Surgical Decision-Making: Who Should Be Offered Sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS: Women undergoing surgery for apical pelvic organ prolapse have several medically sound options for specific surgical approaches. METHODS: We review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit. RESULTS: We emphasize the importance of collaboration between patients and surgeons in surgical decision-making. CONCLUSION: All medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.

Single-Port Robotic Sacrocolpopexy: Description of an Advanced Minimally Invasive Approach and Review of the Relevant Literature.

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is the gold standard for the surgical management of apical prolapse. Over the years, surgical advancements have transformed the procedure from a laparotomy with a hospital stay of several days to a minimally invasive approach with a much shorter hospital stay. One recent innovation has the potential to transform minimally invasive sacrocolpopexy. METHODS: The da Vinci single-port robotic platform has allowed urological procedures to generate improved recovery, pain control, and cosmesis, with no differences in complications rates. RESULTS: Although the data with respect to sacrocolpopexy are more limited owing to the novelty of this application, the results appear to be similar to those of urological procedures such as prostatectomy. CONCLUSIONS: We present our surgical technique for completing single-port robotic sacrocolpopexy, with and without a hysterectomy, as well as a review of the relevant literature.

Short-term outcomes of single port robotic hysterectomy with concomitant sacrocolpopexy.

The Da Vinci single port® (SP) robotic platform heralds a new era of minimally invasive surgery (MIS). The primary objective of this study was to assess short-term outcomes in patients undergoing SP robotic hysterectomy with concomitant sacrocolpopexy for pelvic organ prolapse (POP). We performed a retrospective case series at two tertiary care centers between January 2021 and August 2023. Patients with POP electing to undergo SP robotic hysterectomy with concomitant sacrocolpopexy were included. Chart abstraction was used to collect patient demographics and clinical outcomes. Recurrent POP was defined as new bothersome vaginal bulge symptoms and evidence of POP beyond the hymen on postoperative examination. 69 patients were included. Median operative time was 209 min (135-312) and estimated blood loss was 100 mL (20-2000). 1 (1.4%) patient sustained a major vascular injury resulting in laparotomy. Median pain score and morphine equivalents administered in PACU were low at 3 (0-7) and 3.2 (0-27) respectively. At 3 months, 60 (86.9%) patients were seen either in person or via telemedicine for their follow up appointment. 59/60 (98.3%) reported no vaginal bulge symptoms and 50/51 (98.0%) had stage 0 or 1 prolapse on exam. One (1.4%) patient had recurrent prolapse and underwent an additional repair. Postoperative complications included 2 (2.9%) cases of ileus/small bowel obstruction, 1 (1.4%) pelvic hematoma requiring a blood transfusion, and 1 (1.4%) umbilical hernia. The SP robotic platform is a safe and feasible platform for MIS hysterectomy and sacrocolpopexy with good short term anatomic and symptomatic outcomes.

Activity Restrictions After Gynecologic Surgery.

Gynecologic surgeons have traditionally restricted the physical activity of postoperative patients. Minimally invasive surgery and enhanced recovery after surgery programs have contributed to decreased hospital stays and more expeditious recovery. In this narrative review, we review the current state of postoperative activity restrictions in gynecology and other specialties, the purported risks and potential benefits of postoperative activity, the available evidence to refute or support activity in the postoperative activity, and, finally, the potential benefit of added activity in the postoperative period.

Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction.

PURPOSE: Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts. METHODS: Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed. RESULTS: Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion. CONCLUSIONS: We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective Study.

Gender Differences in Letters of Recommendation for Gynecology Surgical Fellowship Applicants: Analysis of One Program's Recruitment Cycle.

STUDY OBJECTIVE: To examine whether there are gender differences in letters of recommendation (LORs) written for residents applying to gynecology surgical fellowships. DESIGN: Retrospective study. SETTING: Single, academic institution. PATIENTS: LORs for applicants to gynecology oncology, urogynecology, and minimally invasive gynecology fellowships during the 2019-2020 application cycle. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: We analyzed the linguistic content of the letters for the presence of 4 summary variables and 21 word categories based on previous studies using validated computerized text analysis software. We used multivariable analysis using linear mixed models to compare linguistic characteristics of letters by applicant gender. We performed qualitative content analysis on letters and compared the frequency of code themes by gender. The mixed-method design was planned to allow for analysis of domains not captured in text analysis. Among 680 letters written for 186 applicants, 124 (18.2%) were written for men, and 556 (81.8%) were written for women. There were no differences in the least square mean (standard error) word counts for LORs written for men and women applicants, 465 (20.0) vs 458(9.4) words, p = .74. In multivariable analysis, LORs written for men were found to have higher authentic tone and more risk words (p = .005 and p = .03, respectively). LORs written for women contained more communal (relationship-oriented) words (p = .006). The qualitative analysis demonstrated that ability, interpersonal traits, surgical skills, and research were the most often mentioned themes. Comments about compassion/empathy, leadership potential, teaching, interpersonal skills, and patient rapport were found more often in letters for men. More doubt raisers (words that raise doubt or concern) were present in letters for men, but letters for both genders had similar levels of negative criticism. In contrast, comments on ability, being "drama-free," and self-awareness were found more often in letters for women. CONCLUSION: There were gender differences in LORs written for obstetrics and gynecology surgical subspecialty fellowship applicants indicating the presence of gender bias.

Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN).

BACKGROUND: The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms. OBJECTIVE: This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement. STUDY DESIGN: Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not). RESULTS: A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4). CONCLUSION: Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.

Mesh complications after total vs supracervical laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Our objective was to compare mesh exposure rates (4 months and 1 year) after total (TLH) vs supracervical (SLH) laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy (SCP). Secondary outcomes included 30-day complications and midurethral mesh exposure rates. METHODS: This a retrospective cohort study at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes. Demographics, operative characteristics, and perioperative complications were abstracted from medical records. RESULTS: Four hundred three women met the inclusion criteria: 91 SLH+SCP and 312 TLH+SCP. Median follow-up was 52 weeks with an overall mesh exposure rate of 1.5%. Follow-up was available for 90% of patients at 4 months and 51% at 1 year. Half of patients had lightweight mesh (n = 203), and half had ultralightweight mesh (n = 200). Vaginal mesh fixation was performed with permanent suture in 86% (n = 344) and delayed absorbable suture in 14% (n = 56) of patients. At 4 months, vaginal mesh exposure rates did not differ between groups (0% SLH vs 1% TLH, p = 1.00). All mesh exposures in the study period occurred with lightweight mesh in the TLH arm. No differences were noted in 1-year mesh exposure rates, 30-day perioperative complications (p = 0.57), or midurethral mesh exposure rates at 4 months (p = 0.35) and 1 year (p = 1.00) between groups. CONCLUSIONS: Short-term mesh exposure following SCP with ultralightweight and lightweight polypropylene mesh is rare regardless of type of hysterectomy and much lower than reported in earlier studies with heavier weight mesh. These data suggest TLH at the time of SCP is a safe option in appropriately counseled patients.

The Leadership Landscape: The Role of Gender in Current Leadership Positions in Obstetrics and Gynecology Departments.

STUDY OBJECTIVE: To describe the proportion of female faculty in departmental administrative and educational leadership roles in Obstetrics and Gynecology departments. DESIGN: Cross-sectional observational study (II-3). SETTING: Accredited Obstetrics and Gynecology residency programs. PARTICIPANTS: A total of 288 accredited residency programs were identified from 2019 to 2020 with 1237 individuals in leadership positions. INTERVENTIONS: Similar to a 2012 to 2013 survey by Hofler et al, residency program websites and corresponding fellowships (Maternal Fetal Medicine, Female Pelvic Medicine and Reconstructive Surgery, Reproductive Endocrinology and Infertility, and Gynecologic Oncology), departmental websites, and divisional websites were queried for those in administrative and educational leadership positions. Information regarding gender (as determined by the surrogates of name and photographic gender expression), medical and academic degrees, academic rank, and subspecialty certification was abstracted. MEASUREMENTS AND MAIN RESULTS: Within administrative leadership roles, women comprised 29% of chairs, 46% of vice chairs, and 47% of division directors, all significantly lower than men in administrative leadership (p <.001). In educational leadership, women made up 71% of medical school clerkship directors, 58% of residency directors, and 50% fellowship directors. Women were more likely to hold educational leadership positions (56% vs 40%; p <.001), although men were more likely to hold administrative leadership positions (68% vs 52%; p <.001). Among subspecialties, there was greatest gender equity within Female Pelvic Medicine and Reconstructive Surgery. Female leaders were more likely to have received additional academic degrees (e.g. MBA, MPH) than their male counterparts (19% vs 13%; p = .002). CONCLUSION: Women continue to be underrepresented in administrative leadership positions. Compared with 2012 to 2013, there is only a 9% increase in proportion of women chairing and 10% vice chairing Obstetrics and Gynecology departments; however, the increase is more substantial in other positions, such as division directors (17%). Our findings demonstrate ongoing gender disparity in the highest levels of departmental leadership and the need to further improve on diversity and gender equity within leadership roles.

Sex Differences in Commercial Patient Reviews of Women and Men Urogynecologic Surgeons.

OBJECTIVE: The objective of our study was to describe differences in commercial patient reviews of women and men urogynecologic surgeons. MATERIALS AND METHODS: Reviews of surgeons on Healthgrades.com in 4 metropolitan areas were included. Based on the qualitative assessment using qualitative content analysis of major and minor elements, we defined 4 theme categories: global experience, social interaction, technical skills, and ancillary aspects, each embedded with discrete elements. Differences in proportions of mentioned themes as well as quantitative ratings were evaluated by sex with the appropriate statistical tests. RESULTS: Three hundred sixty-four patient reviews (51% for women surgeons and 49% for men surgeons) were identified for 141 gynecologic surgeons self-identifying as "urogynecologists." The majority of the cohort (77%) held subspecialty certification in female pelvic medicine and reconstructive surgery. Reviews of women demonstrated a lower mean quantitative "likelihood to recommend" score compared with men (4.0 vs 4.3, P = 0.002) on the 5-point scale. Women received more mention in comfort (52% vs 40%, P = 0.023) and professionalism (19% vs 9%, P = 0.007) themes and less mention with respect to surgical outcomes (28% vs 53%, P < 0.001) and technical skills (5% vs 15%, P = 0.011) compared with men. CONCLUSIONS: Commercial online patient reviews for urogynecologic surgeons reveal sex bias with women receiving lower scores overall and more comments related to social interaction and fewer comments related to surgical outcomes and technical skill compared with men.

How Does the Urethra Respond to Bladder Filling in Continent and Incontinent Women?

OBJECTIVE: The objective of this study was to describe mean urethral pressure (MUP) during filling cystometry in continent and incontinent women. METHODS: Incontinent women were recruited from a urogynecology clinic if they answered "sometimes" or "always" to 1 of the items on the Medical, Epidemiologic, and Social Aspects of Aging questionnaire. Participants were categorized by Medical, Epidemiologic, and Social Aspects of Aging scores into stress urinary incontinence (SUI) or urgency urinary incontinence (UUI) groups. Continent women were recruited from the community. Multichannel urodynamics were performed using microtip catheters. Urethral pressure profiles were obtained with an empty bladder and at 100-mL increments during filling. Data were analyzed in SPSS. Continuous variables were compared with independent t test or analysis of variance, categorical variables with the χ2 test, and multivariable comparisons were made with linear regression. RESULTS: Eighty-six women (30 continent, 56 incontinent: 37 SUI, 19 UUI) with a mean ± SD age of 48 ± 15 years and a body mass index (BMI) of 31 ± 9 participated. Sixty-nine percent were White, 43% were postmenopausal, and 80% were parous. Continent women were younger (P < 0.001) and had a lower BMI (P = 0.004). Mean cystometric capacity was higher in women with SUI and continent women than in women with UUI (430 ± 142, 448 ± 101, and 332 ± 160, P = 0.04). Continent women had higher MUP at baseline when controlling for age, BMI, and parity (84 ± 35 cmH2O vs 62 ± 28 cmH2O; aR2 = 0.2, P = 0.02) compared with incontinent women. During filling, MUP in continent women was 20-30 cmH2O higher at all bladder volumes than incontinent women. Mean urethral pressure increased significantly between baseline and 300 mL in continent women (P < 0.005) and women with SUI (P = 0.04), but not in women with UUI (P = 0.48). CONCLUSIONS: Continent women have greater baseline MUP and greater increases in MUP during bladder filling than incontinent women.

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.

Neuromuscular urethral function and urethral urodynamic parameters between urgency and stress incontinence do not differ.

INTRODUCTION AND HYPOTHESIS: To describe and compare urethral neuromuscular function using concentric needle electromyography (CNEMG) and urodynamic (UDS) parameters between stress incontinent (SUI) and urge incontinent (UUI) women. METHODS: Incontinent women were recruited from a urogynecology clinic if they answered "sometimes" or "always" to one of the items on the Medical, Epidemiologic, and Social Aspects of Aging questionnaire. Participants were categorized by MESA scores into stress (SUI) or urgency (UUI) incontinence groups. Participants underwent CNEMG of the striated urethral sphincter at three insertion sites using Medtronic multiple motor unit action potential analysis. UDS was performed with Laborie microtip catheters: urethral pressure profiles were obtained at baseline and 300 ml. Data were analyzed in SPSS. Continuous variables were compared with independent t-test or Mann-Whitney U, categorical variables with chi-square test. A logistic regression was performed to control for variables found to be significant on univariate analysis. RESULTS: Fifty-six women (37 SUI, 19 UUI) with mean ± SD age of 53 ± 13 years participated. At baseline, patients with SUI were younger, more likely to be premenopausal and had lower BMIs. There were no differences in urethral EMG or UDS parameters between UUI and SUI women except lower maximum cystometric capacity in women with UUI. When controlling for age, BMI and MCC on logistic regression, there remained no differences between SUI and UUI groups on EMG or UDS parameters. CONCLUSIONS: Women with UUI and DO show similar evidence of denervation-reinnervation injury to the striated urethral sphincter muscle as women with SUI.

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.

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy. METHODS: In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum. RESULTS: Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index. CONCLUSION: At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.

Baseline Characteristics, Evaluation, and Management of Women With Complaints of Recurrent Urinary Tract Infections.

OBJECTIVE: The aims of this study were to determine the proportion of women presenting for recurrent urinary tract infections (UTIs) who met the diagnostic criteria (culture-proven UTI ≥3 in 1 year or ≥2 in 6 months) and to assess advanced testing utilization, preventive therapy use, and risk factors. METHODS: This is a retrospective chart review of women seen as new urogynecology consults for recurrent UTI (rUTI) between April 1, 2017, and April 1, 2018, followed through April 1, 2019. Exclusion criteria included catheter use, cancer treatment within 2 years, and prior organ transplant, urinary diversion, conduit, or bladder augmentation. RESULTS: Of 600 women, 71% had follow-up with a median of 179 days. Urinary tract infection symptoms included frequency (50%), dysuria (46%), urgency (43%), and malodorous urine (7%). One third met the rUTI diagnostic criteria. Two hundred thirty-four (39%) underwent advanced testing, and 9% (21/234) of women who underwent advanced testing had a change in clinical care. Preventive therapy use increased after consultation (P < 0.001), with vaginal estrogen (47%) being most common. Compared with women not meeting the rUTI criteria, women meeting the rUTI criteria were more likely to be older (adjusted odds ratio [aOR], 1.03/year; 95% confidence interval [CI], 1.02-1.04), have a prior history of gynecologic cancer (aOR, 4.07; 95% CI, 1.02-16.25), or report UTI symptoms of dysuria (aOR, 2.27; 95% CI, 1.57-3.27), or malodorous urine (aOR, 2.96; 95% CI, 1.47-5.94) and, while equally likely to be receiving preventive treatment prior to consultation, were more likely after consultation (OR, 3.06; 95% CI, 2.05-4.55). DISCUSSION: Thirty-seven percent of women seen for rUTI met the diagnostic criteria. Advanced imaging rarely changed care. Education about diagnostic criteria and preventive therapy is warranted.

The Influence of Patients' Goals on Surgical Satisfaction.

OBJECTIVE: The objectives of this study were to describe patients' surgical goals and determine if goal attainment is associated with postoperative satisfaction and regret. METHODS: Women undergoing surgery for pelvic floor disorders between June and December 2019 were recruited. At their initial visit, patients listed up to 4 surgical goals. Three months after surgery, patients completed the Pelvic Floor Distress Inventory, Patient Global Impression of Improvement, Satisfaction with Decision Scale, and Decision Regret Scale. They were also shown their initial goals and asked, "Did you achieve this goal by having surgery?" Women who achieved all goals were designated "goal achievers," and those who did not achieve even 1 goal were "goal nonachievers" (GNAs). RESULTS: Ninety-nine patients listed a median of 1 (range, 1-4) goals. Goals were categorized as follows: symptom improvement (52%), treatment achievement (23%), lifestyle improvement (17%), and information gathering (6%). Ninety-one percent of patients were goal achievers, and 9% were GNAs. Goal achievers had higher Satisfaction with Decision Scale scores (5.0 [4.7-5.0] vs 4.0 [3.8-4.8], P = 0.002), lower Decision Regret Scale scores (1.0 [1.0-1.4] vs 2.0 [1.1-2.7], P = 0.001), and better Patient Global Impression of Improvement scores (1.0 [1.0-2.0] vs 2.0 [1.0-4.0], P = 0.004). In prolapse surgery patients, postoperative Pelvic Floor Distress Inventory scores were similar; however, GNAs had higher postoperative Urinary Distress Inventory scores (17.0 ± 18.0 vs 45.8 ± 20.8, P = 0.01). CONCLUSIONS: Ninety-one percent of women achieved their presurgical goals, the most common being symptom relief. Goal achievers have higher satisfaction and less regret; however, those with worsening or de novo urinary symptoms are more likely to be GNAs and be unsatisfied.

Challenges in pediatric urologic practice: a lifelong view.

The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.

Truth or Myth: Intra-abdominal Pressure Increases in the Lithotomy Position.

STUDY OBJECTIVE: To determine if there were differences in intra-abdominal pressure (IAP) in the supine, low lithotomy, and high lithotomy positions. DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Twenty-nine women undergoing surgery for prolapse or stress incontinence. INTERVENTIONS: Relevant medical history, including the pelvic organ prolapse quantification stage, body mass index, and airway grade (Mallampati score), was abstracted from patients' medical charts. IAP was measured in centimeters of water (cmH2O) on the day of their surgery before induction of general or intravenous anesthesia using a T-doc air charged urodynamic catheter (Laborie Aquarius; Ontario, Canada) placed in a patient's vagina (for patients with incontinence) or rectum (for patients with prolapse). MEASUREMENTS AND MAIN RESULTS: IAP was measured in 3 positions: supine (legs at 0°), low lithotomy (legs in Yellowfin stirrups at 45°; Allen Medical, Acton, MA), and high lithotomy (legs at 90°). The means ± SDs IAP for the groups were as follows: in the supine position, 18.6 cmH2O ± 7.6; low lithotomy, 17.7 cmH2O ± 6.6; and high lithotomy, 17.1 cmH2O ± 6.3. In the same women, there was a significant decrease in IAP from the supine to high lithotomy positions, with a mean difference of 1.4 cmH2O ± 3.7, p = .05. Similarly, there was a significant, though smaller, decrease in mean IAP when moving from the supine to low lithotomy positions in these same women (mean decrease of 0.9 cmH2O ± 1.5, p = .004). Neither change is clinically significant based on previous research that suggests 5 cmH2O is a clinically significant change. CONCLUSION: Placing patients' legs in a low or high lithotomy position does not result in a clinically significant increase in IAP. Therefore, surgeons and anesthesiologists can consider positioning patients' lower extremities in stirrups while patients are awake to minimize discomfort and possibly reduce the risk of nerve injuries.

Fibroids and Urinary Symptoms Study (FUSS).

OBJECTIVE: The aims of the study were to characterize pelvic floor and urinary symptoms in women seeking treatment for uterine fibroids and to explore the association between uterine/fibroid size and pelvic floor symptoms. METHODS: Women seeking treatment for uterine fibroids at a single academic center were enrolled in this cross-sectional study. All participants underwent pelvic imaging and completed the Symptom Severity Subscale of the Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL) and the Pelvic Floor Distress Inventory (PFDI-20). RESULTS: One hundred ninety-five women with a mean age of 41 ± 6 years and body mass index of 29 ± 7 kg/m2 were included. In this cohort, 58% identified as Black and 38% had at least 1 vaginal delivery. Women attributed pelvic pain (68%), dyspareunia (37%), and urinary incontinence (31%) to their fibroids. The mean ± SD UFS-QOL score was 48.7 ± 25.4, and 63% of participants reported being at least "somewhat bothered" by tightness/pressure in pelvic area, 60% by frequent daytime urination, and 47% by nocturia. The mean PFDI-20 score was 45.5 ± 31.9. Women reported being at least "somewhat bothered" by heaviness/dullness in the pelvis (60%), frequent urination (56%), pelvic pain or discomfort (48%), and sensation of incomplete bladder emptying (43%). The PFDI-20 and UFS-QOL scores were not correlated with uterine volume (r = 0.12, P = 0.12, and r = 0.06, P = 0.44) or fibroid size (r = 0.09, P = 0.26, and r = 0.01, P = 0.92). CONCLUSIONS: Women presenting for evaluation and treatment of fibroids report high rates of pelvic floor symptoms, particularly urinary frequency and pelvic pressure. However, uterine size and fibroid size are not associated with pelvic floor symptom bother.