Assessment of patient satisfaction with home vs office indwelling catheter removal placed for urinary retention after female pelvic floor surgery: a randomized controlled trial.

BACKGROUND: Postoperative urinary retention is burdensome for patients. We seek to improve patient satisfaction with the voiding trial process. OBJECTIVE: This study aimed to assess patient satisfaction with location of indwelling catheter removal placed for urinary retention after urogynecologic surgery. STUDY DESIGN: All adult women who were diagnosed with urinary retention requiring postoperative indwelling catheter insertion after undergoing surgery for urinary incontinence and/or pelvic organ prolapse were eligible for this randomized controlled study. They were randomly assigned to catheter removal at home or in the office. Those who were randomized to home removal were taught how to remove the catheter before discharge, and were discharged home with written instructions, a voiding hat, and 10-mL syringe. All patients had their catheter removed 2 to 4 days after discharge. Those patients who were allocated to home removal were contacted in the afternoon by the office nurse. Subjects who graded their force of urine stream 5, on a scale of 0 to 10, were considered to have safely passed their voiding trial. For patients randomized to the office removal group, the voiding trial consisted of retrograde filling the bladder to maximum they could tolerate up to 300 mL. Urinating >50% of instilled volume was considered successful. Those who were unsuccessful in either group had catheter reinsertion or self-catheterization training in the office. The primary study outcome was patient satisfaction, measured based on patients' response to a question, "How satisfied were you with the overall removal process of the catheter?" A visual analogue scale was created to assess patient satisfaction and 4 secondary outcomes. A sample size of 40 participants per group were needed to detect a 10 mm difference in satisfaction between groups on the visual analogue scale. This calculation provided 80% power and an alpha of 0.05. The final number accounted for 10% loss to follow up. We compared the baseline characteristics, including urodynamic parameters, relevant perioperative indices, and patient satisfaction between the groups. RESULTS: Of the 78 women enrolled in the study, 38 (48.7%) removed their catheter at home and 40 (51.3%) had an office visit for catheter removal. Median and interquartile range for age, vaginal parity, and body mass index were 60 (49-72) years, 2 (2-3), and 28 (24-32) kg/m2, respectively, in the overall sample. Groups did not differ significantly in age, vaginal parity, body mass index, previous surgical history, or type of concomitant procedures. Patient satisfaction was comparable between the groups, with a median score (interquartile range) of 95 (87-100) in the home catheter removal group and 95 (80-98) in the office catheter removal group (P=.52). Voiding trial pass rate was similar between women who underwent home (83.8%) vs office (72.5%) catheter removal (P=.23). No participants in either group had to emergently come into the office or hospital due to inadequate voiding afterwards. Within 30 days post operatively, a lower proportion of women in the home catheter removal group (8.3%) had urinary tract infection, compared to patients in the office catheter removal group (26.3%) (P=.04). CONCLUSION: In women with urinary retention after urogynecologic surgery, there is no difference in satisfaction concerning the location of indwelling catheter removal when comparing home and office.

Perioperative Outcomes of Colpocleisis at a Single Institution: A Retrospective Cohort Study.

IMPORTANCE: There is limited literature reporting perioperative outcomes among colpocleisis types. OBJECTIVES: This study aimed to describe perioperative outcomes after colpocleisis at a single institution. STUDY DESIGN: Patients who underwent colpocleisis at our academic medical center between August 2009 and January 2019 were included. A retrospective chart review was performed. Descriptive and comparative statistics were generated. RESULTS: A total of 367 of 409 eligible cases were included. Median follow-up was 44 weeks. There were no major complications or mortalities. Le Fort and posthysterectomy colpocleises were faster than transvaginal hysterectomy (TVH) with colpocleisis (95 and 98 minutes, respectively, vs 123 minutes; P = 0.00) with decreased estimated blood loss (100 and 100 mL, respectively, vs 200 mL; P = 0.000). Urinary tract infection and postoperative incomplete bladder emptying occurred in 22.6% and 13.4% of all patients, respectively, with no difference among the colpocleisis groups (P = 0.83 and P = 0.90). Patients who underwent concomitant sling were not at increased risk of postoperative incomplete bladder emptying (14.7% for Le Fort and 17.2% for total colpocleisis). Prolapse recurred after 0 Le Fort (0%), 6 posthysterectomy (3.7%), and 0 TVH with colpocleisis procedures (0%) (P = 0.02). CONCLUSIONS: Colpocleisis is a safe procedure with a relatively low complication rate. Le Fort, posthysterectomy, and TVH with colpocleisis have similarly favorable safety profiles and very low overall recurrence rates. Concomitant TVH at the time of colpocleisis is associated with increased operative time and increased blood loss. Concomitant sling procedure at the time of colpocleisis does not increase the risk of short-term incomplete bladder emptying.

Voided volume for postoperative voiding assessment following prolapse and urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the safety and accuracy of voided volume with the standard retrograde fill approach for voiding assessment after pelvic floor surgery. METHODS: This cohort represents all women in our repository who underwent postoperative voiding assessment following procedures for pelvic floor disorders between September 2011 and June 2014. One surgeon utilized a spontaneous voiding (SV) protocol and allowed any patient who voided 150 ml or more at one time to pass the trial. The other surgeon used a retrograde fill (RF) protocol. This involved instilling the bladder with 300 ml of water or until maximum capacity immediately after the outpatient procedures and on the first postoperative day for hospitalized patients. For this protocol, a voided volume of 200 ml was considered sufficient to pass the trial. RESULTS: In this cohort, 431 women had a voiding trial with SV, and 318 with RF. The groups were similar with respect to baseline characteristics but more women in the RF group had a sling-only procedure. The failure rates of the RF (22.8%) and SV (20.0%) groups were similar (p = 0.46). Among women who passed the voiding trial, similar percentages of women returned with urinary retention and needed catheter insertion after the RF (1.6%) and SV (0.9%) methods (p = 0.65). CONCLUSION: Spontaneous voiding trial based on a minimum voided volume of 150 ml is a safe and reliable alternative to the retrograde fill method after female pelvic floor procedures.

Short-Term Outcomes of Vaginal Hysterectomy at the Time of Robotic Sacrocolpopexy.

OBJECTIVE: With the introduction of robotic sacrocolpopexy (RSC) at our institution in 2008, we noted a reduction in residents' vaginal hysterectomy (VH) experience. In 2012, we made a transition to perform VH on all robotic sacrocolpopexies. Our objective was to report our short-term outcomes and adverse events. METHODS: In this case series, we evaluated women who underwent VH with concomitant RSC for stages II to IV pelvic organ prolapse between 2012 and 2017. In these cases, the vesicovaginal and rectovaginal spaces were developed transvaginally. Descriptive analysis including demographics, short-term outcomes, and adverse events are reported. RESULTS: In this group of 209 women, median (interquartile interval) duration of follow-up was 49 (26-60) weeks. The majority of the women were white (84.7%) and postmenopausal (80.9%), with a mean (SD) age of 59 (9) years. At a median follow-up time of 49 weeks, pelvic organ prolapse quantification revealed 20 patients (12.4%) with Ba or Bp greater or equal to 0 and 1.4% of patients required repeat prolapse surgery. Among 9 women (4.3%) with postoperative fever, 4 (1.9%) were treated for pelvic collection/abscess. Of 5 women (2.4%) who had venous thromboembolism, 3 (1.4%) were diagnosed with pulmonary embolism. There were 18 patients (8.6%) treated for urinary tract infection within 6 postoperative weeks. Mesh exposure was noted in 16 (7.7%) of the patients, and 11 (6.2%) required reoperation. CONCLUSIONS: Vaginal hysterectomy at the time of RSC may increase the risk of infection and mesh exposure compared with procedures without concomitant hysterectomy.

Optimizing the robotic surgery team: an operations management perspective.

INTRODUCTION AND HYPOTHESIS: To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions. METHODS: All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify 'optimal' surgical team configuration. RESULTS: The database included 359 consecutive RASCPs, all performed for stage III-IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3 years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7 kg/m2. A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively. CONCLUSION: Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.

The Effectiveness of Community-based Outreach Events for the Promotion of African American Research Participation.

INTRODUCTION: African Americans (AA) are disproportionately affected by Alzheimer's disease and related dementias yet are under-represented in clinical research. Outreach events for AA are offered to encourage research participation; however, this approach's effectiveness remains largely unexplored. METHODS: To explore the effectiveness of AA-focused versus general audience events, the authors examined attendance data over 5 years, encompassing 10 general audience events and 4 events focused on AA. For each individual, the authors searched center records for recruitment contacts and research enrollment. Summary scores for attendance at AA-focused events, general audience events, and total events were compared between those with and without research involvement. RESULTS: Out of 773 unique AA that attended ≥1 event, 88 became or were involved in research (11.4% engagement). AA-focused events achieved greater AA attendance than general audience events. Although research-engaged individuals were more likely to have ever attended an AA-focused event than a general audience event, attendance at AA-focused events did not statistically relate to research engagement. In contrast, attendance at events focused on the general public was related to an increased likelihood of research participation. DISCUSSION: These findings have important implications for designing and implementing community events to encourage AA research participation.

Anterior Bilateral Sacrospinous Ligament Fixation: A Safe Route for Apical Repair.

OBJECTIVES: Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. METHODS: This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. RESULTS: In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. CONCLUSIONS: Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

Sling Plication for Failed Midurethral Sling Procedures: A Case Series.

OBJECTIVES: The aim of this article is to report the outcomes of sling plications performed on women who presented with persistent stress urinary incontinence after midurethral sling. METHODS: All women who underwent sling plication for persistent stress urinary incontinence after placement of either retropubic or transobturator midurethral sling were included in this case series. For plication, first, the suburethral incision was opened. After mobilization of the mesh in the midline, the sling was plicated with absorbable sutures. Descriptive data were extracted from the electronic medical record. Postoperative stress urinary incontinence was diagnosed based on patients' response to the relevant question on the urinary distress inventory and compared this outcome with respect to the original sling placement approach. RESULTS: We identified 36 women who underwent sling plication between March 2013 and November 2016: 26 (72.2%) following a retropubic and 10 (27.7%) following a transobturator sling. Median time between midurethral sling and plication procedure was 6.8 weeks (range, 2-148 weeks). Median follow-up after sling plication was 17 weeks (range, 2-104 weeks). Overall, 24 women (66.6%) reported subjective resolution of stress incontinence. Success rate for plication of retropubic slings was 20 (76.9%) of 26 and significantly higher compared with 4 (40%) of 10 for transobturator slings (P = 0.034). There were no mesh erosions or persistent urinary retention after sling plication. CONCLUSIONS: Sling shortening by plication is an effective low-risk option for the management of persistent stress urinary incontinence following a midurethral sling. This approach was found to be more successful after retropubic slings.

Colpocleisis: A Survey of Current Practice Patterns.

BACKGROUND: Currently, there are no standard treatment guidelines for colpocleisis. Clinical practice varies widely for this safe and effective procedure. OBJECTIVE: The aim of this study was to evaluate the current practice patterns in the United States among surgeons who perform colpocleisis. METHODS: A 27-item anonymous Web-based survey was sent to all practicing physicians affiliated with the American Urogynecologic Society. It consisted of questions regarding the demographic background of the physicians and their current practice as it relates to colpocleisis. RESULTS: Of the 1422 physicians contacted, 322 responded (23%) to the questionnaire. Slightly more than half were female with an average time of 15 years in practice. The majority of respondents (79%) were urogynecologists. Most surgeons chose colpocleisis for its high success rate, short operating time, and low risk of complications. Approximately half of the providers performed both LeFort and total colpocleisis. Only 18% performed a routine hysterectomy at the time of surgery. Routine preoperative endometrial evaluation was preferred by 68% of the respondents, with 81% utilizing a transvaginal ultrasound first. Almost all providers would perform concomitant incontinence procedures, with 54% requiring a positive cough stress test and normal postvoid residual. CONCLUSIONS: There is variation in the current practice of colpocleisis in the United States. LeFort colpocleisis is most commonly performed, and routine hysterectomy is uncommon. Two thirds of surgeons evaluate the endometrium prior to surgery. Concomitant anti-incontinence procedures appear to be standard.

Hysterectomy at the time of colpocleisis: a decision analysis.

INTRODUCTION AND HYPOTHESIS: Colpocleisis is an obliterative procedure for the treatment of pelvic organ prolapse (POP) with success rates nearing 100 %. Concomitant hysterectomy is commonly performed to avoid potential difficulty or delay in diagnosis and management of endometrial cancer (EMC). The objective was to assess the utility of vaginal hysterectomy at the time of a colpocleisis using decision analysis. METHODS: A decision analysis model was constructed to compare the outcomes of Le Fort colpocleisis (C) with those of colpocleisis and concomitant vaginal hysterectomy (CH). Probability and utility values from published data and expert opinions were utilized. As EMC risk changes with age, the total expected utility for each alternative was calculated for each decade using the rollback method. Sensitivity analysis was performed using Monte Carlo simulation. When evaluating specifically the risk of developing EMC in those patients with uterine conservation (C) and the risk of laparotomy in patients undergoing CH, one-way sensitivity analysis was used to determine a threshold for decision reversal. Two-way sensitivity analysis determined a threshold for complications common to both C and CH. RESULTS: The expected overall utility for C was higher than for CH for all ages 30-90 years. This difference was statistically significant for ages 40-90, favoring C. The Monte Carlo simulation results confirmed that the difference between the two alternatives was statistically significant. Multiple one-way sensitivity analyses confirmed model robustness. CONCLUSIONS: Colpocleisis should be preferred to CH. Concomitant hysterectomy commonly performed for cancer may be justified in patients younger than 40 years of age.

Use of Bakri balloon for treatment of persistent hematocolpos after a LeFort Colpocleisis: a case report.

LeFort colpocleisis is a simple and effective procedure for pelvic organ prolapse in women who no longer wish to preserve coital function. If the vaginal channels created during this procedure are not large enough, blood or pus may collect within the uterus or proximal vagina. Hematocolpos, accumulation of blood in apical vagina, may be difficult to manage especially when a patient is frail and has medical comorbidities. Here, we present a case of LeFort colpocleisis in which excessive anticoagulation led to an infected hematocolpos and persistent bleeding. This was successfully managed with a Bakri balloon via a vaginal channel without recurrence of her prolapse.

Obstetrician-gynecologists' opinions on elective bilateral oophorectomy at the time of hysterectomy in the United States: a nationwide survey.

OBJECTIVE: This study aims to assess obstetrician-gynecologists' opinions on elective bilateral oophorectomy (BO) at the time of hysterectomy in the United States and to describe factors that influence their views. METHODS: In April 2012, an anonymous survey was mailed twice to practicing obstetrician-gynecologists, randomly selected from a list produced by the American Medical Association, in an effort to assess their opinions regarding elective BO at the time of hysterectomy. The effects of gynecologists' various characteristics on their opinions were also evaluated. RESULTS: Of 1,002 mailed surveys, 443 (44%) were returned completed. Of the respondents, 59% were male and 79% were white. The largest age group was 51 to 55 years (20%), and the mean time since completion of residency was 23 years. In women with an average risk of ovarian cancer, the proportions of physicians who favored elective BO were as follows: women younger than 51 years, 32%; women aged 51 to 65 years, 62%; women older than 65 years, 6%. These recommendations were not influenced by the physicians' age, sex, training, or geographic region. If a hysterectomy candidate was younger than 51 years and had a personal history of breast or ovarian cancer and a family history of ovarian cancer, these proportions were increased to 77% and 64%, respectively. Other factors that influenced the respondents' recommendations were the women's personal history of cardiovascular disease (21%), osteoporosis (23%), and sexual dysfunction (23%). CONCLUSIONS: One third of obstetrician-gynecologists continue to recommend elective BO for hysterectomy candidates younger than 51 years. The majority recommend elective BO for women aged 51 to 65 years. Their demographic characteristics do not influence their opinions.

Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis.

INTRODUCTION AND HYPOTHESIS: A recent randomized controlled trial (RCT) with and without prophylactic antibiotics (pABX) for midurethral slings (MUS) was terminated early owing to lower than predicted infectious complications in both groups. Adequate power required an unattainable sample size. Because of low infectious risks, omitting pABX may be justified. Since an RCT was not feasible, we aimed to use decision analysis modeling to determine if pABX are necessary for MUS. METHODS: We created a decision analysis model comparing 1-year quality adjusted life years (QALYs) between women who do and do not receive pABX for MUS. The model included complications that might differ depending on whether antibiotics were given, such as allergic reaction to pABX (mild/severe), vulvovaginal candidiasis, urinary tract infections including pyelonephritis, pseudomembranous colitis, wound infection, and mesh erosion. Multiple one-way sensitivity analyses confirmed model robustness. RESULTS: One year after MUS, women who did not receive pABX had higher average QALYs than pABX (0.989 vs 0.977). This difference is less than published minimally important differences (MID) for utilities, suggesting that the strategies are comparable. Ultimately, pABX increased some complications and reduced others with an overall minimal effect on outcomes. Very few thresholds were identified, indicating model robustness and strengthening our conclusions. CONCLUSIONS: Women had slightly higher overall QALY when pABX were not given, but not greater than the MID. Since infectious complications are rare, our model suggests that pABX might be an unnecessary precaution because of similar outcomes with and without pABX.

Vaginal myofibroblastoma with prostatic glands: is there an association with tamoxifen use? A case report.

BACKGROUND: Both ectopic prostate tissue in the female genital tract and vaginal myofibroblastoma have rarely been reported in the literature. Tamoxifen use has been associated with the development of vaginal myofibroblastoma. CASE: A 76-year-old, multiparous woman who had taken tamoxifen for breast cancer presented with postmenopausal bleeding and a vaginal mass. Endometrial work-up revealed a benign polyp, and the polypoid tumor in the vagina was found to be a myofibroblastoma harboring ectopic prostatic glands. CONCLUSION: To our knowledge this is the first case of these two rare pathologic entities occurring together. Of note, this patient also had a history of tamoxifen therapy, like some of the previous patients with vaginal myofibroblastoma.

Massive subcutaneous emphysema in robotic sacrocolpopexy.

The advent of robotic surgery has increased the popularity of laparoscopic sacrocolpopexy. Carbon dioxide insufflation, an essential component of laparoscopy, may rarely cause massive subcutaneous emphysema, which may be coincident with life-threatening situations such as hypercarbia, pneumothorax, and pneumomediastinum. Although the literature contains several reports of massive subcutaneous emphysema after a variety of laparoscopic procedures, we were not able to identify any report of this complication associated with laparoscopic or robotic sacrocolpopexy. Massive subcutaneous emphysema occurred in 3 women after robotic sacrocolpopexy in our practice. The patients had remarkable but reversible physical deformities lasting up to 1 week. A valveless endoscopic dynamic pressure system was used in all 3 of our cases. Our objective is to define the risk of massive subcutaneous emphysema during robotic sacrocolpopexy in light of these cases and discuss probable predisposing factors including the use of valveless endoscopic dynamic pressure trocars.

Minimally invasive diagnosis and treatment of endometrial cancer after LeFort colpocleisis.

BACKGROUND: Endometrial carcinoma is rare after LeFort colpocleisis. Standards for its diagnosis and treatment have not been established. CASE: A 74-year-old woman presented with postmenopausal bleeding 14 months after LeFort colpocleisis. Here, we describe the use of the colpocleisis channels in our novel 2-stage approach. In the first stage, endometrial carcinoma was diagnosed with vaginohysteroscopy and dilatation and curettage via the channels. In the second stage, the cancer was optimally treated with total robotic hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection. Assistance and specimen retrieval were achieved through the vaginal channels. The patient recovered without compromise to the pelvic floor. CONCLUSIONS: Endometrial cancer after LeFort colpocleisis can be diagnosed and treated with minimally invasive approaches without disrupting the colpocleisis or the pelvic floor support.

Effect of obesity on perioperative outcomes of laparoscopic hysterectomy.

OBJECTIVE: To compare the effect of obesity on perioperative outcomes in women undergoing laparoscopic hysterectomy. STUDY DESIGN: In this retrospective cohort study, perioperative outcomes of all women who underwent laparoscopic supracervical hysterectomy (LSH) or total laparoscopic hysterectomy (TLH) for benign conditions were compared between obese (body mass index > or = 30 kg/m2) and nonobese women. RESULTS: Baseline characteristics were similar between 320 (33.0%) obese and 550 (67%) nonobese women except for race and the rates of hypertension and diabetes. The adjusted rates of urinary tract injury, vaginal cuff dehiscence, postoperative fever, and ileus were similar between the groups. For obese women, however, bleeding requiring transfusion was almost 3-fold (3.1 vs. 1.1%, adjusted odds ratio [AOR] 2.93, 95% confidence interval [CI] 1.10-7.80) and laparotomy risk was approximately 2-fold (7.5 vs. 3.5%, AOR 2.35, 95% CI 1.30-4.24) increased. The rate of urinary tract injury was 3.2% when obese women had TLH, but it was 0.3% for LSH performed on nonobese women. Of all 7 cuff dehiscences, 5 (71%) occurred in nonobese women undergoing TLH. CONCLUSION: Obesity increased the risk of bleeding requiring transfusion and conversion to laparotomy but did not influence the other perioperative complications. On subgroup analysis, LSH in nonobese women seems to result in best outcomes.