Minimizing Risks in Minimally Invasive Surgery: Rates of Surgical Site Infection Across Subtypes of Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To compare the 30-day incidence of deep or organ-space and/or superficial incisional surgical site infections (SSIs) by the subtype of laparoscopic hysterectomy and to report on additional risk factors for SSIs following laparoscopic hysterectomy. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program Database. PATIENTS: Women undergoing laparoscopic hysterectomy from 2012 to 2014. INTERVENTIONS: Women were stratified into 3 groups by the type of hysterectomy: total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and laparoscopic supracervical hysterectomy (LSCH). Demographic and clinical characteristics were compared for the 3 groups using the Kruskal-Wallis test or 1-way analysis of variance, where appropriate, for continuous variables and the chi-square or Fisher's exact test for categoric variables. Post hoc analyses were performed for multiple comparisons. Univariate analyses to examine the association with SSI were performed using the t test or Wilcoxon rank sum test as appropriate for continuous variables and the chi-square test or Fisher's exact test as appropriate for categoric variables. Significant variables on univariate analysis were included in a stepwise, backward multivariable logistic regression to identify the independent risk factors of SSI. MEASUREMENTS AND MAIN RESULTS: In total, 46 755 women underwent laparoscopic hysterectomy. Most were classified as TLH (26 009, 56%), followed by LAVH (13 884, 30%), and LSCH (6862, 14%). The overall rate of 30-day deep or organ-space SSI was 1.8% (n = 445). Thirty-day deep or organ-space SSI was lower in women who underwent LSCH (0.6%) than in women who underwent TLH (1.0%) or LAVH (1.1%; p = .001), but there was no difference in the incidence of superficial incisional SSI (0.8%, 0.8%, and 0.8% for TLH, LAVH, and LSCH, respectively; p = .75). On multivariate regression analysis, LSCH remained independently associated with a decreased risk of deep or organ-space SSI (adjusted odds ratio, 0.60; 95% confidence interval, 0.43-0.84; p = .003). In addition, relative to the women who were discharged on the same day, women admitted for >24 hours had 2-fold increased odds of deep or organ-space SSI. Asian race, smoking, perioperative transfusion, dirty or infected cases, and American Society of Anesthesiologist class 3 were associated with increased odds for deep or organ-space SSI. Length of stay >24 hours and Native Hawaiian/Pacific Islander race were associated with increased odds of superficial incisional SSI. CONCLUSION: LSCH is associated with a decreased risk of deep or organ-space SSI compared with other subtypes of laparoscopic hysterectomy. Same-day discharge after laparoscopic hysterectomy is associated with decreased odds of SSI.

Sec24 interaction is essential for localization and virulence-associated function of the bacterial effector protein NleA.

Enteropathogenic and enterohaemorrhagic Escherichia coli (EPEC and EHEC) are food-borne pathogens that cause severe diarrhoeal disease in humans. Citrobacter rodentium is a related mouse pathogen that serves as a small animal model for EPEC and EHEC infections. EPEC, EHEC and C. rodentium translocate bacterial virulence proteins directly into host cells via a type III secretion system (T3SS). Non-LEE-encoded effector A (NleA) is a T3SS effector that is common to EPEC, EHEC and C. rodentium and is required for bacterial virulence. NleA localizes to the host cell secretory pathway and inhibits vesicle trafficking by interacting with the Sec24 subunit of mammalian coatamer protein II complex (COPII). Mammalian cells express four paralogues of Sec24 (Sec24A-D), which mediate selection of cargo proteins for transport and possess distinct, but overlapping cargo specificities. Here, we show that NleA binds Sec24A-D with two distinct mechanisms. An NleA protein variant with greatly diminished interaction with all Sec24 paralogues does not properly localize, does not inhibit COPII-mediated vesicle budding, and does not confer virulence in the mouse infection model. Together, this work provides strong evidence that the interaction and inhibition of COPII by NleA is an important aspect of EPEC- and EHEC-mediated disease.

Mind the Gap: Changes in Levator Dimensions After Sacrocolpopexy.

OBJECTIVE: The aim of the study was to compare levator hiatus (LH) and levator area (LA) on transvaginal 3-dimensional (3D) ultrasound (US) and genital hiatus (GH) size by Pelvic Organ Prolapse Quantification (POP-Q) examination before and after minimally invasive sacrocolpopexy. METHODS: Women with prolapse (POP) beyond the hymen undergoing minimally invasive sacrocolpopexy without concomitant POP repairs completed Pelvic Floor Distress Inventory short form (PFDI), POP-Q, and transvaginal 3D US before and 14 weeks after surgery. Data were analyzed by 2 urogynecologists, blinded to US image sequence and to corresponding POP-Q scores. RESULTS: Forty-three patients were enrolled; 35 with complete data are included. Patients had a mean ± SD age of 55 ± 11 years. Most were white (89%), vaginally parous (94%), postmenopausal (66%), sexually active (63%), and had stage 3 POP (86%). The majority (89%) had concomitant hysterectomy, and 60% had midurethral slings. At baseline, the mean ± SD PFDI and Prolapse subscale of the Pelvic Floor Distress Inventory scores were 98 ± 50 and 42 ± 22. The median (interquartile range) POP-Q stage decreased after surgery from 3 (3) to 0 (0-1, P < 0.001) and the mean ± SD PFDI scores decreased to 55 ± 42 (P = 0.002). At baseline, the mean ± SD GH and perineal body measurements were 3.5 ± 0.7 and 2.4 ± 0.6 cm. Although the GH size decreased by 0.5 cm after surgery, perineal body was unchanged. Levator hiatus remained unchanged between the baseline and 14-week visits (P = 0.07), whereas LA increased by 0.8 cm2 (P = 0.03). At 14 weeks, the change in LA was not correlated with the change in GH (ρ = -0.2, P = 0.2) or POP stage (ρ = -0.2, P = 0.9). CONCLUSIONS: Restoring the apex with sacrocolpopexy alone reduces GH size on clinical examination; however, it does not impact the size of the underlying LH on US.

Does a Hysterectomy Hurt? Comparing Narcotic Requirements and Pain Scores in Patients Undergoing Apical Prolapse Repair With or Without Hysterectomy.

OBJECTIVE: The aim of the study was to compare narcotic requirements with early postoperative pain scores in women undergoing apical prolapse surgery with or without hysterectomy. METHODS: All cases of apical prolapse repair at our institution in 2016 were identified. The following was abstracted from the health record: demographics, comorbidities, procedure details, baseline and postoperative care unit (PACU) pain scores, and operating room (OR) and PACU narcotic doses. Doses were converted to morphine milligram equivalents (MME) for analysis. Correlations are reported using Pearson ρ. RESULTS: One hundred fifty-six cases were identified. Seventy-eight percent of participants were white and the mean ± SD age was 59 ± 11 years. One hundred seventeen patients (75%) underwent laparoscopic/robotic sacrocolpopexy, 35 (22%) native tissue vaginal repairs, and 4 (3%) open sacrocolpopexy. One hundred twenty-two patients (78%) underwent concomitant hysterectomy: 93 (76%) were laparoscopic, 25 (20%) vaginal, and 4 (4%) abdominal.The groups were similar, with the exception of younger age and longer OR time in the hysterectomy group. Hysterectomy by any route was not associated with increased OR MMEs (29 vs 22, P = 0.22), PACU MMEs (13 vs 13, P = 0.54), 4-hour PACU pain scores (2.5 vs 2.0, P = 0.22), or 6-hour PACU pain scores (2.6 vs 2.3, P = 0.54). After controlling for age and OR time, there remained no differences in these variables. Likewise, when analyzing laparoscopic or vaginal groups separately on multivariate regression, there were no differences in MMEs or postoperative pain scores in patients with and without concomitant hysterectomy. CONCLUSIONS: Concomitant hysterectomy at the time of prolapse repair does not increase pain medication requirements or patient-reported postoperative pain scores.

The Influence of Patients' Goals on Surgical Satisfaction.

OBJECTIVE: The objectives of this study were to describe patients' surgical goals and determine if goal attainment is associated with postoperative satisfaction and regret. METHODS: Women undergoing surgery for pelvic floor disorders between June and December 2019 were recruited. At their initial visit, patients listed up to 4 surgical goals. Three months after surgery, patients completed the Pelvic Floor Distress Inventory, Patient Global Impression of Improvement, Satisfaction with Decision Scale, and Decision Regret Scale. They were also shown their initial goals and asked, "Did you achieve this goal by having surgery?" Women who achieved all goals were designated "goal achievers," and those who did not achieve even 1 goal were "goal nonachievers" (GNAs). RESULTS: Ninety-nine patients listed a median of 1 (range, 1-4) goals. Goals were categorized as follows: symptom improvement (52%), treatment achievement (23%), lifestyle improvement (17%), and information gathering (6%). Ninety-one percent of patients were goal achievers, and 9% were GNAs. Goal achievers had higher Satisfaction with Decision Scale scores (5.0 [4.7-5.0] vs 4.0 [3.8-4.8], P = 0.002), lower Decision Regret Scale scores (1.0 [1.0-1.4] vs 2.0 [1.1-2.7], P = 0.001), and better Patient Global Impression of Improvement scores (1.0 [1.0-2.0] vs 2.0 [1.0-4.0], P = 0.004). In prolapse surgery patients, postoperative Pelvic Floor Distress Inventory scores were similar; however, GNAs had higher postoperative Urinary Distress Inventory scores (17.0 ± 18.0 vs 45.8 ± 20.8, P = 0.01). CONCLUSIONS: Ninety-one percent of women achieved their presurgical goals, the most common being symptom relief. Goal achievers have higher satisfaction and less regret; however, those with worsening or de novo urinary symptoms are more likely to be GNAs and be unsatisfied.

Clinical Utility of Routine Preoperative Laboratory Assessment in a Urogynecologic Population.

OBJECTIVE: The objective of this study was to determine the incidence of newly diagnosed, clinically meaningful laboratory abnormalities on routine preoperative laboratory testing in women undergoing urogynecologic surgery. METHODS: All urogynecologic cases performed at a single institution over a 3-year period were reviewed. Women undergoing major surgery routinely had a basic metabolic panel, complete blood count (CBC), and type and screen, whereas women undergoing minor surgery had testing at the surgeon's discretion. Demographics, surgical details, preoperative laboratory values, and instances of postoperative transfusion were abstracted. If testing revealed a clinically meaningful abnormality, physician notes were reviewed to determine whether the abnormality was previously known or led to surgical postponement. RESULTS: A total of 836 cases were identified: 411 major (49%) and 425 minor (51%). Patients had a mean ± SD age of 57 ± 13 years and body mass index of 27 ± 6 kg/m. Medical comorbidities were hypertension, 38%; diabetes, 24%; chronic kidney disease, 3%; and congestive heart failure, 4%; 89% had an American Society of Anesthesiologists class of less than or equal to 2. A total of 453 (54%) had preoperative CBC, and 367 (44%) had preoperative basic metabolic panel. Six (1.3%) new abnormalities (hemoglobin between 8.0 and 10.0) were identified on CBC. Thirty-one women had elevated creatinine level (>1.0), and 28 (90%) of these had a history of hypertension. No surgeries were postponed or changed owing to anemia, thrombocytopenia, or renal dysfunction. No clinically significant electrolyte abnormalities were identified. Type and screen were collected on 394 patients; none were transfused intraoperatively. CONCLUSIONS: Routine preoperative laboratory testing does not identify clinically meaningful abnormalities or alter surgical management in women undergoing urogynecologic surgery.

Patients' Perceptions on Surgical Care Suspension for Pelvic Floor Disorders During the COVID-19 Pandemic.

OBJECTIVES: The primary objective of the study was to evaluate patients' attitudes toward the postponement of their scheduled procedures for pelvic floor disorders (PFD) because of the COVID-19 pandemic. Secondary objectives were to identify patients who were upset with the postponement of their PFD procedures and to identify factors that are associated with being upset because of the delay in care. METHODS: This was a cross-sectional, survey-based study of women from a single urban, academic practice using a novel questionnaire. The study cohort included women whose PFD surgeries or office procedures were postponed between March 17 and April 30, 2020. RESULTS: Ninety-eight women had surgeries postponed; 68 (70%) responded to our questionnaire. Nearly half of the respondents (32/68, 47.1%) were upset about their procedures being postponed. Upset patients reported a greater impact of PFD symptoms on their mood than those who were not upset (P=0.002). Those who were upset were also more likely to report feelings of isolation (P=0.006), fear that their PFD would worsen because of delayed care (P < 0.001), and anxiety over surgery postponement (P < 0.001) than those who were not upset about the delays. When controlling for anxiety, social isolation, and impact of PFD symptom, anxiety (adjusted odds ratio = 15.7; 95% confidence interval = 3.7-66.6) and feeling of isolation (adjusted odds ratio = 9.7; 95% confidence interval = 1.5-63.7) remained associated with increased odds of being upset because of procedure delays. CONCLUSIONS: Half of women whose pelvic reconstructive procedures were postponed because of the COVID-19 pandemic were upset because of the delay in care, especially those who are emotionally and socially vulnerable during the COVID-19 pandemic.

Reduced hemoglobin on day of peripheral blood progenitor cell collection is associated with low graft content of vascular progenitors and increased toxicity after autologous hematopoietic stem cell transplantation.

BACKGROUND: Tissue damage after hematopoietic stem cell transplantation (HSCT) occurs as a result of high-dose chemotherapy and radiation. The aim was to determine the importance of pretransplant anemia on toxicity and red blood cell (RBC) transfusion requirements after autologous HSCT. STUDY DESIGN AND METHODS: A total of 350 patients undergoing autologous HSCT were included in the analysis. Patient factors and pretransplant laboratory values of possible relevance were assessed in multivariate regression analysis. RESULTS: Reduced hemoglobin (Hb) on the first day of peripheral blood progenitor cell (PBPC) collection was significantly associated with increased organ toxicity after HSCT, as measured by the Seattle criteria. Lower Hb levels at baseline before transplantation, but not at PBPC collection, were significantly associated with increased RBC transfusion requirements. In a second cohort of 28 patients, higher Hb levels on the day of PBPC collection were significantly associated with increased levels of endothelial-like vascular progenitor cells in PBPC grafts. CONCLUSION: Our observations suggest that higher Hb levels on the day of PBPC collection may be a marker of reduced toxicity associated with HSCT and increased vascular progenitors in PBPC collections. Further, baseline anemia before transplant may reflect an unfavorable hematopoietic microenvironment that leads to increased RBC transfusion requirements.

Increased plasma EPO and MIP-1 alpha are associated with recruitment of vascular progenitors but not CD34(+) cells in autologous peripheral blood stem cell grafts.

OBJECTIVE: Increased levels of endothelial-like vascular progenitor cells (VPCs) in peripheral blood stem cell (PBSC) products have been associated with reduced transplant-related toxicity following autologous hematopoietic stem cell transplantation. In this study, a panel of angiogenic and inflammatory plasma proteins were quantitatively analyzed in patients undergoing PBSC collection for autologous hematopoietic stem cell transplantation to identify profiles associated with greater VPC recruitment. MATERIALS AND METHODS: A panel of 16 candidate plasma factors were quantified using multianalyte fluorescence and/or enzyme-linked immunosorbent assay. VPC clusters were enumerated using a standard cell culture assay. RESULTS: Thirty-six patients (mean age=51 years, 42% female) had plasma collected at baseline prior to PBSC mobilization and on the day of PBSC collection. Only erythropoietin (EPO) levels increased significantly on the day of PBSC collection in comparison with baseline plasma levels (2.2-fold increase; p=0.003). Interleukin-2, -10, epidermal growth factor, interferon-alpha, and angiopoietin-1 all decreased significantly between baseline and the day of PBSC collection (p<0.02). The remaining cytokine levels did not change appreciably (p=NS). The cohort was divided into "low" graft VPCs (<2.0 x 10(3)/kg) and "high" graft VPCs (>or=2.0 x 10(3)/kg) and cytokine levels were compared between the groups. At baseline, increased levels of macrophage inflammatory protein-1 alpha (MIP-1 alpha) were associated with increased graft VPCs (p=0.05) while higher EPO concentrations on the day of PBSC collection predicted higher graft VPC levels (p=0.02). These cytokines were not associated with CD34(+) cell mobilization. CONCLUSIONS: The association of different plasma proteins with graft VPC and CD34(+)-cell levels suggests that mobilization of vascular and hematopoietic progenitors occurs through independent mechanisms. Patients with low levels of MIP-1 alpha at baseline may be candidates for interventions aimed at increasing graft VPC levels. Strategies that increase plasma EPO concentrations may be most promising to augment the regenerative properties of PBSC products.