The Influence of Surgical Complexity and Center Experience on Postoperative Morbidity After Minimally Invasive Surgery in Gynecologic Oncology: Lessons Learned from the ROBOGYN-1004 Trial.

BACKGROUND: This study was a secondary analysis of the ROBOGYN-1004 trial conducted between 2010 and 2015. The study aimed to identify factors that affect postoperative morbidity after either robot-assisted laparoscopy (RL) or conventional laparoscopy (CL) in gynecologic oncology. METHODS: The study used two-level logistic regression analyses to evaluate the prognostic and predictive value of patient, surgery, and center characteristics in predicting severe postoperative morbidity 6 months after surgery. RESULTS: This analysis included 368 patients. Severe morbidity occurred in 49 (28 %) of 176 patients who underwent RL versus 41 (21 %) of 192 patients who underwent CL (p = 0.15). In the multivariate analysis, after adjustment for the treatment group (RL vs CL), the risk of severe morbidity increased significantly for patients who had poorer performance status, with an odds ratio (OR) of 1.62 for the 1-point difference in the WHO performance score (95 % CI 1.06-2.47; p = 0.027) and according to the type of surgery (p < 0.001). A focus on complex surgical acts showed significant more morbidity in the RL group than in the CL group at the less experienced centers (OR, 3.31; 95 % CI 1.0-11; p = 0.05) compared with no impact at the experienced centers (OR, 0.87; 95 % CI 0.38-1.99; p = 0.75). CONCLUSION: The findings suggest that the center's experience may have an impact on the risk of morbidity for patients undergoing complex robot-assisted surgical procedures.

Validation of the Safety and Efficacy of Apixaban as Postoperative Thromboembolism Prophylaxis for Patients with Gynecologic Malignancies.

BACKGROUND: Venous thromboembolism is a preventable complication of gynecologic cancer surgery that leads to postoperative morbidity and mortality. This study compared apixaban with enoxaparin to identify whether apixaban had the same safety and efficacy for patients undergoing gynecologic cancer surgery. METHODS: The study identified patients with a gynecologic malignancy who underwent surgery and were prescribed apixaban at discharge between June 2020 and April 2023. International Classification of Diseases 10 codes were used to identify patients who had a thromboembolism within 90 days or a bleeding event within 60 days after surgery. The rates of events for patients prescribed apixaban were compared with those for a historical cohort of patients who received enoxaparin. Fisher's exact tests were used to compare categorical variables, and t tests were used to compare continuous variables. A logistic regression was performed to compare the odds of thromboembolism between the two groups. RESULTS: Baseline patient characteristics differed in terms of body mass index (BMI), race, route of surgery, and type of cancer. Of the 490 patients in the apixaban cohort, 12 (2.4%) had a thromboembolism compared with 3 (2.1%) of the 138 patients in the enoxaparin group (adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI] 0.30-4.70; p > 0.999). The odds ratio was adjusted for BMI, age, and route of surgery. A bleeding event occurred for 1 (0.2%) of the 490 patients in the apixaban group and for 1 (0.7%) of the 138 patients in the enoxaparin group. CONCLUSIONS: This validation study showed that apixaban is a safe and effective method of postoperative venous thromboembolism prophylaxis. The data provide support to previous data and guideline updates recommending the use of apixaban for postoperative prophylaxis.

A multi-center study to predict the risk of intraoperative hypothermia in gynecological surgery patients using preoperative variables.

OBJECTIVES: Hypothermia is highly common in patients undergoing gynecological surgeries under general anesthesia, so the length of hospitalization and even the risk of mortality are substantially increased. Our aim was to develop a simple and practical model to preoperatively identify gynecological surgery patients at risk of intraoperative hypothermia. METHODS: In this retrospective study, we collected data from 802 patients who underwent gynecological surgery at three medical centers from June 2022 to August 2023. We further allocated the patients to a training group, an internal validation group, or an external validation group. The preliminary predictive factors for intraoperative hypothermia in gynecological patients were determined using the least absolute shrinkage and selection operator (LASSO) method. The final predictive factors were subsequently identified through multivariate logistic regression analysis, and a nomogram for predicting the occurrence of hypothermia was established. RESULTS: A total of 802 patients were included, with 314 patients in the training cohort (mean age 48.5 ± 12.6 years), 130 patients in the internal validation cohort (mean age 49.9 ± 12.5 years), and 358 patients in the external validation cohort (mean age 47.6 ± 14.0 years). LASSO regression and multivariate logistic regression analyses indicated that body mass index, minimally invasive surgery, baseline heart rate, baseline body temperature, history of previous surgery, and aspartate aminotransferase level were associated with intraoperative hypothermia in gynecological surgery patients. This nomogram was constructed based on these six variables, with a C-index of 0.712 for the training cohort. CONCLUSIONS: We established a practical predictive model that can be used to preoperatively predict the occurrence of hypothermia in gynecological surgery patients. CLINICAL TRIAL REGISTRATION: chictr.org.cn, identifier ChiCTR2300071859.

The activity advantage: Objective measurement of preoperative activity is associated with postoperative recovery and outcomes in patients undergoing surgery with gynecologic oncologists.

OBJECTIVE: To examine the association between objectively-measured preoperative physical activity with postoperative outcomes and recovery milestones in patients undergoing gynecologic oncology surgeries. METHODS: Prospective cohort study of patients undergoing surgery with gynecologic oncologists who wore wearable actigraphy rings before and after surgery from 03/2021-11/2023. Exposures encompassed preoperative activity intensity (moderate- and vigorous-intensity metabolic equivalent of task-minutes [MAVI MET-mins] over seven days) and level (average daily steps over seven days). Intensity was categorized as <500, 500-1000, and >1000 MAVI MET-mins; level categorized as <8000 and ≥8000 steps/day. Primary outcome was 30-day complications. Secondary outcomes included reaching postoperative goal (≥70% of recommended preoperative intensity and level thresholds) and return to baseline (≥70% of individual preoperative intensity and level). RESULTS: Among 96 enrolled, 87 met inclusion criteria, which constituted 39% (n = 34) with <500 MET-mins and 56.3% (n = 49) with <8000 steps preoperatively. Those with <500 MET-mins and <8000 steps had higher ECOG scores (p = 0.042 & 0.037) and BMI (p = 0.049 & 0.002) vs those with higher activity; all other perioperative characteristics were similar between groups. Overall, 29.9% experienced a 30-day complication, 29.9% reached postoperative goal, and 64.4% returned to baseline. On multivariable models, higher activity was associated with lower odds of complications: 500-1000 MET-mins (OR = 0.26,95%CI = 0.07-0.92) and >1000 MET-mins (OR = 0.25,95%CI = 0.07-0.94) vs <500 MET-mins; ≥8000 steps (OR = 0.25,95%CI = 0.08-0.73) vs <8000 steps. Higher preoperative activity was associated fewer days to reach postoperative goal. CONCLUSION: Patients with high preoperative activity are associated with fewer postoperative complications and faster attainment of recovery milestones. Physical activity may be considered a modifiable risk factor for adverse postoperative outcomes.

Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative.

OBJECTIVE: To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. METHODS: Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. RESULTS: Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. CONCLUSION: Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.

Efficacy, safety, and feasibility of Apixaban for postoperative venous thromboembolism prophylaxis following open gynecologic cancer surgery at a comprehensive cancer center.

OBJECTIVES: To evaluate safety, efficacy, and feasibility of apixaban for postoperative venous thromboembolism (VTE) prophylaxis following open gynecologic cancer surgery at a comprehensive cancer center. METHODS: This retrospective, cohort study included patients with gynecologic cancer who underwent open surgery between 3/2021 and 3/2023 and received 28-day postoperative VTE prophylaxis. Patients on therapeutic anticoagulation preoperatively were excluded. Predictors of 90- and 30-day VTE and 30-day bleeding events were determined using multivariable logistic regression, adjusting for known confounders. RESULTS: 452 patients were included in the cohort: 348 received apixaban and 104 received enoxaparin. Those who received enoxaparin were more likely to be American Society of Anesthesiologists class III/IV (compared to I/II) (p = 0.033), current or former smokers (p = 0.012) and have a higher BMI (p < 0.001), Charlson Comorbidity Index (p = 0.005), and age (p = 0.046). 30-day VTE rate was significantly lower in the apixaban group (0.6%) compared to the enoxaparin group (6.2%) (adjusted OR 0.13, 95% CI 0.03-0.56; p = 0.006). 90-day VTE rate was 2.7% and 6.2% in the apixaban and enoxaparin groups, respectively (adjusted OR 0.85, 95% CI 0.38-1.92; p = 0.704). Major bleeding complications (2.4% vs. 2.0%) and minor bleeding complications (0.9% vs. 3.0%) were similar in the apixaban and enoxaparin groups, respectively, on multivariate analyses. The median patient out of pocket cost was $10 (IQR 0.0-40.0) for apixaban and $20 (IQR 3.7-67.7) for enoxaparin (p = 0.001). CONCLUSIONS: Our findings along with previously published data suggest that apixaban should be considered the standard of care for VTE prophylaxis in patients undergoing open surgery for gynecologic malignancies.

Impact of pharmacogenomic profiles on post-surgical pain following laparotomy for gynecologic pathology.

OBJECTIVES: The aim of this prospective study was to compare perioperative opioid use in women by status of CYP2D6, a highly polymorphic pharmacogene relevant to opioid metabolism. METHODS: Patients undergoing laparotomy were prospectively recruited and provided a preoperative saliva swab for a pharmacogenomic (PGx) gene panel. Postoperative opioid usage and pain scores were evaluated via chart review and a phone survey. Pharmacogenes known to be relevant to opioid metabolism were genotyped, and opioid metabolizing activity predicted by CYP2D6 genotyping. Patient and procedural factors were compared using Fisher's exact and Kruskal-Wallis tests. RESULTS: The 96 enrolled patients were classified as ultra-rapid (N = 3, 3%), normal (58, 60%), intermediate (27, 28%), and poor (8, 8%) opioid metabolizers. There was no difference in surgical complexity across CYP2D6 categories (p = 0.61). Morphine Milligram Equivalents (MME) consumed during the first 24 h after peri-operative suite exit were significantly different between groups: ultrarapid metabolizers had the highest median MME (75, IQR 45-88) compared to the other three groups (normal metabolizers 23 [8-45], intermediate metabolizers 48 [20-63], poor metabolizers 31 [12-53], p = 0.03). Opioid requirements were clinically greater in ultrarapid metabolizers during the second 24 h and last 24 h but were statistically similar (p = 0.07). There was no difference in MME prescribed at discharge (p = 0.22) or patient satisfaction with pain control (p = 0.64) between groups. CONCLUSIONS: A positive association existed between increased CYP2D6 activity and in-hospital opioid requirements, especially in the first 24 h after surgery. This provides important information to further individualize opioid prescriptions for patients undergoing laparotomy for gynecologic pathology.

Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis.

OBJECTIVE: This study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries. DATA SOURCES: We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis. STUDY ELIGIBILITY CRITERIA: Eligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L. METHODS: A teams of 2 reviewers independently assessed eligibility, performed data extraction, and evaluated the risk of bias of the eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine the cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors and used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the evidence certainty. RESULTS: We included 131 studies (1,741,519 patients) that reported venous thromboembolism risk estimates for 50 gynecologic noncancer procedures and bleeding requiring reintervention estimates for 35 procedures. The evidence certainty was generally moderate or low for venous thromboembolism and low or very low for bleeding requiring reintervention. The risk for symptomatic venous thromboembolism varied from a median of <0.1% for several procedures (eg, transvaginal oocyte retrieval) to 1.5% for others (eg, minimally invasive sacrocolpopexy with hysterectomy, 1.2%-4.6% across patient venous thromboembolism risk groups). Venous thromboembolism risk was <0.5% for 30 (60%) of the procedures; 0.5% to 1.0% for 10 (20%) procedures; and >1.0% for 10 (20%) procedures. The risk for bleeding the require reintervention varied from <0.1% (transvaginal oocyte retrieval) to 4.0% (open myomectomy). The bleeding requiring reintervention risk was <0.5% in 17 (49%) procedures, 0.5% to 1.0% for 12 (34%) procedures, and >1.0% in 6 (17%) procedures. CONCLUSION: The risk for venous thromboembolism in gynecologic noncancer surgery varied between procedures and patients. Venous thromboembolism risks exceeded the bleeding risks only among selected patients and procedures. Although most of the evidence is of low certainty, the results nevertheless provide a compelling rationale for restricting pharmacologic thromboprophylaxis to a minority of patients who undergo gynecologic noncancer procedures.

Complications of obliterative versus reconstructive vaginal surgery for pelvic organ prolapse in octogenarians: A retrospective cohort study.

AIMS: Women of advanced age may choose between restorative or obliterative surgery for surgical management of pelvic organ prolapse. Obliterative surgery is traditionally reserved for a subset of older women with more severe medical comorbidities, since obliterative approaches are generally considered to be less morbid and older individuals have higher rates of perioperative complications than younger cohorts. This study compared perioperative complications amongst octogenarians undergoing obliterative versus reconstructive approaches. This data will help to inform perioperative counselling as previous studies have not been powered to evaluate complications in this population. METHODS: The National Surgical Quality Improvement Program database was used to identify patients that had Pelvic organ prolapse surgery between 2012 and 2021, aged 80 years or older. Single-compartment procedures, vaginal mesh procedures, and oncologic surgery were excluded. The primary outcome was any complication within the first 30 days excluding urinary tract infection (UTI). UTI, readmission, and severe complications were secondary outcomes. RESULTS: Of the 4149 patients identified, 2514 (60.6%) underwent reconstructive surgery and 1635 (39.4%) underwent obliterative surgery. Patients undergoing reconstructive surgery were more likely to have an American Society of Anesthesiologists (ASA) class of 1 or 2 (46.1% vs. 31.3%, p = 0.002) and were less likely to be on antihypertensive medication (72.0% vs. 75.8%, p = 0.006). Further, there was an increased length of stay (1.47 ± 1.84 vs. 1.03 ± 1.31 days, p < 0.001) in hospital for reconstructive surgery which was more often performed as an inpatient (45.7% vs. 37.9%, p < 0.001). There was no difference in the primary outcome: any complication excluding UTIs. However, UTI was more common in the reconstructive group (aOR 0.48; 95% confidence interval 0.34-0.0). The rate of serious complications (Clavien-Dindo Class IV) was low overall and not different between reconstructive and obliterative approaches (1.3% vs. 1.0%, respectively). CONCLUSIONS: Both vaginal reconstructive and obliterative approaches have low complication rates in octogenarians, with only UTI rate being different between cohorts. When choosing surgical approach, we suggest a case-based, patient center discussion on the anatomic outcomes, durability and patient satisfaction.

Fine-tuning the needle: analysis of acupuncturist response to alarming events during gynecological oncology surgery.

OBJECTIVE: Examining an intra-operative acupuncture/acupressure setting, with real-time "fine-tuning" in response to alarming events (AEvs) during gynecological oncology surgery. METHODS: Narratives of acupuncturists providing intraoperative acupuncture during gynecological oncology surgery were qualitatively analyzed. These described real time "fine-tuning" in response to AEvs during surgery, identified through hemodynamic changes (e.g., systolic/diastolic arterial pressure); bispectral index (BIS) elevation; and feedback from surgeons and anesthesiologists. Documentation of acupuncturist responses to AEvs was addressed as well. RESULTS: Of the 48 patients in the cohort, 33 had at least one intraoperative AEv (69%), of which 30 were undergoing laparoscopic surgery and 18 laparotomies. A total of 77 AEvs were documented throughout surgery (range 1-7; mean: 2.3 events per patient), identified through increased (63 events) or decreased (8) mean arterial pressure (MAP); increased BIS levels (2), or other hemodynamic parameters (4). Integrative oncology interventions implemented in response to AEs included acupressure alone (59); combining acupressure with acupuncture (10); or acupuncture alone (4). In 54 (70%) events, documentation was provided from beginning to conclusion of the AEv, with a mean duration of 9.7 min, with 32 events including a documented anesthesiologist intervention. CONCLUSION: The present study demonstrated the feasibility of intraoperative acupuncture with acupressure, with ongoing "fine-tuning" to AEvs identified through objective pain-related parameters (MAP, heart rate and BIS) and real-time input from surgeons and anesthesiologists. Documentation of the intraoperative IO practitioner's response to these AEvs is important, and should be addressed in future research of the innovative integrative model of care. TRIAL REGISTRATION NUMBER: CMC-18-0037 (Carmel Medical Center, June 11, 2018).

Low serum creatinine levels are associated with major post-operative complications in patients undergoing surgery with gynecologic oncologists.

OBJECTIVE: Serum creatinine is a byproduct of muscle metabolism, and low creatinine is postulated to be associated with diminished muscle mass. This study examined the association between low pre-operative serum creatinine and post-operative outcomes. METHODS: This retrospective cohort study utilized the 2014-2021 National Surgical Quality Improvement Program to identify patients undergoing surgery with gynecologic oncologists. Patients with missing pre-operative creatinine, end-stage renal disease, sepsis, septic shock, dialysis, or pregnancy were excluded. Pre-operative creatinine was categorized into markedly low (≤0.44 mg/dL), mildly low (0.45-0.64 mg/dL), normal (0.65-0.84 mg/dL), and four categories of elevated levels (0.85-1.04, 1.05-1.24, 1.25-1.44, and ≥1.45 mg/dL). Outcomes included major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, and thromboembolic complications. Also examined were 30-day readmissions, reoperations, and mortality. Logistic regressions assessed the association between creatinine and complications, with stratification by albumin and sensitivity analysis with propensity score matching. RESULTS: Among 84 786 patients, 0.8% had markedly low, 19.6% mildly low, and 50.2% normal creatinine; the remainder had elevated creatinine. As creatinine decreased, the risks of major complications increased in a dose-dependent manner on univariable and multivariable analyses. A total of 9.6% (n=63) markedly low patients experienced major complications, second to creatinine ≥1.45 mg/dL (9.9%, n=141). On multivariable models, both markedly and mildly low creatinine were associated with higher odds of major complications (OR 1.715, 95% CI 1.299 to 2.264 and OR 1.093, 95% CI 1.001 to 1.193) and infections (OR 1.575, 95% CI 1.118 to 2.218 and OR 1.165, 95% CI 1.048 to 1.296) versus normal. Markedly low creatinine had similar ORs to creatinine ≥1.45 mg/dL and was further associated with higher odds of cardiovascular and pulmonary complications (OR 2.301, 95% CI 1.300 to 4.071), readmissions (OR 1.403, 95% CI 1.045 to 1.884), and mortality (OR 2.718, 95% CI 1.050 to 7.031). After albumin stratification, associations persisted for markedly low creatinine. Propensity-weighted analyses demonstrated congruent findings. CONCLUSIONS: Low creatinine levels are associated with major post-operative complications in gynecologic oncology in a dose-dependent manner. Low creatinine can offer useful information for pre-operative risk stratification, surgical counseling, and peri-operative management.

Perioperative Morbidity Associated with Same-day Discharge in Elderly Patients.

INTRODUCTION AND HYPOTHESIS: We compared postoperative complications in elderly patients discharged on POD#0 versus POD#1 after prolapse repair. METHODS: Data were obtained from the National Surgical Quality Improvement database. A total of 20,984 women 65 years and older who underwent prolapse repair between 2014 and 2020 were analyzed. Patient demographics, comorbidities, readmission, reoperation, and 30-day postoperative complications were compared in patients discharged on POD#0 versus POD#1. A sensitivity analysis was completed to examine outcomes in patients who underwent an apical prolapse repair. Multivariate logistic regression was performed to evaluate for potential confounders. RESULTS: Age, race, ethnicity, American Society of Anesthesiologists class, prolapse repair type, and operative time were significantly different in patients discharged on POD#0 vs POD#1 (all p < 0.01). Patients discharged on POD#0 had significantly fewer postoperative complications (2.63% vs 3.44%) and readmissions (1.56% vs 2.18%, all p < 0.01). On multivariate regression modeling, postoperative discharge day was independently associated with complications, but not with readmissions or reoperation after. Patients who underwent an apical prolapse repair and were discharged on POD#0 had significantly more postoperative complications (3.5% vs 2.5%, p = 0.02) and readmissions (2.42% vs 10.08%, p < 0.01) than those discharged on POD#1. In this group, multivariate regression modeling demonstrated that postoperative discharge day was independently associated with any postoperative complication. CONCLUSIONS: For elderly women undergoing prolapse repair, the type of surgery should be considered when determining postoperative admission versus same-day discharge. Admission overnight does not seem to benefit women undergoing vaginal repairs but may decrease overall morbidity and risk of readmission in women undergoing an apical prolapse repair.

Long-Term Mesh Exposure 5 Years Following Minimally Invasive Total Hysterectomy and Sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to assess long-term mesh complications following total hysterectomy and sacrocolpopexy. METHODS: In this second extension study, women from a multicenter randomized trial were followed for more than 36 months after surgery. Owing to COVID-19, participants were assessed through either in-person visits or telephone questionnaires. The primary outcome was the incidence of permanent suture or mesh exposure. Secondary outcomes included surgical success and late adverse outcomes. RESULTS: Out of the 200 initially enrolled participants, 82 women took part in this second extension study. Among them, 46 were in the permanent suture group, and 36 in the delayed absorbable group. The mean follow-up duration was 5.3 years, with the cumulative mesh or suture exposure of 9.9%, involving 18 cases, of which 4 were incident cases. Surgical success after more than 5 years stood at 95%, with few experiencing bothersome bulge symptoms or requiring retreatment. No serious adverse events occurred, including mesh erosion into the bladder or bowel. The most common adverse events were vaginal pain, bleeding, dyspareunia, and stress urinary incontinence, with no significant differences between suture types. CONCLUSION: The study found that mesh exposure risk gradually increased over time, reaching nearly 10% after more than 5 years post-surgery, regardless of suture type. However, surgical success remained high, and no delayed serious adverse events were reported.

Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery. METHODS: We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP). RESULTS: For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90. CONCLUSIONS: A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.

Rapid Onset of De Novo Rectal Prolapse Following Colpocleisis.

INTRODUCTION: The aim of this video case series is to demonstrate our experience of the clinical findings and the surgical management of the rapid onset de novo rectal prolapse (RP) following colpocleisis METHODS: This is a case series of three patients who developed de novo RP within 1 month after colpocleisis, which was repaired by laparoscopic ventral mesh rectopexy (LVMR). The video shows the physical, radiological, and intraoperative findings of these patients. A retrospective review of our surgical cases of RP was also performed to analyze the onset timing of de novo RP after various pelvic organ prolapse (POP) procedures. RESULTS: The pathological condition of all three patients' RP was evacuation enterocele, and LVMR was feasible without postoperative complications or recurrences. In the retrospective case review of 158 RP surgeries in our institution (June 2015 to September 2023), 18 cases (11.4%) occurred following POP surgery. De novo RP following colpocleisis developed significantly earlier than those following other procedures (average: 6.1 vs 66.4 months, p = 0.010). CONCLUSIONS: Although de novo RP following colpocleisis is relatively rare, this complication could have a detrimental effect on patients' quality of life. Preoperative informed consent may be advisable before planning colpocleisis.

Changes in Stress Urinary Incontinence Symptoms after Pelvic Organ Prolapse Surgery: a Nationwide Cohort Study (FINPOP).

INTRODUCTION AND HYPOTHESIS: Various strategies are employed to manage stress urinary incontinence (SUI) during pelvic organ prolapse (POP) surgery. This study was aimed at facilitating shared decision-making by evaluating SUI symptom changes, staged SUI procedures, and their prognostic factors following POP surgery without concomitant SUI intervention. METHODS: We analyzed 2,677 POP surgeries from a population-based observational cohort, excluding patients with prior SUI surgery. The outcome measures were subjective SUI utilizing the Pelvic Floor Distress Inventory-20 questionnaire and number of subsequent SUI procedures. Multivariable linear models were applied to identify predictors of persistent SUI, procedures for persistent SUI, and de novo SUI. The primary assessment occurred at the 2-year follow-up. RESULTS: At baseline, 50% (1,329 out of 2,677) experienced SUI; 35% (354 out of 1,005) resolved, an additional 14% (140 out 1,005) improved, and 5.1% (67 out of 1,308) underwent a procedure for persistent SUI. De novo SUI symptoms developed in 20% (218 out of 1,087), with 3.2% (35 out of 1,087) reporting bothersome symptoms; 0.8% (11 out of 1,347) underwent a procedure for de novo SUI. High baseline symptom severity increased the risk of persistent SUI (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.65-2.53), whereas advanced preoperative apical prolapse decreased the risk (aOR 0.89, 95% CI 0.85-0.93). De novo SUI was more common with advancing age (aOR 1.03, 95% CI 1.01-1.05), baseline urgency urinary incontinence (aOR 1.21, 95% CI 1.06-1.38), and after transvaginal mesh surgery (aOR 1.93, 95% CI 1.24-3.00). It was not dependent on the compartment or preoperative degree of prolapse. CONCLUSIONS: In a pragmatic setting, POP surgery results in a low rate of subsequent SUI procedures.

Labiaplasty Outcomes and Complications in Turkish Women: A Multicentric Study.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the outcomes, complication rates, and complication types of different labiaplasty techniques. METHODS: In this cross-sectional retrospective study, a total of 2,594 patients who underwent surgery owing to hypertrophy or asymmetry of the labium minus were retrospectively analyzed. Data were collected by individual interviews with 43 experts from different centers. The patients were between 18 and 50 years of age. During the interview information about the presence and nature of complications, and about concomitant or revision surgeries, were gathered. The surgeons who performed these surgeries were also questioned about their training and surgical experience. RESULTS: The most frequently observed complication was complete dehiscence, accounting for 29% of all complications. Complete dehiscence was most commonly seen after wedge resection (16 cases). The second most common complication was labium majus hematoma, accounting for 12.5% of all cases. Among the labiaplasty techniques, wedge resection had the highest complication rate at 3% (26 cases out of 753 patients). This was followed by composite labiaplasty at 1.2% (5 cases out of 395 patients), Z-plasty at 0.8% (1 case out of 123 patients), and trimming labiaplasty at 0.5% (7 cases out of 1,323 patients). CONCLUSION: Considering the heterogeneity and low quality of the existing studies on this subject, this study provides valuable information for surgeons practicing in this field. However, further research is clearly warranted as female genital aesthetic procedures are being performed with a steadily increasing trend.

Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIHs) while accounting for surgeon volume. DESIGN: Retrospective cohort study of patients who underwent an MIH between 2014 and 2017. SETTING: Single community hospital system. PATIENTS: Patients were identified via Current Procedural Terminology codes for MIH: vaginal, laparoscopic, or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in minimally invasive gynecologic surgery, urogynecology and pelvic reconstructive surgery, or gynecologic oncology; 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. MEASUREMENTS AND MAIN RESULTS: Surgical outcomes, including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and were stratified by surgeon volume status, with high-volume (HV) defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. Of 1631 MIHs, 855 (52.4%) were performed by generalists and 776 (47.6%) by subspecialists. HV generalists performed 618 (37.9%) of MIHs, and 237 (14.5%) were performed by low-volume generalists. All subspecialists were HV surgeons; 38.1% of generalists were HV. The odds ratio of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to HV generalists after adjusting for potential confounding variables (p <.001). Subspecialists and HV surgeons had significantly lower incidences of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared with generalists and low-volume surgeons, respectively. CONCLUSION: Both subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

The Importance of Lumbar Lordosis During Laparoscopic Trocar Entry.

STUDY OBJECTIVE: Investigating the effect of lumbar lordosis on the relationship between abdominal trocar entry points and major vascular structures. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Distances between the skin and the aorta and inferior vena cava at the trocar entry points, both at the umbilicus and 3 cm and 5 cm superior to the umbilicus, were measured at entry angles of 90 and 45 degrees in 101 abdominal computer tomography images. INTERVENTIONS: The relationship of these values with lumbar lordosis was investigated concerning menopausal status, body mass index (BMI), and parity differences. To assess the isolated effect of lumbar lordosis, a simulated 30-degree increase in the lordosis angle was applied to the patients' computed tomography images. The impact of this increased lumbar lordosis angle on the distances between the skin and major vessels was then evaluated at both the umbilical and supraumbilical trocar entry sites. MEASUREMENTS AND MAIN RESULTS: In the tomographic images of all patients, the distances from the skin to vascular structures were measured at a 90-degree entry angle, resulting in measurements of 8.97 cm ± 2.81 at the umbilicus, 10.89 cm ± 3.02 at 3 cm above the umbilicus, and 11.36 cm ± 2.88 at 5 cm above the umbilicus. These distances exhibited significant differences between patients with BMI <30 and BMI ≥30, as well as between premenopausal and postmenopausal patients. However, at a 45-degree entry angle, vascular structures were observed in only a few patients during trocar projection, and no measurable values were determined. In the simulation, it was found that a 1-degree increase in lumbar lordosis angle resulted in a decrease of 0.272 mm ± 0.018 in the distance between the skin and vascular structures at the umbilicus, 0.425 mm ± 0.024 at 3 cm above the umbilicus, and 0.428 mm ± 0.024 at 5 cm above the umbilicus. CONCLUSION: An increase in the degree of lumbar lordosis reduces the distance between trocar entry points and major vascular structures. Along with other factors during Veress and trocar entry, lumbar lordosis should be carefully considered.

Is Intravenous Dextrose Infusion During Emergence From Anesthesia Effective in Improving the PONV in Gynecologic Laparoscopy? A Randomized Controlled Trial.

STUDY OBJECTIVE: This study aimed to explore the relationship between intravenous 5% dextrose infusion during emergence from anesthesia to postoperative nausea and vomiting (PONV) in patients after gynecologic laparoscopic surgery. DESIGN: This was a double-blind randomized controlled trial. Participants were randomized into the experimental group and control group using a computer-generated random number generator. Intervenors and measurers were blinded to group assignments of the study. SETTING: A single academic tertiary medical center. PATIENTS: Patients undergoing gynecologic laparoscopic surgery. INTERVENTIONS: On completion of surgery, participants were randomized into the test group (receive 5% dextrose) and control group (receive Ringer's lactate solution). MEASUREMENTS AND MAIN RESULTS: The primary outcome of the present study was the incidence of PONV. Other outcomes included postoperative rescue analgesic and rescue antiemetic, postoperative pain response, and recovery time of postanesthesia care unit. Baseline characteristics were statistically similar between the 2 groups of participants. There were 49 of 105 patients experienced PONV within 24 hours postoperatively. The overall incidence of PONV within 24 hours postoperatively was not significantly different (45.5% vs 48%; relative risk [RR], 0.95; 95% confidence interval [CI], 0.67-1.37; p = .794). However, fewer patients experienced PONV in the test group than in the control group during 0 to 1 hours (6.0% vs 20.0%; RR, 0.85; 95% CI, 0.73-0.99; p = .024) and 1 to 3 hours (14.5% vs 32.0%; RR, 0.80; 95% CI, 0.64-0.99; p = .033) postoperatively. In addition, recovery time in the postanesthesia care unit was less in the test group (17.07 ± 6.36 vs 22.04 ± 7.33; mean difference, -4.97; 95% CI, -7.62 to -2.32; p <.001) and pain score was lower in the test group during 0 to 0.5 hours postoperatively (2.29 ± 1.74 vs 3.08 ± 1.64; mean difference, -0.79; 95% CI, -1.45 to -0.13; p = .019). CONCLUSION: In patients after gynecologic laparoscopic surgery, postanesthesia 5% dextrose infusion may be useful in improving the early management of PONV and pain response and may warrant further study.