Same-day Discharge Following Vaginal Hysterectomy and Native-tissue Apical Repair for Uterovaginal Prolapse: A Prospective Cohort Study.

INTRODUCTION AND HYPOTHESIS: The safety and feasibility of same-day discharge (SDD) has been consistently reported across the benign and gynecologic oncology literature. However, outcomes of SDD in the urogynecology population are sparse. The objectives of this study were to describe the success of SDD following vaginal hysterectomy and native-tissue colpopexy, and to compare the incidence of postoperative adverse events in patients discharged same-day versus postoperative day 1 (POD1). Further objectives were to compare pain, quality of recovery (QoR), and satisfaction between the groups. METHODS: This was a single-center, prospective cohort study of patients with planned SDD. A standardized ERAS protocol was utilized. The QoR-40 questionnaire was administered at baseline, POD2, and the 6-week postoperative visit. Pain scores were captured similarly, and a satisfaction survey was administered at 6 weeks. The primary outcome was composite adverse events defined as any postoperative adverse event and/or health care utilization, excluding telephone calls, and urinary tract infection. RESULTS: A total of 101 patients were enrolled in the study; the primary outcome was available for 99. SDD was achieved for 76 patients (77.0%); 23 patients stayed overnight (23.2%). The overall incidence of composite adverse events was 20.2% (95% CI, 13.5-29.2), and was not different between the groups (26.1% vs 18.4%, p = 0.42). Additionally, there were no differences in the QoR-40 or pain scores on POD2 and at 6 weeks. Patient satisfaction was high and similar between the groups. CONCLUSIONS: Successful SDD was achieved in 77.0% of the patients. SDD following vaginal hysterectomy and native-tissue colpopexy appears to be safe, feasible, and associated with good QoR and a high degree of patient satisfaction.

Is there an association between 6-month genital hiatus size and 24-month composite prolapse recurrence following minimally invasive sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS: Although an enlarged postoperative genital hiatus (GH) size has been identified as a predictor of recurrence following pelvic organ prolapse (POP) surgery, the protective role of concurrent level III support procedures to reduce the GH size at the time of minimally invasive sacrocolpopexy (MI-SCP) remains unclear. The objective of this study was to compare 24-month composite prolapse recurrence following MI-SCP between patients with a 6-month postoperative GH measurement of <3 cm versus ≥3 cm; and to explore the impact of concurrent level III support procedures on prolapse recurrence, bowel, and sexual function. METHODS: This was a secondary analysis of two randomized controlled trials of women who underwent MI-SCP from 2014 to 2020. Our primary outcome was composite prolapse recurrence defined as retreatment with either pessary or surgery, and/or subjective bothersome vaginal bulge. A receiver operating characteristic (ROC) curve was generated to identify a 6-month GH cutoff point associated with 24-month composite recurrence. RESULTS: Of the 108 women who met the inclusion criteria, 13 (12%) had composite prolapse recurrence at 24 months: 12 patients (11.1%) reported a bothersome vaginal bulge, and 3 patients (2.8%) underwent retreatment with surgery. A ROC curve demonstrated that a 6-month postoperative GH size of 3 cm had 84.6% sensitivity to predict vaginal bulge and/or retreatment at 24 months (area under curve = 0.52). There was no difference in the composite prolapse recurrence between the groups; however, only patients with a 6-month GH >3 cm underwent retreatment. CONCLUSIONS: Twenty-four-month composite prolapse recurrence does not differ based on 6-month GH size; however, surgical failure may be more common in those with a GH size greater than 3 cm.

Assessment of Adverse Events in a Matched Cohort of Women Undergoing Concurrent Midurethral Sling at the Time of Minimally Invasive Benign Gynecologic Surgery.

IMPORTANCE: Procedures for stress urinary incontinence and benign gynecologic surgery are often performed concurrently, and associated complication rates have previously been unexplored. OBJECTIVE: The aim of this study was to compare postoperative complication rates between women undergoing midurethral sling (MUS) placement at the time of benign gynecologic surgery and those undergoing MUS alone. STUDY DESIGN: This was a retrospective matched cohort study of women undergoing MUS with or without concurrent minimally invasive benign gynecologic surgery from January 2010 through December 2020. Eligible women undergoing concurrent surgery were matched to a cohort of women undergoing MUS placement alone. The electronic medical record was queried for demographic and perioperative/postoperative data up to 12 months after surgery. RESULTS: Thirty-eight women met inclusion criteria for the concurrent group, and 152 women were matched accordingly. The overall adverse event rate was 39.5% (95% confidence interval [CI], 0.25-0.55) for the concurrent group and 24.3% (95% CI, 0.18-0.32) for the MUS-only group ( P = 0.05). Adverse events with Clavien-Dindo grade ≤ 2 were higher in the concurrent group (Clavien-Dindo Grade 1: 5% vs 0%, P = 0.04; Clavien-Dindo Grade 2: 16% vs 6%, P = 0.04), as was composite postoperative resource utilization (76% vs 49%, P = 0.003). Mesh exposure ( P = 0.03) and sling lysis/excision rates ( P = 0.02) were higher in the concurrent group. On logistic regression, concurrent surgery cases remained significantly associated with sling mesh erosion (adjusted odds ratio, 12.6; 95% CI, 1.4-116.4). CONCLUSIONS: Midurethral sling placement at the time of minimally invasive benign gynecologic surgery is safe but is associated with a higher incidence of postoperative hospital resource utilization and sling mesh extrusion, and a need for revision.

Risk Factors for Bladder Perforation at the Time of Retropubic Midurethral Sling Placement.

IMPORTANCE: There is conflicting evidence regarding predictive factors for bladder perforation during retropubic midurethral sling (R-MUS) placement and lack of evidence to support adoption of techniques to minimize such injury. OBJECTIVES: The aims of the study were to describe the incidence of and factors associated with bladder perforation during R-MUS placement and to explore whether retropubic hydrodissection decreases the likelihood of perforation. STUDY DESIGN: This is a case-control study of women undergoing R-MUS placement from 2007 to 2017. Cases were identified by review of the operative reports for evidence of bladder perforation. Patients without bladder perforation were defined as controls and were matched to cases in a 3:1 ratio by surgeon, sling type, and surgery date. RESULTS: A total of 1,187 patients underwent R-MUS placement. The incidence of bladder perforation was 8% (n = 92 patients); 276 controls were matched accordingly (N = 368). Patients with bladder perforations were more likely to have a body mass index (BMI) less than 30 (P = 0.004) and to have a diagnosis of endometriosis (P = 0.02). They were also more likely to have had previous hysterectomy (P = 0.03) and urethral bulking (P = 0.01). On logistic regression, bladder perforation remained associated with a BMI less than 30 (adjusted odds ratio, 2.22 [95% confidence interval, 1.30-3.80]) and endometriosis (adjusted odds ratio 2.90 [95% confidence interval, 1.15-7.01]). Retropubic hydrodissection was performed in 62% of the patients and was not associated with a lower risk of perforation (P = 0.86). CONCLUSIONS: The incidence of bladder perforation was 8%. The risk of this complication is higher in patients with a BMI less than 30 and/or endometriosis. Retropubic hydrodissection may not decrease the likelihood of this event.

Compliance With Pelvic Floor Physical Therapy in Patients Diagnosed With High-Tone Pelvic Floor Disorders.

OBJECTIVE: The primary objective of this study was to describe patient compliance with pelvic floor physical therapy (PFPT) for high-tone pelvic floor disorders (HTPFD) and to compare patients who are compliant with prescribed therapy to those who are not. The secondary objective is to describe second-line treatments offered for HTPFD for returning patients. METHODS: This is a retrospective cohort study of women with a HTPFD who were prescribed PFPT at a tertiary care referral center. Patients were excluded if they had a primary diagnosis of urinary incontinence, had undergone prior PFPT, or if PFPT was part of preoperative planning. Noncompliance with PFPT was defined as not being formally discharged from therapy by the treating therapist. RESULTS: Data on PFPT compliance were available for 662 patients (87.3%). A total of 128 patients (19.4%) were fully compliant. Noncompliant patients were more likely to smoke and to have mental health disease compared with compliant patients (18% vs 8.7%, P = 0.01, and 50.4% vs 37.5%, P = 0.009, respectively). A total of 285 patients (43.1%) returned to their prescribing provider. Noncompliant patients were less likely to return to their provider: 63.4% versus 29.7%, P = <0.0001. Of the patients who returned, 183 (64.2%) were offered second-line treatment. CONCLUSIONS: Only 1 in 5 patients referred to PFPT for management of a high-tone pelvic floor disorder is compliant with the recommended therapy. Patients who are noncompliant are less likely to return to their prescribing provider, and less than half of referred patients return. Sixty percent of patients who return are offered second-line treatment.

Pelvic Organ Prolapse Recurrence and Patient-Centered Outcomes Following Minimally Invasive Abdominal Uterosacral Ligament and Mesh-Augmented Sacrohysteropexy.

OBJECTIVES: The objective of this study was to compare outcomes after minimally invasive uterosacral ligament hysteropexy (USLH) and mesh-augmented sacrohysteropexy (MSH) for women with uterovaginal prolapse including prolapse recurrence and long-term patient satisfaction. METHODS: This was a retrospective cohort study with a cross-sectional survey component. The medical record was queried for perioperative data for patients undergoing USLH and MSH between 2004 and 2016. Pelvic organ prolapse (POP) recurrence was defined as bulge symptoms and/or retreatment with a pessary or surgery. A cross-sectional survey assessed for adverse events and used validated questionnaires to assess symptoms and improvement. RESULTS: Ninety-seven patients met the inclusion criteria: 42 MSH and 55 USLH. Mean age was 48 ± 14 years. Patients undergoing MSH were older, had more advanced POP, and were less likely to undergo concurrent procedures. There were no differences in perioperative complications between groups; 22.7% (n = 22) of patients experienced POP recurrence with 8.3% (n = 8) undergoing repeat surgery. After controlling for preoperative differences, there was no difference in POP recurrence between groups. The incidence of sacrohysteropexy mesh exposure was 7% (n = 3). Sixty-one percent (n = 59) of patients completed the survey; median follow-up time was 104 (46-164) months. Forty-one percent of respondents reported bothersome pelvic floor symptoms. Bulge symptoms were more common after MSH (41% vs 10%, P = 0.006). Ninety-three percent of all patients reported improvement after surgery, which was not different between groups. CONCLUSIONS: One in 5 patients experienced POP recurrence with fewer than 10% undergoing repeat surgery for recurrence. There does not seem to be a significant difference in the incidence of recurrence between MSH and USLH.

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.

Perioperative Adverse Events in Women Undergoing Concurrent Hemorrhoidectomy at the Time of Urogynecologic Surgery.

OBJECTIVE: The aim of this study was to describe the incidence and trends of outcomes after concurrent surgeries for symptomatic hemorrhoids and pelvic floor disorders. METHODS: This was a retrospective matched cohort study. Women who underwent concurrent vaginal urogynecologic and hemorrhoid surgery between 2007 and 2017 were identified by their surgical codes and matched to a cohort of women who underwent vaginal urogynecologic surgery only. The medical record was queried for demographic and perioperative data. RESULTS: Thirty-three subjects met the inclusion criteria; 198 subjects were matched accordingly (N = 231). Mean age and body mass index were 57 ± 12 years and 28.9 ± 5.6 kg/m, respectively. Subjects who underwent concurrent hemorrhoidectomy were more likely to have had previous prolapse surgery (27.3% vs 15.2%, P = 0.09) and preoperative fecal incontinence (27.3% vs 13.6%, P = 0.05). Concurrent cases were more likely to have unplanned office visits (27.2% vs 12.6%, P = 0.03) and phone calls (range, 1-7 vs 0-10; P = 0.001), mostly for pain complaints. Reoperation was higher in combined cases (3% vs 0%, P = 0.01); however, the overall rate of serious perioperative adverse events was low and not different between groups. Concurrent cases were more likely to be discharged home with a Foley (42.4% vs 18.2%, P = 0.002) and to have a postoperative urinary tract infection (33.3% vs 10.6%, P = 0.005). In the concurrent group, 33.3% of the patients experienced severe rectal pain. CONCLUSIONS: Patients undergoing concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery are at higher risk of minor events such as postoperative urinary tract infection and need for discharge home with a Foley, as well as risk of pain that may be greater than urogynecologic surgery alone.