Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery. METHODS: We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP). RESULTS: For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90. CONCLUSIONS: A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.

The Response of the Urinary Microbiome to Botox.

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate if botox alters the urinary microbiome of patients with overactive bladder and whether this alteration is predictive of treatment response. METHODS: This multicenter prospective cohort study included 18-89-year-old patients undergoing treatment for overactive bladder with 100 units of botox. Urine samples were collected by straight catheterization on the day of the procedure (S1) and again 4 weeks later (S2). Participants completed the Patient Global Impression of Improvement form at their second visit for dichotomization into responders and nonresponders. The microbiome was sequenced using 16s rRNA sequencing. Wilcoxon signed rank and Wilcoxon rank sum were used to compare the microbiome, whereas chi-square, Wilcoxon rank sum, and the independent t-test were utilized for clinical data. RESULTS: Sixty-eight participants were included in the analysis. The mean relative abundance and prevalence of Beauveria bassiana, Xerocomus chrysenteron, Crinipellis zonata, and Micrococcus luteus were all found to increase between S1 and S2 in responders; whereas in nonresponders the mean relative abundance and prevalence of Pseudomonas fragi were found to decrease. The MRA and prevalence of Weissella cibaria, Acinetobacter johnsonii, and Acinetobacter schindleri were found to be greater in responders than nonresponders at the time of S1. Significant UM differences in the S1 of patients who did (n = 5) and did not go on to develop a post-treatment UTI were noted. CONCLUSIONS: Longitudinal urobiome differences may exist between patients who do and do not respond to botox.

Neglect as an undefined and overlooked aspect of medical student mistreatment: A systematic review of the literature.

PURPOSE: Although the mistreatment of medical students is a well-researched topic, the scope of mistreatment often leaves out neglect, a subtype for which there is no accepted definition based in the published literature. This review sought to summarize the existing data on the prevalence and descriptors of neglect, identify strategies seen in the literature designed to improve it, and offer a synthesized definition of this phenomenon to guide future research. METHODS: Following PRISMA guidelines, a relevant systematic literature search from 2000 to April 2021 was performed to identify literature on neglect in clinical settings within American medical schools. RESULTS: Neglect, a poorly defined phenomenon in medical education related to the suboptimal learning environment, is often excluded from research on medical student mistreatment. Neglect is a barrier to a successful learning environment, yet a paucity of data and the heterogeneous nature of the present literature render it difficult to estimate its true prevalence. Studies that include neglect frequently assess it solely as the result of identity discrimination or stated career interests. Recent interventions include promoting longitudinal relationships between students and clinical faculty and establishing teaching expectations. CONCLUSIONS: Neglect is the mistreatment of medical students by the medical care team via a lack of meaningful inclusion in the clinical environment such that it has a notable negative impact on learning and student well-being, regardless of intentionality. An established definition that is grounded in the literature is required to create a common point of reference and understand its true prevalence, its associated variables, and the best mitigation strategies, as well as to guide future research, which should examine neglect independently and as a consequence of personal and professional identities.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVE: To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated. DATA SOURCES: PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines. METHODS OF STUDY SELECTION: Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded. TABULATION, INTEGRATION, AND RESULTS: Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes. CONCLUSION: Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021278796.

Opioid use following pelvic reconstructive surgery: a predictive calculator.

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median. METHODS: This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery. RESULTS: One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review. CONCLUSIONS: Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.

A systematic review and in silico study of potential genetic markers implicated in cases of overactive bladder.

OBJECTIVE: The contribution of genetic factors to the presence of an overactive bladder is recognized. This study aimed to (1) assemble and synthesize available data from studies assessing differential gene expression in patients with overactive bladder vs controls without overactive bladder and (2) determine possible correlations and functional pathways between genes. DATA SOURCES: We searched PubMed, Ovid or Medline, and Wiley Cochrane Central Register of Controlled Trials databases between January 1, 2000, and December 15, 2021. STUDY ELIGIBILITY CRITERIA: Studies were included if gene expression was detected and quantified using molecular approaches performed on human bladder tissue specimens directly and excluded if the gene expression analysis was carried out from blood and urine specimens alone. METHODS: A systematic review was completed to identify publications that reported differently expressed gene candidates among patients with overactive bladder vs healthy individuals. Gene networking connections and pathway analysis were performed employing Metascape software, where inputs were identified from our systematic review of differentially expressed genes in overactive bladder. RESULTS: A total of 9 studies were included in the final analysis and 11 genes were identified as being up-regulated (purinergic receptor P2X 2 [P2RX2], smoothelin [SMTN], growth-associated protein 43 [GAP43], transient receptor potential cation channel subfamily M member 8 [TRPM8], cadherin 11 [CDH1], gap junction protein gamma 1 [GJC1], cholinergic receptor muscarinic 2 [CHRM2], cholinergic receptor muscarinic 3 [CHRM3], and transient receptor potential cation channel subfamily V member 4 [TRPV4]) or down-regulated (purinergic receptor P2X 2 [P2RX3] and purinergic receptor P2X 5 [P2RX5]) in patients with overactive bladder. Gene network analysis showed that genes are involved in chemical synaptic transmission, smooth muscle contraction, blood circulation, and response to temperature stimulus. Network analysis demonstrated a significant genetic interaction between TRPV4, TRPM8, P2RX3, and PR2X2 genes. CONCLUSION: Outcomes of this systematic review highlighted potential biomarkers for treatment efficacy and have laid the groundwork for developing future gene therapies for overactive bladder in clinical settings.

Skene's Gland Malignancy: A Case Report and Systematic Review.

OBJECTIVE: To present a recent clinical case of Skene's gland carcinoma and review all published literature of Skene's gland malignancy with associated treatment and outcomes. METHODS: We review a new case of metastatic Skene's gland adenocarcinoma. We then performed a systematic search of PubMed and Ovid-Medline through December 2021 and retrieved English language articles for review. Peer-reviewed articles were deemed eligible if they included patients with Skene's gland malignancy. Reports were reviewed for pathologic accuracy, patient characteristics, clinical presentation, tumor pathology, treatment and outcome. RESULTS: We reviewed 211 articles and included 15 cases from 1974 to 2022. The median patient age was 71 years (range 46-88). The most common presentation was an asymptomatic periurethral or urethral lesion in five cases (33.3%), followed by hematuria or vaginal bleeding in three patients (20.0%). In eight cases, a prostate-specific antigen was measured and found to be elevated, range 0.8-60.8 ng/mL. Treatment approaches varied and included local excision in eight cases, radical surgical resection in two cases, radiation therapy in two cases, and adjunctive androgen deprivation therapy in one case. Pathology was consistent with adenocarcinoma resembling prostate in all cases. In all cases tested, prostate-specific antigen normalized after definitive therapy of any type. Median follow up was 11.5 months, and there were no cases of recurrence or mortality secondary to Skene's gland adenocarcinoma. CONCLUSION: There are 15 published cases of a Skene's gland malignancy, all adenocarcinoma resembling prostate. Local excision is most often utilized for treatment, with androgen deprivation therapy emerging as a new treatment consideration.

Pelvic Organ Prolapse Surgery in the Elderly and Frail: Safety of a Reconstructive Versus Obliterative Approach.

OBJECTIVES: The aim of this study was to compare the risk of complications associated with obliterative surgery versus reconstructive surgery in elderly and frail patients undergoing surgery for pelvic organ prolapse. METHODS: We performed a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2017. We compared characteristics and perioperative complications in patients aged 80 years or older who underwent obliterative surgery versus reconstructive surgery. Multivariate logistic regression and propensity score matching were used to control for confounding. A subanalysis was performed that included patients who were considered frail as defined by the National Surgical Quality Improvement Program Modified Frailty Index 5. RESULTS: Of 1,654 total patients, reconstructive surgery was performed in 56.9% of patients, and obliterative surgery was performed in 43.1%. The respective composite complication rates were 9.2% and 9.8% (P = 0.69), whereas severe complications were experienced by 1.9% in the reconstructive group versus 0.8% in the obliterative group (P = 0.07). On multivariate logistic regression, reconstructive surgery was not significantly associated with the composite complication rate (adjusted odds ratio, 1.0; 95% confidence interval, 0.7-1.4; P = 0.80). After propensity score matching, composite complications did not differ between groups, but the rate of severe complications was significantly higher in patients who underwent reconstructive surgery compared with obliterative surgery (2.1% vs 0.8%; odds ratio, 2.53; 95% confidence interval, 1.01-6.36; P = 0.05). In frail patients only, complication rates did not differ between groups. CONCLUSIONS: In patients aged 80 years or older, the overall rate of complications did not differ between those who underwent reconstructive surgery versus obliterative surgery. However, propensity score matching identified an increased risk of the most severe complications in patients who underwent reconstructive surgery.

Abdominal and vaginal pelvic support with concomitant hysterectomy for uterovaginal pelvic prolapse: a comparative systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse. METHODS: A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2. RESULTS: Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2-2.4; P = 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P = 0.58 and P = 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33-1.70; P = 0.02) and better POP-Q Ba scores [MD = -0.23; 95% CI = -0.37; -0.10; P = 0.01]. CONCLUSIONS: ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.

Tamsulosin vs placebo to prevent postoperative urinary retention following female pelvic reconstructive surgery: a multicenter randomized controlled trial.

BACKGROUND: Postoperative urinary retention is common after female pelvic reconstructive surgery. Alpha receptor antagonists can improve dysfunctional voiding by relaxing the bladder outlet and may be effective in reducing the risk of postoperative urinary retention. OBJECTIVE: This study aimed to determine whether tamsulosin is effective in preventing postoperative urinary retention in women undergoing surgery for pelvic organ prolapse. STUDY DESIGN: This was a multicenter, double-blind, randomized controlled trial between August 2018 and June 2020, including women undergoing surgery for pelvic organ prolapse. Patients were excluded from recruitment if they had elevated preoperative postvoid residual volume, history of postoperative urinary retention, or a contraindication to tamsulosin. Those who experienced cystotomy were excluded from analysis. Participants were randomized to a 10-day perioperative course of tamsulosin 0.4 mg vs placebo, beginning 3 days before surgery. A standardized voiding trial was performed on postoperative day 1. The primary outcome was the development of postoperative urinary retention, as defined by the failure of the voiding trial or subsequent need for catheterization to empty the bladder. Secondary outcomes included the rate of urinary tract infection and the impact on lower urinary tract symptoms as measured by the American Urological Association Symptom Index. RESULTS: Of 119 patients, 57 received tamsulosin and 62 received placebo. Groups were similar in regard to demographics, preoperative prolapse and voiding characteristics, and surgical details. Tamsulosin was associated with a lower rate of postoperative urinary retention than placebo (5 patients [8.8%] vs 16 patients [25.8%]; odds ratio, 0.28; 95% confidence interval, 0.09-81; P=.02). The number needed to treat to prevent 1 case of postoperative urinary retention was 5.9 patients. The rate of urinary tract infection did not differ between groups. American Urological Association Symptom Index scores significantly improved after surgery in both groups (median total score, 14 vs 7; P<.01). Scores related to urinary stream improved more in the tamsulosin group than in placebo (P=.03). CONCLUSION: In this placebo-controlled trial, tamsulosin use was associated with a reduced risk of postoperative urinary retention in women undergoing surgery for pelvic organ prolapse.

Counseling, contraception, and conception rates in patients undergoing bariatric surgery: A retrospective review.

OBJECTIVES: To determine conception rates, contraceptive use patterns, and frequency of counseling regarding pregnancy recommendations in patients undergoing bariatric surgery. STUDY DESIGN: Using a database of bariatric surgery patients at our institution, we identified female patients aged 18 to 45 who underwent surgery from 2013 to 2018. Patient charts were reviewed for demographic information, documentation of counseling regarding pregnancy recommendations, conception during the postoperative period, and pre and postoperative contraception use. We examined rates of contraception use and used standard statistical tests to compare conception rates between groups. RESULTS: Of the 460 patients that met inclusion criteria and did not have a history of permanent contraception, 54% (95% CI 49-58) had documented postoperative contraception use, most commonly the levonorgestrel-releasing intrauterine device followed by combination oral contraceptive pills. In the 18 months following bariatric surgery, 6% of patients (95% CI 4-8) had a documented pregnancy. Over 50% (95% CI 35-71) of pregnancies occurred in patients without documented postoperative contraception. CONCLUSIONS: For bariatric surgery patients at risk of pregnancy, postoperative contraception use patterns and conception rates are not consistent with the recommendation to refrain from pregnancy for 18 months. IMPLICATIONS: Individualized contraceptive counseling that includes a discussion of fertility and weight loss goals, planned bariatric procedure type, and patient preference should be implemented as part of standard preoperative care for patients at risk of pregnancy undergoing bariatric surgery.

Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis.

INTRODUCTION AND HYPOTHESIS: It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly. METHODS: The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications. RESULTS: A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications. CONCLUSION: ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

Medical Malpractice Litigation in Non-Mesh-Related Pelvic Organ Prolapse Surgery: An Analysis of 91 Cases.

INTRODUCTION: Malpractice litigations have significant implications for patients and physicians. Studies have investigated mesh litigations in female pelvic reconstructive surgery, but none on nonmesh pelvic organ prolapse (POP) surgery. Our purpose is to determine the reasons for and outcomes of medical malpractice after nonmesh POP surgery. METHODS: Westlaw (Thompson Reuters, New York, New York) is a legal research database of US court records. We identified completed POP litigations from 1987 to 2018 using the following: "pelvic organ prolapse," "enterocele," "rectocele," "cystocele," "uterine prolapse," and "vaginal wall prolapse." Mesh-related cases were excluded. Outcomes included reasons for litigation, verdict, injury, and payments. Statistical analysis was performed with nonparametric tests and χ2 independence test. RESULTS: Ninety-one litigations were included. The median plaintiff age was 53 years (range, 36-85 years). The leading allegation was negligence of surgery (n = 59; 65%). The jury sided with the defendant physician in 67% of cases (n = 61). There was no association between case verdict and patient age (P = 0.781), geographic region (P = 0.824), or allegation (P = 0.904). The primary complications were urinary tract injury (n = 24; 26%), need for additional surgery (n = 22; 24%), and new postoperative urinary symptoms (n = 22; 24%). The median payout was $280,000 (interquartile range, $137,250-$1,300,000), with no difference between plaintiff awards or settlements (P = 0.659). CONCLUSION: The leading allegation of malpractice litigations for nonmesh POP surgery is negligence of surgery, whereas the most common complication was urinary tract injury. A verdict in favor of the physician defendant was the most likely outcome. Plaintiff awards and settlements were not statistically different with no variation by region or time.

Factors Influencing Selection of Concomitant Total Versus Supracervical Hysterectomy at the Time of Sacrocolpopexy and Associated Perioperative Outcomes.

OBJECTIVES: The objective of this study was to describe national practice patterns of hysterectomy type performed with concurrent sacrocolpopexy and determine clinical factors associated with surgical route. METHODS: We used the National Surgical Quality Improvement Program database with hysterectomy data for this retrospective cohort study. We identified sacrocolpopexy cases from 2014 to 2016 with concurrent hysterectomy and stratified patients into supracervical hysterectomy (SCH) or total hysterectomy (TH). As a secondary analysis, we compared the laparoscopic subset of cases. We performed χ2 and backward stepwise logistic regression analyses to identify factors associated with hysterectomy type and compare complication rates. RESULTS: A total of 4,615 women underwent SCP with hysterectomy: 55.8% TH and 44.2% SCH. Mean ± SD age was 56.5 ± 11.7 years. Gynecologists represent 96.3% of surgeons; 51.2% were urogynecologists. Urogynecologists were more likely than generalists to perform SCH (58.4% vs 41.6%, P < 0.001). Total hysterectomy was associated with younger age (adjusted odds ratio [aOR], 0.98 per year [0.97-0.99]), greater uterine weight (aOR, 1.05 per 10 g [1.03-1.06]), and non-Caucasian race (aOR, 0.73 [0.58-0.92]). Complication rates were equivalent between hysterectomy type (SCH, 6.2% vs TH, 6.2%; P = 0.956). Laparoscopy was used for 84.4% of surgical procedures. In this subgroup, TH was associated with greater uterine weight (aOR, 1.06 per 10 g [1.04-1.08]) and younger age (aOR, 0.97 per year [0.96-0.98]). Complication rates were similar (SCH, 5.1% vs TH, 5.0%; P = 0.824). CONCLUSIONS: At the time of sacrocolpopexy, TH is more common than SCH and is associated with younger age and greater uterine weight, although urogynecologists more commonly perform SCH. The overall risk of complications was low and similar between hysterectomy type.

Perioperative Complications of Laparoscopic versus Open Surgery for Pelvic Inflammatory Disease.

STUDY OBJECTIVE: To compare complications in patients undergoing laparoscopic vs open surgery for acute pelvic inflammatory disease (PID). DESIGN: We performed a retrospective cohort study of patients who underwent surgery for PID, using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2015. Propensity score matching was used to balance baseline characteristics and compare complications in patients who underwent laparoscopic vs open surgery. SETTING: Surgical management of acute PID. PATIENTS: Patients with a preoperative diagnosis of PID were identified using International Classification of Diseases, Ninth Revision, codes. We excluded patients with chronic PID, gynecologic malignancy, and those for whom the surgical route was unknown. INTERVENTIONS: Surgery for acute PID. MEASUREMENTS AND MAIN RESULTS: The study included 367 patients. The mean age was 43.0 ± 11.1 years, body mass index was 30.9 ± 11.2 kg/m2, and American Society of Anesthesiology class was 2 (interquartile range 2-3). Preoperative signs of sepsis were noted in 33.8% of the patients, and septic shock was present in 1.4%. Hysterectomy was performed in 67.6%, oophorectomy in 12.0%, and salpingectomy in 4.6%. Complications were experienced by 114 patients (31.1%), 11 (3.0%) of which were potentially life-threatening. Multivariate logistic regression identified the following to be independently associated with complications: laparoscopy (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI], 0.3-0.8; p <.01), operative time (aOR 1.01; 95% CI, 1.00-1.01; p <.01), appendectomy (aOR 2.36; 95% CI, 1.0-5.4; p = .04), elevated international normalized ratio (aOR 2.30; 95% CI, 1.3-4.2; p <.01), and low hematocrit level (aOR 2.53; 95% CI, 1.4-4.5; p <.01). Propensity scores were calculated and used to generate a matched cohort of patients who underwent laparoscopic vs open surgery; the groups were similar, with p <.05 for all covariates. After balancing confounding variables, a laparoscopic approach to surgery remained significantly associated with a lower risk of complications (coefficient -0.07; 95% CI, -0.11 to -0.02; p = .008). CONCLUSION: Laparoscopy was associated with lower complication rates than open surgery in this well-matched cohort of patients who underwent surgery for acute PID.

Baseline Brain Segmental Volumes in Responders and Nonresponders to Anticholinergic Therapy for Overactive Bladder Syndrome.

OBJECTIVE: Evaluate structural differences in brains of responders (R) and nonresponders (NR) to anticholinergic (AC) therapy for overactive bladder (OAB). MATERIALS AND METHODS: This was a retrospective cohort study of age matched women treated with an AC medication for OAB and underwent magnetic resonance imaging within 12 months before treatment. Data on pretreatment demographic and clinical variables and symptom severity was also collected.T1-weighted magnetic resonance images of the brain for each subject were segmented using FreeSurfer software. Structures included for analysis were cerebral cortex, white matter, subcortical gray matter, cerebellum, and brain stem.Nonresponders were defined as patients who reported less than 50% improvement after a minimum of 4 weeks on the maximum dose of the prescribed medication. Pairwise analysis between groups was performed using the Wilcoxon-Rank Sum test and Fisher exact test where appropriate. Spearman ρ was used to evaluate for correlations between neurologic structures and symptom severity. RESULTS: There were no differences in pretreatment characteristics or symptom severity between the 21 R and 18 NR. Nonresponders had lower volumes of the right caudal anterior cingulate gyrus white matter (1919 mm3 vs 2416 mm3, P = 0.008) and right parahippocampal gyrus white matter (1008 mm3 vs 1469 mm3, P = 0.001). Incontinence episode frequency showed a negative moderate correlation with the anterior cingulate gyrus white matter volume (ρ = -0.4228, P = 0.007). The right and left cerebellar cortices showed weak and moderate negative correlations to frequency of nocturia (ρ = -0.384, P = 0.02 and ρ -0.443, P = 0.005, respectively). CONCLUSION: There are measurable volumetric differences in brain structures in R and NR to AC therapy.

Apical suspension is underutilized for repair of stage IV pelvic organ prolapse: an analysis of national practice patterns in the United States.

INTRODUCTION AND HYPOTHESIS: Support of the vaginal apex is paramount for a durable repair of pelvic organ prolapse (POP). Our aim is to assess national utilization of apical suspension procedures for the surgical treatment of complete POP. We hypothesize that there might be a high rate of apical suspension with advanced prolapse. METHODS: The 2006-2016 National Surgical Quality Improvement Program database was queried for a primary postoperative diagnosis of complete POP. The primary outcome was type of repair. Secondary outcomes included patient characteristics associated with apical suspension or colpocleisis. Procedures were delineated using CPT codes. Chi-squared and multivariate logistic regression analyses were used to evaluate factors associated with repair type. RESULTS: A total of 2,784 women underwent surgery for complete POP with a mean age of 64.6 ± 11.0 years. Overall, 1,300 (46.7%) patients underwent apical suspension: 487 sacrocolpopexies (17.5%), 428 extraperitoneal suspensions (15.4%), and 391 uterosacral suspensions (14.0%). 5.2% (144) underwent colpocleisis, and 47.5% (1,332) of women had a concurrent hysterectomy (CH). With CH, 38.6% (502) had apical suspension or colpocleisis versus 69.5% (940) of post-hysterectomy cases. On logistic regression, CH was inversely associated with apical suspension (adjusted odds ratio [aOR] 0.37, CI 0.32-0.44, p < 0.001). Colpocleisis was associated with older age (aOR 4.9 per 10 years, CI 3.8-6.3, p < 0.001), post-hysterectomy surgery (aOR 0.23, CI 0.1-0.4, p < 0.001 for CH), and higher comorbidity index (OR 1.7, CI 1.1-2.6, p = 0.009). Complication rates are similar with and without apical suspension (8.2% versus 7.0%, p = 0.269). CONCLUSIONS: During surgery for complete POP, an apical suspension procedure is performed in 46.7% of patients and is more common post-hysterectomy.

Gene expression in urinary incontinence and pelvic organ prolapse: a review of literature.

PURPOSE OF REVIEW: To review current evidence on gene expression in women with urinary incontinence and pelvic organ prolapse (POP). RECENT FINDINGS: Our literature review revealed numerous genes that are associated with urinary incontinence and POP. For overactive bladder and urge urinary incontinence, four genes were highlighted: adrenergic receptor ß3, Rho guanine nucleotide exchange factor 10, Rho-associated coiled-coil containing protein kinase 2, and potassium two pore domain channel subfamily K member-1. For Stress Urinary incontinence (SUI), 13 genes were included: skin-derived antileukoproteinase, collagen type XVII alpha 1 chain, plakophilin 1, keratin 16, decorin, biglycan, protein bicaudal D homolog 2, growth factor receptor-bound protein 2, signal transducer and activator of transcription 3, apolipoprotein E, Golgi SNAP receptor complex member 1, fibromodulin, and glucocerebrosidase. For POP seven genes were identified: homeobox A13, matrix metallopeptidase 9, estrogen receptor 2, collagen type XIV alpha 1 chain, collagen type V alpha 1 chain, collagen type IV alpha 2 chain, and catenin beta 1. SUMMARY: The current review highlights many genes which are potential biomarkers and targets for drug development.

Cystoscopy with antibiotic irrigation during pelvic reconstruction and minimally invasive gynecologic surgery: A double-blind randomized controlled trial.

AIMS: After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI. METHODS: This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ2 and multivariable logistic regression analyses were performed. RESULTS: We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ2 (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569). CONCLUSION: When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.