Alexandriah Nicole Alas, MD

All Publications

• Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review. Obstetrics and gynecology Casiano Evans, E. A., Hobson, D. T., Aschkenazi, S. O., Alas, A. N., Balgobin, S., Balk, E. M., Dieter, A. A., Kanter, G., Orejuela, F. J., Sanses, T. V., Rahn, D. D. 2023; 142 (3): 555-570

  Abstract

  To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM).MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators.We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group.Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function.Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.

  View details for DOI 10.1097/AOG.0000000000005288

  View details for PubMedID 37543737

• Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review. Obstetrics and gynecology Gupta, A., Balk, E. M., Lenger, S. M., Yang, L. C., Misal, M., Balgobin, S., Chang, O. H., Sharma, V., Stuparich, M., Behbehani, S., Nihira, M., Alas, A., Jampa, A., Sheyn, D., Meriwether, K., Antosh, D. D. 2023; 142 (2): 319-329

  Abstract

  To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms.PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans.Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible.Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature.Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures.PROSPERO, CRD42021272678.

  View details for DOI 10.1097/AOG.0000000000005260

  View details for PubMedID 37411023

• Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review. Obstetrics and gynecology Doyle, P. J., Grimes, C. L., Balk, E. M., Wieslander, C., Richardson, M., Mamik, M. M., Sleemi, A., Alas, A., Kudish, B., Walter, A. J., Aschkenazi, S., Mama, S., Foda, M., Meriwether, K. V. 2022; 139 (2): 277-286

  Abstract

  To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications.A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal.All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible.We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent.Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed.PROSPERO, CRD 42018093099.

  View details for DOI 10.1097/AOG.0000000000004646

  View details for PubMedID 34991142

• Sexual function after pelvic organ prolapse surgery: a systematic review comparing different approaches to pelvic floor repair. American journal of obstetrics and gynecology Antosh, D. D., Dieter, A. A., Balk, E. M., Kanter, G., Kim-Fine, S., Meriwether, K. V., Mamik, M. M., Good, M. M., Singh, R., Alas, A., Foda, M. A., Rahn, D. D., Rogers, R. G. 2021; 225 (5): 475.e1-475.e19

  Abstract

  Women consider preservation of sexual activity and improvement of sexual function as important goals after pelvic organ prolapse surgery. This systematic review aimed to compare sexual activity and function before and after prolapse surgery among specific approaches to pelvic organ prolapse surgery including native tissue repairs, transvaginal synthetic mesh, biologic grafts, and sacrocolpopexy.MEDLINE, Embase, and ClinicalTrials.gov databases were searched from inception to March 2021.Prospective comparative cohort and randomized studies of pelvic organ prolapse surgeries were included that reported the following specific sexual function outcomes: baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Notably, the following 4 comparisons were made: transvaginal synthetic mesh vs native tissue repairs, sacrocolpopexy vs native tissue repairs, transvaginal synthetic mesh vs sacrocolpopexy, and biologic graft vs native tissue repairs.Studies were double screened for inclusion and extracted for population characteristics, sexual function outcomes, and methodological quality. Evidence profiles were generated for each surgery comparison by grading quality of evidence for each outcome across studies using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.Screening of 3651 abstracts was performed and identified 77 original studies. The overall quality of evidence was moderate to high. There were 26 studies comparing transvaginal synthetic mesh with native tissue repairs, 5 comparing sacrocolpopexy with native tissue repairs, 5 comparing transvaginal synthetic mesh with sacrocolpopexy, and 7 comparing biologic graft with native tissue repairs. For transvaginal synthetic mesh vs native tissue repairs, no statistical differences were found in baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, persistent dyspareunia, and de novo dyspareunia. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form change scores were not different between transvaginal synthetic mesh and native tissue repairs (net difference, -0.3; 95% confidence interval, -1.4 to 0.8). For sacrocolpopexy vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, de novo dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form score differences were not different. For biologic graft vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form changes were also not different. For transvaginal synthetic mesh vs sacrocolpopexy, there was no difference in sexual activity and sexual function score change. Based on 2 studies, postoperative total dyspareunia was more common in transvaginal synthetic mesh than sacrocolpopexy (27.5% vs 12.2%; odds ratio, 2.72; 95% confidence interval, 1.33-5.58). The prevalence of postoperative dyspareunia was lower than preoperative dyspareunia after all surgery types.Sexual function comparisons are most robust between transvaginal synthetic mesh and native tissue repairs and show similar prevalence of sexual activity, de novo dyspareunia, and sexual function scores. Total dyspareunia is higher after transvaginal synthetic mesh than sacrocolpopexy. Although sexual function data are sparse in the other comparisons, no other differences in sexual activity, dyspareunia, and sexual function score change were found.

  View details for DOI 10.1016/j.ajog.2021.05.042

  View details for PubMedID 34087227

• International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain. International urogynecology journal Harvey, M. A., Chih, H. J., Geoffrion, R., Amir, B., Bhide, A., Miotla, P., Rosier, P. F., Offiah, I., Pal, M., Alas, A. N. 2021; 32 (10): 2575-2594

  Abstract

  This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP.An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category.The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies.The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.

  View details for DOI 10.1007/s00192-021-04941-5

  View details for PubMedID 34338825

  View details for PubMedCentralID 4498030

• Relationship of postoperative vaginal anatomy and sexual function: a systematic review with meta-analysis. International urogynecology journal Kim-Fine, S., Antosh, D. D., Balk, E. M., Meriwether, K. V., Kanter, G., Dieter, A. A., Mamik, M. M., Good, M., Singh, R., Alas, A., Foda, M., Rahn, D. D., Rogers, R. G. 2021; 32 (8): 2125-2134

  Abstract

  This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018.The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes.We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12.Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery.

  View details for DOI 10.1007/s00192-021-04829-4

  View details for PubMedID 33988785

  View details for PubMedCentralID 4174312

• Comparison of Methods to Identify Stress Urinary Incontinence in Women With Pelvic Organ Prolapse. Female pelvic medicine & reconstructive surgery Martin, L., Ossin, D., Schachar, J., Devakumar, H., Alas, A., Davila, G. W., Reis, I. M., Miao, F., Hurtado, E. 2021; 27 (1): e127-e132

  Abstract

  The aim of the study was to compare which test is most sensitive in identifying stress urinary incontinence (SUI) in women with pelvic organ prolapse using urodynamics (UDS) as the criterion standard: cough stress test (CST) or pyridium pad test.This was a prospective study of women with pelvic organ prolapse stage II or greater who desired surgical management for prolapse. Each patient underwent preoperative urinary testing: UDS, CST, and a 24-hour pyridium pad test.A total of 84 patients were analyzed. Using UDS as the criterion standard, both the CST and the pyridium pad test showed a fair agreement with UDS outcomes (κ = 0.27 for both tests). There was no statistically significant difference between the CST and the pyridium pad test, with estimated sensitivities of 34.4% versus 40.6% (P = 0.791), specificities of 90.4% versus 84.6% (P = 0.508). The pyridium pad test was found to have a statistically significant difference in identifying the subjective complaint of SUI (38.6%, P = 0.003) compared with other tests. Patients with occult incontinence were identified 42.5%, 17.5%, and 10% of the time during UDS, CST, and pyridium pad testing, respectively.Our data suggest that the sensitivities of the CST and pyridium pad test for stress incontinence and occult stress incontinence in patients with pelvic organ prolapse are low when compared with UDS as the criterion standard. Urodynamics has an important role in preoperative identification of occult SUI.

  View details for DOI 10.1097/SPV.0000000000000858

  View details for PubMedID 33369965

• Changes in Sexual Activity and Function After Pelvic Organ Prolapse Surgery: A Systematic Review. Obstetrics and gynecology Antosh, D. D., Kim-Fine, S., Meriwether, K. V., Kanter, G., Dieter, A. A., Mamik, M. M., Good, M., Singh, R., Alas, A., Foda, M. A., Balk, E. M., Rahn, D. D., Rogers, R. G. 2020; 136 (5): 922-931

  Abstract

  We aimed to systematically review the literature to describe sexual activity and function before and after prolapse surgery.We searched MEDLINE, EMBASE, and ClinicalTrials.gov databases from inception to April 2018.Prospective, comparative studies of reconstructive pelvic organ prolapse (POP) surgeries that reported sexual function outcomes were included. Studies were extracted for population characteristics, sexual function outcomes, and methodologic quality. Data collected included baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Change in validated scores were used to categorize overall sexual function as improved, unchanged, or worsened after surgery.The search revealed 3,124 abstracts and identified 74 articles representing 67 original studies. The overall quality of evidence was moderate to high. Studies reporting postoperative results found higher rates of sexual activity than studies reporting preoperative sexual activity in all POP surgeries except sacrospinous suspension, transvaginal mesh, and sacrocolpopexy. The prevalence of dyspareunia decreased after all prolapse surgery types. The risk of de novo dyspareunia ranged from 0% to 9% for all POP surgeries except posterior repair, which lacked sufficient data. Overall sexual function based on PISQ-12 (Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12) scores improved for mixed native tissue repairs, anterior repairs, uterosacral suspensions, sacrospinous suspensions, and sacrocolpopexy; scores were similar for posterior repairs, transvaginal mesh, and biologic grafts. Sexual function did not worsen after any POP surgeries.Sexual function improves or remains unchanged after all types of reconstructive POP surgeries and does not worsen for any surgery type. Prevalence of total dyspareunia was lower after all POP surgery types, and de novo dyspareunia was low ranging 0-9%. This information can help surgeons counsel patients preoperatively.PROSPERO, CRD42019124308.

  View details for DOI 10.1097/AOG.0000000000004125

  View details for PubMedID 33030874

• Anesthetics' role in postoperative urinary retention after pelvic organ prolapse surgery with concomitant midurethral slings: a randomized clinical trial. International urogynecology journal Alas, A., Martin, L., Devakumar, H., Frank, L., Vaish, S., Chandrasekaran, N., Davila, G. W., Hurtado, E. 2019

  Abstract

  Spinal anesthesia can be a potential risk factor for postoperative urinary retention (POUR). Our objective was to compare POUR rates for outpatient vaginal pelvic floor surgeries when using spinal versus general anesthesia. Our hypothesis was that spinal anesthesia would have higher POUR rates compared with general anesthesia.This was a randomized clinical trial on subjects undergoing outpatient pelvic organ prolapse (POP) surgery with a concomitant midurethral sling (MUS). Subjects were discharged home the same day as surgery. Subjects were excluded if they had a preoperative post-void residual > 150 ml, they were < 40 years of age, surgery was < 1 h, or they had contraindications to spinal or general anesthesia. A standardized voiding trial was performed. The primary aim was to compare POUR rates between anesthesia groups. A power analysis estimated 28 subjects were required per group to detect a 37% difference with 80% power and an alpha of 0.05.The trial was registered at ClinicalTrials.gov on July 15, 2015. Sixty-one subjects were enrolled between June 22, 2015, and December 31, 2017. Three were excluded, leaving 29 in each group. Groups were similar in demographics. For the primary outcome, there was a 14.3% difference in POUR rates between spinal and general anesthesia, which did not reach statistical significance based on our power calculation (p = 0.2516).Based on this study, there is not an increased rate of POUR with the use of spinal anesthesia for POP surgery with MUS. However, since there was a trend toward higher rates of POUR in the spinal group, it is possible that a larger powered study design would be able to detect a statistically significant difference between the groups. Based on these findings, if surgical patients would benefit from spinal anesthesia, the risk of urinary retention should not be considered a reason to not utilize this form of anesthesia.Does spinal anesthesia for prolapse surgery with concomitant sling lead to an increase in urinary retention compared to general anesthesia? https://clinicaltrials.gov/ct2/show/NCT02547155?term=laura+martin&rank=3 (NCT02547155).

  View details for DOI 10.1007/s00192-019-03917-w

  View details for PubMedID 30904934

• Does spinal anesthesia lead to postoperative urinary retention in same-day urogynecology surgery? A retrospective review. International urogynecology journal Alas, A., Hidalgo, R., Espaillat, L., Devakumar, H., Davila, G. W., Hurtado, E. 2019

  Abstract

  Spinal anesthesia has been reported to be a risk factor for postoperative urinary retention (POUR) in various surgical specialties. We hypothesized that spinal anesthesia was a risk factor for POUR after outpatient vaginal surgery for pelvic organ prolapse (POP).This was a retrospective review of an urogynecology database for all outpatient POP vaginal surgeries performed in 2014 to evaluate the risk of POUR after general versus spinal anesthesia. A standardized voiding trial was performed by backfilling the bladder with 300 ml of saline. A successful trial was achieved if the patient voided two-thirds of the total volume instilled, confirmed by bladder ultrasound. Our primary outcome was to compare POUR requiring discharge with a Foley catheter between spinal and general anesthesia. Multivariate logistic regression was performed for variables with significance at p < 0.1 at the bivariate level.A total of 177 procedures were included, 126 with general and 51 with spinal anesthesia. The overall POUR rate was 48.9%. Type of anesthesia was not a risk factor for POUR. Multivariate logistic regression demonstrated that age < 55 years (adjusted odds ratio [OR] 3.73; 95% confidence interval [CI], 1.31-11.7), diabetes (adjusted OR 4.18, 95% CI 1.04-21.67), and having a cystocele ≥ stage 2 (adjusted OR 4.23, 95% CI 1.89-10) were risk factors for developing POUR.Acute urinary retention after outpatient vaginal pelvic floor surgery can vary by procedure, but overall is 48.9%. Spinal anesthesia does not contribute to POUR, but rates are higher in those women that are younger than 55 years of age, have a cystocele ≥ stage 2 preoperatively, and a history of diabetes.

  View details for DOI 10.1007/s00192-019-03893-1

  View details for PubMedID 30810782

• Countdown to CREOG Series: Geriatric Care Song , J., Alas , A. acog. 2019
• Advanced uterovaginal prolapse: is vaginal hysterectomy with McCall culdoplasty as effective as in lesser degrees of prolapse? International urogynecology journal Alas, A., Chandrasekaran, N., Devakumar, H., Martin, L., Hurtado, E., Davila, G. W. 2018; 29 (1): 139-144

  Abstract

  There is a paucity of data on the success of vaginal surgery for severe prolapse. The authors hypothesized that the success rates of total vaginal hysterectomy (TVH) with McCall culdoplasty in women with advanced pelvic organ prolapse (POP) and in women with less severe POP are similar.This was a retrospective review of women undergoing TVH with McCall culdoplasty from 2005 to 2014. Advanced POP was defined as exteriorized uterovaginal prolapse with Pelvic Organ Prolapse Quantification (POP-Q) point C, Ba or Bp ≥50% of the total vaginal length. The primary aim was to compare surgical success of TVH with McCall culdoplasty for the repair of advanced POP and less severe POP at ≥1 year.A total of 311 women were included, 38 with advanced POP and 273 with less severe POP. Women with advanced POP were older (71.6 vs. 61.8 years, respectively; p < 0.0001), but there were no significant differences in the length of follow-up (102.5 vs. 117 weeks, p = 0.2378), success rates (76.3% vs. 68.5%, p = 0.3553) or reoperation rates (2.6% vs. 4%, p > 0.9999) between women with advanced POP and less severe POP, respectively. There was a higher failure rate in the anterior compartment in those with advanced POP (18.4% vs. 6.2%, p = 0.0168), but not in the apical or posterior compartment.TVH with McCall culdoplasty is equally effective for the treatment of advanced uterovaginal prolapse as for the treatment of less severe POP. Surgeons should consider this traditional surgery for their patients even if they have high-stage uterovaginal prolapse.

  View details for DOI 10.1007/s00192-017-3436-y

  View details for PubMedID 28779416

• Resolution of Rectal Prolapse by Vaginal Reconstruction. Female pelvic medicine & reconstructive surgery Devakumar, H., Chandrasekaran, N., Alas, A., Martin, L., Davila, G. W., Hurtado, E. 2017; 23 (1): e4-e7

  Abstract

  Rectal prolapse is a disorder of the pelvic floor in which the layers of the rectal mucosa protrude outward through the anus. Surgical repair is the mainstay of treatment. Options include intra-abdominal procedures such as rectopexy and perineal procedures such as the Delorme and Altemeier perineal rectosigmoidectomy. Rectal and vaginal prolapse can often coexist. However, to our knowledge, there are no reported cases of rectal prolapse resolved by the repair of a compressive enterocele abutting the anterior rectal wall through a vaginal approach alone. We present a novel case of rectal prolapse that resolved by correction of the vaginal defect.A 53-year-old female with prior history of abdominal hysterectomy, presented to the urogynecology clinic with complaints of vaginal bulge, urge urinary incontinence, and rectal bulge on straining with no fecal incontinence for several years. On physical examination, she was found to have stage 2 anterior, posterior, and apical vaginal prolapse and reducible rectal prolapse. Colorectal surgery (CRS) evaluation was requested, which revealed minimal anterior mucosal prolapse on Valsalva with no full-thickness prolapse. Magnetic resonance imaging (MRI) defecogram was performed, which demonstrated a large rectocele, enterocele, and small bowel prolapsing between the rectum and vagina during the evacuation phase, with no rectal prolapse. The decision to proceed with vaginal prolapse surgery without concomitant rectal prolapse repair was made, as the patient had no fecal incontinence, and the degree of rectal prolapse was minimal. On the day of surgery, which was 2 months later, she presented with a 2-cm anterior rectal prolapse with no incontinence. Colorectal surgery was consulted again, but unavailable. After counseling, the patient wished to proceed with her planned surgery. It was felt that correcting the anterior rectocele and enterocele, thereby eliminating the descent of the bowel on the anterior rectal wall, might cause resolution of the rectal prolapse. She then underwent a sacrospinous ligament fixation with mesh through an anterior vaginal approach, enterocele repair, Moschcowitz culdoplasty, and posterior colporraphy. She had an uneventful postoperative course and noted resolution of both vaginal and rectal prolapse. At 54 weeks, she continues without any complaints of rectal prolapse, which was confirmed on physical examination.Usually, the choice of surgical approach is tailored to each individual based on anatomy, age, comorbidity, and patient factors. Correcting both vaginal and rectal prolapse at the same time with a minimally invasive approach is an advantage to the patient. Restoring the apical, anterior, and posterior vaginal wall anatomy and an enterocele repair through the vaginal route caused resolution of the rectal prolapse. Further research is required as to whether rectal prolapse caused by anterior rectal compression needs an additional procedure or repair of the vaginal prolapse and enterocele alone will suffice.

  View details for DOI 10.1097/SPV.0000000000000354

  View details for PubMedID 27898453

• De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence. International urogynecology journal Alas, A. N., Chinthakanan, O., Espaillat, L., Plowright, L., Davila, G. W., Aguilar, V. C. 2017; 28 (4): 583-590

  Abstract

  There is a paucity of data evaluating the risk of de novo stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) in women with no preoperative occult SUI. We hypothesized that apical suspension procedures would have higher rates of de novo SUI.This was a retrospective database review of women who had surgery for POP from 2003 to 2013 and developed de novo SUI at ≥6 months postoperatively. Preoperatively, all patients had a negative stress test and no evidence of occult SUI on prolapse reduction urodynamics. The primary objective was to establish the incidence of de novo SUI in women with no objective evidence of preoperative occult SUI after POP surgeries at ≥6 months.A total number of 274 patients underwent POP surgery. The overall incidence of de novo SUI was 9.9 % [95 % confidence interval (CI) 0.07-0.14]. However, the incidence of de novo SUI in those with no baseline complaint of SUI was 4.4 % (95 % CI 0.03-0.1). There was no difference in de novo SUI rates between apical [9.7 % (n = 57)] and nonapical [10.5 %, (n = 217] procedures (p = 0.8482). Multivariate logistic regression identified sacrocolpopexy [adjusted odds ratio (OR) 4.54, 95 % CI 1.2-14.7] and those with a baseline complaint of SUI (adjusted OR 5.1; 95 % CI 2.2-12) as risk factors for de novo SUI.The incidence of de novo SUI after surgery for POP without occult SUI was 9.9 %. We recommend counseling patients about the risk of de novo SUI and offering a staged procedure.

  View details for DOI 10.1007/s00192-016-3149-7

  View details for PubMedID 27678145

• Transvaginal Repair of Complex Rectovaginal Fistulas Using the Porcine Urinary Bladder Matrix as an Augmenting Graft. Female pelvic medicine & reconstructive surgery Devakumar, H., Chandrasekaran, N., Alas, A., Martin, L., Davila, G. W., Hurtado, E. 2017; 23 (3): e25-e28

  Abstract

  After the US Food and Drug Administration issued a safety warning concerning vaginal mesh implants in 2008, their use in correction of pelvic floor defects have decreased in the United States (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm). However, we are still treating patients who have had complications associated with their use, rectovaginal fistulas (RVFs) being one of them. Rectovaginal fistulas are considered complex if greater than 2.5 cm, recurrent, associated with inflammatory bowel disease, or if they are proximal in location. Various surgical techniques have been described for treating RVFs. Interposition grafts such as Martius, gracilis, omental J flaps, and rectus abdominis flaps have been used extensively in correcting RVFs (Am J Gastroenterol 2014;109(8):1141-1157). However, these techniques may increase morbidity or have poor cosmesis. Pelvic surgeons have chronicled the use of biologic grafts for fistula repair. Of the various biologic grafts in use, there have been no reports describing the use of porcine urinary bladder matrix (UBM) for fistula repair. We report on 2 cases of large, complex RVFs secondary to mesh erosion, which were effectively treated with transvaginal repair using the UBM.An 80-year-old woman was referred by the colorectal service to our urogynecology service with complaints of rectal bleeding and vaginal spotting secondary to mesh erosion. Surgical history included hysterectomy with mesh augmented posterior repair with synthetic midurethral sling placement in 2002. Examination revealed a 3-cm mesh exposure located in the middle third of the posterior vaginal wall. On rectovaginal examination, a 3-cm full-thickness RVF with through-and-through mesh erosion was noted between the rectum and vagina.A 65-year-old woman presented to our service with complaints of passage of fecal material through the vagina. Surgical history was significant for hysterectomy in 1988 and prolapse repair with anterior and posterior vaginal mesh in 2009. Subsequently in 2011, she had part of the mesh removed because of exposure. Vaginal examination revealed mesh exposure at the right sulcus of the anterior wall consistent with evidence of prior sling and another mesh exposure on the posterior vaginal wall. Rectovaginal examination revealed palpable mesh in the rectovaginal septum with a 3-cm large and complex fistula. Both of our patients underwent transvaginal excision of mesh, RVF repair, and posterior repair with augmentation with UBM. At 6- and 10-month follow-up, they reported complete resolution of their symptoms with no fistula noted on physical examination.Typically, traditional repair with use of muscular advancement flaps is performed for complex RVF closures. Recently, however, various biologic agents have been successfully used to augment RVF repair. In our cases, the use of UBM led to successful follow-up at 6 to 8 months. Despite existing literature, there remains a void in the depth of knowledge regarding the UBM grafts. Larger studies utilizing it for repair of RVFs are warranted to further understand the success and effectiveness of the UBM grafts for RVF repair.

  View details for DOI 10.1097/SPV.0000000000000410

  View details for PubMedID 28277472

• The Quality of Care Provided to Women with Urinary Incontinence in 2 Clinical Settings. The Journal of urology Anger, J. T., Alas, A., Litwin, M. S., Chu, S. D., Bresee, C., Roth, C. P., Rashid, R., Shekelle, P., Wenger, N. S. 2016; 196 (4): 1196-200

  Abstract

  Our aim was to test the feasibility of a set of quality of care indicators for urinary incontinence and at the same time measure the care provided to women with urinary incontinence in 2 clinical settings.This was a pilot test of a set of quality of care indicators. A total of 20 quality of care indicators were previously developed using the RAND Appropriateness Method. These quality of care indicators were used to measure care received for 137 women with a urinary incontinence diagnosis in a 120-physician hospital based multispecialty medical group. We also performed an abstraction of 146 patient records from primary care offices in Southern California. These charts were previously used as part of ACOVE (Assessing Care of Vulnerable Elders Project). As a post-hoc secondary analysis, the 2 populations were compared with respect to quality, as measured by compliance with the quality of care indicators.In the ACOVE population, 37.7% of patients with urinary incontinence underwent a pelvic examination vs 97.8% in the multispecialty medical group. Only 15.6% of cases in the multispecialty medical group and 14.2% in ACOVE (p = 0.86) had documentation that pelvic floor exercises were offered. Relatively few women with a body mass index of greater than 25 kg/m(2) were counseled about weight loss in either population (20.9% multispecialty medical group vs 26.1% ACOVE, p = 0.76). For women undergoing sling surgery, documentation of counseling about risks was lacking and only 9.3% of eligible cases (multispecialty medical group only) had documentation of the risks of mesh.Quality of care indicators are a feasible means to measure the care provided to women with urinary incontinence. Care varied by population studied and yet deficiencies in care were prevalent in both patient populations studied.

  View details for DOI 10.1016/j.juro.2016.05.005

  View details for PubMedID 27164512

  View details for PubMedCentralID PMC5067158

• Apical sling: an approach to posthysterectomy vault prolapse. International urogynecology journal Alas, A. N., Pereira, I., Chandrasekaran, N., Devakumar, H., Espaillat, L., Hurtado, E., Davila, G. W. 2016; 27 (9): 1433-6

  Abstract

  This video demonstrates a transvaginal technique for vaginal vault suspension using an apical sling suspended from the sacrospinous ligaments.This was a retrospective review of apical sling procedures performed from July 2013 to November 2014. The technique is started by marking the vaginal apex. A posterior dissection is performed and the sacrospinous ligaments are identified after dissection into the pararectal space. A 10-cm piece of monofilament, inelastic polypropylene tape is attached to the underside of the vaginal apex. Polypropylene sutures are placed into the sacrospinous ligament and threaded though the lateral edges of the apical sling and tied down, restoring apical support. Finally, the vaginal epithelium is closed.A total of 67 women underwent an apical sling procedure with 70 % (47/67) completing 6 months follow-up. The subjective cure rate ("cured" or "greatly improved") was 78.7 % and the objective cure rate (anatomical success, defined as apical prolapse stage ≤1) was 100 % (47 patients).Our apical sling sacrospinous ligament fixation approach is a unique, minimal mesh approach using a tape commonly used for midurethral slings to suspend the vaginal apex. We achieved high anatomical success and patient satisfaction.

  View details for DOI 10.1007/s00192-016-3010-z

  View details for PubMedID 27052327

• EA Intraoperative Cystoscopic Evaluation of Ureteral Patency: A Randomized Controlled Trial Espaillat-Rijo , L., Siff , L., Alas , A., Chadi , S., Zimberg , S., Vaish , S., Davila , G., Barber , M., Hurtado , E. Obstet Gynecol. . 2016
• Health Care Disparities Among English-Speaking and Spanish-Speaking Women With Pelvic Organ Prolapse at Public and Private Hospitals: What Are the Barriers? Alas , A., Dunivan , G., Wieslander , C., Sevilla , C., Barrera , B., Rashid , R., Maliski , S., Eilber , K., Rogers , R., Anger , J. Female Pelvic Med Reconstr Surg. 2016
• Same-day surgery for pelvic organ prolapse and urinary incontinence: Assessing satisfaction and morbidity Perioperative Care and Operating Room Management Alas , A., Espaillat , L., Plowright , L., Aguilar , V., Davila , G. 2016
• Are suburethral slings less successful in the elderly? Alas , A., Chinthakanan , O., Espaillat , L., Plowright , L., Aguilar , V., Davila, G. Int Urogynecol J. 2016
• Management of apical pelvic organ prolapse. Current urology reports Alas, A. N., Anger, J. T. 2015; 16 (5): 33

  Abstract

  Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery.• Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10]. • Pessaries should be managed with regular follow-up care to minimize complications [14•]. • Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•]. • Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•]. • Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy. • Obliterative procedures are effective but are considered definitive surgery [24••]. • The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.

  View details for DOI 10.1007/s11934-015-0498-6

  View details for PubMedID 25874589

• Misconceptions and miscommunication among Spanish-speaking and English-speaking women with pelvic organ prolapse. International urogynecology journal Wieslander, C. K., Alas, A., Dunivan, G. C., Sevilla, C., Cichowski, S., Maliski, S., Eilber, K., Rogers, R. G., Anger, J. T. 2015; 26 (4): 597-604

  Abstract

  Limited data exist on women's experience with pelvic organ prolapse (POP) symptoms. We aimed to describe factors that prevent disease understanding among Spanish-speaking and English-speaking women.Women with POP were recruited from female urology and urogynecology clinics in Los Angeles, California, and Albuquerque, New Mexico. Eight focus groups were conducted, four in Spanish and four in English. Topics addressed patients' emotional responses when noticing their prolapse, how they sought support, what verbal and written information was given, and their overall feelings of the process. Additionally, patients were asked about their experience with their treating physician. All interview transcripts were analyzed using grounded theory qualitative methods.Qualitative analysis yielded two preliminary themes. First, women had misconceptions about what POP is as well as its causes and treatments. Second, there was a great deal of miscommunication between patient and physician which led to decreased understanding about the diagnosis and treatment options. This included the fact that women were often overwhelmed with information which they did not understand. The concept emerged that there is a strong need for better methods to achieve disease and treatment understanding for women with POP.Our findings emphasize that women with POP have considerable misconceptions about their disease. In addition, there is miscommunication during the patient-physician interaction that leads to further confusion among Spanish-speaking and English-speaking women. Spending more time explaining the diagnosis of POP, rather than focusing solely on treatment options, may reduce miscommunication and increase patient understanding.

  View details for DOI 10.1007/s00192-014-2562-z

  View details for PubMedID 25516231

  View details for PubMedCentralID PMC4550586

• The quality of care provided to women with pelvic organ prolapse: an infrastructure for quality assessment Alas , A., Bresee , C., Eilber , K., Rashid , R., Roth , C., Shekelle , P., Wenger , N., Anger , J. Am J Obstet Gynecol. 2015
• Is postpartum urinary retention a neurogenic phenomenon? Alas , A., Hurtado , A. Curr Bladder Dysfunct Rep. 2015
• Role of apical support defect: correction in women undergoing vaginal prolapse surgery. Current opinion in obstetrics & gynecology Alas, A. N., Anger, J. T. 2014; 26 (5): 386-92

  Abstract

  The aim was to review most recent literature and provide updates in clinical management and surgical treatment of apical pelvic organ prolapse.In patients who decline surgical intervention, formal referral to pelvic floor muscle training is beneficial over self-directed Kegel exercises. Systematic reviews revealed that sacrocolpopexy has better long-term outcomes than vaginal approaches. Uterosacral ligament suspension and sacrospinous ligament suspension have equal efficacy at 1 year. These procedures should be considered as acceptable alternatives to sacrocolpopexy. Two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy.Minimally invasive sacrocolpopexy should be considered the gold standard for apical prolapse, but these techniques are associated with longer operating times and higher complication rates and longer convalescence than nonmesh vaginal surgery. Surgeons must individualize surgical technique for each patient and should consider a vaginal approach in patients who do not desire laparotomy and are not candidates for minimally invasive surgery.

  View details for DOI 10.1097/GCO.0000000000000105

  View details for PubMedID 25136761

• Pelvic organ prolapse: a disease of silence and shame. Female pelvic medicine & reconstructive surgery Dunivan, G. C., Anger, J. T., Alas, A., Wieslander, C., Sevilla, C., Chu, S., Maliski, S., Barrera, B., Eiber, K., Rogers, R. G. 2014; 20 (6): 322-7

  Abstract

  The objectives of this study are to better understand women's experience with pelvic organ prolapse (POP) and to compare this experience between English-speaking and Spanish-speaking women.Women with POP were recruited from female urology and urogynecology clinics. Eight focus groups of 6 to 8 women each were assembled-4 groups in English and 4 in Spanish. A trained bilingual moderator conducted the focus groups. Topics addressed patients' perceptions, their knowledge and experience with POP symptoms, diagnostic evaluation, physician interactions, and treatments.Both English-speaking and Spanish-speaking women expressed the same preliminary themes-lack of knowledge regarding the prevalence of POP, feelings of shame regarding their condition, difficulty in talking with others, fear related to symptoms, and emotional stress from coping with POP. In addition, Spanish-speaking women included fear related to surgery and communication concerns regarding the use of interpreters. Two overarching concepts emerged-first, a lack of knowledge, which resulted in shame and fear and second, public awareness regarding POP is needed. From the Spanish speaking, an additional concept was the need to address language barriers and the use of interpreters.Both English-speaking and Spanish-speaking women felt ashamed of their POP and were uncomfortable speaking with anyone about it, including physicians. Educating women on the meaning of POP, symptoms, and available treatments may improve patients' ability to discuss their disorder and seek medical advice; for Spanish-speaking women, access to translators for efficient communication is needed.

  View details for DOI 10.1097/SPV.0000000000000077

  View details for PubMedID 25185629

  View details for PubMedCentralID PMC4213231

• Readability of common health-related quality-of-life instruments in female pelvic medicine. Female pelvic medicine & reconstructive surgery Alas, A. N., Bergman, J., Dunivan, G. C., Rashid, R., Morrisroe, S. N., Rogers, R. G., Anger, J. T. 2013; 19 (5): 293-7

  Abstract

  The average American adult reads below the eighth-grade level. To determine whether self-reported health-related quality-of-life questionnaires used for pelvic floor disorders are appropriate for American women, we measured reading levels of questionnaires for urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI).An online literature search identified questionnaires addressing UI, POP, and FI. Readability was assessed using Flesch-Kincaid reading level and ease formulas. Flesch-Kincaid grade level indicates the average grade one is expected to completely and lucidly comprehend the written text. Flesch-Kincaid reading ease score, from 0 to 100, indicates how easy the written text can be read.Questionnaires were categorized by UI, POP, FI, and combined pelvic floor symptoms. The median Flesch-Kincaid reading level was 7.2, 10.1, 7.6, and 9.7, for UI, POP, FI, and combined pelvic floor symptoms, respectively. Reading levels varied greatly between questionnaires, with only 54% of questionnaires written below the eighth-grade level.We identified significant variation in reading levels among the questionnaires and found the 2 most commonly used questionnaires per survey in 2008 at Society of Urodynamics and Female Pelvic Medicine and Urogenital Reconstruction were above the recommended eighth-grade reading level. As specialty societies focus on standardizing questionnaires for research, reading levels should be considered so they are generalizable to larger populations of women with pelvic floor disorders.

  View details for DOI 10.1097/SPV.0b013e31828ab3e2

  View details for PubMedID 23982579

  View details for PubMedCentralID PMC5063233

• The rapidly increasing usefulness of social media in urogynecology. Female pelvic medicine & reconstructive surgery Alas, A., Sajadi, K. P., Goldman, H. B., Anger, J. T. 2013; 19 (4): 210-3

  Abstract

  We assessed the availability and quality of urinary incontinence and pelvic organ prolapse information in social medias and the growth of such information in the past 13 months.We focused on the most popular social medias (Facebook, Twitter, and YouTube) to evaluate the key words "urogynecology," "pelvic organ prolapse," "stress incontinence," "urge incontinence," and "incontinence." Initial evaluation included top 30 search results for key word "incontinence" to compare with our study in 2010, followed by a secondary search using the top 100 items. Results were classified as useful or not useful and then further categorized by health care providers, others, commercial, or humorous in intent. Results with the intent of providing information were presumed to be informative.Comparative search over a 13-month period showed a stable amount of useful information, 40% to 39%, but an increase in the number of health professionals (22% vs 13%). However, of the 817 search results, 406 (50%) were medically useful. Only 28% were written by health professionals, but of the informative results, 56% were written by health professionals. Finally, specific search terms provided the highest relevant and useful information, but also limited the number of search items found.Over 13 months, there was an increase in useful information presented from health professionals. These changes may reflect the medical community's growing awareness of the usefulness of social media. If these trends continue, we predict the use of these medias for medical purposes will continue to increase among medical professionals.

  View details for DOI 10.1097/SPV.0b013e3182909872

  View details for PubMedID 23797519

• The pessary process: Spanish-speaking Latinas' experience. International urogynecology journal Sevilla, C., Wieslander, C. K., Alas, A., Dunivan, G., Khan, A., Maliski, S., Rogers, R., Anger, J. T. 2013; 24 (6): 939-46

  Abstract

  Little is known about women's experience with conservative management of pelvic organ prolapse. We sought to understand the experiences of Spanish-speaking women who choose a pessary.Spanish-speaking women from a urogynecological pessary clinic were recruited for this study. Interviews were conducted and the women were asked about their pessary experience including questions involving symptom relief, pessary management, and quality of life. All interview transcripts were analyzed using the qualitative methods of grounded theory.Sixteen Spanish-speaking women who had been using a pessary for at least 1 month were enrolled in this study. Grounded theory methodology yielded several preliminary themes, in which one major concept emerged as a pessary adjustment process. In this process patients had to first decide to use a pessary, either because of physician's recommendations or out of personal choice. Second, the patients entered an adjustment period in which they learned to adapt to the pessary, both physically and mentally. Lastly, if the patients properly adjusted to wearing a pessary they experienced relief of bothersome symptoms.Our findings demonstrate that Spanish-speaking women go through a process in order to adjust to a pessary. Furthermore, the physician plays a major role in not only determining a woman's decision to use a pessary, but also whether she can adjust to wearing the pessary. This process is most successful when patients receive comprehensive management from a healthcare team of physicians and nurses who can provide individualized and continuous pessary care.

  View details for DOI 10.1007/s00192-012-1946-1

  View details for PubMedID 23208002

  View details for PubMedCentralID PMC3857934

• Communication between physicians and Spanish-speaking Latin American women with pelvic floor disorders: a cycle of misunderstanding? Female Pelvic Med Reconstr Surg Sevilla , C., Wieslander , C., Alas , A., Dunivan , G., Khan , A., Maliski , S., Rogers , R., Anger , J. 2013
• Use of a Tissue Expander to Aid in Repeat Urethrolysis: A Case Report Female Pelvic Med Reconstr Surg Alas , A., Hall , C. 2012