Comparison of complications and prolapse recurrence between laparoscopic and vaginal uterosacral ligament suspension for the treatment of vaginal prolapse.

INTRODUCTION AND HYPOTHESIS: Our objective was to compare complications and prolapse recurrence between laparoscopic (L-USLS) and vaginal (V-USLS) uterosacral ligament suspensions. METHODS: This is a retrospective study of USLS procedures performed at a large academic center from 2011 to 2014. Patient demographics, surgical data, complications, and prolapse recurrence of L-USLS and V-USLS were compared. Logistic regression identified predictors of operative time, complications, and prolapse recurrence. RESULTS: There were 54 L-USLS and 119 V-USLS procedures with median follow-up of 21.5 weeks (IQR 9.3-50.8). Women undergoing L-USLS were less likely to have medical comorbidities and had less severe prolapse, but were more likely to report prior hysterectomy. L-USLS had longer operative times (190.1 ± 46.8 vs 172.7 ± 47.3 min, p = 0.03), but after correcting for concomitant procedures, the operative times of the two approaches were not significantly different (adjusted OR 1.00, 95%CI 0.99-1.00). There was no significant difference in complications between groups (24.1 % vs 21.8 %, p = 0.75). However, there were nonsignificant trends toward more ureteral injuries and suture removals following V-USLS. Postoperative POP-Q points of the groups did not differ, except for total vaginal length (TVL), which was longer after L-USLS (8.3 ± 1.1 cm vs 7.4 ± 1.2 cm, p < 0.001). 19 patients met the composite definition of prolapse recurrence, with no significant difference between groups (16.2 % vs 16 %, p = 0.98). After adjusting for preoperative prolapse stage, route was not a significant predictor of prolapse recurrence (adjusted OR 0.39, 95 % CI 0.12-1.30). CONCLUSIONS: L-USLS has comparable clinical outcomes, with similar rates of complications and prolapse recurrence to the traditional vaginal approach.

Apical support at the time of hysterectomy for uterovaginal prolapse.

INTRODUCTION AND HYPOTHESIS: The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. METHODS: Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. RESULTS: A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1%) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8% vs 9.4%, p < 0.001), but less likely to have rectocele (3.4% vs 12.2%, p < 0.001) or combined cystocele/rectocele repair (16.4% vs 25.6%, p < 0.001). Of those without apical procedures, 95.7% were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1% and 88.8% vs 23.6%, p < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95% CI 3.127-8.304). Surgeons practicing for 10-14 years and >20 years were less likely to perform apical procedures than those practicing <5 years (p < 0.001 vs. p = 0.01). CONCLUSIONS: At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.

Utility of dipstick urinalysis in peri- and postmenopausal women with irritative bladder symptoms.

INTRODUCTION AND HYPOTHESIS: Previous studies of dipstick urinalysis (UA) in asymptomatic peri- and postmenopausal women demonstrate poor sensitivity to detect a urinary tract infection (UTI). We hypothesized that sensitivity of this test would be improved in symptomatic peri- and postmenopausal women. METHODS: This was a cross-sectional study of 76 women seeking urogynecology care for irritative bladder symptoms. Subjects with a positive clean-catch (CC) dipstick UA for leukocyte esterase (LE) or nitrites (NIT) were offered enrollment. Dipstick UA was performed on CC and catheterized specimens, followed by microbiologic culture. Test characteristics were calculated for CC and catheterized UA. CC culture was compared with catheterized culture (gold standard) using Spearman's correlation coefficient. RESULTS: Data was available for analysis in 75/76 (98.7 %) enrolled subjects. Mean age was 68 ± 11 years. Most subjects were postmenopausal (98.7 %) and Caucasian (97.3 %). Dipstick sensitivity ranged from 48 % to 87 % and 35 % to 57 % in CC and catheterized specimens, respectively. Dipstick UA from a CC specimen positive for NIT had the highest sensitivity (60.9), specificity (100), negative predictive value (85.2), and positive predictive value (100) in this population. Dipstick UA from CC and catheterized specimens had similar sensitivity for detecting UTIs. When culture results of 10(3) colony-forming units were considered positive, CC and catheterized specimens were moderately correlated (ρ = 0.470). CONCLUSIONS: Dipstick UA in this study had improved sensitivity compared with previously published results in both CC and catheterized samples. Initiation of empiric antibiotic treatment in women with irritative bladder symptoms and NIT-positive CC dipstick UA prior to obtaining urine culture results is a reasonable option.

Changes in prolapse surgery trends relative to FDA notifications regarding vaginal mesh.

INTRODUCTION AND HYPOTHESIS: In 2008 and 2011, the US Food and Drug Administration (FDA) released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native tissue repairs would increase. METHODS: Operative reports were reviewed for all prolapse repairs performed from 2008 to 2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of two FDA notifications. We used linear regression to analyze surgical trends and chi-square for demographic comparisons. RESULTS: One thousand two hundred and eleven women underwent 1,385 prolapse procedures. Mean age was 64 ± 12, and 70 % had stage III prolapse. Vaginal mesh procedures declined over time (p = 0.001), comprising 27 % of repairs in early 2008, 15 % at the first FDA notification, 5 % by the second FDA notification, and 2 % at the end of 2011. The percentage of native tissue anterior/posterior repairs (p < 0.001) and apical suspensions (p = 0.007) increased, whereas colpocleisis remained constant (p = 0.475). Despite an overall decrease in open sacral colpopexies (p < 0.001), an initial increase was seen around the first FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter (p < 0.001). All sacral colpopexies combined as a group declined over time (p = 0.011). CONCLUSIONS: Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing two FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native tissue repairs and minimally invasive sacral colpopexies.

Hysterectomy surgery trends: a more accurate depiction of the last decade?

OBJECTIVE: The objective of the study was to describe trends in hysterectomy route at a large tertiary center. STUDY DESIGN: We reviewed all hysterectomies performed at Magee-Womens Hospital from 2000 to 2010. This database was chosen over larger national surveys because it has been tracking laparoscopic procedures since 2000, well before laparoscopic hysterectomy International Classification of Diseases, ninth revision (ICD-9) procedure codes were developed. RESULTS: There were 13,973 patients included who underwent hysterectomy at Magee-Womens Hospital. In 2000, 3.3% were laparoscopic (LH), 74.5% abdominal (AH), and 22.2% vaginal hysterectomy (VH). By 2010, LH represented 43.5%, AH 36.3%, VH 17.2%, and 3.0% laparoscopic converted to open (LH→AH). Hysterectomies performed for gynecological malignancy represented 24.4% of cases. The average length of stay for benign LH and VH, 1.0 ± 1.0 and 1.6 ± 1.0 days respectively, was significantly shorter than the average 3.1 ± 2.3 day stay associated with AH (P < .001). The average patient age was 46.9 ± 10.9 years for LH, 51.5 ± 12.1 years for AH, and 51.7 ± 14.1 years for VH, and over the study period there was a significant trend of increasing patient age (b1 = 0.517, 0.583, and 0.513, respectively [P < .001 for all]). CONCLUSION: The percentage of LH increased over the last decade and by 2010 had surpassed AH. The 43.4% LH rate in 2010 is much higher than previously reported in national surveys. This likely is due to an increase in the number of laparoscopic procedures being performed over the last few years as well as the ability of our study to capture LH prior to development of appropriate ICD-9 procedure codes. Our unique ability to determine hysterectomy route, which predates appropriate coding, may provide a more accurate characterization of hysterectomy trends.

Impact of COVID-19 on gynecologic and obstetrical services at two large health systems.

BACKGROUND: The COVID-19 pandemic disrupted medical care in the US, leading to a significant drop in utilization of some types of health services. We sought to quantify how the pandemic influenced obstetrics and gynecology care at two large health care organizations. MATERIALS AND METHODS: Comparing 2020 to 2019, we quantified changes to obstetrics and gynecology care at two large health care organizations in the United States, Allegheny Health Network (in western Pennsylvania) and Johns Hopkins University (in Maryland). The analysis considered the numbers of surgical encounters, in-person visits, and telemedicine visits. For each system, we quantified temporal changes in surgical volume, in-person and telemedicine visits, and financial impact related to professional fee revenues. We used segmented regression to evaluate longitudinal effects. RESULTS: At both institutions, the volume of care was similar in the first few months of 2020 compared to 2019 but dropped precipitously in March 2020. From April to June 2020, surgical volumes were 67% of the same period in 2019 at Allegheny Health and 48% of the same period in 2019 at Johns Hopkins. During that same interval, televisits accounted for approximately 21% of all ambulatory care at both institutions. Although surgical and ambulatory volumes recovered in the second half of 2020, annual surgical volumes in 2020 were significantly lower than 2019 at both institutions (p<0.05) and 2020 ambulatory volumes remained significantly lower at Johns Hopkins (p = .0006). Overall, revenues in 2020 were 91% of 2019 revenues for both institutions. CONCLUSIONS: Obstetrical and gynecologic ambulatory visits and gynecologic surgeries were sharply reduced during the COVID-19 pandemic. Although care volumes returned to 2019 levels in late 2020, we observed an overall reduction in the volume of care provided and a 9% reduction in professional revenue for both institutions.

Intravenous Acetaminophen Before Pelvic Organ Prolapse Repair: A Randomized Controlled Trial.

OBJECTIVE: To compare the effect of preoperative intravenous (IV) acetaminophen compared with placebo on pain scores after pelvic organ prolapse surgery. METHODS: This double-blind placebo-controlled multicenter trial randomized women undergoing prolapse surgery to IV acetaminophen (1,000 mg) or preoperative saline stratified by surgical route (laparoscopic or vaginal). The primary outcome was the change from baseline in patient-reported visual analog scale pain scores at 24 hours after surgery. Secondary outcomes included narcotic use measured in morphine milligram equivalents, satisfaction and quality of life (QOL) using validated questionnaires on postoperative days 1 and 7, and overall side effects. RESULTS: Between 2014 and 2017, 204 women were enrolled and primary-outcome data from 162 were analyzed. Women had a mean (±SD) age of 66±10 years, were predominantly Caucasian (96%) and postmenopausal (96%). Acetaminophen was administered to 52 of the 101 women undergoing vaginal surgery, and 50 of the 101 women undergoing laparoscopy. There were no overall or route of surgery differences in mean change from baseline pain scores at 24 hours between acetaminophen and placebo (overall 25±26 vs 21±24 mm; vaginal 29±28 vs 21±23 mm; laparoscopic 20±26 vs 21±25 mm). There were no differences in 24-hour morphine milligram equivalent narcotic use (overall 38±25 vs 40±25 mg; vaginal 32±24 vs 33±25 mg; laparoscopic 45±24 vs 47±24 mg). No differences were seen in patient satisfaction, QOL, or side effects, except for urinary retention. CONCLUSION: In women undergoing prolapse repair, preoperative IV acetaminophen did not reduce pain scores or opioid use and had no effect on patient satisfaction or QOL. Routine use of preemptive IV acetaminophen alone is not supported by this study. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02155738.

Impact of Case Order on Laparoscopic Sacrocolpopexy: Do Surgeons Need a Warm-Up?

OBJECTIVES: Warm-up is defined as a preparatory activity or procedure. Using case order as a surrogate for surgeon warm-up, first cases were compared with second or later cases for intraoperative complications, operative time, and length of stay (LOS) among women undergoing laparoscopic sacrocolpopexy. METHODS: This is a retrospective study of laparoscopic sacrocolpopexies performed from 2009 through 2014 at a large academic center. Any surgery preceding laparoscopic sacrocolpopexy was considered a surrogate for surgeon warm-up. Logistic and linear regression analyses were used to identify predictors of complications, operative time, and LOS. RESULTS: Of 480 procedures, 192 (40%) were first cases and 288 (60%) were second or later. Baseline characteristics were similar between groups. Intraoperative complication rate was not different between groups (6.3% vs 3.1%, P = 0.50) even after controlling for risk factors. Operative times were comparable on initial analysis (231.2 ± 55.2 vs 225.9 ± 51.2 minutes, P = 0.28l), but a small difference was detected after adjusting for confounding factors (body mass index, menopausal status, surgeon experience, intraoperative complications, and concomitant hysterectomy or midurethral sling; adjusted ß = 8.44 minutes, P = 0.037). Length of stay was longer for first case patients (1.44 ± 0.67 vs 1.24 ± 0.50 days, P < 0.001) even after adjusting for age, medical comorbidities, operative time, conversion to laparotomy, ileus/bowel obstruction, and postoperative urinary retention (adjusted ß = 0.183 days, P = 0.001) as well as after accounting for delayed start time of second or later cases. CONCLUSIONS: Laparoscopic sacrocolpopexy performed first case of the day without preoperative surgeon warm-up conferred no significant increase in intraoperative complications. Second or later cases were associated with small decreases in operative time and in LOS.

Predictors of postoperative acute urinary retention in women undergoing minimally invasive sacral colpopexy.

OBJECTIVES: Our aim was to determine predictors of acute urinary retention in women undergoing laparoscopic and robotic sacral colpopexy. METHODS: Records from all minimally invasive sacral colpopexies performed from 2009 to 2012 were reviewed. All women had a retrograde fill voiding trial (RGVT) on postoperative day 1, except in cases of intraoperative bladder injury or chronic urinary retention. Patient demographics, medical comorbidities, and surgical factors were compared between women who did and did not pass the RGVT. Univariable and multivariable logistic regression analyses were used to identify predictors of postoperative voiding dysfunction. RESULTS: Three hundred two subjects met the inclusion criteria, but 12 were excluded because of planned prolonged catheterization. Of the remaining 290 subjects, 211 (72.8%) passed the RGVT. The mean (SD) for the duration of urinary retention in those who failed was 3.7 (4.2) days. The mean (SD) for age was 58.5 (8.6) years, and the median preoperative prolapse was Pelvic Organ Prolapse Quantification stage III (76.1% with ≥ stage III) with mean Ba = +2.3. There were no significant independent risk factors identified on multivariable logistic regression to predict RGVT failure, with only concurrent midurethral sling approaching significance (6.1% vs 12.5%; adjusted odds ratio, 2.25; 95% confidence interval, 0.93-5.45; P = 0.07). CONCLUSIONS: No significant predictors of acute urinary retention were identified among women undergoing minimally invasive sacral colpopexy. In contrast to published analyses of vaginal prolapse repairs, large preoperative cystocele and concurrent midurethral sling were not significantly associated with retention. Given the inability to predict who will have postoperative urinary retention, all patients should be counseled about the potential need for catheterization.