaginal wall prolapse, anorectal symptoms, and physiology. Materials and Methods: This is a prospective IRB approved study including all patients evaluated at a Multidisciplinary Pelvic Floor Center by a urogynecologist and colorectal surgeon. A standardized bladder and TABLE 1. Oral Presentation 11 Symptoms Obstructive Defecation Wexner Fecal Incontinence Score ⬎9 Feeling of anal blockage Anal digitation BM ⬍3/week Group I% Group II % P value 41.9 30.6 40 20 NS NS 17.7 12.9 11.3 20 12.9 4.3 NS NS NS bowel function questionnaire and POP-Q clinical examination was performed on all patients. Anal physiologic testings (anorectal manometry, transanal ultrasound (US), surface electromyography and pudendal nerve terminal latencies-PNTML) were selectively performed based on bowel symptoms. Defecography was performed on patients with constipation and to rule out rectal prolapse. Patients were divided into 2 groups based on posterior vaginal wall prolapse Group I: Ap/Bp ⬍ ⫺1, and Group II Ap/BP ⱖ ⫺1. Patient information was entered into a centralized database and statistical analysis was performed using Fisher’s Exact T-test and p value ⬍0.05 was considered statistically significant. Results: One hundred and thirty-two patients with a mean age of 63 (range: 24 –90) years old were evaluated. Sixty-two (47%) in Group I and 70 (52%) in Group II. Overall, obstructive defecation was present in 40.9%, a Wexner fecal incontinence score ⬎9 in 25%, a feeling of anal blockage in 18.9%, digitation in 12.9%, evacuation less than 3 BM/week in 7.6%. Bowel symptoms are summarized in Table 1. Ninety-seven patients underwent physiologic tests. At manometry, both resting (RP) and squeeze pressures (SP) were significantly higher in patients Group II (RP: 63.1 vs. 36.6, SP 86.3 vs. 51, respectively; p ⬍ .001). There was no association between rectal capacity, first sensation, urgency and the degree of prolapse. US demonstrated anterior sphincter defect in 21.9% and a perineal body ⬍10 mm in 67.1% of the patients, with no correlation with the degree of prolapse. There was no association between EMG and PNTML tests results and the degree of prolapse. On defecography, 28% of the patients had concomitant enterocele and 21.3% intussusception, with no correlation with the severity of prolapse. Conclusion: Anorectal symptoms do not correlate to the degree of posterior vaginal wall prolapse nor does the presence of prolapse equate to abnormal physiologic studies. However, elevated resting and squeeze sphincter pressures in patients with higher degree of posterior vaginal wall prolapse may help to explain the pathogenesis of posterior wall prolapse. When the sphincter pressures are elevated, a defect in the rectovaginal septum provides a “path of least resistance.” Key Words: posterior vaginal wall prolapse, physiology, anorectal symptoms Disclosure - Speakers Bureau: Gil Levy, Ortho Pharamaceutical. ORAL PRESENTATION 12 Rectocele Repair: A Randomized Trial of Three Surgical Techniques Including Graft Augmentation M. R. Paraiso, M. D. Barber, T. W. Muir, and M. D. Walters OBGYN, The Cleveland Clinic Foundation, Cleveland, OH Objectives: To compare anatomic and functional outcomes of 3 different surgical techniques for treating rectoceles. Materials and Methods: 106 women with stage 2 or greater posterior vaginal wall prolapse were randomized to one of three treatments: traditional posterior colporrhaphy (n ⫽ 37), site-specific rectocele repair (n ⫽ 37), or site-specific rectocele repair augmented with a porcine small intestinal submucosa bioengineered collagen matrix (Fortagen™). Subjects underwent a physical examination that Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 69 included POPQ and completed the Pelvic Floor Distress Inventory-20 (PFDI-20), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and the Prolapse and Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) at baseline, 6 months, 1 year and 2 years after surgery. Anatomic failure was defined as POPQ point Bp ⬎ ⫺1 at one year follow-up. Functional failure was defined as a worsening in prolapse or colorectal symptoms as assessed by the PFDI-20. Results: Of 106 subjects who enrolled in this study, 105 underwent surgery and 99 subjects (93%) returned for follow-up with a mean follow-up of 16 ⫹ 7 months (range 3.5 to 32 mos.). At baseline, 44 subjects (42%) had stage 2 posterior vaginal wall prolapse; 56 (53%) had stage 3; and 5 (5%) had stage 4. Mean operating time, change in hematocrit, and length of stay were similar between groups. Intraoperative and postoperative complications were infrequent and similar between groups. After one year of follow-up, subjects who received a site-specific repair with graft augmentation had a significantly greater anatomic failure rate (9/27; 33%) than those who received a sitespecific repair alone (5/37; 13.5%) or a traditional posterior colporraphy (3/33; 9%), p ⫽ 0.035. Three percent (1/33) of those in the traditional posterior colporraphy group, 5% (2/35) in the site-specific group, and 14% (4/29) in the graft augmentation group had posterior vaginal prolapse to or beyond the hymen at one year, p ⫽ 0.22. There were significant improvements in the prolapse and colorectal scales and overall summary scores of the PFDI-20 and PFIQ-7 after surgery in all groups (p ⬍ .0001 for each) with no differences between groups. The proportion of subjects with functional failures was 15% (15/99) overall, and not significantly different between groups. At baseline, 64% of subjects were sexually active. Of these, 48% (31/64) complained of dyspareunia prior to surgery. There was no significant change in the rate of dyspareunia one year after surgery and there were no differences between groups. Overall sexual function as measured by the PISQ-12 improved significantly in all groups postoperatively (p ⬍ .01), with no differences between groups. Conclusion: Traditional posterior colporraphy and site-specific rectocele repair result in similar anatomic and functional outcomes. Graft augmentation with a porcine-derived acellular collagen matrix does not improve and may worsen anatomic outcomes. All three methods of rectocele repair result in significant improvements in prolapse and bowel symptoms, quality of life, and sexual function with no overall change in the rate of dyspareunia. Key Words: prolapse, vaginal surgery, rectocele, site-specific repair, graft augmentation, posterior colporrhaphy Disclosure - Consultant: Marie Fidela R. Paraiso, Gynecare and AMS, Mark D. Walters, AMS; Grant/Research Support: Marie Fidela R. Paraiso, Organogenesis, Inc., Matthew D. Barber, Eli-Lilly and AMS. ORAL PRESENTATION 13 Histologic Evaluation and Biomechanical Measurements of Implanted Graft Material in a Rabbit Vaginal and Abdominal Model W. S. Hilger1, A. J. Walter3, M. Zobitz2, P. Magtibay1, and J. Cornella1 1 Gynecology, Mayo Clinic Arizona, Scottsdale, AZ; 2Orthopedic Biomechanics, Mayo Clinic Rochester, Rochester, MN; 3Urogynecology, Kaiser Sacramento, Sacramento, CA Objectives: The purpose of this study is to describe histologic and biomechanical changes of vaginally and abdominally implanted graft materials (human cadaveric dermal allograft (Repliform), porcine dermal xenograft (Pelvisoft), porcine collagen coated polypropylene mesh (Pelvitex) and autologous fascia) in New Zealand white rabbits. Materials and Methods: Twenty Retired New Zealand Breeder rabbits underwent abdominal and vaginal surgery. Each rabbit had four materials randomly placed in the abdomen and vagina (autologous, Repliform, Pelvisoft, Pelvitex or Pelvisoft). The rabbits underwent harvesting of the graft material at 6 and 12 weeks after implantation. Biomechanical testing 70 on a tensiometer measured the maximum strength of the tissue (Ultimate Stress MPa) and the tissue elasticity (Elastic Modulous MPa). We performed 2-way ANOVA (Sites X Material) to assess magnitude of decline from baseline contributed by sites and materials. Histologic evaluation assessed the extent of inflammatory response, neovascularization, and collagen deposition. Results: Ultimate stress declined from baseline in all materials and was dependent on material used and anatomic site (99% CI, P ⬍ 0.05 and 94% CI, P ⫽ 0.057). The decline in ultimate stress for abdominally implanted materials from baseline were: autologous 0.19 MPa, Pelvisoft 3.54 MPa, Pelvitex 0.96 MPa and Repliform 10.3 MPa. The decline in ultimate stress for each vaginally implanted materials from baseline were: autologous 0.26 MPa, Pelvisoft 3.84 MPa, Pelvitex 4.00 MPa and Repliform 13.1 MPa. Elastic modulous was found to be dependent on the material (99% CI, P ⬍ 0.05) but not anatomic site (P ⫽ 0.73). The decline in Elastic Modulous for abdominally implanted materials from baseline were: autologous 0.29 MPa, Pelvisoft 20.1 MPa, Pelvitex 0.75 MPa and Repliform 25.5 MPa. The decline in elastic modulous for vaginally implanted materials from baseline were: autologous 0.56 MPa, Pelvisoft 18.1 MPa, Pelvitex 0.66 MPa, Repliform 29.0 MPa. Histologic evaluation noted minimal inflammatory response in autologous and Pelvitex, and moderate to strong inflammatory response in Pelvisoft and Repliform. Minimal neovascularization was noted in all materials. Minimal collagen ingrowth was noted in Repliform and Pelvisoft. Collagen ingrowth was moderate in autologous and Pelvitex but encapsulation was noted in Pelvitex. The histologic findings were not affected by graft site. Conclusion: All implanted materials demonstrated a decline in ultimate stress and elastic modulous from baseline. The changes in ultimate stress were affected by the anatomic site, with the vaginally implanted materials showing a greater decline. Autologous and Pelvitex had minimal inflammatory response but the collagen ingrowth differed. Repliform and Pelvisoft showed greater inflammatory response and less collagen ingrowth. Future studies should determine what factors contribute to the host response to graft materials and how they effect graft performance. Key Words: graft material, vagina, rabbit model Disclosure - Nothing to disclose. ORAL PRESENTATION 14 Can Advanced Stages of Anterior or Posterior Vaginal Wall Prolapse Occur Without Apical Involvement? K. Rooney1, E. R. Mueller2,1, K. Kenton1,2, M. P. Fitzgerald1,2, S. Shott3, 1 and L. Brubaker1,2 Obstetrics/Gynecology, Loyola University Medical Center, Maywood, IL; 2Urology, Loyola University Medical Center, Maywood, IL; 3Obstetrics/Gynecology, Rush University Medical Center, Chicago, IL Objectives: An increasing number of surgical techniques have been developed for anterior vaginal wall prolapse. Some of these techniques address the apex while others may not. Our objective was to determine the associations between the most prolapsed portion of the anterior and posterior vaginal wall and the apex. Materials and Methods: After obtaining IRB approval, we retrospectively reviewed the charts of all new patients who presented to our tertiary care urogynecology practice from January 2004 to February 2005. We extracted demographic data, previous surgical history and physical exam findings including pelvic organ prolapse quantification (POP-Q). POP-Q points Ba, C, and Bp, measured the anterior, apical and posterior segments of the vaginal respectively. Data were analyzed using SPSS version 13 software. Correlations between variables were analyzed using a Spearman’s analysis. Results: Three hundred twenty-five women had completed POP-Q measurements that allowed for analysis. The mean age was 60 years and 81% were Caucasian. Thirty-nine percent of the women had a Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 FIGURE 1. previous hysterectomy. The position of the cervix or vaginal cuff (POP-Q point C) strongly correlated with POP-Q point Ba (most distal position of the anterior wall) (r ⫽ 0.835, p ⬍ 0.001). There was a moderate correlation between the position of the apex and the posterior wall (r ⫽ 0.556, p ⬍ 0.001). The following scatter plot demonstrates the relationship between point C (the cervix or vaginal apex) and point Ba (the most distal portion of the anterior wall). The relationship is strongly linear and using linear regression the following equation can be developed; C ⫽ Ba (1.4) ⫺ 4.4 (r ⫽ 0.869). Using this equation we can predict that when the anterior wall is at the hymen (point Ba ⫽ 0) the equation calculates C at ⫺4.4. Seventy-five percent of the women in this study had point C at ⫺4 or greater when point Ba was at 0 (n ⫽ 153). Conclusion: Anterior vaginal wall prolapse is strongly associated with apical prolapse. Anterior vaginal wall defects that are being surgical repaired often require a concomitant repair of the apical defect. Key Words: anterior prolapse, apical prolapse, posterior prolapse Disclosure - Grant /Research: Elizabeth R. Mueller, Allergan, Astellas; Grant/ Research: Kimberly Kenton, Allergan, Astellas, Yamanouchi, Lifetech, Pifzer; Grant/Research: Mary Pat FitzGerald, Allergan, Yamanouchi, Lifetech; GrantResearch, Linda Brubaker, Allergan, Astellas, Yamanouchi, Lifetech, Pifzer. Results: After a primary repair, 48 women had complete healing of their fistulas (48/95 ⫽51%) with 39 women being dry (39/95 ⫽ 41%) and 9 having urinary incontinence (9/95 ⫽ 9%). Failed fistula repair was noted in 19 (19/95 ⫽ 20%) and 28 patients were lost to follow up (28/95 ⫽ 29%). If all patients lost to follow up are assumed wet, our failure rate is 49% (47/95). Secondary repairs were performed on 18 of the 19 known failed primary repairs. A second vaginal repair was performed in 15 patients, and an abdominal procedure was undertaken in 3 patients. Healing of the fistulas occurred in 39% (7/18) of surgeries with 3 (17%) women becoming dry and 4 (22%) having urinary incontinence. A second failed surgery occurred in 7 (39%) women and 4 (22%) of patients were lost to follow up. Three of the failed repairs underwent a third surgery with no known successes. A fourth repair was attempted in two patients with one patient having a successful closure and being dry. Conclusion: Success rates for vesico-vaginal fistula repairs have been controversial with questions remaining regarding staging and follow up. Our report confirms the best chance of successful fistula repair, regardless of stage, location or size, is with the initial repair. This series also demonstrates that when all patients appearing with a fistula are included in the reported surgical series, the success rates are less than the impression of reported experiences. We tabulated all patients lost to follow up as failed repairs and wet. While this method, counting patients lost to follow up as wet, is controversial, we feel our data is made more accurate in this manner. Key Words: birth trauma, vesico-vaginal fistulas, urinary incontinence, obstructed labor ORAL PRESENTATION 15 Repair of Obstetrical Vesico-Vaginal Fistulas in Africa M. L. Roenneburg1,2, R. Genadry2, and C. R. Wheeless2 1The Weinberg Center for Women’s Health & Medicine, Mercy Medical Center, Baltimore, MD; 2Dept of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD Objectives: Obstetrical fistulas in sub-Sahara Africa result from obstructed labors. Our intent is to report on a series of vesico-vaginal fistula repairs in an ongoing program for repair of obstetrical trauma in Niger, Africa. Materials and Methods: From October 2003 to April 2005, 95 patients presented with vesico-vaginal fistulas and no previous repair. Patients ranged in age from 14 to 51. Their fistulas were variable in location and ranged from 0.5 cm to 7 cm in size. All patients were offered surgical repair regardless of stage and circumstances. Vaginal repairs were performed in 89 patients (94%). Abdominal transvesical repairs were utilized in 6 patients (6%). Disclosure - Nothing to disclose. ORAL PRESENTATION 16 A Comparison of Outcomes of Transurethral Versus Suprapubic Catheterization After Urogynecologic Procedures T. S. Dunn1, L. Hurt2,1, and B. Hessler2 1Obstetrics and Gynecology, Denver Health Medical Center, Denver, CO; 2Obstetrics and Gynecology, University of Colorado Health Science Center, Denver, CO; 3Obstetrics and Gynecology, University of Colorado Health Science Center, Denver, CO Objectives: To determine if there were any differences in outcomes in patients undergoing urogynecologic procedures when suprapubic or transurethral catheter was used for post-operative bladder drainage. Materials and Methods: This was an IRB approved randomized controlled study comparing suprapubic to transurethral catheterization Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 71 TABLE 1. Oral Presentation 17 Prolapse Reduction Method Pessary Hand Swab Forceps Speculum Stress Leakage at UDS Control, N (%) Incontinent after ASC Only Burch, N (%) Incontinent after ASC and Burch Benefit (⫺) (⫹) (⫺) (⫹) (⫺) (⫹) (⫺) (⫹) (⫺) (⫹) 19 of 46 (41%) 1 of 2 (50%) 18 of 53 (34%) 4 of 8 (50%) 22 of 63 (35%) 11 of 14 (79%) 20 of 41 (49%) 4 of 8 (50%) 17 of 42 (40%) 11 of 20 (55%) 8 of 37 (22%) 1 of 3 (33%) 13 of 50 (26%) 5 of 11 (45%) 12 of 63 (19%) 5 of 18 (28%) 5 of 36 (14%) 3 of 13 (23%) 7 of 41 (17%) 8 of 15 (53%) 19% 17% 8% 5% 16% 50% 35% 27% 23% 2% in patients undergoing procedures for pelvic prolapse, or stress urinary incontinence. Patients were included from 1/2002 through 1/2005. A two-sample T-test power analysis was performed and a sample size of 51 and 51 to achieve 93% power to detect a difference was calculated. Ten patients were added to cover for patients in case of loss to follow-up, incomplete records or inability to place catheter. The attending surgeon was the same in all cases. A randomization card was opened in the Operating Room designating whether a transurethral or suprapubic catheter should be placed. A visual analog scale was used for evaluation of postoperative pain. A 16 French Foley was then placed either transurethrally or suprapubically. Extracted data included patient demographics, blood loss, operating room time, incidence of urinary tract infection, pain scores, and length of hospital stay (for patients undergoing procedures requiring a stay). Fishers exact test and Wilcoxon rank sum analysis were used when indicated. Results: One hundred and ten charts were reviewed, and 104 patients were included; 51 in the transurethral group and 53 in the suprapubic group. Demographics were similar in each group relating to age, ethnicity, menopausal status, body mass index, and type of procedure. There were no differences in blood loss, urinary tract infections, length of hospital stay or length of catheterization in either group. There was an increased length of operative time when the suprapubic catheter was placed (mean 11 minutes) but was not statistically significant (p ⫽ .1). There was a statistical difference in pain perception on a visual scale, which was significantly less in the supra-pubic group (mild vs. severe) p ⫽ .01. Conclusion: There was no significant difference in outcomes for transurethral versus suprapubic catheterization in patients undergoing urogynecologic procedures. Patients did have significantly less pain when a suprapubic catheter was used, and should be considered when undertaking urogynecologic procedures requiring postoperative bladder drainage. Key Words: urogynecologic, transurethral catheter, suprapubic catheter Objectives: Our objective was to determine, in stress continent women undergoing sacrocolpopexy, whether urodynamics with prolapse reduction predicts postoperative stress incontinence. Materials and Methods: 322 stress-continent women with Stage II–IV prolapse underwent standardized urodynamics with water-based transducers. Five prolapse reduction methods were tested, two at each site and both performed for each subject. At sacrocolpopexy (ASC), participants were randomized to Burch colposuspension or no Burch (control). Clinicians were masked to urodynamic results. Pvalues were computed by two-tailed Fisher’s exact test. Results: Preoperatively, 12 of 313 (4%) subjects demonstrated urodynamic stress incontinence (USI) without prolapse reduction. The order of prolapse reduction methods did not affect detection of USI with reduction, 16% with 1st method versus 22% with 2nd. Preoperative detection of USI with prolapse reduction at 300 ml was, in ascending order: pessary, 6% (5 of 88); hand, 16% (19 of 122); swab, 19% (32 of 168); ring forceps, 21% (21 of 98); and speculum, 30% (35 of 118). As seen in the table below, the Benefit column estimates the decrease in postoperative stress incontinence when the prolapse reduction method is used preoperatively. In evaluating test characteristics of the prolapse reduction methods, the highest benefit was seen with the swab technique, with high positive predictive value (PPV) in controls, followed by low PPV in the Burch group. In addition, incontinence was always lower after negative urodynamic testing. In the control group, the swab technique of prolapse reduction had the highest positive predictive value for postoperative SUI, and the highest benefit between Burch and control groups. Conclusion: In stress continent women with prolapse undergoing sacrocolpopexy, the addition of Burch colposuspension reduced postoperative stress incontinence symptoms whether or not preoperative urodynamic stress incontinence was diagnosed with reduction testing. However, preoperative USI with prolapse reduction (regardless of method) was associated with a higher likelihood of postoperative stress incontinence, compared to subjects who did not leak with prolapse reduction during urodynamics. Disclosure - Nothing to disclose. Key Words: urodynamics, prolapse, CARE Trial, stress incontinence, sacrocolpopexy ORAL PRESENTATION 17 The Role of Pre-Operative Urodynamic Testing in Stress Continent Women Undergoing Sacrocolpopexy: The Colpopexy and Urinary Reduction Efforts (CARE) Randomized Surgical Trial A. G. Visco1, for the Pelvic Floor Disorders Network2 1Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; 2U01 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269, and U10 HD41267, NICHD, Bethesda, MD Disclosure - Nothing to disclose. 72 ORAL PRESENTATION 18 Do Pessaries Improve Lower Urinary Tract Symptoms? J. Schaffer1, G. W. Cundiff2, C. L. Amundsen3, A. Bent5, K. W. Coates6, K. Strohbehn4, and D. D. McIntire1 1Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX; 2Johns Hopkins Bayview Medical Center, Baltimore, MD; 3Duke University, Durham, OH; Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 4 Dartmouth Hospital, Hanover, NH; 5IWK Health Care, Halifax, NS, Canada; 6Scott & White Clinic, Temple, VA Objectives: To determine the effects of pessary use on lower urinary tract symptoms in patients with symptomatic pelvic organ prolapse and to compare symptoms in Gellhorn and ring with support users. Materials and Methods: This study was a sub-analysis of data collected during a multi-center randomized cross-over trial comparing the Gellhorn and ring with support pessaries in the relief of prolapse symptoms. Subjects with symptomatic pelvic organ prolapse at 6 institutions were randomized to one pessary for three months, followed by the other pessary for 3 months. The Pelvic Floor Distress Inventory (PFDI) was administered at baseline and after completion of 3 months with each pessary. The urinary scale of the PDFI is divided into 3 subscales: Obstructive/Discomfort, Irritative, and Stress. For this sub-analysis we evaluated pessary effects on urinary symptoms by comparing the baseline subscales with the subscales after 3 months of pessary use. We also calculated the Urinary Distress Inventory score before and after pessary use. Only patients with complete PFDI data after 3 months of pessary use were included. All pessary patients were analyzed as one group. Additionally, analysis was performed comparing urinary symptoms in subjects using the Gellhorn vs. the ring with support. Statistical analysis included paired student’s t-test and McNemar chi-square. RESULTS: 134 patients were enrolled in the study and 97 patients completed the first 3 months of the trial and had complete PFDI data. Of the completers, 68% were White, 14% African-American, 14% Hispanic and 3% other. The mean age was 62 years (range 30 – 89). There was a reduction in urinary symptoms from baseline to 3 months: urinary frequency (49% to 38%, p⫽0.04), urgency (54% to 42%, p ⫽ 0.04), leakage with cough (48% to 38%, p ⫽ 0.03). All 3 urinary subscales, as well as the urinary distress inventory, showed significant reduction in urinary symptoms after 3 months of pessary use. The Obstructive/Discomfort subscale had a baseline mean value of 20.32 which improved to 8.61 after 3 months (p⬍ 0.0001). The Irritative subscale went from an initial mean of 15.85 to 10.59 (p⫽0.0005). The Stress subscale went from a mean of 15.55 to a mean of 12.24 after pessary use (p ⫽ 0.04). The Urinary Distress Inventory improved from a mean of 51.31 at baseline to 31.45 (p ⬍ 0.0001). There were no significant differences in reduction of urinary symptoms between subjects with the Gellhorn and ring with support pessaries. Conclusion: In subjects with symptomatic pelvic organ prolapse who complete 3 months of pessary use with the Gellhorn or the ring with support there is a modest but significant reduction in obstructive, irritative and stress symptoms. Based on this evidence, pessaries should be included in the armamentarium of treatments for symptomatic prolapse patients with lower urinary tract symptoms. Key Words: prolapse, incontinence, pessary, urinary symptoms Disclosure - Research: K Strobehn, Duramed, Eli Lilly; Research, Consultant: C Amundsen, Life Tech, AMS, NDI Medical, Pfizer, Allergan; Research, Consultant, Advisory Board: GW Cundiff, Cook Ob/Gyn, Bard, Eli Lilly; Research, Speakers Bureau: JI Schaffer, Cook Ob/Gyn, Eli Lilly, GSK, Novartis, Yamanouchi; Research, Speakers Bureau, Consultant, Advisory Board: AE Bent, Eli Lilly, Q-Med Scand, Cook ObGyn, Gynecare. ORAL PRESENTATION 19 Randomized Crossover Trial of Ring and Gelhorn Pessaries: Satisfaction Outcomes G. W. Cundiff1, C. L. Amundsten2, A. E. Bent3, K. Coates4, and J. Schaffer5 1Gynecology and Obstetrics, Johns HOpkins School of Medicine, Baltimore, MD; 2Obstetrics and Gynecology, Duke University Medical Center, Durham, NC; 3Obstetrics and Gynecology, IWK Health Care, Halifax, NS, Canada; 4Obtetrics and Gynecology, Scott & White Hospital, Temple, TX; 5Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX Objectives: The aim of this randomized crossover trial was to compare patient satisfaction and symptom relief between the ring with support and gelhorn pessaries. Materials and Methods: Subjects were women presenting with symptomatic pelvic organ prolapse. They were randomized to one pessary for 3 months. After collection of outcome data, subjects switched to the other pessary for 3 months. They could quit either pessary at any time. Outcome data included a visual analog satisfaction score, and quality of life data using the Pelvic Floor Distress Inventory Pelvic Floor Impact Questionnaire, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire. Analysis included paired t-test for continuous data, Chi squared for nonparametric and ordinal data, and logistical regression. Results: Subjects had a mean age of 61 (30 – 89) and were primarily white, parous, postmenopausal women with 26% on ERT. The majority described their lifestyle as active. The median POPQ stage was 3 (stg 2 ⫽ 48%, stg 3 ⫽ 42%, stg 4 ⫽ 10%). Prior surgeries included hysterectomy (45%), incontinence surgery (10%), and prolapse surgery (9%). 134 subjects were enrolled with 63 initially randomized to a ring and 71 to a gelhorn. 18 subjects could not be fitted (ring pessary ⫽ 7, gelhorn ⫽ 5, neither 6), and 56 did not complete one of the 3-month trials. This included 26 who quit the ring pessary (5 moved to gelhorn, and 21 quit the study, 4 to have surgery), while 30 quit the gelhorn pessary (10 moved to the ring, and 20 quit the study, 4 to have surgery). There were an additional 6 subjects lost to follow-up. Subjects who would not wear a pessary for 3 months tended to be younger (57 v. 66, p ⫽ 0.0004) and were less apt to be white (p ⫽ 0.006). 62 subjects had satisfaction scores for both pessaries. There was no difference between the mean satisfaction scores for the ring (6.2, 0 –10, sd 4.05) and gelhorn (6.4, 0 –10, sd 4.09) yet only 22 (35%) had high satisfaction scores with both pessaries. The 36 (58%) subjects that reported high satisfaction with the ring pessary tended to be older (p ⫽ 0.036), more parous (p ⫽ 0.024), and non-white(p ⫽ 0.001). The 39 (63%) who reported a high satisfaction score with the gelhorn pessary were less apt to have had a hysterectomy (p⫽ 0.035) or prior prolapse surgery (p ⫽ 0.014). The 9 (15%) subjects who were not satisfied with either pessary tended to be white (p ⫽ 0.067), and were more likely to have had prior prolapse surgery (p ⫽ 0.009). Women with stage II prolapse were more likely to report dissatisfaction with either pessary (p ⫽ 0.196). Conclusion: While most women (87%) can be fitted with a pessary, the majority of women in this trial (55%) did not use a pessary for 3 months and 7% of women were unsatisfied with either pessary. Younger women and those with prior prolapse surgery are less likely to be satisfied with a pessary. For those who liked pessaries there were clear preferences between the ring and gelhorn. Women reporting high satisfaction with a ring pessary tend to be older and more parous, while women who report high satisfaction with a gelhorn were those without a prior hysterectomy or prolapse surgery. Key Words: pelvic organ prolapse, ring pessary, gelhorn pessary, PESSRI trial Disclosure - GW Cundiff, Cook Ob/GYN, Bard, Eli Lilly; Research, Consultant, Advisory Board: AE Bent, Eli Lilly, Q-Med Scand, Cook Ob/GYN, Gyncare: JI Schaffer, Cook Ob/GYN, Eli Lilly, GSK, Novartis, Yamanouchi; Research, Speakers Bureau, Consultant, Advisory Board. ORAL PRESENTATION 20 Quantification of Levator Ani Cross-Sectional Area Differences Between Women With and Without Prolapse Y. Hsu1, L. Chen2, M. Huebner1, J. A. Ashton-Miller2, and J. O. Delancey1 1 Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; 2 Biomechanical Engineering, Univ. of Michigan, Ann Arbor, MI Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 73 FIGURE 1. Objectives: An ongoing project has established that women with prolapse are four times more likely to have a major defect detected in MR imaging in the pubic portion of the levator ani (LA) muscle compared to women with normal support. Measurement of crosssectional area (CSA) perpendicular to muscle fiber direction is the preferred estimate of maximal muscle contraction strength. The present study was undertaken to compare CSA as a function of prolapse status and defect status in the ventral and dorsal components of the pubic portion of the levator ani muscle. Materials and Methods: Thirty women with prolapse were selected from an ongoing study with 10 having no levator ani defects, 10 minor, and 10 major defects. The severity of LA defects was established using MR images and a previously validated visual scoring system. A similar group of 30 controls with normal support were selected with 10 patients in each of the three defect status groups. Additionally, groups were ageand parity-matched (mean age: prolapse ⫽ 61.9 ⫾ 1.6 years, controls ⫽ 61.3 ⫾ 1.4 years; mean vaginal parity: prolapse ⫽ 2.7 ⫾ 0.3, controls ⫽ 3.7 ⫾ 0.4). All patients had pelvic MR scans performed in the supine position. 3-D models of the levator ani muscles were made using 3-D slicer (version 2.1b1) using bi-planar reconstruction (axial and coronal) to reduce partial volume averaging artifacts in individual scan planes. The pubic portion (which includes the pubovisceralis and the puborectalis muscles) of the levator ani muscle was isolated from the iliococcygeal portion. Using I-DEAS®, cross-sections for the pubic portion were measured perpendicular to a fiber direction line from the pubic origin to the middle of the visceral insertion at equally spaced points. CSA from the ventral and dorsal components of the muscle were analyzed separately. One-way analysis of variance was performed. Results: In the ventral component of the muscle, women with major LA defects had 37% smaller CSA and women with minor LA defects had a 30% smaller CSA compared to women with no defects regardless of prolapse status (F2,57 ⫽ 9.579, p ⬍ 0.001). In the dorsal component of the muscle, there were significant differences in CSA found according to defect status (F2,57 ⫽ 5.53, p ⫽ 0.01). Women with major LA defects had the largest CSA compared to the other defect groups (Fig. 1). For each defect severity level (none, minor, major), there were no significant differences in CSA when women with normal support were compared to women with prolapse. Conclusion: 1.) Women with visible LA defects on MR imaging had significantly smaller CSA in the ventral component of the pubic portion of the muscle compared to women with intact muscles. 2.) Dorsally, women with prolapse and severe LA defects have larger levator CSA than women with minor or no defects. Comments: The ventral component of 74 pubic portion of the LA is comprised of the pubovisceralis (which is known to be damaged during birth); in the dorsal component the puborectalis predominates. The finding that women with prolapse and major defects have larger CSA in the dorsal region of the levator ani may be due to an attempt by the puborectal muscle to compensate for birthinduced ventral muscle loss. Key Words: pelvic organ prolapse, levator ani muscle defect, cross-sectional area Disclosure - Advisory Board: John DeLancey, Eli Lilly; Consultant: John DeLancey, SuRx, Kimberly Clark, Johnson & Johnson, Gynecare, John DeLancey, Shaw Science, James Ashton-Miller, Johnson & Johnson, BioLogic Engineering, Cybernet, James Ashton-Miller, NFL. ORAL PRESENTATION 21 Effect of Hospital Volume on Operative Outcomes Following Urogynecologic Procedures V. W. Sung1, M. L. Rogers2, C. R. Rardin1, and D. L. Myers1 1Obstetrics and Gynecology, Brown Medical School, Providence, RI; 2Center for Gerontology and Health Care Research, Brown University, Providence, RI Objectives: To estimate the effect of urogynecologic hospital volume on operative outcomes following urogynecologic procedures. Materials and Methods: We conducted a retrospective cohort study utilizing data from the Nationwide Inpatient Sample from 1998 –2003. Urogynecologic cases were identified using urogynecologic ICD-9-CM procedure-diagnosis code combinations. Hospital volume was expressed as the average number of urogynecologic cases per year. Hospitals were ranked by volume and then categorized into three groups: low, medium and high volume. These groups were defined by choosing cutoff points for annual hospital volume that most closely sorted the number of patients into three equal groups. Cut-off points were established before outcomes were examined. Outcome measures included inhospital mortality, peri-operative complications, and non-routine discharges, defined as patients who were not directly discharged home. Patient and hospital characteristics were abstracted from the database. To adjust for case-mix, comorbidities were compiled into a weighted index based on the Dartmouth-Manitoba method. Descriptive statistics and univariate analyses were performed as appropriate. Multivariable logistic regression was performed to obtain Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 TABLE 1. Adjusted Odds Ratios (95% CI) for the Effect Of Hospital Volume on Outcomes Following Urogynecologic Procedures, Oral Presentation 21 Outcome Death Complication Non-routine discharge Low volume Hospital volume Medium volume High volume* 1.77 (1.04, 3.02) 1.06 (1.03, 1.10) 1.60 (1.40, 1.85) 1.08 (0.62, 1.88) 1.03 (0.99, 1.10) 1.17 (1.05, 1.29) 1.00 1.00 1.00 Adjusted for age, race, number of procedures, comorbidity, and hospital characteristics using multivariable logistic regression. *Reference group. adjusted odds ratios estimating the relative risks of death, complication, and non-routine discharge by hospital volume, adjusting for confounders. Results: There were 315,035 women in our study population and 2,569 hospitals. Overall in-hospital mortality risk was 0.04%, complication risk was 14.4%, and non-routine discharge risk was 1.0%. Low-volume hospitals (LVH) performed ⬍92 cases/year, mediumvolume hospitals (MVH) performed 92–185 cases/year, and highvolume hospitals (HVH) performed ⬎185 cases/year. Mortality risk decreased with increasing hospital volume (LVH, 0.02%; MVH, 0.01%; HVH, 0.01%; p ⬍ 0.05). This inverse relationship was also observed for complications (p ⬍ 0.01) and non-routine discharges (p ⬍ 0.01). After adjusting for potential confounders, LVHs were associated with an increased risk of death 关LVH, OR 1.77 (1.04, 3.02); MVH, OR 1.08 (0.62, 1.88)兴 compared to HVHs. Low-volume hospitals were also associated with an increased risk of complications 关LVH, OR 1.06 (1.03, 1.10); MVH, OR 1.03 (0.99, 1.10) and non-routine discharges 关LVH, OR 1.60 (1.40, 1.85); MVH, OR 1.17 (1.05, 1.29)兴 compared to HVHs. Conclusion: The overall risks following urogynecologic procedures are low. However, differences in hospital volume of urogynecologic procedures may contribute to variations in mortality and morbidity risks. Key Words: pelvic floor disorders, morbidity, mortality, hospital volume, urogynecologic surgery Disclosure - Consultant: Charles R. Rardin, Gynecare; Speaker Bureau: Charles R. Rardin, Pfizer, Charles R. Rardin, Novartis. ORAL PRESENTATION 22 Neuropathic Injury to the Levator Ani Occurs in 1 in 4 Primiparous Women A. C. Weidner1, V. Branham1, M. M. South1, K. L. Borawski2, and A. A. Romero1 1OBGYN, Duke University Medical Center, Durham, NC; 2 Urology, Duke University Medical Center, Durham, NC Objectives: We measured levator ani neuromuscular function before and after the first obstetric delivery to identify the location, timing, and mechanism of injury. Materials and Methods: Fifty eight primiparous women recruited in the early third trimester underwent concentric needle electromyographic (EMG) exam of the levator ani at four sites (right and left, lateral and medial) during voluntary muscle contraction. Exams were repeated 6 weeks and 6 months post partum. Data were saved digitally and analyzed using a quantitative EMG analysis program to assess muscle function at rest, moderate, and maximal contraction. Turns/amplitude analysis was used, measuring the relationship between density of the muscle recruitment pattern (represented by electrical turns in direction around the baseline) and amplitude of the motor unit potentials in ␮V. This method yielded an XY plot of number of turns vs. log(amplitude) as previously described.1 Turns/amplitude data from all 58 subjects at the antepartum visit were pooled to create a normal range through the full muscle effort from rest to maximum contraction. Individual subjects with ⱖ10% of observed data points outside 95% confidence intervals of the normal range were considered abnormal. We calculated percent outliers for each subject at both 6 weeks and 6 months post partum at each muscle site and assessed relationships between mode of delivery and extent of injury. Appropriate obstetrical and demographic data were collected. Results: Of the 58 subjects, 36 had spontaneous vaginal delivery, 8 operative vaginal delivery, 11 cesarean sections in labor, and 3 elective cesareans without labor. Forty one self identified as Caucasian, 11 African American, and 6 Hispanic or Asian. Body mass index at 6 months post partum was 26 ⫾ 5.6 kg/m2. Neonatal weight was 3337 ⫾ 590 g. At 6 weeks post partum, 14/58 (24.1%) had EMG evidence of abnormal muscle function with 9 of 14 recovering by 6 months. At 6 months post partum, 17/58 (29.3%) were abnormal, including 12 new injuries that were not evident at 6 weeks. Subjects having cesarean in labor had the greatest proportion of levator injury at 6 weeks, while subjects having vaginal delivery had a slightly greater proportion of injury at 6 months. Subjects having elective cesarean had virtually no injury. Analysis by muscle site showed injury across all sites. Women who had either spontaneous vaginal delivery or cesarean in labor sustained more injury to lateral muscle sites, whereas operative vaginal delivery was associated with greater injury to the medial muscle, particularly on the right. Conclusion: Obstetrical delivery is frequently associated with EMG evidence of neuropathic injury to the levator ani both in the early and late post partum period. While some spontaneous recovery occurs, new observations of abnormal muscle at 6 months are consistent with the established mechanism of recovery from a neuropathic injury and emphasize the lengthy time course of muscle repair. Our observed localization of injury indicates that the entire levator ani complex is at risk and that cesarean in labor is not protective. Key Words: electromyography, levator ani, obstetrical delivery Disclosure - Nothing to disclose. REFERENCE 1. Nandedkar et al. Muscle Nerve 9(5):423– 430. ORAL PRESENTATION 23 Obesity and Retropubic Surgery for Stress Incontinence: Is There Really an Increased Risk of Intra-Operative Complications? R. Rogers1, U. Lebkuechner1, D. N. Kammerer-Doak2, P. K. Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 75 Thompson3, and M. D. Walters4 1University of New Mexico, Albuquerque, NM; 2Lovelace Sandia Health Systems, Albuquerque, NM; 3Baylor College of Medicine, Houston, TX; 4Cleveland Clinic, Cleveland, OH; 5University of Iowa, Iowa City, IA Objectives: To evaluate the impact of obesity on length of surgery, blood loss and intra-operative complications in women who underwent retropubic surgery for stress urinary incontinence (SUI). Materials and Methods: Of 449 women participating in a multi center randomized trial evaluating antibiotic prophylaxis in women with suprapubic catheters, 250 women underwent retropubic anti incontinence procedures. This is a prospective nested cohort study of these women; 79 (32%) of whom were obese (BMI ⬎ 30) and 171 (68%) overweight or normal weight (BMI ⬍ 30). Data collected included demographic variables, past medical history, physical exam recording prolapse severity and intraoperative and postoperative complications. Data were analyzed with Fisher’s Exact for dichotomous variables, t tests for continuous variables and ANOVA for multivariate analysis. Significance was set at P ⬍ .05. Results: Obese women undergoing SUI surgery were younger than non-obese women (48.7 vs. 51.9 years, respectively, P ⬍ .019), and Hispanic women were more likely to be obese than all other ethnicities (P ⫽ 0.005). Severity of anterior, apical or posterior prolapse was similar between groups. (P ⫽ NS) The number and type of additional surgeries performed were similar between groups with the exception that obese women were less likely to undergo abdominal apical suspensions (P ⫽ .006) or abdominal paravaginal repairs (P ⫽ .001); therefore all comparisons are adjusted for the performance of these procedures. Estimated surgical blood loss was greater for obese women (344 vs. 284 P ⫽ .027) however, change in hematocrit (preoperative minus postoperative hematocrit) was lower for obese than non-obese women (6.6 vs 7.3, P ⫽ 0.048). Mean length of surgery was 20 minutes longer in obese women (P ⫽ 0.024). Length of hospital stay did not vary between groups. (P ⫽ NS) Major intraoperative complications were uncommon (14 (6%)) with no difference between weight groups. Incidence of postoperative urinary tract infection, wound infections or postoperative major complications were likewise similar between groups (all P ⬎ .05). Conclusion: In this nested prospective cohort study, retropubic anti incontinence surgery did not increase intra-operative risk for obese patients when compared to non-obese women. Surgery takes longer for obese patients, but blood loss as recorded by change in hematocrit is lower. Major complications were rare and similar between weight groups, as were infectious complications. The Applied GelPort™ is an advanced access device that combines the advantages of a self-retaining wound retractor with the benefits and option of laparoscopy, particularly hand-assisted laparoscopy. A standard kit is comprised of an incision template, a 100 millimeter GelSeal™ Cap, a wound retractor base, and an Alexis™ wound retractor. This technique relies on the presence a mobile, unilocular, and anteriorly located ovarian cyst. After placing the patient in modified dorsal lithotomy, a small transverse or vertical 2–3 centimeter suprapubic incision is made with the aide of the incision template and a scalpel. This incision is carried all the way through into the peritoneal cavity and the Alexis™ wound retractor is subsequently placed along with the wound retractor base. A circular area of self-retraction with superior exposure is created. Visual and manual inspection of the cyst and pelvis can occur at this time in addition to obtaining pelvic washings. The area of the ovarian cyst that is visible through the self-retaining retractor is carefully dried with a Ray-Tec™. A Tegaderm™ transparent dressing sheet large enough to cover the entire Alexis™ wound retractor is then secured to the cyst wall surface with Dermabond™, a sterile surgical glue. A Behrman needle attached to wall suction is used to puncture and drain the ovarian cyst in a “leak proof” fashion thereby minimizing the risk of intra-peritoneal spillage. Once decompressed, the pathologic ovary can be exteriorized through the mini-laparotomy incision and either an ovarian cystectomy or salpingo-oophorectomy performed. Should malignancy be encountered after a frozen section is obtained, the GelSeal™ Cap can be attached to the Alexis™ wound retractor. The case is then readily converted to a laparoscopy with the ability to place either a trocar or hand through the specialized cap. Results: We have used this advanced access technique in a variety of cases. Patients were able to undergo either an ovarian cystectomy or salpingo-oophorectomy through the mini-laparotomy incision as an outpatient when pathology was benign. In cases of malignancy, the Applied GelPort™ allowed for the conversion to and completion of a laparoscopic staging with the option of hand-assistance. Conclusion: The use of the Applied GelPort™ advanced access device allows for the management of large ovarian cysts without compromising the benefits of minimally invasive surgery or the surgical management of a malignancy. Key Words: laparoscopy, surgical technique, ovarian cysts, mini-laparotomy Disclosure - Advisory Board: Arnold Advincula, SurgRx; Consultant: Arnold Advincula, Gyrus Medical; Grant/Research Support: Arnold Advincula, Intuitive Surgical. Key Words: obesity, stress urinary incontinence, surgery, complications Disclosure - Grant/Research Support: Rebecca Rogers, Wyeth, Mark Walters, Pfiser; Grant/Research support: Rebecca Rogers, Pfiser; Lecturer: Mark Walters, American Medical Systems. TIPS & TRICKS 1 A Novel Technique for the Minimally Invasive Management of Large Ovarian Cysts A. P. Advincula, W. M. Burke, and R. K. Reynolds Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI Objective: We sought to develop a minimally invasive technique for the management of large ovarian cysts with a low suspicion for malignancy and not amenable to laparoscopy by using the Applied GelPort™. Materials and Methods: The management of large ovarian cysts (⬎10 centimeters) by laparoscopy is particularly challenging because of a limited surgical field and concerns for cyst rupture with intra-peritoneal spillage. As a result, traditional laparotomy continues to be considered the standard despite the vast majority of these returning benign on final pathology. 76 TIPS & TRICKS 2 Teaching Salpingo-Oophorectomy With Vaginal Hysterectomy P. A. Riss Gynecology & Obstetrics, Landesklinikum Thermenregion Moedling, Moedling, Austria Objective: To improve the teaching and performance of salpingooophorectomy at the time of vaginal hysterectomy, using a step-bystep approach based on optimal exposure. Description: (for the left side). Step 1 The uterus has been removed. The assistant places traction on the ovarian pedicles and on the stay suture at the posterior peritoneum and vaginal fornix. Step 2 The surgeon places a pack (10 x 30 cm) at 3 o’clock, pushing it upward towards the pelvic brim along the infundibulopelvic ligament. Step 3 A long Breisky retractor (3 x 15 cm) is inserted between the pack and the adnexae. The Breisky blade retracts the small bowel medially and upward to expose the adnexae. Step 4 A second, smaller and shorter Breisky (2.5 x 11 cm) is introduced on Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 top of the first Breisky, and is rotated clockwise. Step 5 The adnexae are grasped with a ring forceps and pulled downwards and medially. The tip of the anterior Breisky rests on the extended infundbuilopelvic ligament. Step 6 The ovarian vessels - which lie in the medial part of the extended infundibulopelvic ligament - are ligated with a Deschamps needle. The tip of the Deschamps needle is introduced into the avascular triangle formed by the ovarian vessels medially, the pelvic sidewall laterally, and the adnexae below. The ureter is safely located at the pelvic sidewall. The suture is passed, retrieved and tied. Step 7 The ovarian pedicle is cut below the tie. Step 8 A curved clamp is placed on the base of the adnexae and this pedicle is ligated. Good exposure is achieved with the following maneuvers: - Intraabdominal placement of a 10 x 30 cm pack which is held medially with the long Breisky speculum. - Insertion of the second Breisky. - Medial and downward traction on the adnexae which are grasped with ring forceps to pull the ovarian vessels and the supporting peritoneum medially into the cavity of the small pelvis. Conclusion: The method presented here emphasizes good exposure before actually beginning with salpingo-oophorectomy. A step-by-step approach facilitates teaching and learning of this adjunct to vaginal hysterectomy. Key Words: vaginal surgery, adnexectomy, teaching, salpingo-oophorectomy Disclosure - Eli Lilly, Gynecare: Paul A Riss, Speaker Bureau, Advisory Board/Eli Lilly-BI. TIPS & TRICKS 3 Fascia-Synthetic Graft Seam Technique for Sacrocolpopexy P. M. Fine 1Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX; 2Urology, Baylor College of Medicine, Houston, TX Objective: The fascia-synthetic graft seam technique is a technical trick to minimize graft erosion and maximize graft durability in the performance of sacrocolpopexy. A recent and extensive published review of the ASC literature cited a 0.5–5% incidence of mesh erosion with various synthetic materials and no erosions with autologous or cadaveric fascia.1 Anterior rectus fascia, although easily harvested at abdominal wall entry, often lacks adequate width or length for optimum technical placement. Attachment of harvested autologous abdominal fascia first to the vaginal cuff and then lengthening the graft by attachment of a synthetic graft using a seam of sutures allows adequate sacral attachment without tension. Description: The abdomen is opened with the incision of choice down to the anterior rectus fascia. A strip of 10 x 2 cm fascia is harvested and placed in antibiotic solution of choice. The vaginal cuff is prepared in the standard fashion with opening of the pelvic peritoneum and dissecting the bladder from the proximal anterior vaginal wall. Each end of the harvested fascial graft is cut vertically in the midline about 1.5 cm to create a wider Y shaped configuration for attachment to the anterior and posterior vaginal walls. Interrupted permanent sutures of choice attach each end of the, now folded over on itself, fascial graft to the anterior and posterior vaginal walls and vaginal cuff. A 2 cm wide piece of synthetic mesh of choice is sutured to the now proximal (cephalad) elbow of folded fascia with 4 –5 interrupted permanent sutures. These seam sutures penetrate both folded sheets of fascia and include about 3 mm of fascia to minimize possibility of pullout. The proximal (cephalad) portion of the synthetic mesh is trimmed and attached to the sacral promontory with standard technique of choice. Closure of the peritoneum over the graft is then performed. Conclusion: The author has successfully used this technique for about 25 years in over 100 patients. Because charts from his former private practice were lost in transfer, storage, or conversion to electronic medical record by the university, specific detail of followup unfortunately cannot be given. Anecdotally there were no known vaginal erosions or infectious complications with most patients followed over 3 years, and some over 15 years. Only a couple of patients required repeat pelvic reconstructive surgery and none of these were apical failures. There were no known incisional hernias. Attachment of harvested autologous abdominal fascia first to the vaginal cuff and then lengthening the graft by attachment of a synthetic graft using a seam of sutures has the following advantages: 1) a shorter length of fascia can be used, 2) allows more flexibility in length to attach the graft to the sacrum and 3) it eliminates the risk of erosion if a total (rather than supracervical) hysterectomy is performed or in the case of thin and atrophic post-hysterectomy vaginal cuff. Key Words: sacrocolpopexy, autologous rectus fascia, seam technique Disclosure - Nothing to disclose. REFERENCE 1. Nygaard et al. Abdominal Sacrocolpopexy: A Comprehensive Review. Obstet Gynecol Oct 2004;104:805– 823. ORAL POSTER 1 Impact of Transdermal Oxybutynin on Sexual Function in Patients With Overactive Bladder: Results From the Matrix Study P. K. Sand1, R. Goldberg1, and M. McIlwain2 1Feinberg School of Medicine, Northwestern University, Evanston, IL; 2Watson Laboratories, Morristown, NJ Objectives: This analysis was conducted to assess the impact of treatment with transdermal oxybutynin on sexual function in patients with overactive bladder (OAB) in a large, community-based population. Materials and Methods: The Multicenter Assessment of Transdermal Therapy in Overactive Bladder with Oxybutynin (MATRIX) study was a cohort analysis trial of community-dwelling adults diagnosed with overactive bladder (OAB). Patients were treated with transdermal oxybutynin for up to 6 months and evaluated for safety and patientreported outcomes. The King’s Health Questionnaire® (KHQ) and Beck Depression Inventory®-II (BDI-II) were used to assess OAB impact on patients’ interest in sexual intimacy. The KHQ, a quality of life instrument specific to OAB, is scored from 0 (best) to 100 (worst), while the BDI-II, which measures depression symptoms, is scored from 0 (best) to 63 (worst), with scores ⬎12 indicating clinical depression. P values were based on chi-squared test. Results: The MATRIX study enrolled 2878 patients (mean age, 62.5y ⫾ 14.8y; 2508 关87.1%兴 women, 2406 关83.6%兴 Caucasian). At baseline, 1334 patients (46.4%) reported experiencing OAB symptoms for ⱖ4 years, while 346 patients (12.0%) had experienced symptoms for ⱕ1 year. Of 2859 patients who responded, 1632 (57.1%) had been treated before for OAB. At baseline, KHQ responses indicated that 1845/2571 (71.8%) were embarrassed by their bladder problems. In 586/2534 (23.1%) patients, OAB affected their sex life; in 622/2555 (24.4%), OAB affected their relationships with their partners. Baseline responses to the BDI-II indicated that 1219/2341 (52.1%) patients experienced decreased interest in sex: 589 (25.2%) less interest, 228 (9.7%) much less interest, 402 (17.2%) complete loss of interest. By end of study, paired patient responses showed significant (P ⬍ .0001) improvement in embarrassment (828/2330 关35.5%兴 improved; 235 关10.1%兴 worsened), in OAB effects on sex life (429/2250 关19.1%兴 improved; 251 关11.2%兴 worsened), in relationships with partners (444/2269 关19.6%兴 improved; 271 关11.9%兴 worsened), and in interest Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006 77 in sex (472/2018 关23.4%兴 improved; 246 关12.2%兴 worsened). Patients reported significant (P ⬍ .0001) improvement from baseline to end of study in symptoms that may impact sexual intimacy. Intercourse incontinence, experienced by 569/2493 (22.8%) patients at baseline, improved in 277/2190 patients (12.6%) and worsened in 165 (7.5%). Frequent UTIs, 931/2467 (37.7%) at baseline, improved in 450/2164 patients (20.8%) and worsened in 242 (11.2%). Bladder pain, experienced by 1092/2505 (43.6%) patients at baseline, improved in 553/2211 (25.0%) and worsened in 240 (10.9%). Disclosure - Advisory Board: Karl Tamussino, Lilly Boehringer; Consultant: Karl Tamussino, Gynecare. Conclusion: The degree to which OAB symptoms affect sexual function may be influenced by physiologic, psychosocial, or socioeconomic factors, in addition to disease severity. Specific bladder symptoms may cause embarrassment and a resultant decrease in sexual interest. Many of these sexual function symptoms significantly improved in patients who were treated for up to 6 months with transdermal oxybutynin in this study. S. Minaglia1, B. Ozel1, N. M. Gatto2, D. R. Mishell1, Jr., and D. A. Miller1 1Obstetrics and Gynecology, University of Southern California, LosAngeles, CA; 2Preventive Medicine, University of Southern California, Los Angeles, CA Key Words: incontinence, urinary incontinence, sexual function, oxybutynin, urge incontinence, quality of life Disclosure - Consultant, Advisory Board: Peter Sand, Watson Pharma, Inc; employee: Marilyn McIlwain, Watson Laboratories. ORAL POSTER 2 Quality of Life and Continence One Year After the Tension-Free Vaginal Tape (TVT) Operation V. Bjelic-Radisic, M. Dorfer, E. Greimel, A. Frudinger, P. Kern, and K. Tamussino OB/GYN, Medical University of Graz, Graz, Austria Objectives: To evaluate changes in quality of life (QoL) and continence rates one year after the Tension-free vaginal tape (TVT) operation. Materials and Methods: We evaluated clinical outcomes and quality of life in 95 of 116 consecutive patients who underwent a retropubic TVT procedure (Gynecare) between May 2002 and June 2004. Before and 12 months after surgery patients underwent clinical assessment with cystometry and urethral profilometry and completed Germanlanguage versions of the Kings Health questionnaire and the SF-36. 47 (50%) of women had undergone previous surgery for incontinence or prolapse. 66 (74%) TVTs were performed as isolated procedures, 29 (26%) with concomitant operations. Cronbachs alpha coefficients were calculated for KHQ subscales. Scale responsiveness was examined by comparing mean differences in the KHQ domains before and after treatment in relationship to the results of the cough stress test. Results: Overall the objective continence rate at 1 year was 82% and did not differ significantly between women undergoing TVT alone or in combination (84% vs. 68%, respectively). Significant improvements were seen in the following domains of the KHQ: incontinence impact, role limitations, physical limitations, emotions, severity measures and overactive bladder; no significant changes were seen in the domains general health perception, social limitations, personal relationships and sleep/energy. Similar but less prononced improvements in QOL were seen in women with no change or worsening of continence postoperatively. The SF-36 showed changes only in the domain general health. Conclusion: The TVT operation is associated with improved conditionspecific QOL in women with stress urinary incontinence. Changes in QOL do not necessarily correlate with the objective continence status of continent/incontinent. The condition-specific KHQ is more appropriate than the generic SF-36 for evaluating treatment results in women treated for stress incontinence. Apparently urinary incontinence can be perceived as a nuisance rather than as as an illness. Key Words: stress incontinence, tension-free vaginal tape, quality of life 78 ORAL POSTER 3 Decreased Rate of Obstetrical Anal Sphincter Laceration Reflects Change in Obstetric Practice Objectives: To estimate the rate of obstetrical anal sphincter laceration in a large cohort of women undergoing vaginal delivery and to identify characteristics associated with this complication, including modifiable risk factors. Materials and Methods: Information from a computerized database that included all deliveries occurring between January 4, 1996 and December 8, 2004 at one institution was used to calculate the rate of anal sphincter laceration as well as to compare women with and without an anal sphincter laceration at vaginal delivery. T-tests and chi-square tests were used to identify factors associated with anal sphincter laceration including maternal age, gestational age, birth weight, vacuum or forceps delivery, episiotomy, estimated blood loss at delivery, presence of shoulder dystocia, use of epidural anesthesia, and use of oxytocin. Generalized estimating equations were used to identify significant independent risk factors for anal sphincter lacerations as well as estimate odds ratios associated with each factor while accounting for repeated measures in women with multiple births at the hospital. Results: Mean age (SD) years was 27.1 (6.5), and the women were 87.7% Hispanic, 6.1% African American, 3.2% Asian Pacific Islander, 2.7% Caucasian, and 0.03% other or unknown. 1,703 (10.2%) third and fourth-degree lacerations occurred among 16,667 vaginal deliveries: 857 (17.5%) occurred among 4891 primiparas and 846 (7.2%) occurred among 11,776 multiparas. All factors considered were individually significant predictors of anal sphincter lacerations at p ⬍ 0.0001. Women with an anal sphincter laceration were significantly more likely to have a fetus of higher gestational age or increased birth weight. Results from regression models suggested that episiotomy (OR 1.35; 95% CI 1.16, 1.57), vacuum delivery (OR 3.20; 95% CI 2.70, 3.80), and forceps delivery (OR 2.79; 95% CI 1.94, 4.02) were all associated with increased risk of anal sphincter laceration. Increasing parity (OR 0.64; 95% CI 0.61, 0.68) and use of epidural anesthesia (OR 0.86; 95% CI 0.76, 0.97) each demonstrated a protective effect. Year of delivery was also associated with a decreased risk of anal sphincter laceration (OR 0.94; 95% CI 0.91, 0.96) with the rate of laceration decreasing from 11.2% to 1.1% during the study period. Conclusion: This report demonstrates a high rate of anal sphincter laceration in a predominantly Hispanic population. Episiotomy and operative vaginal delivery are significant, modifiable risk factors for obstetrical anal sphincter laceration. Changes in obstetric practice such as increased cesarean delivery and decreased episiotomy may have contributed to the dramatic reduction in anal sphincter laceration during the study period. Key Words: fecal incontinence, obstetrical anal sphincter laceration, cesarean section, vacuum delivery, forceps delivery, episiotomy Disclosure - Advisory Board: Daniel R. Mishell, Jr., Barr, Organon; Advisory Board, Speaker Bureau: Steven Minaglia, OrthoMcNeil; Consultant: Steven Minaglia, American Medical Systems, Daniel R. Mishell, Jr., Pfizer; Research Support, Advisory Board: Daniel R. Mishell, Jr., Berlex; Speaker Bureau: Steven Minaglia, Pfizer. Journal of Pelvic Medicine & Surgery • Volume 12, Number 2, March/April 2006