Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence.

ABSTRACT: Historically, our health care system has been based on a fee-for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a paradigm in which health care providers are incentivized to provide cost-effective, coordinated, value-based care in an effort to control costs and ensure high-quality care for all patients. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was created and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development.

Time to rethink: an evidence-based response from pelvic surgeons to the FDA Safety Communication: "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse".

In July of 2011 the U.S. Food and Drug Administration (FDA) released a safety communication entitled "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse." The stated purpose of this communication is to inform health care providers and patients that serious complications with placement of this mesh are not rare and that it is not clear that these repairs are more effective than nonmesh repair. The comments regarding efficacy are based on a systematic review of the scientific literature from 1996-2011 conducted by the FDA. Our review of the literature during this time yields some different conclusions regarding the safety and efficacy of mesh use in prolapse repair. It may be useful to consider this information prior to making recommendations regarding mesh use in prolapse surgery according to the recent UPDATE.

Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison.

UNLABELLED: Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison. PURPOSE: To determine if local injection, prior to incision with lidocaine plus epinephrine (L + E) influences the rate of mesh exposure in the early postoperative period following synthetic mesh augmented vaginal reconstructive surgery (MAVR). METHODS: We performed a chart review over an 18-month period of patients who underwent MAVR. The presence of mesh exposure at the 3-month postoperative visit, demographic data and whether or not L + E was used to hydrodissect was recorded. Statistical analysis was performed to determine whether hydrodissection influenced erosion rates. RESULTS: A total of 143 meshes were placed, hydrodissection with L + E was used in 78 cases and was not in the remaining 65 cases. There were 10 (7.0% 10/143) total erosions at the 3-month postoperative visit, 6 (7.7%; 6/78) in the group that got L + E and 4 (6.2%; 4/65) in the group that did not get local injection. This difference was not significant (p = 0.740, OR 1.54 95% CI 0.41-5.76). There was no difference between the two groups in terms of age, presence of diabetes, concurrent incontinence repair or estimated blood loss. CONCLUSION: Mesh exposure is a known complication of MAVR. Our study suggests that local injection with L + E prior to vaginal surgery does not influence exposure rates.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery. METHODS: The charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial. RESULTS: Forty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3-9.8). CONCLUSIONS: A higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs.

INTRODUCTION AND HYPOTHESIS: Our objective was to establish the overall graft erosion rate in a synthetic graft-augmented repair 3 months postoperatively. METHODS: A retrospective chart review was performed on a cohort of subjects who underwent mesh-augmented vaginal reconstructive surgery during an 18-month period. We defined graft erosion as exposure of any mesh upon visual inspection of the entire vagina at the 3-month postoperative visit. Statistical tests performed to evaluate proportional differences were the Pearson chi square and Fisher exact tests. Independent t test was performed to compare mean differences. RESULTS: A total of 124 grafts were implanted. The overall erosion rate was 11.3%. There was a significantly lower erosion rate when using "commercial kits" vs. our traditional repairs (1.4% [one out of 69] vs. 23.6% [13 out of 55]; p < 0.001). CONCLUSIONS: Our study demonstrates a significantly lower erosion rate when using a "commercial kit" to repair pelvic organ prolapse compared to our traditional synthetic graft-augmented repair.

The distance between the perceived and the actual arcus tendineus fascia pelvis during vaginal paravaginal repair.

OBJECTIVE: This study was undertaken to determine whether the arcus tendineus fascia pelvis (ATFP) can be accurately identified from the paravaginal space (PVS) without entering the retropubic space (RPS). STUDY DESIGN: Eight patients undergoing vaginal paravaginal repair were enrolled. The paravaginal dissection was completed to the most cephalad portion of the PVS without entering the RPS. The apex of each PVS was stained with methylene blue. The RPS was entered, the ATFP visualized, and 4 sutures were placed along its length to be used for the repair. The perpendicular distance between each suture and the most cephalad area of stain was measured. RESULTS: The mean distance from the perceived to actual ATFP at each suture point (1-4) was 3.5 cm, 2.75 cm, 2.0 cm, and 0.91 cm, respectively. CONCLUSION: In these 8 cases, the RPS had to be entered to accurately identify the ATFP. The degree of error increases as the ischial spine is approached (P < .001).

Metastatic colon carcinoma found within an enterocele sac: a case report.

The incidental finding of cancer in a hernial sac is rare, but there are many case reports in the literature. There has never been a report of carcinoma found in an enterocele sac. We present the case of a 77-year-old female with symptomatic pelvic organ prolapse who presented for reconstructive pelvic surgery and was found to have metastatic adenocarcinoma contained within an enterocele sac. Incidental diagnosis of asymptomatic carcinoma found on typically discarded tissue from surgical procedures is rare. However, routine pathologic review of all tissue removed from a patient may save a life if carcinoma is found early.

Reduction clitoroplasty: a technique for debulking the enlarged clitoris.

Clitoral reduction, especially in an adult, is a rare procedure which often leaves the glans clitoris without the capacity for tactile sensation. We present the case of a 34-year-old woman with symptomatic clitoromegaly since puberty who underwent a clitoral reduction procedure designed to preserve the neurovascular supply of the glans clitoris. The surgical technique presented here removes the corpora cavernosa of the clitoris, but conserves important neurovascular attachments. While this procedure was done on an adult, it could just as easily be performed on children or adolescents with clitoromegaly, typically the at-risk group for this condition.

Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction.

OBJECTIVES: To evaluate the effectiveness of transvaginal manual therapy of the pelvic floor musculature (Thiele massage) in symptomatic female patients with interstitial cystitis and high-tone dysfunction of the pelvic floor. METHODS: A total of 21 women with documented interstitial cystitis and high-tone pelvic floor dysfunction underwent transvaginal massage using the Thiele technique twice a week for 5 weeks. Symptoms were evaluated before massage, at protocol conclusion, and at a mean of 4.5 months after therapy completion (long-term follow-up). The response to treatment was evaluated through the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indexes, Likert Visual Analogue Scales for urgency and pain, and Short-Form 12-item (SF-12) Quality-of-Life Scale, and through changes in the physical examination findings using a 5-point modified Oxford Scale to document pelvic floor tenderness. RESULTS: A statistically significant improvement was seen in the Symptom and Problem Indexes of the O'Leary-Sant Questionnaire (P = 0.015 and P = 0.039, respectively), Likert Visual Analogue Scales for urgency and pain (P = 0.001 and P = 0.005, respectively), the Physical and Mental Component Summary from the SF-12 Quality-of-Life Scale (P = 0.049 and P = 0.044, respectively), and the modified Oxford Scale (P <0.05) after protocol completion. At long-term follow-up, the O'Leary-Sant Interstitial Cystitis Symptom and Problem Indexes (P = 0.049 and P = 0.02, respectively), Likert Visual Analogue Scales for urgency and pain (P = 0.004 and P = 0.005, respectively), and modified Oxford Scale for three of four muscles in the pelvic floor (P <0.05) remained significantly improved. CONCLUSIONS: Thiele massage appears to be very helpful in improving irritative bladder symptoms in patients with interstitial cystitis and high-tone pelvic floor dysfunction in addition to decreasing pelvic floor muscle tone.