Bowel preparation prior to minimally invasive sacrocolpopexy: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The objective was to determine if a bowel preparation prior to minimally invasive sacrocolpopexy (MIS) influences post-operative constipation symptoms. We hypothesized that women who underwent a bowel preparation would have an improvement in post-operative defecatory function. METHODS: In this randomized controlled trial, women undergoing MIS received a pre-operative bowel preparation or no bowel preparation. Our primary outcome was post-operative constipation measured by the Patient Assessment of Constipation Symptoms (PAC-SYM) 2 weeks post-operatively. Secondary outcomes included surgeon's perception of case difficulty. Both intention-to-treat (ITT) and per-protocol analyses (PPA) were performed. Analyses were carried out using t test, Fisher's exact test, the Wilcoxon test and the Chi-squared test. RESULTS: Of 105 enrolled women, 95 completed follow-up (43 preparation and 52 no preparation). Baseline characteristics and rates of complications were similar. No differences were noted on ITT. The post-operative abdominal PAC-SYM subscale was closer to baseline for women who received a bowel preparation on PPA (change in score 0.74 vs 1.08, p = 0.045). Women who underwent a preparation were less likely to report strain (6.0% vs 26.7%, p = 0.009) or type 1 Bristol stool on their first post-operative bowel movement (4.3% vs 17.5%, p = 0.047). Surgeons were more likely to rate the complexity of the case as "more difficult than average" (54.4% vs 40.1%, p = 0.027) in those without a bowel preparation. CONCLUSIONS: Although there was no difference in ITT analysis, women who underwent a bowel preparation prior to MIS demonstrated benefit to post-operative defecatory function with a corresponding improvement in surgeon's perception of case complexity.

The use of mechanical bowel preparation in laparoscopic gynecologic surgery: a decision analysis.

OBJECTIVE: The use of mechanical bowel preparation prior to laparoscopy is common in gynecology, but its use may affect the rates of perioperative events and complications. Our objective was to compare different mechanical bowel preparations using decision analysis techniques to determine the optimal preparation prior to laparoscopic gynecological surgery. STUDY DESIGN: A decision analysis was constructed modeling perioperative outcomes with the following mechanical bowel preparations: magnesium citrate, sodium phosphate, polyethylene glycol, enema, and no bowel preparation. Comparisons were made using published utility values. Secondary analyses included the percentages that had 1 or more preoperative events and 1 or more intra- or postoperative complications. RESULTS: Overall, the highest utility values were for no bowel preparation (0.98) and magnesium citrate (0.97), whereas the other values were as follows: enema (0.95), sodium phosphate (0.94), and polyethylene glycol (0.91). The difference between no bowel preparation and magnesium citrate was less than the published minimally important differences for utilities, so there is likely no real difference between these strategies. The probability of having at least 1 preoperative event was lowest for no bowel preparation (1%), whereas the probability of having at least 1 intra- or postoperative complication was lowest with magnesium citrate (8%). CONCLUSION: The highest utilities were seen with no bowel preparation, but the absolute difference between no bowel preparation and magnesium citrate was less than the minimally important difference. With similar overall utilities, our model raises questions as to whether mechanical bowel preparation is a necessary step prior to laparoscopic gynecological surgery. However, if a surgeon prefers a bowel preparation, magnesium citrate is the preferred option.

Apical support at the time of hysterectomy for uterovaginal prolapse.

INTRODUCTION AND HYPOTHESIS: The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. METHODS: Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. RESULTS: A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1%) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8% vs 9.4%, p < 0.001), but less likely to have rectocele (3.4% vs 12.2%, p < 0.001) or combined cystocele/rectocele repair (16.4% vs 25.6%, p < 0.001). Of those without apical procedures, 95.7% were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1% and 88.8% vs 23.6%, p < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95% CI 3.127-8.304). Surgeons practicing for 10-14 years and >20 years were less likely to perform apical procedures than those practicing <5 years (p < 0.001 vs. p = 0.01). CONCLUSIONS: At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.

Introduction of laparoscopic sacral colpopexy to a fellowship training program.

INTRODUCTION AND HYPOTHESIS: Minimally invasive sacral colpopexy has increased over the past decade, with many senior physicians adopting this new skill set. However, skill acquisition at an academic institution in the presence of postgraduate learners is not well described. This manuscript outlines the introduction of laparoscopic sacral colpopexy to an academic urogynecology service that was not performing minimally invasive sacral colpopexies, and it also defines a surgical learning curve. METHODS: The first 180 laparoscopic sacral colpopexies done by four attending urogynecologists from January 2009 to December 2011 were retrospectively analyzed. The primary outcome was operative time. Secondary outcomes included conversion to laparotomy, estimated blood loss, and intra- and postoperative complications. Linear regression was used to analyze trends in operative times. Fisher's exact test compared surgical complications and counts of categorical variables. RESULTS: Mean total operative time was 250 ± 52 min (range 146-452) with hysterectomy and 222 ± 45 (range 146-353) for sacral colpopexy alone. When compared with the first ten cases performed by each surgeon, operative times in subsequent groups decreased significantly, with a 6-16.3% reduction in overall times. There was no significant difference in the rate of overall complications regardless of the number of prior procedures performed (p = 0.262). CONCLUSIONS: Introduction of laparoscopic sacral colpopexy in a training program is safe and efficient. Reduction in operative time is similar to published learning curves in teaching and nonteaching settings. Introducing this technique does not add additional surgical risk as these skills are acquired.

Sacral neuromodulation and intravesical botulinum toxin for refractory overactive bladder.

PURPOSE OF REVIEW: To provide an overview of sacral neuromodulation (SNM) and intravesical botulinum toxin (BTX) injections in the treatment of refractory overactive bladder (OAB) and urge urinary incontinence. RECENT FINDINGS: SNM has been a successful treatment option for OAB for over a decade with efficacy rates reported between 50 and 90%. Recently, intravesical BTX has been studied as a less invasive but more transient option with similar efficacy rates. Side-effect profiles differ greatly between the treatments, with elevated postvoid residuals and urinary tract infections most commonly occurring after botulinum injection and pain or device revision or removal occurring with SNM. Recent studies have tried to elucidate the optimal dosing regimen for BTX and patient variables predicting success for both therapies in order to improve outcomes while reducing adverse events. SUMMARY: Both intravesical BTX and SNM have been shown to be effective treatment options for OAB. Further research is needed to determine equivalence or if one therapy is superior and to identify the ideal patient population for each therapy.

The Impact of Individual Surgeon Volume on Hysterectomy Costs.

BACKGROUND AND OBJECTIVE: Hysterectomy is one of the most common surgical procedures women will undergo in their lifetime. Several factors affect surgical outcomes. It has been suggested that high-volume surgeons favorably affect outcomes and hospital cost. The objective is to determine the impact of individual surgeon volume on total hospital costs for hysterectomy. METHODS: This is a retrospective cohort of women undergoing hysterectomy for benign indications from 2011 to 2013 at 10 hospitals within the University of Pittsburgh Medical Center System. Cases that included concomitant procedures were excluded. Costs by surgeon volume were analyzed by tertile group and with linear regression. RESULTS: We studied 5,961 hysterectomies performed by 257 surgeons: 41.5% laparoscopic, 27.9% abdominal, 18.3% vaginal, and 12.3% robotic. Surgeons performed 1-542 cases (median = 4, IQR = 1-24). Surgeons were separated into equal tertiles by case volume: low (1-2 cases; median total cost, $4,349.02; 95% confidence interval [CI] [$3,903.54-$4,845.34]), medium (3-15 cases; median total cost, $2,807.90; 95% CI [$2,693.71-$2,926.93]) and high (>15 cases, median total cost $2,935.12, 95% CI [$2,916.31-$2,981.91]). ANOVA analysis showed a significant decrease (P < .001) in cost from low-to-medium- and low-to-high-volume surgeons. Linear regression showed a significant linear relationship (P < .001), with a $1.15 cost reduction per case with each additional hysterectomy. Thus, if a surgeon performed 100 cases, costs were $115 less per case (100 × $1.15), for a total savings of $11,500.00 (100 × $115). CONCLUSION: Overall, in our models, costs decreased as surgeon volume increased. Low-volume surgeons had significantly higher costs than both medium- and high-volume surgeons.

Predictors of postoperative acute urinary retention in women undergoing minimally invasive sacral colpopexy.

OBJECTIVES: Our aim was to determine predictors of acute urinary retention in women undergoing laparoscopic and robotic sacral colpopexy. METHODS: Records from all minimally invasive sacral colpopexies performed from 2009 to 2012 were reviewed. All women had a retrograde fill voiding trial (RGVT) on postoperative day 1, except in cases of intraoperative bladder injury or chronic urinary retention. Patient demographics, medical comorbidities, and surgical factors were compared between women who did and did not pass the RGVT. Univariable and multivariable logistic regression analyses were used to identify predictors of postoperative voiding dysfunction. RESULTS: Three hundred two subjects met the inclusion criteria, but 12 were excluded because of planned prolonged catheterization. Of the remaining 290 subjects, 211 (72.8%) passed the RGVT. The mean (SD) for the duration of urinary retention in those who failed was 3.7 (4.2) days. The mean (SD) for age was 58.5 (8.6) years, and the median preoperative prolapse was Pelvic Organ Prolapse Quantification stage III (76.1% with ≥ stage III) with mean Ba = +2.3. There were no significant independent risk factors identified on multivariable logistic regression to predict RGVT failure, with only concurrent midurethral sling approaching significance (6.1% vs 12.5%; adjusted odds ratio, 2.25; 95% confidence interval, 0.93-5.45; P = 0.07). CONCLUSIONS: No significant predictors of acute urinary retention were identified among women undergoing minimally invasive sacral colpopexy. In contrast to published analyses of vaginal prolapse repairs, large preoperative cystocele and concurrent midurethral sling were not significantly associated with retention. Given the inability to predict who will have postoperative urinary retention, all patients should be counseled about the potential need for catheterization.

Adoption of robotic sacrocolpopexy at an academic institution.

OBJECTIVES: To describe the introduction of robotic sacrocolpopexy (RSC) in a urogynecology fellowship program, including operative times and patient outcomes. METHODS: Data were retrospectively extracted from all women who underwent RSC between May 1, 2009 and December 31, 2011 by a single urogynecologist with fellow and resident assistance. Patient demographics, operative times, intraoperative complications, length of hospital stay, and postoperative course were analyzed. Cases were grouped chronologically in blocks of 10 for analysis. Trend analysis of operative time was done with linear and negative binomial regression. Fisher's exact test was used to compare complications among blocks. RESULTS: Fifty-two patients (mean age 58.5±8.4 years) underwent RSC. The majority (75%) had stage III prolapse. Forty-one patients (79%) had concomitant procedures, including supracervical hysterectomy (44%), bilateral salpingo-oophorectomy (9.6%), midurethral sling (9.6%), and lysis of adhesions (40.4%). There was no trend toward decreased operative time with increased surgical experience (linear regression P=.453, negative binomial regression P=.998). Mean operative time was 301.1±53.1 minutes (range 205-440). Overall complication rate was not associated with number of robotic cases performed (P=.771). Nine cases (17.3%) were converted to laparotomy. Five of these occurred in the first 15 cases. There were 2 bladder injuries (3.8%) and no bowel injuries. CONCLUSIONS: Although a learning curve was not demonstrated, the adoption of RSC into a urogynecology fellowship program yields similar rates of bladder/bowel injuries, postoperative complications, and operative times when compared with other published studies.

Cost analysis when open surgeons perform minimally invasive hysterectomy.

BACKGROUND AND OBJECTIVE: The costs to perform a hysterectomy are widely variable. Our objective was to determine hysterectomy costs by route and whether traditionally open surgeons lower costs when performing laparoscopy versus robotics. METHODS: Hysterectomy costs including subcategories were collected from 2011 to 2013. Costs were skewed, so 2 statistical transformations were performed. Costs were compared by surgeon classification (open, laparoscopic, or robotic) and surgery route. RESULTS: A total of 4,871 hysterectomies were performed: 34.2% open, 50.7% laparoscopic, and 15.1% robotic. Laparoscopic hysterectomy had the lowest total costs (P < .001). By cost subcategory, laparoscopic hysterectomy was lower than robotic hysterectomy in 6 and higher in 1. When performing robotic hysterectomy, open and robotic surgeon costs were similar. With laparoscopic hysterectomy, open surgeons had higher costs than laparoscopic surgeons for 1 of 2 statistical transformations (P = .007). Open surgeons had lower costs performing laparoscopic hysterectomy than robotic hysterectomy with robotic maintenance and depreciation included (P < .001) but similar costs if these variables were excluded. CONCLUSION: Although laparoscopic hysterectomy had lowest costs overall, robotics may be no more costly than laparoscopic hysterectomy when performed by surgeons who predominantly perform open hysterectomy.

Cost-effectiveness of test phase implantation strategies for InterStim® sacral neuromodulation.

OBJECTIVE: Sacral neuromodulation with InterStim can be performed with staged implants or peripheral nerve evaluation followed by a combined stage I/II procedure. In both, unilateral or bilateral leads can be placed for the testing phase. Our objective was to determine the cost-effectiveness of these strategies in patients with refractory overactive bladder. METHODS: A cost-effectiveness model compared 6 strategies, namely, unilateral and bilateral testing for both stage I and peripheral nerve evaluation, combined stage I/II, and no treatment. Costs were derived from a societal perspective using Medicare physician fee schedules and published studies. Quality-adjusted life-years (QALYs) were assigned using utility values. Results were reported using incremental cost-effectiveness ratios. Model robustness was assessed using probabilistic sensitivity analysis. Monte Carlo analysis sampled statistical distributions for each variable to examine the effects of varying all values simultaneously. RESULTS: No InterStim treatment was the least expensive but also the least effective option. Unilateral and bilateral stage I were the only cost-effective options with incremental cost-effectiveness ratios of $3533 and $7600, respectively. Because bilateral stage I was more effective, it is preferred. Probabilistic sensitivity analysis showed bilateral stage I was most likely to be cost-effective at willingness-to-pay thresholds greater than $6000 per QALY. At lower thresholds, no treatment was more economically acceptable. CONCLUSIONS: Bilateral and unilateral stage I lead placement were the only cost-effective strategies. Bilateral stage I was preferred due to greater effectiveness. In probabilistic sensitivity analysis, bilateral stage I was the most likely cost-effective strategy at all willingness-to-pay thresholds greater than $6000 per QALY confirming model robustness.

Menstrual suppression in the adolescent.

Menstrual suppression, the use of contraceptive methods to eliminate or decrease the frequency of menses, is often prescribed for adolescents to treat menstrual disorders or to accommodate patient preference. For young women using hormonal contraceptives, there is no medical indication for menstruation to occur monthly, and various hormonal contraceptives can be used to decrease the frequency of menstruation with different side effect profiles and rates of amenorrhea. This article reviews the different modalities for menstrual suppression, common conditions in adolescents which may improve with menstrual suppression, and strategies for managing common side effects.