Urinary Tract Infections After Urogynecologic Surgery: Risk Factors, Timeline, and Uropathogens.

IMPORTANCE: Urinary tract infection (UTI) is a common and potentially avoidable postoperative (PO) adverse event after urogynecologic surgery. Understanding pathophysiology will help prevent the associated morbidity of the disease and treatment of PO-UTI. OBJECTIVE: The objective of this study is to determine the following: (1) risk factors for both PO-UTI and PO recurrent UTI (RUTI) after urogynecologic surgery, (2) temporal distribution of UTI, and (3) uropathogen identification. STUDY DESIGN: Women undergoing urogynecologic surgery were retrospectively reviewed. Urinary tract infection was defined by culture or antibiotic prescription for symptoms. Recurrent UTI was defined as occurring outside a 6-week perioperative period. The χ 2 test or Fischer exact and Student t tests or Mann-Whitney U test were used as appropriate. Individual odds ratio (OR), 95% confidence interval [CI], and sequential multivariable logistic regression were calculated. Statistical significance was set at P < 0.05. RESULTS: The 6-week PO-UTI rate after 33,626 procedures was 12.9%. Recurrent UTI increased from 3.7% preoperatively to 4.4% postoperatively ( P < 0.001). A 6-week preoperative UTI and RUTI increased the risk of 6-week PO-UTI (OR, 1.65; 95% CI < 1.26-2.16; P = 0.001 and OR, 2.19; 95% CI, 1.84-2.62; P < 0.001, respectively) and PO-RUTI (OR, 2.95; 95% CI, 2.11-4.11; P < 0.001 and OR, 6.79; 95% CI, 5.61-8.23; P < 0.001, respectively). Compared with pelvic organ prolapse (POP) surgery only, stress urinary incontinence (SUI) surgery (OR 1.57[1.30-1.89]), and combined POP/SUI surgery (OR, 1.36; 95% CI, 1.13-1.63]) increased the risk of PO-RUTI ( P < 0.001). Urinary tract infection within 1 week preoperatively was protective against 6-week PO-UTI (OR, 0.68; 95% CI, 0.48-0.97; P = 0.035). No perioperative factors were protective of PO-RUTI. CONCLUSIONS: The PO-RUTI rate in the first year after urogynecologic surgery is low; however, SUI procedures may increase PO-RUTI risk. Potentially, modifiable risk factors for both PO-UTI and PO-RUTI include UTI diagnosis within 6 weeks preoperatively or preoperative RUTI diagnosis. Retesting women the week before surgery to ensure adequate treatment of preoperative UTI may reduce 6-week PO-UTI.

Urinary microbiota of women with recurrent urinary tract infection: collection and culture methods.

INTRODUCTION AND HYPOTHESIS: Many clinicians utilize standard culture of voided urine to guide treatment for women with recurrent urinary tract infections (RUTI). However, despite antibiotic treatment, symptoms may persist and events frequently recur. The cyclic nature and ineffective treatment of RUTI suggest that underlying uropathogens pass undetected because of the preferential growth of Escherichia coli. Expanded quantitative urine culture (EQUC) detects more clinically relevant microbes. The objective of this study was to assess how urine collection and culture methods influence microbial detection in RUTI patients. METHODS: This cross-sectional study enrolled symptomatic adult women with an established RUTI diagnosis. Participants contributed both midstream voided and catheterized urine specimens for culture via both standard urine culture (SUC) and EQUC. Presence and abundance of microbiota were compared between culture and collection methods. RESULTS: Forty-three symptomatic women participants (mean age 67 years) contributed specimens. Compared to SUC, EQUC detected more unique bacterial species and consistently detected more uropathogens from catheterized and voided urine specimens. For both collection methods, the most commonly detected uropathogens by EQUC were E. coli (catheterized: n = 8, voided: n = 12) and E. faecalis (catheterized: n = 7, voided: n = 17). Compared to catheterized urine samples assessed by EQUC, SUC often missed uropathogens, and culture of voided urines by either method yielded high false-positive rates. CONCLUSIONS: In women with symptomatic RUTI, SUC and assessment of voided urines have clinically relevant limitations in uropathogen detection. These results suggest that, in this population, catheterized specimens analyzed via EQUC provide clinically relevant information for appropriate diagnosis.

Impact of Vaginal Estrogen on the Urobiome in Postmenopausal Women With Recurrent Urinary Tract Infection.

OBJECTIVE: The aim of this study was to describe effects of vaginal estrogen (VE) on the urogenital microbiome in postmenopausal women with recurrent urinary tract infections (rUTIs). METHODS: This is a secondary analysis of 17 participants enrolled in a randomized controlled trial of VE versus placebo on urinary tract infection recurrence in postmenopausal women with rUTIs. Paired clean-catch urine samples were collected at baseline and after 6 months of VE and sequenced using 16S rRNA gene sequencing. Sequence reads were analyzed using Quantitative Insights Into Microbial Ecology 2. Changes in α diversity, ß diversity, and differentially abundant genera were measured between paired baseline and 6-month samples and between those with a urinary tract infection at 6 months (failures) and those without (successes). RESULTS: Of the 17 women, 11 were successes and 6 were failures after 6 months of VE treatment. There was a significant change in α diversity from baseline to month 6 in samples overall (Kruskal-Wallis χ2 = 3.47, P = 0.037) and in the treatment success group (Yuen T = -2.53, P = 0.035). The increase in relative abundance of Lactobacillus crispatus, Lactobacillus gasseri, and Lactobacillus iners AB-1 was correlated with month 6. A relative bloom of L. crispatus compared with L. gasseri was associated with treatment success (Kruskal-Wallis χ2 = 4.9, P = 0.0014). CONCLUSIONS: Lactobacillus increases in the urogenital microbiome of postmenopausal women with rUTI after 6 months of VE. However, only the relative increase in L. crispatus specifically may be associated with treatment success.

Lavender Aromatherapy for Anxiety and Pain During Multichannel Urodynamics: A Randomized Controlled Pilot Trial.

OBJECTIVE: Our objective was to determine if there is a difference in anxiety during urodynamics in women given lavender aromatherapy (lavender) versus placebo. METHODS: This was a randomized, controlled trial of women scheduled for urodynamic testing with baseline anxiety. Participants rated their anxiety and pain immediately before the examination and then were randomized to lavender or placebo. Anxiety and pain were assessed immediately after catheter placement and 15 minutes after termination of the study. RESULTS: Data for 40 women who received lavender and 38 women who received placebo were available for analysis. Decrease in anxiety from baseline to catheter placement (-2 vs -0.5, P = 0.01) and 15 minutes post procedure was significantly greater in the lavender group. Postprocedure anxiety was lower in the lavender group compared with controls (0 vs 0.5, P = 0.001). No differences were seen in pain. CONCLUSIONS: Lavender aromatherapy reduces anxiety during urodynamics.

Vaginal Estrogen for the Prevention of Recurrent Urinary Tract Infection in Postmenopausal Women: A Randomized Clinical Trial.

OBJECTIVES: We aimed to compare the efficacy of 2 commonly used contemporary vaginal estrogen administrations versus placebo for the prevention of urinary tract infection (UTI) in postmenopausal women with a clinical diagnosis of recurrent UTI (rUTI). METHODS: This was an investigator-initiated, multicenter, single-blind, randomized, placebo-controlled trial of vaginal estrogen (delivered via ring or cream) compared with placebo. Postmenopausal women with documented rUTI were randomized to receive either vaginal estrogen (via ring or cream) or placebo cream in a 1:1:1 fashion. The primary outcome was occurrence of UTI at 6 months. After 6 months, open-label use of ring or active cream was offered to all participants for an additional 6 months. Because of slower than expected recruitment, sample size calculations and block randomization schema were revised to combine estrogen groups (ring or cream) for statistical comparisons to placebo cream in a 1:1 fashion. RESULTS: Thirty-five women were randomized with 9 dropouts (1 ring, 2 cream, and 6 placebo) prior to the 6 months. Intention-to-treat analysis (assuming dropouts as failures) revealed fewer women treated with vaginal estrogen had a UTI within 6 months versus placebo (11/18 vs 16/17, respectively; P = 0.041). Per-protocol analysis revealed fewer subjects treated with vaginal estrogen had a UTI at 6 months (8/15 vs 10/11, respectively; P = 0.036). CONCLUSIONS: Commonly prescribed forms of vaginal estrogen with contemporary dosing schedules prevent UTIs in postmenopausal women with an active diagnosis of rUTI.

Percutaneous tibial nerve stimulation maintenance therapy for overactive bladder in women: long-term success rates and adherence.

PURPOSE: Our objectives are to (1) identify predictors of treatment success in women with overactive bladder (OAB) after 1 year of percutaneous tibial nerve stimulation (PTNS) maintenance therapy, (2) identify trends in success rates during that 1 year, and (3) assess maintenance treatment adherence. MATERIALS AND METHODS: A retrospective study of 141 women with OAB was performed with the definition of success based on a Patient Global Impression-Improvement (PGI-I) score of 1 ("very much better") or 2 ("much better") or a PGI-I score of 1, 2, or 3 ("a little better"). Multivariable logistic regression was performed to identify factors associated with treatment response and the Cochrane-Armitage trend test to identify changes in the scores over time. RESULTS: After completing 12 weekly treatments, 141 women initiated maintenance therapy with a mean treatment interval of 29 days. At 1 year, 75/141 (53.2%) had discontinued treatment. Those adherent with treatment had a sustained treatment response, with 66.2% of women reporting a PGI-I score of 1, 2 and 92.3% reporting a PGI-I score of 1, 2, or 3 at 1 year. Considering those women who discontinued maintenance therapy as treatment failures, the success rate of 1 year of maintenance therapy ranged from 30.7%-42.9%. No clinical factors were found to be predictive of maintenance treatment success or failure. CONCLUSIONS: Although an effective treatment for those adherent, discontinuation rates of PTNS maintenance therapy at 1 year are high. Given the low numbers of women referred to maintenance therapy, and the high discontinuation rates, long-term PTNS treatment may be feasible for only a minority of women with OAB.

8 versus 12 weeks of percutaneous tibial nerve stimulation and response predictors for overactive bladder.

INTRODUCTION AND HYPOTHESIS: The primary objective is to compare weekly success rates after 8 vs 12 weekly percutaneous tibial nerve stimulation (PTNS) sessions for treatment of overactive bladder (OAB) in women and the secondary objective is to identify treatment response predictors. METHODS: A retrospective study of 470 women was performed with the primary definition of success a Patient Global Impression-Improvement (PGI-I) score of 1 ("very much better") or 2 ("much better") and a ≥ 10-point improvement in both subscales of the Overactive Bladder Questionnaire-Short Form (OABq-SF). Additional analyses were performed to include a success definition of a PGI-I score of 3 ("a little better"). Categorical variables were compared using the Chi-squared test. Multivariate logistic regression was performed to identify factors associated with response. RESULTS: One hundred and thirty-six out of 470 (29%) discontinued treatment before 12 weeks. One hundred out of 334 (29.9%) were successes at 8 weeks vs 138 out of 334 (41.3%) at 12 weeks (p = 0.002). Including a PGI-I score of 3 as an indicator of success, 181 out of 334 (54.2%) at 8 weeks and 202 out of 334 (60.5%) at 12 weeks were successes (p = 0.10). Factors associated with treatment response were neurological disorder (OR 4.32 [1.10-16.04]), prolapse surgery history (OR 3.89 [1.12-14.49]), and vaginal estrogen use (OR 1.76 [1.01-3.08]). Recurrent UTI was associated with failure (OR 0.42 [0.21-0.86]). CONCLUSIONS: The PTNS treatment success rate for OAB in women is greater at 12 weeks than at 8 weeks based on two validated questionnaires, the PGI-I and the OABq-SF. However, the success rates were equivalent if women who are "a little better" are also considered successes; with this definition, clinicians may consider shortening treatment duration to 8 weeks. Four clinical factors were significantly associated with response and may help to guide patient selection.

Postoperative urinary tract infection after urogynecologic surgery: timing and uropathogens.

INTRODUCTION AND HYPOTHESIS: Although postoperative urinary tract infections (UTIs) after urogynecologic surgery are a common adverse event, there is no standardized postoperative time period used to assess this outcome, and the uropathogens unique to this sub-population of patients have not been well described. Our objective is to describe the timing and uropathogens of postoperative UTI after urogynecologic surgery. METHODS: This retrospective study analyzed postoperative UTI occurring within 90 days following urogynecologic procedures from November 2013 to January 2018 at a single academic institution. Postoperative UTI was defined as any uropathogen growth from standard urine culture. Continuous variables were compared with independent samples t-test and categorical variables with chi-square with Bonferonni corrections as appropriate. RESULTS: One hundred and two of 1085 (9.4%) patients experienced UTI; 63.7% occurred within 6 weeks and 78.4% within 8 weeks; 36.3% of UTIs occurred at a time period of 6 weeks to 90 days. Most commonly isolated uropathogens were Escherichia coli (47.8%) with an additional 11.2% extended-spectrum beta-lactamase (ESBL) Escherichia coli. Other bacteria included Enterococcus faecalis (10.4%), Klebsiella pneumoniae (9%), and one culture each for ESBL Klebsiella pneumoniae and vancomycin-resistant (VRE) Enterococcus faecium. CONCLUSIONS: More than one third of UTIs after urogynecologic surgery occur between 6 weeks and 90 days postoperatively. A plateau of UTI incidence occurs at 8 weeks, a time period at which 78.4% of all UTIs were captured. Escherichia coli was the most commonly isolated uropathogen, and multi-drug-resistant bacteria were implicated in 12.8% of UTIs.

Benchmarking urine storage and collection conditions for evaluating the female urinary microbiome.

Standardized conditions for collection, preservation and storage of urine for microbiome research have not been established. We aimed to identify the effects of the use of preservative AssayAssure® (AA), and the effects of storage time and temperatures on reproducibility of urine microbiome results. We sequenced the V3-4 segment of the 16S rRNA gene to characterize the bacterial community in the urine of a cohort of women. Each woman provided a single voided urine sample, which was divided into aliquots and stored with and without AA, at three different temperatures (room temperature [RT], 4 °C, or -20 °C), and for various time periods up to 4 days. There were significant microbiome differences in urine specimens stored with and without AA at all temperatures, but the most significant differences were observed in alpha diversity (estimated number of taxa) at RT. Specimens preserved at 4 °C and -20 °C for up to 4 days with or without AA had no significant alpha diversity differences. However, significant alpha diversity differences were observed in samples stored without AA at RT. Generally, there was greater microbiome preservation with AA than without AA at all time points and temperatures, although not all results were statistically significant. Addition of AA preservative, shorter storage times, and colder temperatures are most favorable for urinary microbiome reproducibility.

The etiology and management of recurrent urinary tract infections in postmenopausal women.

Urinary tract infections (UTIs) are one of the most common infections and affect up to 50% of women in their lifetime, with almost half of these women experiencing a recurrence in 6-12 months. Menopause predisposes women to recurrent UTI (rUTI), as normally lower levels of estrogen lead to changes in the urogenital epithelium and subsequently urogenital microbiome. The recently discovered urobiome is now known to have different compositions in both healthy and unhealthy bladders, including a role in the pathophysiology of rUTI, and may be a therapeutic target for prevention and treatment options for rUTI. In postmenopausal women with frequent UTI, the diagnosis of acute UTI should be made using a combination of the symptom assessment and urine diagnostic studies. The choice of UTI antibiotic should include consideration of efficacy, collateral effects, and side-effects. Some women may be candidates for self-start therapy, in which the patient accurately recognizes her UTI symptoms and then starts previously prescribed antibiotics. A large component of the management of women with rUTI is prevention. Urobiome research for bladder health and disease is a young field of investigation with significant potential to improve care for postmenopausal women affected by rUTI through novel, evidence-based prevention and treatment strategies.

Timing of Intrauterine Manipulator Insertion During Minimally Invasive Surgical Staging and Results of Pelvic Cytology in Endometrial Cancer.

STUDY OBJECTIVE: Considering the hypothetical concern of retrograde tumor spread to the peritoneal cavity by insertion of an intrauterine manipulator, we examined the correlation between the timing of manipulator insertion and the results of pelvic cytology during total laparoscopic hysterectomy (TLH) in endometrial cancer. DESIGN: Case-control study (Canadian Task Force classification II-2). SETTING: University-based hospitals. PATIENTS: Stage I to IV endometrial cancer patients who underwent TLH in which an intrauterine manipulator was used. Medical records were reviewed for patient demographics, surgical details, and tumor characteristics. INTERVENTIONS: Archived medical record review. MEASUREMENTS AND MAIN RESULTS: A total of 333 patients was identified. Cases were divided into those with intrauterine manipulator insertion after pelvic cytology sampling (Group 1, n = 103) and those with intrauterine manipulator insertion before pelvic cytology sampling (Group 2, n = 230). Types of intrauterine manipulator were similar across the 2 groups (p = .77). There was no statistical difference in the results of pelvic cytology between the 2 groups: Group 1 versus 2, atypical cells 2.9% versus 4.8% and malignant cells 5.8% versus 9.6% (p = .36). Uterine perforation related to intrauterine manipulator insertion was seen in 1.0% and .4% of each group (p = .52). In a multivariate analysis controlling for demographics and tumor characteristics, advanced-stage disease remained an independent risk factor associated with increased risk of atypical and malignant cells (adjusted odds ratio, 10.3; 95% confidence interval, 4.44-23.8; p < .001). CONCLUSION: Our study suggested that the timing of intrauterine manipulator insertion during TLH for endometrial cancer is not associated with the results of pelvic cytology.

Predictive Factor of Conversion to Laparotomy in Minimally Invasive Surgical Staging for Endometrial Cancer.

OBJECTIVE: The aim of the study was to identify risk factors associated with laparotomy conversion during total laparoscopic hysterectomy for endometrial cancer. METHODS: This is a retrospective study examining endometrial cancer cases that underwent hysterectomy-based surgical staging initiated via conventional laparoscopic approach. Factors related to patient, tumor, and surgeon were examined to establish risk of laparotomy conversion using a multivariate logistic regression model. RESULTS: There were 251 cases identified including 30 cases (12.0%) of laparotomy conversion. The most common indication for laparotomy conversion was a large uterus (27.0%), followed by extensive adhesions (24.3%) and surgical complications (18.9%). Outcomes of cases resulting in laparotomy conversion include longer surgical time (333 vs 224 minutes, P < 0.001), larger blood loss (350 vs 100 mL, P < 0.001), longer hospital stay (4 vs 2 days, P < 0.001), and increased risk of hospital readmission (10% vs 1.4%, P = 0.024). In multivariate analysis, morbid obesity (odds ratio [OR], 4.51; P = 0.011), suboptimal pelvic examination or enlarged uterus during preoperative evaluation (OR, 3.55; P = 0.034), para-aortic lymphadenectomy (OR, 10.5; P = 0.001), uterine size 250 g or greater (OR, 3.49; P = 0.026), and extrauterine disease (OR, 4.68; P = 0.012) remained the independent predictors for laparotomy conversion. The following numbers of risk factors were significantly correlated with laparotomy-conversion rate: none, 1.1%; single risk factor, 5.3% (OR, 5.00; P = 0.15); double risk factors, 21.7% (OR, 24.9; P = 0.002); and triple or more risk factors, 50% (OR, 90.0; P < 0.001). Ultrasonographic 3-dimensional volumes of 496 cm in preoperative uterine size correlate with actual uterine weight of 250 g (Y = 61.5 + 0.38X, P < 0.001). CONCLUSIONS: Laparotomy conversion significantly impacts outcomes of patients with endometrial cancer. In this setting, our predictive model for laparotomy conversion will be useful to guide the surgical management of endometrial cancer.

Surgical menopause and increased risk of nonalcoholic fatty liver disease in endometrial cancer.

OBJECTIVE: Our objective was to examine risk factors associated with development of nonalcoholic fatty liver disease (NAFLD) among women with endometrial cancer who underwent surgical staging with or without oophorectomy. METHODS: This is a retrospective study that evaluated endometrial cancer cases that underwent surgical staging (n = 666) and endometrial hyperplasia cases that underwent hysterectomy-based treatment (n = 209). This study included 712 oophorectomy cases and 163 nonoophorectomy cases. Archived records were reviewed for participant demographics, medical comorbidities, operative notes, histology results, and radiology reports for NAFLD. Cumulative risks of NAFLD after surgical operation were correlated to demographics and medical comorbidities. RESULTS: The cumulative prevalence of NAFLD in 875 women with endometrial tumor was 14.1%, 20.5%, and 38.4% at 1, 2, and 5 years after surgical operation, respectively. On multivariate analysis, after controlling for age, ethnicity, body mass index, medical comorbidities, tumor type, hormonal treatment pattern, and oophorectomy status, age younger than 40 years (2-y cumulative prevalence, 26.6% vs 16.8%; hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = 0.001) and age 40 to 49 years (2-y cumulative prevalence, 23.1% vs 16.8%; HR, 1.49; 95% CI, 1.08-2.04; P = 0.015) remained significant predictors for developing NAFLD after surgical operation compared with age 50 years or older. Oophorectomy was an independent predictor for increased risk of NAFLD (20.9% vs 15.9%; HR, 1.70; 95% CI, 1.01-2.86; P = 0.047). In addition, NAFLD was significantly associated with postoperative development of diabetes mellitus (39.2% vs 15.3%; HR, 2.26; 95% CI, 1.52-3.35; P < 0.0001) and hypercholesterolemia (34.3% vs 17.5%; HR, 1.71; 95% CI, 1.12-2.63; P = 0.014). CONCLUSIONS: Oophorectomy in young women with endometrial cancer significantly increases the risk of NAFLD. This is associated with development of diabetes mellitus and hypercholesterolemia after oophorectomy.

Significance of adenomyosis on tumor progression and survival outcome of endometrial cancer.

BACKGROUND: To examine the effects of adenomyosis on tumor progression and survival outcome of endometrial cancer patients. METHODS: This is a retrospective study examining stage I-IV endometrial cancer patients who underwent hysterectomy-based surgical staging (n = 571), and endometrial hyperplasia patients who underwent hysterectomy (n = 213). Clinical demographics, histopathological factors, and survival outcomes were analyzed based on the presence or absence of adenomyosis. RESULTS: Among the endometrial cancer cohort, adenomyosis was observed in 47.5 % of cases and was significantly associated with lower grade (grade 1-2 tumors, 81.2 vs. 73.3 %; p = 0.028), earlier stage (stage I disease, 74.8 vs. 64.3 %; p = 0.023), and lower likelihood of deep myometrial invasion (19.2 vs. 28.2 %; p = 0.039) and cervical invasion (13.7 vs. 21.2 %; p = 0.024) than those without adenomyosis. In survival analysis, endometrial cancer coexisting with adenomyosis was associated with a significantly better disease-free survival (5-year rate, 89.2 vs. 78.2 %; p < 0.001) and overall survival (91.8 vs. 83.9 %; p = 0.004) after hysterectomy. In multivariate analysis, controlling for other significant variables in univariate analysis, presence of adenomyosis remained an independent prognostic factor associated with decreased risk of disease recurrence after surgery (hazard ratio [HR] 0.53; 95 % confidence interval [CI] 0.30-0.92; p = 0.023). Endometrial hyperplasia had a significantly increased incidence of adenomyosis when compared with type I endometrial cancer (grade 1-2 endometrioid adenocarcinoma, n = 411) on multivariate analysis (62.9 vs. 48.9 %; HR 1.88; 95 % CI 1.32-2.69; p < 0.001). CONCLUSIONS: Adenomyosis appears to be associated with less aggressive tumor behavior of endometrial cancer, suggesting that it may have inhibitory effects on the progression of this disease.

Feto-maternal outcome of pregnancy complicated by vulvar cancer: a systematic review of literature.

Vulvar cancer is an extremely rare complication during pregnancy, and its effect on pregnancy and survival is not well understood. A systematic literature review was conducted in order to examine the fetal and maternal outcomes and optimal management of pregnancy complicated by vulvar cancer. PubMed/MEDLINE were used to identify case reports with searching keywords "pregnancy" and "vulvar cancer" between January 1955 and February 2014 that identified 36 cases for analysis. Mean age was 30.7. The most common presenting symptom and gestational age were vulvar mass/swelling (75.0%) and the second trimester of pregnancy (54.8%), respectively. Vulvar biopsy at the time of initial presentation to care during pregnancy was performed in only 46.7% of cases. Among delayed cases for biopsy, mean duration of delay was 12.8 weeks and the majority had a delay for more than 8 weeks (62.5%). The majority of vulvar cancer was squamous histology (47.2%) and stage I disease (60.0%). Vulvectomy and inguinal-femoral lymphadenectomy were performed in 97.1% and 63.9%, respectively. Abdominal delivery was recorded in 46.2% of cases. Live birth and full term delivery rates were 96.3% and 74.0%, respectively. For survival analysis, delay in diagnosis and advanced stage disease were commonly associated with decreased disease-free survival (5-year rate, delay in diagnosis >8 versus ≤8 weeks, 0% versus 69.1%, hazard ratio (HR) 7.86, 95% confidence interval (CI) 2.03-30.6, p=0.001; and stage III-IV versus stage I-II, 0% versus 59.8%, HR 3.35, 95% CI 1.16-9.68, p=0.011) and overall survival (5-year rate, delay in diagnosis >8 versus ≤8 weeks, 0% versus 67.1%, hazard ratio (HR) 14.8, 95% CI 1.77-124, p=0.001; and stage III-IV versus stage I-II, 0% versus 86.4%, HR 8.22, 95% CI 2.06-33.2, p<0.001). In conclusion, while the majority of cases resulted in good pregnancy outcomes, diagnosis of vulvar cancer during pregnancy is frequently delayed. Since delayed diagnosis is a significant prognosticator of decreased survival outcomes, early recognition is integral in the management of pregnancy complicated by vulvar cancer.