Nationwide assessment of practice variability in the utilization of hysteropexy at laparoscopic apical suspension for uterine prolapse.

BACKGROUND: Although hysteropexy has been used to preserve the uterus during uterine prolapse surgery for a long time, there is a scarcity of data that describe the nationwide patterns of use of this surgical procedure. OBJECTIVE: This study aimed to examine the national-level use and characteristics of hysteropexy at the time of laparoscopic apical suspension surgery for uterine prolapse in the United States. STUDY DESIGN: This cross-sectional study used data from the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population included 55,608 patients with a diagnosis of uterine prolapse who underwent laparoscopic apical suspension surgery from 2016 to 2019. Patients who had a hysterectomy were assigned to the hysterectomy group, and those who did not have a hysterectomy were assigned to the hysteropexy group. The main outcome was clinical characteristics associated with hysteropexy, assessed using a multivariable binary logistic regression model. A classification tree was further constructed to assess the use pattern of hysteropexy during laparoscopic apical suspension procedures. The secondary outcome was surgical morbidity, including urinary tract injury, intestinal injury, vascular injury, and hemorrhage. RESULTS: A hysteropexy was performed in 6500 (11.7%) patients. In a multivariable analysis, characteristics associated with increased use of a hysteropexy included (1) patient factors, such as older age, Medicare coverage, private insurance, self-pay, and medical comorbidity; (2) pelvic floor dysfunction factor of complete uterine prolapse; and (3) hospital factors, including medium bed capacity center and location in the Southern United States (all P<.05). Conversely, (1) the patient factor of higher household income; (2) gynecologic factors such as uterine myoma, adenomyosis, and benign ovarian pathology; (3) pelvic floor dysfunction factor with stress urinary incontinence; and (4) hospital factors including Midwest and West United States regions and rural setting center were associated with decreased use of a hysteropexy (all P<.05). A classification tree identified a total of 14 use patterns for hysteropexies during laparoscopic apical suspension procedures. The strongest factor that dictated the use of a hysteropexy was the presence or absence of uterine myomas; the rate of hysteropexy use was decreased to 5.6% if myomas were present in comparison with 15% if there were no myomas (P<.001). Second layer factors were adenomyosis and hospital region. Patients who did not have uterine myomas or adenomyosis and who underwent surgery in the Southern United States had the highest rate of undergoing a hysteropexy (22.6%). Across the 14 use patterns, the percentage rate difference between the highest and lowest uptake patterns was 22.0%. Patients who underwent a hysteropexy were less likely to undergo anteroposterior colporrhaphy, posterior colporrhaphy, and sling procedures (all P<.05). Hysteropexy was associated with a decreased risk for measured surgical morbidity (3.0 vs 5.4 per 1000 procedures; adjusted odds ratio, 0.57; 95% confidence interval, 0.36-0.90). CONCLUSION: The results of these current, real-world practice data suggest that hysteropexies are being performed at the time of ambulatory laparoscopic apical suspension surgery for uterine prolapse. There is substantial variability in the application of hysteropexy based on patient, gynecologic, pelvic floor dysfunction, and hospital factors. Developing clinical practice guidelines to address this emerging surgical practice may be of use.

Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making.

Objectives: Urinary incontinence (UI) is a highly prevalent burdensome condition among adult females in the United States, yet rates of care-seeking, evaluation, and treatment are nonoptimal. Components of evaluation and treatment are informed by research and professional society guidelines; however, a visual representation of this guidance does not exist. The objectives of this study are to review the literature regarding female UI care and to synthesize this information into a graphical format to facilitate health education, health care delivery, and shared decision-making. Methods: We reviewed published society guidelines, position statements, and associated references from the American College of Obstetrics and Gynecology, the Women's Preventive Services Initiative, American Academy of Family Physicians, American College of Physicians, the Society of Urodynamics and Female Urology, the American Urological Association, and the American Urogynecologic Society, and searched PubMed for related literature. We synthesized these findings into an evidence-based infographic depicting female UI risk factors, influences on care-seeking and provision, screening, evaluation, and a stepwise treatment approach. Results: This study summarizes current evidence and professional guidelines related to female UI into a compelling visual format and accompanying narrative. The infographic is intended as a tool for patient education, clinical practice, and research to facilitate shared decision-making and health care delivery. Conclusions: Female UI is highly prevalent, yet diagnosis and treatment are suboptimal. Use of an evidence-based infographic may positively impact patient knowledge and certainty about UI treatment and support health care provider counseling and decision-making.

Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women.

INTRODUCTION: Most causes of microscopic hematuria (MH) are benign but may indicate an underlying malignancy. Current MH evaluation guidelines are reflective of male urologic malignancy risks. The objective of this systematic review was to evaluate whether the finding of MH predicts subsequent urologic malignancy in women. METHODS: MEDLINE was searched between January 1990 and June 8, 2018. The positive predictive value (PPV) of MH as a screening tool for urologic malignancy was calculated for each study individually and collectively. The pooled relative risk of urologic malignancy associated with MH was calculated. RESULTS: Seventeen studies were included. Eight studies included only women. In total, 300 urinary tract cancers were identified in 110,179 women with MH. The PPV of MH as a screening tool for cancer ranged from approximately 0.6% to 2.8%; confidence intervals (CIs) suggested this is a relatively unstable performance indicator because of small sample sizes. Average PPV across all studies was 2.13%, but the weighted average PPV was 0.24%. The risk of urologic malignancies among women with relative those without MH was 2.01 (95% CI, 1.61-2.51). Based on these limited data, we estimate that 859 (95% CI, 654-1250) women with MH would require complete evaluation to identify 1 urinary tract malignancy. CONCLUSIONS: A very small proportion of women with MH are likely to have a urologic malignancy. Approximately 859 women require full screening to identify 1 malignancy. Current evidence is limited, and further studies, specifically in women, are needed.

American Urogynecologic Society Systematic Review: The Impact of Weight Loss Intervention on Lower Urinary Tract Symptoms and Urinary Incontinence in Overweight and Obese Women.

OBJECTIVE: Obesity can contribute to urinary symptoms such as urgency, frequency, and incontinence. In addition to classic treatments, weight loss interventions offer a unique clinical opportunity to improve these symptoms. STUDY DESIGN: The American Urogynecologic Society Systematic Review Group conducted a review of articles on the impact of surgical and behavioral weight loss (BWL) interventions on urinary symptoms in overweight and obese women. The certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: The review group identified 43 publications from 39 studies, including 10 reports that used data from 5 randomized trials. Overall, there is high-certainty evidence that BWL, such as diet and exercise, decreases the prevalence of stress urinary incontinence 15% to 18% and overall urinary incontinence (UI) by 12% to 17% at 1 to 2.9 years. The certainty of evidence on the long-term impact of these interventions was lower. The certainty of the evidence was moderate to low regarding the benefit of BWL on urgency UI and overactive bladder symptoms. No randomized trials evaluated the impact of surgical weight loss on urinary symptoms, and the certainty of evidence of other study types was very low. CONCLUSIONS: There is high-certainty evidence that BWL results in modest improvements in stress and overall UI in overweight and obese women at 1 to 2.9 years after the intervention. Robust studies with low risk of bias are needed to assess whether these benefits are maintained over the long term and are associated with adverse events and to assess the impact of surgical weight loss interventions on urinary outcomes in overweight and obese women.

Opioid Prescription and Patient Use After Gynecologic Procedures: A Survey of Patients and Providers.

STUDY OBJECTIVE: To describe opioid distribution and patient use after gynecologic procedures. DESIGN: Survey study (Canadian Task Force classification III). SETTING: An urban academic tertiary care hospital. SUBJECTS: Ninety-six gynecologists in the Boston area, and 147 patients who underwent a benign hysterectomy between January 2015 and April 2016. INTERVENTIONS: Survey study of physicians and patients composed of 2 parts: (1) a physician survey on opioid prescribing practices after gynecologic procedures and (2) a patient survey on opioid consumption after hysterectomy. Physicians were contacted via e-mail to participate in an online survey. Eligible patients were contacted via telephone and asked to participate in a telephone survey. MEASUREMENTS AND MAIN RESULTS: Fifty-one physicians responded to an online survey and prescribed a mean of 27.1 tablets (range, 5-30) of oxycodone (5 mg) or hydromorphone (2 mg) after abdominal hysterectomy (AH), a mean of 22.6 tablets (range, 5-30) after laparoscopic hysterectomy (LH), and a mean of 16.8 tablets (range 5-30) after vaginal hysterectomy (VH). Physicians prescribed more opioids for AH compared with LH, with a mean difference of 4.5 tablets (standard deviation, 4.7; p < .01), and AH compared with VH, with a mean difference of 6.8 tablets (standard deviation, 5.8; p < .01), which were both statistically significant. In addition, 40.0% of physicians prescribe opioids after a hysteroscopy and 19.2% after a dilation and curettage. Fifty-six patients participated in the telephone survey: 64.6% of patients used less than half of the opioids prescribed and 16.1% used none. For AH, patients reported being prescribed a mean of 25.7 tablets and using a mean of 8.7 tablets (range, 0-60; 33.9% used). For LH or VH, patients reported being prescribed a mean of 24.2 tablets and using a mean of 10.0 tablets (range, 0-30; 41.4% used). Opioid consumption was not significantly different for AH compared with LH or VH (p = .613 for AH to LH, p = .279 for AH to VH). CONCLUSIONS: With respect to the physician survey, we conclude there is a wide range of opioid prescription practices and patient opioid consumption after gynecologic surgery. The patient survey revealed that physicians prescribe fewer opioid tablets after a minimally invasive approach to hysterectomy versus open hysterectomy. However, most patients use less than half of prescribed opioids, and a fraction did not use any opioids at all.

Case Report: Vessel Injury During Suprapubic Catheter Placement and the Importance of Patient Positioning in Obese Patients.

Obesity is a well-known risk factor for increased perioperative morbidity. As surgeons see higher volumes of obese patients, it is important to recognize how an elevated body mass index can impact even the most basic surgical steps, such as patient positioning. This case report describes an iatrogenic injury to the external iliac artery in a morbidly obese patient caused by an abdominal trocar during suprapubic catheter insertion secondary to malrotation of the bony pelvis. It highlights the importance of recognizing the impact of obesity on patient positioning.

Nephrogenic adenoma in a urethral diverticulum.

Nephrogenic adenoma (NA) is a rare finding that represents metaplasia of the urothelium. We present a case of a 46-year-old woman who presented with a symptomatic anterior vaginal wall cyst that was found to be an NA within a urethral diverticulum. Although this remains an infrequently reported entity in the literature, prevalence has been shown to be higher in consecutive case series than what may be presumed by the rarity of case reports in clinical literature. Nephrogenic adenoma within a urethral diverticulum may represent an under-recognized entity which needs to be carefully distinguished from clear cell adenocarcinoma occurring within urethral diverticula. We discuss salient clinical features of NA occurring within a urethral diverticulum and describe a review of literature of published cases to date.

Enterococcus osteomyelitis secondary to pyelonephritis.

We report a case of enterococcus lumbar osteomyelitis that developed after post-operative pyelonephritis. A 78-year-old G2P2 with Stage III uterovaginal prolapse and genuine stress urinary incontinence who underwent laparoscopic-assisted vaginal hysterectomy, high uterosacral ligament suspension, tension-free vaginal tape-obturator approach, and cystoscopy presented with post-operative back pain. Work-up of her back pain revealed enterococcus pyelonephritis. She continued to have back pain despite outpatient antibiotic treatment and further work-up revealed enterococcus lumbar osteomyelitis at the level of L1-L2. Enterococcus vertebral osteomyelitis is a rare infection that can occur by hematogenous spread from an infection of the urinary tract.

Bladder calculus presenting as recurrent urinary tract infections: a late complication of cervical cerclage placement: a case report.

BACKGROUND: A cervical cerclage is often placed for women with cervical shortening or insufficiency. There are early and late complications of cervical cerclage placement, but they rarely involve the lower urinary tract. We present a case of a lower urinary tract complication from this procedure presenting as recurrent urinary tract infections. CASE: A 43-year-old woman with a history of cerclage placement during her second pregnancy (10 years prior) presented with recurrent urinary tract infections and hematuria. Radiologic imaging and cystoscopy revealed a 2-cm bladder stone attached to suture that was subsequently removed during cystoscopy. CONCLUSION: Retained suture from a cervical cerclage can act as a nidus for bladder stone formation.

Laparoscopic sacrocervicopexy for the treatment of uterine prolapse: a retrospective case series report.

STUDY OBJECTIVE: To evaluate apical support in patients desiring uterine preservation with pelvic organ prolapse who underwent laparoscopic sacrocervicopexy. DESIGN: Retrospective case series report (Canadian Task Force classification III). SETTING: Academic community teaching hospital. PATIENTS: Forty consecutive women who underwent laparoscopic sacrocervicopexy. INTERVENTIONS: Synthetic mesh was used to attach the distal uterosacral ligaments and posterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory. MEASUREMENTS AND MAIN RESULTS: Pelvic organ prolapse quantification system measurements were used and apical support was evaluated using point C. Mean C was -1.13 (+9 to -4) preoperatively, -5.28 (-3 to -13) at 6 weeks postoperatively, -5.26 (-3 to -8) at 6 months postoperatively, and -4.84 (-3 to -7) at 1 year postoperatively. CONCLUSION: Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation.

Use of synthetic mesh in pelvic reconstructive surgery: a survey of attitudes and practice patterns of urogynecologists.

This study surveyed attitudes and practice patterns of urogynecologists regarding the use of synthetic mesh in pelvic reconstructive surgery. A web-based survey was administered to members of the American Urogynecologic Society. The survey evaluated the use of the mesh for sacrocolpopexy, suburethral sling, and vaginal pelvic reconstructive surgery. The survey had a 30.5% response rate. One hundred one (39%) respondents were women, and 158 (61%) were men. One hundred forty-seven (56.8%) participated in fellowship training. Two hundred forty-seven (99.5%) currently perform procedures using synthetic mesh, including 93% who perform sacrocolpopexy and 93% who perform suburethral slings. In a logistic regression model including gender, fellowship training, and practice setting, male surgeons and those who had not undergone fellowship training were more likely to use the mesh than those who were fellowship trained. Respondents use the mesh most commonly when performing sacrocolpopexies and suburethral slings. The use of the mesh for anterior and posterior colporrhaphy is less common.