Differences in Sexual and Physical Abuse History by Presenting Chief Complaint in an Outpatient Urogynecology Population.

IMPORTANCE: One in 3 women experience sexual or physical violence in their lifetimes. Health consequences for survivors are numerous, including urogynecologic symptoms. OBJECTIVES: We aimed to determine prevalence and factors that predict a history of sexual or physical abuse (SA/PA) in outpatient urogynecology, specifically whether the chief complaint (CC) predicts a history of SA/PA. STUDY DESIGN: This cross-sectional study analyzed 1,000 newly presenting patients to 1 of 7 urogynecology offices in western Pennsylvania from November 2014 to November 2015. All sociodemographic/medical data were retrospectively abstracted. Univariable and multivariable logistic regression analyzed risk factors based on known associated variables. RESULTS: One thousand new patients had a mean age of 58.4 ± 15.8 years with a body mass index (BMI) of 28.8 ± 6.5. Nearly 12% reported a history of SA/PA. Patients with CC of pelvic pain were more than twice as likely to report abuse compared with all other CCs (odds ratio [OR], 2.690; 95% confidence interval [CI], 1.576-4.592). Prolapse was the most common CC (36.2%) but had the lowest prevalence of abuse (6.1%). Nocturia was an additional urogynecologic variable predictive of abuse (OR, 1.162 per nightly episode; 95% CI, 1.033-1.308). Increasing BMI and decreasing age both increased the risk of SA/PA. Smoking conferred the highest likelihood of abuse history (OR, 3.676; 95% CI, 2.252-5.988). CONCLUSIONS: Although those with a CC of prolapse were less likely to report abuse history, we recommend routine screening for all women. Pelvic pain was the most common CC among women reporting abuse. Special efforts should be made to screen those at higher risk with complaints of pelvic pain who are younger, smokers, with higher BMI, and with increased nocturia.

Age and Perioperative Outcomes After Implementation of an Enhanced Recovery After Surgery Pathway in Women Undergoing Major Prolapse Repair Surgery.

OBJECTIVE: As perioperative care pathways are developed to improve recovery, there is a need to explore the impact of age. The aim of this study was to compare the impact of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway on perioperative outcomes across 3 age categories: young, middle age, and elderly. METHODS: A retrospective cohort study was conducted assessing same-day discharge, opioid administration, pain scores, and complications differences across and within 3 age categories, young (<61 years), middle age (61-75 years), elderly (>75 years), before and after ERAS implementation. RESULTS: Among 98 (25.7%) young, 202 (52.9%) middle-aged, and 82 (21.5%) elderly women, distribution before and after ERAS implementation was similar. In each age category, we found a commensurate increase in same-day discharge and decrease in length of stay independent of age. Age was associated with a variable response to opioid administration after ERAS. In women who received opioids, we found there was a greater reduction in opioids in elderly. Young women received 22.5 mg more than middle-aged women, whereas elderly women received 24.3 mg less than middle-aged women (P < 0.0001, P < 0.0001) for a mean difference of 46.8 mg between the youngest and oldest group. We found no significant differences in postanesthesia care unit pain scores with ERAS implementation. Complications did not increase after ERAS implementation in any age group, although younger and elderly women were more likely to experience complications independent of ERAS. CONCLUSIONS: Elderly women had similar outcomes compared with their younger counterparts after implementation of an ERAS pathway. Further research is needed to assess whether our age-related observations are generalizable.

Sacral Neuromodulation: Determining Predictors of Success.

OBJECTIVE: To determine predictors of success for sacral neuromodulation in women with overactive bladder, urinary retention, and fecal incontinence. METHODS: A retrospective chart review was performed on women who underwent a staged sacral neuromodulation implantation between 2007 and 2018. Clinical and procedural characteristics were recorded. Presence of intraoperative motor responses in either all 4 or <4 electrodes were used to group women. Endpoints included completion of stage II implant, tined lead revision, and patient-reported success. RESULTS: In 198 women with a mean age of 62.9 years (SD+/- 14.7), completion of stage II implant occurred in 92.4% of women, and 83.3% of these women reported success at the first postoperative visit. Continued success at 6 months was reported in 70.3%. Lead revision was noted in 23.0%. Age >65 years (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.06-0.8) and prior onabotulinumtoxinA (onaBoNT-A) (OR = 0.2, 95% CI = 0.06-0.9) were negative predictors for completion of stage II implant on multivariable analysis. Also, prior pelvic floor physical therapy was a significant negative predictor of postoperative patient-reported success on multivariable analysis (OR = 0.25, 95% CI = 0.1-0.6). There were no differences seen in women who had motor responses with either all 4 electrodes or <4 electrodes in any endpoint (P > .05). CONCLUSION: Patient age >65 and history of prior onaBoNT-A were associated with failure to complete stage II implant. Women with prior pelvic floor physical therapy were less likely to report success after sacral neuromodulation. Motor responses in <4 electrodes during lead testing did not impact patient-reported success.

Assessing the Performance of the De Novo Postoperative Stress Urinary Incontinence Calculator.

OBJECTIVE: The aim of the study was to determine the performance of a previously published stress urinary incontinence (SUI) risk calculator in women undergoing minimally invasive or transvaginal apical suspensions. METHODS: Using a database of stress-continent women who underwent minimally invasive or transvaginal apical suspensions, we calculated 2 prediction risks for development of SUI within 12 months based on inclusion of a "prophylactic" midurethral sling at the time of prolapse surgery. Observed subjective and objective continence status was abstracted from medical records. Regression models were created for the outcome of de novo SUI to generate receiver operating curves. Concordance (c) indices were estimated for the overall and procedure subgroups to determine the calculator's ability to discriminate between SUI outcomes. RESULTS: Analyses included 502 women. De novo SUI was observed in 23.5% of women. The mean ± SD calculated risk of de novo SUI if a sling was performed was 18.9% ± 13.9 at 12 months compared with 36.4% ± 8.3 without sling. The calculator's discriminative ability for those with a planned sling was moderate (c-index = 0.55, P = 0.037). The calculator failed to discriminate continence outcomes when a sling was not planned in the overall group (c-index = 0.50, P = 0.799) and individual apical procedures. CONCLUSIONS: The SUI risk calculator is significantly limited in its ability to predict de novo SUI in our population of women planning minimally invasive apical suspensions. Refinements to the calculator model are needed to improve its utility in clinical practice.

The Impact of a Dedicated Robotic Team on Robotic-Assisted Sacrocolpopexy Outcomes.

BACKGROUND: Robotic-assisted sacrocolpopexy has been criticized for high cost. A strategy to increase operating room efficiency and decrease cost is implementation of a dedicated robotic team. Our objective was to determine if a dedicated robotic team decreases operative time. STUDY DESIGN: This institutional review board-approved retrospective cohort study included all robotic-assisted sacrocolpopexy performed from June 2010 to August 2015 by a single surgeon at 2 institutions in 1 health system. One hospital had a dedicated robotic team, whereas the other did not. To assess baseline differences, χ and t tests were used. Multivariable linear regression identified factors impacting operative time. RESULTS: Eighty-eight robotic-assisted sacrocolpopexy cases met inclusion criteria. Subjects were primarily white (92.8%) and postmenopausal (85.5%) with stage III prolapse (71.1%). Mean age was 60.6 ± 9.0 years, and BMI was 28.5 ± 5.1 kg/m. Seventeen cases (19.3%) had a dedicated team. In the 71 cases without a dedicated team, there were 16 different surgical technologist and no advanced practice providers. Groups had similar baseline characteristics (all P > 0.05).Mean operative time for the dedicated team was significantly less (131.8 vs 160.2 minutes, P < 0.001), a 17.7% time reduction. The decrease persisted on multivariable regression (ß = -25.98 minutes, P < 0.001) after adjusting for case order on the day (ß = -8.6 minutes, P = 0.002) and prior to hysterectomy (ß = -36.1 minutes, P < 0.001). Operative complications and prolapse recurrence were low overall and not different between the dedicated and nondedicated teams (0% vs 2.9%, P = 0.50; 0% vs 7.5%, P = 0.29). CONCLUSIONS: A dedicated robotic team during robotic-assisted sacrocolpopexy significantly decreased operative time by 26 minutes, a 17.7% reduction at our institution.

Evaluating the Impact of Intraoperative Surgical Team Handoffs on Patient Outcomes.

OBJECTIVE: The aim of the study was to assess the impact of intraoperative personnel handoffs on clinical outcomes in patients undergoing minimally invasive sacrocolpopexy (SCP). METHODS: We retrospectively reviewed SCPs performed at an academic center between 2009 and 2014. We analyzed the number of staff handoffs, defined as any instance a scrub technician (tech) or circulating nurse handed off responsibility for a break or shift change. Outcomes included operative (OR) time and composite variables for major complications (conversion to an open procedure, bladder injury, bowel injury, blood transfusion, infection, ileus, bowel obstruction, readmission, or mesh complication) and prolapse recurrence (prolapse at or beyond the hymen or retreatment). Postoperative complications were defined as being within 6 weeks of surgery. Mesh complications and prolapse recurrence were recorded for the entire 68-month study period. RESULTS: Of 814 patients, 97.4% were white, 85.3% postmenopausal, mean (SD) age 59.7 (8.8) years, and mean (SD) body mass index 27.5 (4.5) kg/m. Most had stage 3 prolapse (n = 563, 69.9%). There were 478 (58.7%) laparoscopic and 336 (41.3%) robotic SCPs. The median scrub tech and nurse handoff per case was 1.0 (interquartile range [IQR], 0.0-1.0) and 1.0 (IQR, 1.0-2.0), respectively. Mean (SD) OR time was 204.8 (69.0) minutes. One hundred twenty-nine patients (15.8%) had a major complication and 45 (7.5%) experienced prolapse recurrence over a median follow-up interval of 41.0 weeks (IQR, 12.0-101.0). On multivariable linear regression, each tech and nurse handoff was associated with an increased OR time of 13.6 (P < 0.001) and 9.4 minutes (P < 0.001), respectively. Thus, the median of 1 tech and 1 nurse handoff per case will increase OR time by 23.0 minutes (11.2%). On multivariable logistic regression, staff handoffs were not associated with major complications or prolapse recurrence. CONCLUSIONS: Intraoperative scrub technician and circulating nurse handoffs increased OR time for minimally invasive SCP procedures.

Impact of Case Order on Laparoscopic Sacrocolpopexy: Do Surgeons Need a Warm-Up?

OBJECTIVES: Warm-up is defined as a preparatory activity or procedure. Using case order as a surrogate for surgeon warm-up, first cases were compared with second or later cases for intraoperative complications, operative time, and length of stay (LOS) among women undergoing laparoscopic sacrocolpopexy. METHODS: This is a retrospective study of laparoscopic sacrocolpopexies performed from 2009 through 2014 at a large academic center. Any surgery preceding laparoscopic sacrocolpopexy was considered a surrogate for surgeon warm-up. Logistic and linear regression analyses were used to identify predictors of complications, operative time, and LOS. RESULTS: Of 480 procedures, 192 (40%) were first cases and 288 (60%) were second or later. Baseline characteristics were similar between groups. Intraoperative complication rate was not different between groups (6.3% vs 3.1%, P = 0.50) even after controlling for risk factors. Operative times were comparable on initial analysis (231.2 ± 55.2 vs 225.9 ± 51.2 minutes, P = 0.28l), but a small difference was detected after adjusting for confounding factors (body mass index, menopausal status, surgeon experience, intraoperative complications, and concomitant hysterectomy or midurethral sling; adjusted ß = 8.44 minutes, P = 0.037). Length of stay was longer for first case patients (1.44 ± 0.67 vs 1.24 ± 0.50 days, P < 0.001) even after adjusting for age, medical comorbidities, operative time, conversion to laparotomy, ileus/bowel obstruction, and postoperative urinary retention (adjusted ß = 0.183 days, P = 0.001) as well as after accounting for delayed start time of second or later cases. CONCLUSIONS: Laparoscopic sacrocolpopexy performed first case of the day without preoperative surgeon warm-up conferred no significant increase in intraoperative complications. Second or later cases were associated with small decreases in operative time and in LOS.

Incidence of Occult Uterine Pathology in Women Undergoing Hysterectomy With Pelvic Organ Prolapse Repair.

OBJECTIVES: The objectives of this study are to determine the incidence of and associated risk factors for occult uterine pathology in patients undergoing hysterectomy with pelvic organ prolapse (POP) repair. METHODS: Medical records were reviewed from all cases of hysterectomy with POP surgery at a tertiary medical center from January 2007 through July 2014. Exclusion criteria included known endometrial hyperplasia or malignancy. A power calculation determined that 1000 subjects would demonstrate a lower rate of leiomyosarcoma in a urogynecology population compared to the rate of 1:352 reported by the Food and Drug Administration. RESULTS: There were 1196 cases identified with a mean age of 62.3 ± 11.3 years and body mass index of 27.8 ± 5.7. Most patients were white (95.5%) and postmenopausal (81.6%). Malignancy was present in 3 (0.3%) specimens. Seven (0.6%) specimens had endometrial hyperplasia. This overall abnormal pathology incidence of 0.8%, with 95% confidence interval of 0% to 1.4% is significantly lower than published rates of 2.6% (P < 0.001). There were no specimens with sarcoma (rate of 0%; 95% confidence interval, 0%-0.2%). There were no associations between demographic or clinical variables with the presence of hyperplasia and/or malignancy. CONCLUSIONS: The incidence of uterine hyperplasia/malignancy and sarcoma in women undergoing hysterectomy with POP were both significantly lower than previously published values in other populations. The use of power morcellation in urogynecologic populations should be revisited as the incidence of occult pathology is lower than the general population, and a condition-specific risk profile should be considered in the informed consent process.

The use of mechanical bowel preparation in laparoscopic gynecologic surgery: a decision analysis.

OBJECTIVE: The use of mechanical bowel preparation prior to laparoscopy is common in gynecology, but its use may affect the rates of perioperative events and complications. Our objective was to compare different mechanical bowel preparations using decision analysis techniques to determine the optimal preparation prior to laparoscopic gynecological surgery. STUDY DESIGN: A decision analysis was constructed modeling perioperative outcomes with the following mechanical bowel preparations: magnesium citrate, sodium phosphate, polyethylene glycol, enema, and no bowel preparation. Comparisons were made using published utility values. Secondary analyses included the percentages that had 1 or more preoperative events and 1 or more intra- or postoperative complications. RESULTS: Overall, the highest utility values were for no bowel preparation (0.98) and magnesium citrate (0.97), whereas the other values were as follows: enema (0.95), sodium phosphate (0.94), and polyethylene glycol (0.91). The difference between no bowel preparation and magnesium citrate was less than the published minimally important differences for utilities, so there is likely no real difference between these strategies. The probability of having at least 1 preoperative event was lowest for no bowel preparation (1%), whereas the probability of having at least 1 intra- or postoperative complication was lowest with magnesium citrate (8%). CONCLUSION: The highest utilities were seen with no bowel preparation, but the absolute difference between no bowel preparation and magnesium citrate was less than the minimally important difference. With similar overall utilities, our model raises questions as to whether mechanical bowel preparation is a necessary step prior to laparoscopic gynecological surgery. However, if a surgeon prefers a bowel preparation, magnesium citrate is the preferred option.

Predictors of postoperative acute urinary retention in women undergoing minimally invasive sacral colpopexy.

OBJECTIVES: Our aim was to determine predictors of acute urinary retention in women undergoing laparoscopic and robotic sacral colpopexy. METHODS: Records from all minimally invasive sacral colpopexies performed from 2009 to 2012 were reviewed. All women had a retrograde fill voiding trial (RGVT) on postoperative day 1, except in cases of intraoperative bladder injury or chronic urinary retention. Patient demographics, medical comorbidities, and surgical factors were compared between women who did and did not pass the RGVT. Univariable and multivariable logistic regression analyses were used to identify predictors of postoperative voiding dysfunction. RESULTS: Three hundred two subjects met the inclusion criteria, but 12 were excluded because of planned prolonged catheterization. Of the remaining 290 subjects, 211 (72.8%) passed the RGVT. The mean (SD) for the duration of urinary retention in those who failed was 3.7 (4.2) days. The mean (SD) for age was 58.5 (8.6) years, and the median preoperative prolapse was Pelvic Organ Prolapse Quantification stage III (76.1% with ≥ stage III) with mean Ba = +2.3. There were no significant independent risk factors identified on multivariable logistic regression to predict RGVT failure, with only concurrent midurethral sling approaching significance (6.1% vs 12.5%; adjusted odds ratio, 2.25; 95% confidence interval, 0.93-5.45; P = 0.07). CONCLUSIONS: No significant predictors of acute urinary retention were identified among women undergoing minimally invasive sacral colpopexy. In contrast to published analyses of vaginal prolapse repairs, large preoperative cystocele and concurrent midurethral sling were not significantly associated with retention. Given the inability to predict who will have postoperative urinary retention, all patients should be counseled about the potential need for catheterization.

Abdominal wall endometriosis: 12 years of experience at a large academic institution.

OBJECTIVE: The objective of the study was to review patient characteristics and intraoperative findings for excised cases of abdominal wall endometriosis (AWE). STUDY DESIGN: A 12 year medical record search was performed for cases of excised AWE, and the diagnosis was confirmed on pathological specimen. Descriptive data were collected and analyzed. RESULTS: Of 65 patients included, the primary clinical presentation was abdominal pain and/or a mass/lump (73.8% and 63.1%, respectively). Most patients had a history of cesarean section (81.5%) but 6 patients (9.2%) had no prior surgery. Time from the initial surgery to presentation ranged from 1 to 32 years (median, 7.0 years), and time from the most recent relevant surgery ranged from 1 to 32 years (median, 4.0 years). Five patients (7.7%) required mesh for fascial closure following the resection of the AWE. We were unable to demonstrate a correlation between the increasing numbers of open abdominal surgeries and the time to presentation or depth of involvement. Age, body mass index, and parity also were not predictive of depth of involvement. There were increased rates of umbilical lesions (75% vs 5.6%, P < .001) in nulliparous compared with multiparous women as well as in women without a history of cesarean section (66.7% vs 1.9%, P < .001). CONCLUSION: In women with a mass or pain at a prior incision, the differential diagnosis should include AWE. Although we were unable to demonstrate specific characteristics predictive for AWE, a large portion of our population had a prior cesarean section, suggesting a correlation.

Should endocervical curettage routinely be performed at the time of colposcopy? A cost-effectiveness analysis.

OBJECTIVES: Endocervical curettage (ECC) has been used with colposcopy-directed biopsy to increase diagnostic sensitivity for detecting cellular abnormality. Our objective was to determine if routine ECC was cost-effective compared with colposcopy alone in women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cervical cytology, who are older and younger than 50 years. MATERIALS AND METHODS: We generated a cost-effectiveness model using outcomes from cervical screening including repeat Pap smears, colposcopy, and loop electrosurgical excision procedure. Cervical cancer costs, survival, as well as incidence and complications after loop electrosurgical excision procedure (preterm birth, cervical stenosis, dysmenorrhea, amenorrhea, and infertility) were modeled. Cost and probability values were obtained from published literature and Medicare databases. Direct medical costs were analyzed in 2011 US dollars. Effectiveness outcomes were cervical cancer deaths and incident cases of cancer prevented. Model robustness was evaluated using probabilistic sensitivity analysis. RESULTS: For women older than 50 years, routine ECC is the dominant strategy (less expensive and more effective at reducing cervical cancer deaths/incidence). For women younger than 50 years, routine ECC costs $96,737 more per cervical cancer death prevented. Cost per incident cancer case prevented ranged from $21,894 (local spread or greater) to $235,873 (distal spread). Sensitivity analysis confirmed these conclusions. In women older than 50 years, routine ECC was always the most likely cost-effective choice. In women younger than 50, routine ECC was most likely cost-effective for all willingness-to-pay thresholds greater than $80,000 to prevent 1 cancer death. CONCLUSIONS: In women older than 50 years, routine ECC is favored over colposcopy alone because this strategy is cost saving and reduces the number of cancer deaths and incident cancer cases. For women younger than 50 years, cost-effectiveness is dependent on willingness to pay to prevent 1 cancer death but still seems to be cost-effective.

Cost-effectiveness of test phase implantation strategies for InterStim® sacral neuromodulation.

OBJECTIVE: Sacral neuromodulation with InterStim can be performed with staged implants or peripheral nerve evaluation followed by a combined stage I/II procedure. In both, unilateral or bilateral leads can be placed for the testing phase. Our objective was to determine the cost-effectiveness of these strategies in patients with refractory overactive bladder. METHODS: A cost-effectiveness model compared 6 strategies, namely, unilateral and bilateral testing for both stage I and peripheral nerve evaluation, combined stage I/II, and no treatment. Costs were derived from a societal perspective using Medicare physician fee schedules and published studies. Quality-adjusted life-years (QALYs) were assigned using utility values. Results were reported using incremental cost-effectiveness ratios. Model robustness was assessed using probabilistic sensitivity analysis. Monte Carlo analysis sampled statistical distributions for each variable to examine the effects of varying all values simultaneously. RESULTS: No InterStim treatment was the least expensive but also the least effective option. Unilateral and bilateral stage I were the only cost-effective options with incremental cost-effectiveness ratios of $3533 and $7600, respectively. Because bilateral stage I was more effective, it is preferred. Probabilistic sensitivity analysis showed bilateral stage I was most likely to be cost-effective at willingness-to-pay thresholds greater than $6000 per QALY. At lower thresholds, no treatment was more economically acceptable. CONCLUSIONS: Bilateral and unilateral stage I lead placement were the only cost-effective strategies. Bilateral stage I was preferred due to greater effectiveness. In probabilistic sensitivity analysis, bilateral stage I was the most likely cost-effective strategy at all willingness-to-pay thresholds greater than $6000 per QALY confirming model robustness.

InterStim Sacral Neuromodulation and Botox Botulinum-A Toxin Intradetrusor Injections for Refractory Urge Urinary Incontinence: A Decision Analysis Comparing Outcomes Including Efficacy and Complications.

OBJECTIVE: : Overactive bladder is a common disease for which current pharmaceutical therapy is often unsatisfactory. Newer modalities, including Botox and InterStim, can be used when antimuscarinics fail. We compare InterStim and Botox using decision analysis. METHODS: : A Markov state transition decision analysis model was constructed using values for efficacy and complications from the literature. Overall utility was compared monthly. Multiple 1-way sensitivity analyses were performed. RESULTS: : For every month during the simulation, overall utility was higher for Botox than InterStim. After 54 months, cumulative utility was 3.86 versus 3.74, favoring Botox for an average yearly quality-adjusted life-year value of 0.86 versus 0.83. All differences were less than minimally important differences for utilities. Few meaningful thresholds were established supporting the robustness of the model. CONCLUSIONS: : Until appropriately powered randomized controlled trials are available, both InterStim and Botox are reasonable and effective strategies with similar outcomes.

Effect of suture selection on the rate of suture or mesh erosion and surgery failure in abdominal sacrocolpopexy.

OBJECTIVE: : To determine if suture type used for mesh attachment in abdominal sacrocolpopexy increases the rate of erosion/infection. METHODS: : Two groups were temporally divided from June 1996 to May 2001 where braided permanent sutures (2-0 Ethibond, Ethicon, Somerville, New Jersey) were exclusively used for graft placement (n = 161) and from August 2001 to May 2006 where exclusively monofilament delayed absorbable (2-0 PDS, Ethicon) was used (n = 254). Data were analyzed for demographics, medical history, presenting/postoperative physical examination, concomitant surgeries, and complications. RESULTS: : Mesh/suture exposure rate was 3.7% (6/161) with Ethibond. There were no erosions with PDS (P = 0.002). Colpopexy failure was 1.7% (2/116) with Ethibond and 0% (0/235) with PDS (P = 0.11). CONCLUSIONS: : Delayed absorbable, monofilament suture appears to reduce the risk of graft/suture erosion without increasing surgical failure.