Peggy Norton

University of Texas Southwestern Medical Center, Dallas, Texas, United States

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Publications (77)459.16 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 (
    Journal of Pelvic Medicine and Surgery 01/2015; DOI:10.1097/SPV.0000000000000160
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    ABSTRACT: AimsTo examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow-up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures.Methods We performed a secondary analysis of the SISTER and ToMUS trials of participants who underwent primary stress urinary incontinence (SUI) treatment (without prior SUI surgery or concomitant procedures). Using Kaplan–Meier analysis, retreatment-free survival rates by initial surgical procedure were compared. Mean MESA (Medical Epidemiologic and Social Aspects of Aging) stress index was also compared between those retreated for rSUI compared to those not retreated.ResultsHalf of the women in the SISTEr trial met inclusion criteria for this analysis (329/655, 174 Burch and 155 fascial sling), as did 444/597 (74%) of subjects in ToMUS (221 transobturator midurethral sling (TMUS), and 223 retropubic midurethral sling (RMUS). Types of surgical retreatment included autologous fascial sling (19), synthetic sling (1), and bulking agent (18). Five-year retreatment free survival rates (and standard errors) were 87% (3%), 96% (2%), 97% (1%), and 99% (0.7%) for Burch, autologous fascial sling, TMUS, and RMUS groups respectively (P < 0.0001). For all index surgery groups, the mean MESA stress index at last visit prior to retreatment for those retreated (n = 23) was significantly higher than mean MESA stress index at last visit for those not retreated (n = 645) (P < 0.0001).Conclusion In these cohorts, 6% of women after standard anti-incontinence procedures were retreated within 5 years, mostly with injection therapy or autologous fascial sling. Not all women with rSUI chose surgical retreatment. Neurourol. Urodynam. © 2015 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 01/2015; DOI:10.1002/nau.22714 · 2.46 Impact Factor
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    ABSTRACT: We conducted a genome-wide linkage analysis to identify pelvic organ prolapse (POP) predisposition genes using a resource of high-risk POP pedigrees. Cases are defined as women who reported bothersome symptoms of POP based on standardized symptom questions (Pelvic Floor Distress Inventory (PFDI), moderately or quite bothered), and/or received treatment for POP documented in medical records. Our complete pedigree resource contains 299 familial POP cases in 83 high-risk pedigrees. Genotype data were obtained from Illumina HumanHap550, 610Q, the Human1M-Duo, Human Omni1-Quad, or the Human Omni 2.5 platforms. A set of single nucleotide polymorphism (SNP) markers common to all platforms was identified and markers in high linkage disequilibrium were removed. We performed a genome-wide linkage analysis under general dominant and recessive models using a Markov Chain, Monte Carlo linkage analysis method implemented in MCLINK software. Because 70 individuals in 32 pedigrees were used in a previously published linkage analysis for a phenotype of POP requiring treatment/surgery, we also performed linkage only including the 225 newly recruited and genotyped cases in 61 pedigrees. Linkage analysis using our complete pedigree resource for the loosened criteria of bothersome POP showed evidence for significant genome-wide linkage on chromosome 10q24-26 (recessive model, max HLOD 3.4); suggestive evidence was identified on chromosomes 6, 17, and an additional region on chromosome 10. In the subset of only the newly recruited familial POP cases, significant evidence for genome-wide linkage was observed on chromosome 17q25 (recessive model, max HLOD 3.3), and suggestive evidence for linkage was observed on chromosomes 10 and 11. Neither analysis duplicated the previously published linkage evidence for the POP-requiring-treatment/surgery phenotype observed on chromosome 9. While the etiology of this common condition is unknown, this study provides evidence that loci on chromosomes 10q and 17q may contribute to POP etiology. Copyright © 2014 Elsevier Inc. All rights reserved.
    American Journal of Obstetrics and Gynecology 12/2014; DOI:10.1016/j.ajog.2014.12.037 · 3.97 Impact Factor
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    ABSTRACT: To identify genetic variants associated with urgency urinary incontinence (UUI) in post-menopausal women. A two-stage genome wide association analysis was conducted to identify variants associated with UUI. The Women's Health Initiative-Genomics & Randomized Trials Network (GARNET) sub-study with 4,894 genotyped post-reproductive white women was randomly split into independent discovery and replication cohorts. Genome-wide imputation was performed using IMPUTE2 with the 1000-Genomes-ALL-Phase-I integrated variant set as a reference. Controls reported no UUI at enrollment or follow-up; cases reported monthly or greater UUI and leaked sufficiently to wet/soak underpants/clothes. Logistic regression models were used to predict UUI case versus control status based on genotype, assuming additive inheritance. Age, obesity, diabetes and depression were included in the models as covariates. Following quality control, 975,508 single nucleotide polymorphisms (SNPs) in 2,241 cases (discovery=1,102, replication=1,133) and 776 controls (discovery=405, replication=371) remained. Genotype imputation resulted in 9,077,347 SNPs and insertions/deletions with minor allele frequency >0.01 available for analysis. Meta-analysis of the discovery and replication samples identified six loci on chromosomes 5, 10, 11, 12 & 18 associated with UUI at p<10(-6). Three of the loci were within genes, the zinc finger protein 521 (ZFP521) gene on chromosome 18q11, the ADAMTS16 gene on chromosome 5p15, and the CIT gene on chromosome 12q24. The other three loci were intergenic. Although environmental factors also likely contribute, this first exploratory Genome-Wide Associated Study (GWAS) for UUI suggests that genetic variants in the ZFP521, CIT, and ADAMTS16 genes might account for some of the observed heritability of the condition. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
    The Journal of Urology 12/2014; 193(6). DOI:10.1016/j.juro.2014.12.023 · 3.75 Impact Factor
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    ABSTRACT: Introduction and hypothesis Understanding the clustering of pelvic floor disorders (PFDs) within families is important because it may suggest underlying risk factors that may be environmental, genetic or both. The objective of this study was to describe clinical characteristics observed in familial cases with PFDs and compare them with strictly defined controls. Methods Women evaluated and treated for PFDs were recruited as part of a larger genetic study. Here, we define familial cases as those with bothersome symptoms or treatment for a PFD (pelvic organ prolapse [POP], stress urinary incontinence [SUI], and overactive bladder [OAB]) and who had a first-degree relative with bothersome symptoms or treatment for the same pelvic floor defect. We assigned clinical characteristics to probands and their relatives using standardized symptom questions (PFDI), examination, and review of treatment records, if any. Results We identified 126 familial POP cases, 183 familial SUI cases, and 101 familial OAB cases. Familial cases were more likely to have bothersome symptoms for more than one PFD. Among familial POP cases, bothersome SUI (71 %), OAB (54 %), and a combination of all three disorders (48 %) were common. Among familial SUI cases, bothersome OAB (60 %), POP (59 %), and combinations of all disorders (40 %) were common. Among familial OAB cases, bothersome SUI (88 %), POP (66 %), and combinations of all three disorders (59 %) were common. Conclusions Familial cases of POP, SUI, and OAB are more likely to have more than one pelvic floor defect. It is likely that underlying genetic factors contribute to more than one pelvic floor defect.
    International Urogynecology Journal 10/2014; 26(3). DOI:10.1007/s00192-014-2513-8 · 2.16 Impact Factor
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    ABSTRACT: Urological chronic pelvic pain syndrome includes interstitial cystitis/painful bladder syndrome (IC/PBS), a chronic bladder pain condition of unknown etiology. Interstitial cystitis/painful bladder syndrome can co-occur with a number of associated conditions such as irritable bowel syndrome and fibromyalgia. The purpose of this study was to estimate the heritability of approximately 20 associated conditions in first-degree relatives (and if appropriate, second- and third-degree relatives) of patients with IC/PBS to identify shared genetic contributions for the disease combinations.
    Journal of Pelvic Medicine and Surgery 10/2014; DOI:10.1097/SPV.0000000000000139
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    ABSTRACT: AimsUrodynamic studies (UDS) are generally recommended prior to surgical treatment for stress urinary incontinence (SUI), despite insufficient evidence that it impacts treatment plans or outcomes in patients with uncomplicated SUI. This analysis aimed to calculate the cost incurred when UDS was performed as a supplement to a basic office evaluation and to extrapolate the potential savings of not doing UDS in this patient population on a national basis.Methods This is a secondary analysis from the Value of Urodynamic Evaluation (ValUE) trial, a multicenter non-inferiority randomized trial to determine whether a basic office evaluation (OE) is non-inferior in terms of SUI surgery outcomes to office evaluation with addition of urodynamic studies (UDS). All participants underwent an OE; those patients who randomized to supplementary UDS underwent non-instrumented uroflowmetry, filling cystometry, and a pressure flow study. Costs associated with UDS were calculated using 2014 U.S. Medicare allowable fees. Models using various patient populations and payor mixes were created to obtain a range of potential costs of performing UDS in patients undergoing SUI surgery annually in the United States.ResultsSix hundred thirty women were randomized to OE or OE plus UDS. There was no difference in surgical outcomes between the two groups. The per patient cost of UDS varied from site to site, and included complex cystometrogram $314–$343 (CPT codes 51728–51729) plus complex uroflowmetry $16 (CPT code 51741). Extrapolating these costs for US women similar to our study population, 13–33 million US dollars could be saved annually by not performing preoperative urodynamics.Conclusion For women with uncomplicated SUI and a confirmatory preoperative basic office evaluation, tens of millions of dollars US could be saved annually by not performing urodynamic testing. In the management of such women, eliminating this preoperative test has a major economic benefit. Neurourol. Urodynam. 9999:1–4, 2014. © 2014 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 10/2014; DOI:10.1002/nau.22684 · 2.46 Impact Factor
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    ABSTRACT: Few studies have characterized longer-term outcomes after retropubic and transobturator midurethral slings.
    The Journal of Urology 08/2014; 193(1). DOI:10.1016/j.juro.2014.08.089 · 3.75 Impact Factor
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    ABSTRACT: Objective To estimate the effect of Burch and fascial sling surgery on out-of-pocket urinary incontinence (UI) management costs at 24 months post-operatively and identify predictors of change in cost among women enrolled in a randomized trial comparing these procedures. Methods Resources used for UI management (supplies, laundry, dry cleaning) were self-reported by 491 women at baseline and 24 months post-surgery and total out-of-pocket costs for UI management (in 2012 US dollars) were estimated. Data from the two surgical groups were combined to examine change in cost for UI management over 24 months. Univariate and bivariate changes in cost were analyzed using Wilcoxon signed rank test. Predictors of change in cost were examined using multivariate mixed models. Results At baseline mean (±SD) age of participants was 53±10 years, and frequency of weekly UI episodes was 23±21. Weekly UI episodes decreased by 86% at 24 months (P<0.001). Mean weekly cost was $16.60±$27 (median $9.39) at baseline and $4.57±$15 (median $0.10) at 24 months (P<0.001), a decrease of 72%. In multivariate analyses, cost decreased by $3.38±$0.77 per week for each decrease of 1 UI episode per day (P<0.001) and was strongly associated with greater improvement in UDI and IIQ scores (P<0.001) and decreased 24-hour pad weight (P<0.02). Conclusion Following Burch or fascial sling surgery, UI management cost at 24 months decreased by 72% ($625 per woman per year) and was strongly associated with decreasing UI frequency. Reduced out-of-pocket expenses may be a benefit of these established urinary incontinence procedures.
    American journal of obstetrics and gynecology 08/2014; 211(2). DOI:10.1016/j.ajog.2014.03.012 · 3.97 Impact Factor
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    ABSTRACT: AimsThe Blaivas–Groutz nomogram defines voiding obstruction in women using Qmax from the NIF and the maximum detrusor pressure (Pdetmax) from the PFS. The aim of this study was to understand the relationship between NIF and PFS maximum flow rates in women with stress incontinence.Methods We analyzed the UDS of 597 women with stress-dominant urinary incontinence. Each subject underwent a NIF and then a PFS. Mixed model was used to test the hypothesis that the relationship between flow rates and voided volume (VV) were similar for NIF and PFS.ResultsThere were 452 subjects with both NIF and PFS studies that met the inclusion criteria and had max flow rate (Qmax) for both NIF and PFS. The mean age was 53. Overall, higher VV were observed during PFS compared to NIF and subjects had higher Qmax with NIF compared to PFS. The relationship between Qmax and VV was significantly different between NIF and PFS (P < 0.004). At 200 ml, NIF Qmax was 14% higher than PFS Qmax and this difference increased to 30% at 700 ml.Conclusion The difference between PFS Qmax and NIF Qmax increases as VV increase. As a result, values from PFS and NIF cannot be used interchangeably as has been suggested in the Blaivas–Groutz nomogram for obstruction in women. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 04/2014; DOI:10.1002/nau.22625 · 2.46 Impact Factor
  • The Journal of Urology 04/2014; 191(4):e343-e344. DOI:10.1016/j.juro.2014.02.966 · 3.75 Impact Factor
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    ABSTRACT: More than 300,000 surgeries are performed annually in the United States for pelvic organ prolapse. Sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) are commonly performed transvaginal surgeries to correct apical prolapse. Little is known about their comparative efficacy and safety, and it is unknown whether perioperative behavioral therapy with pelvic floor muscle training (BPMT) improves outcomes of prolapse surgery. To compare outcomes between (1) SSLF and ULS and (2) perioperative BPMT and usual care in women undergoing surgery for vaginal prolapse and stress urinary incontinence. Multicenter, 2 × 2 factorial, randomized trial of 374 women undergoing surgery to treat both apical vaginal prolapse and stress urinary incontinence was conducted between 2008 and 2013 at 9 US medical centers. Two-year follow-up rate was 84.5%. The surgical intervention was transvaginal surgery including midurethral sling with randomization to SSLF (n = 186) or ULS (n = 188); the behavioral intervention was randomization to receive perioperative BPMT (n = 186) or usual care (n = 188). The primary outcome for the surgical intervention (surgical success) was defined as (1) no apical descent greater than one-third into vaginal canal or anterior or posterior vaginal wall beyond the hymen (anatomic success), (2) no bothersome vaginal bulge symptoms, and (3) no re-treatment for prolapse at 2 years. For the behavioral intervention, primary outcome at 6 months was urinary symptom scores (Urinary Distress Inventory; range 0-300, higher scores worse), and primary outcomes at 2 years were prolapse symptom scores (Pelvic Organ Prolapse Distress Inventory; range 0-300, higher scores worse) and anatomic success. At 2 years, surgical group was not significantly associated with surgical success rates (ULS, 59.2% [93/157] vs SSLF, 60.5% [92/152]; unadjusted difference, -1.3%; 95% CI, -12.2% to 9.6%; adjusted odds ratio [OR], 0.9; 95% CI, 0.6 to 1.5) or serious adverse event rates (ULS, 16.5% [31/188] vs SSLF, 16.7% [31/186]; unadjusted difference, -0.2%; 95% CI, -7.7% to 7.4%; adjusted OR, 0.9; 95% CI, 0.5 to 1.6). Perioperative BPMT was not associated with greater improvements in urinary scores at 6 months (adjusted treatment difference, -6.7; 95% CI, -19.7 to 6.2), prolapse scores at 24 months (adjusted treatment difference, -8.0; 95% CI, -22.1 to 6.1), or anatomic success at 24 months. Two years after vaginal surgery for prolapse and stress urinary incontinence, neither ULS nor SSLF was significantly superior to the other for anatomic, functional, or adverse event outcomes. Perioperative BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years. Identifier: NCT00597935.
    JAMA The Journal of the American Medical Association 03/2014; 311(10):1023-34. DOI:10.1001/jama.2014.1719 · 30.39 Impact Factor
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    ABSTRACT: OBJECTIVE: The aim of our study was to observe pelvic organ prolapse (POP) over time, treated and untreated, in a group of highly characterized women being followed up subjectively and objectively over 5-7 years following continence surgery. STUDY DESIGN: We measured baseline prolapse symptoms and anatomic prolapse in subjects enrolled in the trial of midurethral sling (TOMUS) and E-TOMUS, and measured these same parameters annually for 5-7 years after the index surgery. Additional information about subsequent treatment for POP was also recorded. RESULTS: In all, 597 women were randomized to 1 of 2 midurethral sling procedures in the TOMUS; concomitant vaginal procedures for POP were allowed at the surgeon's discretion. Stage 2 POP was present at baseline in 291 subjects (49%). Symptoms of POP were reported in 67 (25%). Of the asymptomatic women, 34 of 223 (15%) underwent a concomitant POP repair at the time of index sling surgery. Anatomic progression of prolapse in women with asymptomatic, unoperated stage 2 POP over the next 72 months was infrequent and occurred in only 3 of 189 subjects (2%); none underwent surgery for POP. Most symptomatic women (47/67 [70%]) underwent a concomitant repair for POP at the index sling surgery. Three of the 47 women who had undergone concomitant repair for symptomatic stage 2 POP underwent repeat POP surgery (2 at 36 months and 1 at 48 months.) CONCLUSION: For patient populations similar to the TOMUS and E-TOMUS populations, surgeons may counsel women with asymptomatic stage 2 POP that their prolapse is unlikely to require surgery in the next 5-7 years.
    Journal of Minimally Invasive Gynecology 03/2014; 21(2):S1. DOI:10.1016/j.ajog.2014.07.053 · 1.58 Impact Factor
  • Journal of Minimally Invasive Gynecology 03/2014; 21(2):S3. DOI:10.1016/j.jmig.2013.12.010 · 1.58 Impact Factor
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    ABSTRACT: AIMS: To determine if pre-operative urodynamic testing (UDS) affects physicians' diagnostic confidence and if physician confidence affects treatment outcomes at 1 year. METHODS: The Value of Urodynamic Evaluation (ValUE) trial randomized 630 women with predominant stress urinary incontinence (SUI) to office evaluation (OE) or OE plus UDS prior to surgery. After OE, physicians completed a checklist of five clinical diagnoses: SUI, overactive bladder (OAB) wet and dry, voiding dysfunction (VD), and intrinsic sphincter deficiency (ISD), and reported their confidence in each. Responses ranged from 1 to 5 with; 1 = "not very confident (<50%)" to 5 = "extremely confident (95 + %)." After UDS, investigators again rated their confidence in these five clinical diagnoses. Logistic regression analysis correlated physician confidence in diagnosis with treatment success. RESULTS: Of 315 women who received OE plus UDS, 294 had complete data. Confidence improved after UDS in patients with baseline SUI (4.52-4.63, P < 0.005), OAB-wet (3.55-3.75, P < 0.001), OAB-dry (3.55-3.68 P < 0.005), VD (3.81-3.95, P < 0.005), and suspected ISD (3.63-3.92, P < 0.001). Increased confidence after UDS was not associated with higher odds of treatment success although mean changes in confidence were slightly higher for those who achieved treatment success. Physician diagnoses shifted more from not confident to confident for ISD and OAB-wet after UDS (McNemar's P-value <0.001 for both). CONCLUSIONS: In women undergoing UDS for predominant SUI, UDS increased physicians' confidence in their clinical diagnoses; however, this did not correlate with treatment success. Neurourol. Urodynam. 9999:XX-XX, 2013. © 2013 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 03/2014; 33(3). DOI:10.1002/nau.22398 · 2.46 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: The objectives of this study are (1) to describe the presenting symptoms, findings, and treatment and (2) to describe the self-reported improvement and function at least 6 months after presentation in women presenting to 1 urogynecology division for complications associated with synthetic vaginal mesh. Women evaluated between 2006 and 2011 were identified by diagnostic codes. We abstracted information from the medical record and attempted to contact all women to complete a follow-up telephone survey questionnaire consisting of several validated instruments. A total of 111 women were evaluated for complications associated with synthetic vaginal mesh. The mean interval from index surgery was 2.4 years. Of these, 84% were referred from outside hospitals. Index surgeries included vaginal mesh kits/vaginally placed mesh (47%), midurethral mesh slings (37%), abdominally placed vaginal mesh (11%), and vaginal mesh kit with concomitantly placed mesh sling (5%). The most common complications were extrusion (65%), contraction (17%), and chronic pelvic pain (16%). A total of 98 women underwent some type of treatment (85 surgical) by urogynecologists, pelvic pain specialists, or physical therapists. Eighty-four (76%) provided follow-up information at mean interval since presentation of 2.3 years. At follow-up, the mean (SD) Pelvic Floor Distress Inventory score was 98 (67), the mean (SD) EQ-5D index score was 0.69 (0.23), and 22% reported vaginal discharge, 15% vaginal bleeding or spotting, and 45% sexual abstinence due to problems related to mesh. A total of 71% reported being overall better, whereas 29% were the same or worse. Two years after tertiary care level multidisciplinary treatment of vaginal mesh complications, many women still report symptoms that negatively impact their quality of life.
    01/2014; 20(3):126-30. DOI:10.1097/SPV.0000000000000084
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    ABSTRACT: To report the frequency of abnormal cystoscopy at incontinence surgery and identify risk factors and sequelae of injury. Findings of cystoscopy were prospectively collected in 3 multicenter surgical trials. Clinical, demographic, procedure characteristics and surgeon experience were analyzed for association with iatrogenic injury and non-injury abnormalities. Impact of abnormalities on continence outcomes and adverse events during 12 months post-procedure were assessed. Abnormal findings in the bladder or urethra were identified in 95 of 1,830 (5.2%) women. Most injuries were iatrogenic (75.8%). Lower urinary tract (LUT) injury was most common at retropubic urethropexy and retropubic midurethral slings (MUS) (6.4% each), followed by autologous pubovaginal slings (PVS) (1.7%) and transobturator MUS (0.4%). Increasing age (56.9 v. 51.9 years; p=0.04), vaginal deliveries (3.2 vs. 2.6, p=0.04), and blood loss (393 vs. 218 ml, p=0.01) were associated with LUT injury during retropubic urethropexy, but only age (62.9 vs 51.4 yrs, p=0.02) and smoking history (p=0.04) were associated for PVS. No factors correlated with increased risk of injury at retropubic and transobturator MUS. Notably, prior incontinence surgery, concomitant procedures, anesthesia type and trainee participation did not increase LUT injury frequency. Though discharge with an indwelling catheter was more common after trocar perforation compared to the non-injury group (55.6% vs. 18.5%, p < 0.001), they did not differ in overall success, voiding dysfunction, recurrent UTIs or urge urinary incontinence. Universal cystoscopy at incontinence surgery detects abnormalities in 1 in 20 women. Urinary trocar perforations addressed intraoperatively have no long-term adverse sequelae.
    American journal of obstetrics and gynecology 12/2013; 210(5). DOI:10.1016/j.ajog.2013.12.040 · 3.97 Impact Factor
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    ABSTRACT: To describe the prevalence and risk factors for incomplete bladder emptying after midurethral slings (MUS) in a large multicenter trial. Five hundred ninety-seven women were randomized to retropubic (RMUS) or transobturator midurethral slings as part of the Trial of MidUrethral Slings study. Demographic data and voiding symptoms were obtained preoperatively along with urodynamics. Patients underwent a standardized voiding trial at discharge after continence surgery. Incomplete bladder emptying was defined as a postvoid residual of >150 mL. Three-quarters of patients (454 of 597) were self-voiding at discharge, whereas 114 of 597 (19%) were managed with an indwelling urethral catheter and 29 of 597 (5%) with intermittent catheterization. At 2 weeks, only 38 of 586 (6%) reported any catheter use, and by 6 weeks, only 9 of 587 (2%) reported any catheter use. Women with incomplete bladder emptying at discharge were more likely to have had a RMUS (odds ratio 1.79; 95% confidence interval 1.22-2.62) and to report preoperative voiding accommodations such as straining to void (odds ratio 1.75; 95% confidence interval 1.04-2.96). Urodynamic and clinicodemographic parameters were not predictive of incomplete bladder emptying. Incomplete bladder emptying at discharge after MUS is common, especially after RMUS, but of short duration. Risk factors include preoperative voiding accommodations such as straining or bending over to void, but other variables including urodynamics did not predict incomplete bladder emptying after MUS.
    Urology 11/2013; 82(5):1038-41. DOI:10.1016/j.urology.2013.05.060 · 2.13 Impact Factor
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    ABSTRACT: Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life. The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ). Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008). Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.
    International Urogynecology Journal 08/2013; 25(1). DOI:10.1007/s00192-013-2184-x · 2.16 Impact Factor

Publication Stats

1k Citations
459.16 Total Impact Points


  • 2014
    • University of Texas Southwestern Medical Center
      • Department of Urology
      Dallas, Texas, United States
  • 2006–2014
    • University of Utah
      • Department of Obstetrics and Gynecology
      Salt Lake City, Utah, United States
  • 2012
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
  • 2010
    • University of Alabama at Birmingham
      • Department of Obstetrics and Gynecology
      Birmingham, Alabama, United States
    • Loyola University Medical Center
      Maywood, Illinois, United States
  • 2008
    • Magee-Womens Hospital
      Pittsburgh, Pennsylvania, United States
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 2007
    • University of California, San Diego
      • Division of Urology
      San Diego, CA, United States