Black women's perspectives on bladder health: Social-ecological and life course contexts.

AIMS: This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective. METHODS: We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American. RESULTS: Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems. CONCLUSIONS: Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Underrepresentation of Non-White Participants in the American Academy of Orthopaedic Surgeons Guidelines for Surgical Management of Knee Osteoarthritis.

BACKGROUND: The aim of this study was to examine the racial and ethnic representation in studies included in the 2015 American Academy of Orthopaedic Surgeons Surgical Management of the Knee Evidence-Based Clinical Practice Guideline relative to their representation of the United States (US). METHODS: The demographic characteristics reported in articles included in the 2015 American Academy of Orthopaedic Surgeons Surgical Management of the Knee Evidence-Based Clinical Practice Guideline were analyzed. The primary outcome of interest was the representation quotient, which is the ratio of the proportion of a racial/ethnic group in the guideline studies relative to their proportion in the US. There were 211 studies included, of which 15 (7%) reported race. There were 35 studies based in the US and 7 of the US-based studies reported race. RESULTS: No US-based studies reported race and ethnicity separately, no studies reported American Indian/Alaska Native participants and no US-based studies reported Asian participants. The representation quotient of US-based studies was 0.66 for Black participants, 0.33 for Hispanic participants, and 1.30 for White participants, which indicates a relative over-representation of White participants compared to national proportions. CONCLUSION: This study illustrated that the evidence base for the surgical management of knee osteoarthritis has been constructed from studies which fail to consider race and ethnicity. Of those US-based studies which do report race or ethnicity, study cohorts do not reflect the US population. These results illustrate a disparity in clinical orthopedic surgical evidence and highlight the need for improved research recruitment strategies.

Development of a tool to assess bladder health knowledge, attitudes, and beliefs (BH-KAB).

INTRODUCTION: Few instruments measure knowledge, attitudes, and beliefs (KAB) related to bladder health. Existing questionnaires have predominantly focused on KAB related to specific conditions such as urinary incontinence, overactive bladder, and other pelvic floor disorders. To address this literature gap, the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium developed an instrument that is being administered in the baseline assessment of the PLUS RISE FOR HEALTH longitudinal study. METHODS: The bladder health knowledge, attitudes, and beliefs (BH-KAB) instrument development process consisted of two phases, item development and evaluation. Item development was guided by a conceptual framework, review of existing KAB instruments, and a review of qualitative data from the PLUS consortium Study of Habits, Attitudes, Realities, and Experiences (SHARE). Evaluation comprised three methods to assess content validity and reduce and refine items: q-sort, e-panel survey, and cognitive interviews. RESULTS: The final 18-item BH-KAB instrument assesses self-reported bladder knowledge; perceptions of bladder function, anatomy, and related medical conditions; attitudes toward different patterns of fluid intake, voiding, and nocturia; the potential to prevent or treat urinary tract infections and incontinence; and the impact of pregnancy and pelvic muscle exercises on bladder health. CONCLUSION: The PLUS BH-KAB instrument may be used independently or in conjunction with other KAB instruments for a more comprehensive assessment of women's KAB related to bladder health. The BH-KAB instrument can inform clinical conversations, health education programming, and research examining potential determinants of bladder health, LUTS, and related behavioral habits (e.g., toileting, fluid intake, pelvic muscle exercises).

Surgical versus nonsurgical treatment selection patterns among Asian American patients with pelvic floor disorders: a matched cohort study.

INTRODUCTION AND HYPOTHESIS: The objective was to determine if Asian racial identity was associated with the selection of surgical versus nonsurgical treatments for pelvic floor disorders (PFDs). Secondarily, we aimed to determine if there were other demographic or clinical characteristics associated with treatment selection patterns. METHODS: This was a retrospective matched cohort study that examined new patient visits (NPVs) of Asian patients at an academic urogynecology practice in Chicago, IL, USA. We included NPVs with primary diagnoses of anal incontinence, mixed urinary incontinence, stress urinary incontinence, overactive bladder, or pelvic organ prolapse. We identified Asian patients with self-identified racial identity recorded in the electronic medical records. Every Asian patient was age matched to white patients in a 1:3 ratio. The primary outcome was surgical versus nonsurgical treatment selection for their primary PFD diagnosis. Comparison of demographic and clinical variables between the two groups and multivariate logistic regression models were performed. RESULTS: A total of 53 Asian patients and 159 white patients were included in this analysis. Asian patients were less likely to be English speaking (92% vs 100%, p=0.004), endorse history of anxiety (17% vs 43%, p<0.001), and report history of any pelvic surgery (15% vs 34%, p=0.009) than white patients. When controlling for race, age, history of anxiety, depression, prior pelvic surgery, sexual activity, Pelvic Organ Prolapse Distress Inventory, Colorectal-Anal Distress Inventory, and Urinary Distress Inventory scores, Asian racial identity (adjusted odds ratio 0.36 [95% CI 0.14-0.85]) was independently associated with decreased likelihood of choosing surgical treatments for PFDs. CONCLUSIONS: Asian patients with PFDs were less likely than white patients to undergo surgical treatment for their PFDs despite similar demographic and clinical characteristics.

Exploratory mixed methods study on care-seeking behaviors of Asian Americans with pelvic floor symptoms.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate whether younger age was associated with noncare-seeking behavior among Asian Americans with pelvic floor symptoms, and secondarily, to explore multilevel factors that may contribute to noncare-seeking behavior in this population. METHODS: We performed a concurrent mixed methods study and heterogeneously sampled Asian Americans with urinary incontinence, urgency-frequency, vaginal bulge, or anal incontinence. We stratified the participants into two groups, care seekers vs noncare seekers. Using Anderson's model as the main framework, we administered validated questionnaires and conducted semi-structured interviews to explore factors associated with care-seeking behaviors. RESULTS: Seventy-eight surveys and 20 interviews were completed and analyzed. Most participants reported urinary leakage (67%), followed by urinary urgency-frequency (50%), anal incontinence (18%), and vaginal bulge (17%). The mean age of the study cohort was 46.1 ± 16.2 years. We found noncare seekers to be younger and with an increased proportion of lifetime spent in the USA than care seekers. When controlling for age, proportion of lifetime spent in the USA, symptom severity, and individual-level resources, both younger age and increased proportion of lifetime spent in USA remained independently associated with noncare-seeking behavior. From qualitative data, we found that noncare seekers often experienced anti-Asian racism across workplace, neighborhoods, and health care settings. Additionally, noncare seekers also reported symptom minimization and decreased self-efficacy when coping with their pelvic floor symptoms. CONCLUSIONS: We found that one's age and proportion of lifetime spent in the USA may affect the extent of exposure to anti-Asian racism that is associated with symptom minimization, increased perceived barrier, and noncare-seeking behavior.

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

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

Opportunities to Advance Postpartum Pelvic Floor Care With a Health Equity-based Conceptual Framework.

An essential part of postpartum care includes the evaluation and treatment of pelvic floor disorders (PFDs). Postpartum PFDs are common and occur in over 40% of postpartum women. Despite significant advancements in urogynecology to understand postpartum PFDs and their treatments, there has been a lack of attention to addressing equity in postpartum pelvic floor care. In this article, we address the current scientific understanding of postpartum PFDs while adapting a health equity-based conceptual framework to highlight areas of opportunity in optimizing postpartum pelvic floor care.

The association between surgeon subspecialty training and postoperative outcomes following surgery for pelvic organ prolapse.

BACKGROUND: Symptomatic pelvic organ prolapse is common and affects 25% to 35% of women worldwide. As this growing patient need is being met by surgeons from diverse training backgrounds, it is important to both characterize the differences in surgeon practice patterns and examine postoperative outcomes to ensure optimal patient care. OBJECTIVE: To determine the association between surgeon specialty and postoperative outcomes following surgery for pelvic organ prolapse. STUDY DESIGN: This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Gynecologic reconstructive surgery targeted database between 2014 and 2018. Pelvic organ prolapse surgeries were identified using Current Procedural Terminology codes, and surgical cases performed by urogynecologists or obstetrician-gynecologists were included for analysis. The primary outcome was any 30-day postoperative complication following prolapse surgery. The secondary outcomes were any major or minor postoperative complications, genitourinary complications, reoperation, or readmission within 30-days following surgery. Descriptive statistics were used to characterize the cohort, and pairwise analyses were used to describe the differences between the cases performed by the surgeon specialties. Multivariable logistic regression was used to control for potential confounders. RESULTS: A total of 3358 women underwent prolapse surgery-68% performed by urogynecologists and 32% by obstetrician-gynecologists. The 30-day postoperative complication rate was higher for surgeries performed by obstetrician-gynecologists than for surgeries performed by urogynecologists (10.7% vs 7.0%, respectively; P<.001). There was no difference in the readmission rates between the 2 groups (2.1% vs 2.0%; P=1.000). However, the reoperation rates were higher for surgeries performed by obstetrician-gynecologists (1.8% vs 1.0%; P=.040). In a multivariable logistic regression model controlling for age, body mass index, American Society of Anesthesiology class, smoking, and type of concomitant surgery (hysterectomy, apical suspension, other prolapse surgery, obliterative procedure, or sling), prolapse surgery performed by a urogynecologist remained associated with nearly 40% lower odds of any 30-day postoperative complication (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80). CONCLUSION: Prolapse surgery performed by a urogynecologist is associated with lower odds of any 30-day postoperative complication than that performed by an obstetrician-gynecologist.

Racial disparities in complications and costs after surgery for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The study objective was to examine the impact of race on inpatient complications and costs after inpatient surgery for pelvic organ prolapse (POP). METHODS: In this retrospective cohort study, we identified women who underwent surgery for POP between 2012 and 2014. Patient demographics, outcomes, hospital characteristics, and hospital costs were extracted. Demographic and clinical characteristics were compared by race using Kruskal-Wallis for continuous variables and Chi-squared test for categorical variables. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs respectively. RESULTS: A total of 29,347 women with a median age of 62 years underwent inpatient surgery for POP between 2012 and 2014. There were 4,419 women (15%) who had at least one in-hospital postoperative complication. Rates of any postoperative complication were significantly higher among Black women (20%) than among white, Hispanic, and women of other races (16%, 11%, and 13% respectively, p < 0.01). The median total cost associated with surgeries for POP was $8,267 (IQR $6,008-$11,734). After multivariate analyses controlled for potential confounders, postoperative complications remained independently associated with Black race (aOR 1.21) whereas Hispanic and other races were associated with decreased odds of complications (aOR 0.62, and aOR 0.77) relative to white race. After controlling for confounders, Hispanic women had lower associated hospital costs. CONCLUSIONS: Black women undergoing inpatient surgery for POP had a 21% increase in the odds of complications, but no difference in costs compared with white women, whereas Hispanic women had the lowest odds of complications and lowest costs.

Perioperative outcomes of laparoscopic sacrocolpopexy with and without hysterectomy: a secondary analysis of the National Surgical Quality Improvement Program Database.

INTRODUCTION AND HYPOTHESIS: The objective was to compare 30-day perioperative complications in women undergoing minimally invasive sacrocolpopexy with and without a concomitant hysterectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified women undergoing minimally invasive sacrocolpopexy between 2014 and 2018. Women were then stratified into two groups: sacrocolpopexy only and sacrocolpopexy + hysterectomy. The primary outcome was the occurrence of any 30-day postoperative complication. Group comparisons were performed using Student's t test, Mann-Whitney U test, and Chi-squared test. Multivariate logistic regression was used to identify independent factors associated with the occurrence of any complication. RESULTS: A total of 8,553 women underwent laparoscopic sacrocolpopexy, 5,123 (59.9%) of whom had a concomitant hysterectomy. Median operative time was longer in women who had sacrocolpopexy + hysterectomy compared with sacrocolpopexy alone (185 [129-241] versus 172 [130-224] min, p < 0.001). The rate of any 30-day postoperative complication did not differ between groups (sacrocolpopexy + hysterectomy 5.5% versus sacrocolpopexy alone 5.8%, p = 0.34). Likewise, organ space, deep, and superficial surgical site infections did not differ between groups. There was also no difference in reoperation or readmission rates between groups. On multivariate logistic regression, sacrocolpopexy + hysterectomy were not associated with increased odds of 30-day postoperative complications relative to women who underwent sacrocolpopexy alone. CONCLUSIONS: Complication rates during the first 30 days after minimally invasive sacrocolpopexy are low and concomitant hysterectomy is not associated with increased risks of 30-day complications after surgery.

Predictors of postoperative complications from stress urinary incontinence procedures: a NSQIP database study.

INTRODUCTION AND HYPOTHESIS: There are few studies examining patient risk factors for postoperative complications following midurethral sling (MUS) placement for stress urinary incontinence (SUI). The objective of this study was to describe 30-day postoperative complications after MUS using the National Surgical Quality Improvement Program database. Secondary objectives included rates of readmission and patient factors associated with postoperative complications and readmissions following MUS. METHODS: We identified 16,491 women who underwent MUS for SUI between 2014 and 2018. American Society of Anesthesia (ASA) classification, medical comorbidities, readmission, reoperation, and 30-day postoperative complications were extracted. Outcomes included the 30-day postoperative complications, readmission, and reoperations. Descriptive statistics, univariate analyses, and multivariate logistic regression were used. RESULTS: The majority of patients were white (66.9%) and had an ASA classification II (60.9%). Postoperative complications occurred in 4.2% of patients; 1.5% required readmission and 1.0% required reoperation. The most common complication was urinary tract infection (3.4%). Using multivariate logistic regression, older age, i.e., ≥80 years of age, was associated with increased odds of complication (aOR 1.77, 95%CI 1.14-2.72) and readmission (aOR 3.84, 95%CI 1.76-8.66). ASA class III and IV were associated with increased odds of complications (aOR 1.55, 95%CI 1.13-2.14, and aOR 3.06, 95% CI 1.48-5.86 respectively) and readmissions. Women of Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander descent ("other") were associated with increased postoperative complications (aOR 1.51, 95%CI 1.07-2.07). CONCLUSION: Postoperative complications following MUS are rare. Factors associated with complications following MUS for SUI include age, ASA class, and women of "other" race.

Considerations for the Use of Race in Research in Obstetrics and Gynecology.

The race variable in research has been the topic of debate in both research and clinical realms. The tension surrounding the discourse of the use of race in research stem from the difficulties in defining race, the limitations of the variable, and the implications for health and racial equity. In this review, we dissect the challenges faced when incorporating race into research and offer a guide for incorporating race in research in a manner that promotes racial and health equity.

Is there an Association between Vaginal Birth after Cesarean Prediction and Obstetric Anal Sphincter Injury?

OBJECTIVE: This study aimed to estimate whether there is an association between the predicted probability of vaginal birth after cesarean delivery (VBAC) and the occurrence of obstetric anal sphincter injuries (OASIS). STUDY DESIGN: This was a single-site retrospective cohort study of all women with a singleton vaginal birth after a previous cesarean section between January 2011 and December 2016. Women were divided into four ordinal groupings by the predicted probability of achieving vaginal birth after cesarean using the Maternal-Fetal Medicine Units Network VBAC calculator (less than 41%, 40.1-60%, 60.1-80%, and greater than 80%). The primary outcome was OASIS, defined as a 3rd or 4th degree perineal laceration. Bivariable and multivariable analyses were used to examine the association between predicted VBAC probability and OASIS. RESULTS: In total, 1,411 women met inclusion criteria and 73 (5.2%) sustained OASIS. The median predicted probability of VBAC was lower in women with OASIS compared with those without OASIS (60% [interquartile range {IQR}: 48-70%] vs. 66% (IQR: 52-80%), p = 0.02]. On bivariable and multivariable logistic regression, predicted probability of VBAC was associated with increased odds of OASIS (less than 41% probability: adjusted odds ratio [aOR]: 3.18, 95% confidence interval [CI]: 0.90-11.21; 41-60% probability: aOR: 3.76, 95% CI: 1.34-10.57; 61-80% probability aOR: 3.47, 95% CI: 1.25-9.69) relative to women with a predicted probability of VBAC of greater than 80%. CONCLUSION: Having a lower predicted probability of VBAC is associated with an increased risk of OASIS at the time of a VBAC relative to those with greater than 80% predicted probability. Incorporation of this aspect of maternal morbidity may inform risk-stratification at the time of trial of labor after cesarean, as well as the choice of performing an operative vaginal delivery. KEY POINTS: · Predicted probability of VBAC is associated with OASIS.. · Low predicted probability of VBAC is associated with increased odds of OASIS.. · Forceps delivery was associated with the highest odds of OASIS..

Safety of Abdominoplasty with Concomitant Abdominal or Minimally Invasive Hysterectomy: An ACS NSQIP Study.

BACKGROUND: To compare 30-day postoperative complications following abdominoplasty with and without concomitant hysterectomy. Our secondary objective was to compare outcomes following abdominoplasty by route of hysterectomy. METHODS: This was a retrospective cohort study using American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database from 2014 to 2018. We included women who underwent abdominoplasty alone (ABP) and abdominoplasty with concomitant hysterectomy (ABP+Hyst). The ABP+Hyst group included both abdominal hysterectomy (ABP+AH) and minimally invasive hysterectomy (ABP+MIH). RESULTS: Analysis included 9064 women of whom 2.4% had ABP+Hyst (216 ABP+AH and 53 ABP+MIH). Both ABP and ABP+Hyst had similar 30-day postoperative complication rates (11.5% vs. 14.1%, p=.22). Patients with ABP+Hyst had a longer length of hospital stay when compared to ABP alone [2 days (IQR 1-2) vs. 1 day (IQR 0-2), p<.001). Operating time was longer in ABP+Hyst by 76 minutes (p<.001). In a multivariable logistic regression model controlling for age, race, BMI, ASA class, smoking status, hysterectomy, operative time, and major medical comorbidity, concomitant hysterectomy was not associated with increased odds of 30-day postoperative complications. Both ABP+AH and ABP+MIH had low 30-day complication rates (15.3% vs. 9.4%, p=.273). However, ABP+MIH had a 38 minute longer median operating time (p=.008) but with a shorter length of stay by 1 day (p<.001). CONCLUSION: Concomitant hysterectomy at the time of abdominoplasty was not associated with an increase in complications during the first 30-days after surgery regardless of route of hysterectomy. These data suggest that selected patients can safely be offered combined surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018.

BACKGROUND: There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women. OBJECTIVE: This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience. STUDY DESIGN: A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time. RESULTS: A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications. CONCLUSION: This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.

Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery.

BACKGROUND: Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. OBJECTIVE: This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. STUDY DESIGN: This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December 2016. RESULTS: In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. CONCLUSION: Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.

Timing of diagnosis of complex lower urinary tract injury in the 30-day postoperative period following benign hysterectomy.

BACKGROUND: Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period. OBJECTIVE: This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database. STUDY DESIGN: This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses. RESULTS: In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3-19) and varied significantly based on type of injury (P<.01) with ureteral obstruction (6; interquartile range, 2-16) recognized earlier than ureteral fistula (12; interquartile range, 7-21) and bladder fistula (14; interquartile range, 4-23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21-3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16-3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26-3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders. CONCLUSION: Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period.

Do gender and racial differences exist in letters of recommendation for obstetrics and gynecology residency applicants?

BACKGROUND: Studies in several fields demonstrate gender and racial differences in descriptions of applicants in letters of recommendation. However, gender and racial biases in obstetrics and gynecology residency letters of recommendation are understudied. OBJECTIVE: This study aimed to determine whether there are differences in the letters of recommendation written for medical students applying for obstetrics and gynecology residency based on applicant gender and underrepresented in medicine status. STUDY DESIGN: We analyzed all letters of recommendation submitted to a single obstetrics and gynecology residency program during the 2019-2020 application cycle using a computerized text analysis software to evaluate the presence of 25 word categories. Multivariable regression was used to compare differences in the frequency of word categories by gender and underrepresented in medicine status. Concurrently, we performed a qualitative content analysis of letters from a random sample of applicants balanced for gender and underrepresented in medicine status and explored emerging themes until thematic saturation was reached. RESULTS: We analyzed 3060 letters written for 834 applicants, 721 (87%) of whom were women and 198 (24%) of whom were underrepresented in medicine. Men authored 1605 letters (53%). There was no difference in word categories used in letters written for men and women applicants on multivariable analysis. Similarly, there was no word category difference between letters written for applicants who were underrepresented in medicine compared with White and Asian applicants. However, women letter writers used more communal (relationship-oriented) words compared with men letter writers (P<.001). Moreover, on the qualitative analysis of letters from a random sample of 30 applicants, comments about personality traits were frequent in all letters. Comments on surgical skills, work ethic, and leadership were found more in letters for White and Asian applicants, and phrases that were doubt raisers were found more in letters written for underrepresented medicine applicants. CONCLUSION: On linguistic analysis, letters of recommendation written for obstetrics and gynecology residency applicants were similar overall compared with applicant race and gender.

Prevalence of pelvic organ prolapse among US racial populations: A systematic review and meta-analysis of population-based screening studies.

AIMS: To determine the differences in pooled prevalence rates of symptomatic pelvic organ prolapse (POP) across different US racial/ethnic groups using existing screening-based epidemiologic studies. METHODS: A systematic search of MEDLINE, EMBASE, Cochrane, and Scopus was conducted to retrieve eligible studies. We included studies that identified POP by either physical exam or questionnaire, conducted in non-gynecologic care-seeking settings, and had a representative sample of US community-dwelling women from more than one racial/ethnic group with prevalence rates reported for each population. Meta-analysis was performed with the pooled estimates calculated, and χ 2 tests were performed to examine the associations between race and POP prevalence. RESULTS: Of the 2604 studies reviewed, 5 were included. One study used physical exam findings while others used questionnaires to identify POP. All but one study demonstrated statistically significant differences in POP prevalence rates based on race/ethnicity. The overall pooled POP prevalence rates were determined for each racial/ethnic group-White women: 10.76% (95% confidence interval [CI], 10.30%-11.22%); Hispanic women: 6.55% (95% CI, 5.83%-7.28%); Black women: 3.80% (95% CI, 3.22%-4.38%); and Asian American women: 3.40% (95% CI, 2.09%-4.71%). There was a significant difference in the pooled prevalence rates among these four racial/ethnic groups (p < 0.01). CONCLUSIONS: Our study found that White women had the highest pooled POP prevalence rate overall, while Hispanic women had the highest pooled prevalence among minority women. Additionally, American Indians and Pacific Islanders were absent from the current prolapse epidemiologic literature.

Lower urinary tract symptoms in older Chinese American women: prevalence and risk factors.

INTRODUCTION AND HYPOTHESIS: The aim was to examine the prevalence of and risk factors for lower urinary tract symptoms (LUTS) in a community-dwelling cohort of older Chinese American women. METHODS: We performed a secondary analysis of a prospective cross-sectional population-based survey of community-dwelling Chinese Americans aged 60 and older in English, Mandarin, Cantonese, Taishanese, or Teochew between 2011 and 2013. A clinical Review of Systems (ROS) was used to assess LUTS, which included urinary frequency, urgency, burning or pain, blood in urine, and urinary incontinence. RESULTS: Of the 1,829 women queried, 28.6% reported LUTS. The cohort of women who reported LUTS had a mean ± SD age of 74.7 ± 8.7 years, with a BMI of 23.4 ± 3.7 kg/m2 and had lived in the USA for 21.5 ± 13.1 years. Nearly 90% earned less than $10,000 a year, 50% were married, and 50% used traditional Chinese medicine (TCM) once monthly or more. In comparison with women without LUTS, women with LUTS had significantly higher rates of medical comorbidities and a poorer perception of their general health and quality of life. In multivariate regression analysis, any LUTS were significantly associated with older age (aOR 1.03, 95% CI 1.01-1.04), TCM use (aOR 1.67, 95% CI 1.34-2.07), anxiety (aOR 1.45, 95% CI 1.02-2.06), depression (aOR 2.00, 95% CI 1.53-2.61), and a history of stroke (aOR 1.90, 95% CI 1.19-3.02). CONCLUSIONS: Lower urinary tract symptoms are common among older Chinese American women, particularly in those who are older, use TCM regularly, or report a history of anxiety, depression, or stroke.