Treatment patterns in women with urinary urgency and/or urgency urinary incontinence in the symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study.

BACKGROUND: Limited epidemiological data exist describing how patients engage with various treatments for overactive bladder (OAB). To improve care for patients with OAB, it is essential to gain a better understanding of how patients interface with OAB treatments longitudinally, that is, how often patients change treatments and the pattern of this treatment change in terms of escalation and de-escalation. OBJECTIVES: To describe treatment patterns for women with bothersome urinary urgency (UU) and/or urgency urinary incontinence (UUI) presenting to specialty care over 1 year. STUDY DESIGN: The Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) study enrolled adult women with bothersome UU and/or UUI seeking care for lower urinary tract symptoms (LUTS) between January 2015 and September 2016. An ordinal logistic regression model was fitted to describe the probabilities of escalating or de-escalating level of treatment during 1-year follow-up. RESULTS: Among 349 women, 281 reported UUI and 68 reported UU at baseline. At the end of 1 year of treatment by a urologist or urogynecologist, the highest level of treatment received by participants was 5% expectant management, 36% behavioral treatments (BT), 26% physical therapy (PT), 26% OAB medications, 1% percutaneous tibial nerve stimulation, 3% intradetrusor onabotulinum toxin A injection, and 3% sacral neuromodulation. Participants using BT or PT at baseline were more likely to be de-escalated to no treatment than participants on OAB medications at baseline, who tended to stay on medications. Predictors of the highest level of treatment included starting level of treatment, hypertension, UUI severity, stress urinary incontinence, and anticholinergic burden score. CONCLUSIONS: Treatment patterns for UU and UUI are diverse. Even for patients with significant bother from OAB presenting to specialty clinics, further treatment often only involves conservative or medical therapies. This study highlights the need for improved treatment algorithms to escalate patients with persistent symptoms, or to adjust care in those who have been unsuccessfully treated.

Development and validation of models predicting treatment patterns in women with urinary urgency and/or urgency incontinence: A Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study.

PURPOSE: To develop a tool to predict a woman's treatment pattern for bothersome urinary urgency (UU) and/or UU incontinence over 1 year after presenting for care at urology or urogynecology clinics. METHODS: The Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study enrolled adult women with bothersome UU and/or UU incontinence using the lower urinary tract symptoms (LUTS) Tool who were seeking care for LUTS. Treatments for UU and/or urgency incontinence were ordered from least to most invasive. Ordinal logistic and Cox proportional hazard regression models were fit to predict the most invasive level of treatment during follow-up and overactive bladder (OAB) medication discontinuation, respectively. Binary logistic regression was performed to predict sling treatment during the study follow-up. Clinical tools were then created using the models listed above to predict treatment pattern over 12 months. RESULTS: Among 349 women, 281 reported UU incontinence, and 68 reported UU at baseline. The highest level of treatment during the study was as follows: 20% no treatment, 24% behavioral treatments, 23% physical therapy, 26% OAB medication, 1% percutaneous tibial nerve stimulation, 3% onabotulinumtoxin A, and 3% sacral neuromodulation. Slings were placed in 10% (n = 36) of participants before baseline and in 11% (n = 40) during study follow-up. Baseline factors associated with predicting the most invasive level of treatment included baseline level of treatment, hypertension, UU incontinence severity, stress urinary incontinence (SUI) severity, and anticholinergic burden score. Less severe baseline depression and less severe UU incontinence were associated with OAB medication discontinuation. UU and SUI severity were associated with sling placement during the study period. Three tools are available to predict: (1) highest level of treatment; (2) OAB medication discontinuation; and (3) sling placement. CONCLUSIONS: OAB treatment prediction tools developed in this study can help providers individualize treatment plans and identify not only patients at risk for treatment discontinuation but also patients who may not be escalated to potentially beneficial OAB treatments, with the goal to improve clinical outcomes for patients suffering from this chronic and often debilitating condition.

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

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

Safety of Abdominoplasty with Concomitant Abdominal or Minimally Invasive Hysterectomy: An ACS NSQIP Study.

BACKGROUND: To compare 30-day postoperative complications following abdominoplasty with and without concomitant hysterectomy. Our secondary objective was to compare outcomes following abdominoplasty by route of hysterectomy. METHODS: This was a retrospective cohort study using American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database from 2014 to 2018. We included women who underwent abdominoplasty alone (ABP) and abdominoplasty with concomitant hysterectomy (ABP+Hyst). The ABP+Hyst group included both abdominal hysterectomy (ABP+AH) and minimally invasive hysterectomy (ABP+MIH). RESULTS: Analysis included 9064 women of whom 2.4% had ABP+Hyst (216 ABP+AH and 53 ABP+MIH). Both ABP and ABP+Hyst had similar 30-day postoperative complication rates (11.5% vs. 14.1%, p=.22). Patients with ABP+Hyst had a longer length of hospital stay when compared to ABP alone [2 days (IQR 1-2) vs. 1 day (IQR 0-2), p<.001). Operating time was longer in ABP+Hyst by 76 minutes (p<.001). In a multivariable logistic regression model controlling for age, race, BMI, ASA class, smoking status, hysterectomy, operative time, and major medical comorbidity, concomitant hysterectomy was not associated with increased odds of 30-day postoperative complications. Both ABP+AH and ABP+MIH had low 30-day complication rates (15.3% vs. 9.4%, p=.273). However, ABP+MIH had a 38 minute longer median operating time (p=.008) but with a shorter length of stay by 1 day (p<.001). CONCLUSION: Concomitant hysterectomy at the time of abdominoplasty was not associated with an increase in complications during the first 30-days after surgery regardless of route of hysterectomy. These data suggest that selected patients can safely be offered combined surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Feasibility and Outcomes of Opportunistic Bilateral Salpingectomy in Patients with Traditional Relative Contraindications to Vaginal Hysterectomy.

STUDY OBJECTIVE: To compare the feasibility of opportunistic bilateral salpingectomy (OBS) at the time of vaginal hysterectomy (VH) for benign disease in patients with and without relative contraindications (RCs) to the vaginal approach and to evaluate the factors that contribute to the inability to perform OBS. DESIGN: Retrospective chart review. SETTING: Tertiary medical center. PATIENTS: Women undergoing hysterectomy for benign indications between November 2014 and October 2017 who were consented for either VH with or without removal of tube(s) and/or bilateral salpingectomy. INTERVENTIONS: RCs to the vaginal approach are defined as lack of prolapse (cervix high, cervix not visualized, cervix tucked underneath pubis, or minimal descent), enlarged uterus (≥250 g or a size of a ≥12-week uterus), nulliparity, obesity (body mass index ≥30 kg/m2), previous cesarean section (CS), known adhesions, and known adnexal pathologic condition. MEASUREMENTS AND MAIN RESULTS: A total of 258 patients underwent VH and attempted to undergo OBS within the study period; of these, 112 patients (43.4%) had no RC, and 146 patients (56.6%) had ≥1 RCs. Overall, successful salpingectomy was performed in 86.8% of patients. There was no significant difference in the rate of success in patients without or with ≥1 RCs (84.9% vs 89%, p = .15). Salpingectomy was unsuccessful in 13.2% of patients (n = 34). In a multivariable logistic regression analysis, the odds of unsuccessful OBS were 3.83 times higher in patients without prolapse (confidence interval [CI], 0.99-14.76; p = .051), 2.71 times higher in patients with obesity (CI, 1.23-5.94; p = .013), and 3.07 times higher in patients with previous CS (CI, 1.17-8.08; p = .023) as compared to patients without any relative contraindications. An enlarged uterus was associated with successful salpingectomy (odds ratio, 0.28; 95% CI, 0.08-0.94; p = .039) compared with a normal-sized uterus. When excluding enlarged uterus, patients with 2 to 3 RCs had 11.24 and 6.8 higher odds of an unsuccessful OBS than patients with no (CI, 3.73-33.87; p <.001) and 1 RC (CI, 2.36-19.63; p <.001), respectively. There were no differences in postoperative stay or rates of readmission among patients with or without successful salpingectomy at the time of VH. CONCLUSION: OBS is associated with a high overall rate of success in patients with and without traditional RCs to VH. Lack of prolapse, obesity, and previous CS were associated with failed attempt at salpingectomy. Patients with ≥2 RCs to VH should be counseled about the high likelihood of failed salpingectomy.

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document.

BACKGROUND: The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial. AIMS: In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. MATERIALS & METHODS: This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures. RESULTS: Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. DISCUSSION: The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. CONCLUSION: At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document.

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

Concurrent Surgery for Locoregional Gynecologic Cancers and Pelvic Floor Disorders in a Population of Patients With Medicare Insurance.

OBJECTIVE: To estimate the rate of concurrent surgery for locoregional gynecologic cancer and pelvic organ prolapse-urinary incontinence (POP-UI) and to assess the rate of surgery for POP-UI within 5 years for those who did not undergo concurrent surgery. METHODS: This is a retrospective cohort study. The SEER-Medicare data set was used to identify cases of local or regional endometrial, cervical, and ovarian cancer diagnosed from 2000 to 2017. Patients were followed up for 5 years from diagnosis. We used χ 2 tests to identify categorical variables associated with having a concurrent POP-UI procedure with hysterectomy or within 5 years of hysterectomy. Logistic regression was used to calculate odds ratios and 95% CIs adjusted for variables statistically significant (α=.05) in the univariate analyses. RESULTS: Of 30,862 patients with locoregional gynecologic cancer, only 5.5% underwent concurrent POP-UI surgery. Of those with a preexisting diagnosis related to POP-UI, however, 21.1% had concurrent surgery. Of the patients who had a diagnosis of POP-UI at the time of initial surgery for cancer and who did not undergo concurrent surgery, an additional 5.5% had a second surgery for POP-UI within 5 years. The rate of concurrent surgery remained constant over the time period (5.7% in 2000 and 2017) despite an increase in the frequency of POP-UI diagnosis in the same time frame. CONCLUSION: The rate of concurrent surgery for patients with an early-stage gynecologic cancer and POP-UI-associated diagnosis in women older than age 65 years was 21.1%. Of women who did not undergo concurrent surgery but had a diagnosis of POP-UI, 1 in 18 underwent surgery for POP-UI within 5 years of their index cancer surgery. Dedicated efforts must be made to identify patients who would most benefit from concurrent cancer and POP-UI surgery in those with locoregional gynecologic cancers and pelvic floor disorders.

Removal of Large Primary Vaginal Calculus Using the Nephroscope and Endoscopic Ultrasonic Lithotrite: A Case Report.

Background: Vaginal calculi are rare and can grow quite large if they remain undetected. Vaginal stones are caused by the pooling of urine in the vagina and can be classified as either primary or secondary, depending on the absence or presence, respectively, of a nidus. Primary stones without any urethrovaginal or vesicovaginal fistula are even more uncommon but appear to be more commonly reported in incontinent women with significant physical disabilities. Case Presentation: We present a case of an ∼11 cm primary vaginal stone in a 61-year-old woman with cerebral palsy. This was removed using a nephroscope and an endoscopic ultrasonic lithotrite through the vaginal introitus with subsequent analysis demonstrating a struvite stone composition. Conclusion: This case is unique not only for the large size of the calculi but also for our less invasive approach, using a nephroscope and endoscopic ultrasonic lithotrite to fragment and remove the stone. We hope that this report will assist other providers in the timely and accurate diagnosis and treatment of future vaginal stone patients.

Nephrogenic Adenoma in the Setting of Refractory Labial Agglutination in an Elderly Woman.

BACKGROUND: Severe labial agglutination can be refractory to outpatient management and can lead to voiding dysfunction in postmenopausal women. Labial agglutination is often a sequela of long-standing inflammatory processes, which include untreated lichen planus, lichen sclerosus, and atrophic vaginitis. CASE: An 82-year-old parous woman presented with severe labial agglutination and complete obstruction of her vaginal introitus, causing obstructive voiding symptoms. She underwent a surgical procedure to release the fused labia. Pathologic evaluation of a vulvar biopsy revealed nephrogenic adenoma, which is an uncommon benign lesion usually presenting in the urinary tract. CONCLUSIONS: Refractory, severe labial agglutination in postmenopausal women can lead to significant voiding dysfunction, and the underlying chronic inflammation may result in pathologic changes such as nephrogenic adenoma. Pathologic tissue diagnosis is important to plan appropriate surveillance for patients with this chronic condition.