Lasers in Gynecology.

The first published reports on the use of laser for cervical pathology date back to 1973. Technical advancements in flexible and rigid laser fibers revolutionized video laser laparoscopy in the 1990s. Fractionated lasers have been used to treat vulvovaginal symptoms associated with genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence. Review of available data suggests that fractionated lasers can improve both subjective and objective signs of vaginal atrophy and lichen sclerosus, but the evidence is weak because most of the trials are underpowered, are at risk for bias, and lack long-term follow-up. There is no strong evidence to support fractionated laser therapy for urinary incontinence or low-level laser therapy for chronic pelvic pain. Although short-term, single-arm trials suggest benefit of fractionated laser therapy for genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence, additional adequately powered, prospective, randomized, and longer-term comparative trials are needed before lasers can be recommended for these specific conditions. The purpose of this Clinical Expert Series is to review basic laser biophysics and the mechanism of action for modern fractionated lasers as relevant to the gynecologist. We also summarize safety and effectiveness data for lasers used for some of the most commonly studied gynecologic conditions: the vulvovaginal atrophy component of genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence.

A randomized trial of retropubic vs single-incision sling among patients undergoing vaginal prolapse repair.

BACKGROUND: The choice of midurethral sling type may impact efficacy and complications in women undergoing transvaginal native tissue repair of pelvic organ prolapse. OBJECTIVE: The primary aim was to determine if the single-incision sling is noninferior to retropubic sling for the management of stress urinary incontinence among patients undergoing reconstructive or obliterative native tissue vaginal repair. The secondary aims were to compare adverse events and surgeon ease of use with sling assignment. STUDY DESIGN: A multicenter, noninferiority, randomized trial of women with ≥ stage II pelvic organ prolapse and objectively confirmed stress urinary incontinence undergoing reconstructive or obliterative vaginal repair was performed. Women were randomized to concomitant single-incision (Altis sling, Coloplast Minneapolis, MN) with suprapubic sham incisions or retropubic slings. The primary dichotomous outcome was abnormal lower urinary tract function within 12 months postsurgery, defined as bothersome stress urinary incontinence symptoms (>1 Pelvic Floor Distress Inventory question no. 17); retreatment for stress urinary incontinence or treatment for urinary retention. Secondary outcomes were adverse events, Patient Global Impression of Improvement of bladder function, and surgeon ease of use (1, worst; 10, best). All subjects completed validated questionnaires and underwent a Pelvic Organ Prolapse Quantification, cough stress test, and postvoid residual preoperatively, at 6 weeks and 12 months postoperatively. Assuming a subjective cure rate for retropubic of 82%, 80% power, and 1-sided 5% significance level, we estimated that 127 patients in each arm were needed to declare noninferiority of the single-incision sling if the upper bound of the 95% confidence interval for the between-group difference per protocol in abnormal bladder function was <12%. Assuming a 10% loss to follow-up, the total enrollment goal was 280. RESULTS: Between December 2018 and January 2023, 280 subjects were enrolled across 7 sites, and 255 were randomized: 126 were for single-incision, and 129 were for retropubic sling. There were no preoperative or operative characteristic differences between groups. Overall, 81% had reconstructive, and 19% had obliterative native tissue repairs. The primary outcome, abnormal lower urinary tract function at 12 months, occurred in 29 (25%) of single-incision vs 24 (20%) of the retropubic sling group (risk difference, 0.04472 [95% confidence interval, -0.03 to 0.1133]; P=.001 for noninferiority). Bothersome stress urinary incontinence occurred in 20% vs 17% (P=.27) and was retreated in 4% vs 2% (P=.44) of single-incision vs retropubic groups, respectively. Adverse events were reported in 24 (16%) of single-incision vs 14 (9%) of the retropubic group (95% confidence interval, 0.95-3.29; P=.70) and included de novo or worsening urgency incontinence symptoms, urinary tract infection, mesh exposure, need for prolonged catheter drainage, and de novo pain, without differences between groups. Patient Global Impression of Improvement (very satisfied and satisfied) was 71% vs 67% (P=.43), and median surgeon ease of sling use was 8 (7-10) vs 9 (8-10), P=.03 in single-incision vs retropubic, respectively. CONCLUSION: For women undergoing vaginal repair, single-incision was noninferior to retropubic sling for stress urinary incontinence symptoms, and complications, including treatment for urinary retention, did not differ.

Sexual Harassment, Abuse, and Discrimination in Obstetrics and Gynecology: A Systematic Review.

Importance: Unlike other surgical specialties, obstetrics and gynecology (OB-GYN) has been predominantly female for the last decade. The association of this with gender bias and sexual harassment is not known. Objective: To systematically review the prevalence of sexual harassment, bullying, abuse, and discrimination among OB-GYN clinicians and trainees and interventions aimed at reducing harassment in OB-GYN and other surgical specialties. Evidence Review: A systematic search of PubMed, Embase, and ClinicalTrials.gov was conducted to identify studies published from inception through June 13, 2023.: For the prevalence of harassment, OB-GYN clinicians and trainees on OB-GYN rotations in all subspecialties in the US or Canada were included. Personal experiences of harassment (sexual harassment, bullying, abuse, and discrimination) by other health care personnel, event reporting, burnout and exit from medicine, fear of retaliation, and related outcomes were included. Interventions across all surgical specialties in any country to decrease incidence of harassment were also evaluated. Abstracts and potentially relevant full-text articles were double screened.: Eligible studies were extracted into standard forms. Risk of bias and certainty of evidence of included research were assessed. A meta-analysis was not performed owing to heterogeneity of outcomes. Findings: A total of 10 eligible studies among 5852 participants addressed prevalence and 12 eligible studies among 2906 participants addressed interventions. The prevalence of sexual harassment (range, 250 of 907 physicians [27.6%] to 181 of 255 female gynecologic oncologists [70.9%]), workplace discrimination (range, 142 of 249 gynecologic oncologists [57.0%] to 354 of 527 gynecologic oncologists [67.2%] among women; 138 of 358 gynecologic oncologists among males [38.5%]), and bullying (131 of 248 female gynecologic oncologists [52.8%]) was frequent among OB-GYN respondents. OB-GYN trainees commonly experienced sexual harassment (253 of 366 respondents [69.1%]), which included gender harassment, unwanted sexual attention, and sexual coercion. The proportion of OB-GYN clinicians who reported their sexual harassment to anyone ranged from 21 of 250 AAGL (formerly, the American Association of Gynecologic Laparoscopists) members (8.4%) to 32 of 256 gynecologic oncologists (12.5%) compared with 32.6% of OB-GYN trainees. Mistreatment during their OB-GYN rotation was indicated by 168 of 668 medical students surveyed (25.1%). Perpetrators of harassment included physicians (30.1%), other trainees (13.1%), and operating room staff (7.7%). Various interventions were used and studied, which were associated with improved recognition of bias and reporting (eg, implementation of a video- and discussion-based mistreatment program during a surgery clerkship was associated with a decrease in medical student mistreatment reports from 14 reports in previous year to 9 reports in the first year and 4 in the second year after implementation). However, no significant decrease in the frequency of sexual harassment was found with any intervention. Conclusions and Relevance: This study found high rates of harassment behaviors within OB-GYN. Interventions to limit these behaviors were not adequately studied, were limited mostly to medical students, and typically did not specifically address sexual or other forms of harassment.

Treatment of women with vaginal laxity: systematic review with meta-analysis.

BACKGROUND: Despite several treatments that have been used for women reporting vaginal laxity (VL), to our knowledge no systematic review is available on the topic so far. AIM: In this study, we sought to summarize the best available evidence about the efficacy and safety of interventions for treating VL, whether conservative or surgical. METHODS: A comprehensive search strategy was performed in Medline, Embase, Scopus, Web of Science, and Cochrane Library for reports of clinical trials published from database inception to September 2022. Studies selected for inclusion were in the English language and were performed to investigate any type of treatment for VL, with or without a comparator, whether nonrandomized studies or randomized controlled trials (RCTs). Case reports and studies without a clear definition of VL were excluded. OUTCOMES: The outcomes were interventions (laser, radiofrequency, surgery, and topical treatment), adverse effects, sexual function, pelvic floor muscle (PFM) strength, and improvement of VL by the VL questionnaire (VLQ). RESULTS: From 816 records, 38 studies remained in the final analysis. Laser and radiofrequency (RF) were the energy-based treatment devices most frequently studied. Pooled data from eight observational studies have shown improved sexual function assessed by a Female Sexual Function Index score mean difference (MD) of 6.51 (95% CI, 5.61-7.42; i2 = 85%, P < .01) before and after intervention, whether by RF (MD, 6.00; 95% CI, 4.26-7.73; i2 = 80%; P < .001) or laser (MD, 6.83; 95% CI, 5.01-8.65; i2 = 92%; P < .01). However, this finding was not shown when only 3 RCTs were included, even when separated by type of intervention (RF or laser). When RF treatment was compared to sham controls, VLQ scores did not improve (MD, 1.01; 95% CI, -0.38 to 2.40; i2 = 94%; P < .001). Patient PFM strength improved after interventions were performed (MD, 4.22; 95% CI, 1.02-7.42; i2 = 77%; P < .001). The ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions) tool classified all non-RCTs at serious risk of bias, except for 1 study, and the risk of bias-1 analysis found a low and unclear risk of bias for all RCTs. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) certainty of the evidence was moderate for sexual function and the VLQ questionnaire and low for PFM strength. CLINICAL IMPLICATIONS: Sexual function in women with VL who underwent RF and laser treatment improved in observational studies but not in RCTs. Improvement in PFM strength was observed in women with VL after the intervention. STRENGTHS AND LIMITATIONS: Crucial issues were raised for the understanding of VL, such as lack of standardization of the definition and for the development of future prospective studies. A limitation of the study was that the heterogeneity of the interventions and different follow-up periods did not make it possible to pool all available data. CONCLUSIONS: Vaginal tightening did not improve sensation in women with VL after intervention, whereas RF and laser improved sexual function in women with VL according to data from observational studies, but not from RCTs. PFM strength was improved after intervention in women with VL.

A Retrospective Cohort Study of At-Home Catheter Removal After Urogynecologic Surgery.

IMPORTANCE: In-office postoperative voiding trials (VTs) increase health care burden for patients and physicians. Adoption of an at-home VT option may decrease burden without increasing adverse events postoperatively. OBJECTIVE: The purpose of this study was to compare 30-day postoperative outcomes between participants who performed an at-home autofill VT after catheter self-discontinuation during the Assessing Healthcare Utilization and Feasibility of Transurethral Catheter Self-discontinuation (FLOTUS) study and a "historic" control cohort of patients who presented to the office for backfill-assisted VT on postoperative day (POD) 1. STUDY DESIGN: This was a retrospective cohort study of women with postoperative urinary retention after urogynecologic surgery between June 2020 and March 2022. Outcomes from the FLOTUS study were compared with a "historic" control cohort of patients that were identified on chart review from the year before FLOTUS initiation. Demographic, medical history, and procedure-related data were collected. Thirty-day outcome data included office calls/messages, office visits, emergency department visits, complications, and catheterization outcomes. RESULTS: Forty-six participants were included in the FLOTUS cohort and 65 participants in the historic cohort. There was no difference in the POD1 VT pass rate, number of office calls/messages, emergency department visits, or postoperative complications between the 2 cohorts. The FLOTUS patients attended 1 less office visit (1 vs 2 office visits, P <0.001), and this difference persisted on regression analysis (-0.87 office visits; 95% CI, -1.18 to -0.56, P <0.001). CONCLUSION: Patients who had backfill-assisted VTs on POD1 attended 1 additional office visit compared with those who removed their catheters at home.

Pelvic floor symptoms among premenopausal women with pelvic organ prolapse in the Democratic Republic of the Congo.

INTRODUCTION AND HYPOTHESIS: Most of the literature on pelvic organ prolapse (POP) has been generated from postmenopausal patients in high-income countries. In the Democratic Republic of the Congo (DRC), a significant proportion of patients who present for surgical management of POP are premenopausal. Little is known about the impact of POP on pelvic floor symptoms in this population. The objective was to describe pelvic floor symptoms and sexual function among premenopausal patients presenting for POP surgery in DRC. METHODS: We performed a prospective cohort study of symptomatic premenopausal patients undergoing fertility-sparing POP surgery at a large referral hospital in the DRC. Pelvic floor symptoms were evaluated with the Pelvic Floor Distress Inventory Questionnaire and sexual function with the Pelvic organ prolapse/urinary Incontinence Sexual Questionnaire. Data are presented as means with standard deviations or counts with percentages. RESULTS: A total of 107 patients were recruited between April 2019 and December 2021. All had either stage III (95.3%) or stage IV (4.7%) prolapse. Ages were 34.2 ± 6.7 years; 78.5% were married. A majority of patients experienced low abdominal pain (82.2%), heaviness or dullness (95.3%), and bulging or protrusion of the prolapse (92.5%). Almost two-thirds of patients reported no longer being sexually active, and 80% stated that they were not sexually active because of POP. Of the 37 sexually active patients (34.6%), nearly all reported significant sexual impairment because of the prolapse, with only 4 reporting no sexual impairment. CONCLUSIONS: This study represents one of the largest prospective series of patients with premenopausal POP. Our results highlight the severity of pelvic floor symptoms and the negative effects on sexual function among this patient population with POP.

Safely Introducing New Surgical Devices in Minimally Invasive Gynecologic Surgery: An Argument for Use of the IDEAL Framework.

OBJECTIVE: To review the Food and Drug Administration (FDA) premarket regulatory and postmarket surveillance processes for 2 minimally invasive gynecologic surgery case studies-the laparoscopic power morcellator and the Essure permanent birth control device-and to introduce the IDEAL (Idea, Development, Exploration, Assessment, Long-term) framework for safely introducing and monitoring minimally invasive gynecologic surgery devices. DATA SOURCES: News media publications, agency websites, legal articles, and scientific papers. METHODS OF STUDY SELECTION: Articles and papers were selected that described events leading to FDA approval of these devices and subsequent complications. TABULATION, INTEGRATION, AND RESULTS: Based on current FDA premarket regulatory processes, 67% of devices do not currently require premarket review and only 1% are subject to clinical trial requirements. The IDEAL framework delineates 5 phases for safe introduction of medical devices: idea, development, exploration, assessment, and long-term study. CONCLUSION: The laparoscopic power morcellator and Essure cases illustrate possible shortcomings in our device approval system that could be improved upon using the IDEAL framework, which limits device use until safety and efficacy data have been established and recommends postmarket surveillance.

The effect of 12-month postoperative weight change on outcomes following midurethral sling for stress urinary incontinence: a secondary analysis of the ESTEEM and TOMUS randomized trials.

INTRODUCTION AND HYPOTHESIS: Prior studies demonstrate mixed results on the impact of obesity on the success of midurethral slings (MUS), with little known about how postoperative weight change affects outcomes. We aimed to examine the effect of postoperative weight change on outcomes 12 months after MUS for stress urinary incontinence (SUI). METHODS: This secondary analysis utilized data from two multicenter randomized trials of women undergoing MUS placement. Subjects were categorized into cohorts based on change in body weight at 12 months postoperatively: weight gain (≥5% increase); weight loss (≥5% decrease), and weight stable (<5% change). The primary outcome was SUI cure (no SUI episodes in a 3-day bladder diary). Patients with mixed urinary incontinence (MUI) were analyzed for changes in daily average urge incontinence (UUI) episodes in a 3-day diary. Penalized logistic regression assessed the impact of demographic and perioperative variables on the primary outcome. RESULTS: Of the 918 women included, 635 (70%) were weight stable, 144 (15%) had weight gain, and 139 (15%) had weight loss. Patients in the weight loss cohort had a higher smoking rate and a higher baseline body mass index (SD 0.29, 2.7 respectively). All cohorts experienced high SUI cure rates ranging from 77 to 81%, with no significant difference in SUI cure between cohorts (p = 0.607). Of 372 subjects with MUI, the weight loss cohort had significantly greater improvement in UUI episodes. CONCLUSIONS: Weight change at 12 months postoperatively did not significantly alter efficacy of MUS for treatment of SUI. Patients with MUI who lost ≥5% body weight had significantly greater improvement in UUI episodes.

A prospective pilot study to assess for histologic changes on vulvar biopsies in postmenopausal women with lichen sclerosus treated with fractionated CO2 laser therapy.

OBJECTIVES: To investigate the histologic characteristics of vulvar tissues before and after completion of fractionated carbon dioxide (CO2 ) laser therapy (FxCO2) for vulvar lichen sclerosus (LS). The secondary objective was to assess subjective improvement in symptoms via the Skindex-16 questionnaire. METHODS: This prospective single-arm study was conducted from April 2021 to August 2022 at one academic medical center. Ten postmenopausal women with biopsy-proven LS planning FxCO2 laser treatment were enrolled. Exclusion criteria included prior transvaginal mesh for prolapse, topical corticosteroid use within 8 weeks, prior pelvic radiation, malignancy, active genital infection, or pregnancy. The vulvovaginal SmartXide2-V2-LR laser system fractionated CO2 laser (DEKA) was utilized to treat visually affected areas of vulvar and perianal LS with a single pass. Subjects underwent three treatments 4-6 weeks apart. Subjects completed the Skindex-16 questionnaire and had vulvar biopsy at baseline and at 4 weeks after completion of fractionated CO2 laser therapy. Blinded histologic slides were scored by one dermatopathologist (Michael A. Cardis) rating from 1 to 5 the degree of dermal sclerosis, inflammation, and epidermal atrophy. Change scores were calculated as the difference between pre- and post-treatment scores for each subject. RESULTS: The 10 subjects enrolled had a mean age of 61 and most were white, privately insured, and had a college/graduate-level education. Post-fractionated CO2 laser treatment vulvar biopsies showed significant improvement in sclerosis and epidermal atrophy compared with pretreatment baseline biopsy specimens (p < 0.05) with no statistically significant change found in inflammation score. Skindex-16 and FSFI scores showed a trend towards improvement (p > 0.05 for both). A statistically significant correlation was found between change in sclerosis and Skindex-16 symptoms scores with an average change of 21.4 units in Skindex-16 symptoms score for every one-point change in histologic sclerosis score (p = 0.03). CONCLUSIONS: In postmenopausal women with vulvar LS undergoing fractionated CO2 laser, symptomatic improvements correlated with histologic change in degree of sclerosis on vulvar biopsy. These results demonstrate FxCO2 laser therapy as a promising option for the treatment of LS and suggest that further studies should assess degree of sclerosis on histopathology.

Assessing Health Care Utilization and Feasibility of Transurethral Catheter Self-Discontinuation.

OBJECTIVE: To compare the rates of health care utilization (office messages or calls, office visits, and emergency department [ED] visits) and postoperative complications within 30 days after surgery between patients with successful voiding trials on postoperative day 0 and those with unsuccessful voiding trials on postoperative day 0 and between patients with successful and unsuccessful voiding trials on postoperative day 1. Secondary objectives were to identify risk factors for unsuccessful voiding trials on postoperative days 0 and 1 and to explore the feasibility of catheter self-discontinuation by assessing for any complications associated with at-home catheter self-discontinuation on postoperative day 1. METHODS: This study was a prospective observational cohort study of women undergoing outpatient urogynecologic or minimally invasive gynecologic surgery for benign indications at one academic practice from August 2021 to January 2022. Enrolled patients with unsuccessful immediate postoperative voiding trials on postoperative day 0 performed catheter self-discontinuation by cutting their catheter tubing per instructions at 6 am on postoperative day 1 and recording their voided volumes over the subsequent 6 hours. Patients who voided less than 150 mL underwent a repeat voiding trial in the office. Demographics, medical history, perioperative outcomes, and number of postoperative office calls or visits and ED visits within 30 days were collected. RESULTS: Of the 140 patients who met inclusion criteria, 50 patients (35.7%) had unsuccessful voiding trials on postoperative day 0, and 48 of these 50 (96%) performed catheter self-discontinuation on postoperative day 1. Two patients did not perform catheter self-discontinuation on postoperative day 1: One had her catheter removed in the ED on postoperative day 0 during an ED visit for pain control, and the other performed catheter self-discontinuation off protocol at home on postoperative day 0. There were no adverse events associated with at-home postoperative day 1 catheter self-discontinuation. Of the 48 patients who performed catheter self-discontinuation on postoperative day 1, 81.3% (95% CI 68.1-89.8%) had successful postoperative day 1 at-home voiding trials, and 94.5% (95% CI 83.1-98.6%) of those with successful voiding trials did not require additional catheterization. Patients with unsuccessful postoperative day 0 voiding trials had more office calls and messages (3 vs 2, P <.001) and those with unsuccessful postoperative day 1 voiding trials attended more office visits (2 vs 1, P <.001) compared with those with successful postoperative day 0 or 1 voiding trials, respectively. There was no difference in ED visits or postoperative complications between patients with successful voiding trials on postoperative day 0 or 1 and those with unsuccessful voiding trials on postoperative day 0 or 1. Patients with unsuccessful postoperative day 0 voiding trials were older and more likely to have undergone vaginal hysterectomy or prolapse repair than those with successful postoperative day 0 voiding trials. Patients with unsuccessful postoperative day 1 voiding trials were older than those with successful postoperative day 1 voiding trials. CONCLUSION: Catheter self-discontinuation is a feasible alternative to in-office voiding trials on postoperative day 1 after advanced benign gynecologic and urogynecologic surgery, with low rates of subsequent retention and no adverse events seen in our pilot study.

Vaginal Natural Orifice Transluminal Endoscopic Surgery Revolution: The Next Frontier in Gynecologic Minimally Invasive Surgery.

Despite guidelines that assert that the vaginal route for benign hysterectomy is preferred as the most minimally invasive approach, rates of vaginal hysterectomy remain very low in the United States. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) might reverse the trend. Potential advantages of vNOTES compared to traditional laparoscopic and robotic approaches include the potential for less pain, decreased operative time, improved cosmesis, and decreased risks. Importantly, vNOTES might allow for the conversion of laparoscopic and robotic routes back to vaginal due to surgeon factors.

Association of Artificially Sweetened Beverage Consumption and Urinary Tract Cancers in the Women's Health Initiative Observational Study.

Background: Insufficient data exist to conclude whether consumption of artificially sweetened beverages is associated with a higher risk of urinary tract cancers. Objective: We sought to investigate whether urinary tract cancer incidence differed among women who consumed various amounts of artificially sweetened beverages. Design setting and participants: This was a secondary analysis of data from the Women's Health Initiative Observational Study, a multicenter longitudinal prospective study of the health of 93 676 postmenopausal women with a mean follow-up time of 13.5 yr. Women were identified at 40 clinical centers across the USA and enrolled from 1993 to 1998. Women between the ages of 50 and 79 yr were enrolled. We included women who answered questions about artificially sweetened beverage consumption and reported no prior urinary tract cancer diagnoses. The frequency of artificially sweetened beverage consumption was categorized as follows: rare artificially sweetened beverage consumption (never to fewer than one serving per week), frequent consumption (one to six servings per week), and daily consumption (more than one servings per day). Outcome measurements and statistical analysis: The incidence of urinary tract cancer reported during subsequent visits until February 28, 2020 was recorded. Demographic characteristics were compared between those with varying levels of artificially sweetened beverage consumption. Descriptive statistics were used to report the rates of urinary tract cancer diagnosis, and Cox regression models were constructed to determine hazard ratios and adjust for potential confounders. Results and limitations: We identified 80 388 participants who met the inclusion criteria. Most participants (64%) were infrequent consumers of artificially sweetened beverages, with 13% (n = 10 494) consuming more than one servings per day. The incidence of urinary tract cancers was low, with only 804 cases identified. Cox regression models showed that frequent artificially sweetened beverage consumption was associated with a higher risk of kidney cancer (adjusted hazard ratio 1.34, 95% confidence interval 1.03-1.75). There was no significant association between artificially sweetened beverage intake and bladder cancer. Conclusions: Frequent consumption of artificially sweetened beverages may be associated with a higher risk of kidney cancer among postmenopausal women. Patient summary: A secondary analysis of the Women's Health Initiative Observational Study showed that higher consumption of artificially sweetened beverages was associated with a higher risk of kidney cancer.

Length of Stay and 30-Day Postoperative Complications Following Minimally Invasive Apical Prolapse Repair.

IMPORTANCE: Data on the correlation between length of stay and postoperative complications following urogynecologic surgery are limited. OBJECTIVES: The objective of this study was to use a nationwide database to examine the correlation between length of stay and 30-day postoperative complications following minimally invasive apical prolapse repair. STUDY DESIGN: This retrospective cohort study included women in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2018 who underwent laparoscopic/robotic sacrocolpopexy or uterosacral/sacrospinous repair and were discharged on postoperative day 0 (POD0) or 1 (POD1). The primary outcome was 30-day postoperative complication rate. RESULTS: Of the 28,269 women discharged home on POD0/1, 12,663 (45%) underwent laparoscopic/robotic sacrocolpopexy, and 15,606 (55%) underwent uterosacral/sacrospinous repair. Women discharged on POD0 were less likely to be White, less likely to have diabetes or hypertension, had lower mean body mass index, and were less likely to have undergone a hysterectomy ( P < 0.05 for all). Within 30 days of surgery, 7% had a postoperative complication, and 3% had a major complication. Women discharged on POD0 had a lower risk of any complication or any major complication. The most common complication, urinary tract infection, was lower in women discharged on POD0 (3% vs 4%, P < 0.01). Women discharged home on the same day had a higher risk of superficial surgical site infection after undergoing laparoscopic/robotic sacrocolpopexy (1.3% vs 0.5%, P < 0.01) and a higher risk of myocardial infarction/cardiac arrest after uterosacral/sacrospinous repair (0.2% vs 0%, P < 0.04). CONCLUSIONS: In women undergoing minimally invasive reconstructive apical repair, discharge on POD0 is correlated with similar or better (lower) 30-day postoperative complication rates compared with women discharged on POD1.

Surgical Outcomes in Benign Gynecologic Surgery Patients during the COVID-19 Pandemic (SOCOVID study).

STUDY OBJECTIVE: To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. DESIGN: A multicenter prospective cohort study. SETTING: Ten institutions in the United States. PATIENTS: Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. INTERVENTIONS: Benign gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4-50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). CONCLUSION: In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.

Description of Vaginal Laxity and Prolapse and Correlation With Sexual Function (DeVeLoPS).

INTRODUCTION: Vaginal laxity (VL) is a sensation of vaginal looseness which may develop after pregnancy and vaginal delivery and may be affected by prior pelvic surgery, menopause and aging. Pelvic organ prolapse (POP) is a disorder in which pelvic organs descend from the normal position. VL has attracted recent attention due to the advent of energy-based treatments for this symptom. AIM: To determine the correlation between VL symptoms and physical exam findings of POP, specifically the introital measurement of genital hiatus. METHODS: This was a multi-center cross-sectional study of sexually active women over 18 years of age with a parity of one or greater. Subjects completed the Vaginal Laxity Questionnaire (VLQ), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index (FSFI), and were asked if a sexual partner had commented on laxity. Subjects underwent pelvic exam, including the pelvic organ prolapse quantification (POP-Q). MAIN OUTCOMES MEASURES: Correlation between VL symptoms as measured by the VLQ and POP as measured by elements of the POP-Q. RESULTS: A total of 95 subjects with an average age was 54.3 ± 13.18 years were included. Sixty-three percent of patients were postmenopausal. The average VLQ score was 4.2 ± 1.35 and the average FSFI score was 23.42 out of 36. There was no significant correlation between VLQ score and POP or mid-vaginal caliber. Sensation of vaginal tightness was significantly associated with age (P=0.03) and menopausal status (P=0.04). Only 28% of partners commented on laxity and the majority commented on the vagina being tight (21%) rather than loose (7%). CONCLUSION: VL was not correlated with physical exam findings quantifying POP or sexual function. This study emphasizes the need to develop a more standardized definition of VL and a better assessment tool for VL symptoms. Polland A, Duong V, Furuya R, et al. Description of Vaginal Laxity and Prolapse and Correlation With Sexual Function (DeVeLoPS). Sex Med 2021;9:100443.

Clobetasol Compared With Fractionated Carbon Dioxide Laser for Lichen Sclerosus: A Randomized Controlled Trial.

OBJECTIVE: To compare 6-month safety and efficacy outcomes of fractionated CO2 laser (laser) with topical clobetasol propionate (steroid) for treatment of symptomatic vulvar lichen sclerosus. METHODS: We conducted a single-center randomized controlled trial that compared fractionated CO2 laser with steroid treatment for patients with biopsy-proven lichen sclerosus. Randomization was stratified by prior clobetasol propionate use. The primary outcome was mean change in Skindex-29 score at 6 months. A total sample size of 52 participants were recruited to detect a mean difference of 16 points on the Skindex-29 (SD±22) with 80% power, based on a one-sided two-sample t test with α=0.05, accounting for 10% attrition. Secondary outcomes included validated subjective and objective measures. Intention-to-treat, per protocol, and regression analysis based on prior steroid exposure were performed. RESULTS: From October 2015 to July 2018, 202 women were screened, 52 were randomized, and 51 completed a 6-month follow-up. No significant difference was found in baseline demographics, symptoms, and physician assessment scores. There was greater improvement in the Skindex-29 score in the laser arm at 6-months (10.9 point effect size, 95% CI 3.42-18.41; P=.007). Overall, 89% (23/27) of patients in the laser group rated symptoms as being "better or much better" compared with 62% (13/24) of patients in the steroid group, P=.07. More patients (81%, 21/27) were "satisfied or very satisfied" with laser treatment compared with steroid treatment (41%, 9/24); P=.01. After stratification for previous steroid use, the significant change of Skindex-29 score was only seen in the previously exposed group. There was one adverse event in each group: minor burning and blistering at the laser site and reactivation of genital herpes 1 week after starting steroid. CONCLUSION: Fractionated CO2 laser treatment showed significant improvement in subjective symptoms and objective measures compared with clobetasol propionate, without serious safety or adverse events at 6 months. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02573883.

Physical Activity, Diet, and Incident Urinary Incontinence in Postmenopausal Women: Women's Health Initiative Observational Study.

BACKGROUND: Physical activity and macronutrient intake, important contributors to energy balance, may be independently associated with female urinary incontinence (UI). METHODS: We evaluated the association of baseline self-reported physical activity and macronutrient intake, via food frequency questionnaire, with incident UI subtypes after 3 years among 19 741 postmenopausal women in the Women's Health Initiative Observational Study. Odds ratios (ORs) for incident urgency, stress, and mixed UI were calculated using multivariable logistic regression. RESULTS: Women who reported total physical activity (metabolic equivalent task [MET]-hours/week) ≥30 versus <0.1 were 16% less likely to develop urgency UI (OR = 0.84; 95% CI 0.70, 1.00) and 34% less likely for mixed UI (OR = 0.66; 95% CI 0.46, 0.95), although linear trends were no longer statistically significant after adjusting for baseline weight and weight change (p trend = .15 and .16, respectively). The association between physical activity and incident stress UI was less consistent. Higher uncalibrated protein intake was associated with increased odds of incident urgency UI (≥19.4% vs <14.1% of energy intake OR = 1.14; 95% CI 0.99, 1.30; p trend = .02), while CIs were wide and included 1.0 for calibrated protein intake. Other macronutrients were not associated with urgency UI and macronutrient intake was not associated with incident stress or mixed UI (p trend > .05 for all). CONCLUSIONS: Among postmenopausal women, higher physical activity was associated with lower risk of incident urgency and mixed UI, but not stress UI, independent of baseline weight and weight change. Higher protein intake was associated with increased risk of urgency UI, but no associations were observed between other macronutrient and UI subtypes.

#MIGS: Minimally Invasive Gynecologic Surgery Tag Ontology Project.

STUDY OBJECTIVE: The creation of an ontology may enable providers to more definitively engage the public in evidence-based and meaningful discussions about women's health. The goal of this study is to review and analyze the current social media status of minimally invasive gynecologic surgery (MIGS) on Twitter and create a tag ontology. DESIGN: Tag ontologies are lists of hashtags used to standardize searches within a social media platform. We examined trending terms and influencers on Twitter on the basis of the keyword "MIGS." We then compiled a list of top hashtags on the basis of the number of tweets from January 2018 to August 2020. Terms were identified with manual Twitter queries and Symplur Signals and selected for inclusion in the ontology on the basis of frequency of use and clinical relevance. The ontology was then categorized by pelvic disease and intervention and reviewed/supplemented by key social media influencers for inclusivity. SETTING: N/A PATIENTS: N/A INTERVENTIONS: N/A MEASUREMENTS AND MAIN RESULTS: We identified 4550 tweets and 1836 users while searching #MIGS in August 2020. Twenty-nine terms were included in our ontology, which were then subcategorized into 6 groups (uterine pathology, adnexal pathology, menstruation, pelvic pathology, pelvic pain, and other). CONCLUSION: Our study has created an ontology specific to the MIGS on the basis of Twitter usage over the last 2 years that may facilitate more effective social media communication.

#UTOPia: Urogynecology Tag Ontology Project.

OBJECTIVE: The objective of this study was to review and analyze the current social media status of urogynecology/female pelvic medicine and reconstructive surgery on Twitter and create a tag ontology. METHODS: A "tag ontology" is a standardized list of hashtags used to organize specific subject matter within a social media platform. We used an online social media analytics tool, Symplur to identify tweets and hashtags related to #urogynecology between January 2018 and July 2020. Hashtags identified using Symplur were verified manually via Twitter inquiries and reviewed by urogynecology social medial influencers for external validation. The hashtags were selected based on frequency of use, social media influencer opinion, and clinical relevance. RESULTS: We identified 6,847 tweets and 2,946 users. Our ontology includes 67 terms categorized into 5 groups (urinary, prolapse, anus/rectum, vulva, and other). Using "Symplur Rank," the 2 top influencers included @FPMRS and @FPMRSJournal. CONCLUSIONS: Adaptation of a standardized hashtag ontology facilitates communication between providers and patients about pertinent health care issues. Our study has created a urogynecology-specific ontology based on 2018-2020 Twitter usage.