Eric R. Sokol, MD

All Publications

• Abdominal sacral colpopexy versus sacrospinous ligament fixation: a cost-effectiveness analysis INTERNATIONAL UROGYNECOLOGY JOURNAL Ohno, M. S., Richardson, M. L., Sokol, E. R. 2016; 27 (2): 233-237

  Abstract

  For the surgical correction of apical prolapse the abdominal approach is associated with better outcomes; however, it is more expensive than the transvaginal approach. This cost-effectiveness analysis compares abdominal sacral colpopexy (ASC) with sacrospinous ligament fixation (SSLF) to determine if the improved outcomes of ASC justify the increased expense.A decision-analytic model was created comparing ASC with SSLF using data-modeling software, TreeAge Pro (2013), which included the following outcomes: post-operative stress urinary incontinence (SUI) with possible mid-urethral sling (MUS) placement, prolapse recurrence with possible re-operation, and post-operative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) of less than $50,000 per quality-associated life year (QALY). Base-case, threshold, and one-way sensitivity analyses were performed.At the baseline, ASC is more expensive than SSLF ($13,988 vs $11,950), but is more effective (QALY 1.53 vs 1.45) and is cost-effective (ICER $24,574/QALY) at 2 years. ASC was not cost-effective if the following four thresholds were met: the rate of post-operative SUI was above 36 % after ASC or below 28 % after SSLF; the rate of MUS placement for post-operative SUI was above 60 % after ASC or below 13 % after SSLF; the rate of recurrent prolapse was above 15 % after ASC or below 4 % after SSLF; the rate of post-operative dyspareunia was above 59 % after ASC or below 19 % after SSLF.Abdominal sacral colpopexy can be cost-effective compared with sacrospinous ligament fixation; however, as the post-operative outcomes of SSLF improve, SSLF can be considered a cost-effective alternative.

  View details for DOI 10.1007/s00192-015-2819-1

  View details for Web of Science ID 000370044300007

  View details for PubMedID 26282093

• Might Pelvic Surgeons Be Unaware of Their Surgical Failures? Patient Reporting and Perceptions After Failed Incontinence or Pelvic Organ Prolapse Surgery FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Elliott, C. S., Sokol, E. R. 2015; 21 (5): 298-300

  Abstract

  : Prior studies suggest that pelvic organ prolapse (POP) and stress urinary incontinence (SUI) may recur following surgery in 20% or more of patients. Despite these numbers, we have anecdotally found that some surgeons performing pelvic floor reconstruction feel their success rates exceed these figures. Based on our experience, we hypothesized that significant numbers of patients with recurrent POP or SUI following prior surgery do not return or notify their original surgeon of their recurrence. We also aimed to identify reasons why the patient was seeking care elsewhere.We investigated patients presenting to a tertiary referral center urogynecologic practice with recurrence after prior POP or SUI surgery over a 2-year period. Data were collected using an institutional review board-approved 15-item questionnaire and after 2 years were analyzed.We found that 16 (31%) of 51 patients did not notify their primary surgeon of surgical failure. Of these patients, roughly half (9/16) did not return because of moving to a different area of the country, changing their insurance, or their prior physician retiring. Despite the surgical failures, of all patients presenting to our clinic, very few stated they had a poor relationship with their prior surgeon (6%); however, a large majority (63%) did not think that their primary surgeon could fix their problem.Roughly one third of patients who suffer from recurrence after POP or SUI surgery do not notify their original surgeon. This may artificially inflate a clinician's perceived success rate of pelvic floor repair.

  View details for DOI 10.1097/SPV.0000000000000187

  View details for Web of Science ID 000360902600013

  View details for PubMedID 26197042

• A cost-effectiveness analysis of conservative versus surgical management for the initial treatment of stress urinary incontinence AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Richardson, M. L., Sokol, E. R. 2014; 211 (5)

  View details for DOI 10.1016/j.ajog.2014.07.006

  View details for Web of Science ID 000344470500045

• Efficacy and Safety of Polyacrylamide Hydrogel for the Treatment of Female Stress Incontinence: A Randomized, Prospective, Multicenter North American Study JOURNAL OF UROLOGY Sokol, E. R., Karram, M. M., Dmochowski, R. 2014; 192 (3): 843-849

  Abstract

  Bulkamid® is a new polyacrylamide hydrogel bulking agent for stress urinary incontinence that is injected in the urethral submucosa using a specifically designed device. We evaluated the safety and efficacy of Bulkamid vs Contigen® collagen gel for stress urinary incontinence or stress predominant mixed urinary incontinence.This was a single-blind, randomized, prospective, 33-center, 2-arm parallel study of hydrogel vs collagen gel with followup to 1 year. At baseline patients underwent physical examination and bladder testing, and completed quality of life questionnaires and bladder diaries. After randomization patients could receive up to 3 injections at 1-month intervals. Patients were assessed 3, 6, 9 and 12 months after bulking. They completed bladder diaries and quality of life questionnaires, and pad weight was tested. At the last visit Valsalva leak point pressure was measured. Subjective and objective incontinence outcomes and adverse events were compared.Of the 345 women 229 were randomized to hydrogel and 116 were randomized to collagen gel. At 12 months a 50% or greater decrease in leakage and incontinence episodes was seen in 53.2% and 55.4% of patients who received hydrogel and collagen gel, respectively. At 12 months 47.2% of patients with hydrogel and 50% with collagen gel reported zero stress incontinence episodes, and 77.1% and 70%, respectively, considered themselves cured or improved. Major adverse events were rare in each group.Bulkamid is not inferior to Contigen. It has a favorable, persistent effect on stress urinary incontinence with a low risk of serious adverse events. Bulkamid is a new, simple, office based bulking system that shows promise as a treatment in women with stress urinary incontinence, particularly since Contigen is no longer commercially available.

  View details for DOI 10.1016/j.juro.2014.03.109

  View details for Web of Science ID 000342105600062

  View details for PubMedID 24704117

• Improving the accuracy of prolapse and incontinence procedure epidemiology by utilizing both inpatient and outpatient data INTERNATIONAL UROGYNECOLOGY JOURNAL Elliott, C. S., Rhoads, K. F., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 24 (11): 1939-1946

  Abstract

  INTRODUCTION AND HYPOTHESIS: The epidemiologic description of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) procedures is documented in several large studies using national database cohorts. These studies, however, may underestimate the number of procedures performed because they only capture procedures performed in either the inpatient or outpatient settings alone. We present a complete annual description of all inpatient and outpatient surgeries for POP and SUI in California. METHODS: We reviewed a record of all inpatient and outpatient POP and SUI surgeries performed in California in 2008 using data from the Office of Statewide Health Planning (OSHPD). RESULTS: In 2008, 20,004 and 20,330 women in California underwent POP and SUI procedures, respectively. Of these, 3,134 (15.6 %) and 9,016 (44.3 %) were performed in an outpatient setting. The age-adjusted rates of POP and SUI were 1.20 and 1.20 per 1,000 US females, respectively. This correlates to 186,000 POP and 186,000 SUI procedures per year nationally. Vaginal apical suspensions were more common in those undergoing surgery as an inpatient (45.1 vs 19.4 %). The use of mesh to augment prolapse repairs was similar (22.3 % inpatient vs 19.3 % outpatient). SUI procedures performed in the outpatient setting were more likely to be performed as stand-alone procedures (82.9 vs 18.8 %, respectively). CONCLUSIONS: In California, 16 % of POP and 44 % of SUI procedures were performed in an outpatient surgical setting in 2008. Epidemiologic studies of POP and SUI should account for the fact that a substantial number of repairs are performed in the outpatient setting in order to achieve accuracy.

  View details for DOI 10.1007/s00192-013-2113-z

  View details for Web of Science ID 000325828800020

• To Sling or Not To Sling at Time of Abdominal Sacrocolpopexy: A Cost-Effectiveness Analysis JOURNAL OF UROLOGY Richardson, M. L., Elliott, C. S., Shaw, J. G., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 190 (4): 1306-1312

  Abstract

  OBJECTIVES: To compare the cost-effectiveness of three strategies for use of a mid-urethral sling (MUS) to prevent occult stress urinary incontinence (SUI) in those undergoing abdominal sacrocolpopexy (ASC). METHODS: Using decision-analysis modeling, we compared cost-effectiveness over a 1 year post-operative time period of three treatment approaches: 1) ASC alone with deferred option for MUS; 2) ASC with universal concomitant MUS; and 3) preoperative urodynamic study (UDS) for selective MUS. Using published data, we modeled probabilities of SUI after ASC with or without MUS, the predictive value of UDS to detect occult SUI, and the likelihood of complications after MUS. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost effectiveness ratio (ICER) per quality-adjusted life years (QALY) gained. In addition to base-case analysis, one-way sensitivity analyses were performed. RESULTS: In our model, universally performing MUS at the time of ASC was the most cost-effective approach, with an incremental cost per QALY gained of $2867 when compared to performing ASC alone. Preoperative UDS was more costly and less effective than universally performing intraoperative MUS. The cost-effectiveness of ASC + MUS was robust to sensitivity analysis, with a cost-effectiveness ratio consistently below $20,000 per QALY. CONCLUSIONS: Universal concomitant MUS is the most cost-effective prophylaxis strategy for occult SUI in women undergoing ASC. The use of pre-operative UDS to guide MUS placement at the time of ASC is not cost-effective.

  View details for DOI 10.1016/j.juro.2013.03.046

  View details for Web of Science ID 000325091700058

  View details for PubMedID 23524201

• Three-Year Outcomes of Vaginal Mesh for Prolapse A Randomized Controlled Trial OBSTETRICS AND GYNECOLOGY Gutman, R. E., Nosti, P. A., Sokol, A. I., Sokol, E. R., Peterson, J. L., Wang, H., Iglesia, C. B. 2013; 122 (4): 770-777

  Abstract

  To present the 3-year outcomes of a double-blind, multicenter, randomized trial comparing vaginal prolapse repair with and without mesh.This was a planned final analysis of women with Pelvic Organ Prolapse Quantification (POP-Q) stage 2-4 prolapse randomized to traditional vaginal prolapse surgery without mesh and vaginal colpopexy repair with mesh. We evaluated anatomic, symptomatic, and combined cure rates for those with at least 3-year validated quality-of-life questionnaires and 2- or 3-year postoperative blinded POP-Q examination. Participants undergoing reoperation for recurrent prolapse were removed for anatomic and subjective outcomes analysis and considered failures for combined outcomes analysis.Sixty-five women were enrolled (33 mesh, 32 no mesh) before the study was prematurely halted as a result of a 15.6% mesh exposure rate. At 3 years, 51 of 65 (78%) had quality-of-life questionnaires (25 mesh, 26 no mesh) and 41 (63%) had examinations. Three participants died, three required reoperation for recurrent prolapse (all in mesh group), and eight were lost to follow-up. No differences were observed between groups at 3 years for prolapse stage or individual prolapse points. Stage improved for each group (90% and 86%) from baseline to 3 years (P<.01). Symptomatic improvement was observed with no differences in scores between groups. Cure rates did not differ between groups using a variety of definitions, and anatomic cure was lowest for the anterior compartment.There was no difference in 3-year cure rates when comparing patients undergoing traditional vaginal prolapse surgery without mesh with those undergoing vaginal colpopexy repair with mesh.Clinicaltrials.gov, www.clinicaltrials.gov, NCT00475540.: I.

  View details for DOI 10.1097/AOG.0b013e3182a49dac

  View details for Web of Science ID 000330446900007

• The Predictive Value of a Cystocele for Concomitant Vaginal Apical Prolapse JOURNAL OF UROLOGY Elliott, C. S., Yeh, J., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 189 (1): 200-203

  Abstract

  Recent studies showing a correlation between descent of the anterior and apical vaginal compartments suggest that cystoceles may recur if associated apical prolapse is not corrected. However, to date the anatomical relationship of apical prolapse with respect to cystocele has been incompletely reported. We present the predictive value of a cystocele for clinically significant vaginal apical prolapse.We retrospectively reviewed the records of all new patient visits to a urogynecology clinic in a 30-month period. Women with a point Ba value of -1 or greater (stage 2 cystocele and above) were included in analysis. Predictive values of clinically significant apical prolapse, defined as point C -3 or greater, were calculated and stratified by cystocele stage.A total of 385 women were included in study. Point Ba was the leading edge of prolapse in 83.9% of cases. The position of Ba strongly correlated with that of the vaginal apex (Spearman ρ = 0.769, p <0.001). Overall 59.7% of patients had a point C of -3 or greater. The finding of clinically significant apical prolapse increased significantly with increasing Ba values. Of patients with stage 2, 3 and 4 cystocele point C was -3 or greater in 42%, 85% and 100%, respectively.The finding of stage 2 or greater cystocele is highly suggestive of clinically significant apical vaginal descent to -3 or greater. Furthermore, as cystocele stage increases, the predictive value of apical prolapse also increases. Surgeons contemplating cystocele repair should have high suspicion for vaginal apical prolapse and consider concomitant repair.

  View details for DOI 10.1016/j.juro.2012.08.177

  View details for Web of Science ID 000312604800066

  View details for PubMedID 23174246

• Posterior Compartment Prolapse: A Urogynecology Perspective UROLOGIC CLINICS OF NORTH AMERICA Richardson, M. L., Elliot, C. S., Sokol, E. R. 2012; 39 (3): 361-?

  Abstract

  Posterior compartment prolapse is often caused by a defect in the rectovaginal septum, also known as Denonvillier's fascia. Patients with symptomatic posterior compartment prolapse can present with bulge symptoms as well as defecatory dysfunction, including constipation, tenesmus, splinting, and fecal incontinence. The diagnosis can successfully be made on clinical examination. Treatment of posterior prolapse includes pessaries and surgery. Both traditional colporrhaphy and site-specific defect repair have excellent success rates. Complications from surgery can include sexual dysfunction, de novo dyspareunia, and defecatory dysfunction. Compared with native tissue repair, biological and synthetic grafting has not improved overall anatomic and subjective outcomes.

  View details for DOI 10.1016/j.ucl.2012.06.005

  View details for Web of Science ID 000308380500014

  View details for PubMedID 22877719

• Robot-Assisted Versus Open Sacrocolpopexy: A Cost-Minimization Analysis JOURNAL OF UROLOGY Elliott, C. S., Hsieh, M. H., Sokol, E. R., Comiter, C. V., Payne, C. K., Chen, B. 2012; 187 (2): 638-643

  Abstract

  Abdominal sacrocolpopexy is considered a standard of care operation for apical vaginal vault prolapse repair. Using outcomes at our center we evaluated whether the robotic approach to sacrocolpopexy is as cost-effective as the open approach.After obtaining institutional review board approval we performed cost-minimization analysis in a retrospective cohort of patients who underwent sacrocolpopexy at our institution between 2006 and 2010. Threshold values, that is model variable values at which the most cost effective approach crosses over to an alternative approach, were determined by testing model variables over realistic ranges using sensitivity analysis. Hospital billing data were also evaluated to confirm our findings.Operative time was similar for robotic and open surgery (226 vs 221 minutes) but postoperative length of stay differed significantly (1.0 vs 3.3 days, p <0.001). Base case analysis revealed an overall 10% cost savings for robot-assisted vs open sacrocolpopexy ($10,178 vs $11,307). Tornado analysis suggested that the number of institutional robotic cases done annually, length of stay and cost per hospitalization day in the postoperative period were the largest drivers of cost. Analysis of our hospital billing data showed a similar trend with robotic surgery costing 4.2% less than open surgery.A robot-assisted approach to sacrocolpopexy can be equally or less costly than an open approach. This depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo the robot-assisted procedure.

  View details for DOI 10.1016/j.juro.2011.09.160

  View details for Web of Science ID 000299070400102

  View details for PubMedID 22177180

• One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse Sokol, A. I., Iglesia, C. B., Kudish, B. I., Gutman, R. E., Shveiky, D., Bercik, R., Sokol, E. R. MOSBY-ELSEVIER. 2012

  Abstract

  The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh.Women with stage ?2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ?1 at 12 months. Secondary outcomes included quality of life and complications.All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh.Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.

  View details for DOI 10.1016/j.ajog.2011.08.003

  View details for Web of Science ID 000298369200037

  View details for PubMedID 21974992

• Variation in the Quality of Surgical Care for Uterovaginal Prolapse Rhoads, K. F., Sokol, E. R. LIPPINCOTT WILLIAMS & WILKINS. 2011: 46-51

  Abstract

  Pelvic organ prolapse is a common disorder, affecting an estimated 24% of women in the United States, with more than 200,000 surgical procedures performed annually. Current treatment recommendations from the American College of Obstetricians and Gynecologists include pelvic floor reconstruction (or pexy) procedures to correct prolapse, with or without hysterectomy; however, many women are treated by hysterectomy alone.To determine whether hospital characteristics predict compliance with recommended surgical care for uterovaginal prolapse.Retrospective analysis of linked California hospital discharge and financial data. International Classification of Diseases, ninth Edition Clinical Modification codes identified records with a primary diagnosis of prolapse and concomitant coding for surgical procedures. ?2 analysis and multivariable models were used to characterize the associations between hospital characteristics and compliance. Compliant care was defined as prolapse treatment by pelvic floor reconstruction (pexy) procedure with or without hysterectomy. Failed compliance was defined as hysterectomy alone.A total of 28,539 cases in 343 hospitals were analyzed. Low compliance rates were detected in all hospital types, though some were better than others. High-volume (odds ratios [OR] = 1.75; 95% CI: [1.62, 1.89]), teaching (OR = 2.03; 95% CI: [1.84, 2.25]), and private (OR = 1.28; 95% CI: [1.14, 1.46]) hospitals were more likely, while disproportionate share hospitals were less likely (OR = 0.58; 95% CI: [0.54, 0.63]) to comply with evidence-based recommendation.Although we did find significant variation in compliance by hospital characteristics, compliance rates were low in all settings. Quality improvement efforts in the surgical treatment of uterovaginal prolapse should focus on increasing adherence to evidence-based practice.

  View details for DOI 10.1097/MLR.0b013e3181f37fed

  View details for Web of Science ID 000285407100007

  View details for PubMedID 21102358

• Vaginal Mesh for Prolapse A Randomized Controlled Trial OBSTETRICS AND GYNECOLOGY Iglesia, C. B., Sokol, A. I., Sokol, E. R., Kudish, B. I., Gutman, R. E., Peterson, J. L., Shott, S. 2010; 116 (2): 293-303

  Abstract

  To present 3-month outcomes of a double-blind, multicenter randomized controlled trial comparing traditional vaginal prolapse surgery without mesh with vaginal surgery with mesh.Women with pelvic organ prolapse quantification prolapse stages 2-4 were randomized to vaginal colpopexy repair with mesh or traditional vaginal colpopexy without mesh. The primary outcome measure was objective treatment success (pelvic organ prolapse quantification stage 1 or lower) at 3 months. Secondary outcome measures included quality-of-life variables and complication rates.Sixty-five women were recruited from January 2007 to August 2009, when the study was halted due to predetermined stopping criteria for vaginal mesh erosion at a median follow-up of 9.7 months (range, 2.4-26.7 months). Thirty-two women underwent mesh colpopexy (24 anterior mesh, eight total mesh), and 33 women had vaginal colpopexies without mesh (primarily uterosacral ligament suspension) and concurrent colporrhaphy. There were no statistically significant baseline differences between the mesh and no-mesh groups with respect to demographics, menopausal status, and race. Analysis of the mesh and no-mesh women found no difference with respect to overall recurrence (mesh: 19 [59.4%] compared with no mesh: 24 [70.4%], P=.28). There were five (15.6%) vaginal mesh erosions. Two cystotomies and one blood transfusion occurred in the mesh group only. Subjective cure of bulge symptoms was noted in 93.3% of mesh patients and 100% of no-mesh patients. Furthermore, subjective quality-of-life measurements did not differ between the two groups at baseline or 3 months postoperatively.At 3 months, there is a high vaginal mesh erosion rate (15.6%) with no difference in overall objective and subjective cure rates. This study questions the value of additive synthetic polypropylene mesh for vaginal prolapse repairs.Clinicaltrials.gov, www.clinicaltrials.gov, NCT00475540.I.

  View details for DOI 10.1097/AOG.0b013e3181e7d7f8

  View details for Web of Science ID 000280186300008

  View details for PubMedID 20664388

• Alternative method of suprapubic assistance in operative cystoscopy INTERNATIONAL UROGYNECOLOGY JOURNAL Chang, P. L., Sokol, E. R. 2010; 21 (2): 247-249

  Abstract

  Complications of tension-free vaginal tape (TVT) procedures have become more prevalent as the procedure has become more popular for the treatment of stress urinary incontinence. A common complication of TVT slings is bladder perforation, which is estimated to occur in 0.7-24% of treated patients. While easily treated if identified intraoperatively, unrecognized bladder perforation generally requires further surgery to correct. We propose a novel minimally invasive technique using the suture passer of the Carter-Thomason CloseSure system for suprapubic assistance during cystoscopic removal of TVT mesh from the bladder. This novel approach allows for the avoidance of an open incision or a larger accessory port placed through the bladder to assist with mesh excision.

  View details for DOI 10.1007/s00192-009-0940-8

  View details for Web of Science ID 000273787500018

  View details for PubMedID 19543675

• Is lysyl oxidase-like protein-1, alpha-1 antitrypsin, and neutrophil elastase site specific in pelvic organ prolapse? INTERNATIONAL UROGYNECOLOGY JOURNAL Man, W. C., Ho, J. Y., Wen, Y., Sokol, E. R., Polan, M. L., Chen, B. 2009; 20 (12): 1423-1429

  Abstract

  We investigated whether the expression of alpha-1 antitrypsin (ATT), neutrophil elastase (NE), and lysyl oxidase-like protein 1 (LOXL-1) vary within the vagina in subjects with pelvic organ prolapse (POP).Biopsies were obtained from the anterior and posterior vaginal wall of 22 women with POP (> or =stage 2 by POP-Q). The subjects were grouped by the most prominent defect: cystocele, cystocele plus uterine prolapse, and rectocele. Comparative real-time PCR, Western blotting, and NE enzyme activity assay were performed.The ratio of anterior and posterior vaginal wall ATT, NE, and LOXL-1 expression varied between individuals within the same defect group.ATT, NE, and LOXl-1 expression was variable among different biopsy sites in the vagina. No consistent pattern was present when the subjects were grouped by the most prominent defect. We recommend careful consideration of biopsy sites in future studies on POP to enhance reproducibility of data.

  View details for DOI 10.1007/s00192-009-0905-y

  View details for Web of Science ID 000272796900006

  View details for PubMedID 19763368

• An Instructional Video to Improve Teaching Techniques and Learning in the Operating Room MedEdPORTAL. Available from: www.aamc.org/mededportal Sokol E, Metheny W, Ward R 2009: 1754
• Novel Repair of Tension-free Midurethral Sling Erosion into the Urethra JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY Sokol, E. R., Urban, R. 2008; 15 (6): 755-757

  Abstract

  Severe urinary tract injury is a relatively uncommon occurrence after the placement of a tension-free vaginal tape sling. Bladder perforation is the most common urinary tract injury, but bladder drainage for a few days is usually the only intervention that is required. Urethral erosions of synthetic sling tapes are much rarer, but can result in more significant sequelae such as voiding dysfunction or fistula formation. A 50-year-old woman had an erosion of a synthetic, tension-free midurethral sling through the urethra. She underwent resection of the sling with closure of the urethral defect. The internal urethral sphincter was used during the primary repair to cover the defect because of periurethral scarring and fibrosis. This technique may reduce the risk of subsequent fistula formation, and may be a less invasive alternative to the use of a Martius interposition flap.

  View details for DOI 10.1016/j.jmig.2008.07.012

  View details for Web of Science ID 000260845100023

  View details for PubMedID 18971143

• Combined trans- and periurethral injections of bulking agents for the treatment of intrinsic sphincter deficiency INTERNATIONAL UROGYNECOLOGY JOURNAL Sokol, E. R., Aguilar, V. C., Sung, V. W., Myers, D. L. 2008; 19 (5): 643-647

  Abstract

  The purpose of this study was to compare Contigen combined with Durasphere to Contigen injections alone for the treatment of stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). Subjective and objective incontinence outcomes were compared at 2 weeks and 6 months. We compared rates of urinary retention and future incontinence surgery between groups. Thirty-three women underwent combined injections, and 51 underwent Contigen injections. Two weeks postoperatively, more women in the combined group were cured (72.7 vs. 39.2%, P = 0.003), but this difference diminished at 6 months (33.3 vs. 29.4%, P = 0.70). Retention was more common in the combined group (P = 0.002, odds ratio [OR] = 0.062 [95% confidence interval (CI) = 0.007, 0.52]). Twenty-three women in the Contigen and ten in the combined group underwent subsequent incontinence surgery (P = 0.17, OR = 2.03 [95% CI = 0.80, 5.1]). Combining Contigen and Durasphere injections to treat SUI with ISD does not improve outcomes compared to Contigen injections alone.

  View details for DOI 10.1007/s00192-007-0493-7

  View details for Web of Science ID 000254751000008

  View details for PubMedID 17965815

• Is alpha 2-macroglobulin important in female stress urinary incontinence? HUMAN REPRODUCTION Wen, Y., Man, W. C., Sokol, E. R., Polan, M. L., Chen, B. H. 2008; 23 (2): 387-393

  Abstract

  Loss of mechanical stability of the urethra and bladder is thought to be important in the development of stress urinary incontinence (SUI). The vaginal wall is the main supporting tissue for pelvic organs and changes in components of supporting tissues are known to be involved in the pathophysiology of SUI.We evaluated changes in expression of alpha2-macroglobulin (alpha2-M), a protease inhibitor, in vaginal wall tissues from premenopausal women (aged 42-45 years) with SUI (n = 28) compared with menstrual cycle-matched continent women (controls, n = 29). The distribution of alpha2-M in vaginal wall tissues and fibroblasts was analysed by immunohistochemistry and immunofluorescence. Expression levels of alpha2-M mRNA and protein was determined by relative real-time quantitative PCR and enzyme-linked immunosorbent assay, respectively. Protease inhibition was measured to assess bioactivity.Vaginal wall tissues do express alpha2-M. Expression of alpha2-M mRNA and protein was significantly higher in tissues from controls compared to women with SUI in both proliferative and secretory phases (P < 0.05). Protease inhibitory activity of alpha2-M was significantly higher in tissues from controls compared to women with SUI in the secretory phase (P < 0.05), but we found no difference in the proliferative phase between groups. alpha2-M protein level was lower in the proliferative phase than the secretory phase in both controls and SUI patients, while for alpha2-M mRNA this was found only in controls.Decreased expression of alpha2-M mRNA and protein and protease inhibitory activity in the vaginal wall tissues of women with SUI may contribute to the development of SUI.

  View details for DOI 10.1093/humrep/dem370

  View details for Web of Science ID 000252544300023

  View details for PubMedID 18077315

• Long-term follow-up of a transvaginal Burch urethropexy for stress urinary incontinence AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Rardin, C. R., Sung, V. W., Hampton, B. S., Clemons, J. L., Aguilar, V., Sokol, E. R. 2007; 197 (6)

  Abstract

  The objective of the study was to describe long-term objective and subjective success rates and complications following transvaginal Burch urethropexy for stress urinary incontinence.A case series of 66 women who underwent vaginal Burch urethropexy for urodynamic stress urinary incontinence with urethral hypermobility using a suture carrier device is presented. Concurrent prolapse repairs were performed as indicated.Sixty-six women (mean age 49.4 +/- 12.1 years) underwent vaginal Burch urethropexy. Mean follow-up time was 20.9 +/- 18.9 months. Objective failure was observed in 16 patients (24.2%). Subjective failure was reported by 21.2% of patients, with 50% and 28.8% reporting success and improvement, respectively. Six patients (9%) experienced febrile illness, 4 (6%) experienced intraoperative hemorrhage, 1 (1.5%) received transfusion, and 1 (1.5%) experienced pelvic abscess. Twelve patients (18.2%) experienced suture erosion; half required surgical revision or excision.Vaginal Burch urethropexy is generally well tolerated but is associated with poor long-term success and high suture erosion rates.

  View details for DOI 10.1016/j.ajog.2007.08.060

  View details for Web of Science ID 000251675700039

  View details for PubMedID 18060969

• Variability of current symptoms in women with pelvic organ prolapse INTERNATIONAL UROGYNECOLOGY JOURNAL Sung, V. W., Clark, M. A., Sokol, E. R., Rardin, C. R., Myers, D. L. 2007; 18 (7): 787-798

  Abstract

  To describe the variability of current (day-to-day) symptoms of pelvic organ prolapse (POP) and to compare women's overall (comprehensive) and current ratings of prolapse symptoms. This was a prospective observational study of 45 women with symptomatic POP followed-up for 3 months between November 2004 and June 2005. Women had a total of three visits during the study period. We measured current symptoms using daily symptom diaries completed for a total of 4 weeks during the study period. The diaries included 100-mm visual analogue scales anchored at 0 (no symptoms) and 100 (extremely severe symptoms) and patients completed these at three different times each day. At each study visit, patients were examined and completed a 10-item questionnaire, which included questions adapted from the PFDI. This questionnaire compared overall and current symptoms at each study visit. Statistical analyses included descriptive statistics, ANOVA, and Pearson's correlation coefficient. Current symptoms of vaginal bulging varied on a day-to-day basis. Current symptoms varied depending on the time of day with women reporting more severe symptoms in the evenings (P<.01). Women reported experiencing their most severe symptoms at only 13.7% of all study visits. On average, women reported less severe ratings of current symptoms at the time of each visit compared to overall recall ratings (P<.05). Women seeking care for symptomatic POP can have dynamic symptoms and are often not evaluated at the time of their most severe symptoms. This should be considered by clinicians evaluating women for symptoms of POP.

  View details for DOI 10.1007/s00192-006-0237-0

  View details for Web of Science ID 000247504200015

  View details for PubMedID 17115232

• Incarcerated vaginal herniation of the omentum mimicking vaginal prolapse. American journal of obstetrics and gynecology Sokol, E. R., Munro, E. G. 2007; 196 (3): e7-8

  Abstract

  We present a 33-year-old woman with a history of radical hysterectomy and pelvic radiation who developed a nonreducible high anterior vaginal wall bulge, postoperative pelvic pain, and dyspareunia. Dynamic MRI revealed herniation of the omentum into the vesico-vaginal space. The incarcerated hernia was repaired transvaginally, and the patient's symptoms improved.

  View details for PubMedID 17346517

• Effect of patient age on increasing morbidity and mortality following urogynecologic surgery AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Sung, V. W., Weitzen, S., Sokol, E. R., Rardin, C. R., Myers, D. L. 2006; 194 (5): 1411-1417

  Abstract

  The purpose of this study was to estimate the effect of age on the risk of in-hospital mortality and morbidity following urogynecologic surgery and to compare risks associated with obliterative versus reconstructive procedures for prolapse in elderly women.We conducted a retrospective cohort study utilizing data from 1998 to 2002 from the Nationwide Inpatient Sample. Multivariable logistic regression was performed to obtain odds ratios estimating the effect of age on risk of death and complications, adjusting for comorbidities and demographic factors.There were 264,340 women in our study population. Increasing age was associated with higher mortality risks per 1000 women (< 60 years, 0.1; 60-69 years, 0.5; 70-79 years, 0.9; > or = 80 years, 2.8; P < .01) and higher complication risks per 1000 women (< 60 years, 140; 60-69 years, 130; 70-79 years, 160; > or = 80 years, 200; P < .01). Using multivariable logistic regression, increasing age was associated with an increased risk of death (60-69 years, odds ratio [OR] 3.4 [95% CI 1.7-6.9]; 70-79 years, OR 4.9 [95% CI 2.2-10.9]; > or = 80 years, OR 13.6 [95% CI 5.9-31.4]), compared with women < 60 years. The risk of peri-operative complications was also higher in elderly women 80 years of age and older (OR 1.4 [95% CI 1.3-1.5]) compared with younger women. Elderly women 80 years and over who underwent obliterative procedures had a lower risk of complication compared with those who underwent reconstructive procedures for prolapse (17.0% vs 24.7%, P < .01).Although the absolute risk of death is low, elderly women have a higher risk of mortality and morbidity following urogynecologic surgery.

  View details for DOI 10.1016/j.ajog.2006.01.050

  View details for Web of Science ID 000237331900035

  View details for PubMedID 16647926

• The usefulness of urinary cytology testing in the evaluation of irritative voiding symptoms AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Sokol, E. R., Patel, S. R., Clemons, J. L., Sung, V. W., Rardin, C. R., Myers, D. L. 2005; 192 (5): 1554-1559

  Abstract

  The purpose of this study was to assess the clinical usefulness of urinary cytology testing for the evaluation of urothelial cancer in women with irritative voiding symptoms who were examined at a urogynecology service.Urinary cytology studies results that were obtained from January 1, 2000, to December 31, 2002, were cross-matched with the Rhode Island Department of Health Cancer Registry to identify those women who were diagnosed with urinary tract malignancies. The prevalence of urothelial cancer was determined, and the sensitivity, specificity, and positive and negative predictive values of urinary cytologic testing were calculated for 2 common classification strategies: (1) consideration of atypical cytologic test results to be normal and (2) consideration of atypical cytologic test results to be abnormal.Among 1516 cross-matched cytologic test results from 1324 patients, 5 urothelial cancers were identified. Two of the 5 malignancies were associated with positive cytology results. The prevalence of urothelial cancer was 0.38% (95% CI, 0.1%, 0.9%). When atypical cytology studies were classified as normal, the sensitivity of urinary cytology was 40% (95% CI, 7.2%, 83.0%); the specificity was 99.9% (95% CI, 99.5%, 100%); the positive predictive value was 66.7% (95% CI, 12.5%, 98.2%), and negative predictive value was 99.8% (95% CI, 99.2%, 100%). In contrast, when atypical cytology results were classified as abnormal, the sensitivity and negative predictive value remained the same, but the specificity declined to 93.6% (95% CI, 92.1%, 94.8%), and the positive predictive value decreased to 2.3% (95% CI, 0.4%, 8.8%).The low prevalence of urothelial cancers and low sensitivity of urinary cytology studies severely limit the usefulness of this test in the evaluation of women with irritative voiding symptoms.

  View details for DOI 10.1016/j.ajog.2004.10.627

  View details for Web of Science ID 000229384100049

  View details for PubMedID 15902157

• Suburethral sting treatment of occult stress incontinence and intrinsic sphincter deficiency in women with severe vaginal prolapse of the anterior vs posterior/apical compartment AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Clemons, J. L., Aguilar, V. C., Sokol, E. R., Sung, V. W., Myers, D. L. 2005; 192 (5): 1566-1572

  Abstract

  The purpose of this study was to compare the efficacy of a Mersilene mesh suburethral sling for occult stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with severe vaginal prolapse of the anterior compartment to the posterior/apical compartment.This was a retrospective study that compared women with stage or grade III/IV prolapse of the anterior compartment (group 1) with the posterior/apical compartment (group 2); both groups demonstrated occult SUI (leakage only with prolapse reduced) and ISD on urodynamics, and underwent concurrent pelvic reconstructive surgery. The sling was defined as efficacious if SUI was prevented in 85% of women and if obstructive symptoms (de novo or worsening urge incontinence, or urinary retention greater than 2 weeks) occurred in less than 10% of women.There were 39 women in group 1 and 25 women in group 2. There were no differences between women in group 1 or group 2 in preoperative demographics (except parity) or urodynamic findings. SUI cure rates were lower for group 1 than group 2, but this difference was not significant (87% vs 100%, P = .15). Rates of de novo or worsening urge incontinence (8% vs 4%, P = 1.00) and urinary retention (none occurred) were similar between groups.In women with severe vaginal prolapse, slings effectively treat occult SUI and ISD, whether associated with anterior or posterior/apical prolapse.

  View details for DOI 10.1016/j.ajog.2004.11.041

  View details for Web of Science ID 000229384100051

  View details for PubMedID 15902159

• Results of urine cytology testing and cystoscopy in women with irritative voiding symptoms AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Sokol, E. R., Pate, S. R., Sung, V. W., Rardin, C. R., Weitzen, S., Clemons, J. L., Myers, D. L. 2005; 192 (5): 1560-1565

  Abstract

  The purpose of this study was to assess rates of urinary cytologic abnormalities and cystoscopic outcomes in women with irritative voiding symptoms who were examined at a urogynecology clinic.All urinary cytology studies results that were sent between January 1, 2000, and July 31, 2003, for the evaluation of irritative voiding symptoms were reviewed. Data were then extracted from the charts of a subset of these patients to evaluate cystoscopic outcomes. Demographics, risk factors for urothelial cancer, laboratory results, and radiology imaging results were then analyzed and compared between patients with and without abnormal cytology and cystoscopic results.Of the 1783 total urinary cytology that were reviewed, 1661 test results were read as normal (93.2%); 112 test results (6.3%) were read as atypical, and 3 test results (0.2%) were read as unsatisfactory. Seven cytologic test results were categorized as suspicious or malignant, which accounts for only 0.4% of all cytologic test results that were sent. Of the 564 consecutive women whose cases were chosen for subanalysis, cytology was normal in 91.5% and atypical in 8.5% of cases. No cytology were suspicious or malignant. Cystoscopic findings were normal in 548 patients (97.2%). Only 1 patient (0.2%) received a diagnosis of transitional cell carcinoma.Urinary cytology and cystoscopy are low yield tests and should not be used routinely in the initial evaluation of women with irritative voiding symptoms.

  View details for DOI 10.1016/j.ajog.2004.10.629

  View details for Web of Science ID 000229384100050

  View details for PubMedID 15902158

• Patient characteristics that are associated with continued pessary use versus surgery after 1 year AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Clemons, J. L., Aguilar, V. C., Sokol, E. R., Jackson, N. D., Myers, D. L. 2004; 191 (1): 159-164

  Abstract

  The purpose of this study was to identify patient characteristics in women with symptomatic pelvic organ prolapse that is associated with continued pessary use versus surgery after 1 year.Fifty-nine women with symptomatic pelvic organ prolapse who were satisfied with their pessary at 2 months were evaluated prospectively at 1 year. Characteristics of women who continued to use a pessary were compared with women who underwent pelvic reconstructive surgery to identify predictors for continued pessary use versus surgery.Forty-three women (73%) continued pessary use, and 16 women (27%) underwent surgery. Characteristics that were associated with continued pessary use were older age (76 vs 61 years; p <.001) and poor surgical risk (26% vs 0%; P =.03). Characteristics that were associated with surgery were sexual activity (81% vs 26%; P <.001), stress incontinence (44% vs 16%; P =.03), stage III-IV posterior vaginal wall prolapse (44% vs 16%; P =.03), and desire for surgery at the first visit (63% vs 12%; P <.001). Age >or=65 years was the best cut-off value for continued pessary use, with sensitivity of 95% (95% CI, 84%, 99%) and a positive predictive value of 87% (95% CI, 74%, 94%). Logistic regression demonstrated that age >or=65 years ( P <.001), stage III-IV posterior vaginal wall prolapse ( P =.007), and desire for surgery ( P =.04) were independent predictors.Age >or=65 years was associated highly with continued pessary use. Desire for surgery and stage III-IV posterior vaginal wall prolapse were associated with discontinued pessary use and pelvic reconstructive surgery.

  View details for DOI 10.1016/j.ajog.2004.04.048

  View details for Web of Science ID 000223139100024

  View details for PubMedID 15295358

• Ultrasound examination of the postpartum uterus: what is normal? journal of maternal-fetal & neonatal medicine Sokol, E. R., Casele, H., Haney, E. I. 2004; 15 (2): 95-99

  Abstract

  To establish normal ultrasonographic findings for the postpartum uterus after vaginal delivery, and to characterize associated bleeding patterns.Postpartum women were scanned by transabdominal ultrasound within 48 h after normal vaginal delivery. Uterine length, uterine width, endometrial stripe thickness and endometrial contents were evaluated by a single sonographer. Patients maintained a daily symptom diary for 6 weeks and were interviewed by telephone at 2 weeks. Statistical analysis was performed using chi2, Fisher's exact test, Student's t test and Pearson correlation.Mean endometrial stripe thickness was 1.1 +/- 0.6 cm, mean uterine length was 16.1 +/- 1.7 cm and mean uterine width was 8.7 +/- 1.0 cm. Postpartum bleeding requiring more than four protective pads per day for > or =10 days was associated with a thicker endometrial stripe (1.5 +/- 0.7 cm vs. 0.9 +/- 0.4 cm, p = 0.006). However, no patients experienced postpartum bleeding complications requiring intervention. Of the 40 women evaluated, 16 had echogenic material in the uterine cavity (mean size 12.7 +/- 6.9 cm2). The presence of echogenic material was not associated with the amount or duration of bleeding.Frequent postpartum ultrasonographic findings include a thickened endometrial stripe and echogenic material in the uterine cavity. The echogenic material commonly seen in the endometrial cavity of asymptomatic patients was not associated with the development of bleeding complications.

  View details for PubMedID 15209115

• Laparoscopic morcellator-related injuries JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS Milad, M. P., Sokol, E. 2003; 10 (3): 383-385

  Abstract

  To identify and summarize all electric morcellator-related injuries published in the medical literature.Systematic review (Canadian Task Force classification II-2).Databases.Articles on morcellator-related injuries published from 1992 through February 2002, plus additional sources of information.Search of MEDLINE and referencing of the FDA device report database. Measurements and Main Results: We were unable to locate any references to morcellator-related visceral injuries in the medical literature. Of 17 cases identified from the FDA database, 3 were excluded based on the trivial nature of the event (e.g., instrument did not function). The remaining 14 visceral injuries were to small and large bowel (11), kidney (2), pancreas (1), and major vascular structures (3). Identification of the complication was immediate in 10 patients, but was not until 4 days postoperatively in 1 woman. Three patients died. No device manufacturer or surgical specialty was responsible for a preponderance of the injuries.These potentially fatal complications are unreported in the medical literature.

  View details for Web of Science ID 000188064600016

  View details for PubMedID 14567817