Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women.

BACKGROUND: Vaginal estrogen is considered to be the standard of care for recurrent urinary tract infection prevention in women with hypoestrogenism. However, literature supporting its use is limited to small clinical trials with narrow generalizability. OBJECTIVE: This study aimed to assess the association between vaginal estrogen prescription and the frequency of urinary tract infections over the following year in a diverse population of women with hypoestrogenism. Secondary objectives included evaluation of medication adherence and predictors of postprescription urinary tract infection. STUDY DESIGN: This multicenter retrospective review included women who were prescribed vaginal estrogen for the indication of recurrent urinary tract infection from January 2009 through December 2019. Recurrent urinary tract infection was defined as having ≥3 positive urine cultures (separated by at least 14 days) in the 12 months preceding the index vaginal estrogen prescription. Patients were asked to fill their prescriptions and continue care within Kaiser Permanente Southern California system for at least 1 year. Exclusion criteria included anatomic abnormalities, malignancy, or mesh erosion of the genitourinary tract. Data on demographics, medical comorbidities, and surgical history were collected. Adherence was captured through refill data after the index prescription. Low adherence was defined as no refills; moderate adherence was defined as 1 refill; high adherence was defined as ≥2 refills. Data were abstracted from the electronic medical record system using the pharmacy database and diagnosis codes. A paired t test was used to compare pre- and postprescription urinary tract infections over the year preceding and following the vaginal estrogen prescription. A multivariate negative binomial regression was used to evaluate predictors of postprescription urinary tract infection. RESULTS: The cohort included 5638 women with a mean (±standard deviation) age of 70.4 (±11.9) years, body mass index of 28.5 (±6.3) kg/m2, and baseline urinary tract infection frequency of 3.9 (±1.3). Most of the participants were White (59.9%) or Hispanic (29.7%) and postmenopausal (93.4%). The mean urinary tract infection frequency in the year following the index prescription decreased to 1.8 (P<.001) from 3.9 in the year preceding the prescription, which is a 51.9% reduction. During the 12 months after the index prescription, 55.3% of patients experienced ≤1 urinary tract infections, and 31.4% experienced no urinary tract infections. Significant predictors of postprescription urinary tract infection included age of 75 to 84 years (incident rate ratio, 1.24; 95% confidence interval, 1.05-1.46) and >85 years (1.41; 1.17-1.68), increased baseline urinary tract infection frequency (1.22; 1.19-1.24), urinary incontinence (1.14; 1.07-1.21), urinary retention (1.21; 1.10-1.33), diabetes mellitus (1.14; 1.07-1.21), and moderate (1.32; 1.23-1.42) or high medication adherence (1.33; 1.24-1.42). Patients with high medication adherence demonstrated more frequent postprescription urinary tract infections than patients with low adherence (2.2 vs 1.6; P<.0001). CONCLUSION: In this retrospective review of 5600 women with hypoestrogenism who were prescribed vaginal estrogen for the prevention of recurrent urinary tract infections, the frequency of urinary tract infection decreased by more than 50% in the following year. Baseline urinary tract infection frequency, increasing age, urinary incontinence or retention, and diabetes were associated with an increased risk of postprescription urinary tract infection. The paradoxical finding that women with moderate and high medication adherence experienced the lowest-magnitude reduction in urinary tract infection frequency may represent unobserved selection or unmeasured confounding.

Long-term reoperation risk after apical prolapse repair in female pelvic reconstructive surgery.

BACKGROUND: Although several different apical suspension procedures are available to women with pelvic organ prolapse, data on long-term efficacy and safety profiles are limited. OBJECTIVE: The primary aim of this study was to analyze longitudinal reoperation risk for recurrent prolapse among the 4 apical suspension procedures over 2 to 15 years. Secondary aims included evaluation of all-cause reoperation, defined as a repeated surgery for the indications of recurrent prolapse and adverse events, and total retreatment rate, which included a repeated treatment with another surgery or a pessary. STUDY DESIGN: This was a multicenter, retrospective cohort study within Kaiser Permanente Southern California that included women who underwent sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament fixation, or colpocleisis from January 2006 through December 2018. Women who underwent concomitant rectal prolapse repair or vaginal prolapse repair with mesh augmentation were excluded. Data were abstracted using procedural and diagnostic codes through July 2021, with manual review of 10% of each variable. Patient demographics and pessary use were compared using analysis of variance or chi square tests for continuous and categorical variables, respectively. Time-to-event analysis was used to contrast reoperation rates. A Cox regression model was used to perform an adjusted multivariate analysis of the following predictors of reoperation for recurrence: index surgery, concomitant procedures, patient demographics, baseline comorbidities, and year of index surgery. Censoring events included exit from the health maintenance organization and death. RESULTS: The cohort included 9681 women with maximum follow-up of 14.8 years. The overall incidence of reoperation for recurrent prolapse was 7.4 reoperations per 1000 patient-years, which differed significantly by type of apical suspension (P<.0001). The incidence of reoperation was lower after colpocleisis (1.4 events per 1000 patient-years) and sacrocolpopexy (4.8 events per 1000 patient-years) when compared with uterosacral ligament suspension (9 events per 1000 patient-years) and sacrospinous ligament fixation (13.9 events per 1000 patient-years). All pairwise comparisons between procedures were significant (P=.0003-.0018) after correction for multiplicity, except for uterosacral ligament suspension or uterosacral ligament hysteropexy vs sacrospinous ligament fixation or sacrospinous ligament hysteropexy (P=.05). The index procedure was the only significant predictor of reoperation for recurrence (P=.0003-.0024) on multivariate regression analysis. Reoperations for complications or sequelae (overall 2.9 events per 1000 patient-years) also differed by index procedure (P<.0001) and were highest after sacrocolpopexy (4.4 events per 1000 patient-years). The incidence of all-cause reoperation for recurrence and adverse events after sacrocolpopexy, however, was comparable to that of the other reconstructive procedures (P=.1-.4) in pairwise comparisons with Bonferroni correction. Similarly, frequency of pessary use differed by index procedure (P<.0001) and was highest after sacrospinous ligament fixation at 9.3% (43/464). CONCLUSION: Among nearly 10,000 patients undergoing prolapse surgery within a large managed care organization, colpocleisis and sacrocolpopexy offered the most durable obliterative and reconstructive prolapse repairs, respectively. All-cause reoperation rates were lowest after colpocleisis by a large margin, but similar among reconstructive apical suspension procedures.

The impact of midurethral sling surgery on the development of urinary tract infections.

PURPOSE/OBJECTIVE: To measure the impact of the placement of a midurethral sling (MUS) on development of urinary tract infections (UTI) in women with stress urinary incontinence. METHODS: This is an analysis of a large managed care organization MUS database from 2005 to 2016. The database was queried to identify UTI and diagnosis of recurrent UTI. The primary outcome was the UTI rate after MUS. Secondary outcomes included the recurrent UTI rate and rates of UTI over time. RESULTS: Over the study period, 13,404 MUS were performed. In the 12 postoperative months, 23% of patients developed a UTI, while 4% developed a de novo recurrent UTI diagnosis. UTIs were most frequently diagnosed in the 1st month, with the 7th postoperative day the most common. Predictors of UTI development included increased age (OR 3.69 [95% CI 2.58-5.26]), being diabetic (OR 1.43 [95% CI 1.28-1.60]), and having urinary retention requiring prolonged catheterization (OR 2.45 [95% CI 2.11-2.85]). UTIs were less likely to be diagnosed in those with transobturator MUS (OR 0.85 [95% CI 0.78-0.94]). Patients who developed a UTI were more likely to have a reoperation (p = 0.0147), including a reoperation for mesh revision/removal (p = 0.0287), and recurrent SUI (p = 0.0394). Patients who developed a UTI were more likely to develop postoperative de novo urgency urinary incontinence (UUI) (p < 0.0001). CONCLUSION: Patients are at risk of UTI and rUTI after MUS. Risk of developing UTIs decreases with time. Predictors of developing UTI can help surgeons in the care of patients after MUS.

The Impact of Surgical Center Volume on Reoperation Risk after Mid Urethral Sling.

PURPOSE: We sought to determine whether a center's surgical volume affects patient reoperation rates after mid urethral sling (MUS) surgery. MATERIALS AND METHODS: We performed a retrospective cohort study evaluating a large managed care organization from 2005 to 2016. The primary outcome was the MUS reoperation rate. Perioperative factors and reoperation of patients were compared using Wilcoxon rank-sum for continuous variables and chi-square for categorical variables. We estimated the adjusted hazard ratio and the 95% confidence interval of reoperation using Cox proportional hazards model. RESULTS: Within the managed care system, 13,404 primary MUSs were performed at 11 centers over the study period (19/105 center years were considered low volume). Higher-volume centers (>58 procedures/year based on concentration curve) performed 93% of surgeries in this cohort. Overall reoperation risk for patients of higher-volume centers was smaller than those of lower-volume centers, 4.9% vs 9.8% at 9 years (hazard ratio 0.45 [p <0.01]). Risk of reoperation for recurrent stress urinary incontinence (SUI) for patients was lower in the higher-volume centers, 4% vs 9.1% at 9 years (p <0.01). Patient of higher-volume centers were less likely to have a reoperation for mesh exposure 0.2% vs 0.7% (p <0.01) or infection 0% vs 0.2% (p <0.01). CONCLUSIONS: Patients who had their MUS surgery at a higher-volume medical center were less likely to have any reoperation including for recurrent SUI, mesh exposure or infection. These findings persisted even when controlling for potential covariates including patient demographics and surgeon volume and specialty.

Readmission and emergency department visits after minimally invasive sacrocolpopexy and vaginal apical pelvic organ prolapse surgery.

BACKGROUND: Minimally invasive pelvic reconstructive surgery is becoming increasingly common; however, data on readmission and emergency department visits within 30 days of surgery are limited. OBJECTIVE: Our objective was to report the risk factors for 30-day readmission and emergency department visits after minimally invasive pelvic organ prolapse surgery. STUDY DESIGN: This retrospective cohort study included all minimally invasive urogynecologic prolapse procedures with and without concomitant hysterectomy performed within a large managed healthcare organization of 4.5 million members from 2008 to 2018. We queried the system-wide medical record for current procedural terminology and International Classification of Diseases, Ninth or Tenth Revision codes for all included procedures and patient demographic and perioperative data. Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department visits. Risk factors including demographics, surgical approach, and characteristics for 30-day outcomes were examined using odds ratios and chi-square tests for categorical variables and Wilcoxon rank sum tests for continuous variables. RESULTS: Of the 13,445 patients undergoing prolapse surgery, 6171 patients underwent concomitant hysterectomy whereas 7274 did not. Readmission within 30 days was 2.1% for those with and 1.5% for those without a concomitant hysterectomy. Emergency department visit within 30 days was 9.5% in those with and 9.2% in those without a concomitant hysterectomy. Concomitant hysterectomy (adjusted odds ratio, 1.41; 95% confidence interval, 1.07-1.81) was associated with an increased risk of 30-day readmission. There was no difference in risk of 30-day readmission when comparing the various approaches to hysterectomy. When compared with patients who underwent sacrocolpopexy, undergoing a sacrospinous ligament suspension increased the risk (adjusted odds ratio, 2.43; 95% confidence interval, 1.22-4.70) of 30-day readmission, while undergoing uterosacral ligament suspension (adjusted odds ratio, 0.99; 95% confidence interval, 0.57-1.63) or colpocleisis (adjusted odds ratio, 1.79; 95% confidence interval, 0.50-5.24) did not in the concomitant hysterectomy subgroup, when compared with patients who underwent sacrocolpopexy, there was no difference in the risk of 30-day readmission for sacrospinous ligament suspension (adjusted odds ratio, 1.09; 95% confidence interval, 0.61-3.34), uterosacral ligament suspension (adjusted odds ratio, 1.39; 95% confidence interval, 0.61-3.34) or colpocleisis (adjusted odds ratio, 1.88; 95% confidence interval, 0.71-4.02). Similarly, sacrocolpopexy was not associated with an increased risk of emergency department visits in either subgroup. For those who had a concomitant hysterectomy, the patient factors that were associated with an increased 30-day readmission risk were hypertension (odds ratio, 1.54; 95% confidence interval, 1.03-2.31; P=.03) and chronic obstructive pulmonary disease (odds ratio, 2.52; 95% confidence interval, 1.32-4.81; P<.01). For those whose prolapse procedure did not include concomitant hysterectomy, the patient factors that were associated with an increased 30-day readmission risk were age (odds ratio, 1.05; 95% confidence interval, 1.02-1.07; P<.01) and heart failure (odds ratio, 3.26; 95% confidence interval, 1.68-6.33; P<.01). CONCLUSION: In women undergoing minimally invasive pelvic organ prolapse surgery, sacrocolpopexy was not associated with an increased risk of 30-day readmission and emergency department visits. Clinicians may consider surgical approach and other factors when counseling patients about their risks after minimally invasive pelvic organ prolapse surgery.

The impact of the 2011 US Food and Drug Administration transvaginal mesh communication on utilization of synthetic mid-urethral sling procedures.

INTRODUCTION AND HYPOTHESIS: We sought to examine the change in utilization of the midurethral sling (MUS) for the treatment of stress urinary incontinence (SUI) after the 2011 US FDA communication regarding transvaginal mesh. METHODS: This is a retrospective cohort study evaluating surgical utilization of MUS at a managed care organization of 4.5 million patients from 2008 to 2016. The primary outcome was the change in utilization of synthetic mesh MUS before and after the July 2011 FDA communication. Secondary outcomes were the changes in surgeon level MUS utilization. RESULTS: MUS procedures decreased from 131 to 116 per 100,000 adult women with a decrease of 11.5% from 2010 to 2012. Year over year utilization of MUS was rapidly increasing (p < 0.01) prior the FDA communication from 116 (in 2008) to 131 (in 2010) per 100,000 women and then significantly declined (p < 0.01) after its release from 135 (in 2011) to 75 (in 2016) per 100,000 women (13% increase vs 44% decrease). The number of surgeons performing MUS increased (p < 0.01) from 172/year to 186/year from 2008 to 2010 (Table 1). This decreased (p < 0.01) from 183/year to 121/year from 2011 to 2016. CONCLUSIONS: MUS for SUI drastically declined after the FDA communication. Despite the 2011 FDA communication concerning only transvaginal mesh for pelvic organ prolapse, there was a significant decrease in MUS with synthetic mesh utilization. Our findings support the importance of continued long-term outcome data regarding the safety and efficacy of MUS and highlight the impact of the FDA warning on MUS utilization.

Anchor vs suture for the attachment of vaginal mesh in a robotic-assisted sacrocolpopexy: a randomized clinical trial.

BACKGROUND: Vaginal mesh attachment can be one of the most time-consuming components of a minimally invasive sacrocolpopexy. OBJECTIVE: To assess the impact on the duration vaginal mesh attachment of using absorbable anchors compared to interrupted sutures for vaginal mesh attachment in robotic-assisted sacrocolpopexy. STUDY DESIGN: This was a single-masked, randomized clinical trial of women with pelvic organ prolapse that underwent a robotic-assisted sacrocolpopexy at 2 clinical sites. The participants were randomized to receive either interrupted delayed absorbable anchors or sutures during the vaginal mesh attachment portion of the surgery. The participants completed validated questionnaires at baseline and at 6 weeks, 6 months, and 12 months after the surgery. A certified examiner, masked to the attachment technique that was used, performed a clinical examination using the Pelvic Organ Prolapse Quantification system and also assessed for mesh exposure and the overall appearance of the vaginal walls using a 10-cm visual analog scale at each follow-up visit. The primary outcome was the vaginal mesh attachment time. The categorical variables were compared using chi-square or Fischer's Exact test, whereas the continuous variables were compared using Student's t-test or Mann-Whitney U test where appropriate. An intention-to-treat analysis was performed. RESULTS: Fifty-three participants were randomized, 26 to mesh attachment with anchor, 27 to mesh attachment with suture, and 81% (21/26) and 93% (25/27) had 12-month follow up respectively. There were no significant differences between the groups with regard to age (P=.12), body mass index (P=.23), stage of prolapse (P=.97), or other preoperative factors. Mesh attachment interval time was faster in the anchor compared to suturing study arm (12.2±7.8 vs 21.2±5.2 minutes; P<.001), while sacrocolpopexy times (107.6±33.2 vs 109.8±21.2 minutes; P=.774) were not different. The ease of placement for the surgeon based on a visual analog scale (P=.16), the appearance of the mesh attachment (P=.07), and the overall satisfaction with the use of the specific attachment type (P=.65) were similar for the arms. There was no difference in perioperative adverse events rates between arms and by 12 months follow-up there were no sacrocolpopexy mesh, anchor, or suture exposures. There was no difference in outcomes at 12 months including composite failure (10% vs 12%; P=.79), patient global impression of improvement (1.06 vs 1.19; P=.27), or patient pelvic pain (9.81 vs 9.67; P=.56). CONCLUSION: In patients undergoing a robotic-assisted sacrocolpopexy, the anchor vaginal mesh attachment technique required significantly less time than suturing. There was no difference between techniques in complications, failure, surgeon, or patient-reported outcomes through 12 months of follow-up. Mesh attachment during sacrocolpopexy can be performed in less time by using the anchor technique, providing surgeons with an alternative surgical technique for this procedure.

Urethrographic Evaluation of Anatomic Findings and Complications after Perineal Masculinization and Phalloplasty in Transgender Patients.

Transgender patients seeking gender-affirming surgery are a growing population with unique health care needs. The radiologist must understand the challenges these patients face to facilitate a positive patient-physician interaction during the series of postoperative fluoroscopic evaluations. The authors present a standard two-stage surgical approach and common postoperative fluoroscopic findings after perineal masculinization and phalloplasty procedures. Perineal masculinization including urethral lengthening is performed first, followed by skin-flap-based phalloplasty. Patients undergo voiding cystourethrography (VCUG) after intravesical administration of contrast media by way of an indwelling suprapubic catheter after each stage. Retrograde urethrography plays a complementary role to supplement the limitations of VCUG after the second stage. The article reviews the expected postoperative anatomy and explains standardized terminology developed at the authors' institution. Imaging features of common and rare complications are discussed, including contained leak, stenosis, occlusion, and fistula. The successful postoperative imaging study in a transmasculine patient relies on open communication among the interdisciplinary team of specialized surgeons, radiologists, and medical providers, as well as special modifications to existing imaging techniques. ©RSNA, 2020.

Surgeon volume and reoperation risk after midurethral sling surgery.

BACKGROUND: Emerging research supports that fewer complications occur in patients who undergo surgery by higher surgical volume surgeons. The midurethral sling surgery has been involved in recent warnings and litigation, which further supports a need to understand features that enhance its safety and efficacy. OBJECTIVE: The purpose of this study was to measure the impact of a surgeon's volume on their patient's rate of reoperation after midurethral sling surgery. STUDY DESIGN: This was a retrospective cohort study that evaluated all surgeons who performed synthetic mesh midurethral sling surgery for stress urinary incontinence at a large managed care organization with >4.5 million members from 2005-2016. Physicians Current Procedural Terminology and International Classification of Diseases, version 9/10, codes were used to identify the procedures and the reoperations that were performed. The system-wide medical record was queried for demographic and perioperative data. The primary outcome was the overall reoperation rate after midurethral sling surgery. Concentration curves were used to identify the impact of a surgeon's surgical volume on their rate of reoperation. Demographics, characteristics, and reoperation of patients were compared with the use of chi-square test for categoric variables and Wilcoxon rank sum test for continuous variables. Poisson regression models with a robust error variance were used to calculate the unadjusted and the adjusted risk ratios of reoperation with the use of age, body mass index, marital status, race, parity, vaginal estrogen use, sling type, smoking, diabetes mellitus, and menopausal status as covariates. RESULTS: Two hundred twenty-seven surgeons performed 13,404 midurethral sling surgeries over the study period; patients had a mean of 4.4 years of follow up. Higher-volume surgeons (>40 procedures/year, ≥95th percentile) performed 47% of the surgeries in this cohort and had an overall lower rate of reoperation (3.6% vs 4.2%; 95% confidence interval, 0.67-0.94; P=.04) compared with lower-volume surgeons. Higher-volume surgeons had a lower rate of reoperation for surgical failure (2.7% vs 3.6%; 95% confidence interval, 0.55-0.92; P<.01). Rates of reoperation for complications were similar between the 2 groups (1.1% vs 0.9%; 95% confidence interval, 0.82-1.13; P=.32). For patients whose condition required a reoperation secondary to complication, the rates of reoperation for urinary retention (0.9% vs 0.6%; P=.06), mesh exposure (0.2% vs 0.3%; P=.31), hemorrhage/bleeding (0.1% vs 0.0%; P=.11), pain (0.1% vs 0.1%; P=.52), and infection (0.0% vs 0.0%; P=.37) did not differ between higher- and lower-volume surgeons. The risk ratio for reoperation that compared higher- and lower-volume surgeons was 0.83 (95% confidence interval, 0.67-0.98; P=.01) in the adjusted model. CONCLUSION: Although the reoperation rates were low for both higher- and lower-volume surgeons, higher-volume surgeons had lower overall rates of reoperation after midurethral sling surgery. This effect is seen most dramatically in reoperation for surgical failure, in which patients who have surgery with a higher-volume surgeon are 25% less likely to have postoperative stress urinary incontinence that leads to reoperation.

Ergonomics in gynecologic surgery.

PURPOSE OF REVIEW: Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and result in significant disability. We aimed to review the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations of gynecologic surgery. RECENT FINDINGS: Surgeon WMSDs are prevalent, with rates ranging from 66 to 94% for open surgery, 73-100% for conventional laparoscopy, 54-87% for vaginal surgery, and 23-80% for robotic-assisted surgery. Risk factors for injury in open surgery include use of loupes, headlamps, and microscopes. Unique risks in laparoscopic surgery include table and monitor position, long-shafted instruments, and poor instrument handle design. In vaginal surgery, improper table height and twisted trunk position create injury risk. Although robotic surgery offers some advantages in neck and shoulder strain, it remains associated with trunk, wrist, and finger strain. SUMMARY: WMSDs are prevalent among surgeons but have received little attention because of under-reporting of injury and logistical constraints of studying surgical ergonomics. Future research must aim to develop objective surgical ergonomics instruments and guidelines and to correlate ergonomics assessments with pain and tissue-level damage in surgeons with WMSDs. Ergonomics training should be developed and implemented in order to protect surgeons from preventable, potentially career-altering injuries.

Measuring the impact of a posterior compartment procedure on symptoms of obstructed defecation and posterior vaginal compartment anatomy.

INTRODUCTION AND HYPOTHESIS: We hypothesized that there would be a significant difference in changes in obstructed defecation symptoms and posterior compartment prolapse between women who underwent posterior vaginal wall prolapse repair (PR) and those who did not. METHODS: This was a two-site prospective cohort study of women undergoing prolapse or incontinence surgery in which a PR was, or was not, performed at the discretion of the surgeon. Women were assessed using validated obstructed defecation questionnaires and standardized examination measures (including POP-Q, measurement of transverse gh, and assessment for a rectovaginal pocket and laxity) prior to pelvic surgery and 12 weeks after surgery. RESULTS: Of 68 women who underwent surgery, 43 had PR. The PR group had higher obstructed defecation symptoms and greater posterior compartment prolapse at baseline. At 12 weeks, obstructed defecation symptoms had improved significantly more in the PR group than in the no PR group (all p < 0.03). Anatomic outcomes showed greater improvement in point Bp in the PR group (-3.4 vs. -0.7 no PR, p < 0.001) and resolution of the rectovaginal pocket (86 % vs. 42 %, p = 0.002). There were no significant changes in obstructed defecation symptoms or anatomic outcomes from baseline in the no PR group, while the PR group showed significantly improved obstructed defecation symptoms and anatomic outcomes after repair (p < 0.001 for both). CONCLUSIONS: Significant improvements in obstructed defecation symptoms and posterior compartment prolapse were seen after PR, but not in women who did not receive PR. Obstructed defecation symptoms, Bp and rectovaginal pocket were the measures best able to demonstrate improvement after PR. We recommend the use of these measures to assess the impact of surgery in the posterior compartment.

Genetic contributions to urgency urinary incontinence in women.

PURPOSE: We identify genetic variants associated with urgency urinary incontinence in postmenopausal women. MATERIALS AND METHODS: A 2-stage genome-wide association analysis was conducted to identify variants associated with urgency urinary incontinence. The WHI GARNET substudy with 4,894 genotyped post-reproductive white women was randomly split into independent discovery and replication cohorts. Genome-wide imputation was performed using IMPUTE2 with the 1000 Genomes ALL Phase I integrated variant set as a reference. Controls reported no urgency urinary incontinence at enrollment or followup. Cases reported monthly or greater urgency urinary incontinence and leaked sufficiently to wet/soak underpants/clothes. Logistic regression models were used to predict urgency urinary incontinence case vs control status based on genotype, assuming additive inheritance. Age, obesity, diabetes and depression were included in the models as covariates. RESULTS: Following quality control, 975,508 single nucleotide polymorphisms in 2,241 cases (discovery 1,102; replication 1,133) and 776 controls (discovery 405, replication 371) remained. Genotype imputation resulted in 9,077,347 single nucleotide polymorphisms and insertions/deletions with minor allele frequency greater than 0.01 available for analysis. Meta-analysis of the discovery and replication samples identified 6 loci on chromosomes 5, 10, 11, 12 and 18 associated with urgency urinary incontinence at p <10(-6). Of the loci 3 were within genes, the zinc finger protein 521 (ZFP521) gene on chromosome 18q11, the ADAMTS16 gene on chromosome 5p15 and the CIT gene on chromosome 12q24. The other 3 loci were intergenic. CONCLUSIONS: Although environmental factors also likely contribute, this first exploratory genome-wide association study for urgency urinary incontinence suggests that genetic variants in the ZFP521, CIT and ADAMTS16 genes might account for some of the observed heritability of the condition.

Uterine sarcomas and parasitic myomas after laparoscopic hysterectomy with power morcellation.

OBJECTIVE: The purpose of this study was to describe the incidence and risk factors for uterine sarcomas and parasitic myomas at the time of power morcellation. STUDY DESIGN: We performed a retrospective review of 3523 women who underwent laparoscopic hysterectomy from 2001-2012. Univariate analyses were used for the morcellation cases to identify potential risk factors. Multivariable logistic regression was performed. RESULTS: Nine hundred forty-one patients underwent power morcellation at the time of hysterectomy; 10 of 941 patients (1.1%) were diagnosed subsequently with uterine sarcomas or parasitic myomas. The overall incidence of uterine sarcoma was 6 of 941 (0.6%), with a median age of 47 years (range, 41-52 years). There was no association among any of the factors analyzed and uterine sarcoma. Three of 6 patients had sarcoma diagnosed on initial pathologic evaluation of the morcellated specimen; 3 patients had delayed diagnosis of sarcoma with benign disease at the time of the initial procedure (median time to second evaluation, 6 years). For parasitic myomas (n=4), the median age was 35 years (range, 32-40 years), and the median time to second evaluation was 5 years. On multivariate analysis, age<40 years (odds ratio, 26; 95% confidence interval, 2.7015-261.9; P≤.01) was associated with higher risk of the development of parasitic myomas. CONCLUSION: Uterine sarcoma was found in 0.6% of patients who underwent power morcellation but was not found to be associated significantly with any preoperative factors. All 6 cases were noted to have apparent fibroid tumors as an indication for their hysterectomy. Age<40 years was a risk factor for parasitic myomas after power morcellation. Patients should be counseled about these complications before power morcellation.

Midurethral slings: which should I choose and what is the evidence for use?

PURPOSE OF REVIEW: Midurethral slings are currently the most commonly performed surgeries for stress urinary incontinence (SUI). This review examines the pros and cons of the main types of midurethral slings that are available for the surgical treatment of SUI - full-length retropubic, full-length transobturator, and single-incision slings - to assist patients and physicians in choosing between them. RECENT FINDINGS: Comparative studies have shown that full-length retropubic and transobturator midurethral slings have similar efficacy but differ in their risk profiles; retropubic slings have higher rates of bladder perforation whereas transobturator slings have more groin pain and dyspareunia. When a certain type of single-incision sling is excluded from systematic reviews, single-incision slings appear comparable to standard midurethral slings. SUMMARY: Both full-length midurethral slings - retropubic and transobturator - are reasonable for the surgical treatment of SUI. The decision to choose one or the other should be individualized based on patient preference after counseling about the risks of each. More recent data suggest that the currently available single-incision slings may be comparable.

Introduction to a new technology for measuring urethral pressures: 3D high-resolution manometry.

INTRODUCTION AND HYPOTHESIS: This video introduces a 3D high-resolution manometry (HRM) system to the field of urogynecology. We demonstrate how to obtain and interpret dynamic urethral pressures with this measurement system and use it to evaluate pre- and postoperative women. METHODS: The 3D HRM catheter is ∼12 F; 11 cm of its length has pressure sensors with eight circumferentially distributed pressure-sensitive segments that collect and transmit individual pressure measurements to construct a 3D pressure map. In this video, we demonstrate the output display of the 3D HRM measurement system. RESULTS: Pressure output maps are shown for one woman with stress urinary incontinence (SUI) and one with a history of SUI who underwent successful midurethral sling insertion. We also show a summary of 3D pressure-measurement patterns of 44 women who underwent pressure measurements to evaluate qualitatively the 3D pressure profile of the urethra in an effort to better understand pelvic floor and urethral sphincter physiology. CONCLUSIONS: Advanced HRM technology to measure urethral pressures under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism in continent and incontinent women and after continence surgeries.

Dynamic maximum urethral closure pressures measured by high-resolution manometry increase markedly after sling surgery.

INTRODUCTION AND HYPOTHESIS: The premise of midurethral sling (MUS) surgery is to apply a tension-free vaginal tape in the midurethra that does not constrict the urethra at rest but stabilizes the urethra and prevents downward descent and opening of the urethra during stress maneuvers, but current technology has limitations in measuring urethral pressures during dynamic conditions. Our objective was to describe the change in maximum urethral closure pressures (MUCPs) after MUS surgery using an 8F high-resolution manometry (HRM) system that can measure urethral pressures during cough and strain maneuvers (ManoScan® ESO; Covidien) without migration or withdrawal limitations. METHODS: We measured rest, cough, and strain MUCPs in 26 women before and after retropubic or transobturator MUS for stress urinary incontinence using the HRM system. RESULTS: The objective success rate after MUS was 92.3 % based on postoperative cough stress testing. Mean resting MUCPs measured by HRM did not change after surgery (59.3 before vs. 59.7 cm H2O after surgery; p = 1.0). Mean cough MUCPs measured by HRM increased from 36.9 to 100.7 cm H2O (p < 0.001), and strain MUCPs increased from 35.0 to 92.7 cm H2O (p < 0.001). CONCLUSIONS: Advanced HRM technology to measure MUCPs under cough and strain conditions without withdrawal techniques provides new insights into the continence mechanism after tension-free MUS: MUCPs do not change at rest but do increase significantly during cough and strain maneuvers.

A randomized trial of vaginal mesh attachment techniques for minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: We investigated the efficiency and efficacy of vaginal mesh attachment using interrupted, non-barbed, delayed absorbable sutures in comparison with a running, barbed, delayed absorbable suture during laparoscopic sacrocolpopexy (LSC) and robotic sacrocolpopexy (RSC). METHODS: Women undergoing LSC or RSC were recruited. Participants were randomized to at least six 0 PDS non-barbed interrupted sutures or at least six passes of a 1 PDS barbed suture (Quill™) on each anterior and posterior polypropylene mesh leaflet. The primary outcome was the time to attach the mesh to the vagina. The LSC and RSC groups were block randomized by suture type. Secondary outcomes included: (1) intraoperative surgeon assessment of satisfaction as measured using a 10-cm visual analog scale (VAS), (2) postoperative POP-Q evaluation for anatomic failure, and (3) overall appearance of vaginal walls measured using a VAS. RESULTS: Of the 64 included subjects who were randomized, 32 had mesh attachment with the barbed suture (16 LSC, 16 RSC) and 32 had attachment with non-barbed sutures (16 LSC, 16 RSC). Among all the subjects (LSC and RSC), the non-barbed suture group had significantly longer mesh attachment times than the barbed suture group (42 vs. 29 min, p < 0.001). The non-barbed suture group had significantly better scores for intraoperative ease of suture placement, surgeon satisfaction with mesh appearance, and global satisfaction. At 12 months, there were no significant differences in anatomic failure between the suture groups or overall appearance of the vaginal walls (p > 0.05). CONCLUSIONS: The barbed suture technique was 11 - 16 min faster for attaching mesh to the vagina than the non-barbed suture technique. Anatomic outcomes at 12 months were comparable between the suture groups. It is reasonable to use a running, barbed suture in minimally invasive sacrocolpopexy.

Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization.

STUDY OBJECTIVES: To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Kaiser Permanente San Diego Medical Center, 2001 to 2012. PATIENTS: Women who underwent attempted laparoscopic hysterectomy for benign indications. INTERVENTIONS: Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury. RESULTS: A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury. CONCLUSION: Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.

Long-term outcomes after native tissue vs. biological graft-augmented repair in the posterior compartment.

INTRODUCTION AND HYPOTHESIS: We aimed to compare the outcomes of native tissue vs. biological graft-augmented repair in the posterior compartment. We hypothesized that the addition of graft would result in superior anatomic and functional outcomes. METHODS: A retrospective review of posterior repairs between 2001 and 2008 was performed to compare the anatomic and functional outcomes between native tissue and graft-augmented techniques. Mann-Whitney and chi-square tests were used. Power calculation determined that 32 subjects were needed in each group. RESULTS: One hundred twenty-four native tissue and 69 graft-augmented repairs were performed with a median follow-up of 35.8 months (range, 6 to 157 months). Anatomic success was similar for native tissue vs. graft (Bp < -1, 86% vs. 80% and Bp ≤ 0, 97% vs. 97%; all p > 0.05). Postoperative splinting and incomplete evacuation was greater in the graft group (splinting, 85% vs. 68%; p = 0.04 and incomplete evacuation, 85% vs. 64%; p = 0.03). CONCLUSION: Long-term success of posterior repair is high. Graft augmentation does not appear to improve anatomic or functional outcomes.

Intraoperative Gentamicin Intravesical Instillation for Prevention of Urinary Tract Infection After Urogynecologic Surgery: A Randomized Controlled Trial.

IMPORTANCE: Currently available evidence for efficacy of postoperative antibiotics to prevent postoperative urinary tract infection (UTI) conflicts. Oral antibiotics rely on patient adherence and can cause unwanted systemic effects. Gentamicin is a broad-spectrum antibiotic with rapid bactericidal activity and, when administered intravesically, has no systemic absorption through intact urothelium. OBJECTIVE: We aimed to determine whether a single intravesical instillation of gentamicin at the conclusion of urogynecologic surgery would reduce the proportion of women treated for UTI within 6 weeks postoperatively compared with sham instillation. STUDY DESIGN: This was a multicenter, randomized (stratified by study site, route of prolapse repair ±suburethral sling, with balanced 1:1 randomization), participant-masked, sham-controlled, study. The primary outcome was the proportion of participants treated with antibiotics for UTI within 6 weeks postoperatively. An adjusted multivariable logistic regression model was constructed to determine predictors of postoperative UTI treatment. RESULTS: Three hundred seventy participants were randomized (gentamicin, 185; sham, 185), and data from 363 participants were analyzed (gentamicin, 183; sham, 180). Nineteen women in the gentamicin group and 20 women in the sham group were treated for UTI within 6 weeks postoperatively (10.4% vs 11.1%, P = 0.87). There were no adverse events related to the instillations. Increasing age (odds ratio, 1.028 [1.000-1.057]) and number of intraoperative transurethral instrumentations (odds ratio, 1.342 [1.080-1.668]) were independent predictors of postoperative UTI treatment. CONCLUSIONS: In women undergoing urogynecologic surgery, postoperative intravesical gentamicin did not reduce the incidence of postoperative UTI. The number of intraoperative transurethral instrumentations is an important, potentially modifiable risk factor for postoperative UTI treatment.