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.

Barriers to Urogynecologic Care for Racial and Ethnic Minority Women: A Qualitative Systematic Review.

IMPORTANCE: Studies have sought to evaluate factors that have perpetuated disparities in health care, including urogynecologic care. However, there remains a lack of understanding of barriers to care specific to racial/ethnic minority populations. OBJECTIVES: We aimed to report identified barriers to urogynecologic care (eg, care for symptoms/diagnoses of urinary incontinence [UI], accidental bowel leakage [ABL], and pelvic organ prolapse [POP]) for underrepresented racial and ethnic minority (URM) women in the United States. STUDY DESIGN: We conducted a systematic search for studies through 5 electronic bibliographic databases. Inclusion criteria for eligible studies included the following: (1) studies reporting barriers to care for those with urogynecologic symptoms/diagnoses, (2) publication date year 2000 or later. Exclusion criteria included study cohorts with children, exclusively non-U.S. populations, cohorts without URM participants, and studies without qualitative research methodology. Study methodology, characteristics, as well as barriers and facilitators to urogynecologic care were captured using a thematic synthesis approach. RESULTS: There were 360 studies identified. Twelve studies met criteria: 6 had study populations with UI, 3 with POP, 2 on UI and/or POP, and 1 on ABL. There were 7 focus group studies (total 44 groups, n = 330), 4 interview studies (total 160 interviews, n = 160), and 1 had both (10 interviews, 6 groups, n = 39). Most studies reported on patient-associated barriers (n = 10/12) and physician/provider-associated barriers (n = 10/12), whereas only half reported system-associated barriers (n = 6/12). CONCLUSION: Identified barriers to urogynecologic care for URM populations were examined. Findings likely do not fully reflect barriers to urogynecologic care for URM populations. Comprehensive evaluation of social determinants of health and systemic racism within studies is needed to understand the unique barriers present for racially/ethnically diverse populations.

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.

Who's Posting What? A Qualitative, Cross-Sectional Study Comparing Twitter and Instagram Patterns Between Health Care Professionals and Patients.

IMPORTANCE: There is a paucity of evidence-based, physician-authored content available on social media. Data are lacking on physicians use of social media, including intended audience and content. OBJECTIVE: The aim of this study was to explore the patterns of Twitter and Instagram use for popular urogynecology hashtags between physicians, patients, and allied health professionals (AHPs). STUDY DESIGN: Twelve hashtags derived from the Urogynecology Tag Ontology project were used as search terms to select Twitter and Instagram posts. Up to 5 top posts per hashtag per author type (physician, patient, or AHP) were included. Posts were analyzed using Dedoose qualitative analytic software by author, hashtag, intended audience, and themes. RESULTS: On Twitter, 109 posts met inclusion criteria: 41% written by physicians, 40% patients, and 18.3% AHPs. For Instagram, 72 posts were included: 50% written by patients, 39% AHPs, and 11% physicians. Twitter physician posts were mainly intended for health professionals (64%) with only 18% for patients. Patients posted to the general public (57%) and patients (36%). Instagram physician posts were intended for health professionals (49%), whereas 62% of AHPs posted to patients. Most patient posts were directed to other patients (90%). Physicians posted about academic peer discussions, medical education, and advocacy. Patients posted about personal experiences, treatments, or dissatisfaction. CONCLUSIONS: Physicians are more likely to post on Twitter than Instagram, with content focused primarily on their peer group, and physicians/patients are unlikely to engage with each other. There is an opportunity to improve social media interactions between physicians and the public while increasing high-quality patient education.

The American Urogynecologic Society Action Plan on Diversity, Equity, and Inclusion: Developed by the Diversity, Equity, and Inclusion Task Force.

ABSTRACT: The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

Perioperative outcomes following pelvic floor reconstruction in women with hereditary disorders of connective tissue: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesized that patients would have increased incidence and severity of perioperative complications up to 6 weeks after surgeries for POP/SUI. Secondary objectives were to compare pre- and post-operative pelvic floor symptoms and anatomical support as well as pelvic floor disorder recurrence. METHODS: In this multi-center retrospective cohort study, we identified patients with HDCTs by patient history and ICD-9 codes over an 11-year period. Controls without HDCTs were matched 2:1 to the primary POP or SUI procedure and surgeon. Demographic characteristics, perioperative pelvic floor information and complications were collected. A sample size of 65 HDCT patients and 130 controls was calculated to detect a 20% difference in complications with 80% power and alpha of 0.05. RESULTS: We identified 59 HDCT patients and 118 controls. Of the women with HDCTs, 49% had Ehlers-Danlos, 22% joint hypermobility syndrome, 15% Marfan syndrome, and 14% had others. Compared with controls, HDCT patients had more total perioperative complications (46% vs 22%, p = 0.002); an age-adjusted relative risk of complications was 1.4 (CI 0.7-2.6). HDCT patients had more Clavien-Dindo grades I and II complications (p = 0.02, 0.03) and more hospital readmissions (14% vs 3%, p = 0.01) than controls. There was no difference in the incidence of specific complications nor was there a difference in recurrence of POP (10%) or SUI (11%) between groups. CONCLUSIONS: Patients with HDCTs had more Clavien-Dindo grade I and II complications following pelvic floor reconstructive surgery and more readmissions.

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.

Assessing the Performance of the De Novo Postoperative Stress Urinary Incontinence Calculator.

OBJECTIVE: The aim of the study was to determine the performance of a previously published stress urinary incontinence (SUI) risk calculator in women undergoing minimally invasive or transvaginal apical suspensions. METHODS: Using a database of stress-continent women who underwent minimally invasive or transvaginal apical suspensions, we calculated 2 prediction risks for development of SUI within 12 months based on inclusion of a "prophylactic" midurethral sling at the time of prolapse surgery. Observed subjective and objective continence status was abstracted from medical records. Regression models were created for the outcome of de novo SUI to generate receiver operating curves. Concordance (c) indices were estimated for the overall and procedure subgroups to determine the calculator's ability to discriminate between SUI outcomes. RESULTS: Analyses included 502 women. De novo SUI was observed in 23.5% of women. The mean ± SD calculated risk of de novo SUI if a sling was performed was 18.9% ± 13.9 at 12 months compared with 36.4% ± 8.3 without sling. The calculator's discriminative ability for those with a planned sling was moderate (c-index = 0.55, P = 0.037). The calculator failed to discriminate continence outcomes when a sling was not planned in the overall group (c-index = 0.50, P = 0.799) and individual apical procedures. CONCLUSIONS: The SUI risk calculator is significantly limited in its ability to predict de novo SUI in our population of women planning minimally invasive apical suspensions. Refinements to the calculator model are needed to improve its utility in clinical practice.

Age and Perioperative Outcomes After Implementation of an Enhanced Recovery After Surgery Pathway in Women Undergoing Major Prolapse Repair Surgery.

OBJECTIVE: As perioperative care pathways are developed to improve recovery, there is a need to explore the impact of age. The aim of this study was to compare the impact of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway on perioperative outcomes across 3 age categories: young, middle age, and elderly. METHODS: A retrospective cohort study was conducted assessing same-day discharge, opioid administration, pain scores, and complications differences across and within 3 age categories, young (<61 years), middle age (61-75 years), elderly (>75 years), before and after ERAS implementation. RESULTS: Among 98 (25.7%) young, 202 (52.9%) middle-aged, and 82 (21.5%) elderly women, distribution before and after ERAS implementation was similar. In each age category, we found a commensurate increase in same-day discharge and decrease in length of stay independent of age. Age was associated with a variable response to opioid administration after ERAS. In women who received opioids, we found there was a greater reduction in opioids in elderly. Young women received 22.5 mg more than middle-aged women, whereas elderly women received 24.3 mg less than middle-aged women (P < 0.0001, P < 0.0001) for a mean difference of 46.8 mg between the youngest and oldest group. We found no significant differences in postanesthesia care unit pain scores with ERAS implementation. Complications did not increase after ERAS implementation in any age group, although younger and elderly women were more likely to experience complications independent of ERAS. CONCLUSIONS: Elderly women had similar outcomes compared with their younger counterparts after implementation of an ERAS pathway. Further research is needed to assess whether our age-related observations are generalizable.

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.

Restoring Genital Hiatus to Normative Values After Apical Suspension Alone Versus With Level 3 Support Procedures.

OBJECTIVE: The aim of the study was to evaluate postoperative genital hiatus after apical suspension procedures without a level 3 support procedure (L3SP), posterior repair, and perineorrhaphy, compared with normative-value genital hiatus of 3.4 cm. METHODS: This an analysis of a pre-existing retrospectively collected database that included all minimally invasive sacrocolpopexies and uterosacral ligament suspensions performed at a tertiary medical center from January 2009 to August 2015. RESULTS: We identified 1006 surgical cases: 160 (15.9%) apical suspensions with L3SPs and 846 (84.1%) without. Mean (SD) age was 59 (9) years and body mass index was 27.6 (4.7) kg/m. Women were mainly white (97.4%) with stage III prolapse (67.8%). Those who underwent L3SPs were more likely to be premenopausal and undergo hysterectomy and USLS.Baseline genital hiatus was similar with and without L3SPs (4.8 [1.2] cm vs 4.6 [1.1] cm, P = 0.096). Postoperative genital hiatus was reduced beyond normative (3.4 cm) after apical suspension without (3.0 [0.7] cm, P < 0.001) and with (2.8 [0.9] cm, P < 0.001) L3SPs. Postoperative genital hiatus after L3SPs was similar to those without (2.8 [0.9] cm vs 3.0 [0.7] cm, P = 0.06). We found that change in genital hiatus was greater, by 0.7 cm, when L3SP was performed versus not performed (2.3 [1.2] cm vs 1.6 [1.1] cm, P < 0.001). CONCLUSIONS: Level 3 support procedures may be unnecessary to restore genital hiatus to normal at time of apical suspension procedures and should be reserved for select patients.

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.

A cost-effectiveness analysis of Onabotulinumtoxin A as first-line treatment for overactive bladder.

INTRODUCTION AND HYPOTHESIS: To determine if Onabotulinumtoxin A (Botox®) should be offered as a first-line therapy for the treatment of overactive bladder (OAB), even before prescribing anticholinergics. METHODS: We performed a cost-effectiveness analysis modeling the following clinical options: no treatment, non-selective anticholinergics, selective anticholinergics, and Botox®. The model timeframe was 2 years to allow Botox® reinjection and discontinuation of anticholinergics. Multiple efficacy levels included response improvement by < 50%, 50%, 75%, and 100%. Botox® reinjection was allowed at 6 months if < 50% efficacy. Botox® complications and anticholinergic side effects were noted. We modeled up to one medication switch. No crossover from Botox® to anticholinergics or vice versa was allowed, and failures remained with refractory untreated overactive bladder. Medical literature data were used for model parameter values. Costs are 2016 $US. RESULTS: Botox® costs more than non-selective anticholinergics and less than selective anticholinergics in models with and without refractory overactive bladder costs. Botox® had the highest effectiveness (1.763 quality-adjusted life years). Using incremental cost-effectiveness ratios, Botox® was found to be cost-effective in models with and without refractory costs ($12,428.75 and $14,437.01, respectively). In both models, Botox® cost less and was more effective than selective anticholinergics, which were "dominated." Over 2 years, subjects averaged 15.6 and 14.3 months on selective and non-selective anticholinergics, respectively, and patients averaged 2.2 Botox® injections. Model results were unchanged with variation of input parameter estimates in sensitivity analyses. CONCLUSIONS: Botox® is a cost-effective therapy for overactive bladder and should be further explored as a first-line option in the treatment paradigm.

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.