CONCLUSION: We propose that the shape and characteristics of the vaginal HPZ are consistent with ... more CONCLUSION: We propose that the shape and characteristics of the vaginal HPZ are consistent with the hypothesis that the puborectalis muscle is responsible for the genesis of the vaginal HPZ.
OBJECTIVE: Despite the significant impact that female pelvic floor disorders (PFDs) have on quali... more OBJECTIVE: Despite the significant impact that female pelvic floor disorders (PFDs) have on quality of life, there are limited data on the prevalence of PFDs derived from psychometrically and biologically validated surveys.
A total of 12,200 women from the Southern California Kaiser Permanente Health System ages 25-84 y... more A total of 12,200 women from the Southern California Kaiser Permanente Health System ages 25-84 years were surveyed using the validated Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ). 1 The presence of stress urinary incontinence (SUI), overactive bladder (OAB), ...
time to revision was 33.2 months. Patients who underwent cuff downsizing for continued incontinen... more time to revision was 33.2 months. Patients who underwent cuff downsizing for continued incontinence had a higher rate of mechanical failure compared to all other forms of AUS revision (p¼0.016). No increased rate of urethral erosion was observed between the two groups (p¼0.244). There was no significant difference among the AUS revision groups with regard to incontinence failure (p¼0.313), mechanical failure (p¼0.310), urethral erosion (p¼0.448), or overall failure (p¼0.336). When assessed individually, none of the revisions was associated with a higher rate of incontinence failure compared to the rest of the cohort: cuff downsizing (p¼0.137), PRB replacement (p¼0.737), cuff repositioning (p¼0.354), and tandem cuff placement (p¼0.146).
Introduction and hypothesis The aim of this study was to determine whether preoperative voiding d... more Introduction and hypothesis The aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery. Methods Opening detrusor pressure, detrusor pressure at maximum flow (p det Q max ), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests. Results There were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes. Conclusions We found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.
We sought to describe the relationship between patient symptoms and pelvic organ prolapse (POP) a... more We sought to describe the relationship between patient symptoms and pelvic organ prolapse (POP) and report the sensitivity, specificity, and positive and negative predictive value of these POP symptoms. Two urologists and four urogynecologists developed a standardized pelvic floor questionnaire based on face validation for use at three female pelvic floor disorder clinics. Specific questions related to prolapse included questions on urinary splinting, digital assistance for defecation, and a bulge per vagina. Prolapse was assessed with the standardized Pelvic Organ Prolapse Quantitative (POP-Q) terminology. The analysis included 1912 women. Urinary splinting was uncommon (<10%) when Ba <0, but ranged between 23 and 36% for stage III and IV Ba prolapse. Digital assistance was equally common in stage II Bp prolapse (21-38%) and stage III-IV Bp prolapse (26-29%). Only 6-11% of women with stage 0 or I POP reported symptoms of bulge, but with stage II it increased to 77%. Urinary splinting is 97% specific for anterior prolapse. The report of a bulge has an 81% positive predictive value and a 76% negative predictive value. Very few patients without anterior prolapse will report urinary splinting. Digital assistance for fecal evacuation is no more common with massive posterior prolapse than with moderate posterior prolapse. Patient report of a bulge is a valuable screening tool for POP and should prompt a careful exam.
... Whitcomb, Emily L. MD*; Lukacz, Emily S. MD*; Lawrence, Jean M. ScD, MPH, MSSA; Nager, Charl... more ... Whitcomb, Emily L. MD*; Lukacz, Emily S. MD*; Lawrence, Jean M. ScD, MPH, MSSA; Nager, Charles W. MD*; Luber, Karl M. MD. Article Outline. Collapse Box ... Supported by NICHD grant R01 HD4113-01A1. Reprints: Emily S. Lukacz, MD, MAS, 9350 Campus Point Drive, No. ...
To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and c... more To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms. 655 women underwent standardized preoperative UDS that included perineal surface EMG prior to undergoing surgery for stress urinary incontinence. Pressure-flow studies were evaluated for abdominal straining and interrupted flow. Quantitative EMG values were extracted from 10 predetermined time-points and compared between fill and void. Qualitative EMG activity was assessed for the percent of time EMG was active during fill and void and for the average amplitude of EMG during fill compared to void. Postoperative voiding dysfunction was defined as surgical revision or catheterization more than 6 weeks after surgery. Fisher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s exact test with a 5% two-sided significance level was used to assess differences in EMG activity and postoperative voiding dysfunction. 321 UDS had interpretable EMG studies, of which 131 (41%) had EMG values at all 10 predetermined and annotated time-points. Quantitative and qualitative EMG signals during flow were usually greater than during fill. The prevalence of postoperative voiding dysfunction in subjects with higher preoperative EMG activity during void was not significantly different. Results were similar in the 42 subjects who had neither abdominal straining during void nor interrupted flow. Perineal surface patch EMG did not measure expected pelvic floor and urethral sphincter relaxation during voiding. Preoperative EMG did not predict patients at risk for postoperative voiding dysfunction.
Purpose-This study investigates the associations of a history of fracture, comorbid chronic condi... more Purpose-This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.
The authors reviewed the medical records of 193 women who underwent sacrocolpopexy with 2 differe... more The authors reviewed the medical records of 193 women who underwent sacrocolpopexy with 2 different types of sutures attaching polypropylene mesh to the vagina: delayed absorbable sutures (median follow-up, 43 weeks) and permanent sutures (median follow-up, 106 weeks). Failure rates for the 45 subjects in the delayed absorbable group and 148 subjects in the permanent suture group were similar and not statistically different in any compartment: apical, anterior, or posterior. Delayed absorbable monofilament suture appears to be a reasonable alternative to permanent suture for mesh attachment to the vagina during sacrocolpopexy.
Female Pelvic Medicine & Reconstructive Surgery, 2011
: To compare operative times, hospital costs, and surgical outcomes for robotic-assisted laparosc... more : To compare operative times, hospital costs, and surgical outcomes for robotic-assisted laparoscopic sacrocolpopexy (RALSC) and laparoscopic sacrocolpopexy (LSC). : A retrospective cohort study of 104 subjects who underwent RALSC (n = 43) or LSC (n = 61) for vaginal vault prolapse was performed. The primary outcomes were operative time and hospital costs. The secondary outcomes included blood loss, complications, and objective cure rates. χ and t tests were used. : The mean operative time was longer in RALSC than in LSC (281 ± 58 vs 206 ± 42 minutes; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) with setup time accounting for only 9 minutes of this difference. Direct costs (expressed in cost units) for hospital stay were similar (437 ± 88 vs 450 ± 119 units; P = 0.738) while surgical costs remained higher for RALSC (2724 ± 413 vs 2295 ± 342 units; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). Blood loss and complications were similar, and objective cure was not significantly different for RALSC vs LSC (90% vs 80%, P = 0.19). : Robotic-assisted laparoscopic sacrocolpopexy achieves similar perioperative outcomes compared to LSC with increased surgical time resulting in increased costs.
American Journal of Obstetrics and Gynecology, 2014
OBJECTIVE: This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and... more OBJECTIVE: This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial assessed whether treatment knowledge differed between randomized groups at 12 months and whether treatment success was affected by treatment perception.
Background and purposeUrodynamic studies (UDS) are routinely obtained prior to surgery for stress... more Background and purposeUrodynamic studies (UDS) are routinely obtained prior to surgery for stress urinary incontinence (SUI) despite a lack of evidence that UDS information has an actual impact on outcome. The primary aim of this non-inferiority randomized clinical trial is to determine whether women with symptomatic, uncomplicated SUI who undergo only a basic office evaluation (BOE) prior to SUI surgery
BACKGROUND:Resting and squeeze pressures in the anal canal are thought to reflect the contributio... more BACKGROUND:Resting and squeeze pressures in the anal canal are thought to reflect the contributions of the internal anal sphincter (IAS) and the external anal sphincter (EAS) respectively. Role of the puborectalis muscle (PRM) in the genesis of anal canal pressure is not known.OBJECTIVES:To determine the functional correlates of anal canal anatomy.METHODS:Seventeen asymptomatic nulliparous women were studied using simultaneous 3D ultrasound
This video introduces a 3D high-resolution manometry (HRM) system to the field of urogynecology. ... more This video introduces a 3D high-resolution manometry (HRM) system to the field of urogynecology. We demonstrate how to obtain and interpret dynamic urethral pressures with this measurement system and use it to evaluate pre- and postoperative women. The 3D HRM catheter is ∼12 F; 11 cm of its length has pressure sensors with eight circumferentially distributed pressure-sensitive segments that collect and transmit individual pressure measurements to construct a 3D pressure map. In this video, we demonstrate the output display of the 3D HRM measurement system. Pressure output maps are shown for one woman with stress urinary incontinence (SUI) and one with a history of SUI who underwent successful midurethral sling insertion. We also show a summary of 3D pressure-measurement patterns of 44 women who underwent pressure measurements to evaluate qualitatively the 3D pressure profile of the urethra in an effort to better understand pelvic floor and urethral sphincter physiology. Advanced HRM technology to measure urethral pressures under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism in continent and incontinent women and after continence surgeries.
CONCLUSION: We propose that the shape and characteristics of the vaginal HPZ are consistent with ... more CONCLUSION: We propose that the shape and characteristics of the vaginal HPZ are consistent with the hypothesis that the puborectalis muscle is responsible for the genesis of the vaginal HPZ.
OBJECTIVE: Despite the significant impact that female pelvic floor disorders (PFDs) have on quali... more OBJECTIVE: Despite the significant impact that female pelvic floor disorders (PFDs) have on quality of life, there are limited data on the prevalence of PFDs derived from psychometrically and biologically validated surveys.
A total of 12,200 women from the Southern California Kaiser Permanente Health System ages 25-84 y... more A total of 12,200 women from the Southern California Kaiser Permanente Health System ages 25-84 years were surveyed using the validated Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ). 1 The presence of stress urinary incontinence (SUI), overactive bladder (OAB), ...
time to revision was 33.2 months. Patients who underwent cuff downsizing for continued incontinen... more time to revision was 33.2 months. Patients who underwent cuff downsizing for continued incontinence had a higher rate of mechanical failure compared to all other forms of AUS revision (p¼0.016). No increased rate of urethral erosion was observed between the two groups (p¼0.244). There was no significant difference among the AUS revision groups with regard to incontinence failure (p¼0.313), mechanical failure (p¼0.310), urethral erosion (p¼0.448), or overall failure (p¼0.336). When assessed individually, none of the revisions was associated with a higher rate of incontinence failure compared to the rest of the cohort: cuff downsizing (p¼0.137), PRB replacement (p¼0.737), cuff repositioning (p¼0.354), and tandem cuff placement (p¼0.146).
Introduction and hypothesis The aim of this study was to determine whether preoperative voiding d... more Introduction and hypothesis The aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery. Methods Opening detrusor pressure, detrusor pressure at maximum flow (p det Q max ), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests. Results There were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes. Conclusions We found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.
We sought to describe the relationship between patient symptoms and pelvic organ prolapse (POP) a... more We sought to describe the relationship between patient symptoms and pelvic organ prolapse (POP) and report the sensitivity, specificity, and positive and negative predictive value of these POP symptoms. Two urologists and four urogynecologists developed a standardized pelvic floor questionnaire based on face validation for use at three female pelvic floor disorder clinics. Specific questions related to prolapse included questions on urinary splinting, digital assistance for defecation, and a bulge per vagina. Prolapse was assessed with the standardized Pelvic Organ Prolapse Quantitative (POP-Q) terminology. The analysis included 1912 women. Urinary splinting was uncommon (<10%) when Ba <0, but ranged between 23 and 36% for stage III and IV Ba prolapse. Digital assistance was equally common in stage II Bp prolapse (21-38%) and stage III-IV Bp prolapse (26-29%). Only 6-11% of women with stage 0 or I POP reported symptoms of bulge, but with stage II it increased to 77%. Urinary splinting is 97% specific for anterior prolapse. The report of a bulge has an 81% positive predictive value and a 76% negative predictive value. Very few patients without anterior prolapse will report urinary splinting. Digital assistance for fecal evacuation is no more common with massive posterior prolapse than with moderate posterior prolapse. Patient report of a bulge is a valuable screening tool for POP and should prompt a careful exam.
... Whitcomb, Emily L. MD*; Lukacz, Emily S. MD*; Lawrence, Jean M. ScD, MPH, MSSA; Nager, Charl... more ... Whitcomb, Emily L. MD*; Lukacz, Emily S. MD*; Lawrence, Jean M. ScD, MPH, MSSA; Nager, Charles W. MD*; Luber, Karl M. MD. Article Outline. Collapse Box ... Supported by NICHD grant R01 HD4113-01A1. Reprints: Emily S. Lukacz, MD, MAS, 9350 Campus Point Drive, No. ...
To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and c... more To describe perineal surface patch electromyography (EMG) activity during urodynamics (UDS) and compare activity between filling and voiding phases and to assess for a relationship between preoperative EMG activity and postoperative voiding symptoms. 655 women underwent standardized preoperative UDS that included perineal surface EMG prior to undergoing surgery for stress urinary incontinence. Pressure-flow studies were evaluated for abdominal straining and interrupted flow. Quantitative EMG values were extracted from 10 predetermined time-points and compared between fill and void. Qualitative EMG activity was assessed for the percent of time EMG was active during fill and void and for the average amplitude of EMG during fill compared to void. Postoperative voiding dysfunction was defined as surgical revision or catheterization more than 6 weeks after surgery. Fisher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s exact test with a 5% two-sided significance level was used to assess differences in EMG activity and postoperative voiding dysfunction. 321 UDS had interpretable EMG studies, of which 131 (41%) had EMG values at all 10 predetermined and annotated time-points. Quantitative and qualitative EMG signals during flow were usually greater than during fill. The prevalence of postoperative voiding dysfunction in subjects with higher preoperative EMG activity during void was not significantly different. Results were similar in the 42 subjects who had neither abdominal straining during void nor interrupted flow. Perineal surface patch EMG did not measure expected pelvic floor and urethral sphincter relaxation during voiding. Preoperative EMG did not predict patients at risk for postoperative voiding dysfunction.
Purpose-This study investigates the associations of a history of fracture, comorbid chronic condi... more Purpose-This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.
The authors reviewed the medical records of 193 women who underwent sacrocolpopexy with 2 differe... more The authors reviewed the medical records of 193 women who underwent sacrocolpopexy with 2 different types of sutures attaching polypropylene mesh to the vagina: delayed absorbable sutures (median follow-up, 43 weeks) and permanent sutures (median follow-up, 106 weeks). Failure rates for the 45 subjects in the delayed absorbable group and 148 subjects in the permanent suture group were similar and not statistically different in any compartment: apical, anterior, or posterior. Delayed absorbable monofilament suture appears to be a reasonable alternative to permanent suture for mesh attachment to the vagina during sacrocolpopexy.
Female Pelvic Medicine & Reconstructive Surgery, 2011
: To compare operative times, hospital costs, and surgical outcomes for robotic-assisted laparosc... more : To compare operative times, hospital costs, and surgical outcomes for robotic-assisted laparoscopic sacrocolpopexy (RALSC) and laparoscopic sacrocolpopexy (LSC). : A retrospective cohort study of 104 subjects who underwent RALSC (n = 43) or LSC (n = 61) for vaginal vault prolapse was performed. The primary outcomes were operative time and hospital costs. The secondary outcomes included blood loss, complications, and objective cure rates. χ and t tests were used. : The mean operative time was longer in RALSC than in LSC (281 ± 58 vs 206 ± 42 minutes; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) with setup time accounting for only 9 minutes of this difference. Direct costs (expressed in cost units) for hospital stay were similar (437 ± 88 vs 450 ± 119 units; P = 0.738) while surgical costs remained higher for RALSC (2724 ± 413 vs 2295 ± 342 units; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). Blood loss and complications were similar, and objective cure was not significantly different for RALSC vs LSC (90% vs 80%, P = 0.19). : Robotic-assisted laparoscopic sacrocolpopexy achieves similar perioperative outcomes compared to LSC with increased surgical time resulting in increased costs.
American Journal of Obstetrics and Gynecology, 2014
OBJECTIVE: This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and... more OBJECTIVE: This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial assessed whether treatment knowledge differed between randomized groups at 12 months and whether treatment success was affected by treatment perception.
Background and purposeUrodynamic studies (UDS) are routinely obtained prior to surgery for stress... more Background and purposeUrodynamic studies (UDS) are routinely obtained prior to surgery for stress urinary incontinence (SUI) despite a lack of evidence that UDS information has an actual impact on outcome. The primary aim of this non-inferiority randomized clinical trial is to determine whether women with symptomatic, uncomplicated SUI who undergo only a basic office evaluation (BOE) prior to SUI surgery
BACKGROUND:Resting and squeeze pressures in the anal canal are thought to reflect the contributio... more BACKGROUND:Resting and squeeze pressures in the anal canal are thought to reflect the contributions of the internal anal sphincter (IAS) and the external anal sphincter (EAS) respectively. Role of the puborectalis muscle (PRM) in the genesis of anal canal pressure is not known.OBJECTIVES:To determine the functional correlates of anal canal anatomy.METHODS:Seventeen asymptomatic nulliparous women were studied using simultaneous 3D ultrasound
This video introduces a 3D high-resolution manometry (HRM) system to the field of urogynecology. ... more This video introduces a 3D high-resolution manometry (HRM) system to the field of urogynecology. We demonstrate how to obtain and interpret dynamic urethral pressures with this measurement system and use it to evaluate pre- and postoperative women. The 3D HRM catheter is ∼12 F; 11 cm of its length has pressure sensors with eight circumferentially distributed pressure-sensitive segments that collect and transmit individual pressure measurements to construct a 3D pressure map. In this video, we demonstrate the output display of the 3D HRM measurement system. Pressure output maps are shown for one woman with stress urinary incontinence (SUI) and one with a history of SUI who underwent successful midurethral sling insertion. We also show a summary of 3D pressure-measurement patterns of 44 women who underwent pressure measurements to evaluate qualitatively the 3D pressure profile of the urethra in an effort to better understand pelvic floor and urethral sphincter physiology. Advanced HRM technology to measure urethral pressures under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism in continent and incontinent women and after continence surgeries.
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Papers by Charles Nager