Development and Validation of Urological and Appearance Domains of the Post-Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) for Transwomen following Genital Surgery.

PURPOSE: As feminizing gender-affirming surgery becomes increasingly accessible, functional outcomes are increasingly relevant. We aimed to develop and validate the first patient-reported outcome questionnaire focusing on postoperative symptomatology and quality of life. MATERIAL AND METHODS: Questions were developed from interviews with postoperative transwomen followed by face validation from a multispecialty clinician group. The measure was co-administered with established relevant questionnaires for concurrent validity testing. Participants were asked to complete the questionnaire at baseline and at a 2-week retest interval. RESULTS: The AFFIRM questionnaire is a 33-item patient-reported outcome measure comprising Appearance, Urological and Gynecologic domains, each scored to create a composite AFFIRM score. A total of 102 women participated, with 60% completing the test-retest. The overall Cronbach's α for AFFIRM was 0.79, and domain α for AFFIRM-A, AFFIRM-U and AFFIRM-G was 0.85, 0.87 and 0.42, respectively. Test-retest demonstrated score reliability (z values -1.862 to -0.005, p >0.05) with intraclass coefficients demonstrating moderate to good absolute correlation (0.54 to 0.88). The AFFIRM-A and AFFIRM-U correlated well with the Genital Appearance Satisfaction Measure and Urinary Distress Inventory-6, respectively (ρ 0.556 and 0.618, p <0.001); 89% of participants confirmed congruence between their external genitalia and gender identity, 87.8% reported clitoral sensation and 75.6% expressed satisfaction with vaginal caliber. Reported symptoms included a misdirected urinary stream (68.9%), nocturia (51.3%), urinary frequency (29.7%) and vaginal pain (46.7%). CONCLUSIONS: Transwomen have diverse symptoms not captured by unstructured questions or cisgender questionnaires. The AFFIRM questionnaire is the first tool available to reliably evaluate outcomes following feminizing gender-affirming surgery.

Patient Satisfaction With Telemedicine During the COVID-19 Pandemic: Retrospective Cohort Study.

BACKGROUND: New York City was the international epicenter of the COVID-19 pandemic. Health care providers responded by rapidly transitioning from in-person to video consultations. Telemedicine (ie, video visits) is a potentially disruptive innovation; however, little is known about patient satisfaction with this emerging alternative to the traditional clinical encounter. OBJECTIVE: This study aimed to determine if patient satisfaction differs between video and in-person visits. METHODS: In this retrospective observational cohort study, we analyzed 38,609 Press Ganey patient satisfaction survey outcomes from clinic encounters (620 video visits vs 37,989 in-person visits) at a single-institution, urban, quaternary academic medical center in New York City for patients aged 18 years, from April 1, 2019, to March 31, 2020. Time was categorized as pre-COVID-19 and COVID-19 (before vs after March 4, 2020). Wilcoxon-Mann-Whitney tests and multivariable linear regression were used for hypothesis testing and statistical modeling, respectively. RESULTS: We experienced an 8729% increase in video visit utilization during the COVID-19 pandemic compared to the same period last year. Video visit Press Ganey scores were significantly higher than in-person visits (94.9% vs 92.5%; P<.001). In adjusted analyses, video visits (parameter estimate [PE] 2.18; 95% CI 1.20-3.16) and the COVID-19 period (PE 0.55; 95% CI 0.04-1.06) were associated with higher patient satisfaction. Younger age (PE -2.05; 95% CI -2.66 to -1.22), female gender (PE -0.73; 95% CI -0.96 to -0.50), and new visit type (PE -0.75; 95% CI -1.00 to -0.49) were associated with lower patient satisfaction. CONCLUSIONS: Patient satisfaction with video visits is high and is not a barrier toward a paradigm shift away from traditional in-person clinic visits. Future research comparing other clinic visit quality indicators is needed to guide and implement the widespread adoption of telemedicine.

A live porcine model for robotic sacrocolpopexy training.

INTRODUCTION AND HYPOTHESIS: Robotic sacrocolpopexy is an effective and durable technique for pelvic organ prolapse repair. However, the learning curve for this procedure has underscored the need for an effective surgical training module. Given the cost, infection risk, poor tissue compliance, and scarcity of human cadavers, the live porcine model represents a realistic, available, and cost-effective alternative. This article describes a live porcine model for teaching robotic sacrocolpopexy to determine whether it teaches key aspects of live human robotic sacrocolpopexy to the learner. METHODS: This robotic sacrocolpopexy model was created using the Da Vinci Xi or Si robotic system on domestic pigs under general anesthesia. The main steps of the model include: (1) creating the porcine "cervix" and (2) performing robotic sacrocolpopexy. The model was evaluated with a survey given to 18 board-certified surgeons who attended the training course between December 2016 and April 2018. RESULTS: All of the participants reported improvements in their economy of motion, tissue handling ability, suturing efficiency, and overall performance of robotic sacrocolpopexy. Furthermore, a majority of participants were likely to incorporate aspects of the model into their practice (88.8%) and recommend the model to colleagues (94.2%). CONCLUSIONS: The porcine model provides a feasible tool for teaching robotic sacrocolpopexy to physicians.

A posterior anal sling for fecal incontinence: results of a 152-patient prospective multicenter study.

BACKGROUND: The transobturator posterior anal sling (TOPAS) system is a posterior anal sling that is a minimally invasive, self-fixating polypropylene mesh intended to treat fecal incontinence (FI) in women who have failed conservative therapy. OBJECTIVE: We are reporting 1-year outcome in a prospective, multicenter study under investigational device exemption, evaluating this new treatment modality. STUDY DESIGN: A total of 152 women were implanted with the TOPAS system at 14 centers in the United States. FI was assessed preoperatively and at the 12-month follow up with a 14-day bowel diary, Cleveland Clinic Incontinence Scores, and FI Quality of Life questionnaires. Treatment success was defined as reduction in number of FI episodes of ≥50% compared to baseline. Missing bowel diary data were considered treatment failures. The Wilcoxon signed rank test was used to compare changes observed at 12 months vs baseline. RESULTS: Mean age was 59.6 years old (SD 9.7). The mean duration of FI was 110 mo (range 8-712) months. Mean length of the implant procedure was 33.4 (SD 11.6) minutes. Mean EBL was 12.9 (SD 10.5) mL. Average follow-up was 24.9 months. At 12 months, 69.1% of patients met the criteria for treatment success, and 19% of subjects reported complete continence. FI episodes/wk decreased from a median of 9.0 (range 2-40) at baseline to 2.5 (range 0-40) (P < .001). FI days decreased from a median of 5.0 (range 1.5-7) at baseline to 2.0 (range 0-7) (P < .001) over a 7-day period. FI associated with urgency decreased from a median at baseline of 2.0 (range 0-26) to 0 (range 0-14.5) (P < .001). The mean Cleveland Clinic Incontinence Scores decreased from 13.9 at baseline to 9.6 at 12 months (P < .001). FI Quality of Life scores for all 4 domains improved significantly from baseline to 12 months (P < .001). A total of 66 subjects experienced 104 procedure- and/or device-related adverse events (AEs). Most AEs were short in duration and 97% were managed without therapy or with nonsurgical interventions. No treatment-related deaths, erosions, extrusions, or device revisions were reported. The most common AE categories were pelvic pain (n = 47) and infection (n = 26). Those subjects experiencing pelvic pain had a mean pain score (0-10 scale, 0 = no pain) during the 12-month follow-up of 1.2 (SD 2.4). CONCLUSION: The TOPAS system provides significant improvements in FI symptoms and quality of life with an acceptable AE profile and may therefore be a viable minimally invasive treatment option for FI in women.

Genetic Mutation that May Contribute to Failure of Prolapse Surgery in White Women: A Case-Control Study.

OBJECTIVE: To identify a potential genetic basis for early failure after prolapse surgery. DESIGN: Case-control study (Canadian Task Force classification II). SETTING: This study was carried out in 1 academic community medical center referral practice, and all patients had surgery at 1 of 2 hospitals. PATIENTS: Ten women with early, multicompartment prolapse recurrence after robotic sacrocolpopexy compared with 40 control subjects with known success after the same procedure. INTERVENTIONS: Patients were treated with robotic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: DNA was isolated and initially genotyped on a single nucleotide polymorphism (SNP) array to direct more detailed exome analyses. Exome sequences were mapped to the Human Genome Reference Sequence (GRCh37), and variants were compared between groups and to participants in the 1000 Genomes Project. Statistical analyses were performed using a software package commonly used in genetics research. TaqMan assay was used for verification, and p values were adjusted using the false discovery rate. Demographics of groups were compared using χ(2), Mann-Whitney U, and t tests. A SNP [rs171821] located near the ZFYVE16 gene was associated with patients but not control subjects, and the false discovery rate-adjusted p value was .046 (odds ratio, 45.2; 95% confidence interval, 5.06-403). Exome analyses of this gene yielded another SNP [rs249038 (G/A)] in 6 of 10 patients and none of the control subjects (p = .02). This SNP causes a heterozygous missense mutation of glycine to serine predicted to be deleterious by the Protein Variation Effect Analyzer and was also very rare among participants in the 1000 Genomes Project (p < .001). CONCLUSIONS: Two SNPs located near the ZFYVE16 gene on chromosome 5 may have played a role in the early, multicompartment sacrocolpopexy failure experienced by our patients. (www.clinicaltrials.gov Identifier: NCT01614587).

A prospective study of a single-incision sling at the time of robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the efficacy and safety of the Miniarc Precise® single-incision sling (American Medical Systems, Minnetonka, MN, USA) placed at the time of a robotic sacrocolpopexy. METHODS: This was a prospective study of a single-incision suburethral sling placed at the time of robotic sacrocolpopexy in women with stress urinary incontinence (SUI) and pelvic organ prolapse. Primary outcome measure was cure at 1 year, defined objectively by a negative cough stress test (CST) and subjectively by a score of "0 or 1" on question 17 of the Pelvic Floor Distress Inventory (PFDI-20): "Do you experience urine leakage related to coughing/sneezing/laughing?" Secondary outcome measures included the change in Urinary Distress Inventory (UDI-6) and Urinary Impact Questionnaire (UIQ-7) scores at 1 year. All sling-related complications were reported. Paired Student's t test and the Wilcoxon signed-rank test were used for statistical analysis. RESULTS: One hundred and one patients were included between August 2010 and July 2012. One-year follow-up was available for 97 out of 101 patients (96 %). Objective cure was 90 % and subjective cure was 87 %. Baseline UDI-6 scores improved from 34.8 ± 25.1 to 6.7 ± 11.2 at 1 year (p < 0.001). Similarly, UIQ-7 scores improved from 21.1 ± 22.8 to 2.4 ± 8.2 at 1 year (p < 0.001). There were no intraoperative cystotomies, no mesh erosions, no sling revisions, and no cases of urinary retention. The retreatment rate for persistent SUI was 8 % (8 out of 97). CONCLUSIONS: The addition of a single-incision suburethral sling at the time of robotic sacrocolpopexy in women with SUI resulted in an 87 % cure rate at 1 year.

Subjective and objective results 1 year after robotic sacrocolpopexy using a lightweight Y-mesh.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to assess outcomes following robotic sacrocolpopexy using a lightweight polypropylene Y-mesh. METHODS: During our study period, all patients who underwent robotic sacrocolpopexy were enrolled in this single-arm prospective trial. Endpoints included Pelvic Organ Prolapse Quantification (POP-Q) values; Pelvic Floor Distress Inventory, short form 20 (PFDI-20); Pelvic Floor Impact Questionnaire, short form 7 (PFIQ-7); Surgical Satisfaction scores; and the Sandvik Incontinence Severity Index. All surgeries were performed with a pre-configured monofilament type 1 polypropylene Y-mesh (Alyte©, C.R. Bard, Covington, GA, USA). Cure rates at 12 months were calculated using two separate definitions: (1) "clinical cure": no POP-Q points > 0, point C ≤ -5, no prolapse symptoms on the PFDI-20, and no reoperations for prolapse and (2) "objective anatomic cure": POP-Q stage 0 or 1, point C of ≤ -5, and no reoperations for prolapse. RESULTS: A total of 150 patients underwent robotic sacrocolpopexy and 143 (95 %) were available for 12-month follow-up. Mean age was 58.6 ± 9.8 and mean body mass index was 26.3 ± 4.5. Mean operative time and blood loss were 148 ± 27.6 min (range 75-250 min) and 51.2 ± 32, respectively. There were no mesh erosions or exposures, and mesh edges were not palpable in any patient. At 12 months the clinical cure rate was 95 %, and the objective anatomic cure rate was 84 %. The PFDI-20 mean score improved from 98 at baseline to 17 at 12 months (p < 0.0001); PFIQ-7 scores improved from 59 to 6.5 (p < 0.0001). CONCLUSIONS: Robotic sacrocolpopexy using this lightweight polypropylene Y-mesh offers excellent subjective and objective results at 1 year.

Prospective study of an ultra-lightweight polypropylene Y mesh for robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: To prospectively evaluate the use of a particular polypropylene Y mesh for robotic sacrocolpopexy. METHODS: This was a prospective study of 120 patients who underwent robotic sacrocolpopexy. We compared preoperative and 12-month postoperative objective and subjective assessments via the Pelvic Organ Prolapse Quantification (POP-Q), the Pelvic Floor Distress Inventory, Short Form 20 (PFDI-20); the Pelvic Floor Impact Questionnaire, Short Form 7 (PFIQ-7); and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 (PISQ-12). Objective "anatomical success" was defined as POP-Q stage 0 or 1 at all postoperative intervals. We further defined "clinical cure" by simultaneously considering POP-Q points and subjective measures. To be considered a "clinical cure," a given patient had to have all POP-Q points ≤0, apical POP-Q point C ≤5, no reported pelvic organ prolapse symptoms on the PFDI-20, and no reoperation for prolapse at all postoperative intervals. RESULTS: Of the 120 patients, 118 patients completed the 1-year follow-up. The objective "anatomical success" rate was 89 % and the "clinical cure" rate was 94 %. The PFDI-20 mean score improved from 100.4 at baseline to 21.0 at 12 months (p < 0.0001); PFIQ-7 scores improved from 61.6 to 8.0 (p < 0.0001); and PISQ-12 scores improved from 35.7 to 38.6 (p < 0.0009). No mesh erosions or mesh-related complications occurred. CONCLUSION: The use of this ultra-lightweight Y mesh for sacrocolpopexy, eliminated the mesh-related complications in the first postoperative year, and provided significant improvement in subjective and objective outcomes.

Sacrohysteropexy followed by successful pregnancy and eventual reoperation for prolapse.

A multitude of uterine-sparing prolapse repairs exist in the literature, but little is published on subsequent pregnancy and long-term success following a repair. A 35-year-old gravida 2 para 2 underwent laparoscopic sacrohysteropexy and suburethral sling for stage III prolapse and stress urinary incontinence. She conceived 6 months postprocedure. Her antepartum course was complicated by third trimester pelvic pressure--successfully managed with a pessary. She delivered via cesarean section at term. At 12 months postpartum she had no signs of prolapse. Two years postpartum, she reprolapsed and underwent robotic assisted laparoscopic supracervical hysterectomy, sacrocolpopexy, and perineorrhaphy. Two years postoperatively she remained without any prolapse symptoms. Laparoscopic sacrohysteropexy is a reasonable surgical option for patients with pelvic organ prolapse considering future pregnancies.

Contemporary Use and Techniques of Laparoscopic Sacrocolpopexy With or Without Robotic Assistance for Pelvic Organ Prolapse.

The past 4 years have been consequential in the world of surgery to correct pelvic organ prolapse. In 2018, results of a large, multicenter randomized trial demonstrated very disappointing cure rates of traditional native tissue repairs at 5 years or more. In 2019, a vaginal mesh hysteropexy kit was removed from the market by the U.S. Food and Drug Administration only to subsequently demonstrate it provided better cure rates and similar risk profile to vaginal hysterectomy plus native tissue repair in its own 5-year study published in 2021. Meanwhile, the use and techniques of laparoscopic sacrocolpopexy with or without robotic assistance have evolved such that it is commonly adapted to treat all support defects for patients with uterovaginal or posthysterectomy prolapse. This article is intended to provide an overview of the contemporary use and techniques of laparoscopic sacrocolpopexy based on the evidence and our clinical experience.

Randomized trial of fascia lata and polypropylene mesh for abdominal sacrocolpopexy: 5-year follow-up.

INTRODUCTION AND HYPOTHESIS: The purpose of this study is to evaluate the 5-year surgical outcomes of abdominal sacrocolpopexy among subjects randomized to receive polypropylene mesh or cadaveric fascia lata. METHODS: All 100 subjects from the original randomized clinical trial were eligible. Primary outcome was objective anatomic failure: any pelvic organ prolapse quantification (POP-Q) point ≥ - 1. Secondary outcome was clinical failure-presence of bulge or prolapse symptoms and either a POP-Q point C ≥ ½ TVL or any POP-Q point >0-and interim surgical re-treatment. Wilcoxon tests and Fisher's exact test were performed. RESULTS: Fifty-eight subjects returned for 5-year follow-up-29 mesh and 29 fascia. Objective anatomic success rates were: mesh, 93% (27/29) and fascia, 62% (18/29) (p = 0.02). Clinical success rates were: mesh, 97% (28/29) and fascia, 90% (26/29) (p = 0.61). CONCLUSIONS: Polypropylene mesh was superior to cadaveric fascia lata using objective anatomic outcomes. Success rates of mesh and fascia were comparable using a clinical definition that combined symptoms with anatomic measures.

Evaluation of a transvaginal mesh delivery system for the correction of pelvic organ prolapse: subjective and objective findings at least 1 year after surgery.

OBJECTIVE: We sought to track objective and subjective outcomes ≥1 year after transvaginal mesh system to correct prolapse. STUDY DESIGN: This was a retrospective cohort study of 120 women who received a transvaginal mesh procedure (Avaulta Solo, CR Bard Inc, Covington, GA). Outcomes were pelvic organ prolapse quantification values; Pelvic Floor Distress Inventory, Short Form 20/Pelvic Floor Impact Questionnaire, Short Form 7 scores; and a surgical satisfaction survey. "Surgical failure" was defined as pelvic organ prolapse quantification point >0, and/or any reports of vaginal bulge. RESULTS: Of 120 patients, 116 (97%) were followed up for a mean of 14.4 months (range, 12-30). In all, 74 patients had only anterior mesh, 21 only posterior mesh, and 21 both meshes. Surgical cure rate was 81%. Surgical failure was more common if preoperative point C ≥+2 (35% vs 16%; P = .04). Mesh erosion and de novo pain occurred in 11.7% and 3.3%, respectively. Pelvic Floor Distress Inventory, Short Form 20/Pelvic Floor Impact Questionnaire, Short Form 7 scores improved (P < .01). CONCLUSION: Objective and subjective improvements occurred at ≥1 year, yet failure rates were high when preoperative point C was ≥+2.

A randomized clinical trial comparing pelvic floor muscle training to a Pilates exercise program for improving pelvic muscle strength.

INTRODUCTION AND HYPOTHESIS: The purpose of this study is to determine whether a Pilates exercise program and a pelvic floor muscle-training (PFMT) program could provide similar improvements in pelvic muscle strength. METHODS: Sixty-two women with little or no pelvic floor dysfunction were randomized to Pilates or PFMT. Each group had 24 biweekly 1-h sessions with either a physical therapist or Pilates instructor. Strength was measured via perineometry (cmH(2)O). Two questionnaires--pelvic floor distress inventory (PFDI-20) and pelvic floor impact questionnaire (PFIQ-7)--were also collected. RESULTS: At baseline, the Pilates and PFMT groups measured 14.9 +/- 12.5 and 12.5 +/- 10.4 cmH(2)O, respectively (p = 0.41). Both the Pilates and PFMT groups got stronger (6.2 +/- 7.5 cmH(2)O, p = 0.0002 and 6.6 +/- 7.4 cmH(2)O, p = 0.0002, respectively), with no difference between groups p = 0.85. PFIQ and PFDI scores improved from baseline but not between groups. CONCLUSIONS: Further study is required to determine if Pilates can actually treat pelvic floor dysfunction.

Can urethral retroresistance pressures predict midurethral sling outcomes?

OBJECTIVE: To determine whether preoperative urethral resistance pressure (URP) measurements could predict success or failure of a tension-free vaginal tape (TVT) sling. METHODS: Subjects came from a previously published study comparing URP measurements to a validated urinary incontinence symptom survey (UISS). We contacted patients from that study to determine whether they had subsequently undergone TVT surgery. Within that cohort, we determined the "current" (i.e., postoperative) UISS and Sandvik urinary incontinence severity score. Success of a TVT sling in this group was defined in 4 ways: (1) postoperative UISS score <3, (2) postoperative UISS score < 75% of the preoperative score, (3) postoperative Sandvik score <6, and (4) postoperative Sandvik score <2. These definitions of "success" were compared across demographic and treatment variables using the Student's t test, ANOVA, chi2 and ROC curves. RESULTS: We contacted 69 women who had in fact received a TVT sling after their participation in the previously published study mentioned above. Among these 69 women, mean preoperative urethral retroresistance pressure values were not predictive of surgical success. CONCLUSION: Preoperative urethral retroresistance pressure measurements did not reliably predict surgical success or failure; therefore, this urodynamic test is of little value to the clinician.

Long-Term Outcomes of Robotic-Assisted Laparoscopic Sacrocolpopexy Using Lightweight Y-Mesh.

OBJECTIVE: The objective of this study was to describe anatomic and symptomatic outcomes at 5 years or longer after robotic-assisted laparoscopic sacrocolpopexy using very lightweight polypropylene Y-mesh. METHODS: A prospective analysis of consecutive patients who underwent surgery at a single center between 2007 and 2011 was performed. Patients consented to objective and subjective assessment at 5 years or longer postoperatively. Surgical success was defined as meeting all of the following: (1) no retreatment for pelvic organ prolapse (POP) since surgery, (2) no prolapse beyond the introitus, (3) no apical descent below -5, and (4) no prolapse symptoms reported. Secondary outcome measures included Sandvik Incontinence Severity Index, the PFDI-20, the PFIQ-7, the PISQ-12, and the SSQ-8), rates of dyspareunia, mesh complications, and subjects' need for any surgical or nonsurgical prolapse treatment since their index surgery. RESULTS: Eighty percent of the potential study group (253/316) presented for examination and subjective assessment at 5 years or longer after their index surgeries.The surgical success rate was 226 (89.3%) of 253 with no apical failures. Only 4.4% (11/253) of the group met both objective and subjective failure criteria. Sixteen patients were classified as surgical failure owing to subjective criteria alone despite having no significant objective prolapse on examination. Ten patients (4%) elected to undergo subsequent POP repair. These operations consisted of 5 native tissue anterior repairs and 5 native tissue posterior repairs. In addition, 1 patient elected to use a pessary for recurrent anterior POP. The remaining 16 patients who experienced surgical failure elected no further prolapse treatment. CONCLUSIONS: Robotic-assisted laparoscopic sacrocolpopexy using very lightweight mesh provided excellent long-term results with no mesh-related complications.

Sexual Satisfaction Changes Reported by Men After Their Partners' Robotic-Assisted Laparoscopic Sacrocolpopexies.

OBJECTIVES: This study aimed to compare the preoperative and postoperative sexual satisfaction reported by male sexual partners of women undergoing surgical correction of pelvic organ prolapse. METHODS: This was a single-center prospective cohort study. Heterosexual, sexually active English-speaking couples in which the women were planning to undergo robotic-assisted laparoscopic sacrocolpopexy for correction of pelvic organ prolapse were eligible for enrollment in the study. Validated sexual function questionnaires-the Sexual Experience Questionnaire (SEX-Q; Mulhall et al. J Sex Med. 2008) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (Rogers, et al. Int Urogynecol J Pelvic Floor Dysfunct. 2003)-were used to evaluate preoperative and postoperative male and female sexual experience, respectively. These preoperative scores were compared using paired t tests. The Student t and the Mann-Whitney tests were used to compare study-eligible couples with noneligible couples and to compare study participants with nonparticipants. RESULTS: During the study enrollment period, 92 couples met the inclusion criteria and 45 of those were enrolled. Complete data sets of preoperative and postoperative questionnaires were obtained for 36 couples. After their partners' successful reconstructive surgery, male study subjects reported improved total SEX-Q scores (mean ± SD, 71 ± 16.7 vs 76.5 ± 17.8; P = 0.025). Within the subscales of the SEX-Q, there was significant improvement between preoperative and postoperative "individual satisfaction" scores (mean ± SD, 65.7 ± 16.8 vs 78.9 ± 17.5; P < 0.0001), but not within the "erectile dysfunction" or "couple satisfaction" subscales. Female partners reported improved Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 scores after surgery (mean ± SD, 36.6 ± 5.5 vs 40.0 ± 4.6; P = 0.003). CONCLUSIONS: Sexually active heterosexual men and women reported improved sexual experience after successful prolapse repair.

Understanding Your Online Ratings: A Methodological Analysis Using Urogynecologists in the United States.

OBJECTIVE: The influence of online physician ratings is growing, yet their interpretation remains difficult. Our aim was to analyze the online content of urogynecologists on 1 website to transform these ratings into practical tools for care improvement. METHODS: This cross-sectional analysis studied the ratings and reviews of every board-certified urogynecologist listed on Healthgrades.com. The ratio of 5:1 ratings was compared between various physician characteristics and practice qualities. Four investigators classified narrative reviews into one or more of the following themes: about the (1) physician, (2) clinical outcomes, (3) and/or staff. The content of the narrative reviews was analyzed, and word clouds were created to understand the primary motivators behind ratings. RESULTS: In February 2018, the Healthgrades pages for 689 urogynecologists were evaluated, and 523 physicians were included in the study. Higher 5:1 ratios were found among men versus women (4.0 vs 3.0; P < 0.01), and OB-GYN-trained versus urology-trained (4.0 vs 2.2; P < 0.01) physicians. A benchmarking rubric was developed to illustrate the 5:1 ratio distribution for all physicians stratified by number of ratings. A total of 3300 narrative reviews were assigned themes with strong inter- and intrarater reliability (Table 3). Physician qualities most influenced extreme scores (1 or 5 stars), whereas average reviews were more influenced by staff. Commonly discussed physician qualities included professionalism, time with patient, and counseling. CONCLUSIONS: Using the 5:1 rating ratio and simplified review themes as tools, physicians can understand what their ratings signify both as an indicator of their online reputation compared with their peers and as a means for improving the patient experience.

The Validity of Online Patient Ratings of Physicians: Analysis of Physician Peer Reviews and Patient Ratings.

BACKGROUND: Information from ratings sites are increasingly informing patient decisions related to health care and the selection of physicians. OBJECTIVE: The current study sought to determine the validity of online patient ratings of physicians through comparison with physician peer review. METHODS: We extracted 223,715 reviews of 41,104 physicians from 10 of the largest cities in the United States, including 1142 physicians listed as "America's Top Doctors" through physician peer review. Differences in mean online patient ratings were tested for physicians who were listed and those who were not. RESULTS: Overall, no differences were found between the online patient ratings based upon physician peer review status. However, statistical differences were found for four specialties (family medicine, allergists, internal medicine, and pediatrics), with online patient ratings significantly higher for those physicians listed as a peer-reviewed "Top Doctor" versus those who were not. CONCLUSIONS: The results of this large-scale study indicate that while online patient ratings are consistent with physician peer review for four nonsurgical, primarily in-office specializations, patient ratings were not consistent with physician peer review for specializations like anesthesiology. This result indicates that the validity of patient ratings varies by medical specialization.

Prevalence of Occult Malignancy Within Morcellated Specimens Removed During Laparoscopic Sacrocolpopexy.

OBJECTIVE: This study aimed to determine the prevalence of occult malignancy found in morcellated specimens removed in the context of pelvic organ prolapse repair operations. METHODS: A total of 786 cases were reviewed from a single health system between October 2006 and July 2015. Thorough chart reviews were performed to include pathological specimens. Demographic, perioperative, and postoperative data were collected. RESULTS: Four occult malignancies were identified including 3 endometrial adenocarcinomas of the uterus and 1 papillary serous carcinoma of the uterus. The overall prevalence of occult malignancy within morcellated specimens was 0.5% (4 of 786). On adopting universal screening with endometrial biopsy, 5 malignancies were identified (5 of 176) before morcellation and no postoperative malignancies in the remaining patients. CONCLUSIONS: Power morcellation is a low-risk procedure with laparoscopic supracervical hysterectomy and sacrocolpopexy. Universal screening is highly effective in detecting occult malignancy and in our small series eliminated the risk; studies in multiple institutions will be needed to determine its effectiveness in other hospital systems.

A randomized controlled trial comparing fascia lata and synthetic mesh for sacral colpopexy.

OBJECTIVE: To compare the objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh. METHODS: Patients undergoing a sacral colpopexy were randomized to receive either fascia lata or polypropylene mesh in a double-blinded fashion. Data were collected at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The main outcome measures were pelvic organ prolapse quantification (POP-Q) system stage and individual POP-Q points over time. Objective anatomic failure was defined as POP-Q stage 2 or more at any point during the follow-up period. Proportions of patients with objective anatomic failure at 1 year in each group were compared using the chi(2) test. Mean POP-Q points and stage at 1 year were compared by using the independent samples t test. RESULTS: One hundred patients were randomized to receive either fascia (n = 46) or mesh (n = 54). Of the 89 patients returning for 1-year follow-up, 91% (41/45) of the mesh group and 68% (30/44) of the fascia group were classified as objectively cured (P = .007). We found significant differences between the mesh and fascia groups with respect to the 1-year postoperative comparisons of points Aa, C, and POP-Q stage. There were no differences between the 2 groups with respect to points TVL (total vaginal length), GH (genital hiatus), PB (perineal body), Ap or Bp (2 points along the posterior vaginal wall). CONCLUSIONS: Polypropylene mesh was superior to fascia lata in terms of POP-Q points, POP-Q stage, and objective anatomic failure rates. LEVEL OF EVIDENCE: I.