Retrospective Cohort Study of Recovery From Sacrocolpopexy Versus Nonmesh Prolapse Repair.

IMPORTANCE: Providing recovery expectations for prolapse surgery is an important part of patient counseling and aids in patient-centered decision making. OBJECTIVES: The purpose of this study was to determine if postoperative recovery from minimally invasive sacrocolpopexy (MISCP) is noninferior to that of native tissue repair. STUDY DESIGN: Recovery at 2 and 6 weeks was quantified using the Postdischarge Surgical Recovery 13 scale, where higher scores indicate greater patient-perceived recovery. A 2:1 MISCP to native tissue repair ratio was used. The study population was created from 3 prior studies involving patients who underwent prolapse surgery between 2013 and 2021.Independent-samples t test was used for normally distributed data, Mann-Whitney U tests for nonnormally distributed data, and the χ2 test for population proportions. A parsimonious linear regression analysis was performed to determine if the surgical group independently predicted postdischarge surgical recovery at 2 and 6 weeks, after controlling for significant confounders identified during bivariate analysis. RESULTS: The study population included 476 patients: 352 underwent MISCP and 124 underwent native tissue repair.Postdischarge Surgical Recovery 13 scores for patients who underwent MISCP compared with native tissue repair were higher at 2 weeks (mean, 58.4 ± 18.2 vs 54.4 ± 18.7; P = 0.04) and at 6 weeks postoperatively (mean, 77.2 ± 15.6 vs 73.7 ± 18.7; P = 0.1). CONCLUSIONS: Our findings indicate that recovery after MISCP is noninferior to that of native tissue repair. This information is important for delivering patient-centered care during preoperative counseling.

Appropriateness of referrals to a urogynecology practice.

INTRODUCTION AND HYPOTHESIS: The urogynecology subspecialty relies on appropriate referrals from their referral base. We sought to provide guidance for optimizing appropriate referrals to urogynecology by comparing pre-referral characteristics between appropriate and inappropriate referrals. METHODS: This retrospective cohort study examined predictors of appropriate urogynecology referrals. Appropriateness categorization was based upon pelvic floor disorder (PFD) symptoms and signs provided by the referring provider. Patients with both a PFD symptom and sign were considered "appropriate." Patients with neither a PFD symptom nor sign were considered "inappropriate." PFD symptoms were: vaginal bulge, voiding or defecatory dysfunction. PFD signs were: vaginal vault prolapse, urethral hypermobility, mesh/sling exposure, elevated post-void residual, positive standing stress test, abnormal urinalysis or urine culture-proven infection. Continuous and categorical data were analyzed with ANOVA and chi-square test, respectively. A logistic regression model to predict appropriateness was developed from variables identified from the bivariate analysis. RESULTS: Bivariate predictors of an appropriate referral for 1716 study subjects were older age, prior overactive bladder medication use, MD/DO referrer source and OBGYN, urogynecology or urology referrer specialty. Our logistic regression model correctly classified referrals as appropriate in 93.6% of cases. CONCLUSIONS: Age, anti-cholinergic medication use, referrer source and specialty are pre-initial visit predictors of urogynecology referral appropriateness. The predictor-generated model was successful in predicting referral appropriateness. Potential bias from information transfer issues, lack of pre-referral evaluation and referring provider unfamiliarity with urogynecology are possible reasons for inappropriate referrals and potential areas for improvement.

Increasing Anteroposterior Genital Hiatus Widening Does Not Limit Apical Descent for Prolapse Staging During Valsalva's Maneuver: Effect on Symptom Severity and Surgical Decision Making.

OBJECTIVE: Determine if anteroposterior genital hiatus (GH) widening obscures rather than facilitates signs and symptoms, inadvertently altering management decisions for women with pelvic organ prolapse (POP) during Valsalva's Maneuver, at a given total vaginal length (TVL). METHODS: We performed a retrospective cohort with nested cross-sectional study of patients who underwent POP surgery. Data from obstetric and gynecologic history, preoperative and postoperative physical examinations, and 20-item Pelvic Floor Distress Inventory (PFDI-20) and 7-item Pelvic Floor Impact Questionnaire (PFIQ-7) scores were extracted. Study participants were compared in 2 groups: anteroposterior widened (>3 cm) and not widened (≤3 cm) GH, for baseline leading edge and POP stage, while controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were evaluated within GH groups. Delta GH, PFDI-20, and PFIQ-7 scores after apical suspension with and without posterior colporrhaphy were compared to assess the clinical value of the procedure. RESULTS: Study participants with anteroposterior GH widening during Valsalva maneuver had greater baseline leading edge descent and higher POP stage compared with those without anteroposterior GH widening after controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were similar within both GH categories controlling for prolapse severity. Adding posterior colporrhaphy to apical suspension resulted in a greater anteroposterior GH reduction without improving delta PFDI-20 or PFIQ-7 scores. CONCLUSIONS: Facilitation through herniation rather than obscuration from anteroposterior GH widening explains why patients will not be undertreated based on signs and symptoms of disease. Adding posterior colporrhaphy to apical suspension more effectively reduces anteroposterior GH widening without differential improvement in symptoms rendering the operation to no more than a cosmetic procedure.

Patient satisfaction and regret with decision differ between outcomes in the composite definition of success after reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: To evaluate patient satisfaction and regret with their decision for reconstructive surgery, and determine if they valued each item equally in the composite definition of success after making the decision for surgery. METHODS: A list was created including all patients who underwent laparoscopic sacral colpopexy or laparoscopic uterosacrocolpopexy. Patients were placed in mutually exclusive outcome categories (retreatment, symptomatic failure, anatomic failure, and surgical success). Retreatment included any postoperative treatment for urinary incontinence, pelvic organ prolapse including pessary use, or surgery for mesh complications. The validated modified Decision Regret Scale (DRS) and the Satisfaction Decision Scale (SDS) questionnaires were administered by telephone. Higher DRS scores indicate greater regret and higher SDS scores indicate greater satisfaction with the decision for surgery. RESULTS: Of 715 patients, 197 were successfully contacted by telephone following reconstructive surgery and surveyed as study participants. Composite surgical outcomes were available for 150. Information on the need for retreatment was available for all the study participants. Surgery was successful in 101 (67.3 %) of the study participants. Anatomic failure occurred in 14, symptomatic failure occurred in 10, and retreatment was required in 25 of the study participants. Overall, the study participants were more satisfied than regretful with their decision for reconstructive surgery. Regret and satisfaction with their decision differed between outcomes in the composite definition of success after reconstructive surgery. CONCLUSIONS: Surgeons and patients should focus on retreatment rates during preoperative outcome discussions because retreatment will result in the least satisfaction and greatest regret with the decision for reconstructive surgery.

Phase IV trial evaluating the effectiveness and safety of dofetilide.

BACKGROUND: Dofetilide gained Food and Drug Administration approval for persistent atrial fibrillation/flutter (AFF) based on 2 randomized, placebo-controlled, dose-ranging studies. Concerns of proarrhythmia have prompted the manufacturer to develop specific treatment guidelines. OBJECTIVE: To determine the effectiveness and safety of dofetilide in clinical practice as well as to ascertain whether clinicians are following established dosing guidelines. METHODS: This retrospective analysis evaluated guideline adherence and safety in patients who received dofetilide at a tertiary care medical center. Safety assessment included monitoring for the occurrence of excessive QTc interval prolongation and torsade de pointes. Excessive QTc interval prolongation was defined as >15% above baseline after the first dose or >500 msec following any dose (>550 msec in patients with ventricular conduction abnormalities). Patients were included in the effectiveness assessment if they received at least 36 hours of dofetilide for persistent AFF, received an appropriate dose per guidelines, and did not receive direct current cardioversion during the evaluation period. We compared the 36-hour conversion rate with dofetilide in this study with that observed in the EMERALD and SAFIRE-D trials using the Z test, and we evaluated the incidence of excessive QTc interval prolongation in high-risk subgroups by chi(2) analysis. RESULTS: Investigators identified 107 patients. The primary indication for dofetilide was AFF, with 58.9% receiving the drug for paroxysmal disease. Prescribing followed established guidelines, except that it was used intermittently by nonconfirmed prescribers (5.6%) and/or at inconsistent doses (14%). Excessive prolongation of the QTc interval occurred in 17.8% of patients after the first dose and 26.2% during subsequent doses; prolongation was more common in those with structural heart disease (p < 0.01). No patients developed torsade de pointes. In the effectiveness assessment (n = 25), the conversion of persistent AFF at 36 hours was higher than in previous studies (48% vs 27.2%; p = 0.05). CONCLUSIONS: In clinical practice, the conversion of persistent AFF with dofetilide is at least comparable to premarketing studies, with a similar safety profile. Institutions should continue to emphasize adherence with established treatment guidelines.