The American Urogynecologic Society convened for its 26th Annual Scientific Meeting in Atlanta, Georgia, from September 15-17, 2005. Atlanta, whose symbol is the Phoenix, is a fitting location for the meeting of this Society, which has itself undergone meteoric growth over the past quarter century.
This growth is reflected in the rise in membership, which grew 7% this year, reaching an all-time high of 1154 members, and in meeting attendance -- this year's 702 registered attendees rivaled last year's attendance at the combined meeting of the American Urogynecologic Society and Society of Gynecologic Surgeons. These statistics do not fully characterize the maturation of the Society, however, which has arguably become the most rigorous forum for scientific investigation in the field of female pelvic medicine and reconstructive surgery. As the destination for academic investigators, it represents the development of the field itself, which has matured to become a truly evidence-based subspecialty, and this was reflected in the program. This year, 50 scientific papers, 5 oral poster presentations, 54 traditional poster presentations, and 5 video presentations were presented. Overall, the program included 19 presentations of level 1 data, including 7 randomized clinical trials. The breadth of scientific research has also expanded from the clinical focus of several years ago to include investigations in epidemiology, clinometrics, basic research, anatomy, surgical education, and clinical outcomes. Some highlights of the scientific sessions are summarized in this report. The topics included in this review are as follows:
The benefits of performing Burch colposuspension at the time of sacral colpopexy in continent women
Funding for research in female pelvic medicine and reconstructive surgery
Evaluation of commercial products for reconstructive surgery
The negative impact of pelvic organ prolapse on body image
The cost of urinary incontinence
The contribution of pregnancy and vaginal delivery to the
development of pelvic floor dysfunction
Insights into the mechanisms of pelvic floor dysfunction
A highlight of the clinical research presented was the discussion of the CARE (Colpopexy And Urinary Reduction Efforts) study. The Pelvic Floor Disorders Network, sponsored by the National Institute of Child Health and Human Development (NICHD), designed the study to evaluate the benefits of a Burch colposuspension at the time of sacral colpopexy. Subjects were women presenting with symptomatic pelvic organ prolapse, without complaints of stress urinary incontinence, who were randomized to a concurrent Burch or no Burch. The primary outcomes included a stress incontinence endpoint (symptoms, stress test, or re-treatment) and an urge endpoint (symptoms or treatment of urge incontinence, urgency, frequency, nocturia, or enuresis). The presentation summarized the data from the first 3-month interim analysis. The Data and Safety Monitoring Board terminated the trial at this interval as the trial had met the efficacy for the stress incontinence endpoint without a difference in urge endpoint or adverse events profiles.
In addition to the oral presentation, a panel discussion to review the impact of the results took place and was led by Dr. Linda Brubaker, the principal investigator, Dr. Evan Myers, Chair of the Data Safety Monitoring Board, and Dr. Anne Weber, the NICHD Project Scientist. Three months after surgery, 23.8% of women in the Burch group and 44.1% of controls failed the stress endpoint, yet there were no statistically significant differences in the urge endpoint (32.7% Burch vs 38.4% no Burch). Additionally, after surgery, stress-incontinent women in the control group were more likely to be bothered by their symptoms than those who received the Burch (61.7% vs 32.1%). The investigators concluded that Burch colposuspension at the time of sacral colpopexy significantly reduces bothersome stress incontinence without an increase in other lower urinary tract symptoms.
The presentation of the CARE study by the Pelvic Floor Disorders Network highlighted the role of federal funding in research into pelvic floor disorders. This role was also the focus of the Sims Lecture, given by Dr. Vivian Pinn, the Director of the Office of Research on Women's Health at the National Institutes of Health (NIH). She discussed the NIH's priorities in pelvic floor disorders, including research dedicated to the prevention of pelvic floor disorders and outcomes research for treatment of these disorders. The NICHD also provided an informational session to assist investigators planning to pursue the recent requests for applications for the competitive renewal of the Pelvic Floor Disorders Network sites (available at https://grants.nih.gov/grants/guide/rfa-files/RFA-HD-05-019.html ).
The recent increase in funding for research in female pelvic medicine and reconstructive surgery is timely given the current swell in surgical innovations. Many of these industry-sponsored innovations have little more than level 3 data to define their efficacy, but gradually, better studies have been forthcoming. For example, 2 studies that addressed commercially available grafts used for reconstructive surgery were presented. The first, presented by Dr. Howden of the McGee Women's Hospital, Pittsburgh, Pennsylvania, was a retrospective repeated measures cohort study that compared suburethral slings using cadaveric fascia lata or autologous rectus fascia. At mean follow-up of 7.1 years for the autologous rectus fascia and 3.5 years for the cadaveric fascia, the autologous grafts were superior in terms of subjective and objective cure of incontinence. This advantage was maintained by survival analysis, with 5 vs 16 failures per 100 women-years respectively.
The second study, presented by Dr. Arya of the University of Pennsylvania, Philadelphia, used a similar study design to investigate the paravaginal repair reinforced with a cadaveric dermal graft vs a porcine dermal graft. Although there were no differences between the 2 grafts in terms of complications, the risk of recurrence of anterior vaginal wall prolapse was significantly lower using the porcine dermal graft.
Especially noteworthy were 2 studies reporting poor results with commercial surgical products. Dr. Mattox, of the Greenville Hospital System in Greenville, South Carolina, reported a high failure rate (43%) for the posterior vaginal sling in elderly women. This failure rate was based on anatomic assessment using the pelvic organ prolapse quantification (POPQ) system, and the mean time to failure was 12 weeks. Similarly, Dr. Buchsbaum, from the University of Rochester Medical Center, Rochester, New York, reported a retrospective review of the SURx (Cooper Surgical, Lake Forest, California) procedure for urodynamic stress incontinence. Postoperatively, 1 of 18 subjects was continent; 47% had a positive stress test, and 53% were unsatisfied with the procedure.
Epidemiologic studies presented this year provided important insights regarding the impact of pelvic floor dysfunction and its obstetric antecedents. Drs. Jelovsek and Barber, from the Cleveland Clinic, Cleveland, Ohio, won the prize for Best Fellows Paper for their work describing the impact of advanced pelvic organ prolapse on body image and quality of life. Although quality-of-life scales have become routine outcome measures in studies of women with pelvic floor disorders, body image as a determinant of quality of life has not been studied. This case-control study compared subjects with stage 3 to 4 pelvic organ prolapse to women with stage 1 or less. All women completed a validated Body Image Scale as well as generalized and condition-specific quality-of-life instruments. After controlling for age, race, parity, and medical comorbidities, women with advanced pelvic organ prolapse were less likely than controls to feel physically attractive, feminine, or sexually attractive. They also scored worse than controls on prolapse, urinary, and colorectal subscales of the Pelvic Floor Disorders Questionnaire.
A study presented by Dr. Subak, University of California, San Francisco, for the Diagnostic Aspects of Incontinence Study (DAISy) Group, showed that the negative impact of pelvic floor dysfunction is not limited to compromised body image. This multicenter cross-sectional study estimated annual costs of urinary incontinence in 301 community-dwelling incontinent women. The women were questioned about the use of supplies and additional laundry and dry cleaning for urinary incontinence. Costs increased with increasing severity of incontinence, reaching $900 annually for severe incontinence. Dr. Subak reported that this represents a higher overall cost for urinary incontinence than the annual cost of cancer care.
A number of epidemiologic studies presented data supporting the role of pregnancy and vaginal delivery in the pathophysiology of pelvic floor disorders. Dr. Lukacz and colleagues from Kaiser Permanente in San Diego, California, won the Best Paper prize for their study of 12,200 women characterized by the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ). In their population, the risk of pelvic floor dysfunction was independently associated with vaginal parity, but not with pregnancy. Delivery by cesarean section offered a protective effect. Interestingly, pelvic floor dysfunction associated with parity included overactive bladder and anal incontinence in addition to stress incontinence, as well as pelvic organ prolapse. Dr. Ghetti and colleagues' case control study from McGee Women's Hospital corroborated these findings. They found that women undergoing surgery for pelvic organ prolapse or urinary incontinence were 3.7 times more likely to be vaginally parous than controls.
In addition to demonstrating associations between vaginal parity and pelvic floor dysfunction, several studies provided new information on the associations between fecal incontinence and anal sphincter disruption and pelvic floor dysfunction. Dr. Nichols and her colleagues, from Virginia Commonwealth University, Richmond, reported a case-control study that compared 90 controls without pelvic organ prolapse or urinary incontinence to 100 women with urinary incontinence or stage 2 or higher pelvic organ prolapse. The women with pelvic floor dysfunction were more likely to report fecal incontinence (OR 5.1), scored higher on the Rockwood-Thompson fecal incontinence severity index, and had 21% more anal sphincter disruptions at the time of endoanal ultrasonography than controls (51% vs 30%, P = .007). Fecal incontinence was associated with sphincter disruption and operative vaginal delivery.
Nulliparity, episiotomy, and operative vaginal delivery have been touted as risk factors for anal sphincter disruption in the past, but Dr. Lowder and colleagues, from McGee Women's Hospital, reported that vaginal birth after cesarean section (VBAC) is a more significant risk factor than these. In their cross-sectional analysis, women undergoing a VBAC had a similar risk of anal sphincter disruption to that of nulliparous women, but were 5 times more likely to have a sphincter disruption than women undergoing their second vaginal birth.
Basic research in female pelvic medicine and reconstructive surgery has lagged behind clinical and epidemiologic investigations, but it is quickly catching up. This fact was reflected not only in the breadth and quality of the basic research presented, but also in the translational nature of recent investigations. For example, Dr. Lowder and coworkers, from the McGee Women's Research Institute at the University of Pittsburgh, presented a study of the biomechanical properties of the rat vagina before and during pregnancy and following vaginal or cesarean delivery. They showed that pregnancy and delivery had a strong negative impact on the structural properties of the vaginal tissues. Although there was improvement in the biomechanical properties in the late postpartum period, the vaginal tissue of the cesarean section cohort was superior to that of the vaginally delivered rats. Changes in the vaginal and support tissues with pregnancy suggest a mechanism for the increase in pelvic floor symptoms seen with vaginal parity. The results of a study presented by Dr. Hundley and colleagues, from the University of North Carolina, Chapel Hill, which showed differential gene expression of structural proteins related to myosin between women with pelvic organ prolapse and controls, suggest a genetic mechanism may be involved in the tissue changes associated with pelvic floor symptoms, too.
The presentation that won the prize for Best Basic Research Paper provided insight into the etiologic contributions of both genetic predisposition to pelvic floor dysfunction and pregnancy. Dr. Drewes and colleagues, from the University of Texas Southwestern Medical Center, Dallas, studied wild mice and mice with null mutations in the gene encoding fibulin-5 (Fib5), a protein involved in the synthesis and assembly of elastic fibers in the extracellular matrix. The Fib5 knockout mice exhibited genitourinary bulge by as early as 3 months of age and complete prolapse of the anterior and posterior vaginal walls at parturition. Similarly, in late gestation, wild mice had an 8-fold decrease in Fib5 as well as a 2.5-fold decrease in tropoelastin with a gradual rebound in the puerperium. The downregulation of these proteins, essential to synthesis and assembly of elastin during pregnancy and in the Fib5 knockout mice, suggests that Fib5 and tropoelastin are critical to the support of the pelvic organs generally but especially to the recovery of pelvic organ support after vaginal delivery. In a separate study, the same research group reported that lysyl oxidases, a family of enzymes that have a vital role in the extracellular cross-linking of collagen and elastin, are downregulated 8- to 10-fold in the vagina during early pregnancy in mice. Similarly, the expression of these enzymes in the vagina was decreased 25-fold in ovariectomized mice -- a process that could be reversed with exogenous estrogen, suggesting a hormonal mechanism may be involved with increasing prolapse with increasing age.
Burch colposuspension at the time of sacral colpopexy reduces bothersome stress incontinence without an increase in other lower urinary tract symptoms.
Suburethral slings using autologous rectus fascia were found to be superior to cadaveric fascia lata in terms of subjective and objective cure of incontinence.
Complications were similar among patients undergoing cadaveric dermal graft and those undergoing porcine dermal graft for paravaginal repair, but the risk of recurrence of anterior vaginal wall prolapse was significantly lower using the porcine dermal graft.
A high failure rate was reported for the posterior vaginal sling in elderly women.
A high failure rate was reported for the SURx procedure for urodynamic stress incontinence.
Women with advanced pelvic organ prolapse may be less likely to feel physically attractive, feminine, or sexually attractive.
A study estimating the costs of urinary incontinence in community-dwelling incontinent women indicates that the annual cost of severe incontinence is high, on the order of $900.
The risk of pelvic floor dysfunction has been independently associated with vaginal parity, but not with pregnancy. Delivery by cesarean section offers a protective effect.
Pelvic floor dysfunction associated with parity may include overactive bladder and anal incontinence in addition to stress incontinence, as well as pelvic organ prolapse.
Women with pelvic floor dysfunction may be at greater risk for severe fecal incontinence and for anal sphincter disruptions. Fecal incontinence has been associated with sphincter disruption and operative vaginal delivery.
Women undergoing a VBAC may be at greater risk for sphincter disruption than women undergoing their second vaginal birth.
Pregnancy and delivery had a strong negative impact on th structural properties of vaginal tissues in rats. Cesarean delivery had less impact than vaginal delivery. Changes in the vaginal and support tissues with pregnancy suggest a mechanism for the increase in pelvic floor symptoms seen with vaginal parity.
Fib5 and tropoelastin -- proteins essential to synthesis and assembly of elastin -- appear to be critical for the recovery of pelvic organ support after vaginal delivery.
Lysyl oxidases, a family of enzymes that have a vital role in the extracellular cross-linking of collagen and elastin, are downregulated in the vagina during early pregnancy in mice. Ovariectomy also decreases expression of these enzymes in the vagina but can be reversed with exogenous estrogen, suggesting a hormonal mechanism may be involved with increasing prolapse with increasing age.
Medscape Ob/Gyn. 2005;10(2) © 2005 Medscape
Cite this: Highlights of the 26th Annual Scientific Meeting of the American Urogynecology Society - Medscape - Oct 18, 2005.