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.

A Systematic Review of Randomized Trials Investigating Methods of Postoperative Void Trials Following Benign Gynecologic and Urogynecologic Surgeries.

OBJECTIVE: To perform a systematic review of randomized controlled trials (RCTs) studying postoperative void trials (VTs) following gynecologic and urogynecologic surgery to investigate (1) the optimal postoperative VT methodology and (2) the optimal time after surgery to perform a VT. DATA SOURCES: PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHOD OF STUDY SELECTION: We systematically searched the aforementioned data sources from inception to November 22, 2019, using a combination of subject headings and keywords for the following 3 concepts: gynecologic surgery (prolapse, benign gynecologic, and incontinence surgery), postoperative period, and voiding. We identified any RCT in English that studied VT methodology or timing in patients undergoing benign gynecologic or urogynecologic surgery. Discrepancies were adjudicated by a third reviewer. We followed the standard systematic review methodology and used the Jadad scoring system to assess bias. Extracted study outcomes included the following: proportion of patients discharged home with catheter, proportion of VT failure, surgery for retention, retention after initial VT, postoperative calls and visits, time in postanesthesia care unit (PACU), time to discharge, time to spontaneous void, duration of catheterization, patient and provider burden, and urinary tract infection (UTI). TABULATION, INTEGRATION, AND RESULTS: We double screened 618 abstracts and clinical trial descriptions, assessed 56 full-text articles, and ultimately included 21 RCTs. The evidence was of low to moderate quality overall. The studies were divided into the following 2 categories: VT methodology (10 studies) and VT timing (11 studies). VT methodology included backfill-assisted (in operating room vs PACU), autofill, and force of stream studies. One RCT compared backfill-assisted with and without postvoid residual volume check. Outcomes were similar for all VT methods, except backfill-assisted decreased time to spontaneous void compared with autofill. In the VT timing category, earlier VT performance correlated with a shorter time to discharge, time to spontaneous void, duration of catheterization, and lower patient burden and UTI rate but had a higher rate of retention after initial VT. There was no difference between earlier vs later VT timing for proportion of discharged home with catheter or rate of VT failure. No studies reported outcomes of provider burden or postoperative calls. CONCLUSION: In comparing VT methodologies, VT by backfill-assisted (in operating room vs PACU, ± postvoid residual volume), autofill, and force of stream resulted in similar outcomes with no one method being superior. Performing VT at an earlier postoperative time point results in shorter time to discharge and spontaneous void, shorter duration of catheterization, lower patient burden, and lower UTI risk, but it may increase the risk of retention after initial VT.

Opioid Education in Obstetrics and Gynecology Training Programs.

OBJECTIVE: Our primary objective was to assess the current state of pain and opioid education in obstetrics and gynecology (OBGYN) by performing a detailed review of the national educational curricula guiding OBGYN residency and fellowship training programs in the United States. METHODS: From 2019 to 2020 we reviewed seven documents created to guide learning and structure educational training for OBGYN residency and fellowship programs in the United States: the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives Core Curriculum in Obstetrics and Gynecology, the 2016 Educational Objectives-Fellowship in Minimally Invasive Gynecologic Surgery, and the 2018 Guides to Learning in Complex Family Planning, Female Pelvic Medicine & Reconstructive Surgery, Gynecologic Oncology, Maternal Fetal Medicine, and Reproductive Endocrinology and Infertility. Each document was reviewed by two authors to assess for items referring to pain or opioids. RESULTS: The CREOG educational objectives, used to inform educational curricula for residency programs, were the most comprehensive, mentioning pain and/or opioid educational objectives the highest number of times and including the most categories. The CREOG document was followed by the Guides to Learning for Gynecologic Oncology and for Minimally Invasive Gynecologic Surgery. The Reproductive Endocrinology and Infertility Guide to Learning did not mention pain and/or opioids in the educational objectives. CONCLUSIONS: Our study identifies an opportunity for consistent and appropriate opioid and pain management education in OBGYN training.

Perioperative opioid prescriptions associated with stress incontinence and pelvic organ prolapse surgery.

BACKGROUND: There is an opioid epidemic in the United States with a contributing factor of opioids being prescribed for postoperative pain after surgery. OBJECTIVE: Among women who underwent stress urinary incontinence and pelvic organ prolapse surgeries, our primary objective was to determine the proportion of women who filled perioperative opioid prescriptions and to compare factors associated with these opioid prescriptions. We also sought to assess the risk of prolonged opioid use through 1 year after stress urinary incontinence and pelvic organ prolapse surgeries. STUDY DESIGN: Using a population-based cohort of commercially insured individuals in the 2005-2015 IBM MarketScan databases, we identified opioid-naive women ≥18 years who underwent stress urinary incontinence and/or pelvic organ prolapse procedures based on Current Procedural Terminology codes. We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. For our primary outcome, we reported the proportion of opioid-naive women who filled a perioperative opioid prescription and reported the median quantity dispensed in the perioperative period. We also assessed demographic and perioperative factors associated with perioperative opioid prescription fills. Previous studies have defined prolonged use as the proportion of women who fill an opioid prescription between 90 and 180 days after surgery. We report this estimate as well as continuous opioid use, defined as the proportion of women with ongoing monthly opioid prescriptions filled through 1 year after stress urinary incontinence and/or pelvic organ prolapse surgery. RESULTS: Among the 217,460 opioid-naive women who underwent urogynecologic surgery, 61,025 (28.1%) had pelvic organ prolapse and stress urinary incontinence surgeries, 85,575 (39.4%) had stress urinary incontinence surgery without pelvic organ prolapse surgery, and 70,860 (32.6%) had pelvic organ prolapse surgery without stress urinary incontinence surgery. Overall, 167,354 (77.0%) filled a perioperative opioid prescription, and the median quantity was 30 pills (interquartile range, 20-30). In a multivariate regression model, younger age, pelvic organ prolapse surgery with or without stress urinary incontinence surgery, abdominal route, hysterectomy, and mesh use remained significantly associated with opioid prescriptions filled. Among those with a filled perioperative opioid prescription, the risk of prolonged use defined as an opioid prescription filled between 90 and 180 days was 7.5% (95% confidence interval, 7.3-7.6). However, the risk of prolonged use defined as continuous use with at least 1 monthly opioid prescription filled after surgery was significantly lower: 1.2% (1.13-1.24), 0.32% (0.29-0.35), 0.06% (0.05-0.08), and 0.04% (0.02-0.05) at 60, 90, 180, and 360 days after surgery, respectively. CONCLUSION: Among privately insured, opioid-naive women undergoing stress urinary incontinence and/or pelvic organ prolapse surgery, 77% of women filled an opioid prescription with a median of 30 opioid pills prescribed. For prolonged use, 7.5% (95% confidence interval, 7.3-7.6) filled an opioid prescription within 90 to 180 days after surgery, but the rates of continuously filled opioid prescriptions were significantly lower at 0.06% (95% confidence interval, 0.05-0.08) at 180 days and 0.04% (95% confidence interval, 0.02-0.05) at 1 year after surgery.

Catheter burden following urogynecologic surgery.

BACKGROUND: Data on the experience that women who undergo urogynecologic surgery have with postoperative catheterization are severely limited. As the importance of our patients' perioperative experience becomes more valued, assessment of the burden of postoperative catheterization, which has not yet been performed, is increasingly needed. OBJECTIVE: The aim of this study was to compare catheter burden in women who self-selected use of an indwelling Foley catheter vs clean intermittent self-catheterization for voiding dysfunction after reconstructive pelvic surgery. STUDY DESIGN: This is a nested study within a nonblinded randomized controlled trial of 2 different voiding trial protocols that was conducted from March to October 2017. Women who underwent pelvic organ prolapse and/or stress urinary incontinence surgery who were English speaking and ≥18 years old with a preoperative postvoid residual <100 mL were included. Participants who did not pass their voiding trial were discharged with an indwelling Foley catheter or self-catheterization per participant preference. Our primary outcome was catheter burden at 1 week after surgery assessed by the Short-Term Catheter Burden Questionnaire, which is a validated 6-item survey comprised of 2 subscales: difficulty of use and embarrassment. Scores range from 3-15 with higher scores indicating greater difficulty and/or embarrassment, and the sum of the 2 subscale scores measures total catheter burden with a higher score indicating greater burden. Secondary outcomes included the rate of urinary tract infection, the number of postoperative clinic visits, and the number of postoperative phone calls. RESULTS: Of 150 participants, 77 women (51%) did not pass their voiding trial; of those, 47 women (61%) were discharged home with an indwelling catheter and 30 women (39%) with self-catheterization. Baseline demographics were similar, except that women who chose an indwelling Foley catheter were older (62±11 vs 55±11 years; P<.01). There were no significant differences between indwelling Foley catheter and self-catheterization in total catheter burden score (18±5 vs 18±6; P=.77), difficulty of use subscale score (8±3 vs 9±3; P=.20), or embarrassment subscale score (10±4 vs 9±4; P=.12). For secondary outcomes, there were no significant differences in rate of urinary tract infection (23% indwelling vs 30% self-catheterization; P=.60). Consistent with study protocol, women who were discharged with an indwelling Foley catheter did have more postoperative clinic visits (2±1 vs 1±1 visits; P<.01), and those women who were discharged with self-catheterization had more postoperative phone calls (2±3 vs 5±3 phone calls; P<.01). Otherwise there was no significant difference in nonvoiding-related clinic visits (1±1 visits for indwelling and self-catheterization; P=.15) or postoperative phone calls (1±2 indwelling vs 2±3 self-catheterization calls; P=.31). CONCLUSION: In women who used either an indwelling Foley catheter or clean intermittent self-catheterization for management of postoperative voiding dysfunction after pelvic reconstructive surgery, there were no differences in difficulty of use, embarrassment, or overall catheter burden. There were also no differences in nonvoiding-related postoperative phone calls or clinic visits, with similar rates of urinary tract infection between the 2 groups.

Variation in bony landmarks and predictors of success with sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: We assessed variations in sacral anatomy and lead placement as predictors of sacral neuromodulation (SNM) success. Based solely on bony landmarks, we also assessed the accuracy of the 9 and 2 protocol for locating S3. METHODS: This is a retrospective cohort study performed from October 2008 to December 2016 at the University of North Carolina at Chapel Hill. Fluoroscopic images were used to assess sacral anatomy and lead location. Success was defined as >50% symptom improvement after stage I and clinical response at most recent follow-up. RESULTS: Of 249 procedures, 209 were primary implants and 40 were revisions among 187 (89.5%) women and 22 (10.5%) men. Success rate was 83.3% for primary implants and 89.4% for revisions. Success was associated with shorter implant duration (21.3 ± 22.2 vs 33.6 ± 25.8 months), higher body mass index (30.3 ± 7.8 vs 27.6 ± 6.1 kg/m2), and straight vs curved lead (90.5% vs 80.5%) (all p = .05), but not with sacral anatomy or lead placement. In assessing the 9 and 2 protocol, mean distance from coccyx to S3 did not equal 9 cm: 7.4 ± 1.0 vs 7.2 ± 0.8 cm (p = .26), while mean distance from midline to S3 did equal 2 cm: 1.9 ± 0.4 vs 2.0 ± 0.7 cm (p = .37). CONCLUSIONS: Variations in sacral anatomy and lead placement did not predict SNM success. The 2-cm protocol was verified while the 9-cm protocol was not, although neither was predictive of success, which may obviate the need to mark bony landmarks prior to fluoroscopy.

Urinary incontinence and hydration: A population-based analysis.

AIMS: To determine if there is an association between urinary incontinence (UI) and an objective measure of hydration status in men and women in a nationwide, population-based sample. METHODS: We utilized data from the 2009 to 2010 and 2011 to 2012 National Health and Nutrition Examination Surveys (NHANES), cross sectional surveys of the US non-institutionalized population. Our primary outcome was moderate/severe UI measured using a validated scale. Our exposure of interest was hydration status. Urine osmolality ≥ 800 mOsm/kg defined dehydration versus adequate hydration (<800 mOsm/kg). We included men and women ≥ 20 years who had both UI and urine osmolality data. Using multivariable models, we controlled for age, race/ethnicity, BMI, chronic kidney disease, the interaction of age with osmolality, and hysterectomy (women only). RESULTS: Among the 11 482 total subjects, 9497 (83%-4882 men and 4615 women) had both UI and urine osmolality data. Compared to women, men were less likely to report UI (5.9% vs 18.9%; P < 0.001) and more likely to be dehydrated (33.4% vs 24.0%; P < 0.001). In bivariate analysis, men and women who were dehydrated had less UI than men with adequate hydration (men: 3.5% vs 7.6%; P < 0.001; women: 16.3% vs 20.0%; P = 0.02); however, dehydration was not associated with UI in men (OR 0.2, 95% CI 0.6-1.0) or in women (OR 0.8, 95% CI 0.4-1.5) in multivariable models. CONCLUSIONS: Hydration status as defined by urine osmolality was not associated with moderate to severe urinary incontinence in men or women.

Self-reported toileting behaviors in employed women: Are they associated with lower urinary tract symptoms?

AIMS: To describe toileting behaviors working women habitually use and investigate behaviors associated with lower urinary tract symptoms (LUTS), especially urinary urgency with or without leakage. METHODS: Non-pregnant female employees of a large academic medical center 18 years and over were eligible to complete an online survey about bladder health and toileting behaviors. RESULTS: One hundred eighty-two women participated in the survey. The majority were white (83.52%), married (52.49%), had ≥1 pregnancy (54.40%), and in excellent health (93.41%). The average age and body mass index were 47.28 ± 13.56 years and 27.92 ± 6.78, respectively. The sample was further sub-divided into two groups: urinary urgency (N = 119) or no urinary urgency symptoms (N = 51). Habitual toileting behaviors for these groups (N = 170) included: sitting to urinate at home (98.24%), emptying the bladder completely (88.82%), emptying the bladder before leaving home (80.00%), and sitting to urinate when away from home (68.82%). Logistic regression analysis showed age increased the odds of urinary urgency (aOR 1.06, 95%CI 1.02-1.09). Women who waited too long to urinate at work (aOR 7.85, 95%CI 1.57-39.24) and wore panty liners for urinary leakage (aOR 2.86, 95%CI 1.25-6.56) had greater odds of urinary urgency than women who did neither. CONCLUSIONS: Most habitual toileting behaviors were not associated with urinary urgency except waiting too long to urinate when at work. Logistic regression revealed significant relationships among health-related factors, personal characteristics, behaviors, and urinary urgency. LUTS in women is both a women's health and occupational health issue.

Microhematuria in Postmenopausal Women: Adherence to Guidelines in a Tertiary Care Setting.

PURPOSE: In 2012 the AUA (American Urological Association) released a revision of the asymptomatic microscopic hematuria guidelines. Our study objectives were to assess adherence to these guidelines and describe the prevalence of urinary tract malignancy in postmenopausal women at our institution. MATERIALS AND METHODS: This is a cross-sectional analysis of women older than 55 years evaluated at the Division of Urogynecology or Urology from August 2012 to August 2014 for a diagnosis of asymptomatic microscopic hematuria. Women who underwent evaluation for 3 or more red blood cells per high power field on microscopic urinalysis were considered to have true asymptomatic microscopic hematuria. Those evaluated after a dipstick test with blood who had fewer than 3 red blood cells per high power field on urinalysis or no urinalysis were considered positive dipstick. Demographics, laboratory values, imaging results and cystoscopy findings were extracted from electronic medical records. RESULTS: Our study population included 237 women with a mean ± SD age of 67.1 ± 8.3 years. In our overall population 169 of 237 women (71.3%) had true asymptomatic microscopic hematuria, 48 (20.3%) had a positive dipstick test and 20 (8.4%) underwent evaluation in the setting of urinary tract infection. We detected 3 urinary tract malignancies (1.4%). One kidney cancer was identified in a 56-year-old current smoker with a urine dipstick result of 1+ blood. Bladder cancer was detected in a 58-year old smoker with 6 red blood cells per high power field on urinalysis and in a 64-year-old nonsmoker with 42 red blood cells per high power field on urinalysis. CONCLUSIONS: In postmenopausal women evaluated for asymptomatic microscopic hematuria the overall prevalence of urinary tract malignancy was low at 1.4%. Of our population 28.7% underwent evaluation without meeting guideline criteria for asymptomatic microscopic hematuria. This demonstrates an opportunity to improve adherence to existing guidelines to provide high quality care and avoid unnecessary expensive testing.

Vaginal native tissue repair versus transvaginal mesh repair for apical prolapse: how utilizing different methods of analysis affects the estimated trade-off between reoperation for mesh exposure/erosion and reoperation for recurrent prolapse.

INTRODUCTION AND HYPOTHESIS: Informed decision-making about optimal surgical repair of apical prolapse with vaginal native tissue (NT) versus transvaginal mesh (TVM) requires understanding the balance between the potential "harm" of mesh-related complications and the potential "benefit" of reducing prolapse recurrence. Synthesis of data from observational studies is required and the current literature shows that the average follow-up for NT repair is significantly longer than for TVM repair. We examined this harm/benefit balance. We hypothesized that using different methods of analysis to incorporate follow-up time would affect the balance of outcomes. METHODS: We used a Markov state transition model to estimate the cumulative 24-month probabilities of reoperation for mesh exposure/erosion or for recurrent prolapse after either NT or TVM repair. We used four different analytic approaches to estimate probability distributions ranging from simple pooled proportions to a random effects meta-analysis using study-specific events per patient-time. RESULTS: As variability in follow-up time was accounted for better, the balance of outcomes became more uncertain. For TVM repair, the incremental ratio of number of operations for mesh exposure/erosion per single reoperation for recurrent prolapse prevented increased progressively from 1.4 to over 100 with more rigorous analysis methods. The most rigorous analysis showed a 70% probability that TVM would result in more operations for recurrent prolapse repair than NT. CONCLUSIONS: Based on the best available evidence, there is considerable uncertainty about the harm/benefit trade-off between NT and TVM for apical prolapse repair. Future studies should incorporate time-to-event analyses, with greater standardization of reporting, in order to better inform decision-making.

Preoperative Activity Level and Postoperative Pain After Pelvic Reconstructive Surgery.

IMPORTANCE: Higher preoperative activity level is associated with improved postoperative outcomes, but its impact on postoperative pain after urogynecologic surgery is unknown. OBJECTIVE: The aim of the study was to assess the relationship between preoperative activity level and postoperative pain. STUDY DESIGN: In this prospective cohort study, we evaluated women undergoing pelvic reconstructive surgery from April 2019 through September 2021. We used the Activity Assessment Survey (AAS) to create cohorts of high (AAS = 100) and low (AAS < 100) baseline activity (BA). Our primary outcome was postoperative pain scores. Our secondary outcome was postoperative opioid use. RESULTS: Of 132 patients, 90 (68%) were in the low BA group and 42 (32%) were in the high BA group. The groups were similar in age (mean 59 ± 12 years for high BA vs 60 ± 12 for low BA, P = 0.70), body mass index, and surgical procedures performed; however, the high BA group had lower preoperative pain scores (2 ± 6 vs 11 ± 9, P ≤ 0.01). For the primary outcome, the high BA group reported lower postoperative pain scores (16 ± 8 vs 20 ± 9, P = 0.02) and less opioid use (19 ± 32 vs 52 ± 70 morphine milliequivalents, P = 0.01) than the low BA group. However, when adjusting for age, baseline pain, hysterectomy, baseline opioid use, and Charlson Comorbidity Index, high BA did not remain associated with lower postoperative pain scores and less opioid use. CONCLUSION: A higher preoperative activity level among patients undergoing urogynecologic surgery was not associated with lower pain scores nor decreased opioid use.

Postoperative Urinary Retention.

ABSTRACT: This clinical consensus statement on the management of postoperative (<6 weeks) urinary retention (POUR) reflects statements drafted by content experts from the American Urogynecologic Society's POUR writing group. The writing group used a modified Delphi process to evaluate statements developed from a structured literature search and assessed for consensus. After the definition of POUR was established, a total of 37 statements were assessed in the following 6 categories: (1) incidence of POUR, (2) medications, (3) patient factors, (4) surgical factors, (5) urodynamic testing, and (6) voiding trials. Of the 37 original statements, 34 reached consensus and 3 were omitted.

Performance of Perioperative Tasks for Women Undergoing Anti-incontinence Surgery: Developed by the AUGS Quality Improvement and Outcomes Research Network.

OBJECTIVES: Surgery for the correction of stress urinary incontinence is an elective procedure that can have a dramatic and positive impact on quality of life. Anti-incontinence procedures, like inguinal hernia repairs or cholecystectomies, can be classified as high-volume/low-morbidity procedures. The performance of a standard set of perioperative tasks has been suggested as one way to optimize quality of care in elective high-volume/low-morbidity procedures. Our primary objective was to evaluate the performance of 5 perioperative tasks-(1) offering nonsurgical treatment, (2) performance of a standard preoperative prolapse examination, (3) cough stress test, (4) postvoid residual test, and (5) intraoperative cystoscopy for women undergoing surgery for stress urinary incontinence-compared among surgeons with and without board certification in female pelvic medicine and reconstructive surgery (FPMRS). STUDY DESIGN: This study was a retrospective chart review of anti-incontinence surgical procedures performed between 2011 and 2013 at 9 health systems. Cases were reviewed for surgical volume, adverse outcomes, and the performance of 5 perioperative tasks and compared between surgeons with and without FPMRS certification. RESULTS: Non-FPMRS surgeons performed fewer anti-incontinence procedures than FPMRS-certified surgeons. Female pelvic medicine and reconstructive surgery surgeons were more likely to perform all 5 perioperative tasks compared with non-FPMRS surgeons. After propensity matching, FPMRS surgeons had fewer patients readmitted within 30 days of surgery compared with non-FPMRS surgeons. CONCLUSIONS: Female pelvic medicine and reconstructive surgery surgeons performed higher volumes of anti-incontinence procedures, were more likely to document the performance of the 5 perioperative tasks, and were less likely to have their patients readmitted within 30 days.

Randomized Clinical Trial of Gabapentin Versus Placebo for Pain After Sacrospinous Ligament Fixation.

OBJECTIVES: Given the risk of postoperative pain and specifically neuropathic gluteal pain after a sacrospinous ligament suspension, we conducted a randomized trial to compare a 2-week course of gabapentin versus placebo on postoperative pain after a sacrospinous ligament fixation. METHODS: This double-blinded, randomized, placebo-controlled trial compared 2 weeks of gabapentin (300 mg nightly for 3 days and then 300 mg twice a day for 11 days) versus identical-appearing placebo after a sacrospinous ligament fixation procedure. The primary outcome was participant-reported average pain during normal activity in the past 24 hours (score 0-10 on the validated Surgical Pain Scale) assessed on postoperative day (POD) 7. We also assessed average pain at rest and gluteal (buttocks) pain (score 0-10). We needed 17 participants per group to detect a 2.5-point difference in Surgical Pain Scale score with an SD of 2.6 (α = 0.05; power, 80%). RESULTS: The final intention-to-treat analysis compared 19 (49%) in the gabapentin group versus 20 (51%) in the placebo group. Between the gabapentin and placebo groups, average pain (2.0 ± 2.0 vs 3.4 ± 2.8, P = 0.09, respectively) and gluteal pain (2.1 ± 2.0 vs 3.4 ± 2.4, P = 0.09) during normal activity on POD 7 were not significantly different. However, average pain at rest on POD 7 was lower with gabapentin (1.6 ± 1.5 vs 3.2 ± 2.6, P = 0.04). CONCLUSIONS: Although a 2-week course of gabapentin did not significantly decrease overall pain with normal activity after a sacrospinous ligament fixation procedure, pain at rest was lower with gabapentin compared with placebo.

Length of Stay and 30-Day Postoperative Complications Following Minimally Invasive Apical Prolapse Repair.

IMPORTANCE: Data on the correlation between length of stay and postoperative complications following urogynecologic surgery are limited. OBJECTIVES: The objective of this study was to use a nationwide database to examine the correlation between length of stay and 30-day postoperative complications following minimally invasive apical prolapse repair. STUDY DESIGN: This retrospective cohort study included women in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2018 who underwent laparoscopic/robotic sacrocolpopexy or uterosacral/sacrospinous repair and were discharged on postoperative day 0 (POD0) or 1 (POD1). The primary outcome was 30-day postoperative complication rate. RESULTS: Of the 28,269 women discharged home on POD0/1, 12,663 (45%) underwent laparoscopic/robotic sacrocolpopexy, and 15,606 (55%) underwent uterosacral/sacrospinous repair. Women discharged on POD0 were less likely to be White, less likely to have diabetes or hypertension, had lower mean body mass index, and were less likely to have undergone a hysterectomy ( P < 0.05 for all). Within 30 days of surgery, 7% had a postoperative complication, and 3% had a major complication. Women discharged on POD0 had a lower risk of any complication or any major complication. The most common complication, urinary tract infection, was lower in women discharged on POD0 (3% vs 4%, P < 0.01). Women discharged home on the same day had a higher risk of superficial surgical site infection after undergoing laparoscopic/robotic sacrocolpopexy (1.3% vs 0.5%, P < 0.01) and a higher risk of myocardial infarction/cardiac arrest after uterosacral/sacrospinous repair (0.2% vs 0%, P < 0.04). CONCLUSIONS: In women undergoing minimally invasive reconstructive apical repair, discharge on POD0 is correlated with similar or better (lower) 30-day postoperative complication rates compared with women discharged on POD1.

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.

A Randomized Clinical Trial Comparing the Efficacy and Safety of 2% Versus 4% Chlorohexidine Gluconate for Surgical Preparation of the Vagina.

IMPORTANCE: There have been no studies comparing 2% and 4% chlorhexidine gluconate (CHX) for vaginal surgical site preparation despite both commonly being used. OBJECTIVES: The primary objective was to assess the noninferiority of 2% CHX versus 4% CHX to reduce bacterial contamination rates at 60 minutes after surgical preparation of the vagina. Secondary objectives were to assess differences in colony-forming units and the sensation of postoperative vaginal burning and pain. STUDY DESIGN: This is a single-blinded randomized controlled trial of women who underwent vaginal prolapse surgery. Study participants were randomized into 2 groups: 2% CHX versus 4% CHX. Two vaginal bacterial cultures were collected: (1) preoperatively before vaginal preparation and (2) intraoperatively at 60 minutes. A questionnaire on vaginal pain and burning was administered preoperatively and postoperatively. For our sample size, assuming that 2% CHX would have double the contamination rate of 4% CHX, 26 participants were needed per group to demonstrate noninferiority. RESULTS: Sixty-one women participated in the study. There were no differences in baseline demographics, length of surgery, or surgical procedures. For our primary outcome, the postpreparation contamination rates were 7% for 2% CHX versus 10% for 4% CHX, with a difference of 3% ( P = 0.52). This difference did meet the criteria for noninferiority. Secondary outcomes were not different between groups. CONCLUSIONS: Two percent CHX is noninferior to 4% CHX in reducing vaginal bacterial contamination at 60 minutes after vaginal surgical site preparation, with low rates of postpreparation contamination and vaginal discomfort.

Examining Age and Postoperative Opioid Use in the Urogynecology Population: A Prospective Study.

IMPORTANCE: Surgeons must individualize postoperative pain management while also reducing the amount of unused prescribed opioids. OBJECTIVES: This study compared postoperative opioid use in younger versus older women following urogynecologic surgery. We also assessed the likelihood of women returning unused opioids for safe disposal. STUDY DESIGN: This was a prospective study of women undergoing pelvic reconstructive surgery divided into 2 cohorts: younger (<65 years) and older (≥65 years). Our primary outcome was total opioid use, measured in morphine milligram equivalents (MME). We also assessed the average pain score during the first week after surgery measured by a numerical pain scale (range, 0-10). Our secondary outcome was the rate of return of unused prescribed opioids at the 6-week postoperative visit utilizing a disposable drug deactivation system. RESULTS: From April 2019 to September 2021, 152 participants were enrolled: 92 (61%) in the younger cohort (mean age, 51 ± 8 years) and 60 (39%) in the older cohort (mean age, 72 ± 6 years). For our primary outcome, younger women used significantly more opioids during the first postoperative week compared with older women (49 ± 71 vs 28 ± 40 MME, respectively, P = 0.04), despite no difference in average pain scores (4 ± 2 younger vs 3 ± 2 older, P = 0.05). For our secondary outcome, 23% of participants returned their opioids for disposal with the drug deactivation system. CONCLUSIONS: Younger women had higher postoperative opioid use despite similar pain scores after urogynecologic surgery. Among those prescribed opioids, a quarter of participants returned their opioids for disposal at their postoperative visit.

The American Urogynecologic Society Action Plan on Diversity, Equity, and Inclusion: Developed by the Diversity, Equity, and Inclusion Task Force.

ABSTRACT: The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVE: This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. METHODS: A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. RESULTS: A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. CONCLUSIONS: For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.