J Eric Jelovsek

Women’s Health Institute of Illinois, Oak Lawn, Illinois, United States

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Publications (67)225.15 Total impact

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    ABSTRACT: This study aimed to describe the incidence of fecal incontinence (FI) at 6, 12, and 24 weeks postpartum; anal incontinence (AI) and fecal urgency at 24 weeks; and identify predictors of AI in women with obstetric anal sphincter injury (OASI). Primiparous women sustaining OASIs were identified at 8 clinical sites. Third-degree OASIs were characterized using World Health Organization criteria, 3a (<50%) or 3b (>50%) tear through the sphincter. Fecal incontinence was defined as leakage of liquid/solid stool and/or mucus in the past month; AI was defined as leakage of liquid/solid stool and/or mucus and/or gas in the past month and was assessed at 6, 12, and 24 weeks postpartum using the Fecal Incontinence Severity Index. Logistic regression identified variables associated with AI. Three hundred forty-three women participated: 297 subjects sustained a third-degree OASI, 168 type 3a, 98 type 3b and 31 indeterminant; 45 had a fourth-degree OASI. Overall FI incidence at 6, 12, and 24 weeks was 7% [23/326; 95% confidence interval (CI), 4%-10%], 4% (6/145; 95% CI, 2%-9%), and 9% (13/138; 95% CI, 5%-16%), respectively. At 24 weeks, AI incidence was 24% (95% CI, 17%-32%) and fecal urgency 21% (95% CI, 15%-29%). No significant differences in FI and AI rates were noted by third-degree type or between groups with third and fourth OASI. Flatal incontinence was greater in women sustaining a fourth-degree tear (35% vs 16%, P = 0.04). White race (adjusted odds ratio, 4.64; 95% CI, 1.35-16.02) and shorter duration of second stage (adjusted odds ratio, 1.47 per 30 minute decrease; 95% CI, 1.12-1.92) were associated with AI at 24 weeks. Overall 24-week incidence of FI is 9% (95% CI, 5%-16%) and AI is 24% (95% CI, 17%-32%). In women with OASI, white race and shorter second-stage labor were associated with postpartum AI.Clinical Trial Registration: NCT01166399 (http://clinicaltrials.gov).
    Journal of Pelvic Medicine and Surgery 01/2015; DOI:10.1097/SPV.0000000000000160
  • Journal of Pelvic Medicine and Surgery 01/2015; 21(1):46-52. DOI:10.1097/SPV.0000000000000099
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    ABSTRACT: The objective of this study was to compare the standard back-fill voiding trial that relies on the assessment of voided volume to subjective patients' evaluation of their voiding based on the assessment of the force of stream after an outpatient midurethral sling surgery. This double-blinded randomized trial included patients undergoing an outpatient mid-urethral sling surgery without any other concomitant surgery. Participants were randomized to either the Standard Voiding Trial (SVT) group or to the Force of Stream (FOS) group. The primary outcome was the rate of catheterization any time up to 6 weeks after surgery. Both groups underwent the same 'back-fill' voiding trial protocol postoperatively. Measurements of the voided amount, post-void residual and the response to the FOS visual analog scale were collected. The criteria for passing the voiding trial in the SVT group were voiding at least 2/3rd of the instilled amount; while the criteria for passing the trial in the FOS group was assessment of force of stream at least 50% of the baseline, regardless of the voided volume. Participants were interviewed pre-operatively and 2-4, 7-9 days and 6 weeks postoperatively. All post-operative interviews included assessments of pain, tolerance of physical activity, force of the urinary stream, as well as satisfaction with the surgery. Validated questionnaires (ISI and UDI-6) before the surgery and 6 weeks after were used to evaluate urinary symptoms. A total of 108 patients were enrolled and randomized, and 6 weeks follow up data were available for 102 participants (FOS: 50, SVT: 52). The two groups were similar with respect to demographic characteristics and urinary symptoms. The incidence of catheterization was also similar between the groups (FOS: 13 (26%), SVT: 13 (25.5%); p=0.95). Amount voided had a moderate correlation with FOS assessment (Spearman rho 0.5; p<0.001). There was no significant difference in the mean catheter days, pain scores, ISI, and UDI-6 scores between the two groups. Of the patients who were discharged home without a catheter in either group none required catheter reinsertion within 6 weeks after the surgery. Patient's subjective assessment of the force of the urinary stream correlated well with the measured voided amount and no difference in catheterization days was noted between the subjective and objective assessment of voiding. Thus subjective evaluation of the force of stream is a reliable and safe method to use after outpatient midurethral surgery. Copyright © 2014 Elsevier Inc. All rights reserved.
    American Journal of Obstetrics and Gynecology 11/2014; 212(5). DOI:10.1016/j.ajog.2014.11.033 · 3.97 Impact Factor
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    ABSTRACT: To describe peri- and postoperative adverse events associated with uterosacral colpopexy, to describe the rate of recurrent POP associated with uterosacral colpopexy, and to determine whether surgeon technique and suture choice are associated with these rates. This was a retrospective chart review of women who underwent uterosacral colpopexy for pelvic organ prolapse (POP) between January 2006 and December 2011 at a single tertiary care center. The electronic medical record was queried for demographic, intra- and postoperative data. Strict definitions were used for all clinically relevant adverse events. Recurrent POP was defined as the following: symptomatic vaginal bulge, prolapse to or beyond the hymen, or any retreatment for POP. 983 subjects met study inclusion criteria. The overall adverse event rate was 31.2% (95%CI 29.2, 38.6), which included 20.3% (95%CI 17.9,23.6) of subjects with postoperative urinary tract infections. 3.4% of all adverse events were attributed to a pre-existing medical condition, while all other events were ascribed to the surgical intervention. Vaginal hysterectomy, age and operative time were not significantly associated with any adverse event. The intra-operative bladder injury rate was 1% (95%CI 0.6,1.9) and there were no intra-operative ureteral injuries; 4.5% (95%CI 3.4,6.0) of cases were complicated by ureteral kinking requiring suture removal. The rates of pulmonary and cardiac complications were 2.3% (95%CI 1.6,3.5) and 0.8% (95%CI 0.4,1.6); and the rates of postoperative ileus and small bowel obstruction were 0.1% (95%CI 0.02,0.6) and 0.8% (95%CI 0.4,1.6). The composite recurrent POP rate was 14.4% (95%CI 12.4,16.8): 10.6% (95%CI 8.8,12.7) of patients experienced vaginal bulge symptoms, 11% (95%CI 9.2,13.1) presented with prolapse to or beyond the hymen, and 3.4% (95%CI 2.4,4.7) required retreatment. Number and type of suture used were not associated with a higher rate of recurrence. Of the subjects who required unilateral removal of sutures to resolve ureteral kinking, 63.6% did not undergo suture replacement; this was not associated with a higher rate of POP recurrence. Peri- and postoperative complication rates associated with severe morbidity after uterosacral colpopexy appear to be low. Uterosacral colpopexy remains a safe option for the treatment of vaginal vault prolapse. Copyright © 2014 Elsevier Inc. All rights reserved.
    American Journal of Obstetrics and Gynecology 11/2014; 212(5). DOI:10.1016/j.ajog.2014.11.034 · 3.97 Impact Factor
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    ABSTRACT: The objective of this study was to estimate the minimum important difference (MID) for the Fecal Incontinence Severity Index (FISI), the Colorectal-Anal Distress Inventory (CRADI) scale of the Pelvic Floor Distress Inventory, the Colorectal-Anal Impact Questionnaire (CRAIQ) scale of the Pelvic Floor Impact Questionnaire, and the Modified Manchester Health Questionnaire (MMHQ).
    Journal of Pelvic Medicine and Surgery 09/2014; DOI:10.1097/SPV.0000000000000078
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    ABSTRACT: The objective of this study was to describe posterior prolapse (pPOP) and obstructed defecation (OD) symptoms 5 years after open abdominal sacrocolpopexy (ASC).
    Journal of Pelvic Medicine and Surgery 09/2014; 20(5):261-266. DOI:10.1097/SPV.0000000000000085
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    ABSTRACT: Abstract Objective: To measure surgical judgment across the Obstetrics and Gynecology (OBGYN) continuum of practice and identify factors that correlate with improved surgical judgment. Methods: A 45-item written examination was developed using script concordance theory, which compares an examinee's responses to a series of "ill-defined" surgical scenarios to a reference panel of experts. The examination was administered to OBGYN residents, Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows, practicing OBGYN physicians and FPMRS experts. Surgical judgment was evaluated by comparing scores against the experts. Factors related to surgical experience were measured for association with scores. Results: In total, 147 participants including 11 residents, 37 fellows, 88 practicing physicians and 11 experts completed the 45-item examination. Mean scores for practicing physicians (65.2 ± 7.4) were similar to residents (67.2 ± 7.1), and worse than fellows (72.6 ± 4.2, p < 0.001) and experts (80 ± 5, p < 0.001). Positive correlations between scores and surgical experience included: annual number of vaginal hysterectomies (r = 0.32, p = <0.001), robotic hysterectomies (r = 0.17, p = 0.048), stress incontinence (r = 0.29, p < 0.001) and prolapse procedures (r = 0.37, p < 0.001). Inverse correlation was seen between test scores and years in practice. (r = -0.19, p = 0.02). Conclusion: Intraoperative judgment in practicing OBGYN physicians appears similar to resident physicians. Practicing physicians who perform FPMRS procedures perform poorly on this examination of surgical judgment; lower performance correlates with less surgical experience and the greater amount of time in practice.
    Medical Teacher 05/2014; 36(8):1-6. DOI:10.3109/0142159X.2014.910297 · 2.05 Impact Factor
  • Journal of Minimally Invasive Gynecology 03/2014; 21(2):S12-S13. DOI:10.1016/j.jmig.2013.12.027 · 1.58 Impact Factor
  • C A Unger, H B Goldman, J E Jelovsek
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    ABSTRACT: Fecal incontinence is the involuntary loss of solid or liquid stool. While the true prevalence of fecal incontinence is difficult to discern, it is estimated that almost 9 % of non-institutionalized women in the US experience this condition. Disorders leading to fecal urgency alone are usually related to rectal storage abnormalities while incontinence is often a result of anatomic or neurologic disruption of the anal sphincter complex. Many risk factors exist for fecal incontinence and include female sex, increasing age, higher body mass index (BMI), limited physical activity, smoking, presence of neuropsychiatric conditions, higher vaginal parity and history of obstetrical trauma, presence of chronic diarrhea and irritable bowel syndrome, or history of rectal surgery, prostatectomy and radiation. Evaluation of fecal incontinence involves a careful patient history and focused physical exam. Diagnostic tests include endorectal ultrasonography, anal manometry, anal sphincter electromyography, and defecography. Treatment strategies include behavioral, medical and surgical therapies as well as neuromodulation. Treatment is based on the presumed etiology of the condition and a multi-modal approach is often necessary to achieve the maximum benefit for patients.
    Current Urology Reports 03/2014; 15(3):388. DOI:10.1007/s11934-013-0388-8 · 1.51 Impact Factor
  • C.A. Unger, N. Kow, J. Jelovsek
    Journal of Minimally Invasive Gynecology 03/2014; 21(2):S45. DOI:10.1016/j.jmig.2013.12.077 · 1.58 Impact Factor
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    ABSTRACT: To construct and validate a prediction model for estimating the risk of de novo stress urinary incontinence (SUI) after vaginal pelvic organ prolapse (POP) surgery and compare it with predictions using preoperative urinary stress testing and expert surgeons' predictions. Using the data set (n=457) from the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial, a model using 12 clinical preoperative predictors of de novo SUI was constructed. De novo SUI was determined by Pelvic Floor Distress Inventory responses through 12 months postoperatively. After fitting the multivariable logistic regression model using the best predictors, the model was internally validated with 1,000 bootstrap samples to obtain bias-corrected accuracy using a concordance index. The model's predictions were also externally validated by comparing findings against actual outcomes using Colpopexy and Urinary Reduction Efforts trial patients (n=316). The final model's performance was compared with experts using a test data set of 32 randomly chosen Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial patients through comparison of the model's area under the curve against: 1) 22 experts' predictions; and 2) preoperative prolapse reduction stress testing. A model containing seven predictors discriminated between de novo SUI status (concordance index 0.73, 95% confidence interval [CI] 0.65-0.80) in Outcomes Following Vaginal Prolapse Repair and Midurethral Sling participants and outperformed expert clinicians (area under the curve 0.72 compared with 0.62, P<.001) and preoperative urinary stress testing (area under the curve 0.72 compared with 0.54, P<.001). The concordance index for Colpopexy and Urinary Reduction Efforts trial participants was 0.62 (95% CI 0.56-0.69). This individualized prediction model for de novo SUI after vaginal POP surgery is valid and outperforms preoperative stress testing, prediction by experts, and preoperative reduction cough stress testing. An online calculator is provided for clinical use. : III.
    Obstetrics and Gynecology 02/2014; 123(2 Pt 1):279-87. DOI:10.1097/AOG.0000000000000094 · 4.37 Impact Factor
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    ABSTRACT: To develop a valid laparoscopic sacrocolpopexy simulation model for use as an assessment and learning tool for performing this procedure. A training model was developed to simulate performing a laparoscopic sacrocolpopexy. Construct validity was measured by comparing observed masked performances on the model between experienced Female Pelvic Medicine and Reconstructive Surgeons, 'Experts,' and upper level trainees, 'Trainees,' at two tertiary academic centers. All video-taped performances were scored by two surgeons who were masked to subject's identity utilizing the valid and reliable Global Operative Assessment of Laparoscopic Skills (GOALS) scale. The 'Expert' group included Female Pelvic Medicine and Reconstructive Surgeons (N=5) experienced with laparoscopic sacrocolpopexy and the 'Trainee' group (N=15) included fourth year gynecology residents (N=5) and fellows in Female Pelvic Medicine and Reconstructive Surgery and Minimally Invasive Gynecologic Surgery (N=10). 'Experts' performed significantly better than 'Trainees' in the total score and in every domain of the GOALS scale ('Expert' group median = 33 [30.5-39] vs. 20.5 [range 13.5-30.5], p=0.002). Previous surgical experience had a strong association with performance on the model (Rho > 0.75). The majority of subjects 'agreed' or 'strongly agreed' that the model was authentic to the live procedure and a useful training tool. There was strong agreement between masked raters (Interclass Correlation Coefficient 0.84). This simulation model is valid and reliable for assessing performance of laparoscopic sacrocolpopexy and may be used for practicing key steps of this procedure.
    Journal of Minimally Invasive Gynecology 01/2014; 21(4). DOI:10.1016/j.jmig.2013.12.124 · 1.58 Impact Factor
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    ABSTRACT: We describe the presentation, diagnosis, and management of ureterovaginal fistula over a 7-year period at a tertiary care center. A retrospective review of ureterovaginal fistula cases between 2003 and 2011 was performed. Demographic information, antecedent event, symptoms, diagnostic modalities, and management strategies were reviewed. Nineteen ureterovaginal fistulas were identified during the 7-year study period. One fistula followed a repeat cesarean section and 18 fistulas followed a hysterectomy (9 total abdominal, 6 total laparoscopic, 3 vaginal hysterectomies). Ureteral injuries were not recognized in any of the patients at the time of index surgery. Computed tomography (CT) urography was the most commonly utilized diagnostic modality (58 %). Primary non-surgical management with ureteral stents was attempted and successful in 5 out of 7 cases (71 %). There were 14 total surgical repairs, including 2 cases in which stents were successfully placed, but the fistula persisted, and 6 additional cases where attempted stent placement failed. Surgical repair consisted of 10 ureteroneocystostomies performed via laparotomy and 4 performed laparoscopically, 3 of which were robotically assisted. Despite being uncommon, ureterovaginal fistula should remain in the differential diagnosis of new post-operative urinary incontinence after gynecological surgery. Conservative management with ureteral stent appears to be the best initial approach in selected patients, with a success rate of 71 %. Minimally invasive approaches to performing ureteroneocystostomy have high success rates, comparable to those of open surgical repair.
    International Urogynecology Journal 12/2013; 25(5). DOI:10.1007/s00192-013-2272-y · 2.16 Impact Factor
  • American journal of obstetrics and gynecology 07/2013; DOI:10.1016/j.ajog.2013.07.009 · 3.97 Impact Factor
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    J Eric Jelovsek, Nathan Kow, Gouri B Diwadkar
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    ABSTRACT: The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties. An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system. A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence. Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited.
    Medical Education 07/2013; 47(7):650-73. DOI:10.1111/medu.12220 · 3.62 Impact Factor
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    ABSTRACT: OBJECTIVE: To compare operative time and intra- and post-operative complications between laparoscopic (TLH) and robotic-assisted total laparoscopic hysterectomy (RA-TLH). STUDY DESIGN: This study was a blinded, prospective randomized controlled trial conducted at two institutions. Subjects consisted of women who planned laparoscopic hysterectomy for benign indications. Pre-operative randomization to TLH or RA-TLH was stratified by surgeon and uterine size (> or ≤12 weeks). Validated questionnaires (SF-36), activity assessment scales, and visual analogue scales were administered at baseline and during follow-up. RESULTS: 62 women consented, enrolled, and were randomized while 53 women underwent surgery (laparoscopic n=27, robotic n=26). There were no demographic differences between groups. Compared to laparoscopic hysterectomy, total case time (skin incision to skin closure) was significantly longer in the robotic group (mean difference +77 minutes [95% CI 33-121, p<0.001] as was total operating room time (entry into OR to exit) (mean difference +72 [95% CI 14-130, p=0.016] minutes). Mean docking time was 6 (±4) minutes. There were no significant differences between groups in estimated blood loss, pre- and post-operative hematocrit change, and length of stay. There were very few complications, with no difference in individual complication types or total complications between groups. Postoperative pain and return to daily activities were no different between groups. CONCLUSION: Although laparoscopic and robotic-assisted hysterectomies are safe approaches to hysterectomy, robotic-assisted hysterectomy requires a significantly longer operative time.
    American journal of obstetrics and gynecology 02/2013; 208(5). DOI:10.1016/j.ajog.2013.02.008 · 3.97 Impact Factor
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    ABSTRACT: To develop and validate a new ureteral anastomosis simulation model. We designed a training model to simulate the task of ureteral anastomosis required for ureteroneocystostomy that is suitable for robotic and laparoscopic approaches. Face validity was measured using questions related to surgical authenticity and educational value of the model. Construct validity was measured by comparing scores using Global Operative Assessment of Laparoscopic Skills Scale (GOALS) scale between "procedure experts," "robotic experts," and "trainees" groups. One-way analysis of variance was used to compare differences in the scores and operating times between the 3 groups. Associations between previous surgical experience and performance scores were measured using the Spearman rho correlation coefficient. Four urologists experienced with robotically assisted ureteroneocystostomies were included in the procedure experts group. The robotic experts group consisted of 5 gynecologists experienced in robotic surgery. The trainees group consisted of 12 urology and gynecology upper-level residents and fellows. All experts agreed or strongly agreed that the model was authentic to the live procedure and a useful training tool. Mean (SD) total GOALS scores were significantly better for the procedure experts group compared to the robotic experts group and to the trainees group (P=0.02 vs P=0.004, respectively). The robotic experts group's GOALS scores were also significantly higher than that of the trainees group (P=0.05). There were no differences in mean times required to complete the procedure. Surgical experience moderately correlated with scores on all 3 assessment scales. Superior performance on the model by more experienced surgeons demonstrates evidence of construct validity. This authentic and useful model allows surgeons to learn and practice the ureteral anastomosis portion of the ureteral reimplantation surgeries before operating on a live patient.
    Journal of Pelvic Medicine and Surgery 01/2013; 19(6):346-51. DOI:10.1097/SPV.0b013e3182a331bf
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    ABSTRACT: This study aimed to develop and internally validate a nomogram that facilitates decision making between patient and physician by predicting a woman's individual probability of developing urinary (UI) or fecal incontinence (FI) after her first delivery. This study used Childbirth and Pelvic Symptoms Study data, which estimated the prevalence of postpartum UI and FI in primiparous women after vaginal or cesarean delivery. Two models were developed using antepartum variables, and 2 models were developed using antepartum plus labor and delivery variables. Urinary incontinence was defined by a response of leaking urine "sometimes" or "often" using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. Fecal incontinence was defined as any involuntary leakage of mucus, liquid, or solid stool using the Fecal Incontinence Severity Index. Logistic regression models allowing nonlinear effects were used and displayed as nomograms. Overall performance was assessed using the Brier score (zero equals perfect model) and concordance index (c-statistic). A total of 921 women enrolled in the Childbirth and Pelvic Symptoms Study, and 759 (82%) were interviewed by telephone 6 months postpartum. Two antepartum models were generated, which discriminated between women who will and will not develop UI (Brier score = 0.19, c-statistic = 0.69) and FI (Brier score = 0.10, c-statistic = 0.67) at 6 months and 2 models were generated (Brier score = 0.18, c-statistic= 0.68 and Brier score = 0.09, c-statistic = 0.68) for predicting UI and FI, respectively, for use after labor and delivery. These models yielded 4 nomograms that are accurate for generating individualized prognostic estimates of postpartum UI and FI and may facilitate decision making in the prevention of incontinence.
    Journal of Pelvic Medicine and Surgery 01/2013; 19(2):110-8. DOI:10.1097/SPV.0b013e31828508f0
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    ABSTRACT: To investigate attitudes toward hysterectomy in women seeking care for pelvic organ prolapse. Two hundred twenty women referred for evaluation of prolapse without evidence of previous hysterectomy were surveyed with the Pelvic Organ Prolapse Distress Inventory; the Control Preferences Scale; and questions regarding patients' perception of the impact of hysterectomy on health, social life, and emotional well-being. Additional items presented hypothetical scenarios. Surveys were distributed in small batches until 100 responses were obtained from patients who met inclusion criteria. One hundred women with an intact uterus responded. Sixty percent indicated they would decline hysterectomy if presented with an equally efficacious alternative to a hysterectomy-based prolapse repair. The doctor's opinion, risk of surgical complications, and risk of malignancy were the most important factors in surgical decision making. Many women with prolapse prefer to retain their uterus at the time of surgery in the absence of a substantial benefit to hysterectomy. These findings should provide further impetus to investigate the efficacy of uterine-sparing procedures to help women make informed decisions regarding prolapse surgery.
    Journal of Pelvic Medicine and Surgery 01/2013; 19(2):103-9. DOI:10.1097/SPV.0b013e31827d8667
  • Journal of Minimally Invasive Gynecology 11/2012; 19(6):S24. DOI:10.1016/j.jmig.2012.08.082 · 1.58 Impact Factor

Publication Stats

1k Citations
225.15 Total Impact Points


  • 2008–2014
    • Women’s Health Institute of Illinois
      Oak Lawn, Illinois, United States
  • 2013
    • Institute for Urologic Research
      Wheeling, West Virginia, United States
    • Lerner Research Institute
      Cleveland, Ohio, United States
  • 2008–2012
    • Cleveland Clinic
      • • Women's Health Institute
      • • Department of Gynecology and Obstetrics
      Cleveland, Ohio, United States