Racial and ethnic disparity in national practice patterns for stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: There is a paucity of information assessing whether race/ethnicity is associated with differences in surgical treatment of stress urinary incontinence (SUI). The primary objective was to assess for racial/ethnic disparities in SUI surgeries. Secondary objectives were to assess for surgical complication differences and trends over time. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we conducted a retrospective cohort analysis of patients undergoing SUI surgery from 2010 to 2019. Chi-squared or Fisher's exact test and ANOVA were used for categorical and continuous variables respectively. Breslow day score and multinomial and multiple logistic regression models were used. RESULTS: A total of 53,333 patients were analyzed. Using White race/ethnicity and sling surgery as references, Hispanic patients underwent more laparoscopic surgeries (OR1.17 [CI 1.03, 1.33]) and anterior vesico-urethropexy/urethropexies (OR 1.97 [CI 1.66, 2.34]); Black patients underwent more anterior vesico-urethropexy/urethropexies (OR 1.49 [CI 1.07, 2.07]), abdomino-vaginal vesical neck suspensions (OR 2.19 [CI 1.05-4.55]), and inflatable urethral slings (OR 4.28 [CI 1.23-14.90]). White patients had lower rates of inpatient stay (p < 0.0001) and blood transfusion (p < 0.0001) compared with patients who were Black, indigenous, people of color (BIPOC). Over time, Hispanic and Black patients were more likely to undergo anterior vesico-urethropexy/urethropexies than White patients (RR 2.03:1 [CI 1.72-2.40]) and (RR 1.59 CI [1.15-2.20]) respectively. Adjusting for possible confounders, Hispanic and Black patients had a greater chance of having a nonsling surgery, 37% (p < 0.0001) and 44% (p = 0.0001) greater chances respectively. CONCLUSION: We observed racial/ethnic differences in SUI surgeries. Although causality cannot be proven here, our results confirm previous findings suggesting inequities in care.

Patient Removal of Urinary Catheters After Urogynecologic Surgery: A Randomized Controlled Trial.

OBJECTIVE: To compare postoperative urinary retention rates in the early postoperative period between home and office catheter removal. Secondary outcomes included pain, difficulty, satisfaction, likelihood to use again, and health care utilization. METHODS: We conducted a nonblinded, randomized controlled, noninferiority trial of women undergoing surgery for stress incontinence and prolapse from March 2021 to June 2022. Exclusion criteria were preoperative voiding dysfunction (need for self-catheterization or postvoid residual [PVR] greater than 150 mL), urethral bulking, and need for prolonged postoperative catheterization. Participants discharged with indwelling catheters because of an initial failed void trial were randomized 1:1 to home compared with office removal on postoperative day 3-4. For home removal, participants were instructed to remove the catheter at 7 am and to drink two glasses of water. If they had difficulty voiding 5 hours after catheter removal, they came to the office for a void trial. For office removal, participants returned for a backfill void trial with PVR assessment. Our primary outcome was rate of early postoperative urinary retention , defined as confirmed retention (PVR greater than half the voided volume) after catheter removal. Secondary outcomes were assessed at a 2-week call. Health care utilization (telephone calls and office visits) related to catheter issues was also assessed. At 80% power and α=0.05, we needed 100 participants (50/group) to detect a noninferiority margin of 11%. RESULTS: Among 117 participants, the home (n=59) and office (n=58) removal groups were similar in mean age (60 years vs 61 years), mean body mass index (29 vs 30), pelvic organ prolapse quantification system stage 3 or 4, and proportion who underwent hysterectomy or apical suspension. Sling procedures were more common in the office group (45.8% vs 77.6%). For our primary outcome, the rate of early postoperative retention was 11.9% in the home group and 22.4% in the office group ( P =.13). Our predetermined noninferiority margin was greater than the upper bound of our 95% CI; thus, we conclude noninferiority of home removal. For secondary outcomes, the home removal group was more likely to report "no pain" ( P =.02) and "very likely" to use this method again ( P =.004). There were no differences in difficulty or satisfaction between groups. Number of nursing calls was not different ( P =.66); however, number of office visits was higher in the office group (median 0 [interquartile range 0-1] vs 1 [1-1], P <.001). CONCLUSION: Postoperative urinary catheter removal by the patient at home was noninferior to office removal when early urinary retention rates were compared. Participants in the home removal group had fewer office visits and reported low pain, low difficulty, and high satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04783012.

PROMIS pain intensity and interference after pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires provide valid comparisons across disciplines. Pain measures can be used to track functional outcomes. Limited PROMIS pain data exist in gynecological surgery. We sought to use pain intensity and pain interference short forms to assess pain and recovery after pelvic organ prolapse surgery. METHODS: The PROMIS pain intensity and pain interference questionnaires were given to patients undergoing uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF) or minimally invasive sacrocolpopexy (MISC) at baseline, 1 week, and 6 weeks postoperatively. Clinical minimally important change was defined as a difference of 2-6 T-score points. Mean pain intensity and pain interference T-scores were compared at baseline, 1 week and 6 weeks with ANOVA. Multiple linear regression assessed 1-week scores adjusted for apical suspension type, advanced prolapse, concurrent hysterectomy, concurrent anterior or posterior repair, and concurrent sling. RESULTS: At 1 week, all apical suspension groups showed minimally important change in pain intensity and pain interference T-scores. Between groups at 1 week, pain interference was higher in USLS (66.3±6.6) and MISC (65.5±5.9) than in SSLF (59.2±9.8), p=0.01. Multiple linear regression showed an association of hysterectomy with increases in pain intensity and pain interference. USLS had a higher proportion of concurrent hysterectomy (100%) than SSLF (0%) and MISC (30.8%), p<0.01. No difference was found based on apical suspension type alone. CONCLUSIONS: No differences were found in PROMIS pain intensity and pain at 1 week postoperatively after apical suspension procedures.

Accuracy of Visual Assessment of Urimeter Bag Volumes: The Whiz Quiz.

IMPORTANCE: Although visual estimate of urine output via urimeter bag is common, data on accuracy are limited. OBJECTIVE: This study aimed to assess the accuracy of a visual estimate of urine output in standard urimeter bags by health care workers. STUDY DESIGN: This is a prospective observational study. Perioperative health care workers were asked to visually estimate fluid volumes in 5 standard urimeter bags. Actual volumes were 50, 150, 350, 500, and 750 mL. Visual estimates were recorded. The primary outcome was accuracy, defined as estimated visual volume within 20% of actual volume. Secondary outcomes included effect of health care provider type, specialty, experience, sex, and age on accuracy. RESULTS: A total of 159 responses were analyzed. There were 55 (35.3%) registered nurses, 19 (12.2%) certified registered nurse anesthetists, 18 (11.5%) advanced practice providers not identified as a certified registered nurse anesthetist, and 64 (41%) physicians. Mean estimated volumes (in milliliters) ± standard deviation and accuracy for the bags were as follows: (a) actual volume of 50 mL and estimated volume of 66 ± 29 mL (45% accuracy), (b) actual volume of 150 mL and estimated volume of 149 ± 43 mL (46% accuracy), (c) actual volume of 350 mL and estimated volume of 356 ± 74 mL (76% accuracy), (d) actual volume of 500 mL and estimated volume of 452 ± 77 mL (85% accuracy), and (e) actual volume of 750 mL and estimated volume of 675 ± 108 mL (85% accuracy). There was reasonable accuracy for individual volume estimates, but accuracy across all 5 urimeter bags was low: 22 of 159 (13.8%). There were no significant differences in accuracy based on health care provider type, specialty, experience, sex, or age. CONCLUSIONS: Consistent accuracy of visual assessment of calibrated urimeter bag volumes was low and not influenced by health care provider characteristics.

Are Formal Voiding Trials Necessary After Posterior Compartment Reconstructive Surgery?

IMPORTANCE: Posterior compartment surgery is considered a risk factor for postoperative urinary retention because of the impact of postoperative pain on the pelvic floor; however, few studies have examined the association between posterior compartment reconstructive surgery and urinary retention. OBJECTIVE: The aim of the study was to compare rates of urinary retention in patients undergoing vaginal reconstructive surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment). STUDY DESIGN: In this retrospective cohort study, we evaluated patients who underwent surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment) from January 2015 to November 2020. Our primary outcome was rate of postoperative urinary retention, defined as a failed voiding trial before discharge. Secondary outcome was days of catheterization. Multivariable logistic regression was performed to assess variables associated with a failed voiding trial. RESULTS: Of 362 patients, 141 (39.0%) underwent surgery in the posterior compartment only and 221 (61.0%) underwent vaginal apical and/or anterior compartment surgical procedures. Rate of retention was significantly lower in the posterior compartment only group (9.9% vs 41.6%, P < 0.001). The median numbers of days of catheterization were significantly fewer in the posterior compartment only group (0 [0,0] vs 0 [0,3], P < 0.001). In multivariable logistic regression, posterior compartment only surgery was associated with passing the voiding trial (odds ratio, 6.0; 95% confidence interval, 2.97-12.03). CONCLUSIONS: Rates of postoperative urinary retention after surgery in the posterior compartment are low, and these patients may not require formal voiding trials after surgery.

Vaginal repair of vesicovaginal fistula: comparison of national practice patterns by surgeon specialty.

INTRODUCTION AND HYPOTHESIS: There are limited data comparing patient and operative characteristics for vaginal repair of vesicovaginal fistula (VVF) by surgeon specialty. Our objective was to compare national practice patterns by surgeon specialty for vaginal repair of VVF. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we conducted a retrospective cohort analysis of women who underwent vaginal repair of VVF from 2010 to 2019. Demographic and perioperative characteristics were compared by surgeon specialty. RESULTS: A total of 252 women were analyzed. Urologists performed 57% of cases (n=144), gynecologists performed 38% (n=96), and general surgeons performed 5% (n=12). There were differences among surgeon specialties in patient characteristics including age (p=0.002), creatinine (p=0.002), hypertension (p=0.02), morbidity probability (p<0.001), hospital stay (p<0.001), inpatient status (p=0.03). Urologists were more likely than gynecologists to use grafts/flaps (p=0.002). There were trending differences among surgeon specialties in patient race (p=0.07) and ethnicity (p=0.06). Urologists and gynecologists were more likely to operate on younger, healthier patients with differences in racial populations. When directly comparing urologists with gynecologists, there were differences in race (p=0.05) and a trending difference in ethnicity (p=0.06), General surgeons were more likely to operate on older white women with worse health status, more concomitant procedures, and longer hospital stay. CONCLUSIONS: Urologists, gynecologists, and general surgeons perform vaginal repair of VVF. Among these specialties, there were differences in patient and perioperative characteristics. This information may help referring providers and patients to understand which types of surgical providers most commonly manage VVF.

Chronic endometritis: A prevalent yet poorly understood entity.

OBJECTIVE: To examine the prevalent understanding of and management approaches to chronic endometritis among obstetricians/gynecologists. METHODS: In a cross-sectional observational study, 262 members of national and international professional obstetrician/gynecologist societies were surveyed via anonymous electronic survey that investigated knowledge of the pathophysiology, diagnostic criteria, clinical implications, and treatment strategies for chronic endometritis. Statistical analyses of results were performed using Fisher's exact tests, chi square tests and odds ratios with 95% confidence intervals. A two-sided P < 0.05 was deemed statistically significant. RESULTS: Responses identified a concerning spectrum of deficiencies in the understanding of the pathophysiology of chronic endometritis, in awareness of clinical presentation of chronic endometritis, and in the understanding of methodology/ies that allow diagnosis of chronic endometritis. Heterogeneities in management approaches to chronic endometritis were apparent. CONCLUSION: Our findings underscore a need for targeted efforts to gain clarity on chronic endometritis and to establish evidence-based consensus for good clinical practice. In the absence of a clear understanding of chronic endometritis diagnosis, we posit that the prevalent inconsistencies are likely inflicting unquantified and underappreciated burdens on patients and healthcare systems. We propose consideration for a task force to examine existing literature and create standards for good practice for a prevalent condition.

The Diagnostic Criteria for Chronic Endometritis: A Survey of Pathologists.

While acute endometritis is a reasonably well-defined entity of ascending infection and attendant active inflammation, chronic endometritis is less well defined. As part of a broad effort to define and refine the diagnostic criteria and management of the disease, we conducted a survey of pathologists to understand the variability in diagnostic criteria and implications of the diagnosis of nonspecific, nonobstetric chronic endometritis. Members of national and international professional pathology societies were surveyed utilizing anonymous electronic surveys designed to examine diagnostic criteria, etiological understanding and treatment implications of a pathologic diagnosis of nonspecific, nonobstetric chronic endometritis. There was substantial variability among pathologists in the diagnostic criteria used for making a diagnosis of nonspecific, nonobstetric chronic endometritis, with 28.5% of pathologists using the presence of a single plasma cell for making the diagnosis. There was additional variability in the use of special stains, reporting in the presence of coexisting lesions and the hormonal stage of the endometrium. There were no differences between generalists and specialists in the diagnostic criteria used, except the significantly greater likelihood of specialists making the diagnosis in gestational endometrium. The substantial variability in diagnostic criteria for nonspecific, nonobstetric chronic endometritis among pathologists, including among gynecologic pathologists, has the potential to confound the management of patients. Standardization of diagnostic criteria for chronic endometritis is essential to understand the implications of the diagnosis.

Adverse Events in Obstetrics: Impacts on Providers and Staff of Maternity Care.

Objective To determine the frequency of maternity health employee experiences with maternal and perinatal/neonatal adverse outcomes and gain a deeper understanding of how these experiences impact the providers.  Design Single-institution observational study from 2016. Setting The George Washington University Hospital. Population Labor and delivery, postpartum, and neonatal intensive care staff. Methods An anonymous survey was distributed to maternity staff inquiring about feelings surrounding maternal and perinatal/neonatal adverse outcomes. Predictors included demographics and job-related variables. Associations were examined using univariable and multivariable analyses. Main Outcome Measures Outcomes included depression, post-traumatic stress disorder symptoms, and work-related problems following the event. Results  A total of 105 employees of approximately 230 eligible employees answered the survey, including obstetrics and gynecology and anesthesia physicians (residents and attendings), midwives, nurses, nurse practitioners, and medical technicians with a response rate of 46%. Being a physician was protective against symptoms of depression and post-traumatic stress disorder symptoms. Resident physicians had higher levels of anxiety/depression compared to attendings. Statistically significant variables predictive of negative repercussions included non-physician status (p=.045), substance use (p=.0036), considering a career change (p<.0001) and seeking mental health treatment (p=.0005). About half of the respondents were aware that processes exist to help them cope with adverse outcomes. Conclusions Non-physicians, those using substances, those considering career change, and those seeking mental health treatment are more likely to experience anxiety/depression and post-traumatic stress symptoms after a maternal or perinatal/neonatal loss. These individuals should be identified and offered additional support.

Correction to: Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.

The original article was updated to correct the author listing: the last five author names were reversed.

Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.

BACKGROUND: While laparoscopic hysterectomy has benefits compared to abdominal hysterectomy, the operative times are longer. Longer operative times have been associated with negative outcomes. This study's purpose was to elucidate if there is an operative time at which 30-day outcomes for laparoscopic hysterectomy become inferior to a more expeditiously completed abdominal hysterectomy. METHODS: This was a retrospective cohort study (Canadian Task Force classification II-2) using the American College of Surgeons National Surgical Quality Improvement Program database to identify women undergoing hysterectomy for benign indications from 2010 to 2016 by current procedural terminology code. Hysterectomy cases were stratified by approach and 60-min intervals. 30-day post-operative outcomes were analyzed by operative time and approach. RESULTS: 109,821 hysterectomies were included in our analysis, of which 66,560 (61%) were laparoscopic, and 43,261 (39%) were abdominal. In a multivariable logistic regression analysis comparing outcomes by surgical approach and operative time, there was no time combination in which patients who had a abdominal hysterectomy had significantly lower odds of the composite complications variable. This was true even in laparoscopic hysterectomies greater than 240 min compared to abdominal hysterectomies completed between 20 and 60 min. When compared to laparoscopic hysterectomies greater than 240 min, abdominal hysterectomies between 20 and 60 min had lower odds of sepsis and abdominal hysterectomies less than 180 min had lower odds of urinary tract infection. CONCLUSION: Given that benefits persist even in prolonged cases, a laparoscopic approach should be offered to most patients undergoing benign hysterectomy. Surgical efficiency should be prioritized for any surgical approach.

Addison's disease in pregnancy: Case report, management, and review of the literature.

BACKGROUND: Addison's disease is an uncommon condition encountered during pregnancy; however, pregnant patients with Addison's disease are at higher risk for multiple pregnancy related complications. Treatment during pregnancy involves steroid replacement therapy. CASE REPORT: A 34-year-old previously healthy G2P1001 presented with lethargy, skin hyperpigmentation, polyuria, and salt craving. Laboratory evaluation showed hyperkalemia, hyponatremia, elevated ACTH, and low cortisol. The patient terminated the pregnancy due to her symptoms. She was then placed on a regimen of hydrocortisone and fludrocortisone, leading to symptom resolution. On second presentation as a G5P1031, her Addison's disease was managed with hydrocortisone and fludrocortisone. When Addison's symptoms recurred, ACTH levels were checked to determine if her current medications could be optimized. She ultimately delivered a healthy male infant vaginally. For her third presentation as a G6P2032, her pregnancy was managed in a similar manner to the previous pregnancy. CONCLUSION: There is currently minimal cohesive literature on the management of Addison's disease during pregnancy. Patients can be managed successfully by monitoring for recurrence of Addison's symptoms and adjusting medication dosing as needed.

Association of operative time with outcomes in minimally invasive and abdominal myomectomy.

OBJECTIVE(S): To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): Myomectomy cases identified by CPT code from 2005 to 2016. INTERVENTION(S): Cases were stratified and analyzed by surgical approach and 90-minute intervals. MAIN OUTCOME MEASURE(S): Thirty-day postoperative morbidity. RESULT(S): A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases <90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in <270 minutes. CONCLUSION(S): ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.

Teaching and learning of medical biochemistry according to clinical realities: A case study.

To foster medical students to become physicians who will be lifelong independent learners and critical thinkers with healthy skepticism and provide high-quality patient care guided by the best evidence, teaching of evidence-based medicine (EBM) has become an important component of medical education. Currently, the teaching and learning of biochemistry in medical schools incorporates its medical relevance and applications. However, to our knowledge there have been no reports on integrating EBM with teaching and learning medical biochemistry. Here, we present a case study to illustrate the significance of this approach. This case study was based on a biochemistry/nutrition question in a popular board review book about whether a homeless alcoholic man is at risk of developing a deficiency of vitamin E. The possible answers and explanation provided in the book raised a question about the correct answer, which provided us with an opportunity to adapt the philosophy and certain basic EBM principles to find evidence for the clinical applicability of a commonly taught biochemistry topic. The outcome of this case study not only taught us how to conduct an EBM exercise to answer a specific patient question, but also provided us with an opportunity for in-depth teaching and learning of the medical relevance of a specific biochemistry topic based on the best clinical evidence obtained from a systematic research of medical literature.

Vitamin D deficiency in patients with intestinal malabsorption syndromes--think in and outside the gut.

There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.