Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery

INTRODUCTION AND HYPOTHESIS

The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery.

METHODS

We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP).

RESULTS

For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90.

CONCLUSIONS

A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.

Neglect as an undefined and overlooked aspect of medical student mistreatment: A systematic review of the literature

PURPOSE

Although the mistreatment of medical students is a well-researched topic, the scope of mistreatment often leaves out neglect, a subtype for which there is no accepted definition based in the published literature. This review sought to summarize the existing data on the prevalence and descriptors of neglect, identify strategies seen in the literature designed to improve it, and offer a synthesized definition of this phenomenon to guide future research.

METHODS

Following PRISMA guidelines, a relevant systematic literature search from 2000 to April 2021 was performed to identify literature on neglect in clinical settings within American medical schools.

RESULTS

Neglect, a poorly defined phenomenon in medical education related to the suboptimal learning environment, is often excluded from research on medical student mistreatment. Neglect is a barrier to a successful learning environment, yet a paucity of data and the heterogeneous nature of the present literature render it difficult to estimate its true prevalence. Studies that include neglect frequently assess it solely as the result of identity discrimination or stated career interests. Recent interventions include promoting longitudinal relationships between students and clinical faculty and establishing teaching expectations.

CONCLUSIONS

Neglect is the mistreatment of medical students by the medical care team via a lack of meaningful inclusion in the clinical environment such that it has a notable negative impact on learning and student well-being, regardless of intentionality. An established definition that is grounded in the literature is required to create a common point of reference and understand its true prevalence, its associated variables, and the best mitigation strategies, as well as to guide future research, which should examine neglect independently and as a consequence of personal and professional identities.

A systematic review and in silico study of potential genetic markers implicated in cases of overactive bladder

OBJECTIVE

The contribution of genetic factors to the presence of an overactive bladder is recognized. This study aimed to (1) assemble and synthesize available data from studies assessing differential gene expression in patients with overactive bladder vs controls without overactive bladder and (2) determine possible correlations and functional pathways between genes.

DATA SOURCES

We searched PubMed, Ovid or Medline, and Wiley Cochrane Central Register of Controlled Trials databases between January 1, 2000, and December 15, 2021.

STUDY ELIGIBILITY CRITERIA

Studies were included if gene expression was detected and quantified using molecular approaches performed on human bladder tissue specimens directly and excluded if the gene expression analysis was carried out from blood and urine specimens alone.

METHODS

A systematic review was completed to identify publications that reported differently expressed gene candidates among patients with overactive bladder vs healthy individuals. Gene networking connections and pathway analysis were performed employing Metascape software, where inputs were identified from our systematic review of differentially expressed genes in overactive bladder.

RESULTS

A total of 9 studies were included in the final analysis and 11 genes were identified as being up-regulated (purinergic receptor P2X 2 [P2RX2], smoothelin [SMTN], growth-associated protein 43 [GAP43], transient receptor potential cation channel subfamily M member 8 [TRPM8], cadherin 11 [CDH1], gap junction protein gamma 1 [GJC1], cholinergic receptor muscarinic 2 [CHRM2], cholinergic receptor muscarinic 3 [CHRM3], and transient receptor potential cation channel subfamily V member 4 [TRPV4]) or down-regulated (purinergic receptor P2X 2 [P2RX3] and purinergic receptor P2X 5 [P2RX5]) in patients with overactive bladder. Gene network analysis showed that genes are involved in chemical synaptic transmission, smooth muscle contraction, blood circulation, and response to temperature stimulus. Network analysis demonstrated a significant genetic interaction between TRPV4, TRPM8, P2RX3, and PR2X2 genes.

CONCLUSION

Outcomes of this systematic review highlighted potential biomarkers for treatment efficacy and have laid the groundwork for developing future gene therapies for overactive bladder in clinical settings.

Skene's Gland Malignancy: A Case Report and Systematic Review

OBJECTIVE

To present a recent clinical case of Skene's gland carcinoma and review all published literature of Skene's gland malignancy with associated treatment and outcomes.

METHODS

We review a new case of metastatic Skene's gland adenocarcinoma. We then performed a systematic search of PubMed and Ovid-Medline through December 2021 and retrieved English language articles for review. Peer-reviewed articles were deemed eligible if they included patients with Skene's gland malignancy. Reports were reviewed for pathologic accuracy, patient characteristics, clinical presentation, tumor pathology, treatment and outcome.

RESULTS

We reviewed 211 articles and included 15 cases from 1974 to 2022. The median patient age was 71 years (range 46-88). The most common presentation was an asymptomatic periurethral or urethral lesion in five cases (33.3%), followed by hematuria or vaginal bleeding in three patients (20.0%). In eight cases, a prostate-specific antigen was measured and found to be elevated, range 0.8-60.8 ng/mL. Treatment approaches varied and included local excision in eight cases, radical surgical resection in two cases, radiation therapy in two cases, and adjunctive androgen deprivation therapy in one case. Pathology was consistent with adenocarcinoma resembling prostate in all cases. In all cases tested, prostate-specific antigen normalized after definitive therapy of any type. Median follow up was 11.5 months, and there were no cases of recurrence or mortality secondary to Skene's gland adenocarcinoma.

CONCLUSION

There are 15 published cases of a Skene's gland malignancy, all adenocarcinoma resembling prostate. Local excision is most often utilized for treatment, with androgen deprivation therapy emerging as a new treatment consideration.

Analysis of Endometriosis Related Hashtags on Instagram

Study Objective

Instagram is a social media platform that provides education and support for endometriosis patients. The objective of our study was to analyze the authorship and content of Instagram posts utilizing endometriosis related hashtags.

Design

15 hashtags were identified utilizing the ACOG Endometriosis FAQ and a hashtag finder program. Hashtags included: endometriosis, endo, endowarrior, endometriosisawareness, endosisters, endometriosiswarrior, pelvicpain, chronicpelvicpain, painfulperiod, painfulsex, invisibleillness, fatigue, uterus, hysterectomy, and laparoscopy. The authorship and content of the “top 9” and most recent 30 posts were evaluated for each hashtag and categorized by authorship and content. We also analyzed groups of hashtags. Non-English posts were excluded.

Setting

NA

Patients or Participants

NA

Interventions

NA

Measurements and Main Results

585 posts were analyzed. Authorship: patients (54.2%), health professional (16.2%), for-profit group (9.6%), holistic provider (8.7%), and non-profit group (4.6%). Regarding content: support (33.5%), personal post (21.2%), advertisement (17.8%) and education (13.5%).

Endometriosis specific group: patient (74.8%), for-profit commercial group (6%), holistic provider (5.1%), health professional (3.8%), support (40.6%), personal post related to endometriosis (23.5%), personal post unrelated to endometriosis (20.9%), education (6.4%).

General symptoms group: patient (47.4%), holistic provider (14.1%), for-profit commercial group (12.8%), health professional (2.6%), support (34.6%), advertisement (21.8%), personal post related to diagnosis (20.5%), personal post unrelated to diagnosis (15.4%), education (7.7%).

Pain group: health professional (34%), patient (32.7%), for-profit commercial group (15.4%), holistic provider (12.8%), non-profit organization (4.5%), support (27.6%), education (25.6%), personal post related to diagnosis (10.9%), personal post unrelated to diagnosis (7.1%).

Procedure group: patient (59%), health professional (29.5%), non-profit organization (3.8%), personal post related to diagnosis (42.3%), support (20.5%), education (14.1%), personal post unrelated to diagnosis (10.3%).

Conclusion

When analyzing the hashtags, endometriosis specific and general symptoms groups, the majority of posts were authored by patients with education being the least represented content. When grouping into pain and procedure, more posts were authored by health professionals with more educational content.

Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to evaluate the accuracy of the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) surgical risk calculator in predicting postoperative complications in patients undergoing pelvic organ prolapse surgery.

METHODS

We performed a retrospective review of 354 patients who underwent surgery for pelvic organ prolapse from 2013 to 2017 at a single academic institution. Patient medical information and surgical procedure were entered into the calculator to obtain predicted complication rates, which were compared with observed complications. Logistic regression, C-statistic, and Brier score were used to assess the accuracy of the calculator.

RESULTS

Of 354 patients included in the analysis, 79.7% were under the age of 75, and 41.5% were classified as American Society of Anesthesiologists class ≥3. The majority of patients underwent robotic sacrocolpopexy (40.7%) or uterosacral ligament suspension (36.4%), followed by colpocleisis, abdominal sacrocolpopexy, and extraperitoneal suspension. Complications were experienced by 100 patients (28.3%). Most common complications were urinary tract infection (n = 57), surgical site infection (n = 42), and readmission (n = 16); other complications were rare. The surgical risk calculator displayed poor predictive ability for experiencing a complication (C-statistic = 0.547, Brier score = 0.25).

CONCLUSIONS

The NSQIP surgical risk calculator displayed poor predictive ability in our cohort of patients undergoing surgery for pelvic organ prolapse, suggesting that this tool might have limited clinical applicability to individual patients in this population.

Cerebral White Matter Disease and Response to Anti-Cholinergic Medication for Overactive Bladder in an Age-Matched Cohort

OBJECTIVE

To determine if the presence of cerebral white matter disease (WMD) affects the response to anti-cholinergic medications.

MATERIALS AND METHODS

This was a retrospective cohort of age-matched patients treated for OAB with anti-cholinergic medications between January 2010 and December 2017. Inclusion criteria were a chief complaint of OAB, never evaluated by a urogynecologist for OAB, treated with a maximum dose for a minimum of 4 weeks, and underwent head computed tomography (CT) within 12 months of starting therapy. Patients with WMD were matched 1:1 by age and number of prior failed antimuscarinics to controls with normal head CTs. Exclusion criteria included incomplete documentation of therapeutic response, non-WMD CT abnormalities, and non-idiopathic OAB. The primary outcome was anti-cholinergic treatment failure. Pairwise analysis between groups was performed using Wilcoxon rank-sum and Fisher's exact test where appropriate. Univariate logistic regression was performed, and any variable that was associated with treatment failure and a p value ≤ 0.2 was included in the multivariable regression analysis.

RESULTS

Sixty-eight cases were matched with 68 controls. Patients with WMD were more likely to have undergone hysterectomy (57.4% vs. 41.2%, p = 0.04) and to use diuretics (31.1% vs. 19.1%, p = 0.04). Patients with WMD were more likely to fail treatment compared with controls (60.7% vs. 29.4%, p = 0.004). After adjusting for confounders, WMD was strongly associated with an increased probability of failure (aOR = 7.31, 95% CI: 1.49-12.20). Additional significant risk factors for treatment failure were the previous number of failed medications (aOR = 3.65 per medication, 95% CI: 1.48-9.01) and a rising HbA1c (aOR: 1.39 per 1.0% increase, 95% CI: 1.0-1.91).

CONCLUSION

WMD is independently associated with anti-muscarinic treatment failure in women with overactive bladder symptoms.

Predictors of goal achievement in patients undergoing hysterectomy

OBJECTIVE

The primary objective of our study was to identify predictors of goal achievement in patients undergoing simple hysterectomy for benign indications. We also sought to describe the goals of patients in this population.

STUDY DESIGN

This was a prospective cohort study of patients undergoing hysterectomy for benign indications performed at a single academic institution. We documented patient-reported goals of treatment prior to undergoing hysterectomy in 57 patients, and assessed goal achievement and other patient-centered outcomes three months after surgery in 47 of the patients (82.5%). We compared patients who met all of their goals to those who did not, and used multivariate regression to identify predictors of goal achievement. We also characterized the general profile of goals for patients undergoing hysterectomy.

RESULTS

We identified the primary surgical diagnosis of abnormal uterine bleeding (OR 6.5, 1.7-30.1, p = 0.006), as well as an increased feeling of being prepared for postoperative discharge (OR 11.9, 2.1-104.4, p = 0.005), to be independent predictors of patient goal achievement. Goal achievement was correlated with other patient-centered outcomes, including a higher sense of satisfaction and greater patient global impression of improvement. Goals related to symptoms were more commonly stated and more commonly achieved than functional goals.

CONCLUSION

Goal achievement in patients undergoing hysterectomy depends on the preoperative diagnosis and the patient's feeling of preparedness for postoperative discharge. Goal achievement should be considered as a useful patient-centered outcome. Patients undergoing hysterectomy have a unique profile of goals which should be considered and addressed in preoperative counseling.

Comparison of 30-day Complication Rates between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy for the Treatment of Uterine Leiomyoma in Women Older Than Age 40

STUDY OBJECTIVE

To evaluate whether there are differences in complication rates between laparoscopic myomectomy (LM) and total laparoscopic hysterectomy (TLH) for the treatment of uterine leiomyoma in perimenopausal women.

DESIGN

A retrospective cohort study using 1:2 propensity score matching (Canadian Task Force classification II-2).

SETTING

American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS

Women between the ages of 40 and 60 years undergoing surgical laparoscopic surgery for uterine leiomyoma between the years 2010 and 2016.

INTERVENTIONS

Women were stratified to either LM or TLH at a ratio of 1:2 using propensity score matching. Descriptive statistics were reported as means with standard deviations. Pairwise analysis using the Student t test and chi-square test was performed where appropriate. Multivariable logistic regression was used to identify factors associated with the presence of a complication.

MEASUREMENTS AND MAIN RESULTS

After propensity score matching, there were 631 myomectomies and 1262 hysterectomies. The operating time was slightly longer for LM compared with TLH (166.8 ± 90.3 minutes vs 157.9 ± 70.9 minutes, p = .03). The overall complication rate was 6.3%. There were no differences in complications between the LM and TLH groups (5.9% vs 6.6%, p = .54). Urinary tract infections were more common in the TLH group (2.3% vs 0.6%, p = .01). There were no other differences in the rates of specific complications between the 2 groups. On logistic regression, wound class greater than 3 was most strongly associated with a risk of complications (adjusted odds ratio [aOR] = 8.89; 95% confidence interval [CI], 1.28-15.87). Other variables associated with an increased risk of complications were conversion to hysterectomy (aOR = 5.91; 95% CI, 1.7-9.63), total operating time (aOR = 1.05; 95% CI, 1.02-1.07), and length of stay over 1 day (aOR = 3.67; 95% CI, 2.31-5.8).

CONCLUSION

LM is not associated with an increased risk of complications compared with TLH in women over the age of 40 years undergoing treatment for uterine leiomyomata.

Pregnancy Outcomes after Endometrial Ablation in a Multi-institutional Cohort

OBJECTIVE

The objective of this study was to determine the incidence of morbidly adherent placenta in pregnancies after endometrial ablation.

STUDY DESIGN

We performed a retrospective cohort analysis using a large, multiinstitutional deidentified clinical database, IBM EPM: Explore (IBM Corporation, Somers, NY). We identified women who underwent endometrial ablation and had a subsequent delivery between 1999 and 2016. Patients with a delivery and no prior ablation were used as controls. The association between morbidly adherent placenta, ablation, and other known risk factors for morbidly adherent placenta was analyzed using multivariable logistic regression.

RESULTS

Of 162,100 reproductive-aged women who underwent endometrial ablation, 2,770 women (1.71%) subsequently had a delivery. The rate of morbidly adherent placenta was 1 in 13.9 pregnancies after ablation compared with 1 in 838.7 pregnancies in the control group (adjusted odds ratio [aOR], 20.22, p < 0.0001).

CONCLUSION

Pregnancies that occurred after endometrial ablation were associated with increased rates of morbidly adherent placenta.

Trans-abdominal ultrasound shear wave elastographyfor quantitative assessment of female bladder neck elasticity

INTRODUCTION AND HYPOTHESIS

Disorders of micturition result from a wide variety of conditions and evaluation often involves multiple diagnostic modalities. However, the sensitivity and specificity of these techniques are highly variable and may not always yield a diagnosis. Novel imaging techniques such as ultrasound shear wave elastography may help to improve diagnostic accuracy.

METHODS

Continent women were recruited from outpatient gynecology offices from a tertiary medical system. Participants underwent ultrasound evaluation with measurement of the shear wave velocity (SWV) of the bladder neck (BN). SWV was used to determine the Young's modulus of the bladder neck. The median bladder neck stiffness was calculated and univariate and step-wise and backward multivariate logistic regression analyses were used to identify significant patient characteristics associated with bladder neck stiffness above or below the median.

RESULTS

Fifty-seven women underwent SWE of the bladder; 12 were excluded, and 45 were included in the analysis. The median bladder neck stiffness of the study population was 22 (17.1-28.2) kPa. Age greater than 45 years was associated with a bladder neck stiffness above the median, OR 8.39, p < 0.001. Having no vaginal deliveries was also associated with a bladder neck stiffness greater than 22 kPa, unadjusted OR 4.76 (95 % CI 1.41-20.0, p = 0.012). Bladder volume and bladder neck thickness were not significantly associated with bladder neck stiffness above or below the median.

CONCLUSION

Trans-abdominal shear wave elastography can be used to quantitatively assess bladder neck stiffness. This technique may potentially be useful for evaluating chronic urinary retention.

KLF10 Mediated Epigenetic Dysregulation of Epithelial CD40/CD154 Promotes Endometriosis

Endometriosis is a highly prevalent, chronic, heterogeneous, fibro-inflammatory disease that remains recalcitrant to conventional therapy. We previously showed that loss of KLF11, a transcription factor implicated in uterine disease, results in progression of endometriosis. Despite extensive homology, co-expression, and human disease association, loss of the paralog Klf10 causes a unique inflammatory, cystic endometriosis phenotype in contrast to fibrotic progression seen with loss of Klf11. We identify here for the first time a novel role for KLF10 in endometriosis. In an animal endometriosis model, unlike wild-type controls, Klf10^−/− animals developed cystic lesions with massive immune infiltrate and minimal peri-lesional fibrosis. The Klf10^−/− disease progression phenotype also contrasted with prolific fibrosis and minimal immune cell infiltration seen in Klf11^−/− animals. We further found that lesion genotype rather than that of the host determined each unique disease progression phenotype. Mechanistically, KLF10 regulated CD40/CD154-mediated immune pathways. Both inflammatory as well as fibrotic phenotypes are the commonest clinical manifestations in chronic fibro-inflammatory diseases such as endometriosis. The complementary, paralogous Klf10 and Klf11 models therefore offer novel insights into the mechanisms of inflammation and fibrosis in a disease-relevant context. Our data suggests that divergence in underlying gene dysregulation critically determines disease-phenotype predominance rather than the conventional paradigm of inflammation being precedent to fibrotic scarring. Heterogeneity in clinical progression and treatment response are thus likely from disparate gene regulation profiles. Characterization of disease phenotype-associated gene dysregulation offers novel approaches for developing targeted, individualized therapy for recurrent and recalcitrant chronic disease.

Nonantimuscarinic treatment for overactive bladder: a systematic review

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.

Epigenetic regulation of uterine biology by transcription factor KLF11 via posttranslational histone deacetylation of cytochrome p450 metabolic enzymes

Endocrine regulation of uterine biology is critical for embryo receptivity and human reproduction. Uterine endometrium depends on extrinsic sex steroid input and hence likely has mechanisms that enable adaptation to hormonal variation. Emerging evidence suggests that sex steroid bioavailability in the endometrium is determined by adjusting their metabolic rate and fate via regulation of cytochrome (CYP) p450 enzymes. The CYP enzymes are targeted by ubiquitously expressed Sp/Krüppel-like (Sp/KLF) transcription factors. Specifically, KLF11 is highly expressed in reproductive tissues, regulates an array of endocrine/metabolic pathways via epigenetic histone-based mechanisms and, when aberrantly expressed, is associated with diabetes and reproductive tract diseases, such as leiomyoma and endometriosis. Using KLF11 as a model to investigate epigenetic regulation of endometrial first-pass metabolism, we evaluated the expression of a comprehensive array of metabolic enzymes in Ishikawa cells. KLF11 repressed most endometrial CYP enzymes. To characterize KLF11-recruited epigenetic regulatory mechanisms, we focused on the estrogen-metabolizing enzyme CYP3A4. KLF11 expression declined in secretory phase endometrial epithelium associated with increased CYP3A4 expression. Additionally, KLF11 bound to CYP3A4 promoter GC elements and thereby repressed promoter, message, protein as well as enzymatic function. This repression was epigenetically mediated, because KLF11 colocalized with and recruited the corepressor SIN3A/histone deacetylase resulting in selective deacetylation of the CYP3A4 promoter. Repression was reversed by a mutation in KLF11 that abrogated cofactor recruitment and binding. This repression was also pharmacologically reversible with an histone deacetylase inhibitor. Pharmacological alteration of endometrial metabolism could have long-term translational implications on human reproduction and uterine disease.