Female Urology

Reviewing the Literature

9c. RIU0485_07-31.qxd 8/4/10 4:50 PM Page e154 Female Urology Female Urology Female Urology—Future and Present Reviewed by Cristian P. Ilie, MD,1 Michael B. Chancellor, MD2 1 Urology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; 2William Beaumont Hospital, Royal Oak, MI [Rev Urol 2010;12(2/3):e154-e156 doi:10.3909/riu0486] © 2010 MedReviews®, LLC Forecasting the Prevalence of Pelvic Floor Disorders in U.S. Women: 2010-2050 Wu JM, Hundley AF, Fulton RG, Myers ER. Obstet Gynecol. 2009;114:1278-1283. hat will the future be like for urologists and urogynecologists interested in lower urinary tract diseases and pelvic floor dysfunction? With the population aging across most developed countries, will there be enough business to go around or, on the contrary, do we need to train a lot more experts? Researchers from the Department of Obstetrics and Gynecology at Duke University, Durham, NC, and the Department of Obstetrics and Gynecology at The Ohio State University, Columbus, OH, provide this report that aims to project disease prevalence for the next 50 years. The authors used population projections from the US Census Bureau for 2010 to 2050 as well as published agespecific prevalence estimates for bothersome, symptomatic W pelvic floor disorders (urinary incontinence [UI], fecal incontinence [FI], and pelvic organ prolapse [POP]) from the 2005 National Health and Nutrition Examination Survey (NHANES). Suppositions need to be made when projecting for the future. The authors assumed that the age-specific prevalence for these disorders and the population distribution of risk factors remained unchanged through 2050. To achieve their objective, the authors applied to the US Census Bureau population projections, the prevalence rate estimates from Pelvic Floor Disorders Network (PFDN) NHANES publication. The NHANES is a cross-sectional, national health survey from the National Center for Health Statistics. The authors used these prevalence data because they are the only published national estimates for all 3 major pelvic disorders. The PFDN analysis for the 2005-2006 cohorts of NHANES included 1961 nonpregnant women aged  20 years. In this study, UI was defined as moderate to severe incontinence based on the 2-item, validated Sandvik severity index. FI was defined as at least monthly leakage of solid, liquid, or mucous stool using a FI severity index, which accounts for type and frequency. POP was defined as a positive response to the question, “Do you experience bulging or something falling out that you can see or feel in the vaginal area?” Based on these data, the number of US women with at least one pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050. Table 1 highlights the top line number of women with UI, FI, and POP, respectively. The strength of this study is that the authors incorporated valuable data: prevalence rates from national estimates based on NHANES and the US Census Bureau projections. The methodology was similar to previous population projection analyses. Limitations include that Table 1 Projected Prevalence Rates for Lower Urinary Tract and Pelvic Floor Dysfunctions for US Women: 2010-2050 2010 2020 2030 2040 2050 UI 18 million 21 million 24 million 26 million 28 million FI 11 million 12 million 14 million 15 million 17 million POP 3.3 million 3.7 million 4.1 million 4.5 million 4.9 million UI, urinary incontinence; FI, fecal incontinence; POP, pelvic organ prolapse. Data from Wu J et al. Obstet Gynecol. 2009;114:1278-1283. e154 VOL. 12 NO. 2/3 2010 REVIEWS IN UROLOGY 9c. RIU0485_07-31.qxd 8/4/10 4:50 PM Page e155 Female Urology the prevalence rates for each pelvic floor disorder were assumed to remain constant over the course of the next 4 decades, but these could be affected by changes in risk factors such as obesity, smoking, and vaginal deliveries. Prevalence could also be affected by changes in the racial and ethnic composition. Regardless of whether there is an over- or underestimation of actual prevalence rates in the future, the overall trend clearly demonstrates an increasing number of women who will be affected by pelvic floor dysfunction. This study highlights the expectation that a rapidly growing segment of our population will struggle with UI, FI, and POP in the coming years. Based on these estimates, nearly 44 million women will suffer from at least one pelvic floor disorder by 2050. The ability to identify women at high risk would be valuable in determining which women may want to avoid particular risk factors and which women would benefit most from preventive interventions and specific treatment recommendations. The magnitude of women who will be affected by pelvic floor disorders also underscores the importance of developing effective prevention and treatment strategies through the support of research funding. Laparoscopic Management of Incontinence and Pelvic Organ Prolapse Frick AC, Paraiso MFR. Clin Obstet Gynecol. 2009;52:390-400. With the growing interest in laparoscopic and robotic management of pelvic floor dysfunction, readers will be intrigued to discover this favorable review on the topic from experts at the Cleveland Clinic. As it is known, the potential benefits of the laparoscopic approach include excellent intraoperative visualization, shorter hospitalization and recovery time, decreased postoperative pain, improved hemostasis, and better cosmesis. However, these procedures require advanced laparoscopy skills and could also be associated with increased operative time and expense. Few prospective randomized trials have evaluated outcomes and morbidity associated with the laparoscopic incontinence and pelvic floor reconstruction procedures. They are reviewed in this article in the section that discusses laparoscopic Burch surgery. The first reports of laparoscopic Burch procedures were from the early 1990s. Its popularization was blunted by the introduction of transvaginal retropubic and transobturator midurethral sling systems. Laparoscopic Burch colposuspension remains an option for patients in whom synthetic mesh is contraindicated, although one can argue that midurethral slings have rendered it semi-obsolete. For an intraperitoneal laparoscopic Burch colposuspension, the patient is placed in dorsal lithotomy position with her lower extremities in Allen stirrups. A catheter is inserted in the bladder. Ports include a 5-mm infraumbilical port for the laparoscope, 1 or 2 5-mm upper quadrant ports for instrumentation, and 1 or 2 5/12 lower quadrant ports for introducing needles and suture. The bladder is filled with 200 to 300 mL of normal saline. A transverse incision is made 2 cm above the bladder reflection between the medial umbilical folds using sharp dissection with electrosurgical scissors or a harmonic scalpel to expose the pubic symphysis, bilateral Cooper’s ligaments, and periurethral and paravesical endopelvic fascia. With 2 fingers in the vagina or a vaginal probe helping identify the bladder neck, a figure 8 stitch of nonabsorbable suture is placed through the periurethral endopelvic fascia, excluding the vaginal epithelium, at the level of the midurethra. A second stitch is placed at the bladder neck. Each is passed through the ipsilateral Cooper’s ligament. The same steps are performed on the contralateral side. Each suture is tied down while elevating the vaginal wall to the level of the arcus tendineus fasciae pelvis. In women who have not had previous abdominal or retropubic surgery, it has been advocated to use the extraperitoneal approach to laparoscopic Burch colposuspension. To gain extraperitoneal access to the space of Retzius, a 10-mm infraumbilical incision is made through the rectus fascia. The space of Retzius is opened using a balloon dissector and CO2 is then insufflated into the preperitoneal space. The remainder of the procedure is accomplished in a similar fashion to the intraperitoneal approach. Laparoscopic and open Burch are compared in at least 10 trials, with a total of more than 1000 patients and a follow-up of up to 5 years. Subjective cure rates were similar—between 58% and 96% in the open Burch group and 62% to 100% in the laparoscopic group. The authors defined their objective as negative urodynamic testing in 6 studies and a negative pad test in 4 studies. The objective cure rates within 18 months were slightly higher for open colposuspension, with ranges of 80% to 96% for open cases and 69% to 92% for laparoscopic cases. No differences were reported in de novo detrusor overactivity or voiding dysfunction between the open and laparoscopic groups. Laparoscopic colposuspension and tension-free vaginal tape (TVT) are compared in at least 8 trials, and most reported results of up to at least 1 year. Subjective cure VOL. 12 NO. 2/3 2010 REVIEWS IN UROLOGY e155 9c. RIU0485_07-31.qxd 8/4/10 4:50 PM Page e156 Female Urology continued rates ranged from 52% to 88% for laparoscopic Burch, which was lower than that for TVT, although the difference was not statistically significant. When defining objective cure as absence of urodynamic stress incontinence, the authors reported no difference between the 2 procedures. Postoperative de novo detrusor overactivity and voiding dysfunction were also similar between the 2 groups. As expected, the operative time for laparoscopic Burch was slightly longer than the open approach with a similar e156 VOL. 12 NO. 2/3 2010 REVIEWS IN UROLOGY length of stay. Reported complications for laparoscopic colposuspension include cystotomy, obturator vein injury and bowel injuries, conversion to laparotomy, hematoma development, wound infection, urinary retention, and voiding dysfunction. In summary, it appears that laparoscopic Burch is as good, but no better, than open Burch or TVT. Its utility will depend on surgeon, patient preference, and the desire to avoid risk of synthetic mesh. It is good to know that it appears to be a safe procedure for pelvic surgeons with proper training.