Suture-Needle Management Device and Novel Port Configuration for Robotic Sacrocolpopexy

IMPORTANCE

Robot-assisted sacrocolpopexy (SCP) is a commonly performed procedure for the repair of apical pelvic organ prolapse; therefore, novel devices and techniques to improve safety and efficacy of this procedure should be explored.

OBJECTIVE

The objective of this study was to assess safety and efficacy of 8-mm trocar site for use of a disposable suture/needle management device (StitchKit; Origami Surgical, Madison, NJ) for robot-assisted SCP with a 4-arm configuration and no assistant port.

STUDY DESIGN

This is a retrospective case series of patients undergoing robot-assisted SCP at a tertiary center from 2018 to 2021. All surgical procedures were performed using four 8-mm robotic trocars and StitchKit device. Our objective was to review all cases in which this technique was used to determine whether the approach resulted in a safely completed procedure and any complications or adverse events. Secondary objectives were to describe patient and operative characteristics.

RESULTS

In total, 422 patients underwent robot-assisted SCP for pelvic organ prolapse. The mean age was 60 ± 10 years, and mean body mass index was 27 ± 6 (calculated as weight in kilograms divided by height in meters squared). Most patients had stage 3 prolapse (73%) and underwent concomitant hysterectomy (70%). Ninety-nine percent (n = 416) of cases were completed robotically. StitchKit was successfully inserted and removed in all robotic cases with correct needle counts. All patients had postoperative visits, and 80% followed up at 3 months. No umbilical/port site hernias, operative site infections, or adverse events were reported.

CONCLUSIONS

Robot-assisted SCP can be performed safely using a 4-arm robotic configuration and suture kit device. This setup eliminates incisions greater than 8 mm and an assistant port, allowing for surgical efficiency without compromising patient outcomes.

Long-Term Mesh Exposure 5 Years Following Minimally Invasive Total Hysterectomy and Sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective was to assess long-term mesh complications following total hysterectomy and sacrocolpopexy.

METHODS

In this second extension study, women from a multicenter randomized trial were followed for more than 36 months after surgery. Owing to COVID-19, participants were assessed through either in-person visits or telephone questionnaires. The primary outcome was the incidence of permanent suture or mesh exposure. Secondary outcomes included surgical success and late adverse outcomes.

RESULTS

Out of the 200 initially enrolled participants, 82 women took part in this second extension study. Among them, 46 were in the permanent suture group, and 36 in the delayed absorbable group. The mean follow-up duration was 5.3 years, with the cumulative mesh or suture exposure of 9.9%, involving 18 cases, of which 4 were incident cases. Surgical success after more than 5 years stood at 95%, with few experiencing bothersome bulge symptoms or requiring retreatment. No serious adverse events occurred, including mesh erosion into the bladder or bowel. The most common adverse events were vaginal pain, bleeding, dyspareunia, and stress urinary incontinence, with no significant differences between suture types.

CONCLUSION

The study found that mesh exposure risk gradually increased over time, reaching nearly 10% after more than 5 years post-surgery, regardless of suture type. However, surgical success remained high, and no delayed serious adverse events were reported.

Perioperative Morbidity Associated with Same-day Discharge in Elderly Patients

INTRODUCTION AND HYPOTHESIS

We compared postoperative complications in elderly patients discharged on POD#0 versus POD#1 after prolapse repair.

METHODS

Data were obtained from the National Surgical Quality Improvement database. A total of 20,984 women 65 years and older who underwent prolapse repair between 2014 and 2020 were analyzed. Patient demographics, comorbidities, readmission, reoperation, and 30-day postoperative complications were compared in patients discharged on POD#0 versus POD#1. A sensitivity analysis was completed to examine outcomes in patients who underwent an apical prolapse repair. Multivariate logistic regression was performed to evaluate for potential confounders.

RESULTS

Age, race, ethnicity, American Society of Anesthesiologists class, prolapse repair type, and operative time were significantly different in patients discharged on POD#0 vs POD#1 (all p < 0.01). Patients discharged on POD#0 had significantly fewer postoperative complications (2.63% vs 3.44%) and readmissions (1.56% vs 2.18%, all p < 0.01). On multivariate regression modeling, postoperative discharge day was independently associated with complications, but not with readmissions or reoperation after. Patients who underwent an apical prolapse repair and were discharged on POD#0 had significantly more postoperative complications (3.5% vs 2.5%, p = 0.02) and readmissions (2.42% vs 10.08%, p < 0.01) than those discharged on POD#1. In this group, multivariate regression modeling demonstrated that postoperative discharge day was independently associated with any postoperative complication.

CONCLUSIONS

For elderly women undergoing prolapse repair, the type of surgery should be considered when determining postoperative admission versus same-day discharge. Admission overnight does not seem to benefit women undergoing vaginal repairs but may decrease overall morbidity and risk of readmission in women undergoing an apical prolapse repair.

Obesity and Reconstructive Pelvic Surgery: An ACS NSQIP Study

IMPORTANCE

Obesity is steadily increasing in the United States and is a risk factor for many medical and surgical complications. Literature is limited regarding obesity as an independent risk factor for perioperative complications after reconstructive pelvic surgery (RPS).

OBJECTIVE

This study aimed to analyze the association of obesity on 30-day perioperative complications after RPS.

STUDY DESIGN

This was a database study comparing perioperative complications after RPS of obese versus nonobese patients using the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent surgery for uterovaginal or vaginal vault prolapse were selected, and perioperative outcomes were compared between obese and nonobese patients. Obesity was defined as a body mass index ≥30 (calculated as weight in kilograms divided by height in meters squared).

RESULTS

A total of 13,302 patients met the inclusion criteria and were included in this study; 4,815 patients were obese, whereas 8,487 were nonobese. The overall rate of any 30-day postoperative complication was 6.8%, and the rate of complications did not differ between groups. Superficial and organ space surgical site infections were significantly higher in the obese cohort, whereas nonobese patients were more likely to receive a blood transfusion. A multivariable logistic regression model was performed with variables that were statistically significant on bivariate analysis and deemed clinically significant. Variables included obesity, age, American Society of Anesthesiologists class, current smoker, diabetes, hypertension, operative time, colpopexy, and obliterative procedure. After controlling for potential confounding factors, obesity was not associated with any 30-day postoperative complications after pelvic organ prolapse surgery.

CONCLUSION

Obesity was not associated with 30-day postoperative complications after RPS after controlling for possible confounding variables.

Relationships Between Urinary and Nonurinary Symptoms in Treatment-Seeking Women in LURN

IMPORTANCE

Physical health and psychological health represent modifiable factors in the causal pathway of lower urinary tract symptoms (LUTS).

OBJECTIVES

Understand the relationship between physical and psychological factors and LUTS over time.

STUDY DESIGN

Adult women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study completed the LUTS Tool and Pelvic Floor Distress Inventory, including urinary (Urinary Distress Inventory), prolapse (Pelvic Organ Prolapse Distress Inventory), and colorectal anal (Colorectal-Anal Distress Inventory) subscales at baseline, 3 months, and 12 months. Physical functioning, depression, and sleep disturbance were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires; relationships were assessed using multivariable linear mixed models.

RESULTS

Of 545 women enrolled, 472 had follow-up. Median age was 57 years; 61% and 78% reported stress urinary incontinence and overactive bladder, respectively; and 81% reported obstructive symptoms. The PROMIS depression scores were positively associated with all urinary outcomes (range, 2.5- to 4.8-unit increase per 10-unit increase in depression score; P < 0.01 for all). Higher sleep disturbance scores were associated with higher urgency, obstruction, LUTS Total Severity, Urinary Distress Inventory, and Pelvic Floor Distress Inventory (1.9- to 3.4-point increase per 10-unit increase, all P < 0.02). Better physical functioning was associated with less severe urinary symptoms except stress urinary incontinence (2.3- to 5.2-point decrease per 10-unit increase, all P < 0.01). All symptoms decreased over time; however, no association was detected between baseline PROMIS scores and trajectories of LUTS over time.

CONCLUSIONS

Nonurologic factors demonstrated small to medium cross-sectional associations with urinary symptom domains, but no significant association was detected with changes in LUTS. Further work is needed to determine whether interventions targeting nonurologic factors reduce LUTS in women.

Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis

INTRODUCTION AND HYPOTHESIS

In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM).

METHODS

We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy.

RESULTS

IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness.

CONCLUSION

While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.

Risk of postoperative mesh exposure following sacrocolpopexy with supracervical versus total concomitant laparoscopic hysterectomy

INTRODUCTION AND HYPOTHESIS

The primary objective was to compare rates of mesh exposure in women undergoing minimally invasive sacrocolpopexy with concurrent supracervical vs total hysterectomy. We hypothesized there would be a lower risk of mesh exposure for supracervical hysterectomy.

METHODS

This was a retrospective cohort study using the Premier Healthcare Database. Women undergoing sacrocolpopexy with supracervical or total hysterectomy between 2010 and 2018 were identified using Current Procedural (CPT) codes. Complications were identified using CPT and diagnosis codes; reoperations were identified using CPT codes. Mesh exposures were measured over a 2-year period. A multivariable logistic regression was performed with a priori defined predictors of mesh exposure.

RESULTS

This study includes 17,111 women who underwent minimally invasive sacrocolpopexy with concomitant supracervical or total hysterectomy (6708 (39%) vs 10,403 (61%)). Women who underwent supracervical hysterectomy were older (age 60 ± 11 vs 53 ± 13, p < 0.01) and less likely to be obese (4% vs 7%, p < 0.01). Postoperative mesh exposures within 2 years were similar (supracervical n = 47, 0.7% vs total n = 65, 0.62%, p = 0.61). On logistic regression, obesity significantly reduced the odds of mesh exposure (OR 0.2, 95% CI 0.01, 0.8); concomitant slings increased odds (OR 1.91, 95% CI 1.28, 2.83). Supracervical hysterectomy was associated with higher rates of port site hernias (1.3% vs 0.65%, p < 0.01), but lower surgical site infections within 3 months (0.81% vs 1.2%, p = 0.03). Reoperation for recurrent prolapse within 24 months was similar (supracervical n = 94, 1.4% vs total n = 150, 1.4%, p = 0.88).

CONCLUSIONS

Postoperative mesh exposure rates do not significantly differ based on type of concomitant hysterectomy in this dataset.

Comparison of Morbidity and Retreatment After Urethral Bulking or Midurethral Sling at the Time of Pelvic Organ Prolapse Repair

OBJECTIVE

To compare postprocedure retreatment rates for stress incontinence in patients who underwent either midurethral sling or urethral bulking at the time of concomitant repair of pelvic organ prolapse (POP).

METHODS

This was a retrospective cohort study using data from the Premier Healthcare Database. Using Current Procedural Terminology codes, we identified patients who were undergoing POP repair and concomitant urethral bulking or midurethral sling between the years 2001 and 2018. Patients who underwent concomitant nongynecologic surgery, Burch urethropexy, or oncologic surgery, and those who did not undergo concomitant POP and anti-incontinence surgery, were excluded. Additional data collected included patient demographics, hospital characteristics, surgeon volume, and comorbidities. The primary outcome was a repeat anti-incontinence procedure at 2 years, and the secondary outcome was the composite complication rate.

RESULTS

Over the study period, 540 (0.59%) patients underwent urethral bulking, and 91,005 (99.41%) patients underwent midurethral sling. The rate of a second procedure within 2 years was higher for urethral bulking, compared with midurethral sling (9.07% vs 1.11%, P <.001); in the urethral bulking group, 4.81% underwent repeat urethral bulking and 4.81% underwent midurethral sling. In the midurethral sling group, 0.77% underwent repeat midurethral sling and 0.36% underwent urethral bulking. After adjusting for confounders, midurethral sling was associated with a decreased odds of a repeat anti-incontinence procedure at 2 years (adjusted odds ratio 0.11, 95% CI 0.08-0.16). The probability of any complication at 2 years was higher with urethral bulking (23.0% vs 15.0%, P <.001).

CONCLUSION

Urethral bulking at the time of POP repair is associated with a higher rate of repeat procedure and postoperative morbidity up to 2 years after surgery.

Evaluation of gastrointestinal tract injury within 1 year of surgery for pelvic organ prolapse

OBJECTIVE

To identify the incidence and risk factors of gastrointestinal injury (GITI) related to pelvic organ prolapse (POP) surgery.

METHODS

Women who underwent POP surgery between 2000 and 2020 were identified in the Premier Healthcare Database. The primary outcome was GITI, defined as small or large bowel injury or repair, and fistula or fistula repair. Differences between patients with and without GITI were evaluated, and a multivariable regression was performed to determine independent predictors of GITI.

RESULTS

We identified 563,661 index POP surgeries in female patients aged 18 years and older. Of these, 4582 (0.8%) had a bowel injury code within 1 year of index POP surgery. Patients who experienced GITI were more likely to be younger (49.9 ± 12.8 vs 50.9 ± 13.7), and receive surgery with a surgeon who performed less than 12 surgeries per year (48% vs 42%). Most GITI was diagnosed in the same month (73.4%) and same hospital encounter (54%) as index POP surgery. After adjusting for confounders, lysis of adhesions (aOR = 2.03, 95% CI: 1.48-2.72) and perioperative hematoma/hemorrhage (aOR = 2.87, 95%C I: 1.70-4.59) were strongly associated with GITI, while having surgery with a surgeon performing > 50 POP surgeries per year (aOR = 0.66, 95%C I: 0.59-0.75 and concomitant obliterative procedures (aOR = 0.48, 95% CI: 0.34-0.65) were associated with a lower probability of GITI.

CONCLUSIONS

The rate of GITI after POP surgery is less than 1%, and injuries are commonly diagnosed and treated in the same month as index surgery. High-volume surgeons and obliterative procedures may be protective against GITI.

Development and validation of models predicting treatment patterns in women with urinary urgency and/or urgency incontinence: A Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study

PURPOSE

To develop a tool to predict a woman's treatment pattern for bothersome urinary urgency (UU) and/or UU incontinence over 1 year after presenting for care at urology or urogynecology clinics.

METHODS

The Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study enrolled adult women with bothersome UU and/or UU incontinence using the lower urinary tract symptoms (LUTS) Tool who were seeking care for LUTS. Treatments for UU and/or urgency incontinence were ordered from least to most invasive. Ordinal logistic and Cox proportional hazard regression models were fit to predict the most invasive level of treatment during follow-up and overactive bladder (OAB) medication discontinuation, respectively. Binary logistic regression was performed to predict sling treatment during the study follow-up. Clinical tools were then created using the models listed above to predict treatment pattern over 12 months.

RESULTS

Among 349 women, 281 reported UU incontinence, and 68 reported UU at baseline. The highest level of treatment during the study was as follows: 20% no treatment, 24% behavioral treatments, 23% physical therapy, 26% OAB medication, 1% percutaneous tibial nerve stimulation, 3% onabotulinumtoxin A, and 3% sacral neuromodulation. Slings were placed in 10% (n = 36) of participants before baseline and in 11% (n = 40) during study follow-up. Baseline factors associated with predicting the most invasive level of treatment included baseline level of treatment, hypertension, UU incontinence severity, stress urinary incontinence (SUI) severity, and anticholinergic burden score. Less severe baseline depression and less severe UU incontinence were associated with OAB medication discontinuation. UU and SUI severity were associated with sling placement during the study period. Three tools are available to predict: (1) highest level of treatment; (2) OAB medication discontinuation; and (3) sling placement.

CONCLUSIONS

OAB treatment prediction tools developed in this study can help providers individualize treatment plans and identify not only patients at risk for treatment discontinuation but also patients who may not be escalated to potentially beneficial OAB treatments, with the goal to improve clinical outcomes for patients suffering from this chronic and often debilitating condition.

Effects of Same-Day Discharge on 30-Day Readmission Rates in Women Aged 65 Years and Older Undergoing Minimally Invasive Pelvic Organ Prolapse Surgery

OBJECTIVE

To compare the effects of same-day discharge on 30-day readmission after minimally invasive pelvic organ prolapse (POP) surgery in older patients.

METHODS

This retrospective cohort study examined all minimally invasive POP surgeries performed and included in the national Centers for Medicare & Medicaid Services 5% Limited Data Set (2011-2018). Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department (ED) visits.

RESULTS

Of the 7,278 patients undergoing surgery, patients who had same-day discharge were older (73.5 years vs 73.1 years, P=.04) and less likely to undergo concomitant hysterectomy (9.5% vs 34.9%, P<.01) or midurethral sling (36.8% vs 40.1%, P=.02). Same-day discharge increased over the study period from 15.7% in 2011 to 25.5% in 2018 (P<.01). On propensity score-matching multiple logistic regression, the adjusted difference was statistically significant, with same-day discharge increasing the odds of 30-day readmission compared with next-day discharge (adjusted odds ratio [OR] 1.57, 95% CI 1.19-2.08). There was no difference (OR 0.81, 95% CI 0.63-1.05) for 30-day ED visits on propensity score-matching multiple logistic regression.

CONCLUSION

After minimally invasive POP surgery, older women have low rates of readmission and ED visits within 30 days. After propensity score matching and adjustment for perioperative factors, there may be increased odds in readmission and no difference in ED visits risk in those who had same-day discharge. When considering patient factors, same-day discharge after minimally invasive POP surgery may be effective for older patients.

Inequities in Filled Overactive Bladder Medication Prescriptions in the US

Importance

Anticholinergic medications to treat overactive bladder (OAB) have been associated with increased risk of cognitive decline, whereas β3-adrenoceptor agonists (hereafter, β3-agonists) have comparable efficacy and do not carry the same risk. Yet, anticholinergics remain the predominant OAB medication prescribed in the US.

Objective

To evaluate whether patient race, ethnicity, and sociodemographic characteristics are associated with receipt of anticholinergic vs β3-agonist OAB medications.

Design, Setting, and Participants

This study is a cross-sectional analysis of the 2019 Medical Expenditure Panel Survey, a representative sample of US households. Participants included individuals with a filled OAB medication prescription. Data analysis was performed from March to August 2022.

Exposure

A prescription for medication to treat OAB.

Main Outcomes and Measures

The primary outcomes were receipt of a β3-agonist or an anticholinergic OAB medication.

Results

An estimated 2 971 449 individuals (mean age, 66.4 years; 95% CI, 64.8-68.2 years) filled prescriptions for OAB medications in 2019; 2 185 214 (73.5%; 95% CI, 62.6%-84.5%) identified as female, 2 326 901 (78.3%; 95% CI, 66.3%-90.3%) self-identified as non-Hispanic White, 260 685 (8.8%; 95% CI, 5.0%-12.5%) identified as non-Hispanic Black, 167 210 (5.6%; 95% CI, 3.1%-8.2%) identified as Hispanic, 158 507 (5.3%; 95% CI, 2.3%-8.4%) identified as non-Hispanic other race, and 58 147 (2.0%; 95% CI, 0.3%-3.6%) identified as non-Hispanic Asian. A total of 2 229 297 individuals (75.0%) filled an anticholinergic prescription, and 590 255 (19.9%) filled a β3-agonist prescription, with 151 897 (5.1%) filling prescriptions for both medication classes. β3-agonists had a median out-of-pocket cost of $45.00 (95% CI, $42.11-$47.89) per prescription compared with $9.78 (95% CI, $9.16-$10.42) for anticholinergics. After controlling for insurance status, individual sociodemographic factors, and medical contraindications, non-Hispanic Black individuals were 54% less likely than non-Hispanic White individuals to fill a prescription for a β3-agonist vs an anticholinergic medication (adjusted odds ratio, 0.46; 95% CI, 0.22-0.98). In interaction analysis, non-Hispanic Black women had an even lower odds of filing a β3-agonist prescription (adjusted odds ratio, 0.10; 95% CI, 0.04-0.27).

Conclusions and Relevance

In this cross-sectional study of a representative sample of US households, non-Hispanic Black individuals were significantly less likely than non-Hispanic White individuals to have filled a β3-agonist prescription compared with an anticholinergic OAB prescription. These differences may reflect an inequity in prescribing behaviors promulgating health care disparities. Targeted research should assess the relative contribution of a variety of individual and societal factors.

Advanced gynecologic surgery in women with Parkinson's disease

OBJECTIVE

To assess the effect of Parkinson's disease (PD) on perioperative outcomes following gynecologic surgery.

BACKGROUND

Gynecological complaints are common among women with PD but under-reported, under-diagnosed and under-treated, in part due to surgical hesitancy. Non-surgical management options are not always acceptable to patients. Advanced gynecologic surgeries are effective for symptom management. Hesitancy toward elective surgery in PD stems from concern regarding perioperative risks.

METHODS

This retrospective cohort study derived data by querying the Nationwide Inpatient Sample (NIS) database between 2012 and 2016 to identify women who underwent advanced gynecologic surgery. Non-parametric Mann-Whitney U and Fisher exact tests were used to compare quantitative and categorical variables respectively. Age and Charlson Comorbidity Index values were used to create matched cohorts.

RESULTS

526 (0.1%) women with and 404,758 without a diagnosis of PD underwent gynecological surgery. Median age of patients with PD (70 years vs 44 years, p < 0.001) and median comorbid conditions (4 vs 0, p < 0.001) were higher compared to counterparts. Median length of stay (LOS) was longer in PD group (3 days vs 2 days, p < 0.001) with lower rates of routine discharge (58% vs 92%, p = 0.001). Groups were comparable in post-operative mortality (0.8% vs 0.3%, p = 0.076). After matching, there was no difference in LOS (p = 0.346) or mortality (0.8% vs 1.5%, p = 0.385) and PD group was more likely to be discharged to skilled nursing facilities.

CONCLUSION

PD does not worsen perioperative outcomes following gynecologic surgery. Neurologists may use this information to provide reassurance to women with PD undergoing such procedures.

Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy?

BACKGROUND

It is well known that, in general, total laparoscopic hysterectomy is associated with less perioperative morbidity compared with total abdominal hysterectomy. However, total laparoscopic hysterectomy is also associated with longer operating times, which itself is an independent predictor of morbidity. Currently, it is unknown whether there is an operative time threshold beyond which total laparoscopic hysterectomy provides a diminishing return and higher risk of morbidity than a shorter abdominal hysterectomy.

OBJECTIVE

This study aimed to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy diminished compared with shorter total abdominal hysterectomy.

STUDY DESIGN

Targeted hysterectomy-specific data from the National Surgical Quality Improvement Project was used to identify patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years 2014 and 2018. The primary outcomes of interest were any major morbidity, and the length of stay after surgery was analyzed using generalized linear models. The models controlled for demographic data, comorbidities, and hysterectomy-specific information, such as uterine weight, presence of endometriosis, and pelvic inflammatory disease at the time of surgery. Missing data were addressed using multiple imputation analysis. Sensitivity analyses using propensity score matching and generalized additive models were performed to assess the effect of selection bias and nonlinear interactions between covariates and the outcomes, respectively. Common Procedural Terminology codes were used to identify women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570-58,573). Conventional laparoscopy could not be differentiated from robotic surgery as there is no mechanism for doing so within the National Surgical Quality Improvement Project. Therefore, total laparoscopic hysterectomy also includes robotic-assisted surgery. Additional exclusion criteria included any surgery lasting >360 minutes, as these represent significant outliers in the data and clinical practice; pelvic reconstructive procedure; anti-incontinence surgery; lymphadenectomy; radical hysterectomy; cytoreductive surgery; a pre- or postoperative diagnostic code for gynecologic malignancy; preoperative sepsis or renal failure; emergency surgery; or any concurrent nongynecologic surgery. Patients who underwent ureteral stenting during the procedure with no additional urologic procedures were included, as this may be performed at the time of hysterectomy or to address ureteral injury.

RESULTS

The mean operating time was similar for both routes, 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy (P=.45). The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (16.6% vs 7.7%; P<.001); and the median length of stay was longer for total abdominal hysterectomy (2 [interquartile range, 2-3] days vs 1 [interquartile range, 0-1] days; P<.001). After adjusting for confounders, an increase of 1 hour in operative time for hysterectomy was associated with a 45% (95% confidence interval, 41%-49%) increase in the risk of major morbidity; furthermore, total abdominal hysterectomy was associated with an additional time detriment, such that there was an additional 61% (95% confidence interval, 53%-68%) increase in the risk of a major morbidity for each additional hour of a total abdominal hysterectomy. There was no time point at which total abdominal hysterectomy was associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy, even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy. The same conclusions remained true with the propensity-matched analysis and generalized additive model analyses.

CONCLUSION

Our findings showed that there is no reasonable operative time at which total laparoscopic hysterectomy is associated with a higher rate of complications or longer length of stay than total abdominal hysterectomy.

Long-Term Pain After Minimally Invasive Total Hysterectomy and Sacrocolpopexy

IMPORTANCE

There are limited long-term data on patient-reported pain after surgical treatment of uterovaginal prolapse.

OBJECTIVE

This study aimed to evaluate pain in women undergoing minimally invasive total hysterectomy and sacrocolpopexy with a lightweight polypropylene Y-mesh (Upsylon) >2 years after surgery.

STUDY DESIGN

This is a planned secondary analysis of a 5-site randomized trial comparing permanent versus absorbable suture for vaginal attachment of a lightweight polypropylene Y-mesh during total laparoscopic hysterectomy and sacrocolpopexy in women with stage ≥2 uterovaginal prolapse. Our primary outcome was patient-reported pain or dyspareunia at >2 years.

RESULTS

Of the 185 participants eligible for enrollment in the e-PACT study, 106 enrolled; 98 participants (96%) completed either in-person examinations or study questionnaires regarding pain and are included in this analysis. At >2 years, 28% reported any pain: 14% reported dyspareunia on questionnaires, 5% reported pelvic pain on questionnaires, and 14% of those who had an in-person examination reported pain. Of participants who reported pain or dyspareunia at baseline before surgery, 59% reported resolution of their symptoms >2 years. On multiple logistic regression controlling for age and baseline pain or dyspareunia, baseline pain or dyspareunia was associated with a nearly 3-fold increased risk of reporting any pain >2 years (adjusted odds ratio, 2.7; 95% confidence interval, 1.1-6.9). No women had repeat surgical intervention for pain.

CONCLUSIONS

Although 60% of women report pain resolution >2 years after surgery, de novo pain was present in 1 of 5 women. Baseline history of pain or dyspareunia is the only factor associated with an increased likelihood of experiencing pain >2 years after surgery.

Treatment patterns in women with urinary urgency and/or urgency urinary incontinence in the symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study

BACKGROUND

Limited epidemiological data exist describing how patients engage with various treatments for overactive bladder (OAB). To improve care for patients with OAB, it is essential to gain a better understanding of how patients interface with OAB treatments longitudinally, that is, how often patients change treatments and the pattern of this treatment change in terms of escalation and de-escalation.

OBJECTIVES

To describe treatment patterns for women with bothersome urinary urgency (UU) and/or urgency urinary incontinence (UUI) presenting to specialty care over 1 year.

STUDY DESIGN

The Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) study enrolled adult women with bothersome UU and/or UUI seeking care for lower urinary tract symptoms (LUTS) between January 2015 and September 2016. An ordinal logistic regression model was fitted to describe the probabilities of escalating or de-escalating level of treatment during 1-year follow-up.

RESULTS

Among 349 women, 281 reported UUI and 68 reported UU at baseline. At the end of 1 year of treatment by a urologist or urogynecologist, the highest level of treatment received by participants was 5% expectant management, 36% behavioral treatments (BT), 26% physical therapy (PT), 26% OAB medications, 1% percutaneous tibial nerve stimulation, 3% intradetrusor onabotulinum toxin A injection, and 3% sacral neuromodulation. Participants using BT or PT at baseline were more likely to be de-escalated to no treatment than participants on OAB medications at baseline, who tended to stay on medications. Predictors of the highest level of treatment included starting level of treatment, hypertension, UUI severity, stress urinary incontinence, and anticholinergic burden score.

CONCLUSIONS

Treatment patterns for UU and UUI are diverse. Even for patients with significant bother from OAB presenting to specialty clinics, further treatment often only involves conservative or medical therapies. This study highlights the need for improved treatment algorithms to escalate patients with persistent symptoms, or to adjust care in those who have been unsuccessfully treated.

Adverse outcomes after minimally invasive surgery for pelvic organ prolapse in women 65 years and older in the United States

INTRODUCTION AND HYPOTHESIS

To describe complications at the time of surgery, 90-day readmission and 1-year reoperation rates after minimally invasive pelvic organ prolapse (POP) in women > 65 years of age in the US using Medicare 5% Limited Data Set (LDS) Files.

METHODS

Medicare is a federally funded insurance program in the US for individuals 65 and older. Currently, 98% of individuals over the age of 65 in the US are covered by Medicare. We identified women undergoing minimally invasive POP surgery, defined as laparoscopic or vaginal surgery, in the inpatient and outpatient settings from 2011-2017. Patient and surgical characteristics as well as adverse events were abstracted. We used logistic regression for complications at index surgery and Cox proportional hazards regression models for time to readmission and time to reoperations.

RESULTS

A total of 11,779 women met inclusion criteria. The mean age was 72 (SD ± 8) years; the majority were White (91%). Most procedures were vaginal (76%) and did not include hysterectomy (68%). The rate of complications was 12%; vaginal hysterectomy (aOR 2.4, 95% CI 2.2-2.7) was the factor most strongly associated with increased odds of complications. The 90-day readmission rate was 7.3%. The most common reason for readmission was infection (2.0%), three quarters of which were urinary tract infections. Medicaid eligibility (aHR 1.5, 95% CI 1.3-1.8) and concurrent sling procedures (aHR 1.2, 95% CI 1.04-1.4) were associated with a higher risk of 90-day readmission. The 1-year reoperation rate was 4.5%. The most common type of reoperation was a sling procedure (1.8%). Obliterative POP surgery (aHR 0.6, 95% CI 0.4-0.9) was associated with a lower risk of reoperation than other types of surgery.

CONCLUSIONS

US women 65 years and older who are also eligible to receive Medicaid are at higher risk of 90-day readmission following minimally invasive surgery for POP with the most common reason for readmission being UTI.

Incidence and Risk Factors for Genitourinary Tract Injury Within 1 Year After Surgery for Pelvic Organ Prolapse

IMPORTANCE

The rate of genitourinary tract injury (GUTI) following pelvic organ prolapse (POP) surgery is presently ill-defined and based on relatively small trials with short follow-up time. Given the potential for higher risk of injury with POP, a better understanding of this type of injury is important for patient counseling.

OBJECTIVES

The objective of this study was to identify the incidence and risk factors of GUTI related to POP surgery.

STUDY DESIGN

Women undergoing POP surgery between 2010 and 2019 were identified using Current Procedural Terminology codes in the Premier Healthcare Database. The primary outcome was GUTI, defined as bladder or ureteral injury, and vesicovaginal or ureterovaginal fistula within 1 year of surgery. Genitourinary tract injury was identified using International Classification of Diseases and Current Procedural Terminology codes. Patients were divided into those with and without GUTI. Differences between groups were evaluated using the Student t test, Wilcoxon rank-sum test, and Fisher exact test as appropriate. Multivariable logistic regression was used to evaluate the independent predictors of GUTI.

RESULTS

One hundred thirty-nine thousand one hundred fifty-eight surgical procedures for POP were captured between 2010 and 2019. The rate of GUTI was 1.10%: 0.48% bladder, 0.64% ureteral injuries, and 0.01% fistulas. The most significant variables associated with any GUTI were as follows: adhesiolysis (adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.07-6.51), blood transfusion (aOR, 3.67; 95% CI, 1.34-10.04), and low-volume surgeons (<12 cases per year) (aOR, 1.68; 95% CI, 1.60-1.77), nonurologic or gynecologic surgeon specialty (aOR, 1.62; 95% CI, 1.49-2.00), and uterosacral suspension (aOR, 1.30; 95% CI, 1.13-1.49).

CONCLUSIONS

The rate of GUTI following POP surgery is lower than has previously been reported. Surgeon experience and specialty and surgical approach may affect GUTI incidence.

Mesh complications after total vs supracervical laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Our objective was to compare mesh exposure rates (4 months and 1 year) after total (TLH) vs supracervical (SLH) laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy (SCP). Secondary outcomes included 30-day complications and midurethral mesh exposure rates.

METHODS

This a retrospective cohort study at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes. Demographics, operative characteristics, and perioperative complications were abstracted from medical records.

RESULTS

Four hundred three women met the inclusion criteria: 91 SLH+SCP and 312 TLH+SCP. Median follow-up was 52 weeks with an overall mesh exposure rate of 1.5%. Follow-up was available for 90% of patients at 4 months and 51% at 1 year. Half of patients had lightweight mesh (n = 203), and half had ultralightweight mesh (n = 200). Vaginal mesh fixation was performed with permanent suture in 86% (n = 344) and delayed absorbable suture in 14% (n = 56) of patients. At 4 months, vaginal mesh exposure rates did not differ between groups (0% SLH vs 1% TLH, p = 1.00). All mesh exposures in the study period occurred with lightweight mesh in the TLH arm. No differences were noted in 1-year mesh exposure rates, 30-day perioperative complications (p = 0.57), or midurethral mesh exposure rates at 4 months (p = 0.35) and 1 year (p = 1.00) between groups.

CONCLUSIONS

Short-term mesh exposure following SCP with ultralightweight and lightweight polypropylene mesh is rare regardless of type of hysterectomy and much lower than reported in earlier studies with heavier weight mesh. These data suggest TLH at the time of SCP is a safe option in appropriately counseled patients.

Cost-Effectiveness of Prophylactic Retropubic Sling at the time of Vaginal Prolapse Surgery

BACKGROUND

Prophylactic midurethral sling (MUS) at the time of prolapse repair significantly reduces risk of de novo stress urinary incontinence (SUI), but it is associated with some small but significant morbidities. Since there has not been a standardized approach to MUS utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying MUS strategies in addressing risk of de novo SUI.

OBJECTIVES

We aimed to compare the cost-effectiveness of the three MUS utilization strategies in treating de novo SUI one year following vaginal prolapse repair. The three approaches are: 1) staged strategy: prolapse repair without prophylactic MUS, 2) universal sling: prolapse repair with prophylactic MUS, and 3) selective sling: prolapse repair with prophylactic MUS only in patients with a positive prolapse-reduced cough stress test (CST).

STUDY DESIGN

We created a decision analysis model to compare staged strategy, universal sling, and selective sling. We modeled probabilities of de novo SUI, patients choosing subsequent MUS surgery for de novo SUI, and outcomes related to MUS. De novo SUI rates were determined for each strategy from published data. Likelihood of patients with de novo SUI choosing MUS surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic MUS at their index prolapse repair. Finally, outcomes related to MUS including recurrent or persistent SUI, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications were all derived from publicly available data. All MUS was assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or previous literature converted to 2020 US dollars with the Consumer Price Index. The primary outcome was modeled as the incremental cost effectiveness ratio (ICER). We performed multiple one-way sensitivity analyses to assess model robustness.

RESULTS

The lowest cost strategy was the staged strategy which costs $1,051.70 per patient, followed by $1,093.75 for selective sling and $1,125.54 for universal sling. The selective sling approach, however, had the highest health utility value; therefore, universal sling was dominated by selective sling as it is both less costly and more effective. When compared to the staged strategy, selective sling was cost-effective with ICER of $2,664/QALY, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent MUS surgery for de novo SUI after index surgery. Only when this proportion exceeded 62% did universal sling become the cost-effective option as selective sling surpassed the predetermined ICER threshold and became dominated.

CONCLUSION

Selective sling was the preferred and cost-effective strategy in treating de novo SUI one year following vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo SUI after prolapse repair as well as the benefits and risks of prophylactic MUS.

The association between surgeon subspecialty training and postoperative outcomes following surgery for pelvic organ prolapse

BACKGROUND

Symptomatic pelvic organ prolapse is common and affects 25% to 35% of women worldwide. As this growing patient need is being met by surgeons from diverse training backgrounds, it is important to both characterize the differences in surgeon practice patterns and examine postoperative outcomes to ensure optimal patient care.

OBJECTIVE

To determine the association between surgeon specialty and postoperative outcomes following surgery for pelvic organ prolapse.

STUDY DESIGN

This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Gynecologic reconstructive surgery targeted database between 2014 and 2018. Pelvic organ prolapse surgeries were identified using Current Procedural Terminology codes, and surgical cases performed by urogynecologists or obstetrician-gynecologists were included for analysis. The primary outcome was any 30-day postoperative complication following prolapse surgery. The secondary outcomes were any major or minor postoperative complications, genitourinary complications, reoperation, or readmission within 30-days following surgery. Descriptive statistics were used to characterize the cohort, and pairwise analyses were used to describe the differences between the cases performed by the surgeon specialties. Multivariable logistic regression was used to control for potential confounders.

RESULTS

A total of 3358 women underwent prolapse surgery-68% performed by urogynecologists and 32% by obstetrician-gynecologists. The 30-day postoperative complication rate was higher for surgeries performed by obstetrician-gynecologists than for surgeries performed by urogynecologists (10.7% vs 7.0%, respectively; P<.001). There was no difference in the readmission rates between the 2 groups (2.1% vs 2.0%; P=1.000). However, the reoperation rates were higher for surgeries performed by obstetrician-gynecologists (1.8% vs 1.0%; P=.040). In a multivariable logistic regression model controlling for age, body mass index, American Society of Anesthesiology class, smoking, and type of concomitant surgery (hysterectomy, apical suspension, other prolapse surgery, obliterative procedure, or sling), prolapse surgery performed by a urogynecologist remained associated with nearly 40% lower odds of any 30-day postoperative complication (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80).

CONCLUSION

Prolapse surgery performed by a urogynecologist is associated with lower odds of any 30-day postoperative complication than that performed by an obstetrician-gynecologist.

Predictors of postoperative complications from stress urinary incontinence procedures: a NSQIP database study

INTRODUCTION AND HYPOTHESIS

There are few studies examining patient risk factors for postoperative complications following midurethral sling (MUS) placement for stress urinary incontinence (SUI). The objective of this study was to describe 30-day postoperative complications after MUS using the National Surgical Quality Improvement Program database. Secondary objectives included rates of readmission and patient factors associated with postoperative complications and readmissions following MUS.

METHODS

We identified 16,491 women who underwent MUS for SUI between 2014 and 2018. American Society of Anesthesia (ASA) classification, medical comorbidities, readmission, reoperation, and 30-day postoperative complications were extracted. Outcomes included the 30-day postoperative complications, readmission, and reoperations. Descriptive statistics, univariate analyses, and multivariate logistic regression were used.

RESULTS

The majority of patients were white (66.9%) and had an ASA classification II (60.9%). Postoperative complications occurred in 4.2% of patients; 1.5% required readmission and 1.0% required reoperation. The most common complication was urinary tract infection (3.4%). Using multivariate logistic regression, older age, i.e., ≥80 years of age, was associated with increased odds of complication (aOR 1.77, 95%CI 1.14-2.72) and readmission (aOR 3.84, 95%CI 1.76-8.66). ASA class III and IV were associated with increased odds of complications (aOR 1.55, 95%CI 1.13-2.14, and aOR 3.06, 95% CI 1.48-5.86 respectively) and readmissions. Women of Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander descent ("other") were associated with increased postoperative complications (aOR 1.51, 95%CI 1.07-2.07).

CONCLUSION

Postoperative complications following MUS are rare. Factors associated with complications following MUS for SUI include age, ASA class, and women of "other" race.

Outcomes of vaginal and laparoscopic hysterectomy with concomitant pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

Although vaginal hysterectomy(VH) is traditionally considered the safest route of hysterectomy, newer data suggest that laparoscopic hysterectomy (LH) might have lower risks of perioperative complications in contemporary practice. Using a large surgical database, we aimed to assess the hypothesis that there are no significant differences in rates of major and minor complications between LH and VH when performed with pelvic reconstructive surgery, controlling for the number and type of pelvic reconstructive procedures.

METHODS

A total of 27,941 eligible LH and VH from the 2010-2018 National Surgical Quality Improvement Program database were identified. Concomitant pelvic reconstructive surgery was defined as either an apical suspension, enterocele repair, or colporrhaphy. Laparoscopy-assisted VH, gynecological malignancy, and concomitant nongynecological procedures were excluded. Complications within 30 days of surgery were grouped into major (Clavien-Dindo grade ≥3) or minor (grade 1-2) classifications. Bivariate analysis and inverse propensity-weighted logistic regression compared the outcomes of the VH and LH groups. Cochran-Armitage tests and multivariate regression assessed changes over time.

RESULTS

The majority of hysterectomies (72%) were vaginal, although its utilization declined from 89% in 2010 to 64% in 2018 (p < 0.001). In multivariate analysis controlling for patient factors and the type and number of concomitant pelvic reconstructive procedures, LH was associated with a lower odds of major (adjusted odds ratio [aOR] 0.711, 95% confidence interval [CI]:0.639-0.791) and minor (aOR 0.659, 95% CI: 0.612-0.710) complications.

CONCLUSIONS

Relative safety profiles should be considered among other patient factors when counseling women undergoing surgical prolapse repair. Our findings suggest that laparoscopic approaches can be safely utilized among older and sicker patients traditionally counseled toward a vaginal approach.

Timing of diagnosis of complex lower urinary tract injury in the 30-day postoperative period following benign hysterectomy

BACKGROUND

Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period.

OBJECTIVE

This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database.

STUDY DESIGN

This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses.

RESULTS

In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3-19) and varied significantly based on type of injury (P<.01) with ureteral obstruction (6; interquartile range, 2-16) recognized earlier than ureteral fistula (12; interquartile range, 7-21) and bladder fistula (14; interquartile range, 4-23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21-3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16-3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26-3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders.

CONCLUSION

Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period.

Racial disparities in complications and costs after surgery for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The study objective was to examine the impact of race on inpatient complications and costs after inpatient surgery for pelvic organ prolapse (POP).

METHODS

In this retrospective cohort study, we identified women who underwent surgery for POP between 2012 and 2014. Patient demographics, outcomes, hospital characteristics, and hospital costs were extracted. Demographic and clinical characteristics were compared by race using Kruskal-Wallis for continuous variables and Chi-squared test for categorical variables. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs respectively.

RESULTS

A total of 29,347 women with a median age of 62 years underwent inpatient surgery for POP between 2012 and 2014. There were 4,419 women (15%) who had at least one in-hospital postoperative complication. Rates of any postoperative complication were significantly higher among Black women (20%) than among white, Hispanic, and women of other races (16%, 11%, and 13% respectively, p < 0.01). The median total cost associated with surgeries for POP was $8,267 (IQR $6,008-$11,734). After multivariate analyses controlled for potential confounders, postoperative complications remained independently associated with Black race (aOR 1.21) whereas Hispanic and other races were associated with decreased odds of complications (aOR 0.62, and aOR 0.77) relative to white race. After controlling for confounders, Hispanic women had lower associated hospital costs.

CONCLUSIONS

Black women undergoing inpatient surgery for POP had a 21% increase in the odds of complications, but no difference in costs compared with white women, whereas Hispanic women had the lowest odds of complications and lowest costs.

Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018

BACKGROUND

There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women.

OBJECTIVE

This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience.

STUDY DESIGN

A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time.

RESULTS

A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications.

CONCLUSION

This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.

Sexual Function after Minimally Invasive Total Hysterectomy and Sacrocolpopexy

STUDY OBJECTIVE

To evaluate sexual function in women undergoing minimally invasive total hysterectomy and sacrocolpopexy (TLH + SCP) with a lightweight polypropylene Y-mesh 1 year after surgery.

DESIGN

This was a planned secondary analysis of a 5-site randomized trial comparing permanent (2-0 Gore-Tex; W. L. Gore & Associates, Inc., Newark, DE) vs absorbable suture (2-0 polydioxanone suture) for vaginal attachment of a Y-mesh (Upsylon; Boston Scientific Corporation, Natick, MA) graft during TLH + SCP.

SETTING

Multicenter trial at 5 study sites (4 academic and 1 community). The study sites were: (1) University of North Carolina at Chapel Hill, Chapel Hill, NC; (2) Wake Forest Baptist Hospital, Winston-Salem, NC; (3) Northwestern University, Evanston, IL; (4) Georgia Regents University, Augusta, GA; and (5) Atlantic Health Medical Group, Morristown, NJ.

PATIENTS

Women previously enrolled in an original study undergoing TLH + SCP.

INTERVENTIONS

Quality-of-life questionnaires and physical examination.

MEASUREMENTS AND MAIN RESULTS

The primary objective was to assess changes in sexual function at 1 year after surgery as measured by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised. The secondary objective was to assess the factors associated with postoperative sexual activity and dyspareunia. Of the 200 participants enrolled, 182 (92.8%) completed follow-up: n = 95/99 Gore-Tex and n = 87/101 polydioxanone suture. The mean age was 60 ± 10 years; body mass index was 27 ± 5 kg/m²; 78% were menopausal and 56% sexually active before surgery. At 1 year after surgery, 63% were sexually active: 93% of the sexually active women preoperatively remained so at 1 year, and 24% reported new sexual activity at 1 year (p <.001). Sexual function at 1 year showed marked improvement in activity, quality, and arousal/orgasm compared with baseline Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores. Dyspareunia rates decreased from 22% preoperatively to 16.5% at 1 year (p = .65). Women who were sexually active at 1 year were younger (56.8 ± 9.6 years vs 65.4 ± 9.2 years, p <.001), more likely to be premenopausal (31.6% vs 7.4%, p = .001), and less likely to undergo bilateral salpingo-oophorectomy (53.3% vs 78.9%, p <.001).

CONCLUSION

Women undergoing TLH + SCP with a lightweight mesh graft report increased rates of sexual activity, improved sexual quality and arousal/orgasm, and lower rates of dyspareunia at 1 year after surgery.

Perioperative outcomes for benign hysterectomy among women with thrombocytopenia

OBJECTIVE

To determine whether mild or moderate thrombocytopenia is associated with postoperative complications after benign hysterectomy.

METHODS

A retrospective study of data from women who underwent benign hysterectomy included in the American College of Surgeons National Surgical Quality Improvement Project Database. The data were stratified by normal platelet count, mild thrombocytopenia (100-149 × 10³ platelets/µl), and moderate thrombocytopenia (50-99 × 10³ platelets/µl). Multivariable logistic regression was used to determine the relationship between mild or moderate thrombocytopenia and the main outcome measures.

RESULTS

Moderate thrombocytopenia was associated with an increased risk of perioperative transfusion (adjusted odds ratio [aOR], 2.87; 95% confidence interval [CI], 1.96-4.21) and reoperation (aOR, 4.03; 95% CI, 1.94-17.33), but mild thrombocytopenia was not. There was an increased risk of infection among women with both mild (aOR, 1.38; 95% CI, 1.12-1.69) and moderate (aOR, 2.00; 95% CI,1.23-3.22) thrombocytopenia. There was no association between either mild or moderate thrombocytopenia and readmission, prolonged hospital stay, or longer surgical time.

CONCLUSION

Thrombocytopenia was found to be associated with increased infectious morbidity after hysterectomy, and moderate thrombocytopenia was associated with an increased risk of perioperative transfusion and reoperation.

Lower urinary tract symptoms in older Chinese American women: prevalence and risk factors

INTRODUCTION AND HYPOTHESIS

The aim was to examine the prevalence of and risk factors for lower urinary tract symptoms (LUTS) in a community-dwelling cohort of older Chinese American women.

METHODS

We performed a secondary analysis of a prospective cross-sectional population-based survey of community-dwelling Chinese Americans aged 60 and older in English, Mandarin, Cantonese, Taishanese, or Teochew between 2011 and 2013. A clinical Review of Systems (ROS) was used to assess LUTS, which included urinary frequency, urgency, burning or pain, blood in urine, and urinary incontinence.

RESULTS

Of the 1,829 women queried, 28.6% reported LUTS. The cohort of women who reported LUTS had a mean ± SD age of 74.7 ± 8.7 years, with a BMI of 23.4 ± 3.7 kg/m² and had lived in the USA for 21.5 ± 13.1 years. Nearly 90% earned less than $10,000 a year, 50% were married, and 50% used traditional Chinese medicine (TCM) once monthly or more. In comparison with women without LUTS, women with LUTS had significantly higher rates of medical comorbidities and a poorer perception of their general health and quality of life. In multivariate regression analysis, any LUTS were significantly associated with older age (aOR 1.03, 95% CI 1.01-1.04), TCM use (aOR 1.67, 95% CI 1.34-2.07), anxiety (aOR 1.45, 95% CI 1.02-2.06), depression (aOR 2.00, 95% CI 1.53-2.61), and a history of stroke (aOR 1.90, 95% CI 1.19-3.02).

CONCLUSIONS

Lower urinary tract symptoms are common among older Chinese American women, particularly in those who are older, use TCM regularly, or report a history of anxiety, depression, or stroke.

Complications following vaginal colpopexy for the repair of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The primary aim of this study was to compare differences in complication rates across different types of vaginal colpopexy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

METHODS

Patients who underwent intra- or extraperitoneal vaginal colpopexy with or without concurrent hysterectomy were identified in the 2014-2016 NSQIP database using Current Procedural Terminology codes. Patient demographics, preoperative comorbidities, American Society of Anesthesiologists (ASA) classification system scores, and total operating time were obtained. NSQIP-tracked 30-day codes were used to determine the complication, reoperation, and readmission rates.

RESULTS

A total of 9546 colpopexies were performed during the study period. The mean age was 62 ± 12 years, and the mean body mass index (BMI) was 28 ± 6 kg/m². The majority of patients were white (73%) with an ASA class of 2 (65%). The overall rate of postoperative complications was 10.5%. The most common complications were urinary tract infections (UTI) (5.1%), transfusion (1.0%), and superficial surgical site infection (0.7%). Excluding UTI, the rate of postoperative complications was 5.4%. After performing multivariable logistic regression, higher ASA class (class 3: aOR 1.69, 95% CI 1.16-2.51; class 4: aOR 3.98, 95% CI 1.51, 9.30) and extraperitoneal colpopexy with hysterectomy were independently associated with a higher odds of experiencing a non-UTI postoperative complication (aOR1.43, 95% CI 1.10, 1.84). Minority race was also independently associated with higher odds of experiencing a non-UTI postoperative complication (aOR 1.33, 95% CI 1.15, 1.52).

CONCLUSION

One in ten women undergoing vaginal colpopexy experienced a postoperative complication. Minority race and extraperitoneal colpopexy with concurrent hysterectomy were independently associated with an increased risk of a non-UTI postoperative complication.

Pain after permanent versus delayed absorbable monofilament suture for vaginal graft attachment during minimally invasive total hysterectomy and sacrocolpopexy

OBJECTIVES

The objective was to evaluate pain and dyspareunia in women undergoing minimally invasive total hysterectomy and sacrocolpopexy (TLH + SCP) with a light-weight polypropylene mesh 1 year after surgery.

METHODS

This is a planned secondary analysis of a randomized trial comparing permanent (Gore-Tex) versus absorbable suture (PDS) for vaginal attachment of a y-mesh (Upsylon™) during TLH + SCP in women with stage ≥II prolapse. Patient data were collected at baseline and 1 year after surgery. Our primary outcome was patient-reported pain or dyspareunia at 1 year.

RESULTS

Two hundred subjects (Gore-Tex n = 99, PDS n = 101) were randomized and underwent surgery. Overall, the mean age ± SD was 60 ± 10 years, and BMI was 27 ± 5 kg/m². The majority were white (89%), menopausal (77%), and had stage III/IV (63%) prolapse. 93% completed a 1-year follow-up and are included in this analysis (Gor-Tex n = 95, PDS n = 90). The overall rate of participants who reported pain at 1 year was 20%. Of those who did not report any pain at baseline, 23% reported de novo dyspareunia, 4% reported de novo pain, and 3% reported both at 1 year. Of participants who reported pain or dyspareunia at baseline prior to surgery, 66% reported resolution of their symptoms at 1 year. There were no differences in most characteristics, including mesh/suture exposure (7% vs 5%, p = 0.56) between patients who did and did not report any pain at 1 year. On multiple logistic regression controlling for age, baseline dyspareunia, and baseline pain, baseline dyspareunia was associated with a nearly 4-fold increased odds of reporting any pain at 1 year (OR 3.8, 95%CI 1.7-8.9).

CONCLUSIONS

The majority of women report resolution of pain 1 year following TLH + SCP with a low rate of de novo pain.

Delayed recognition of lower urinary tract injuries following hysterectomy for benign indications: A NSQIP-based study

OBJECTIVE

To describe the incidence of and factors associated with lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic indications using the NSQIP (National Surgical Quality Improvement Program) database.

METHODS

Patients who underwent hysterectomy for benign indications from 2014 through 2016 were identified in the NSQIP database using Current Procedural Terminology codes and International Classification of Diseases codes. Patient demographics, preoperative comorbidities, ASA classification system scores, and total operating time were collected. Data on 30-day postoperative complication rates, including rates of reoperation and readmission, were also captured. Genitourinary complications were defined as ureteral obstruction, ureteral fistula, and bladder fistula.

RESULTS

A total of 45,139 patients met inclusion criteria during the study period. Mean age and body mass index were 31 ± 11years and 32 ± 8 kg/m². The majority of patients were white (66%), had an ASA class of 2 (67%), and had no major medical comorbidities (68%). The most commonly performed primary surgery was laparoscopic hysterectomy (43%), followed by abdominal hysterectomy (27%). The incidence of any lower urinary tract complication was 0.2% (95% confidence interval, 0.19-0.28): 55 ureteral obstructions (0.1%, 95% confidence interval, 0.09-0.16), 33 ureteral fistulae (0.07%, 95% confidence interval, 0.05-0.1), and 28 bladder fistulae (0.06%, 95% confidence interval, 0.04-0.09). In a multivariable logistic regression model, black race (adjusted odds ratio, 1.90; 95% confidence interval, 1.20-2.96), endometriosis (adjusted odds ratio, 2.29; 95% confidence interval, 1.44-3.52), and prior abdominal surgery (adjusted odds ratio, 1.53; 95% confidence interval, 1.01-2.28) remained significantly associated with the occurrence of any lower urinary tract complication recognized in the immediate 30-day postoperative window.

CONCLUSION

Lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic disease are rare, with ureteral obstruction being the most commonly reported complication. The risk of these complications may be higher in patients who identify as black, had prior abdominal surgery, and/or have a diagnosis of endometriosis.

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications

BACKGROUND

Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes.

OBJECTIVE

The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications.

MATERIALS AND METHODS

This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO.

RESULTS

Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P <.001) and were more likely to smoke (21.0% vs 15.8%, P = .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P = .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P = .02), and cystotomy repair (1.0% vs 0.3%, P = .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65).

CONCLUSION

Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus

BACKGROUND

There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus.

OBJECTIVE

We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g.

STUDY DESIGN

This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period.

RESULTS

In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m². In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P = .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5).

CONCLUSION

The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy.

Sexual Health Before Treatment in Women with Suspected Gynecologic Malignancy

OBJECTIVES

Sexual health in survivors of gynecologic cancer has been studied; however, sexual health in these women before treatment has not been thoroughly evaluated. The objective of our study was to describe the pretreatment characteristics of sexual health of women with suspected gynecologic cancer before cancer treatment.

MATERIALS AND METHODS

We performed a cross-sectional analysis of women with a suspected gynecologic cancer, who were prospectively enrolled in a hospital-based cancer survivorship cohort from August 2012 to June 2013. Subjects completed the validated Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Questionnaire. Pretreatment sexual health was assessed in terms of sexual interest, desire, lubrication, discomfort, orgasm, enjoyment, and satisfaction.

RESULTS

Of 186 eligible women with suspected gynecologic cancer, 154 (82%) completed the questionnaire pretreatment. Mean age was 58.1 ± 13.3 years. Sexual health was poor: 68.3% reported no sexual activity, and 54.7% had no interest in sexual activity. When comparing our study population to the general U.S. population, the mean pretreatment scores for the subdomains of lubrication and vaginal discomfort were similar, while sexual interest was significantly lower and global satisfaction was higher. In a linear regression model, controlling for cancer site, age remained significantly associated with sexual function while cancer site did not.

CONCLUSIONS

Problems with sexual health are prevalent in women with suspected gynecologic malignancies before cancer treatment. Increasing awareness of the importance of sexual health in this population will improve quality of life for these women.

Perioperative sexual interest in women with suspected gynecologic malignancies

OBJECTIVES

For women with gynecologic cancer, the impact of surgery on sexual interest and desire in the immediate and later postoperative period is not well characterized. The objective of this study was to report the perioperative trends of changing sexual interest and desire in a cohort of women undergoing surgery for suspected gynecologic malignancies.

METHODS

This is an ancillary analysis of a cohort study analyzing health-related outcomes in women who underwent primary surgical management of a suspected gynecologic malignancy between 10/2013 and 10/2014. Subjects completed the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Questionnaire (PROMIS-SFQ) preoperatively and questions on sexual interest and desire at one, three, and six months postoperatively. Bivariate tests and multiple linear regression were used to analyze data.

RESULTS

Of 231 women who completed a baseline PROMIS-SFQ, 187 (81%) completed one-month, 170 (74%) three-month, and 174 (75%) six-month follow-up interviews. Following surgery, 71% of enrolled subjects were diagnosed with a malignancy. Women age <55 had a greater decrease in sexual interest from baseline to one month than women age >55 (-5.5±1.0 vs -2.3±0.9, p=0.02). In a multivariable analysis, age <55 remained associated with a larger decrease in sexual interest at one month postoperatively (-4.6, 95% CI: -1.8, -7.4), as did having cancer vs benign disease for women of all ages (-5.6, 95% CI: -9.6, -1.5).

CONCLUSIONS

This study provides new data regarding the timing and magnitude of changes in sexual interest following gynecologic oncology procedures.

Entry into the peritoneal cavity in posthysterectomy prolapse: an educational video

INTRODUCTION AND HYPOTHESIS

Entry into the peritoneal cavity can be challenging in patients with posthysterectomy prolapse; however, it is important for vaginal surgeons to be able to enter the peritoneal cavity using various techniques to perform an intraperitoneal vaginal vault suspension.

METHODS

We present surgical footage of various methods of accessing the peritoneal cavity in posthysterectomy prolapse using posterior, anterior and apical approaches.

RESULTS

This video highlights surgical techniques that can be used to enter the peritoneal cavity in posthysterectomy prolapse in a safe and reliable manner.

CONCLUSIONS

Vaginal surgeons should be able to safely and confidently identify and enter the peritoneal cavity using various approaches to perform an intraperitoneal vaginal vault suspension.

Minimally invasive hysterectomy for benign indications: an update

Hysterectomy is one of the most commonly performed surgeries worldwide. Indication for hysterectomy is most often benign, which includes conditions such as prolapse, abnormal uterine bleeding, fibroids and pelvic pain. A broad range of surgical approaches exists for hysterectomy, ranging from open to minimally invasive techniques. Under this minimally invasive umbrella, the following techniques are included: vaginal hysterectomy, laparoscopic hysterectomy, and variations of those two techniques, such as laparoscopic-assisted vaginal hysterectomy, robotic-assisted hysterectomy, laparo-endoscopic single-site laparoscopic hysterectomy, mini-laparoscopic hysterectomy, and natural orifice transluminal endoscopic surgery hysterectomy. As hysterectomy is being performed increasingly via a minimally invasive route, it is important that gynecologists are familiar with the established as well as emerging techniques for minimally invasive hysterectomy (MIH). Surgical planning is a complex process, which requires an in depth and informed conversation between a patient and her physician. Patient preferences, surgeon skill and indication for surgery all should be taken into consideration when determining the most appropriate surgical approach. This article will review the different routes of MIH. Perioperative considerations will be discussed, as will the advantages and disadvantages of each minimally invasive approach.

The Association of the Braden Scale Score and Postoperative Morbidity Following Urogynecologic Surgery

The Braden scale is a widely used tool to assess pressure ulcer risk. Preoperative Braden scores were significantly associated with postoperative morbidity among women undergoing urogynecologic surgery for stress incontinence and pelvic organ prolapse.

Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study

INTRODUCTION AND HYPOTHESIS

Understanding of pelvic floor disorders among women with gynecological cancer is limited. The objective of this study was to describe the prevalence of pelvic floor disorders in women with suspected gynecological malignancy before surgery.

METHODS

A cross-sectional study was performed of women aged ≥18 with a suspected gynecological malignancy who enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort (HR/CSC) from August 2012 to June 2013. Demographics were obtained from the HR/CSC self-reported data; clinical data were abstracted from the electronic medical record. Subjects completed validated questionnaires (Rotterdam Symptom Checklist and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms) to assess bladder and bowel function.

RESULTS

Among 186 women scheduled for surgery for gynecological malignancy, 152 (82 %) completed baseline assessments before surgery. Mean age was 58.1 ± 13.3 years, and mean BMI was 33.6 ± 8.8 kg/m(2). The majority of subjects had uterine cancer (61.8 %), followed by ovarian (17.1 %) and cervical (11.1 %). At baseline, the rate of urinary incontinence (UI) was 40.9 %. A third of subjects reported stress UI, and one quarter reported urge UI. The overall rate of fecal incontinence was 3.9 %, abdominal pain was 47.4 %, constipation was 37.7 %, and diarrhea was 20.1 %. When comparing cancer types, there were no differences in pelvic floor symptoms.

CONCLUSION

Pelvic floor disorders are common in women with suspected gynecological malignancy at baseline before surgery. Recognizing pelvic floor disorders in the preoperative setting will allow for more individualized, comprehensive care for these women.

Patient characteristics associated with treatment choice for pelvic organ prolapse and urinary incontinence

INTRODUCTION AND HYPOTHESIS

Women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) frequently undergo more than one treatment prior to settling on their final strategy. We hypothesize that women who are younger, with worse POP and SUI symptoms will desire and choose surgical treatment.

METHODS

A retrospective cohort study was performed over 1 year identifying new patients presenting with POP and/or SUI at a university hospital. Our aim was to determine patient desire for either surgical or conservative treatment, as well as the actual treatment chosen and received after the first visit and 1 year later. To identify predictors of choice, baseline demographic characteristics were obtained.

RESULTS

Of the 203 women who met the inclusion criteria, 44.3 % (90/203) desired surgery and 55.7 % (113/203) desired conservative treatment at their first visit. Women who desired surgery were more likely to be younger (p = 0.003), sexually active (p = 0.001), have more advanced prolapse (p = 0.006), and have more bothersome symptoms (p = 0.05). Of the women who desired surgery at their first visit, 12.2 % (11/90) actually chose conservative treatment. These women were less likely to be insured (p = 0.01). By 1 year, of the women who initially desired and subsequently chose conservative treatment, 26.5 % (30/113) had undergone surgery. The women who changed from conservative to surgical treatment were more likely to be younger (p = 0.01), non-White (p = 0.03), and sexually active (p = 0.04).

CONCLUSIONS

In this study, younger, sexually active women were more likely to either opt for surgery initially or to change their treatment plan from conservative to surgical.