The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

National prevalence of IC/BPS in women and men utilizing veterans health administration data.

Importance: Interstitial cystitis/bladder pain syndrome (IC/BPS) is an immense burden to both patients and the American healthcare system; it is notoriously difficult to diagnose. Prevalence estimates vary widely (150-fold range in women and >500-fold range in men). Objectives: We aimed to create accurate national IC/BPS prevalence estimates by employing a novel methodology combining a national population-based dataset with individual chart abstraction. Study design: In this epidemiological survey, all living patients, with ≥2 clinic visits from 2016 to 2018 in the Veterans Health Administration, with an ICD-9/10 code for IC/BPS (n = 9,503) or similar conditions that may represent undiagnosed IC/BPS (n = 124,331), were identified (other were controls n = 5,069,695). A detailed chart review of random gender-balanced samples confirmed the true presence of IC/PBS, which were then age- and gender-matched to the general US population. Results: Of the 5,203,529 patients identified, IC/BPS was confirmed in 541 of 1,647 sampled charts with an IC/BPS ICD code, 10 of 382 charts with an ICD-like code, and 3 of 916 controls. After age- and gender-matching to the general US population, this translated to national prevalence estimates of 0.87% (95% CI: 0.32, 1.42), with female and male prevalence of 1.08% (95% CI: 0.03, 2.13) and 0.66% (95% CI: 0.44, 0.87), respectively. Conclusions: We estimate the prevalence of IC/BPS to be 0.87%, which is lower than prior estimates based on survey data, but higher than prior estimates based on administrative data. These potentially represent the most accurate estimates to date, given the broader and more heterogeneous population studied and our novel methodology of combining in-depth chart abstraction with administrative data.

Demographic Differences and Disparities in the Misdiagnosis of Interstitial Cystitis/Bladder Pain Syndrome in a National Cohort of VA Patients.

OBJECTIVE: To explore association between misdiagnosis of IC/BPS and demographics. Interstitial cystitis/bladder pain syndrome (IC/BPS) is associated with significant diagnostic uncertainty, resulting in frequent misdiagnosis as there is little known about the potential impact of key demographic factors. METHODS: All patients in the VA system between 1999-2016 were identified by ICD-9/10 codes for IC/BPS (595.1/N30.10) (n = 9,503). ICD code accuracy for true IC/BPS (by strict criteria) was assessed by in-depth chart abstraction (n = 2,400). Associations were explored between rates of misdiagnosis and demographics. RESULTS: IC/BPS criteria were met in only 651 (48.8%) of the 1,334 charts with an ICD code for IC/BPS reviewed in depth. There were no differences in the misdiagnosis rate by race (P=.27) or by ethnicity (P=.97), after adjusting for differences in age and gender. In IC/BPS-confirmed cases, female patients were diagnosed at a younger age than males (41.9 vs. 58.2 years, P<.001). Black and Hispanic patients were diagnosed at a younger age compared to White (41.9 vs. 50.2 years, P<.001) and non-Hispanic patients, respectively (41.1 vs. 49.1 years, P=.002). CONCLUSION: There was a high rate of misdiagnosis of IC/BPS overall, with only 48.8% of patients with an ICD code for IC/BPS meeting diagnostic criteria. There were no significant associations between diagnostic accuracy and race/ethnicity. Black and Hispanic patients were more likely to receive a diagnosis of IC/BPS at a younger age, suggesting there may be differing natural histories or presentation patterns of IC/BPS between racial/ethnic groups.

Comorbidities in a Nationwide, Heterogenous Population of Veterans with Interstitial Cystitis/Bladder Pain Syndrome.

OBJECTIVE: To examine the prevalence of comorbid conditions in a nationwide population of men and women with IC/BPS utilizing a more heterogeneous sample than most studies to date. METHODS: Using the Veterans Affairs Informatics and Computing Infrastructure, we identified random samples of male and female patients with and without an ICD-9/ICD-10 diagnosis of IC/BPS. Presence of comorbidities (NUAS [chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, migraines], back pain, diabetes, and smoking) and psychosocial factors (alcohol abuse, post-traumatic stress disorder, sexual trauma, and history of depression) were determined using ICD-9 and ICD-10 codes. Associations between these variables and IC/BPS status were evaluated while adjusting for the potential confounding impact of race/ethnicity, age, and gender. RESULTS: Data was analyzed from 872 IC/BPS patients (355 [41%] men, 517 [59%] women) and 558 non-IC/BPS patients (291 [52%] men, 267 [48%] women). IC/BPS patients were more likely than non-IC/BPS patients to have a greater number of comorbidities (2.72+/-1.77 vs 1.73+/-1.30, P < 0.001), experience one or more NUAS (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and migraines) (45% [388/872] vs. 18% [101/558]; P < 0.001) and had a higher prevalence of at least one psychosocial factor (61% [529/872] v. 46% [256/558]; P < 0.001). Differences in the frequencies of comorbidities between patients with and without IC/BPS were more pronounced in female patients. CONCLUSION: These findings validate the findings of previous comorbidity studies of IC/BPS in a more diverse population.

Predictors of Colpocleisis Outcomes in an Older Population Based Cohort.

PURPOSE: Colpocleisis is an obliterative surgical option for women with pelvic organ prolapse that is often performed in a frail population. However, because outcomes remain largely unknown we aimed to assess the durability and perioperative safety of colpocleisis in a large population based cohort. MATERIALS AND METHODS: All women undergoing colpocleisis and other pelvic organ prolapse repairs in California (2005-2011) were identified using the Office of Statewide Health Planning and Development data sets. Durability was defined as the absence of future pelvic organ prolapse repair after index repair for the duration of the data sets. Thirty-day morbidity was assessed by identifying readmissions, repeat surgeries and complications. A metric to assess frailty in large administrative databases was applied to assess the impact of frailty on outcomes. Colpocleisis outcomes were compared to other types of pelvic organ prolapse repairs by developing propensity score matched groups. RESULTS: Among the 2,707 women undergoing colpocleisis, reoperation for prolapse occurred in 47 (1.8%). At least 1 complication occurred in 11.1% of the cohort, with serious complications occurring in 2%. Frail patients were more likely to experience any complication (23.3% vs 10.3%, p <0.01) and a serious complication (5.0% vs 1.8%, p=0.02) and was the best predictor of morbidity. Colpocleisis was associated with a more durable repair (overall failure 1.8% vs 3.5%, p <0.01) with no difference in complication rates as compared to the matched cohort. CONCLUSIONS: Colpocleisis provides a more durable outcome than reconstructive pelvic organ prolapse repairs without increased perioperative morbidity. Frailty is a better predictor than age for perioperative complications after colpocleisis.

Reoperation rates for pelvic organ prolapse repairs with biologic and synthetic grafts in a large population-based cohort.

INTRODUCTION AND HYPOTHESIS: As the long-term complications of synthetic mesh become increasingly apparent, re-evaluation of alternative graft options for pelvic organ prolapse (POP) repairs is critical. We sought to compare the long-term reoperation rates of biologic and synthetic grafts in POP repair. METHODS: Using the California Office of Statewide Health Planning and Development database, we identified all women who underwent index inpatient POP repair with either a synthetic or biologic graft between 2005 and 2011 in the state of California. ICD-9 and CPT codes were used to identify subsequent surgeries in these patients for either recurrent POP or a graft complication. RESULTS: A total of 14,192 women underwent POP repair with a biologic (14%) or synthetic graft (86%) during the study period. Women with biologic grafts had increased rates of surgery for recurrent pelvic organ prolapse (3.6% vs 2.5%, p = 0.01), whereas women with synthetic grafts had higher rates of repeat surgery for a graft complication (3.0 vs 2.0%, p = 0.02). There were no significant differences between the overall risk of repeat surgery between the groups (5.7% vs 5.6%, p = 0.79). These effects persisted in multivariate modeling. CONCLUSIONS: We demonstrate in a large population-based cohort that biologic grafts are associated with an increased rate of repeat surgery for POP recurrence whereas synthetic mesh is associated with an increased rate of repeat surgery for a graft complication. These competing risks result in an equivalent overall any-cause repeat surgery rate between the groups. These data suggest that neither type of graft should be excluded from use and encourage a personalized risk assessment.

Statewide Success of Staged Sacral Neuromodulation for the Treatment of Urinary Complaints in California (2005-2011).

PURPOSE: Sacral neuromodulation (SNS) is approved by the Food and Drug Administration as a third-line treatment for refractory overactive bladder, idiopathic urinary retention, and fecal incontinence. Prior to implantation of an implantable pulse generator, all patients undergo a trial phase to ensure symptom improvement. The published success rates of progression from the test phase to permanent implant vary widely (range, 24% to >90%). We sought to characterize success rates using a statewide registry. METHODS: Using nonpublic data, we identified SNS procedures using the California Office of Statewide Planning and Development ambulatory surgery database from 2005 to 2011. A successful trial was defined as receiving a stage 2 generator implantation after trial lead placement. Multivariable logistic regression was performed to identify factors associated with staged success. RESULTS: During the study period, 1396 patients underwent a staged SNS procedure, with 962 (69%) subsequently undergoing generator placement. Successful trial rates were 72% for overactive bladder wet, 69% for urgency/frequency, 68% for interstitial cystitis, 67% for neurogenic bladder, and 57% for urinary retention. On multivariate logistic regression, only male sex (odds ratio, 0.51) and urinary retention [odds ratio, 0.54) were significantly associated with lower odds of success, whereas age, race/ethnicity, medical insurance, and placement at an academic or high-volume institution had no association. CONCLUSIONS: The "real world" success rates for staged SNS implantation in California are less than those observed by some academic centers of excellence but better than previously reported for Medicare beneficiaries. Successful trial rates for interstitial cystitis and neurogenic voiding dysfunction are similar to refractory overactive bladder.

Urologic Injury and Fistula After Hysterectomy for Benign Indications.

OBJECTIVE: To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications. METHODS: In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005-2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed. RESULTS: Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14-0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16-0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30-1.58), an incontinence procedure (OR 1.40, 95% CI 1.21-1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31-1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36-1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01-1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53-0.64) or laparoscopic (OR 0.80, 95% CI 0.75-0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach. CONCLUSION: Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease.

PURPOSE: Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery. MATERIALS AND METHODS: A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery. RESULTS: Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression. CONCLUSIONS: Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.

Rates and Risk Factors for Future Stress Urinary Incontinence Surgery after Pelvic Organ Prolapse Repair in a Large Population-based Cohort in California.

OBJECTIVES: To determine the rate and risk factors for future stress urinary incontinence (SUI) surgery in a large population-based cohort of previously continent women following pelvic organ prolapse (POP) repair without concomitant SUI treatment. METHODS: Data from the Office of Statewide Health Planning and Development were used to identify all women who underwent anterior, apical, or combined anteroapical POP repair without concomitant SUI procedures in the state of California between 2005 and 2011 with at least 1-year follow-up. Patient and surgical characteristics were explored for associations with subsequent SUI procedures. RESULTS: Of 41,689 women undergoing anterior or apical POP surgery, 1,504 (3.6%) underwent subsequent SUI surgery with a mean follow-up time of 4.1 years. Age (odds ratio [OR] 1.01), obesity (OR 1.98), use of mesh at the time of POP repair (OR 2.04), diabetes mellitus (OR 1.19), white race, and combined anteroapical repair (OR 1.30) were associated with increased odds of future SUI surgery. CONCLUSION: The rate of subsequent surgery for de novo SUI following POP repair on a population level is low. Patient and surgical characteristics may alter a woman's individual risk and should be considered in surgical planning.

Care Seeking Patterns for Women Requiring a Repeat Pelvic Organ Prolapse Surgery Due to Native Tissue Repair Failure Compared to a Mesh Complication.

OBJECTIVE: To explore patient migration patterns in patients requiring repeat surgery after Pelvic Organ Prolapse (POP) repair as there is a limited understanding of care seeking patterns for repeat surgery after POP repair. We hypothesized that undergoing repeat surgery for a prolapse mesh complication would be associated with an increased incidence of migration to a new facility for care compared to those undergoing repeat surgery for recurrent POP. METHODS: In this retrospective population based study, all females who underwent an index POP repair procedure (with or without mesh) at nonfederal facilities who subsequently underwent a repeat surgery (recurrent prolapse repair or mesh complication) were identified from the Office of Statewide Health Planning and Development for the state of California (2005-2011). The location of index repair and repeat surgery were identified and factors associated with migration were explored. RESULTS: Of the 3,930 women who underwent repeat surgery for either POP recurrence or a mesh complication, 1,331 (33.9%) had surgery at a new facility. Multivariate analysis revealed that mesh complications (odds ratio [OR] 1.28, P = 0.004) or native tissue same compartment recurrence (OR 1.19, P = 0.02) were both associated with increased odds of undergoing surgery at a new facility. Having surgery in a county with multiple centers increased the odds of migration to a new facility for care (OR = 1.33, P < 0.001), unless the initial repair was at a high volume institution (OR = 0.32, P < 0.001). Overall across indications, women changing locations for their second surgery tended to migrate toward select centers in urban areas. CONCLUSION: Women who undergo repeat surgery after POP repair have similar patterns of migration to a new facility irrespective of the indication for surgery.

What Impacts the All Cause Risk of Reoperation after Pelvic Organ Prolapse Repair? A Comparison of Mesh and Native Tissue Approaches in 110,329 Women.

PURPOSE: Several factors are hypothesized to impact the risks of mesh augmented pelvic organ prolapse repair, including 1) the characteristics of the material, 2) surgical experience and 3) patient selection. We present a large, population based approach to explore the impact of these factors on outcomes and describe an ideal mesh use strategy. MATERIALS AND METHODS: Data from the Office of Statewide Health Planning and Development were accessed to identify all women who underwent pelvic organ prolapse repair in California from 2005 to 2011. Multivariate mixed effects logistic regression models were constructed to explore which patient, surgical and facility factors were associated with repeat surgery for a complication due to mesh or recurrent pelvic organ prolapse. RESULTS: A total of 110,329 women underwent pelvic organ prolapse repair during the study period and mesh was used in 16.2% of the repairs. The overall repeat surgery rate was higher in women who underwent mesh repair (5.4% vs 4.3%, p <0.001). However, multivariate modeling revealed that mesh itself was not independently associated with repeat surgery. Rather, repair at a facility where there was a greater propensity to use mesh was independently associated with repeat surgery (highest vs lowest mesh use quartile OR 1.55, p <0.01). Further modeling revealed that the lowest risk occurred when mesh was used in 5% of anterior and 10% of anterior apical repairs. CONCLUSIONS: Our findings demonstrate that mesh is not independently associated with an increase in the rate of complications of pelvic organ prolapse repair on a large scale. We present a model that supports judicious use of the product on the population level which balances the risk of complications against that of recurrent pelvic organ prolapse.

Where do Women go for Revision Surgeries? Geographic Migration Patterns after Urethral Sling Placement in California.

INTRODUCTION: Although long-term rates of sling revision after urethral sling placement have been well studied, details of these revisions have not been addressed. In this study we explore the timing, location and migration of patients from one facility to another for revision procedures. METHODS: Using data from the Office of Statewide Health Planning and Development (OSHPD) for the state of California (2005 to 2011), all females who underwent index outpatient urethral sling procedures at nonfederal facilities were identified (CPT 57288). Cases requiring eventual sling revision or urethrolysis were subsequently identified. Location, distance traveled and factors associated with seeking a new facility for revision were explored. RESULTS: Of the 44,605 patients undergoing urethral sling surgery 842 (1.9%) underwent sling revision, with 178 (22.5%) at a new facility. Facilities in the top 10% of surgical volume placed 41% of the slings and performed more than 50% of revisions. Patient proximity to multiple facilities and increased time between procedures were associated with an increased odds of changing facilities for revision (OR 2.11, p <0.0001 and OR 1.05 per month, p <0.0001, respectively). Placement at a high volume center was associated with decreased odds of changing facilities for revision (OR 0.32, p <0.0001). Patients migrated toward larger centers in urban areas for revision. CONCLUSIONS: Overall 78% of sling revisions are performed at the facility where the initial placement was performed. This suggests that the majority of facilities where urethral slings are placed also have the capability of sling revision surgery.

Racial and Socioeconomic Disparities in Short-term Urethral Sling Surgical Outcomes.

OBJECTIVE: To evaluate the association of racial and socioeconomic factors with the risk of adverse events in the first 30 days following urethral sling placement. METHODS: We accessed nonpublic data from the Office of Statewide Health Planning and Development in California from 2005 to 2011. All female patients who underwent an ambulatory urethral sling procedure in the entire state of California over the study period were identified (Current Procedural Terminology 57288). Our main outcome was any unplanned hospital visits within 30 days of the patient's surgery in the form of an inpatient admission, revision surgery, or emergency department visit. RESULTS: A total of 28,635 women who underwent outpatient urethral sling placement were identified. Within 30 days, 1628 women (5.7%) had at least 1 unplanned hospital visit. In the adjusted multivariate model, black race and Medicaid insurance status were both independently associated with increased odds of having an unplanned hospital visit (odds ratio 1.80, P < .01 and odds ratio 1.53, P < .01, respectively). This significance persisted even when controlling for patient comorbidities, demographics, and facility characteristics. CONCLUSION: We found that, similar to what has been reported in other fields, disparities in outcomes exist between socioeconomic and racial groups in the field of urogynecology.

Redefining the Stone Belt: Precipitation Is Associated with Increased Risk of Urinary Stone Disease.

OBJECTIVES: The American Southeast has been labeled the "Stone Belt" due to its relatively high burden of urinary stone disease, presumed to be related to its higher temperatures. However, other regions with high temperatures (e.g., the Southwest) do not have the same disease prevalence as the southeast. We seek to explore the association of stone disease to other climate-associated factors beyond temperature, including precipitation and temperature variation. METHODS: We identified all patients who underwent a surgical procedure for urinary stone disease from the California Office of Statewide Health Planning and Development (OSHPD) databases (2010-2012). Climate data obtained from the National Oceanic and Atmospheric Administration (NOAA) were compared to population adjusted county operative stone burden, controlling for patient and county demographic data as potential confounders. RESULTS: A total of 63,994 unique patients underwent stone procedures in California between 2010 and 2012. Multivariate modeling revealed that higher precipitation (0.019 average increase in surgeries per 1000 persons per inch, p < 0.01) and higher mean temperature (0.029 average increase in surgeries per 1000 persons per degree, p < 0.01) were both independently associated with an increased operative stone disease burden. Controlling for county-level patient factors did not change these observed effects. CONCLUSIONS: In the state of California, higher precipitation and higher mean temperature are associated with increased rates of stone surgery. Our results appear to agree with the larger trends seen throughout the United States where the areas of highest stone prevalence have warm wet climates and not warm arid climates.

Intermittent Projectile Urethraggia: An Unusual Sequela of a Skateboarding Accident in an Adolescent Male.

Our patient suffered a perineal straddle injury, resulting in right cavernosal artery pseudoaneurysm in combination with a cavernosal-urethral fistula. The urethra failed to heal after several weeks, and the patient presented with severe intermittent urethral bleeding. The pseudoaneurysm was successfully treated by coil embolization, with resolution of the bleeding. The patient recovered completely, with normal erectile and voiding function. This type of injury is very rare in the literature: traumatic cavernosal arterial pseudoaneurysm is known to cause high flow priapism, but in this case additional cavernosal-urethral fistula resulted in a severe urethraggia. This is the only case, to our knowledge, of delayed urethral bleeding from cavernosal artery pseudoaneursym in combination with a cavernosal-urethral fistula.

Unplanned Hospital Visits in the First 30 Days After Urethral Sling Procedures.

OBJECTIVE: To evaluate unplanned hospital visits within 30 days of urethral sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery. METHODS: We accessed nonpublic data from the Office of Statewide Health Planning and Development in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (Current Procedural Terminology 57288) without concomitant surgery (other than cystoscopy) were included. Any subsequent emergency department visit, inpatient admission, or sling revision operation within 30 days of the original surgery were then examined. RESULTS: A total of 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure. Within 30 days, 1630 women (5.7%) had at least 1 unplanned hospital visit. This included 1327 emergency department visits (4.7%), 295 inpatient admissions (1.0%), and 79 sling revisions (0.28%). Urinary retention and Foley catheter problems were the most common emergency department visit diagnoses (18.7% of visits), followed by urinary tract infection (9.3% of visits). CONCLUSION: One in 18 women will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits (~81%). Our findings can be used to improve patient counseling and suggest areas that one might target to decrease unnecessary emergency department visits in the early postoperative period.

Life after colectomy for fulminant Clostridium difficile colitis: a 7-year follow up study.

BACKGROUND: The long-term prognosis of patients undergoing colectomy for fulminant Clostridium difficile colitis has not been well studied. The authors present 7-year survival trends in such patients. METHODS: Patients were identified through a pathologic database. Medical records were reviewed and follow-up phone calls made to determine relevant patient history, longevity, and quality of life. RESULTS: The 61 patients identified had mean and median survival of 18.1 and 3.2 months, respectively, and 1-year, 2-year, 5-year, and 7-year mortality of 68.5%, 79.6%, 88.9%, and 90.7%, respectively. Previous C difficile infection, hypotension, requirement of vasopressors, mental status changes, elevated arterial lactate, decreased platelet counts, intubation, and longer duration on nonoperative therapy were associated with in-hospital mortality. There were no factors correlated with long-term survival. CONCLUSIONS: Patients who require colectomy for fulminant C difficile colitis have a poor prognosis with poor long-term survival and significant morbidity. Although there are several factors associated with in-hospital mortality, there were no factors correlated with long-term survival.

Laparoscopic versus open inguinal hernia repair in octogenarians: a follow-up study.

AIM: The elderly population is the fastest growing demographic in developed countries. It is thus imperative to assess common medical procedures in this age group. Inguinal hernia repair is a commonly carried out operation in the USA with two methods of repair existing - laparoscopic and open. Although the advantages of laparoscopic inguinal hernia repair in the general population have been shown, its role in the elderly has yet to be elucidated. METHODS: A retrospective medical record review with prospective follow up of 115 patients aged over 80 years who underwent either open or laparoscopic inguinal hernia repair was carried out. Outcome measures included postoperative pain score, recovery time, chronic pain, wound infection, urinary retention, urinary tract infection, hematoma and recurrence. Patient satisfaction was measured with the Likert score. RESULTS: Of the 115 repairs, 31 repairs were carried out laparoscopically and 84 open. Mean patient age was 83.3 years (range 80-95 years), with no difference in demographics or comorbidities between the two groups. Mean recovery time was significantly shorter in the laparoscopic group (7.5 vs 23.1 days, P = 0.02), as was the mean duration of pain in the laparoscopic group (1.4 vs 9.6 days, P = 0.04). There were no significant differences in other outcomes. There was a trend towards increased patient satisfaction in the laparoscopic group (P = 0.10). CONCLUSION: In octogenarians, laparoscopic inguinal hernia repair confers a significantly shorter duration of pain and recovery time as compared with open inguinal hernia repair, with no increase in complications. For elderly patients, laparoscopy is a viable alternative to open repair.

Management and outcomes of colovesical fistula repair.

This large retrospective study presents the largest colovesical fistula (CVF) series to date. We report on recurrence risk factors and patient satisfaction based on quality of life after CVF repair. Approval was obtained from The Mount Sinai School of Medicine Institutional Review Board, and a retrospective review was performed from 2003 to 2010 involving 72 consecutive patients who underwent a colovesical fistula repair. The CVF recurrence rate was 11 per cent. Ten percent of our patients who had a history of radiation therapy were at a significantly higher risk of developing a recurrence. Noted recurrence rates were significantly higher in advanced bladder repairs compared with simple repair (P = 0.022). The modified (Gastrointestinal Quality of Life Index) surveys showed overall patient satisfaction score was 3.6, out of a maximum score of 4, regardless of the type of repair or any postoperative complications. Our study found the CVF recurrence rate to be 11 per cent. Patients at higher risk of recurrence include those needing advanced bladder repair, those with "complex" CVF, and those whose fistulas involve the urethra. Patient satisfaction was found to be more closely linked to the resolution of CVF symptoms, irrespective of the type of repair performed or development of postoperative complications.