Healthcare Resource Utilization Following Minimally Invasive Sacrocolpopexy: Impact of Concomitant Rectopexy.

INTRODUCTION AND HYPOTHESIS: Combined surgical procedures with sacrocolpopexy (SCP) and rectopexy (RP) are more commonly being performed for treatment of multicompartment pelvic organ prolapse. This study aimed to compare healthcare resource utilization (HRU) within 6 weeks following combined surgery (SCP-RP) versus SCP alone (SCP-only). We hypothesized that concomitant RP does not impact HRU. METHODS: A retrospective cohort study of patients who underwent minimally invasive SCP from 2017 to 2022 was conducted at a tertiary referral center. Patients were grouped based on the performance of concomitant RP. HRU was defined as a composite of unscheduled office visits, emergency department visits, and readmissions before the 6-week postoperative visit. HRU was compared in the SCP-RP and SCP-only groups. Multivariable regression analysis was performed to identify factors associated with HRU. RESULTS: There were 144 patients in the SCP-RP group and 405 patients in the SCP-only group. Patient characteristics were similar between the two groups, with the following exceptions: the SCP-RP group was older, more likely to have comorbid conditions, and live >60 miles from the hospital. Of the 549 patients, 183 (33.3%) had ≥1 HRU encounter within 6 weeks after surgery. However, there was no difference between the SCP-RP and SCP-only groups in composite HRU (34.0% vs 33.1%, p = 0.84). The most common reasons for HRU were pain, urinary tract infection symptoms, and wound issues. Concomitant mid-urethral sling was associated with a two-fold increased risk of HRU after surgery. CONCLUSIONS: One in 3 patients undergoing minimally invasive SCP had at least one unanticipated encounter within 6 weeks after surgery. Concomitant RP was not associated with increased postoperative HRU.

Sexual Function in Women at 6 and 12 Months After Obstetric Anal Sphincter Injury: Is Pelvic Floor Physical Therapy Associated With Improved Outcomes?

IMPORTANCE: Women with obstetric anal sphincter injury (OASI) are at increased risk of postpartum sexual dysfunction. Risk persists beyond 3 years after perineal trauma in up to half of patients with OASI. OBJECTIVES: The aims of this study were to determine if postpartum pelvic floor physical therapy (PFPT) is associated with improved sexual function after vaginal delivery with OASI and to describe sexual function in patients with OASI at 6 and 12 months postpartum. STUDY DESIGN: This is a retrospective cohort study of patients with OASI. Women were grouped according to PFPT attendance. The Postpartum Pelvic Floor and Birth Questionnaire (PPFBQ), which compares current sexual function to baseline prepregnancy sexual function, and the Female Sexual Function Index (FSFI) were administered at 6 and 12 months, respectively, to evaluate postpartum sexual function. RESULTS: Two hundred women were included. Sixty-four (32%) women attended PFPT; 136 (68%) did not attend PFPT. Patients reported worse-than-baseline sexual function at 6 months postpartum in the PPFBQ sexual activity domain, but the PFPT group had lower median score than the non-PFPT group (2.3 [2.0, 2.8] vs 2.7 [2.1, 3.1], P = 0.034), with scores <3.0 indicating worse-than-baseline functioning. The FSFI composite scores were similar between groups and showed 80.7% of the patients with OASI meeting the criteria for female sexual dysfunction at 12 months postpartum. Attendance of PFPT was not significantly associated with composite FSFI scores and most domains of PPFBQ. CONCLUSIONS: Attendance of PFPT did not significantly impact overall sexual function in OASI patients at 6 and 12 months postpartum. Sexual function is complex and may be more effectively addressed in the postpartum period using a multidimensional approach.

Healthcare Resource Utilization After Apical Prolapse Surgery in Women Who Received In-Office Versus Telephone-Only Preoperative Teaching.

IMPORTANCE: Despite increasing use of telehealth, no studies have evaluated telehealth use for preoperative teaching and its impact on healthcare resource utilization (HRU) after gynecologic surgery. OBJECTIVES: This study aimed to compare HRU after apical prolapse surgery in women receiving in-office versus telephone-only preoperative teaching and identify factors associated with postoperative HRU. STUDY DESIGN: A retrospective cohort study of women who underwent apical prolapse surgery from 2017 to 2020 at a tertiary referral center was conducted. Women were grouped based on the preoperative teaching type they received. Healthcare resource utilization was defined as a composite of patient-initiated calls, unscheduled outpatient visits, emergency department visits, and readmissions before the scheduled 6-week postoperative visit. Healthcare resource utilization was compared between in-office and telephone-only groups. Multivariable regression analysis was performed to identify factors associated with HRU. RESULTS: A total of 1,168 women underwent in-office teaching, and 181 had telephone-only teaching. Of the 1,349 women, 980 (72.6%) had ≥1 HRU encounter and 222 (16.5%) had ≥5 HRU encounters within 6 weeks after surgery. There was no difference between telephone and office groups for composite outcomes of ≥1 HRU (78.5% vs 71.7%, P = 0.06) and ≥5 HRU (13.3% vs 17.0%, P = 0.21) encounters. A failed voiding trial was associated with a 4.4-fold increased risk of ≥5 encounters. Increasing age and body mass index, concomitant hysterectomy, and abdominal route were associated with a decreased likelihood of ≥5 encounters. CONCLUSIONS: Three of 4 women had at least 1 unanticipated HRU encounter within 6 weeks after apical prolapse surgery. Preoperative teaching type was not associated with postoperative HRU. Telephone visits may be considered as an alternative to in-office visits for preoperative teaching.

Nonhome Discharge in Patients Undergoing Pelvic Reconstructive Surgery: A National Analysis.

IMPORTANCE: Discharge to home after surgery has been recognized as a determinant of long-term survival and is a common concern in the elderly population. OBJECTIVE: The aim of the study was to determine the incidence and risk factors for nonhome discharge in patients undergoing major surgery for pelvic organ prolapse. STUDY DESIGN: We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2018. We included patients who underwent sacrocolpopexy, vaginal colpopexy, and colpocleisis. We compared perioperative characteristics in patients who were discharged home versus those who were discharged to a nonhome location. Stepwise backward multivariate logistic regression was then used to control for confounding variables and identify independent predictors of nonhome discharge. RESULTS: A total of 38,012 patients were included in this study, 209 of whom experienced nonhome discharge (0.5%). Independent predictors of nonhome discharge included preoperative weight loss (adjusted odds ratio [aOR], 5.9; 95% confidence interval [CI], 1.3-27.5), dependent health care status (aOR, 5.0; 95% CI, 2.6-9.5), abdominal hysterectomy (aOR, 2.3; 95% CI, 1.4-3.7), American Society of Anesthesiologists class 3 or greater (aOR, 2.0; 95% CI, 1.5-2.7), age (aOR, 1.1; 95% CI, 1.05-1.09), operative time (aOR, 1.005; 95% CI, 1.003-1.006), laparoscopic hysterectomy (aOR, 0.6; 95% CI, 0.4-1.0), and laparoscopic sacrocolpopexy (aOR, 0.5; 95% CI, 0.3-0.8). CONCLUSIONS: In patients undergoing surgery for pelvic organ prolapse, nonhome discharge is associated with various indicators of frailty, including age, health care dependence, and certain comorbidities. An open surgical approach increases the risk of nonhome discharge, while a laparoscopic approach is associated with lower risk.

The Impact of Pelvic Floor Physical Therapy on Bladder and Bowel Function After Obstetric Anal Sphincter Injury.

IMPORTANCE: Women with obstetric anal sphincter injury (OASI) are at increased risk of pelvic floor disorders. No standard of care exists for management of pelvic floor dysfunction after OASI. OBJECTIVES: The aims of this study were to evaluate the impact of pelvic floor physical therapy (PFPT) on bladder and bowel function after OASI and to describe adherence to PFPT. STUDY DESIGN: A retrospective cohort study of women with OASI presenting at a postpartum care clinic from 2017 to 2021 was conducted. Women were grouped according to PFPT attendance. Urinary Distress Inventory 6 (UDI-6) and Fecal Incontinence Severity Index (FISI) were administered at baseline and 6 months. RESULTS: A total of 430 women with OASI presented to a postpartum care clinic, of which 137 (31.9%) attended PFPT, and 293 (68.1%) did not attend. Baseline and 6-month questionnaires were completed by 169 women: 52 (30.8%) in the PFPT group and 117 (69.2%) in the non-PFPT group. Baseline UDI-6 and FISI scores were higher in the PFPT group. Improvement in UDI-6 was not different between groups (-5.8 ± 14.9 vs -3.7 ± 10.8, P = 0.36). The non-PFPT group had greater worsening of FISI compared with PFPT group (9.8 ± 15.2 vs 1.1 ± 11.5, P < 0.001). Sixty-six percent (n = 136) of women referred to PFFT attended at least 1 session, of which 32.4% (n = 44) completed all sessions. Completely adherent women were referred to PFPT earlier (18.5 vs 28.5 days postpartum, P = 0.027). CONCLUSIONS: Women in both the PFPT and non-PFPT groups reported improvement in bladder leakage 6 months after OASI. Women who did not attend PFPT had significant worsening of bowel leakage. Early referral to PFPT in women with pelvic floor dysfunction following OASI should be considered.

Review of Vaginal Approaches to Apical Prolapse Repair.

PURPOSE OF REVIEW: To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery. RECENT FINDINGS: Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.