Retropubic Versus Transobturator Midurethral Slings at Time of Colpocleisis.

IMPORTANCE: This study aimed to evaluate if there is a difference between outcomes when retropubic or transobturator midurethral sling surgery is performed at the time of colpocleisis. OBJECTIVES: The purpose of this study was to compare the surgical outcomes of the retropubic midurethral sling (RP-MUS) versus the transobturator midurethral sling (TO-MUS) in women who underwent concomitant colpocleisis, specifically 2-year MUS failure and 1-year lower urinary tract symptoms (LUTSs). A secondary aim was to identify factors associated with these surgical outcomes. STUDY DESIGN: All cases of concomitant MUS and colpocleisis within a closed, integrated health care delivery system were reviewed between April 1, 2010, and March 31, 2020. Postoperative MUS failure was defined as (1) postoperative stress urinary incontinence symptoms and/or (2) additional anti-incontinence surgery. Postoperative LUTSs were defined as (1) MUS lysis and/or (2) overactive bladder requiring management with a new treatment. RESULTS: Of the 558 women included, 454 (81%) received RP-MUS and 104 (19%) received TO-MUS. Cohort demographics were similar. Neither MUS failure (7% RP-MUS and 9% TO-MUS, P = 0.450) nor LUTSs (7% RP-MUS and 12% TO-MUS, P = 0.171) were significantly different between RP-MUS and TO-MUS. In multivariable analysis, age was found to be significantly associated with LUTSs (odds ratio 0.29, 95% confidence interval 0.09-0.93, P = 0.038 among 70-74-year-olds; odds ratio 0.28, 95% confidence interval 0.09-0.83, P = 0.022 among 75-79-year-olds). CONCLUSIONS: At the time of colpocleisis, both RP-MUS and TO-MUS were highly successful and associated with a low incidence of LUTSs, including MUS lysis. The findings of this large study support RP-MUS and TO-MUS as similarly effective anti-incontinence options at time of colpocleisis.

Urinary Tract Infections Among Gender Diverse People Assigned Female at Birth on Testosterone.

IMPORTANCE: The current literature lacks evidence to support the relationship between gender-affirming testosterone use and urinary tract infections (UTIs). OBJECTIVES: The aims of the study are to compare UTI rates among gender diverse people assigned female at birth on testosterone (GDT) to cisgender women (CW) and to identify factors associated with UTI. STUDY DESIGN: This is a retrospective cohort study of GDT and age-matched CW over a 5-year period. The primary outcome was based on the International Classification of Diseases, Ninth/Tenth Revisions, Clinical Modification, UTI diagnosis codes with a filled pharmacy order for antibiotics within 7 days of the diagnosis. RESULTS: The study included 2,401 GDT who were then age matched to 2,401 CW. The mean rates of UTI among GDT and CW were not significantly different at 0.09 and 0.10 UTIs per year, respectively. During the study period, 6.9% of GDT and 7.5% of CW had at least 1 UTI. Diabetes mellitus type 1 or 2 was significantly associated with UTI frequency among CW (P = 0.04) but not GDT (P = 0.96). CONCLUSIONS: The rate of UTIs among our young cohort of GDT and CW was similarly low. Diabetes mellitus type 1 or 2 was significantly associated with UTIs among CW but not GDT. These findings suggest that testosterone-induced vaginal atrophy may not be associated with a higher a UTI risk. A deeper understanding of the pathogenesis of UTI in people assigned female at birth and more data on the relationship between testosterone and UTIs are needed before recommending vaginal estrogen to all GDT with recurrent UTI.

Constructing a Novel 'Uterine Sandwich' with Simultaneous Intrauterine Balloon Tamponade and Uterine Compression Sutures to Manage Postpartum Bleeding.

The uterine sandwich is a relatively new surgical technique for managing postpartum hemorrhage, which is the leading cause of maternal mortality worldwide. The purpose of this case series is to describe a novel method of constructing the uterine sandwich by simultaneously combining intrauterine balloon tamponade and uterine compression sutures. Six patients with postpartum bleeding refractory to medical management were successfully treated with this novel method and avoided hysterectomy. There were no additional complications. This novel method of constructing a uterine sandwich appears to be a simple, safe, and effective technique that could be considered in cases of persistent postpartum bleeding. More research is needed to compare the efficacy of various techniques.

Urinary Incontinence and Pelvic Organ Prolapse.

The multifactorial pathophysiology of pelvic floor disorder accounts for the coexistence of several pelvic floor disorders in many women. Up to 54% of women with pelvic organ prolapse (POP) report concurrent stress urinary incontinence (SUI). While POP is a risk factor for coexistent SUI, apical and anterior prolapse can also conceal SUI symptoms that are unmasked by POP repair, resulting in de novo SUI postoperatively. It is important for pelvic reconstructive surgeons to consider the relationship between POP and urinary incontinence in presurgical planning and to discuss with patients the risks and advantages of concurrent versus staged anti-incontinence procedures.

The ALOHA Study: Intimate Partner Violence in Hawai'i's Lesbian, Gay, Bisexual, and Transgender Community.

The Centers for Disease Control and Prevention describes intimate partner violence (IPV) as a serious, preventable problem. The ALOHA (Assessing Lesbian, Gay, Bisexual, and Transgender [LGBT] Violence in Hawai'i) Study examines IPV in Hawai'i's LGBT community. The study's primary outcome is to determine the prevalence of IPV in Hawai'i's LGBT community, and secondary outcomes are to determine the prevalence of help-seeking behavior, associations between IPV and demographics, and associations between help-seeking behavior and demographics. This cross-sectional study included 477 subjects who self-identified as Hawai'i residents and LGBT. The percentages of overall IPV, physical IPV, and sexual IPV were 68.8%, 54.1%, and 49.3%, respectively. Blacks were most likely to report a history of physical IPV (OR=4.93, 95%CI: 1.95-12.47). Blacks (OR=2.49, 95%CI: 1.13-5.74), Native Hawaiians and Pacific Islanders (OR=2.14, 95%CI: 1.30-3.52), and cisgender females (OR=2.27, 95%CI: 1.29-3.45) were more likely to report a history of sexual IPV than other groups. Among victims of physical and sexual IPV, 9.9% and 9.6% sought help, respectively, and transgender and gender non-conforming individuals were the most likely to seek help (physical IPV: 30.8%, sexual IPV: 28.6%). Hawai'i's LGBT community has an extremely high prevalence of IPV and a very low prevalence of help-seeking behavior. This translates into a large number of victims who are left without support. Additional research is needed to fully understand the details of IPV within Hawai'i's LGBT community and the barriers to help-seeking so that potential solutions may be identified.

A fight-and-flight for life: A rare case of advanced cervical cancer in pregnancy.

BACKGROUND: Advanced cervical cancer during pregnancy is an extremely rare event. We describe a case of at least stage IIIB cervical squamous cell carcinoma during pregnancy. This may possibly represent the longest gestation from time of diagnosis to delivery in a case of advanced cervical cancer, with potentially the most advanced gestational age at delivery and a relatively favorable outcome in the current literature.Case: A 29-year-old female at 20 0/7 weeks of gestation with at least stage IIIB squamous cell carcinoma of the cervix flew from Micronesia to Hawaii for oncologic treatment. After consultation with gynecologic oncology and maternal-fetal medicine, she opted to continue the pregnancy and began neoadjuvant chemotherapy with carboplatin and paclitaxel. At 33 2/7 weeks of gestation, she was admitted for preterm prelabor rupture of membranes and immediately underwent a cesarean delivery for heavy vaginal bleeding. Postpartum, she underwent cisplatin chemotherapy with concurrent radiation therapy. After 6 cycles of chemotherapy, the patient's cancer had progressed to the point that hospice was recommended. She died 11 months after initial presentation. CONCLUSION: Advanced cervical cancer during pregnancy requires individualized treatment, shared decision making, and a multidisciplinary team approach. If the pregnancy is continued, antepartum chemotherapy should be strongly considered. Maternal prognoses tend to be poor, but neonatal outcomes appear to be favorable.

Examining the validity of a predictive model for vaginal birth after cesarean.

Background The Maternal-Fetal Medicine Units (MFMU) vaginal birth after cesarean (VBAC) calculator, while accurate for candidates with high predicted success rates, is not as accurate for poor candidates. This study examines the calculator's validity in an understudied multiracial cohort with a high proportion of poor candidates. Methods This retrospective study examined women with one or two prior cesarean deliveries who attempted VBAC at a single institution. Subjects were placed into quartiles based on MFMU-predicted success rates. For each quartile, actual and predicted success rates were compared. The calculated area under the receiver operating characteristic curve (AUC) was compared to the original AUC. Results The study included 1604 women. Actual and predicted VBAC rates were similar in the lowest and highest quartile groups, 18.2% vs. 21.2% (n = 11, P > 0.99) and 87.1% vs. 88.5% (n = 1090, P = 0.14), respectively. In the 51-75% predicted success rate group, the actual VBAC rate was higher than the predicted rate, 69.9% vs. 65.5% (n = 394) but not statistically significant (P = 0.07). In the 25-50% predicted success rate group, the actual VBAC rate was significantly higher than the predicted rate 55.1% vs. 39.6% (n = 109, P = 0.002). The actual AUC was lower than the MFMU model, 0.72 [95% confidence interval (CI) 0.69-0.75] vs. 0.77 (95% CI 0.76-0.78) (P < 0.001). Conclusion The MFMU VBAC calculator's predicted success rates were comparable to actual success rates for candidates with predicted success rates >75%. As predicted success rates declined, the calculator was increasingly inaccurate and underestimated the success rate. Caution should be taken when using the MFMU VBAC calculator for poor candidates.

Completeness of salpingectomy intended for ovarian cancer risk reduction.

BACKGROUND: Prophylactic salpingectomy has been heavily promoted based on the theory that serous tubal intraepithelial carcinoma is a precursor lesion for serous ovarian carcinoma. However, the validity of prophylactic salpingectomy has yet to be proven through adequate research. The purpose of this study is to evaluate the completeness of salpingectomy intended for ovarian cancer risk reduction. MATERIALS AND METHODS: Women without a history of ovarian cancer who were undergoing salpingoophorectomy at a single institution in Honolulu, Hawaii were enrolled in this study. Salpingectomy was performed prior to oophorectomy. A blinded pathologist then examined the ovaries for the presence of residual salpingeal tissue. Data collected included type of surgery (minimally invasive or laparotomy) and level of surgeon (attending or resident). Data were analyzed using Fisher's exact test. RESULTS: A total of 107 ovaries were examined. Following salpingectomy, 5.6% (n = 6/107) of ovaries had residual salpingeal tissue present and 94.4% (n = 101/107) of ovaries were absent of salpingeal tissue. Of the ovaries with residual salpingeal tissue, there was no difference in level of surgeon (attending n = 3/107, resident n = 3/107, p = 1.0) or type of surgery (minimally invasive n = 5/107, laparotomy n = 1/107, p = 0.42). DISCUSSION: This is the largest blinded study ever conducted to examine ovaries for residual salpingeal tissue after salpingectomy. In addition, this is the only study to compare learner versus attending outcomes in this setting. This study found that over 94% of salpingectomies resulted in complete removal of salpingeal tissue. Of the ovaries with residual salpingeal tissue, there wasn't a difference among surgeon level and surgery type, but the study was not powered to detect this. This study supports the continued clinical practice of prophylactic salpingectomy for ovarian cancer risk reduction.

The Dangers of Hymenotomy for Imperforate Hymen: A Case of Iatrogenic Pelvic Inflammatory Disease with Pyosalpinx.

BACKGROUND: Complications associated with imperforate hymen include cyclical abdominal pain, acute urinary retention, endometriosis, and even iatrogenic infections. CASE: A 14-year-old young woman was diagnosed with an imperforate hymen, hematocolpos, and right hematosalpinx. A hymenotomy was performed, followed by a hymenectomy 3 days later. On postoperative day 7, she was admitted for pelvic inflammatory disease with a right pyosalpinx. The infection was refractory to intravenous gentamicin, ampicillin, and clindamycin so the patient underwent computed tomography-guided drainage of the pyosalpinx. Two days later, she was discharged home in good condition. SUMMARY AND CONCLUSION: Small incisions and punctures into imperforate hymens without immediate definitive management should be avoided because inoculation of the newly introduced bacteria can ascend the gynecologic tract and lead to serious infections.

A Case of Vaginal Birth after Cesarean Delivery in a Patient with Uterine Didelphys.

BACKGROUND: The American College of Obstetricians and Gynecologists (ACOG) recommends that most women with one prior low-transverse cesarean delivery should be offered a trial of labor after cesarean (TOLAC). However, very little is known about TOLAC in women with uterine anomalies. CASE: A 32-year-old gravida-2 para-1 female with a history of uterine didelphys and one prior low-transverse cesarean section in the left uterine horn presented with a subsequent pregnancy in the left uterine horn. After extensive counseling on TOLAC versus repeat cesarean delivery, the patient decided to proceed with TOLAC and had a spontaneous vaginal delivery of a healthy infant at 38 3/7 weeks of gestation. CONCLUSION: TOLAC can be considered in women with uterine anomalies using ACOG's standard TOLAC guidelines with informed consent and shared decision-making between the patient and obstetrician.