Feasibility of Home Collection for Urogenital Microbiome Samples.

IMPORTANCE: Feasibility of home urogenital microbiome specimen collection is unknown. OBJECTIVES: This study aimed to evaluate successful sample collection rates from home and clinical research centers. STUDY DESIGN: Adult women participants enrolled in a multicentered cohort study were recruited to an in-person research center evaluation, including self-collected urogenital samples. A nested feasibility substudy evaluated home biospecimen collection prior to the scheduled in-person evaluation using a home collection kit with written instructions, sample collection supplies, and a Peezy™ urine collection device. Participants self-collected samples at home and shipped them to a central laboratory 1 day prior to and the day of the in-person evaluation. We defined successful collection as receipt of at least one urine specimen that was visibly viable for sequencing. RESULTS: Of 156 participants invited to the feasibility substudy, 134 were enrolled and sent collection kits with 89% (119/134) returning at least 1 home urine specimen; the laboratory determined that 79% (106/134) of these urine samples were visually viable for analysis. The laboratory received self-collected urine from the research center visit in 97% (115/119); 76% (91/119) were visually viable for sequencing. Among 401 women who did not participate in the feasibility home collection substudy, 98% (394/401) self-collected urine at the research center with 80% (321/401) returned and visibly viable for sequencing. CONCLUSIONS: Home collection of urogenital microbiome samples for research is feasible, with comparable success to clinical research center collection. Sample size adjustment should plan for technical and logistical difficulties, regardless of specimen collection site.

Short-term outcomes of single port robotic hysterectomy with concomitant sacrocolpopexy.

The Da Vinci single port® (SP) robotic platform heralds a new era of minimally invasive surgery (MIS). The primary objective of this study was to assess short-term outcomes in patients undergoing SP robotic hysterectomy with concomitant sacrocolpopexy for pelvic organ prolapse (POP). We performed a retrospective case series at two tertiary care centers between January 2021 and August 2023. Patients with POP electing to undergo SP robotic hysterectomy with concomitant sacrocolpopexy were included. Chart abstraction was used to collect patient demographics and clinical outcomes. Recurrent POP was defined as new bothersome vaginal bulge symptoms and evidence of POP beyond the hymen on postoperative examination. 69 patients were included. Median operative time was 209 min (135-312) and estimated blood loss was 100 mL (20-2000). 1 (1.4%) patient sustained a major vascular injury resulting in laparotomy. Median pain score and morphine equivalents administered in PACU were low at 3 (0-7) and 3.2 (0-27) respectively. At 3 months, 60 (86.9%) patients were seen either in person or via telemedicine for their follow up appointment. 59/60 (98.3%) reported no vaginal bulge symptoms and 50/51 (98.0%) had stage 0 or 1 prolapse on exam. One (1.4%) patient had recurrent prolapse and underwent an additional repair. Postoperative complications included 2 (2.9%) cases of ileus/small bowel obstruction, 1 (1.4%) pelvic hematoma requiring a blood transfusion, and 1 (1.4%) umbilical hernia. The SP robotic platform is a safe and feasible platform for MIS hysterectomy and sacrocolpopexy with good short term anatomic and symptomatic outcomes.

Suture-Needle Management Device and Novel Port Configuration for Robotic Sacrocolpopexy.

IMPORTANCE: Robot-assisted sacrocolpopexy (SCP) is a commonly performed procedure for the repair of apical pelvic organ prolapse; therefore, novel devices and techniques to improve safety and efficacy of this procedure should be explored. OBJECTIVE: The objective of this study was to assess safety and efficacy of 8-mm trocar site for use of a disposable suture/needle management device (StitchKit; Origami Surgical, Madison, NJ) for robot-assisted SCP with a 4-arm configuration and no assistant port. STUDY DESIGN: This is a retrospective case series of patients undergoing robot-assisted SCP at a tertiary center from 2018 to 2021. All surgical procedures were performed using four 8-mm robotic trocars and StitchKit device. Our objective was to review all cases in which this technique was used to determine whether the approach resulted in a safely completed procedure and any complications or adverse events. Secondary objectives were to describe patient and operative characteristics. RESULTS: In total, 422 patients underwent robot-assisted SCP for pelvic organ prolapse. The mean age was 60 ± 10 years, and mean body mass index was 27 ± 6 (calculated as weight in kilograms divided by height in meters squared). Most patients had stage 3 prolapse (73%) and underwent concomitant hysterectomy (70%). Ninety-nine percent (n = 416) of cases were completed robotically. StitchKit was successfully inserted and removed in all robotic cases with correct needle counts. All patients had postoperative visits, and 80% followed up at 3 months. No umbilical/port site hernias, operative site infections, or adverse events were reported. CONCLUSIONS: Robot-assisted SCP can be performed safely using a 4-arm robotic configuration and suture kit device. This setup eliminates incisions greater than 8 mm and an assistant port, allowing for surgical efficiency without compromising patient outcomes.

Activity Restrictions After Gynecologic Surgery.

Gynecologic surgeons have traditionally restricted the physical activity of postoperative patients. Minimally invasive surgery and enhanced recovery after surgery programs have contributed to decreased hospital stays and more expeditious recovery. In this narrative review, we review the current state of postoperative activity restrictions in gynecology and other specialties, the purported risks and potential benefits of postoperative activity, the available evidence to refute or support activity in the postoperative activity, and, finally, the potential benefit of added activity in the postoperative period.

The brain, gut, and bladder health nexus: A conceptual model linking stress and mental health disorders to overactive bladder in women.

OBJECTIVE: A small, but growing literature links stressors and mental health disorders (MHDs) across the life course to overactive bladder (OAB) and urinary incontinence symptoms. Mechanisms by which stressors and MHDs may impact bladder health are not fully understood, limiting novel prevention and treatment efforts. Moreover, potential biopsychosocial mechanisms involving the brain and gut have not been considered in an integrated, comprehensive fashion. METHODS: Members of the prevention of lower urinary tract symptoms Research Consortium developed conceptual models to inform research on biopsychosocial mechanisms through which stress and MDHs may impact bladder health among girls and women, focusing on brain and gut physiology. RESULTS: Two conceptual models were developed-one to explain central (brain-based) and peripheral (gut-based) mechanisms linking stressors and MHDs to OAB and bladder health, and one to highlight bidirectional communication between the brain, gut, and bladder. Traumatic events, chronic stressors, and MHDs may lead to a maladaptive stress response, including dysregulated communication and signaling between the brain, gut, and bladder. Gut bacteria produce molecules and metabolites that alter production of neurotransmitters, amino acids, short-chain fatty acids, and inflammatory immune response molecules that mediate communication between the gut and brain. Microbiota signal neurogenesis, microglia maturation, and synaptic pruning; they also calibrate brain-gut-bladder axis communication through neurotransmission and synaptogenesis, potentially influencing bladder symptom development. Life course trajectories of risk may be prevented or interrupted by central and peripheral resources for neuropsychological resilience. CONCLUSIONS: Depicted pathways, including brain-gut-bladder communication, have implications for research and development of novel prevention and treatment approaches.

Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction.

PURPOSE: Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts. METHODS: Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed. RESULTS: Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion. CONCLUSIONS: We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective Study.

Use of a Computerized Decisional Analysis Tool in Patients With Urgency Urinary Incontinence.

IMPORTANCE: Decision analysis tools (DAT) are shared decision making instruments that include patient input on treatment goals and values that have been shown to decrease decisional regret in women's health care. OBJECTIVE: We describe a novel, computerized DAT for patients with urinary incontinence (UI), and our primary aim was to assess the concordance between treatment fit as determined by the DAT and treatment selected after physician counseling in patients with urgency urinary incontinence and urgency predominant mixed urinary incontinence. STUDY DESIGN: We partnered with a health care startup to develop a computerized DAT incorporating evidence about UI and patient input about treatment goals and personal values. This is a retrospective cohort study examining the concordance of DAT-predicted treatments identified before consultation with the physician and those chosen after counseling. Electronic medical records were reviewed to abstract demographic, clinical data, and treatments chosen at the initial physician consultation. Because it was possible to pursue concurrent treatment options (ie, pelvic floor physical therapy and medications), the first 2 modalities identified in the treatment plan at consultation were abstracted. Descriptive statistics were conducted using SPSS®, we did not adjust for multiple comparisons. RESULTS: Four hundred eighty-nine patients met the inclusion criteria for our study, and 65% of the cohort chose treatment options after counseling that were concordant with their DAT best treatment fit. CONCLUSION: Patients choosing treatment for urgency urinary incontinence and urgency predominant mixed urinary incontinence using a novel, computer-based DAT to prepare for shared decision making with their physicians often choose to proceed with their top DAT-determined treatment fit after counseling.

Gender Differences in Letters of Recommendation for Gynecology Surgical Fellowship Applicants: Analysis of One Program's Recruitment Cycle.

STUDY OBJECTIVE: To examine whether there are gender differences in letters of recommendation (LORs) written for residents applying to gynecology surgical fellowships. DESIGN: Retrospective study. SETTING: Single, academic institution. PATIENTS: LORs for applicants to gynecology oncology, urogynecology, and minimally invasive gynecology fellowships during the 2019-2020 application cycle. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: We analyzed the linguistic content of the letters for the presence of 4 summary variables and 21 word categories based on previous studies using validated computerized text analysis software. We used multivariable analysis using linear mixed models to compare linguistic characteristics of letters by applicant gender. We performed qualitative content analysis on letters and compared the frequency of code themes by gender. The mixed-method design was planned to allow for analysis of domains not captured in text analysis. Among 680 letters written for 186 applicants, 124 (18.2%) were written for men, and 556 (81.8%) were written for women. There were no differences in the least square mean (standard error) word counts for LORs written for men and women applicants, 465 (20.0) vs 458(9.4) words, p = .74. In multivariable analysis, LORs written for men were found to have higher authentic tone and more risk words (p = .005 and p = .03, respectively). LORs written for women contained more communal (relationship-oriented) words (p = .006). The qualitative analysis demonstrated that ability, interpersonal traits, surgical skills, and research were the most often mentioned themes. Comments about compassion/empathy, leadership potential, teaching, interpersonal skills, and patient rapport were found more often in letters for men. More doubt raisers (words that raise doubt or concern) were present in letters for men, but letters for both genders had similar levels of negative criticism. In contrast, comments on ability, being "drama-free," and self-awareness were found more often in letters for women. CONCLUSION: There were gender differences in LORs written for obstetrics and gynecology surgical subspecialty fellowship applicants indicating the presence of gender bias.

Patient Satisfaction With Telehealth Visits for New Patient Appointments for Pelvic Floor Disorders: A Randomized Trial of Telehealth Versus Standard In-Person Office Visits.

IMPORTANCE: The acceptability and safety of telehealth have been reported in urogynecology for preoperative and postoperative care but not new patient consultation. OBJECTIVES: This study aimed to determine if new patient telehealth encounters are noninferior to in-person encounters for women presenting to a urogynecology clinic using a satisfaction questionnaire. Secondary objectives were to describe patient experiences and follow-up. STUDY DESIGN: A randomized controlled trial of telehealth versus in-person consults for new patients with any urogynecologic condition was conducted. Patients completed the validated Patient Satisfaction Questionnaire 18 (PSQ-18) after the visit. The primary outcome was composite PSQ-18 score. Using a noninferiority margin of 5 points on the PSQ-18, 25 patients per arm were required with a power of 80% and an α of 0.05. RESULTS: From March to September 2021, 133 patients were screened, 71 were randomized, and 58 were included in the final analysis (30 telehealth and 28 in-person). Demographic characteristics were similar between groups. Patient Satisfaction Questionnaire 18 composite scores were high for both groups but higher for in-person versus telehealth visits (75.68 ± 8.55 vs 66.60 ± 11.80; P = 0.001; difference, 9.08); results were inconclusive with respect to noninferiority. Women in the telehealth group expressed uncertainty regarding the telehealth format. There were no differences in short-term follow-up, communication with the office, or treatment chosen between groups. CONCLUSIONS: Women seen by urogynecologic providers for a new consult both via in-person or telehealth visits demonstrated high satisfaction with their first visit. We were unable to determine if telehealth is noninferior to in-person visits. Our study adds to the literature that telehealth is safe, effective, and acceptable to patients.

Longitudinal urinary microbiome characteristics in women with urgency urinary incontinence undergoing sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the stability of the urinary microbiome communities in women undergoing sacral neuromodulation (SNM) for urgency urinary incontinence (UUI). We hypothesized that clinical response to SNM therapy would be associated with changes in the urinary microbiome. METHODS: Women completed the Overactive Bladder Questionnaire Short-Form, the International Consultation on Incontinence Questionnaire Short Form, and the Female Sexual Function Index at baseline and 3 months post-SNM implantation. Transurethral urinary specimens were obtained for microbiome analysis at baseline and 3 months postoperatively. The V4 region of the 16S rRNA gene (515F-806R) was amplified with region-specific primers, and Amplicon Sequence Variants (ASVs) were identified with a closed-reference approach of taxonomic classification. Alpha-diversity was calculated using the phylogenetic (i.e., Faith's phylogenetic diversity) and nonphylogenetic metrics (i.e., Shannon diversity, and Pielou's evenness) using the QIIME2 plugin. Longitudinal paired volatility analysis was performed using the DEICODE and Gemelli plugin to account for host specificity across both time and space. RESULTS: Nineteen women who underwent SNM and provided both baseline and 3-month urine samples were included in this analysis. Women reported improvement in objective (number of UUI episodes) and subjective (symptom severity and health-related quality of life) measures. Ninety percent of the bacteria were classified as Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. No significant differences were observed in each subject's beta-diversity at 3 months compared with their baseline microbiome. CONCLUSIONS: Our descriptive pilot study of a cohort of women who had achieved objective and subjective improvements in UUI following SNM therapy demonstrates that the urinary microbiome remains relatively stable, despite variability amongst the cohort.

Characterization of the GU microbiome in women with self-perceived bladder health over the life course.

BACKGROUND: A variety of factors influence bladder health, including environmental factors, life experiences, biologic foundations, and coexistent medical conditions. A biologically diverse microbial community exists in the urine that is likely influenced by the microbial inhabitants of the vagina. The relationship between the genitourinary (GU) microbiome and self-perceived bladder health is unknown. OBJECTIVE: To longitudinally define the GU microbiome in women with self-percieved bladder health sampled across multiple time points over a year. STUDY DESIGN: Women with no reported lower urinary tract dysfunction or symptoms (LUTS) were recruited from six clinical sites and assessed every 6 weeks for 1 year. Voided urine and vaginal samples were longitudinally collected. Self-perceived bladder health was assessed with select items from the LURN comprehensive assessment of self-reported urinary symptoms (CASUS) tool. We defined four life phases as follows: young (18-34 years, nulliparous), midlife (35-45 years, menstruating), transitional (46-60 years, perimenopausal), mature (>60 years, not using vaginal and/or systemic hormone replacement therapy). DNA was extracted from samples, and the V4 region of the 16S rRNA gene was amplified with region-specific primers. The 16S rRNA sequencing on an Illumina NovaSeq. Microbial beta-diversity was calculated using DEICODE to identify microbial taxa that cluster in the samples. Longitudinal volatility analysis was performed using the gemelli plugin. Log-abundance ratios of microbial features were explored and visualized in Qurro. RESULTS: Fifty-four (N = 16 young, N = 16 midlife, N = 15 transitional, N = 7 mature) women were enrolled and provided baseline data. Most women in each life phase (93%-98%) continued to report self-perceived bladder health throughout the 1-year follow-up as assessed by CASUS items. Temporal-based microbial diversity of urinary and vaginal microbiome remained relatively stable over 1 year in all subjects. The GU microbiomes of mature women were distinct and microbially diverse from that of young, midlife, and transitional women, with genera of Gardnerella, Cupriavidus, and Dialister contributory to the microbial features of the mature microbiome. The mature GU microbiome was statistically different (p < 0.0001) from the midlife, transitional, and young microbiome for the log ratio of Gardnerella and Cupriavidus (in the numerator) and Lactobacillus (in the denominator) for voided samples and Gardnerella and Dialister (in the numerator) and Lactobacillus (in the denominator) for vaginal samples. Differences in the GU microbiome were also demonstrated via longitudinal beta-diversity between women developing urinary frequency as reported by CASUS responses or objectively on bladder diary compared to women without urinary frequency. CONCLUSION: In women with a self-perceived healthy bladder, the GU microbiome remained stable in all age groups over a 1 year period. Differences were seen with respect to life phase, where mature women were distinct from all other groups, and with respect to self-reported LUTS.

Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN).

BACKGROUND: The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms. OBJECTIVE: This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement. STUDY DESIGN: Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not). RESULTS: A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4). CONCLUSION: Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.

Mesh complications after total vs supracervical laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Our objective was to compare mesh exposure rates (4 months and 1 year) after total (TLH) vs supracervical (SLH) laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy (SCP). Secondary outcomes included 30-day complications and midurethral mesh exposure rates. METHODS: This a retrospective cohort study at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes. Demographics, operative characteristics, and perioperative complications were abstracted from medical records. RESULTS: Four hundred three women met the inclusion criteria: 91 SLH+SCP and 312 TLH+SCP. Median follow-up was 52 weeks with an overall mesh exposure rate of 1.5%. Follow-up was available for 90% of patients at 4 months and 51% at 1 year. Half of patients had lightweight mesh (n = 203), and half had ultralightweight mesh (n = 200). Vaginal mesh fixation was performed with permanent suture in 86% (n = 344) and delayed absorbable suture in 14% (n = 56) of patients. At 4 months, vaginal mesh exposure rates did not differ between groups (0% SLH vs 1% TLH, p = 1.00). All mesh exposures in the study period occurred with lightweight mesh in the TLH arm. No differences were noted in 1-year mesh exposure rates, 30-day perioperative complications (p = 0.57), or midurethral mesh exposure rates at 4 months (p = 0.35) and 1 year (p = 1.00) between groups. CONCLUSIONS: Short-term mesh exposure following SCP with ultralightweight and lightweight polypropylene mesh is rare regardless of type of hysterectomy and much lower than reported in earlier studies with heavier weight mesh. These data suggest TLH at the time of SCP is a safe option in appropriately counseled patients.

The Leadership Landscape: The Role of Gender in Current Leadership Positions in Obstetrics and Gynecology Departments.

STUDY OBJECTIVE: To describe the proportion of female faculty in departmental administrative and educational leadership roles in Obstetrics and Gynecology departments. DESIGN: Cross-sectional observational study (II-3). SETTING: Accredited Obstetrics and Gynecology residency programs. PARTICIPANTS: A total of 288 accredited residency programs were identified from 2019 to 2020 with 1237 individuals in leadership positions. INTERVENTIONS: Similar to a 2012 to 2013 survey by Hofler et al, residency program websites and corresponding fellowships (Maternal Fetal Medicine, Female Pelvic Medicine and Reconstructive Surgery, Reproductive Endocrinology and Infertility, and Gynecologic Oncology), departmental websites, and divisional websites were queried for those in administrative and educational leadership positions. Information regarding gender (as determined by the surrogates of name and photographic gender expression), medical and academic degrees, academic rank, and subspecialty certification was abstracted. MEASUREMENTS AND MAIN RESULTS: Within administrative leadership roles, women comprised 29% of chairs, 46% of vice chairs, and 47% of division directors, all significantly lower than men in administrative leadership (p <.001). In educational leadership, women made up 71% of medical school clerkship directors, 58% of residency directors, and 50% fellowship directors. Women were more likely to hold educational leadership positions (56% vs 40%; p <.001), although men were more likely to hold administrative leadership positions (68% vs 52%; p <.001). Among subspecialties, there was greatest gender equity within Female Pelvic Medicine and Reconstructive Surgery. Female leaders were more likely to have received additional academic degrees (e.g. MBA, MPH) than their male counterparts (19% vs 13%; p = .002). CONCLUSION: Women continue to be underrepresented in administrative leadership positions. Compared with 2012 to 2013, there is only a 9% increase in proportion of women chairing and 10% vice chairing Obstetrics and Gynecology departments; however, the increase is more substantial in other positions, such as division directors (17%). Our findings demonstrate ongoing gender disparity in the highest levels of departmental leadership and the need to further improve on diversity and gender equity within leadership roles.

Sex Differences in Commercial Patient Reviews of Women and Men Urogynecologic Surgeons.

OBJECTIVE: The objective of our study was to describe differences in commercial patient reviews of women and men urogynecologic surgeons. MATERIALS AND METHODS: Reviews of surgeons on Healthgrades.com in 4 metropolitan areas were included. Based on the qualitative assessment using qualitative content analysis of major and minor elements, we defined 4 theme categories: global experience, social interaction, technical skills, and ancillary aspects, each embedded with discrete elements. Differences in proportions of mentioned themes as well as quantitative ratings were evaluated by sex with the appropriate statistical tests. RESULTS: Three hundred sixty-four patient reviews (51% for women surgeons and 49% for men surgeons) were identified for 141 gynecologic surgeons self-identifying as "urogynecologists." The majority of the cohort (77%) held subspecialty certification in female pelvic medicine and reconstructive surgery. Reviews of women demonstrated a lower mean quantitative "likelihood to recommend" score compared with men (4.0 vs 4.3, P = 0.002) on the 5-point scale. Women received more mention in comfort (52% vs 40%, P = 0.023) and professionalism (19% vs 9%, P = 0.007) themes and less mention with respect to surgical outcomes (28% vs 53%, P < 0.001) and technical skills (5% vs 15%, P = 0.011) compared with men. CONCLUSIONS: Commercial online patient reviews for urogynecologic surgeons reveal sex bias with women receiving lower scores overall and more comments related to social interaction and fewer comments related to surgical outcomes and technical skill compared with men.

Neuromuscular urethral function and urethral urodynamic parameters between urgency and stress incontinence do not differ.

INTRODUCTION AND HYPOTHESIS: To describe and compare urethral neuromuscular function using concentric needle electromyography (CNEMG) and urodynamic (UDS) parameters between stress incontinent (SUI) and urge incontinent (UUI) women. METHODS: Incontinent women were recruited from a urogynecology clinic if they answered "sometimes" or "always" to one of the items on the Medical, Epidemiologic, and Social Aspects of Aging questionnaire. Participants were categorized by MESA scores into stress (SUI) or urgency (UUI) incontinence groups. Participants underwent CNEMG of the striated urethral sphincter at three insertion sites using Medtronic multiple motor unit action potential analysis. UDS was performed with Laborie microtip catheters: urethral pressure profiles were obtained at baseline and 300 ml. Data were analyzed in SPSS. Continuous variables were compared with independent t-test or Mann-Whitney U, categorical variables with chi-square test. A logistic regression was performed to control for variables found to be significant on univariate analysis. RESULTS: Fifty-six women (37 SUI, 19 UUI) with mean ± SD age of 53 ± 13 years participated. At baseline, patients with SUI were younger, more likely to be premenopausal and had lower BMIs. There were no differences in urethral EMG or UDS parameters between UUI and SUI women except lower maximum cystometric capacity in women with UUI. When controlling for age, BMI and MCC on logistic regression, there remained no differences between SUI and UUI groups on EMG or UDS parameters. CONCLUSIONS: Women with UUI and DO show similar evidence of denervation-reinnervation injury to the striated urethral sphincter muscle as women with SUI.

Incidence of and Risk Factors for Postoperative Venous Thromboembolism in Benign Hysterectomy.

STUDY OBJECTIVE: Describe the incidence of and risk factors associated with postoperative venous thromboembolism (VTE) in patients undergoing hysterectomy for benign indications with emphasis on the impact of route of surgery. DESIGN: Retrospective cohort. SETTING: National Surgical Quality Improvement Project Database. PARTICIPANTS: Data of women aged 18 years and older who underwent hysterectomy for benign indications between 2014 and 2018 were abstracted. INTERVENTIONS: Cases were identified by Current Procedural Terminology codes and International Classification of Diseases codes. Patient demographics, preoperative comorbidities, American Society of Anesthesiologists (ASA) classification system scores, total operating time, length of stay, readmission, reoperation, VTE including deep vein thrombosis and pulmonary embolism were collected. Cases were stratified by route of hysterectomy. MEASUREMENTS AND MAIN RESULTS: t test and multivariable logistic regression were used for analysis. A total of 94 940 patients underwent hysterectomy, of which 23 081 (24.3%) underwent abdominal hysterectomy, 56 656 (59.7 %) laparoscopic hysterectomy, and 15 203 (16.0%) vaginal hysterectomy. The overall incidence of VTE was 0.4%. The incidence of VTE was higher for abdominal (0.7%), than laparoscopic (0.3%, p <.001), and vaginal hysterectomy (0.2%, p <.001). Higher ASA classification was independently associated with postoperative VTE. Age, race, body mass index, uterine weight, operative time, multiple medical comorbidities, and smoking status were not independently associated with increased risk of VTE. CONCLUSION: Postoperative VTE after hysterectomy for benign indications is rare. The risk of postoperative VTE is higher in patients undergoing abdominal hysterectomy compared with minimally invasive hysterectomy including laparoscopic and vaginal routes of surgery. In addition, the risk of VTE may be higher with higher ASA class.

Surgical Outcomes in Benign Gynecologic Surgery Patients during the COVID-19 Pandemic (SOCOVID study).

STUDY OBJECTIVE: To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. DESIGN: A multicenter prospective cohort study. SETTING: Ten institutions in the United States. PATIENTS: Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. INTERVENTIONS: Benign gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4-50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). CONCLUSION: In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.

How Does the Urethra Respond to Bladder Filling in Continent and Incontinent Women?

OBJECTIVE: The objective of this study was to describe mean urethral pressure (MUP) during filling cystometry in continent and incontinent women. METHODS: Incontinent women were recruited from a urogynecology clinic if they answered "sometimes" or "always" to 1 of the items on the Medical, Epidemiologic, and Social Aspects of Aging questionnaire. Participants were categorized by Medical, Epidemiologic, and Social Aspects of Aging scores into stress urinary incontinence (SUI) or urgency urinary incontinence (UUI) groups. Continent women were recruited from the community. Multichannel urodynamics were performed using microtip catheters. Urethral pressure profiles were obtained with an empty bladder and at 100-mL increments during filling. Data were analyzed in SPSS. Continuous variables were compared with independent t test or analysis of variance, categorical variables with the χ2 test, and multivariable comparisons were made with linear regression. RESULTS: Eighty-six women (30 continent, 56 incontinent: 37 SUI, 19 UUI) with a mean ± SD age of 48 ± 15 years and a body mass index (BMI) of 31 ± 9 participated. Sixty-nine percent were White, 43% were postmenopausal, and 80% were parous. Continent women were younger (P < 0.001) and had a lower BMI (P = 0.004). Mean cystometric capacity was higher in women with SUI and continent women than in women with UUI (430 ± 142, 448 ± 101, and 332 ± 160, P = 0.04). Continent women had higher MUP at baseline when controlling for age, BMI, and parity (84 ± 35 cmH2O vs 62 ± 28 cmH2O; aR2 = 0.2, P = 0.02) compared with incontinent women. During filling, MUP in continent women was 20-30 cmH2O higher at all bladder volumes than incontinent women. Mean urethral pressure increased significantly between baseline and 300 mL in continent women (P < 0.005) and women with SUI (P = 0.04), but not in women with UUI (P = 0.48). CONCLUSIONS: Continent women have greater baseline MUP and greater increases in MUP during bladder filling than incontinent women.

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy. METHODS: In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum. RESULTS: Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index. CONCLUSION: At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.