Impact of Preoperative Urinary Tract Infection Screening in Asymptomatic Women Undergoing Midurethral Sling.

INTRODUCTION: There is limited information regarding the utility of preoperative urine culture (Ucx) screening to decrease postoperative UTI rates following midurethral sling (MUS). HYPOTHESIS: The primary objective of this study was to determine if the rate of postoperative UTI within the first 6 weeks after surgery is lower in women undergoing MUS when preoperative Ucx is obtained compared to when it is not. Secondary objectives were to determine clinical factors associated with postoperative UTI risk. METHODS: This is a retrospective cohort study of women who did not have symptoms of or a diagnosis of cystitis at the time of their preoperative evaluation and are undergoing MUS. Patients were grouped into those who had preoperative Ucx screening within 6 weeks preceding surgery and those who did not. UTI rates 6 weeks following surgery were compared between groups. Additionally, factors impacting the risk of developing a UTI within 6 weeks of surgery were assessed. RESULTS: Among 661 patients, 13.2% had a UTI within the first 6 weeks. There was no significant difference in UTI rates between those who did and did not have preoperative Ucx, respectively (14.9% vs 10.2%, p = 0.09). On multivariable analysis, current smoker status (OR 3.02, 95% CI 1.10-8.26), history of recurrent UTI (OR 3.00, 95% CI 1.14-7.86), and requiring postoperative SIC (OR 8.75, 95% CI 1.83-41.74) were independently associated with a UTI within 6 weeks of MUS. CONCLUSION: Obtaining preoperative Ucx in asymptomatic women prior to MUS does not appear to be associated with lower postoperative UTIs rates within 6 weeks of surgery.

Gender Representation in U.S. Urogynecology Fellowship Program Leadership.

IMPORTANCE: The proportion of female physicians in the workforce has been steadily increasing, but the proportion of women in department leadership roles across the United States remains low. Urogynecology has the highest representation of women in leadership roles across obstetrics and gynecology and urology subspecialties; however, the proportion of women in leadership roles within urogynecology fellowship programs has not been described previously. OBJECTIVES: Our objective was to investigate gender representation within urogynecology fellowship program leadership positions. STUDY DESIGN: This was a cross-sectional observational study where urogynecology fellowship program websites were queried for the geographic state as well as the gender expression of the program director and division chair. RESULTS: A total of 68 American Council for Graduate Medical Education-accredited urogynecology fellowship programs were queried. Of these, 53 are obstetrics and gynecology-based programs and 15 are urology-based programs. Overall, women represent 67.6% of fellowship directors and 59.2% of division directors. One in 4 female fellowship directors concurrently hold the role of division chair. Women are significantly more likely to be fellowship directors in obstetrics and gynecology-based programs compared with urology-based urogynecology programs (75.4% versus 40.0%; odds ratio, 4.1; 95% confidence interval, 1.20-14.0). Women are also more likely to be division chairs in obstetrics and gynecology-based compared with urology-based urogynecology programs, although this did not reach statistical significance (63.4% versus 37.5%; odds ratio, 2.9, 95% confidence interval, 0.60-13.8). CONCLUSIONS: Across urogynecology fellowship programs, women are the majority of division chairs and fellowship directors. However, female representation in leadership roles is lagging at urology-based urogynecology programs.

The impact of diabetes mellitus on pelvic organ prolapse recurrence after robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Data examining the effect of diabetes mellitus (DM) on prolapse recurrence after sacrocolpopexy (SCP) is limited. The primary objective of this study was to determine if DM affects prolapse recurrence after robotic SCP. METHODS: This was a retrospective cohort study of women who underwent robotic SCP between 2012 and 2019 at Kaiser Permanente Southern California. The cohort was divided into women with and without DM at the time of SCP. The primary outcome was composite failure. Secondary outcomes included recurrent compartment-specific prolapse, reoperation rates, and surgical complications. RESULTS: Of 547 patients included, 100 had DM. Women with DM were older, had higher BMI, higher parity, and were more likely to be nonwhite. Women with DM had more advanced prolapse at baseline but were not more likely to undergo concomitant procedures at the time of SCP. Over a median follow-up of 2.1 years (IQR 1.3, 3.4), women with DM had significantly increased risk of anterior vaginal prolapse (AVP) recurrence (13% vs 3%, p<0.01), but not composite failure (21% vs 14%, p=0.14). On multivariate regression, women with DM were almost 4 times as likely to experience AVP recurrence over time (AVP hazard ratio (HR) 3.93, 95% CI 1.29-12.03, p=0.02). CONCLUSION: In our cohort, DM was a risk factor for AVP recurrence but not composite failure after robotic SCP.

The Correlation of Diabetes Mellitus and Urinary Retention From Intravesical OnabotulinumtoxinA Injection for Overactive Bladder.

IMPORTANCE AND OBJECTIVES: The objective was to determine whether patients with diabetes mellitus (DM) treated with intravesical onabotulinumtoxinA (BoNT) injection for overactive bladder (OAB) had increased urinary retention requiring clean intermittent catheterization (CIC), as well as the impact of disease duration and severity. We hypothesize that patients with DM will have higher rates of retention after BoNT injection. STUDY DESIGN: We performed a retrospective cohort analysis of women in the Kaiser Permanente Southern California Health System who underwent BoNT injection for OAB, excluding women with a history of urinary retention or neurogenic bladder. RESULTS: We identified 565 patients, 410 in the control group and 155 in the DM group. No significant difference was found in the rate of CIC (9% in the control group versus 5.8% in the DM group, P = 0.2), voiding dysfunction, and peak postprocedure postvoid residual volume (PVR). Patients with diabetes had a significantly increased rate of postprocedure urinary tract infection (UTI; 27.6% versus 38.1%, P = 0.02). Urinary tract infection was significantly associated with urinary retention (adjusted odds ratio [OR], 2.26; 95% confidence interval [CI], 1.02-4.99; P = 0.045) and peak PVR ≥200 mL (adjusted OR, 2.42; 95% CI, 1.15-5.06; P = 0.019). Diabetic disease duration and severity were not a predictor of urinary retention, elevated PVR, or voiding dysfunction; however, the presence of ≥1 disease-related complication was a predictor of UTI (adjusted OR, 2.81; 95% CI, 1.34-5.91; P = 0.006). CONCLUSIONS: Diabetic patients had a similar rate of urinary retention requiring CIC after BoNT injection for OAB compared with nondiabetic patients. Diabetic patients had an increased risk of UTI based on disease severity.

Randomized trial of an enhanced consultation versus standard consultation for prolapse: impact on patient satisfaction.

INTRODUCTION AND HYPOTHESIS: Optimal counseling techniques for Spanish-speaking patients with low health literacy and pelvic organ prolapse (POP) is unknown. We hypothesize that with use of an enhanced consultation (EC) strategy, patient satisfaction with their knowledge of prolapse will improve compared with a standard consultation (SC). METHODS: We conducted a randomized controlled trial of an EC vs SC in Spanish-speaking women seeking treatment for POP. In addition to receiving the same SC as the SC group, the EC group received consultation using images from an Interactive Pelvic Organ Prolapse Quantification (POPQ) Program and a brief anatomy lesson. Thirty participants per group was calculated to achieve a power of 80% with an alpha of 0.05. The primary outcome was to assess the change in patient satisfaction of prolapse understanding utilizing a visual analog scale. Comparisons between groups were done using Student's t test or Wilcoxon Rank-Sum for continuous variables, Mantel-Haenszel for ordinal variables, and Chi-squared and Fisher's exact tests for categorical variables. RESULTS: A total of 78 patients were enrolled and 64 completed the study. There was no difference in the change in satisfaction with disease understanding on a visual analog scale between the EC and SC groups (45.6 vs 51.7, p = 0.623). There were no differences in the change in factual knowledge scores on the prolapse portion of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) between the EC and the SC groups (19.6 vs 18.9, p = 0.914). CONCLUSIONS: In Spanish-speaking women, an EC using a 2-D prolapse animation did not increase prolapse knowledge satisfaction of disease understanding compared with an SC.

Unanticipated 30-day readmission following rectosigmoid resection at the time of cytoreductive surgery in patients with advanced stage ovarian cancer.

The objective of this study was to examine the rate of and indications for readmission in patients with advanced staged ovarian cancer undergoing rectosigmoid resection and primary anastomosis, an important quality metric. A retrospective review was conducted of patients with primary ovarian cancer who underwent rectosigmoid resection as part of cytoreductive surgery between July 2003 and July 2014. Univariate analysis identified rates and predictors of readmission. Fifty patients were eligible for analysis. The unanticipated 30-day readmission rate was 18% (n = 9). Of those readmitted less than 30 days from date of discharge, 3 were readmitted more than once, making 14 total readmissions. A total of 21 indications for readmission were reported, with the most common being: infection (23.8%, n = 5); thromboembolic events (19%, n = 4); and severe malnutrition (14.3%, n = 3). The median time to readmission was 14 days (range, 2-26). There were no deaths within 30 days of surgery in this cohort.IMPACT STATEMENTWhat is already known about the subject? Unanticipated 30-day readmission rates are reported to be between 12 and 20% among patients undergoing cytoreductive surgery for the management of ovarian cancer. The relative contribution of rectosigmoid resection at the time of cytoreductive surgery to readmission is not well studied.What do the results of this study add? In the examined cohort, the unanticipated 30-day readmission rate following rectosigmoid resection with primary reanastomosis at the time of cytoreductive surgery is 18%, similar to the readmission rate for patients undergoing cytoreductive surgery, in general. While the sample size is limited, the perioperative complications in this cohort appear similar to those of patients undergoing cytoreductive surgery.What are the implications of these findings for clinical practice and/or further research? Efforts to reduce unanticipated 30-day readmission following cytoreductive surgery is warranted. Future studies may benefit from multi-centre approaches and prospective data collection, while simultaneously assessing the impact of enhanced recovery programs. Ultimately, identification of risk factors, and programmatic initiatives to drive down readmission will be important across surgical platforms, and the opportunity exists in patients with advanced stage ovarian cancer.

A Novel Approach to Management of Angular Pregnancies: A Case Series.

Cornual, interstitial, and angular pregnancies are terms that are often used interchangeably in both the literature and clinical setting to describe various ectopic pregnancies. The diagnosis of these pregnancies can be difficult, and fear of disrupting an intrauterine pregnancy can cause hesitation during evaluation and management. In our 2 cases, a combination of transvaginal and 3-dimensional ultrasound images provided assistance in the accurate diagnosis of angular ectopic pregnancies. Traditional management of these pregnancies includes a wedge resection for pregnancy resolution. In this set of 2 cases, we describe a unique surgical approach to resolve these pregnancies using operative hysteroscopy.

Subjective and objective responses to PTNS and predictors for success: a retrospective cohort study of percutaneous tibial nerve stimulation for overactive bladder.

INTRODUCTION AND HYPOTHESIS: We investigated the objective improvements in overactive bladder (OAB) symptoms in patients undergoing percutaneous tibial nerve stimulation (PTNS) and predictive factors of patient satisfaction. METHODS: In this single-center retrospective cohort study at a tertiary urogynecology center, we identified all female patients who underwent PTNS therapy from 1 October 2007 - 1 January 2016 and followed them from their initial visit through medication therapy and PTNS treatments. Patients who tried at least one medication prior to starting PTNS therapy and completed at least one PTNS visit were included. Baseline demographic data, urinary data, and details of medication and PTNS therapy sessions were collected from records through chart review. Paired or two-sample t-tests were used to compare changes over time or groups. Bivariate and multivariable logistic regression were performed. RESULTS: Two hundred thirteen patients underwent PTNS therapy and 183 patients met the criteria. Overall patients were able to decrease voiding frequency by 1 h, decrease nocturia episodes by 0.8, and decrease urge incontinence episodes with PTNS therapy by ten episodes per week (p = 0.02). Patients who continued OAB medications did not have additional improvements compared with patients who did not continue OAB medications during PTNS. Overall, 25.4% (43/169) patients reported ≥ 75% improvement during PTNS therapy, and 61.5% (104/169) reported ≥ 50% improvement. When evaluating predictive factors of ≥ 50% overall improvement, the number of PTNS sessions increased odds of subjective success (OR = 1.8, p = 0.004). Other factors were not significant predictors of subjective PTNS success. CONCLUSIONS: PTNS can provide both objective and subjective improvements for patients who do not respond to OAB medication therapy.