Assessment of First-Trimester Utero-Placental Vascular Morphology by 3D Power Doppler Ultrasound Image Analysis Using a Skeletonization Algorithm: The Rotterdam Periconception Cohort

Abstract

The increasing proportion of elderly Americans has brought about an anticipation of 50% rise in prolapse surgeries by 2050. It is anticipated that 25% to 40% of patients undergoing surgeries will develop de novo stress urinary incontinence (SUI) after prolapse repair. The Outcomes Following Vaginal Prolapse Repair with Midurethral Sling (OPUS) found a 36% reduction in the risk for de novo SUI, but also demonstrated increased risk of bladder perforations, urinary tract infections, and incomplete bladder emptying symptoms (N Engl J Med. 2012;366:2358-2367. As a result, pelvic reconstructive surgeons often vary their approach toward prophylactic MUS at the time of vaginal prolapse repair (VPR). Although a cost-effectiveness analysis found universal MUS placement to be the most cost-effective strategy over both selective and staged strategies (J Urol. 2013;190:1306-1312, this analysis did not include an arm for the less-costly option of using a selective approach via a prolapse-reduced cough stress test (CST). In addition, Richardson analysis of patients undergoing sacral colpopexy lacks generalizability for VPR surgeries (which account for two thirds of all prolapse surgeries). The manuscript described here therefore tested the cost-effectiveness of 3 generalizable MUS utilization strategies for preventing de novo SUI within 1 year post-VPR.Three approaches were compared: (1) staged strategy performing VPR with later MUS placement only for de novo SUI;(2) universal sling placement at the time of VPR; and (3) selective sling placement with MUS at the time of VPR when occult SUI was observed at the time of preoperative prolapse-reduced CST. A representative population of women with symptomatic pelvic organ prolapse (at least stage II) was modeled. Included in the VPR model was colpocleisis, apical suspension, or anterior colporrhaphy, with or without hysterectomy. The base assumption was that all VPRs were uncomplicated and anatomically successful. Subsequent treatment pathways were formed based on the 3 aforementioned options if de novo SUI was to occur.A 2017 systematic review by van der Ploeg was used for obtaining literature to gain point estimates concerning the risk for postoperative SUI (Int Urogynecol J. 2016;27:1029-1038). The search was performed via PubMed through January 2017, and exclusionary criteria were as follows: studies examining urodynamics preoperatively, abdominal prolapse repairs, duplicate studies, and studies lacking clear definitions for VPR, MUS, or SUI. Using data from 3 previous studies, for a selective MUS, the authors estimated the rate of de novo SUI after VPR with a negative preoperative CST to be 33.6%. The authors determined the existence of 4 possible adverse outcomes following MUS: (1) persistent SUI, (2) sling lysis required for voiding dysfunction, (3) mesh exposure requiring excision, and (4) anticholinergic medications required for de novo overactive bladder. Information on costs was gathered Physician Fee Schedules from the 2020 Centers for Medicare and Medicaid Services. Incr...