Frailty and Acute Postoperative Urinary Retention in Older Women Undergoing Pelvic Organ Prolapse Surgery.

IMPORTANCE: Acute postoperative urinary retention (POUR) is common after pelvic reconstructive surgery, occurring in 15-45% of women. There is a paucity of data on the relationship between frailty and POUR after prolapse surgery. OBJECTIVE: This study aimed to examine the association between frailty and POUR in older women who underwent pelvic organ prolapse surgery. STUDY DESIGN: This secondary analysis of a prospective study of postoperative delirium enrolled women 60 years and older undergoing prolapse surgery. The Fried Frailty Index was used to assess frailty before surgery. Acute POUR was defined as failure to pass a retrograde voiding trial at hospital discharge with postvoid residual volume of greater than 100 mL. RESULTS: Analyses included 165 women, with a mean ± SD age of 72.5 ± 6.1 years and a body mass index of 28.0 ± 4.4 kg/m2. There were 49 laparoscopic/robotic apical suspension procedures (29.7%), 60 vaginal obliterative procedures (36.4%), 47 vaginal apical suspension procedures (28.5%), and 9 isolated anterior and/or posterior colporrhaphies (5.5%), of which 9 had a concomitant incontinence procedure. Seventy-eight women (47.3%) experienced acute POUR. Thirty-one (18.8%) met the criteria for "not frail," 115 (88.5%) were "prefrail," and 19 (11.5%) were "frail." Neither frailty status nor score was associated with POUR. In an analysis of individual Fried Frailty Index components, self-reported unintentional weight loss was significantly associated with POUR (odds ratio, 4.6; 95% confidence interval, 1.23-17.15). This remained significant on multivariable logistic regression (adjusted odds ratio, 4.06; 95% confidence interval, 1.01-16.39). CONCLUSIONS: Frailty was not associated with POUR in older women undergoing prolapse surgery. The observed association between POUR and unintended weight loss before surgery warrants further investigation.

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.

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.