Comparative analyses of attitude, knowledge, and recollection of preoperative counseling regarding pelvic mesh among women with or without a mesh-related complication.

PURPOSE: Our objective was to compare the recollection of preoperative counseling regarding mesh for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI) among women with or without a mesh-related complication (MRC). We hypothesized that the patients who had MRC would better recollect counseling regarding complications associated with mesh. METHODS: We conducted a retrospective cohort study among women who had prior implantation of synthetic, non-absorbable mesh for POP and/or SUI at least 3 months prior who presented with or without a MRC. The primary outcome was the proportion of women who recalled being counseled preoperatively about the risk of mesh exposure. RESULTS: Ninety-six women were included in the final analysis (50 MRC; 46 no MRC). MRC women presented further in time from the index surgery [median 69 months [IQR 26-115] vs 12 months (IQR 6-64), p < 0.01]. After adjustment for time since surgery and age, MRC women were significantly less likely to recall being counseled about the possibility of any MRC [19/50 (38%) vs 32/44 (73%), aOR 0.29, 95% CI 0.11-0.79, p = 0.01]. They were also less likely to report they would undergo the same surgery again 5-point Likert scale [median 3 (IQR 1-4) vs 5 (IQR 3-5), 5-point Likert scale, p < 0.01], less satisfied with their mesh surgery [median 1 (IQR 1-3) vs 5 (IQR 3-5), 5-point Likert scale, p < 0.01] and recommended improved preoperative counseling [27/50 (54%) vs 6/46 (13%), p < 0.01]. CONCLUSION: Women who experienced MRC were less likely to recall being counseled about the possibility of MRC and report more unmet needs regarding perioperative counseling than women without MRC.

Learner Satisfaction and Experience With a High-definition Telescopic Camera During Vaginal Procedures: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to compare learner satisfaction and experience with a table-mounted, projecting, high-definition telescopic camera system (VITOM) versus traditional learner observation during vaginal surgery. METHODS: Medical student and resident learners were randomized to vaginal surgery observation with or without the use of VITOM. We collected data on learner characteristics and their experience with vaginal surgery. After the surgery, learners completed the faculty/preceptor and working environment domains of the Veterans Affairs Learner's Perceptions Survey (VA LPS). The primary outcome was learners who were "very satisfied" on the VA LPS faculty/preceptor domain. We queried their ability to observe the surgery and satisfaction with learning in the operating room using a 100-mm visual analog scale. RESULTS: Ninety-two learners completed the study (n = 44 VITOM, n = 48 no VITOM). There was no significant difference between groups in the proportion of learners "very satisfied" on the VA LPS faculty/preceptor domain (93.2% VITOM vs 91.5% no VITOM; odds ratio, 1.27; 95% confidence interval, 0.20-9.19; P = 0.99). Learners in the VITOM group were more likely to report ability to see what the main surgeon was doing (93.2% VITOM vs 62.5% no VITOM; odds ratio, 8.02; 95% confidence interval, 2.07-46.32; P < 0.01). Using the visual analog scale, learners in the VITOM group reported higher satisfaction with learning in the operating room (median, 96 [interquartile range, 89-100] VITOM vs median, 80 [interquartile range, 57-98] no VITOM; P < 0.01). CONCLUSION: The use of a table-mounted, projecting, telescopic camera system during vaginal surgery showed no difference in learner satisfaction on validated questionnaires but resulted in improved experience and visualization.

"Landmark" Articles in Female Pelvic Medicine and Reconstructive Surgery: Do We Read What We Cite?

OBJECTIVE: The aim of the study was to describe the provision of a "landmark" article reading list to trainees by their Female Pelvic Medicine & Reconstructive Surgery (FPMRS) fellowship programs. METHODS: In this cross-sectional study, a web-based survey was sent to program coordinators of accredited FPMRS programs. Available reading lists were collected, and a master list compiled. Nonparametric tests were used to investigate the association between the number of faculty members and presence of a reading list. RESULTS: We received a response from 46 (92%) of the 50 Accreditation Council for Graduate Medical Education programs contacted. Half the programs (23/46, 50%) reported that they do not offer a recommended reading list, 5 programs were unsure and over more than 60% with a list (12/18, 67%) shared their list with the investigators. Programs had between 2 and 14 core faculty members with a median (interquartile range) of 4 (3-6). Programs with a reading list had significantly fewer faculty members (3.5, 3-5 vs 5, 3-6, P = 0.03). There were 323 unique articles across the 12 lists, with a median of 25 articles per list. Thirty-four articles were on 4 or more lists; 9 of these (9/34, 26%) have previously been identified as citation classics. CONCLUSIONS: At least 50% of the Accreditation Council for Graduate Medical Education accredited programs do not provide their fellows with a recommended reading list, and fewer core faculty members are associated with the presence of such a list. Although some commonalities are found between reading lists, a universal reading list of "landmark" articles could improve the consistency of FPMRS fellowship education.

Candy Cane Compared With Boot Stirrups in Vaginal Surgery: A Randomized Controlled Trial.

OBJECTIVE: To evaluate differences in physical function at 6 weeks after vaginal surgery among women positioned in candy cane and boot stirrups. METHODS: We conducted a single-masked, randomized controlled trial of women undergoing vaginal surgery with either candy cane or boot stirrup use. The primary outcome was a change in the PROMIS (Patient-Reported Outcomes Measurement Information System) physical function short form-20a from baseline to 6 weeks after surgery. To achieve 80% power to detect a moderate Cohen effect (d=0.5), we required 64 participants in each group. RESULTS: From March 2018 to October 2019, 141 women were randomized, and 138 women (72 in the candy cane group and 66 in the boot stirrup group) were included in the final analysis. There were no baseline differences in participant characteristics including age, body mass index, comorbidities, or preoperative history of joint replacements. There were no between-group differences in surgery type, duration of surgery, estimated blood loss, or adverse events at 6 weeks postoperation. Participants in the candy cane group demonstrated worse physical function at 6 weeks compares with the improvement seen in those in the boot stirrup group; this was significantly different between groups (-1.9±7.9 candy cane vs 1.9±7.0 boot, P<.01). CONCLUSION: Women undergoing vaginal surgery positioned in boot stirrups have significantly better physical function at 6 weeks after surgery when compared with women positioned in candy cane stirrups. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03446950.

Citation classics: the 100 most cited articles in Urogynecology.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to utilize objective citation analyses to describe the 100 most cited articles in the field of Female Pelvic Medicine & Reconstructive Surgery (FPMRS) and to review their characteristics. METHODS: We searched the Thomas Reuters Web of Science database for the most cited articles within all journals classified as Obstetrics and Gynecology (Ob/Gyn), Urology (Uro), Colorectal Surgery (CRS), and vital General Medicine (GM) journals (New England Journal of Medicine; Journal of the American Medical Association; Lancet; The BMJ). We reviewed search results for FPMRS content and compiled a list of the top 100 most cited articles relevant to FPMRS. RESULTS: We screened 34,934 articles yielded by the initial search and compiled the 100 most cited articles relevant to FPMRS. Of these 100 titles, 40% (42 out of 105) were published in Ob/Gyn, 46.7% (49 out of 105) in Uro, 1.9% (2 out of 105) in CRS, and 11.4% (12 out of 105) in GM journals. The most cited FPMRS article was "The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society" (3,810 total and 242 citations per year). Over half the articles were observational in nature and the majority (58%) of them were related to urinary incontinence in women. CONCLUSIONS: Highly cited FPMRS articles come from a variety of journals, and nearly 50% of the 100 most cited FPMRS articles are from the urology literature. The most cited articles were largely observational rather than interventional studies and mostly related to female urinary incontinence.

Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database.

STUDY OBJECTIVE: The objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH). DESIGN: This was a retrospective cohort study. A secondary analysis of the 2006-2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned. SETTING: Hospitals participating in the NSQIP program. PATIENTS: Women who underwent hysterectomy with MISCP. INTERVENTIONS: Not applicable. MEASUREMENT AND MAIN RESULTS: A total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3-3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome. CONCLUSION: Regardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.

The Safety and Feasibility of Gynecologic Cancer Surgery Combined With Surgery for Pelvic Floor Dysfunction.

OBJECTIVES: Women with gynecologic cancer may also present with pelvic floor dysfunction that can have a significant effect on quality of life. Combined surgical intervention for both malignancy and pelvic floor dysfunction may improve quality of life with minimal additional risk. We sought to determine the safety, feasibility, and frequency of combined gynecologic cancer surgery and surgery for pelvic floor dysfunction. METHODS: This is a retrospective cohort study that utilized the National Surgical Quality Improvement Program database provided through the American College of Surgeons. The National Surgical Quality Improvement Program database was queried for patients with a final diagnosis of gynecologic malignancy from 2011 to 2015. Common Procedural Terminology codes for gynecologic oncology procedures and pelvic floor dysfunction surgery were used to identify the study population. Baseline demographics and postoperative complications were abstracted from the database for these patients and compared for patients with combined surgeries versus gynecologic cancer surgeries alone. RESULTS: One hundred twenty-nine women underwent combined procedures compared with 25,838 women undergoing gynecologic cancer surgery alone. Patients who underwent combined procedures were older, had lower body mass index, had higher preoperative albumin and hematocrit, and lower morbidity estimates (P < 0.05). Mean operative time was longer (226.4 vs 174.4 minutes, P < 0.01). There were no statistically significant differences in race, ethnicity, or medical comorbidities. There were no statistically significant differences in postoperative complications or readmissions between the 2 groups (P > 0.1). CONCLUSIONS: Combined gynecologic cancer and pelvic floor dysfunction procedures are feasible and can safely be performed without differences in postoperative complications in appropriately selected patients.

Sentiment Analysis of Web Sites Related to Vaginal Mesh Use in Pelvic Reconstructive Surgery.

OBJECTIVES: The purpose of this study was to utilize sentiment analysis to describe online opinions toward vaginal mesh. We hypothesized that sentiment in legal Web sites would be more negative than that in medical and reference Web sites. METHODS: We generated a list of relevant key words related to vaginal mesh and searched Web sites using the Google search engine. Each unique uniform resource locator (URL) was sorted into 1 of 6 categories: "medical", "legal", "news/media", "patient generated", "reference", or "unrelated". Sentiment of relevant Web sites, the primary outcome, was scored on a scale of -1 to +1, and mean sentiment was compared across all categories using 1-way analysis of variance. Tukey test evaluated differences between category pairs. RESULT: Google searches of 464 unique key words resulted in 11,405 URLs. Sentiment analysis was performed on 8029 relevant URLs (3472 legal, 1625 "medical", 1774 "reference", 666 "news media", 492 "patient generated"). The mean sentiment for all relevant Web sites was +0.01 ± 0.16; analysis of variance revealed significant differences between categories (P < 0.001). Web sites categorized as "legal" and "news/media" had a slightly negative mean sentiment, whereas those categorized as "medical," "reference," and "patient generated" had slightly positive mean sentiments. Tukey test showed differences between all category pairs except the "medical" versus "reference" in comparison with the largest mean difference (-0.13) seen in the "legal" versus "reference" comparison. CONCLUSIONS: Web sites related to vaginal mesh have an overall mean neutral sentiment, and Web sites categorized as "medical," "reference," and "patient generated" have significantly higher sentiment scores than related Web sites in "legal" and "news/media" categories.

A Systematic Assessment of Google Search Queries and Readability of Online Gynecologic Oncology Patient Education Materials.

The Internet is a major source of health information for gynecologic cancer patients. In this study, we systematically explore common Google search terms related to gynecologic cancer and calculate readability of top resulting websites. We used Google AdWords Keyword Planner to generate a list of commonly searched keywords related to gynecologic oncology, which were sorted into five groups (cervical cancer, ovarian cancer, uterine cancer, vulvar cancer, vaginal cancer) using five patient education websites from sgo.org . Each keyword was Google searched to create a list of top websites. The Python programming language (version 3.5.1) was used to describe frequencies of keywords, top-level domains (TLDs), domains, and readability of top websites using four validated formulae. Of the estimated 1,846,950 monthly searches resulting in 62,227 websites, the most common was cancer.org . The most common TLD was *.com. Most websites were above the eighth-grade reading level recommended by the American Medical Association (AMA) and the National Institute of Health (NIH). The SMOG Index was the most reliable formula. The mean grade level readability for all sites using SMOG was 9.4 ± 2.3, with 23.9% of sites falling at or below the eighth-grade reading level. The first ten results for each Google keyword were easiest to read with results beyond the first page of Google being consistently more difficult. Keywords related to gynecologic malignancies are Google-searched frequently. Most websites are difficult to read without a high school education. This knowledge may help gynecologic oncology providers adequately meet the needs of their patients.

Analyzing the Readability of Online Urogynecologic Patient Information.

OBJECTIVE: We sought to describe the readability of Web sites arising from the most common Google search terms related to pelvic organ prolapse, bladder control, and bowel control. METHODS: Google was queried to capture the top 100 search results for the keywords in each disease group. For the top 20 results of each keyword, we analyzed the text for readability using 4 readability formulas: Dale-Chall, Gunning-Fog, Simple Measure of Gobbledygook (SMOG), and Flesch-Kincaid Grade Level.Readability scores were compared using 1-way analysis of variance (α = 0.05), and the Tukey test was performed to characterize any significant differences. The χ tests were used to compare results above and below the eighth grade reading level. Spearman correlations were used to compare the reliability of the different readability formulas. RESULTS: We evaluated 2731 unique Web sites for readability, of which 2334 (85%) had a SMOG score at or above an eighth grade reading level. The mean SMOG score was 9.7 ± 2.1. Web sites in the bladder control keyword group had statistically higher SMOG scores than those in the bowel control and pelvic organ prolapse groups, with means of 9.9 ± 2.0, 9.4 ± 2.1, and 9.6 ± 2.0, respectively. The SMOG was found to be the most reliable. CONCLUSIONS: The vast majority of urogynecologic information available to patients on the Internet is written at or above an eighth grade reading level despite longstanding recommendations to the contrary. Clinicians should advise patients that the information they find online may be difficult to understand.

Trends and Complications of Vulvar Reconstruction After Vulvectomy: A Study of a Nationwide Cohort.

OBJECTIVES: The objective of this study was to determine complications associated with primary closure compared with reconstruction after vulvar excision and predisposing factors to these complications. METHODS: Patients undergoing vulvar excision with or without reconstruction from 2011 to 2015 were abstracted from the National Surgical Quality Improvement Program database. Common Procedural Terminology codes were used to characterize surgical procedures as vulvar excision alone or vulvar excision with reconstruction. Patient characteristics and 30-day outcomes were used to compare the 2 procedures. Descriptive and univariate statistics were performed. Adjusted odds ratios and confidence intervals were calculated using a logistic regression model to control for potential confounders. Two-sided α with P < 0.05 was designated as significant. RESULTS: A total of 2698 patients were identified; 78 (2.9%) underwent reconstruction. There were no differences in age, race, body mass index, diabetes, hypertension, tobacco use, heart failure, renal failure, or functional status between the 2 groups. American Society of Anesthesiologists class 3 and 4 patients and those with disseminated cancer were more likely to undergo reconstruction (both P < 0.001). On univariate analysis, reconstruction was associated with increased risk of readmission, surgical site infection, pulmonary complications, urinary tract infection, transfusion, deep venous thrombosis, sepsis, septic shock, unplanned reoperation, longer hospital stay, need for skilled nursing or subacute rehab on discharge, and death within 30 days. On logistic regression analysis, disseminated cancer, American Society of Anesthesiologists classes 3 and 4 and reconstruction remained significant risk factors for readmission and any postoperative complication. CONCLUSIONS: Patients undergoing vulvar excision with reconstruction are at increased risk for readmission and postoperative complications compared with those undergoing excision alone. Careful patient selection and efforts to optimize surgical readiness are needed to improve outcomes. Long-term data could help determine if these 30-day outcomes are a reliable measure of surgical quality in vulvar surgery.

Changes in the Vaginal Microenvironment as Related to Frequency of Pessary Removal.

OBJECTIVE: The aim of the study was to describe the effect of frequency of pessary removal on the vaginal microenvironment. METHODS: We performed a secondary analysis of a multicenter randomized trial of hydroxyquinoline gel in women presenting for pessary fitting. Patients had vaginal secretions analyzed at baseline, 2 weeks, and 3 months. Patients were stratified by frequency of pessary removal at least once daily, at least once weekly, and less often than once weekly. These groups were compared for prevalence of Lactobacillus predominance (primary outcome), anaerobic predominance, Mobiluncus prominence, vaginal symptoms, and bacterial vaginosis by Nugent criteria, and correction for confounding variables was performed. RESULTS: One hundred thirty-seven women were included in this analysis: 34 (25%) removed the pessary daily, 54 (39%) at least weekly, and 49 (36%) less often than once weekly. Women who removed the pessary less often than weekly were older (P < 0.01), using more hormone therapy (P = 0.03), and more likely to have bacterial vaginosis at baseline (P < 0.01). At 2 weeks, the predominance of Lactobacillus in the group removing pessary daily was higher (41% daily vs 24% weekly vs 9% longer, P = 0.03) and this persisted after confounder correction (P < 0.01). Women who removed their pessary less than weekly were more likely to have anaerobic predominance at 3 months (P = 0.04). CONCLUSIONS: Women who remove their pessaries less often than once weekly have an increased prevalence of anaerobes at 3 months, but no difference in vaginal symptoms or pessary satisfaction.

Genetic structure of Miscanthus sinensis and Miscanthus sacchariflorus in Japan indicates a gradient of bidirectional but asymmetric introgression.

Unilateral introgression from diploids to tetraploids has been hypothesized to be an important evolutionary mechanism in plants. However, few examples have been definitively identified, perhaps because data of sufficient depth and breadth were difficult to obtain before the advent of affordable high-density genotyping. Throughout Japan, tetraploid Miscanthus sacchariflorus and diploid Miscanthus sinensis are common, and occasionally hybridize. In this study, 667 M. sinensis and 78 M. sacchariflorus genotypes from Japan were characterized using 20 704 SNPs and ten plastid microsatellites. Similarity of SNP genotypes between diploid and tetraploid M. sacchariflorus indicated that the tetraploids originated through autopolyploidy. Structure analysis indicated a gradient of introgression from diploid M. sinensis into tetraploid M. sacchariflorus throughout Japan; most tetraploids had some M. sinensis DNA. Among phenotypically M. sacchariflorus tetraploids, M. sinensis ancestry averaged 7% and ranged from 1-39%, with introgression greatest in southern Japan. Unexpectedly, rare (~1%) diploid M. sinensis individuals from northern Japan were found with 6-27% M. sacchariflorus ancestry. Population structure of M. sinensis in Japan included three groups, and was driven primarily by distance, and secondarily by geographic barriers such as mountains and straits. Miscanthus speciation is a complex and dynamic process. In contrast to limited introgression between diploid M. sacchariflorus and M. sinensis in northern China, selection for adaptation to a moderate maritime climate probably favoured cross-ploidy introgressants in southern Japan. These results will help guide the selection of Miscanthus accessions for the breeding of biomass cultivars.

Microsatellite primers in Agave utahensis (Asparagaceae), a keystone species in the Mojave Desert and Colorado Plateau.

PREMISE OF THE STUDY: Utah agave (Agave utahensis) and its putative subspecies, A. utahensis subsp. kaibabensis and A. utahensis subsp. utahensis, are keystone species of the Mojave Desert and Colorado Plateau in the southwestern United States. Here we developed microsatellite markers to study population structure and genetic diversity of the two subspecies of A. utahensis. • METHODS AND RESULTS: We analyzed 22,386 454-pyrosequencing large contigs (>400 bp), derived from a genome reduction experiment consisting of A. utahensis accessions, for putative microsatellites. The use of unique multiplex barcodes for each of the Agave accessions allowed for the identification of putatively polymorphic microsatellites based solely on sequence alignment analysis. We report the characteristics of 11 polymorphic microsatellite loci based on a panel of 104 individuals from the two subspecies. The number of alleles per locus varied from three to eight, with an average of 5.5 alleles per locus. Observed and expected heterozygosity values ranged from 0.038 to 0.777 and 0.038 to 0.707, respectively. • CONCLUSIONS: The microsatellites identified here will be invaluable for future studies of population structure, polyploidy, and genetic diversity across the species.