Association of Neighborhood-Level Socioeconomic Status With Prolapse Management Decision.

IMPORTANCE: This study identifies how neighborhood-level socioeconomic status (SES) may affect patients' treatment decisions for pelvic organ prolapse (POP). OBJECTIVE: This study aimed to evaluate the association of neighborhood-level SES with the decision of surgical versus conservative POP management. STUDY DESIGN: This was a retrospective cohort study of patients newly diagnosed with POP at a tertiary medical center between 2015 and 2021. Patients lost to follow-up or poor surgical candidates were excluded. Patient characteristics, demographics, and treatment selection were abstracted from the electronic health record. Conservative management was defined as expectant, pessary, and/or pelvic floor physical therapy. Five-digit zip codes were linked to the Area Deprivation Index and used as a surrogate for neighborhood-level SES. Area Deprivation Indices were dichotomized at or below the sample median (less disadvantaged area) and above the sample median (more disadvantaged area). Logistic regression models estimated the odds of choosing surgical versus conservative management as a function of the Area Deprivation Index. RESULTS: A total of 459 patients met the eligibility criteria (non-Hispanic White, 88.2%). The median age was 63 years (interquartile range, 52-70 years), and the majority had stage 2 POP (65.7%). Of all patients, 59.3% had Medicare/Medicaid, 39.9% were privately insured, and 0.9% were uninsured. Furthermore, 74.7% selected surgical management, and 25.3% chose conservative management. Increasing age and higher Pelvic Organ Prolapse Quantification System stage were significantly associated with selecting surgery (P = 0.01). Women residing in a more disadvantaged area had a 67% increased odds of choosing surgical over conservative management (adjusted odds ratio, 1.67; 95% confidence interval, 1.06-2.64) after adjusting for age, race/ethnicity, body mass index, and Pelvic Organ Prolapse Quantification System stage. CONCLUSIONS: Residing in a more disadvantaged zip code was associated with 67% increased odds of choosing surgical versus conservative POP management.

Pelvic Floor Disorders Among Minority Women: Differences in Prevalence, Severity and Health-Related Social Needs.

OBJECTIVE: To characterize prevalence and severity of pelvic floor disorders (PFDs) in various health care settings and to examine unmet health-related social needs (HRSN) among minority women. MATERIALS AND METHODS: Minority women with PFDs were recruited from our academic urogynecology clinic, a general urology clinic at our institution's safety net hospital, and a community outreach mobile clinic. Questions from the Urinary Distress Index-6, Pelvic Organ Prolapse Distress Inventory-6, and Female Genitourinary Pain Index were used to identify patients with stress urinary incontinence, overactive bladder (OAB), and chronic pelvic pain syndrome (CPPS). RESULTS: Sixty-one (46.6%) women identified as Hispanic, 53 (40.4%) as Black, and 17 (12.9%) as Other. Overall, self-reported PFDs included stress urinary incontinence in 45%, OAB in 74.8%, and CPPS in 24.4% of women. Hispanic women were more likely to report OAB symptoms, compared to Black women (odds ratio (OR) 3.4 [1.2-10.2], P = .03) or Other women (OR = 5.1 [1.3-20.4], P = .02). Participants held a median of 5 unmet HRSN. Minority women facing issues with family and community support, transportation, and utilities were more likely to report CPPS symptoms, compared to those without psychosocial issues (support OR: 4.8 [1.7-13.7], P = .002; transportation OR: 2.0 [1.0-8.2], P = .05; utility OR: 7.0 [1.9-28.1], P = .005). CONCLUSION: Minority women with PFDs may have several unmet HRSNs which impact their ability to receive appropriate medical care. Our findings may assist in the development of effective strategies to improve health care outcomes for women dealing with PFDs.

Longitudinal Reoperation Risk After Apical Prolapse Procedures in Women Aged 65 Years and Older.

OBJECTIVE: To describe longitudinal reoperation risk among older women undergoing surgery for apical pelvic organ prolapse (POP) and to compare risk of reoperation for prolapse and complications among different surgical approaches. METHODS: This nationwide, retrospective cohort study evaluated older adult women (aged 65 years and older) within the Centers for Medicare & Medicaid Services' (CMS) 5% LDS (Limited Data Set) who underwent sacrocolpopexy, uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF), or colpocleisis, or their uterine-preserving equivalents, from January 1, 2011, to December 31, 2018, with follow-up through 2019. The primary outcome was overall reoperation, and secondary outcomes included reoperation for POP and for complications. Rates were compared using χ 2 tests for categorical variables, Wilcoxon rank-sum for continuous variables and Kaplan Meier estimates of cumulative incidence. Death and exit from CMS insurance were considered as censoring events. We used cumulative incidence to calculate reoperation risk as a function of time at 1 year or more, 3 years or more, and 7 years or more. RESULTS: This cohort included 4,089 women who underwent surgery to treat apical POP from 2011 to 2018: 1,034 underwent sacrocolpopexy, 717 underwent USLS, 1,529 underwent SSLF, and 809 underwent colpocleisis. Demographics varied among patients for each POP surgery. Patients who underwent the different surgeries had differences in age ( P <.01), Charlson Comorbidity Index score ( P <.01), diabetes ( P <.01), chronic obstructive pulmonary disease ( P <.01), hypertension ( P <.01), chronic pain ( P =.01), congestive heart failure ( P <.01), and concomitant hysterectomy ( P <.01). Reoperation rates were low and increased over time. The overall reoperation risk through 7 years was 7.3% for colpocleisis, 10.4% for USLS, 12.5% for sacrocolpopexy, and 15.0% for SSLF ( P <.01). Reoperation for recurrent POP through 7 years was 2.9% for colpocleisis, 7.3% for sacrocolpopexy, 7.7% for USLS, and 9.9% for SSLF ( P <.01). Reoperation for complications through 7 years was 5.3% for colpocleisis, 8.2% for sacrocolpopexy, 6.4% for USLS, and 8.2% for SSLF ( P <.01). CONCLUSION: The type of surgical repair is significantly associated with long-term risk of reoperation. Colpocleisis offers the least likelihood of reoperation for prolapse, followed by sacrocolpopexy; colpocleisis followed by USLS has the least risk of long-term reoperation for complication.

Cost-Utility Analysis of Midurethral Sling Timing Among Women Undergoing Prolapse Surgery.

IMPORTANCE: There are no guidelines regarding the ideal timing of midurethral sling (MUS) placement following prolapse repair. OBJECTIVE: The objective of this study was to estimate the cost-utility of concomitant MUS versus staged MUS among women undergoing apical suspension surgery for pelvic organ prolapse. STUDY DESIGN: Cost-utility modeling using a decision analysis tree compared concomitant MUS with staged MUS over a 1-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER). Six scenarios were modeled to estimate cost-utilities for women with preoperative overt, occult, or no stress urinary incontinence (SUI) who underwent either minimally invasive sacrocolpopexy or vaginal native tissue apical suspension. Possible complications of de novo overactive bladder, urinary retention requiring sling lysis, mesh exposure, and persistent SUI were included. Costs from a third-party payer perspective were derived from Medicare 2022 reimbursements. One-way sensitivity analyses were performed. RESULTS: Among women without preoperative SUI, staged MUS was the dominant strategy for both surgical routes with higher utility and lower costs. For women with either occult or overt SUI undergoing sacrocolpopexy or vaginal repair, concomitant MUS was cost-effective (ICER = $21,114-$96,536 per quality-adjusted life-year). Therefore, concomitant MUS is preferred for patients with preoperative SUI as higher costs were offset by higher effectiveness. One-way sensitivity analyses demonstrated that ICERs were most affected by probability of cure following MUS. CONCLUSIONS: A staged MUS procedure is the dominant strategy for women undergoing apical prolapse repair without preoperative SUI. In women with either overt or occult SUI, the ICER was below the willingness-to-pay threshold of $100,000 per quality-adjusted life-year, suggesting that concomitant MUS surgery is cost-effective.

Vaginal hysteropexy compared with vaginal hysterectomy with apical suspension for the treatment of pelvic organ prolapse: A 5-year cost-effectiveness Markov model.

OBJECTIVE: Our objective was to perform a 5-year cost-effectiveness analysis of transvaginal hysteropexy (HP) via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) versus vaginal hysterectomy (VH) with apical suspension via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) for the treatment of uterine prolapse. DESIGN: A decision analytic model assessed the cost-effectiveness of the surgical intervention over a 5-year horizon. SETTING: This model was constructed using TreeAge® software. POPULATION OR SAMPLE: Healthy women undergoing surgery for uterine prolapse were modeled. METHODS: A Markov model was constructed to simulate the possible recurrence of prolapse. Recurrence rates, repeat surgery for surgical failures and complication rates were modeled. Base case, sensitivity analyses and probabilistic modeling were performed. MAIN OUTCOME MEASURES: The primary outcome was the incremental cost-effectiveness ratio (ICER) of <$100 000 per quality-adjusted life year (QALY). RESULTS: Using the available prolapse recurrence rates and repeat surgery rates in the literature, both HP-SS and HP-US are cost-effective at a willingness-to-pay (WTP) threshold of <$100 000 per QALY. The incremental cost-effectiveness ratio (ICER) for HP-US compared to HP-SS is $90 738.14, while VH-US and VH-SS are both dominated strategies. HP-US is the optimal cost-effective strategy but decays exponentially with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. The cost-effectiveness acceptability curve (CEAC) favors sacrospinous hysteropexy until reaching a WTP threshold between $90 000 and $100 000. CONCLUSION: Hysteropexy surgical strategies are cost-effective transvaginal surgical approaches for uterine prolapse. Vaginal hysterectomy with apical suspension becomes more cost-effective with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. Given the variability of prolapse recurrence rates in the literature, more comparative studies are needed to understand the cost-effectiveness relationship between these different surgical approaches.

Estimated National Cost of Pelvic Organ Prolapse Surgery in the United States.

OBJECTIVE: To estimate the national cost of pelvic organ prolapse (POP) surgery in the United States. METHODS: In this cross-sectional, population-based study, we used the 2016-2018 Healthcare Cost and Utilization Project National Inpatient Samples and National Ambulatory Surgery Samples to identify patients undergoing POP surgery using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, ICD-10 procedural codes, and Current Procedural Terminology codes. Cost-to-charge ratios and weighted estimates were used to calculate nationwide costs. Descriptive analysis was used to identify the sociodemographic, clinical, and surgical characteristics of the population undergoing POP surgery. RESULTS: Between 2016 and 2018, there were 140,762 POP surgical cases annually with an annual national cost estimated at $1.523 billion per year. The median cost per procedure increased slightly from $8,837 in 2016 to $8,958 in 2018. Overall, 82.5% of the total surgeries and 78% of the total national costs associated with POP surgery came from the ambulatory setting over this time period. Of these surgeries, 44.7% included an apical repair, and 42.3% included a concomitant hysterectomy. The average age of the population was 62 years, and 20% of the total population receiving prolapse surgery were younger than age 50 years. CONCLUSION: The annual national cost associated with surgical correction of POP is substantial, and the majority of cases occur in an ambulatory setting. These findings will contribute to enhancing cost-effectiveness analyses and decision-making processes for both health care professionals and policymakers as the national population continues to age.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy. METHODS: We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY. RESULTS: Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone. CONCLUSIONS: In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Healthcare disparities and pelvic organ prolapse operative complications: a nationwide analysis.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the differences in the incidence of peri-operative complications at the time of pelvic organ prolapse (POP) repair based on health care disparities such as race and socioeconomic status. METHODS: The National Inpatient Sample (NIS) database was queried using ICD-9/-10 codes for patients aged >18 years undergoing POP repair in 2008-2018. Demographic information, Elixhauser Comorbidity Index (ECI), insurance status, and peri-operative complications were extracted. Multivariate weighted logistic regression using the discharge weights from NIS were constructed on binary outcomes. Complications with at least 1% incidence were included in the analysis. RESULTS: A total of 172,483 POP repair patients were analyzed: 130,022 (75.4%) were white, 10,561 (6.1%) were Black, 21,915 (12.7%) were Hispanic, and 9,985 (5.8%) were of other races. Patients with Medicaid as well as Black, Hispanic, and other races had higher odds of developing postoperative complications such as urinary tract infections, sepsis, and acute renal failure (p value <0.001-0.02). These were also more common in smaller, rural hospitals and with patients with an annual income of $45,999 or less (p value <0.001-0.03). Black and Hispanic patients had lower odds of intraoperative complications such as hemorrhage (aOR 0.77, 95% CI 0.71-0.84; aOR 0.75, 95% CI 0.7-0.8 respectively) or abdominopelvic injury (aOR 0.86, 95% CI 0.81-0.92; aOR 0.93, 95% CI 0.79-0.88 respectively) compared with white patients. CONCLUSION: Nonwhite patients with lower socioeconomic status had increased postoperative complications and fewer intraoperative complications from POP surgery, whereas white patients with higher socioeconomic status had more intraoperative complications.

A cost-effective model for training in Robot-Assisted Sacrocolpopexy.

BACKGROUND: The number of robotically assisted sacrocolpopexy procedures are increasing; therefore, experienced clinicians are needed. Simulation-based cadaver models are challenging in aspects of cost and availability. Therefore, we need to look at alternative and more cost-effective models. OBJECTIVE: The objective of this video was to design a new surgical model for the training of robotic-assisted sacrocolpopexy, which is affordable and accessible. METHODS: We used a whole chicken model to simulate the female pelvic floor. We used Medtronic's Hugo™ RAS system as the robotic console in that procedure. A vaginal cuff was prepared from the proventriculus (stomach), and a Y shaped mesh was secured to the ischium to simulate the sacrocolpopexy procedure. CONCLUSION: This model is easily constructed and in our view is cost-effective. We have demonstrated a new valuable education tool that can serve as a practical simulation model to teach the sacrocolpopexy procedure and to improve trainees' skills. A larger cohort study size is essential to demonstrate the learning curve among young trainees using this simulation model.

Effects of Same-Day Discharge on 30-Day Readmission Rates in Women Aged 65 Years and Older Undergoing Minimally Invasive Pelvic Organ Prolapse Surgery.

OBJECTIVE: To compare the effects of same-day discharge on 30-day readmission after minimally invasive pelvic organ prolapse (POP) surgery in older patients. METHODS: This retrospective cohort study examined all minimally invasive POP surgeries performed and included in the national Centers for Medicare & Medicaid Services 5% Limited Data Set (2011-2018). Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department (ED) visits. RESULTS: Of the 7,278 patients undergoing surgery, patients who had same-day discharge were older (73.5 years vs 73.1 years, P =.04) and less likely to undergo concomitant hysterectomy (9.5% vs 34.9%, P <.01) or midurethral sling (36.8% vs 40.1%, P =.02). Same-day discharge increased over the study period from 15.7% in 2011 to 25.5% in 2018 ( P <.01). On propensity score-matching multiple logistic regression, the adjusted difference was statistically significant, with same-day discharge increasing the odds of 30-day readmission compared with next-day discharge (adjusted odds ratio [OR] 1.57, 95% CI 1.19-2.08). There was no difference (OR 0.81, 95% CI 0.63-1.05) for 30-day ED visits on propensity score-matching multiple logistic regression. CONCLUSION: After minimally invasive POP surgery, older women have low rates of readmission and ED visits within 30 days. After propensity score matching and adjustment for perioperative factors, there may be increased odds in readmission and no difference in ED visits risk in those who had same-day discharge. When considering patient factors, same-day discharge after minimally invasive POP surgery may be effective for older patients.

Intraoperative ultrasound assessment of ureteral patency after uterosacral ligaments apical suspension for prolapse surgical repair: A feasibility study.

OBJECTIVE: To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions. METHODS: We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min. RESULTS: According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false-negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%. CONCLUSIONS: Ultrasound with power Doppler represents an effective and reliable non-invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis.

BACKGROUND: There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. OBJECTIVE: This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. STUDY DESIGN: We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. RESULTS: There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). CONCLUSION: This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Bilateral posterior Richter sacrospinous fixation with native tissue: Anatomical and functional results and quality of life assessment over 10 years.

INTRODUCTION: Pelvic organ prolapse (POP) is a common condition that affects 50% of women who have given birth in their lifetime. With stop of vaginal mesh sale in 2019, the sacrospinous fixation technique according to Richter with native tissue has seen its incidence tripled in 15 years. Classically, sacrospinous fixation according to Richter is performed unilaterally, however its unilateral or bilateral character is controversial. Objective of this work is to evaluate the efficacy and safety of bilateral sacrospinous fixation according to Richter by the posterior approach with native tissue (SSB). METHODS: We performed a retrospective single-center study. From March 12, 2010 to March 23, 2020, all first-time operated patients who underwent SSB in CHU Strasbourg gynecological surgery unit for symptomatic POP management were included. The main endpoint of our work is the anatomical and functional success rate at 12 and 24 months. The secondary judgment criteria of our work were based on the postoperative evaluation of patient's quality of life according to the PFDI-20 score as well as the rate of postoperative complications. RESULTS: 77 patients were included in our work. The anatomical success rate at 12 months is 94 and 81% at 24 months regardless of the compartment affected. The functional success rate is 94% at 12 months and 82% at 24 months. Quality of life evaluation through the PFDI-20 scale revealed a clear improvement in the symptomatology related to POP: 127/300 +/- 27.3. preoperatively and 59.8 ± 14.7 postoperatively. CONCLUSION: Bilateral sacrospinous fixation according to Richter by posterior approach with native tissue is a safe and effective surgical technique allowing a clear improvement in patients quality of life.

Concurrent Surgery for Locoregional Gynecologic Cancers and Pelvic Floor Disorders in a Population of Patients With Medicare Insurance.

OBJECTIVE: To estimate the rate of concurrent surgery for locoregional gynecologic cancer and pelvic organ prolapse-urinary incontinence (POP-UI) and to assess the rate of surgery for POP-UI within 5 years for those who did not undergo concurrent surgery. METHODS: This is a retrospective cohort study. The SEER-Medicare data set was used to identify cases of local or regional endometrial, cervical, and ovarian cancer diagnosed from 2000 to 2017. Patients were followed up for 5 years from diagnosis. We used χ 2 tests to identify categorical variables associated with having a concurrent POP-UI procedure with hysterectomy or within 5 years of hysterectomy. Logistic regression was used to calculate odds ratios and 95% CIs adjusted for variables statistically significant (α=.05) in the univariate analyses. RESULTS: Of 30,862 patients with locoregional gynecologic cancer, only 5.5% underwent concurrent POP-UI surgery. Of those with a preexisting diagnosis related to POP-UI, however, 21.1% had concurrent surgery. Of the patients who had a diagnosis of POP-UI at the time of initial surgery for cancer and who did not undergo concurrent surgery, an additional 5.5% had a second surgery for POP-UI within 5 years. The rate of concurrent surgery remained constant over the time period (5.7% in 2000 and 2017) despite an increase in the frequency of POP-UI diagnosis in the same time frame. CONCLUSION: The rate of concurrent surgery for patients with an early-stage gynecologic cancer and POP-UI-associated diagnosis in women older than age 65 years was 21.1%. Of women who did not undergo concurrent surgery but had a diagnosis of POP-UI, 1 in 18 underwent surgery for POP-UI within 5 years of their index cancer surgery. Dedicated efforts must be made to identify patients who would most benefit from concurrent cancer and POP-UI surgery in those with locoregional gynecologic cancers and pelvic floor disorders.

Pelvic floor disorder assessment of knowledge and symptoms: an educational intervention for Spanish-speaking women (PAKS study).

INTRODUCTION AND HYPOTHESIS: Educational interventions have been effective in improving postpartum knowledge, performance of pelvic floor exercises, and bowel-specific quality-of-life. Our primary objective was to determine if a video-based educational intervention on pelvic floor disorders (PFDs) would increase Spanish-speaking women's knowledge of PFDs, and secondarily to assess if it would decrease pelvic floor symptoms. We hypothesized that Spanish-speaking women would improve their pelvic floor knowledge and symptoms post-intervention. METHODS: Inclusion criteria included women age 18 years and older and self-reported as a predominantly Spanish-speaker or equally bilingual English- and Spanish-speaker. Changes in knowledge were assessed with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). Changes in symptoms were assessed with the Pelvic Floor Distress Inventory-20 (PFDI-20). Linear regression assessed for independent effects. RESULTS: One hundred and fourteen women were enrolled and 112 completed the pre- and post-intervention PIKQ. Mean (standard deviation [SD]) age was 50 (14) years. Immediate post-intervention scores showed significant improvement in knowledge. Total PIKQ score improved by 5.1 (4.7) points (p < 0.001). POP subscore improved by 2.7 (2.7) points (p<0.001) and UI subscore improved by 2.3 (2.5) points (p < 0.001). Improvement in knowledge continued after four weeks (p < 0.001). PFDI-20 prolapse (p=0.02), colorectal-anal (p < 0.001) and urinary (p = 0.01) scores significantly improved only for the most symptomatic women at baseline. Using linear regression, total PIKQ (p = 0.03) and total PFDI-20 scores (p = 0.04) were associated with predominantly Spanish-speakers versus fully bilingual. CONCLUSION: Findings support the efficacy of a video-based educational intervention to improve knowledge of PFDs in Spanish-speaking women. The most symptomatic women benefitted from this intervention.

Involving people with a lived experience when developing a proposal for Health Technology Assessment research of nonsurgical treatments for pelvic organ prolapse: Process and reflections.

INTRODUCTION: Patient and public involvement (PPI) is an expectation when conducting research, including Health Technology Assessment (HTA), but practical guidance for those wishing to embed PPI into the grant application process is not always easily accessible. We wanted to ensure that PPI was central when preparing a proposal for an investigator-led evidence synthesis HTA investigating nonsurgical interventions for pelvic organ prolapse (POP) in women. Here, we describe our methods. METHODS: We recruited two patient co-applicants separately through an open process to help ensure that patient voice was present within our proposal's management and direction. We invited co-applicants to attend research team meetings and comment on the full proposal. We designed, recruited to and facilitated a scoping workshop, as well as undertook its subsequent evaluation. The insight shared within the workshop for patients with a lived experience of POP, including our patient co-applicants, helped us develop the scope and rationale behind our HTA proposal. We particularly considered the interventions to include within the evidence synthesis. We also considered the outcome measures for both the evidence synthesis and economic evaluation. We elicited ideas about where and how results could be disseminated. Feedback suggested the workshop was as valuable for the attendees as it was for the researchers, making them feel valued and listened to. The time spent by researchers working on the activity was substantial and not directly funded but a necessary and valuable activity in developing our potential HTA. Our work was informed using the UK Standards for Public Involvement and the Authors and Consumers Together Impacting on eVidencE (ACTIVE) framework. CONCLUSIONS: PPI can be enormously valuable in both developing and strengthening research proposals. However, further guidance is needed to help researchers recognise the level and type of involvement to use at this early stage, particularly given the large time investment needed to embed meaningful PPI. PATIENT AND PUBLIC CONTRIBUTION: Women with a lived experience of POP were involved at every stage of the grant application process; their involvement is documented in full throughout this work.

Non-invasive biomechanical assessment of the prolapsed vaginal wall: an explorative pilot study on cutometry and indentometry.

The clinical assessment of pelvic organ prolapse (POP) and associated treatment strategies is currently limited to anatomical and subjective outcome measures, which have limited reproducibility and do not include functional properties of vaginal tissue. The objective of our study was to evaluate the feasibility of using cutometry and indentometry for non-invasive biomechanical assessment of the vaginal wall in women with POP. Both techniques were applied on the vaginal wall of 20 women indicated for surgical correction of POP stage two or higher. The primary outcome was the measurement success rate. Measurements were considered successful if biomechanical parameters were generated after a maximum of three attempts. Secondary outcomes included acquisition time, number of attempts to obtain a successful measurement, and biomechanical parameters. Measurements were successfully performed on the anterior vaginal wall of 12 women with cystocele and the posterior vaginal wall of eight women with rectocele. The success rate was 100% for both techniques and acquisition time was under 1 minute for all 20 measurements. Tissue fast elasticity of the posterior vaginal wall (rectocele) was significantly higher than that of the anterior vaginal wall (cystocele) and negatively correlated with age (r = - 0.57, P < 0.05). In women with POP, measuring the biomechanical properties of the vaginal wall using cutometry and indentometry is technically feasible. Objective evaluation of biomechanical properties may help to understand the pathophysiology behind surgical outcomes, providing an opportunity for the identification of patients at risk for (recurrent) prolapse, and individualized treatment decisions.

General Versus Regional Anesthesia in Sacrospinous Ligament Fixation for Pelvic Organ Prolapse: Assessment of a National Database.

IMPORTANCE: Sacrospinous ligament fixation is a prolapse repair surgical procedure that can be performed under general or regional anesthesia. Little is known about the impact of anesthesia on postoperative outcomes. OBJECTIVES: The primary objective of this study was to compare 30-day complication rates for patients undergoing sacrospinous ligament fixation by anesthesia type. Secondary objectives were to assess factors associated with type of anesthesia selected. STUDY DESIGN: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program for the years of 2015 to 2020. Cases were selected based on procedural codes for sacrospinous ligament fixation and diagnostic codes for prolapse. Complications, readmissions, and reoperations were compared between general versus regional anesthesia cohorts. RESULTS: A total of 2,984 cases were included with 2,742 (91.9%) performed under general and 242 (8.1%) performed under regional anesthesia. The regional anesthesia cohort was older (69.2 vs 65.4 years old; P < 0.001) with no differences in medical history variables. Fewer patients in the regional anesthesia cohort were Hispanic (0.4% in regional vs 10.8% in general cohorts, P < 0.001). More superficial surgical site infections (2.5% vs 0.8%, P = 0.026) and cardiac complications (0.8% vs 0.1%, P = 0.035) were noted in the regional anesthesia cohort. However, multivariable regression analysis showed that anesthesia type was not associated with increased rates of minor or major complications. CONCLUSIONS: Mode of anesthesia was not a significant predictor of minor or major complications. Racial and ethnic differences in mode of anesthesia warrant further investigation to reduce racial disparities.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Early adulthood and current physical activity and their association with symptoms of pelvic floor disorders in middle-aged women: An observational study with retrospective physical activity assessment.

OBJECTIVE: To investigate associations of early and middle adulthood physical activity (PA) with symptoms of pelvic floor disorders (PFDs), i.e. stress urinary incontinence (SUI), urge urinary incontinence (UUI), faecal incontinence (FI), constipation or defecation difficulties (CDDs) and feeling of pelvic organ prolapse (POP) among middle-aged women. DESIGN: A cross-sectional, observational study with retrospective PA assessment. SETTING: University Research Laboratory. SAMPLE: A random population sample of 1098 Finnish women aged 47-55 years. METHODS: Early adulthood PA, current PA, and demographic and gynaecological variables were assessed using self-report questionnaires. Logistic regression analyses were applied to study associations of PA variables with symptoms of PFDs. Potential confounding effects of demographic and gynaecological variables were controlled in multiple logistic regression models. MAIN OUTCOME MEASURES: Structured questionnaire-assessed retrospective PA assessment at the age of 17-29 years, current PA at middle age, and prevalence of symptoms of CDD, FI, POP, SUI and UUI. RESULTS: Current PA was not independently associated with the occurrence of the symptoms of PFDs. Middle-aged women with an early adulthood history of competitive sports were more likely to experience symptoms of UUI (OR 2.16, 95% CI 1.10-4.24, p = 0.025) but not symptoms of SUI, FI, CDD or POP, whereas women with a history of regular PA were more likely to experience symptoms of FI (OR 4.41, 95% CI 1.05-18.49, p = 0.043) but no other symptoms of PFDs. CONCLUSIONS: Competitive sports during early adulthood may increase the risk of UUI in middle age. Regular PA during early adulthood may increase the risk of FI.