Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review.

OBJECTIVE: To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION: The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS: Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION: Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021234511.

Racial and Ethnic Disparities in Obliterative Procedures for the Treatment of Vaginal Prolapse.

OBJECTIVES: Although racial disparities are well documented for common gynecologic surgical procedures, few studies have assessed racial disparities in the surgical treatment of vaginal prolapse. This study aimed to compare the use of obliterative procedures for the treatment of vaginal prolapse across racial and ethnic groups. STUDY DESIGN: This is a retrospective cohort study of surgical cases from 2010 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program, a nationally validated database. Cases were identified by Current Procedural Terminology codes. Modified Poisson regression was used to calculate risk ratios and 95% confidence intervals, adjusting for potential confounders selected a priori. RESULTS: We identified 45,865 surgical cases, of which 10% involved an obliterative procedure. In the unadjusted model, non-Hispanic Asian and non-Hispanic Black patients were more likely to undergo an obliterative procedure compared with non-Hispanic White patients (risk ratio [95% confidence interval], 2.4 [2.1-2.7] and 1.2 [1.03-1.3], respectively). These relative risks were largely unchanged when controlling for age, body mass index, diabetes, American Society of Anesthesiologists classification, and concurrent hysterectomy. CONCLUSIONS: Although both obliterative and reconstructive procedures have their respective risks and benefits, the proportion of patients undergoing each procedure differs by race and ethnicity. It is unclear whether such disparities may be attributable to differences in preference or inequity in care.

The Surgical Approach to Abdominal Sacrocolpopexy and Concurrent Hysterectomy: Trends for the Past Decade.

OBJECTIVE: The aim of the study was to understand the surgical trends and 30-day complications of patients undergoing an abdominal sacrocolpopexy with a concurrent hysterectomy. METHODS: This is a retrospective cohort study of surgical cases from the American College of Surgeons National Surgical Quality Improvement Program from 2010 to 2017 who underwent an abdominal sacrocolpopexy and a concurrent hysterectomy. RESULTS: There were 9327 surgical cases of an abdominal sacrocolpopexy with a concurrent hysterectomy of which 7772 (83.3%) were minimally invasive and 1555 (16.7%) were through a laparotomy. The proportion of patients undergoing a laparotomy decreased by 2.4% per year from 2010 to 2018 (R2 = 0.77). Among minimally invasive procedures, 4359 (46.7%) involved a concurrent supracervical hysterectomy and 4968 (53.3%) involved a concurrent total hysterectomy. Among minimally invasive procedures, patients who had a concurrent supracervical hysterectomy both had a longer operative time and were more likely to be admitted at least 2 days postoperatively compared with those who had a concurrent total hysterectomy (P < 0.001 for both). CONCLUSIONS: Patients undergoing an abdominal sacrocolpopexy and concurrent hysterectomy are increasingly likely to undergo surgery in a minimally invasive approach. The Food and Drug Administration safety communication on electric power morcellation did not impact this trend. Although complication rates are low, regardless of the type of concurrent hysterectomy, some complications, such as blood transfusions and surgical site infections, seem to be highest for those undergoing a concurrent total hysterectomy despite the fact that a concurrent supracervical hysterectomy may be associated with a longer operative time and longer hospital admission.

Postoperative Admission, Readmission, and Complications for Patients 60 Years and Older Who Are Undergoing an Isolated Sling Procedure for Stress Incontinence: A Database Study.

OBJECTIVE: The aim of the study was to determine the effect of increasing age on postoperative admission, readmission, and complications for patients 60 years and older who underwent a synthetic or autologous sling procedure for stress incontinence. METHODS: A retrospective cohort study of surgical cases from 2012 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Eligible patients were at least 60 years old and underwent an isolated sling procedure for stress incontinence identified by Current Procedural Terminology code 57288. Baseline demographics, preoperative comorbidities, and postoperative complications were obtained. Risk ratios (RRs) and 95% confidence intervals were calculated using log-binomial regressions. RESULTS: Of 3,960 eligible patients, 634 (16.0%) were admitted postoperatively. Admission rates differed across age groups (P = 0.04). For example, compared with patients aged 60-64 years, those aged 70-74 years had 1.3 times the risk of admission (95% confidence interval, 1.04-1.6). Other risk factors for admission included diabetes (RR, 1.3) and hypertension (RR, 1.2). Patients who had general anesthesia had 6.3 times the risk of admission compared with those who had monitored anesthesia/intravenous sedation. There were 72 patients (1.8%) readmitted within 30 days. There was no association between age and readmission. Risk factors for readmission included diabetes (RR, 1.8), bleeding disorders (RR, 3.4), severe chronic obstructive pulmonary disease (RR, 3.7), and congestive heart failure (RR, 11.3). There were 192 complications (4.8%), including 45 major complications (1.1%). CONCLUSIONS: Among patients 60 years and older, the risk of postoperative admission and readmission for patients undergoing a synthetic or autologous sling procedure is low and complications are uncommon.

U.S. Food and Drug Administration Statements About Transvaginal Mesh and Changes in Apical Prolapse Surgery.

OBJECTIVE: To assess the effects of the U.S. Food and Drug Administration (FDA) safety communication and the reclassification of transvaginal mesh to a class III device on national trends in the treatment of apical prolapse. METHODS: A retrospective cohort study of surgical cases from 2008 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program was conducted. Patients were included if they underwent apical prolapse repair, as identified by Current Procedural Terminology codes. RESULTS: We identified 36,523 eligible surgical cases. There were no clinically meaningful differences in postoperative complications when stratified by surgical approach. The use of transvaginal mesh decreased from 35.0% to 11.0% from 2008 to 2017. In the year immediately after the first FDA safety communication in 2011, there was a decrease in the proportion of apical procedures using transvaginal mesh of 4.4% per quarter (P<.001), and the proportion of intraperitoneal, extraperitoneal, and abdominal colpopexy all increased. The greatest increase was seen for abdominal colpopexy procedures, which rose by 2.6% per quarter (P<.001). In the year after the FDA reclassification of transvaginal mesh in 2016, there was no significant change in the proportion of apical procedures using transvaginal mesh (P=.56). CONCLUSION: The first FDA safety communication in 2011 was associated with a significant decline in the use of transvaginal mesh and a concurrent rise in abdominal colpopexy procedures using transabdominal mesh. We speculate that the 2019 FDA ban of transvaginal mesh will result in an even more substantial shift toward abdominal colpopexy procedures.

Abdominal sacral colpopexy versus sacrospinous ligament fixation: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: For the surgical correction of apical prolapse the abdominal approach is associated with better outcomes; however, it is more expensive than the transvaginal approach. This cost-effectiveness analysis compares abdominal sacral colpopexy (ASC) with sacrospinous ligament fixation (SSLF) to determine if the improved outcomes of ASC justify the increased expense. METHODS: A decision-analytic model was created comparing ASC with SSLF using data-modeling software, TreeAge Pro (2013), which included the following outcomes: post-operative stress urinary incontinence (SUI) with possible mid-urethral sling (MUS) placement, prolapse recurrence with possible re-operation, and post-operative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) of less than $50,000 per quality-associated life year (QALY). Base-case, threshold, and one-way sensitivity analyses were performed. RESULTS: At the baseline, ASC is more expensive than SSLF ($13,988 vs $11,950), but is more effective (QALY 1.53 vs 1.45) and is cost-effective (ICER $24,574/QALY) at 2 years. ASC was not cost-effective if the following four thresholds were met: the rate of post-operative SUI was above 36 % after ASC or below 28 % after SSLF; the rate of MUS placement for post-operative SUI was above 60 % after ASC or below 13 % after SSLF; the rate of recurrent prolapse was above 15 % after ASC or below 4 % after SSLF; the rate of post-operative dyspareunia was above 59 % after ASC or below 19 % after SSLF. CONCLUSIONS: Abdominal sacral colpopexy can be cost-effective compared with sacrospinous ligament fixation; however, as the post-operative outcomes of SSLF improve, SSLF can be considered a cost-effective alternative.

Practice patterns regarding management of rectovaginal fistulae: a multicenter review from the Fellows' Pelvic Research Network.

OBJECTIVES: Rectovaginal fistulae (RVFs) are often debilitating and there are no established treatment algorithms. We sought to describe current diagnosis and management strategies for RVFs across the United States. METHODS: This institutional review board-approved multicenter retrospective study included 12 sites. Cases were identified using International Classification of Diseases, Ninth Revision codes during a 5-year period. Demographics, management, and outcomes of RVF treatment were collected. RESULTS: Three hundred forty-two charts were identified; 176 (52%) met criteria for inclusion. The mean (SD) age was 45 (17) years. Medical history included hypertension (21%), cancer (17%), Crohn disease (11%), and diabetes (7%). Rectovaginal fistulae were often associated with obstetric trauma (42%), infection/inflammation (24%), and cancer (11%). Overall, most RVFs were primary (94%), small (0.5-1.5 cm; 49%), transsphincteric (31%), and diagnosed via vaginal and rectal (60%) examination. Eighteen percent (32/176) were initially managed conservatively for a median duration of 56 days (interquartile range, 29-168) and 66% (21/32) of these resolved. Almost half (45%) of RVFs treated expectantly were tiny (<0.5 cm). Eighty-two percent (144/176) of subjects were initially managed surgically and 81% (117/144) resolved. Procedures included simple fistulectomy with or without Martius graft (59%), transsphincteric repair (23%), transverse transperineal repair (10%), and open techniques (8%), and 87% of these procedures were performed by urogynecologists. CONCLUSIONS: In this large retrospective review, most primary RVFs were treated surgically, with a success rate of more than 80%. Two thirds of RVFs managed conservatively resolved spontaneously, and most of these were tiny (<0.5 cm). These success rates can be used in counseling to help our patients make informed decisions about their treatment options.

A cost-effectiveness analysis of conservative versus surgical management for the initial treatment of stress urinary incontinence.

OBJECTIVE: We sought to determine whether conservative or surgical therapy is more cost effective for the initial treatment of stress urinary incontinence (SUI). STUDY DESIGN: We created a decision tree model to compare costs and cost effectiveness of 3 strategies for the initial treatment of SUI: (1) continence pessary, (2) pelvic floor muscle therapy (PFMT), and (3) midurethral sling (MUS). We identified probabilities of SUI after 12 months of use of a pessary, PFMT, or MUS using published data. Parameter estimates included Health Utility Indices of no incontinence (.93) and persistent incontinence (0.7) after treatment. Morbidities associated with MUS included mesh erosion, retention, de novo urge incontinence, and recurrent SUI. Cost data were derived from Medicare in 2012 US dollars. One- and 2-way sensitivity analysis was used to examine the effect of varying rates of pursuing surgery if conservative management failed and rates of SUI cure with pessaries and PFMT. The primary outcome was an incremental cost-effectiveness ratio threshold <$50,000. RESULTS: Compared to PFMT, initial treatment of SUI with MUS was the more cost-effective strategy with an incremental cost-effectiveness ratio of $32,132/quality-adjusted life year. Initial treatment with PFMT was also acceptable as long as subjective cure was >35%. In 3-way sensitivity analysis, subjective cure would need to be >40.5% for PFMT and 43.5% for a continence pessary for the MUS scenario to not be the preferred strategy. CONCLUSION: At 1 year, MUS is more cost effective than a continence pessary or PFMT for the initial treatment for SUI.

A new mouse model for female genital schistosomiasis.

BACKGROUND: Over 112 million people worldwide are infected with Schistosoma haematobium, one of the most prevalent schistosome species affecting humans. Female genital schistosomiasis (FGS) occurs when S. haematobium eggs are deposited into the female reproductive tract by adult worms, which can lead to pelvic pain, vaginal bleeding, genital disfigurement and infertility. Recent evidence suggests co-infection with S. haematobium increases the risks of contracting sexually transmitted diseases such as HIV. The associated mechanisms remain unclear due to the lack of a tractable animal model. We sought to create a mouse model conducive to the study of immune modulation and genitourinary changes that occur with FGS. METHODS: To model FGS in mice, we injected S. haematobium eggs into the posterior vaginal walls of 30 female BALB/c mice. A control group of 20 female BALB/c mice were injected with uninfected LVG hamster tissue extract. Histology, flow cytometry and serum cytokine levels were assessed at 2, 4, 6, and 8 weeks post egg injection. Voiding studies were performed at 1 week post egg injection. RESULTS: Vaginal wall injection with S. haematobium eggs resulted in synchronous vaginal granuloma development within 2 weeks post-egg injection that persisted for at least 6 additional weeks. Flow cytometric analysis of vaginal granulomata revealed infiltration by CD4+ T cells with variable expression of the HIV co-receptors CXCR4 and CCR5. Granulomata also contained CD11b+F4/80+ cells (macrophages and eosinophils) as well as CXCR4+MerTK+ macrophages. Strikingly, vaginal wall-injected mice featured significant urinary frequency despite the posterior vagina being anatomically distant from the bladder. This may represent a previously unrecognized overactive bladder response to deposition of schistosome eggs in the vagina. CONCLUSION: We have established a new mouse model that could potentially enable novel studies of genital schistosomiasis in females. Ongoing studies will further explore the mechanisms by which HIV target cells may be drawn into FGS-associated vaginal granulomata.

Management of vesicovaginal fistulae: a multicenter analysis from the Fellows' Pelvic Research Network.

OBJECTIVES: Vesicovaginal fistulae (VVF) are the most commonly acquired fistulae of the urinary tract, but we lack a standardized algorithm for their management. The purpose of this multicenter study was to describe practice patterns and treatment outcomes of VVF in the United States. METHODS: This institutional review board-approved multicenter review included 12 academic centers. Cases were identified using International Classification of Diseases codes for VVF from July 2006 through June 2011. Data collected included demographics, VVF type (simple or complex), location and size, management, and postoperative outcomes. χ(2), Fisher exact, and Student t tests, and odds ratios were used to compare VVF management strategies and treatment outcomes. RESULTS: Two hundred twenty-six subjects were included. The mean age was 50 (14) years; mean body mass index was 29 (8) kg/m(2). Most were postmenopausal (53.0%), nonsmokers (59.5%), and white (71.4%). Benign gynecologic surgery was the cause for most VVF (76.2%). Most of VVF identified were simple (77.0%). Sixty (26.5%) VVF were initially managed conservatively with catheter drainage, of which 11.7% (7/60) resolved. Of the 166 VVF initially managed surgically, 77.5% resolved. In all, 219 subjects underwent surgical treatment and 83.1% of these were cured. CONCLUSIONS: Most of VVF in this series was managed initially with surgery, with a 77.5% success rate. Of those treated conservatively, only 11.7% resolved. Surgery should be considered as the preferred approach to treat primary VVF.

Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms.

OBJECTIVE: The objective of the study was to describe the basic knowledge about prolapse and attitudes regarding the uterus in women seeking care for prolapse symptoms. STUDY DESIGN: This was a cross-sectional study of English-speaking women presenting with prolapse symptoms. Patients completed a self-administered questionnaire that included 5 prolapse-related knowledge items and 6 benefit-of-uterus attitude items; higher scores indicated greater knowledge or more positive perception of the uterus. The data were analyzed using descriptive statistics and multiple linear regression. RESULTS: A total of 213 women were included. The overall mean knowledge score was 2.2 ± 1.1 (range, 0-5); 44% of the items were answered correctly. Participants correctly responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises (34.3%) were prolapse treatment options. Prior evaluation by a female pelvic medicine and reconstructive surgery specialist (beta = 0.57, P = .001) and higher education (beta = 0.3, P = .07) was associated with a higher mean knowledge score. For attitude items, the overall mean score was 15.1 (4.7; range, 6-30). A total of 47.4% disagreed with the statement that the uterus is important for sex. The majority disagreed with the statement that the uterus is important for a sense of self (60.1%); that hysterectomy would make me feel less feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%). Previous consultation with a female pelvic medicine and reconstructive surgery specialist was associated with a higher mean benefit of uterus score (beta = 1.82, P = .01). CONCLUSION: Prolapse-related knowledge is low in women seeking care for prolapse symptoms. The majority do not believe the uterus is important for body image or sexuality and do not believe that hysterectomy will negatively affect their sex lives.

To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis.

PURPOSE: We compare the cost-effectiveness of 3 strategies for the use of a mid urethral sling to prevent occult stress urinary incontinence in patients undergoing abdominal sacrocolpopexy. MATERIALS AND METHODS: Using decision analysis modeling we compared cost-effectiveness during a 1-year postoperative period of 3 treatment approaches including 1) abdominal sacrocolpopexy alone with deferred option for mid urethral sling, 2) abdominal sacrocolpopexy with universal concomitant mid urethral sling and 3) preoperative urodynamic study for selective mid urethral sling. Using published data we modeled probabilities of stress urinary incontinence after abdominal sacrocolpopexy with or without mid urethral sling, the predictive value of urodynamic study to detect occult stress urinary incontinence and the likelihood of complications after mid urethral sling. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost-effectiveness ratio per quality adjusted life-years gained. In addition to base case analysis, 1-way sensitivity analyses were performed. RESULTS: In our model, universally performing mid urethral sling at abdominal sacrocolpopexy was the most cost-effective approach with an incremental cost per quality adjusted life-year gained of $2,867 compared to abdominal sacrocolpopexy alone. Preoperative urodynamic study was more costly and less effective than universally performing intraoperative mid urethral sling. The cost-effectiveness of abdominal sacrocolpopexy plus mid urethral sling was robust to sensitivity analysis with a cost-effectiveness ratio consistently below $20,000 per quality adjusted life-year. CONCLUSIONS: Universal concomitant mid urethral sling is the most cost-effective prophylaxis strategy for occult stress urinary incontinence in women undergoing abdominal sacrocolpopexy. The use of preoperative urodynamic study to guide mid urethral sling placement at abdominal sacrocolpopexy is not cost-effective.

Posterior compartment prolapse: a urogynecology perspective.

Posterior compartment prolapse is often caused by a defect in the rectovaginal septum, also known as Denonvillier's fascia. Patients with symptomatic posterior compartment prolapse can present with bulge symptoms as well as defecatory dysfunction, including constipation, tenesmus, splinting, and fecal incontinence. The diagnosis can successfully be made on clinical examination. Treatment of posterior prolapse includes pessaries and surgery. Both traditional colporrhaphy and site-specific defect repair have excellent success rates. Complications from surgery can include sexual dysfunction, de novo dyspareunia, and defecatory dysfunction. Compared with native tissue repair, biological and synthetic grafting has not improved overall anatomic and subjective outcomes.