Short-Term Outcomes After Hysterectomy for Endometrial Cancer/EIN With Concomitant Pelvic Floor Disorder Surgery

IMPORTANCE

Endometrial cancer and precancer are common gynecologic problems for many women. A majority of these patients require surgery as the mainstay of treatment. Many of these patients often have concurrent pelvic floor disorders. Despite the prevalence and shared risk, fewer than 3% of women undergo concomitant surgery for PFDs at the time of surgery for endometrial cancer or endometrial intraepithelial neoplasia/hyperplasia.

OBJECTIVE

This study aimed to evaluate postoperative morbidity of concomitant pelvic organ prolapse (POP) and/or urinary incontinence (UI) procedures at the time of hysterectomy for endometrial cancer (EC) or endometrial intraepithelial neoplasia/endometrial hyperplasia (EIN/EH).

METHODS

This retrospective analysis of women undergoing hysterectomy for EC or EIN/EH between 2017 and 2022 used the American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome was any major complication within 30 days of surgery. Comparisons were made between 2 cohorts: hysterectomy with concomitant pelvic organ prolapse/urinary incontinence procedures (POPUI) versus hysterectomy without concomitant POP or UI procedures (HYSTAlone). A subgroup analysis was performed in patients with EC. A propensity score matching cohort was also created.

RESULTS

A total of 23,144 patients underwent hysterectomy for EC or EIN/EH: 1.9% (n = 432) had POP and/or UI procedures. Patients with POPUI were older, were predominantly White, had higher parity, and had lower body mass index with lower American Society of Anesthesiologists class. Patients with POPUI were less likely to have EC (65.7% vs 78.3%, P < 0.0001) and more likely to have their hysterectomy performed by a general obstetrician- gynecologists or urogynecologists. Major complications were low and not significantly different between POPUI and HYSTAlone (3.7% vs 3.6%, P = 0.094). A subgroup analysis of EC alone found that the HYSTAlone subset did not have more advanced cancers, yet the surgeon was more likely a gynecologic oncologist (87.1% vs 68.0%, P < 0.0001). There were no statistically significant differences between the 2 cohorts for the primary and secondary outcomes using propensity score matching analysis.

CONCLUSIONS

Concomitant prolapse and/or incontinence procedures were uncommon and did not increase the rate of 30-day major complications for women undergoing hysterectomy for EC/EH.

Pelvic Floor Disorders in Black Women: Prevalence, Clinical Care, and a Strategic Agenda to Prioritize Care

Pelvic floor disorders are a group of common conditions affecting women of all racial and ethnic groups. These disorders are undertreated in all women, but this is especially magnified in Black people who have been historically marginalized in the United States. This article seeks to highlight the prevalence of pelvic floor disorders in Black women, evaluate the clinical care they receive, examine barriers they face to equitable care, and present a strategic agenda to prioritize the care of Black women with pelvic floor disorders.

Associations between gynecologic clinician type and routine female sexual dysfunction screening

BACKGROUND

Female sexual dysfunction (FSD) is a common problem in the United States; however, only 14% to 40% of women are screened by their health care clinicians. There are few data on how differences in clinician type affects screening rates.

AIM

This study aimed to assess differences in FSD screening rates among gynecology clinician types, identify factors associated with screening, and compare screening rates of FSD against conditions with established screening recommendations.

METHODS

Data were collected by retrospective chart review of annual visits at an urban tertiary care center. Screening rates for FSD, depression, cervical cancer, and breast cancer were calculated and compared. Multivariable logistic regression modeling was utilized to assess the correlation between various patient characteristics and FSD screening rates.

OUTCOMES

Study outcome measures included percentages of women who were screened for FSD, depression, cervical cancer, and breast cancer.

RESULTS

FSD screening rate was significantly higher among resident-level clinicians vs nonresident clinicians (59% vs 31%; P < .001). When the nonresident clinicians were subanalyzed, certified nursing midwives were the second most likely to screen for FSD (odds ratio [OR], 0.41), followed by nurse practitioners (OR, 0.29) and attending physicians (OR, 0.22). According to multivariable logistic regression techniques, 5 factors were associated with an increased likelihood of a patient being screened for FSD at an annual examination: patient seen by a resident physician rather than an attending physician, patient history of FSD, patient age ≥40 years, patient report of being sexually active at the time of visit, and patient history of cervical procedures.

CLINICAL IMPLICATIONS

There is an opportunity to improve FSD screening rates by clinicians. Future research may assess what factors, such as increased sexual function education or greater incentives to document FSD screening, may result in higher screening rates. From this, targeted and effective interventions might be crafted to improve future screening rates.

STRENGTHS AND LIMITATIONS

This study is one of the first to compare FSD screening rates among clinician types in the same specialty. Study limitations include the inherent limitations of a retrospective design, including selection biases.

CONCLUSION

Residents were more likely to screen for FSD at annual well-woman visits than attending clinicians, nurse practitioners, and certified nurse midwives. Understanding the reasons for varied FSD screening rates among clinician types may aid in the development of strategies to improve screening for this important aspect of women's health.

Frailty and Acute Postoperative Urinary Retention in Older Women Undergoing Pelvic Organ Prolapse Surgery

IMPORTANCE

Acute postoperative urinary retention (POUR) is common after pelvic reconstructive surgery, occurring in 15-45% of women. There is a paucity of data on the relationship between frailty and POUR after prolapse surgery.

OBJECTIVE

This study aimed to examine the association between frailty and POUR in older women who underwent pelvic organ prolapse surgery.

STUDY DESIGN

This secondary analysis of a prospective study of postoperative delirium enrolled women 60 years and older undergoing prolapse surgery. The Fried Frailty Index was used to assess frailty before surgery. Acute POUR was defined as failure to pass a retrograde voiding trial at hospital discharge with postvoid residual volume of greater than 100 mL.

RESULTS

Analyses included 165 women, with a mean ± SD age of 72.5 ± 6.1 years and a body mass index of 28.0 ± 4.4 kg/m2. There were 49 laparoscopic/robotic apical suspension procedures (29.7%), 60 vaginal obliterative procedures (36.4%), 47 vaginal apical suspension procedures (28.5%), and 9 isolated anterior and/or posterior colporrhaphies (5.5%), of which 9 had a concomitant incontinence procedure. Seventy-eight women (47.3%) experienced acute POUR. Thirty-one (18.8%) met the criteria for "not frail," 115 (88.5%) were "prefrail," and 19 (11.5%) were "frail." Neither frailty status nor score was associated with POUR. In an analysis of individual Fried Frailty Index components, self-reported unintentional weight loss was significantly associated with POUR (odds ratio, 4.6; 95% confidence interval, 1.23-17.15). This remained significant on multivariable logistic regression (adjusted odds ratio, 4.06; 95% confidence interval, 1.01-16.39).

CONCLUSIONS

Frailty was not associated with POUR in older women undergoing prolapse surgery. The observed association between POUR and unintended weight loss before surgery warrants further investigation.

Postpartum urinary retention: an expert review

Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.

Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology

PURPOSE OF REVIEW

To review current US literature and describe the extent, source, and impact of disparities that exist among Black, Indigenous, and people of color (BIPOC) in surgical route and outcomes for hysterectomy, myomectomy, and endometriosis surgery.

RECENT FINDINGS

Despite the nationwide trend toward minimally invasive surgery (MIS), BIPOC women are disproportionally less likely to undergo MIS hysterectomy and myomectomy and have higher rates of perioperative complications. African American women, in particular, receive significantly disparate care. Contemporary literature on the prevalence of endometriosis in BIPOC women is lacking. Further, there is little data on the racial and ethnic differences in endometriosis surgery access and outcomes.

SUMMARY

Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology exist and these differences are not fully accounted for by patient, socioeconomic, or healthcare infrastructure factors. Initiatives that incentivize hiring surgeons trained to perform complex gynecologic surgery, standardized pathways for route of surgery, quality improvement focused on increased hospital MIS volume, and hospital-based public reporting of MIS volume data may be of benefit for minimizing disparities. Further, initiatives to reduce disparities need to address racism, implicit bias, and healthcare structural issues that perpetuate disparities.

Reliability and Validity of 2 Surgical Prioritization Systems for Reinstating Nonemergent Benign Gynecologic Surgery during the COVID-19 Pandemic

STUDY OBJECTIVE

Scientifically evaluate the validity and reproducibility of 2 novel surgical triaging systems, as well as offer modifications to the Medically-Necessary, Time-Sensitive (MeNTS) criteria for improved application in gynecologic surgeries.

DESIGN

Retrospective cohort study.

SETTING

Academic university hospital.

PATIENTS

Ninety-seven patients with delayed benign gynecologic procedures owing to the coronavirus disease 2019 pandemic.

INTERVENTION(S)

Surgical prioritization was assessed using 2 novel scoring systems, the Gynecologic Medically-Necessary Time-Sensitive (Gyn-MeNTS) and modified Elective Surgery Acuity Scale (mESAS) systems for all 93 patients included.

MEASUREMENTS AND MAIN RESULTS

The interrater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. The Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3-level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. The Gyn-MeNTS interrater reliability was tested using Spearman r and paired t tests were used to detect systematic differences between raters. Weighted κ indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Spearman r's for all Gyn-MeNTS rater pairs were above 0.80 (0.84 for 1 vs 2; 0.82 for 1 vs 3; and 0.82 for 2 vs 3, all p <.001) indicating strong agreement. The weighted κ for the 2 mESAS raters was 0.57 (95% confidence interval, 0.40-0.73) indicating moderate agreement. When used together, both scores were significantly independently associated with SSP, with strong discrimination (area under the curve, 0.89).

CONCLUSION

Interrater reliability is acceptable for both scoring systems, and concurrent validity of each is moderate for predicting SSP, but discrimination improves to a high level when they are used together.

Outcomes of a Staged Midurethral Sling Strategy for Stress Incontinence and Pelvic Organ Prolapse

OBJECTIVE

To evaluate the proportion of women who experienced resolution of stress urinary incontinence (SUI) symptoms after surgery for pelvic organ prolapse (POP) without a concomitant incontinence procedure.

METHODS

We conducted a retrospective observational study of women with preoperative subjective and objective SUI who underwent minimally invasive sacrocolpopexy or uterosacral ligament suspension from 2009 to 2015. We excluded cases with incontinence procedures. The primary outcome was the proportion of women with subjective resolution of SUI postoperatively, defined as the absence of patient reported SUI symptoms during follow-up. Secondary outcomes included the proportion of women who underwent a subsequent staged midurethral sling (MUS) procedure and factors associated with resolution of SUI and staged MUS placement.

RESULTS

Of 93 women, most were white (n=90, 98%) with stage III POP (n=55, 59%). Mean age was 59.5±8.9 years and body mass index 28.7±4.7. Seventy-three patients (78%) underwent minimally invasive sacrocolpopexy, and 20 (22%) underwent uterosacral ligament suspension. Median follow-up was 8.3 months (interquartile range 3.4-26.7). Postoperatively, 28 (30%) patients reported resolution of SUI, and 65 (70%) reported persistent SUI. Of the 93 patients, 47 (51%) were treated for persistent SUI and 34 (37%) underwent a staged MUS procedure. Among the staged MUS procedures, 27 (79%) were placed within 12 months. Median time to staged MUS procedure was 5.5 months (interquartile range 4.2-9.9). After controlling for degree of preoperative SUI bother, obese women were less likely to experience resolution of SUI after prolapse repair (odds ratio 0.28, 95% CI 0.08-0.95). We did not identify any factors that were significantly associated with undergoing a staged MUS procedure on univariate analyses (P>.05).

CONCLUSION

Preoperative SUI resolved in nearly a third of women after prolapse surgery without a concomitant incontinence procedure. In a population typically offered a concomitant MUS procedure at the time of prolapse repair, a staged approach may result in nearly two-thirds fewer patients undergoing MUS procedures. This information may be helpful during preoperative shared decision making.

Impact of polypropylene prolapse mesh on vaginal smooth muscle in rhesus macaque

BACKGROUND

The use of polypropylene prolapse mesh to treat pelvic organ prolapse has been limited by mesh-related complications. Gynemesh PS mesh, implanted via sacrocolpopexy in rhesus macaques, had a negative impact on the vagina with thinning of vaginal muscularis and decreased vaginal smooth muscle contractility. The negative effect was attenuated when a bioscaffold derived from urinary bladder extracellular matrix was used as a composite with Gynemesh PS.

OBJECTIVE

The objective of the study was to further elucidate the impact of Gynemesh PS polypropylene mesh and MatriStem extracellular matrix bioscaffolds on the vaginal smooth muscle in terms of micromorphology of vaginal smooth muscle (muscle bundles and individual myocytes), innervation, and nerve-mediated contractile function following their implantations in a rhesus macaque model via sacrocolpopexy.

STUDY DESIGN

Thirty-two middle-aged rhesus macaques were randomized to undergo either a sham surgery (sham, n = 8), or the implantation of Gynemesh PS alone (n = 8) vs composite mesh comprised of Gynemesh PS plus 2-ply MatriStem (n = 8) vs 6-ply MatriStem alone (n = 8) via sacrocolpopexy. The graft-vagina complexes were harvested 3 months later. Histomorphometrics of smooth muscle bundles and myocytes were performed by immunofluorescent labeling of alpha smooth muscle actin, caveolin-3 (membrane protein), and cell nuclei followed by confocal imaging. The cross-sectional diameters of smooth muscle bundles and individual myocytes were quantified using images randomly taken in at least 5 areas of each section of sample. Contractile proteins alpha smooth muscle actin and smoothelin were quantified by Western immunoblotting. Nerve density was measured by immunohistochemical labeling of a pan-neuron marker, PGP9.5. Nerve-mediated smooth muscle contractility was quantified using electrical field stimulation. One-way analysis of variance and appropriate post hoc tests were used for statistical comparisons.

RESULTS

Compared with sham, the implantation of Gynemesh PS alone resulted in a disorganized smooth muscle morphology with the number of small muscle bundles (cross-sectional diameter less than 20 μm) increased 67% (P = .004) and the myocyte diameter decreased 22% (P < .001). Levels of contractile proteins were all decreased vs sham with alpha smooth muscle actin decreased by 68% (P = .009), low-molecular-weight smoothelin by 51% (P = .014), and high-molecular-weight smoothelin by 40% (P = .015). Nerve density was decreased by 48% (P = .03 vs sham) paralleled by a 63% decrease of nerve-mediated contractility (P = .02). Following the implantation of composite mesh, the results of measurements were similar to sham (all P > .05), with a 39% increase in the myocyte diameter (P < .001) and a 2-fold increase in the level of alpha smooth muscle actin relative to Gynemesh (P = .045). Following the implantation of MatriStem alone, the number of small muscle bundles were increased 54% vs sham (P = .002), while the other parameters were not significantly different from sham (all P > .05).

CONCLUSION

The implantation of Gynemesh PS had a negative impact on the structural and functional integrity of vaginal smooth muscle evidenced by atrophic macro- and microscopic muscle morphology, decreased innervation, and impaired contractile property, consistent with a maladaptive remodeling response. The extracellular matrix bioscaffold (MatriStem), when used with Gynemesh PS as a composite (2 ply), attenuated the negative impact of Gynemesh PS; when used alone (6 ply), it induced adaptive remodeling as evidenced by an increased fraction of small smooth muscle bundles with normal contractility.

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway

OBJECTIVE

Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postoperative recovery. Variations of the protocol are being adopted for gynecological procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate whether implementation of an enhanced recovery after surgery pathway would facilitate reduced length of admission in a urogynecology population.

MATERIALS AND METHODS

In this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons, we compared same-day discharge, length of admission and postoperative complications before and after implementation of an enhanced recovery after surgery pathway at a tertiary care hospital. Groups were compared using χ² and Student t tests. Candidate variables that could have an impact on patient outcomes with P < .2 were included in multivariable logistic regression models. Satisfaction with surgical experience was assessed using a phone-administered questionnaire the day after discharge.

RESULTS

Mean age and body mass index of 258 women (137 before enhanced recovery after surgery and 121 enhanced recovery after surgery) were 65.5 ± 11.3 years and 28.2 ± 5.0 kg/m². The most common diagnosis was pelvic organ prolapse (n = 242, 93.8%) including stage III pelvic organ prolapse (n = 61, 65.1%). Apical suspension procedures included 58 transvaginal (25.1%), 112 laparoscopic/robotic (48.8%), and 61 obliterative (26.4%). Hysterectomy was performed in 57.4% of women. Demographic and surgical procedures were similar in both groups. Compared with before enhanced recovery after surgery, the enhanced recovery after surgery group had a higher proportion of same-day discharge (25.9% vs 91.7%, P < .001) and a 13.8 hour shorter duration of stay (25.9 ± 13.5 vs 12.1 ± 11.2 hours, P <.001). Operative and postsurgical recovery room times were similar (2.6 ± 0.8 vs 2.6 ± 0.9 hours, P =.955; 3.7 ± 2.1 vs 3.6 ± 2.2 hours, P = .879). Women in the enhanced recovery after surgery group were more likely to be discharged using a urethral catheter (57.9% enhanced recovery after surgery vs 25.4% before enhanced recovery after surgery, P = .005). There were no group differences in total 30 day postoperative complications overall and for the following categories: urinary tract infections, emergency room visits, unanticipated office visits, and return to the operating room. However, enhanced recovery after surgery patients had higher 30 day hospital readmission rates (n = 8, 6.7% vs n = 2, 1.5%, P = .048). Patients before enhanced recovery after surgery were readmitted for myocardial infarction and chest pain. Enhanced recovery after surgery patients were admitted for weakness, chest pain, hyponatremia, wound complications, nausea/ileus, and ureteral obstruction. Three enhanced recovery after surgery patients returned to the operating room for ureteral obstruction (n = 1), incisional hernia (n = 1), and vaginal cuff bleeding (n = 1). Enhanced recovery after surgery patients also had more postoperative nursing phone notes (2.6 ± 1.7 vs 2.1 ± 1.4, P = .030). On multivariable logistic regressions adjusting for age and operative time, same-day discharge was more likely in the enhanced recovery after surgery group (odds ratio, 32.73, 95% confidence interval [15.23-70.12]), while the odds of postoperative complications and emergency room visits were no different. After adjusting for age, operative time, and type of prolapse surgery, readmission was more likely in the enhanced recovery after surgery group (odds ratio, 32.5, 95% confidence interval [1.1-28.1]). In the enhanced recovery after surgery group, patient satisfaction (n = 77 of 121) was reported as very good or excellent by 86.7% for pain control, 89.6% for surgery preparedness, and 93.5% for overall surgical experience; 89.6% did not recall any postoperative nausea during recovery.

CONCLUSION

Enhanced recovery after surgery implementation in a urogynecology population resulted in a greater proportion of same-day discharge and high patient satisfaction but with slightly increased hospital readmissions within 30 days.

Risk factors for explantation due to infection after sacral neuromodulation: a multicenter retrospective case-control study

BACKGROUND

Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fecal incontinence. Infection after sacral neurostimulation is costly and burdensome. Determining optimal perioperative management strategies to reduce the risk of infection is important to reduce this burden.

OBJECTIVE

We sought to identify risk factors associated with sacral neurostimulator infection requiring explantation, to estimate the incidence of infection requiring explantation, and identify associated microbial pathogens.

STUDY DESIGN

This is a multicenter retrospective case-control study of sacral neuromodulation procedures completed from Jan. 1, 2004, through Dec. 31, 2014. We identified all sacral neuromodulation implantable pulse generator implants as well as explants due to infection at 8 participating institutions. Cases were patients who required implantable pulse generator explantation for infection during the review period. Cases were included if age ≥18 years old, follow-up data were available ≥30 days after implantable pulse generator implant, and the implant was performed at the institution performing the explant. Two controls were matched to each case. These controls were the patients who had an implantable pulse generator implanted by the same surgeon immediately preceding and immediately following the identified case who met inclusion criteria. Controls were included if age ≥18 years old, no infection after implantable pulse generator implant, follow-up data were available ≥180 days after implant, and no explant for any reason <180 days from implant. Controls may have had an explant for reasons other than infection at >180 days after implant. Fisher exact test (for categorical variables) and Student t test (for continuous variables) were used to test the strength of the association between infection and patient and surgery characteristics. Significant variables were then considered in a multivariable logistic regression model to determine risk factors independently associated with infection.

RESULTS

Over a 10-year period at 8 academic institutions, 1930 sacral neuromodulator implants were performed by 17 surgeons. In all, 38 cases requiring device explant for infection and 72 corresponding controls were identified. The incidence of infection requiring explant was 1.97%. Hematoma formation (13% cases, 0% controls; P = .004) and pocket depth of ≥3 cm (21% cases, 0% controls; P = .031) were independently associated with an increased risk of infection requiring explant. On multivariable regression analysis controlling for significant variables, both hematoma formation (P = .006) and pocket depth ≥3 cm (P = .020, odds ratio 3.26; 95% confidence interval, 1.20-8.89) remained significantly associated with infection requiring explant. Of the 38 cases requiring explant, 32 had cultures collected and 24 had positive cultures. All 5 cases with a hematoma had a positive culture (100%). Of the 4 cases with a pocket depth ≥3 cm, 2 had positive cultures, 1 had negative cultures, and 1 had a missing culture result. The most common organism identified was methicillin-resistant Staphylococcus aureus (38%).

CONCLUSION

Infection after sacral neuromodulation requiring device explant is low. The most common infectious pathogen identified was methicillin-resistant S aureus. Demographic and health characteristics did not predict risk of explant due to infection, however, having a postoperative hematoma or a deep pocket ≥3 cm significantly increased the risk of explant due to infection. These findings highlight the importance of meticulous hemostasis as well as ensuring the pocket depth is <3 cm at the time of device implant.

Prolapse recurrence following sacrocolpopexy vs uterosacral ligament suspension: a comparison stratified by Pelvic Organ Prolapse Quantification stage

BACKGROUND

Insufficient evidence evaluates which pelvic organ prolapse surgery is best suited to an individual woman based on the stage of her prolapse.

OBJECTIVE

We sought to compare prolapse recurrence rates following sacrocolpopexy and uterosacral ligament suspension after stratifying by preoperative Pelvic Organ Prolapse Quantification stage.

STUDY DESIGN

We compared all women who underwent minimally invasive sacrocolpopexy or vaginal or minimally invasive uterosacral ligament suspension from 2009 through 2015 at a large academic center. All women with preoperative and postoperative Pelvic Organ Prolapse Quantification data were included. Patients were grouped by preoperative Pelvic Organ Prolapse Quantification stage for analysis. Recurrence rates following sacrocolpopexy and uterosacral ligament suspension were compared for patients presenting with stage II, III, and IV prolapse, adjusting for potential confounders in regression models. Prolapse recurrence was defined as any retreatment for prolapse or any Pelvic Organ Prolapse Quantification point beyond the hymen.

RESULTS

Of 756 women, 633 underwent sacrocolpopexy (83.7%) and 123 (16.3%) underwent uterosacral ligament suspension. In all, 189 (25%) had preoperative Pelvic Organ Prolapse Quantification stage II prolapse, 527 (69.7%) stage III, and 40 (5.3%) stage IV. Patients were predominantly Caucasian (97.3%) with mean age 59.8 ± 9.5 years. Compared to uterosacral ligament suspension patients, more sacrocolpopexy patients had undergone prior prolapse repair (20.9% vs 5.7%, P < .001) and fewer had known diabetes mellitus (7.9% vs 13.8%, P = .034). Characteristics of the groups were otherwise similar. Median follow-up was 41.0 (interquartile range 13.0-88.8) weeks. Stage II prolapse patients had similar recurrence rates following sacrocolpopexy or uterosacral ligament suspension (6.0% vs 5.0, P = 1.00). However, stage III prolapse patients were more likely to experience recurrence following uterosacral ligament suspension (25.7% vs 7.8%, P < .001). This difference persisted after controlling for age, body mass index, smoking, diabetes, and prior prolapse repair (odds ratio, 4.3; 95% confidence interval, 2.2-8.2). There was no discernable difference in recurrence rates for women with stage IV prolapse, although sample size was limited.

CONCLUSION

Sacrocolpopexy resulted in a lower prolapse recurrence rate than uterosacral ligament suspension for stage III prolapse. However, there was no difference in recurrence rate among women with preoperative stage II prolapse, suggesting mesh augmentation may not be indicated for these patients. Larger prospective trials are necessary for confirmation.

The Impact of Individual Surgeon Volume on Hysterectomy Costs

Background and Objective:

Hysterectomy is one of the most common surgical procedures women will undergo in their lifetime. Several factors affect surgical outcomes. It has been suggested that high-volume surgeons favorably affect outcomes and hospital cost. The objective is to determine the impact of individual surgeon volume on total hospital costs for hysterectomy.

Methods:

This is a retrospective cohort of women undergoing hysterectomy for benign indications from 2011 to 2013 at 10 hospitals within the University of Pittsburgh Medical Center System. Cases that included concomitant procedures were excluded. Costs by surgeon volume were analyzed by tertile group and with linear regression.

Results:

We studied 5,961 hysterectomies performed by 257 surgeons: 41.5% laparoscopic, 27.9% abdominal, 18.3% vaginal, and 12.3% robotic. Surgeons performed 1–542 cases (median = 4, IQR = 1–24). Surgeons were separated into equal tertiles by case volume: low (1–2 cases; median total cost, $4,349.02; 95% confidence interval [CI] [$3,903.54–$4,845.34]), medium (3–15 cases; median total cost, $2,807.90; 95% CI [$2,693.71–$2,926.93]) and high (>15 cases, median total cost $2,935.12, 95% CI [$2,916.31–$2,981.91]). ANOVA analysis showed a significant decrease (P < .001) in cost from low-to-medium– and low-to-high–volume surgeons. Linear regression showed a significant linear relationship (P < .001), with a $1.15 cost reduction per case with each additional hysterectomy. Thus, if a surgeon performed 100 cases, costs were $115 less per case (100 × $1.15), for a total savings of $11,500.00 (100 × $115).

Conclusion:

Overall, in our models, costs decreased as surgeon volume increased. Low-volume surgeons had significantly higher costs than both medium- and high-volume surgeons.