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PURPOSE: Our objective was to investigate structural changes in brain white matter tracts using diffusion tensor imaging (DTI) in patients with overactive bladder (OAB). MATERIALS AND METHODS: Treatment-seeking OAB patients and matched controls enrolled in the cross-sectional case-control LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) Neuroimaging Study received a brain DTI scan. Microstructural integrity of brain white matter was assessed using fractional anisotropy (FA) and mean diffusivity. OAB and urgency urinary incontinence (UUI) symptoms were assessed using the OAB Questionnaire Short-Form and International Consultation on Incontinence Questionnaire-Urinary Incontinence. The Lower Urinary Tract Symptoms Tool UUI questions and responses were correlated with FA values. RESULTS: Among 221 participants with evaluable DTI data, 146 had OAB (66 urinary urgency-only without UUI, 80 with UUI); 75 were controls. Compared with controls, participants with OAB showed decreased FA and increased mean diffusivity, representing greater microstructural abnormalities of brain white matter tracts among OAB participants. These abnormalities occurred in the corpus callosum, bilateral anterior thalamic radiation and superior longitudinal fasciculus tracts, and bilateral insula and parahippocampal region. Among participants with OAB, higher OAB Questionnaire Short-Form scores were associated with decreased FA in the left inferior fronto-occipital fasciculus, P < .0001. DTI differences between OAB and controls were driven by the urinary urgency-only (OAB-dry) but not the UUI (OAB-wet) subgroup. CONCLUSIONS: Abnormalities in microstructural integrity in specific brain white matter tracts were more frequent in OAB patients. More severe OAB symptoms were correlated with greater degree of microstructural abnormalities in brain white matter tracts in patients with OAB. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02485808.
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Imagem de Tensor de Difusão , Bexiga Urinária Hiperativa , Substância Branca , Humanos , Estudos Transversais , Bexiga Urinária Hiperativa/diagnóstico por imagem , Bexiga Urinária Hiperativa/patologia , Substância Branca/diagnóstico por imagem , Substância Branca/patologia , Feminino , Estudos de Casos e Controles , Masculino , Pessoa de Meia-Idade , Idoso , Sintomas do Trato Urinário Inferior/etiologia , Sintomas do Trato Urinário Inferior/diagnóstico por imagem , AdultoRESUMO
INTRODUCTION AND HYPOTHESIS: In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM). METHODS: We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy. RESULTS: IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness. CONCLUSION: While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.
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Parto Obstétrico , Trabalho de Parto Induzido , Gravidez , Lactente , Feminino , Humanos , Peso ao Nascer , Parto , Técnicas de Apoio para a DecisãoRESUMO
INTRODUCTION AND HYPOTHESIS: We compared postoperative complications in elderly patients discharged on POD#0 versus POD#1 after prolapse repair. METHODS: Data were obtained from the National Surgical Quality Improvement database. A total of 20,984 women 65 years and older who underwent prolapse repair between 2014 and 2020 were analyzed. Patient demographics, comorbidities, readmission, reoperation, and 30-day postoperative complications were compared in patients discharged on POD#0 versus POD#1. A sensitivity analysis was completed to examine outcomes in patients who underwent an apical prolapse repair. Multivariate logistic regression was performed to evaluate for potential confounders. RESULTS: Age, race, ethnicity, American Society of Anesthesiologists class, prolapse repair type, and operative time were significantly different in patients discharged on POD#0 vs POD#1 (all p < 0.01). Patients discharged on POD#0 had significantly fewer postoperative complications (2.63% vs 3.44%) and readmissions (1.56% vs 2.18%, all p < 0.01). On multivariate regression modeling, postoperative discharge day was independently associated with complications, but not with readmissions or reoperation after. Patients who underwent an apical prolapse repair and were discharged on POD#0 had significantly more postoperative complications (3.5% vs 2.5%, p = 0.02) and readmissions (2.42% vs 10.08%, p < 0.01) than those discharged on POD#1. In this group, multivariate regression modeling demonstrated that postoperative discharge day was independently associated with any postoperative complication. CONCLUSIONS: For elderly women undergoing prolapse repair, the type of surgery should be considered when determining postoperative admission versus same-day discharge. Admission overnight does not seem to benefit women undergoing vaginal repairs but may decrease overall morbidity and risk of readmission in women undergoing an apical prolapse repair.
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Alta do Paciente , Readmissão do Paciente , Prolapso de Órgão Pélvico , Complicações Pós-Operatórias , Humanos , Idoso , Feminino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Alta do Paciente/estatística & dados numéricos , Prolapso de Órgão Pélvico/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Idoso de 80 Anos ou mais , Reoperação/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Estudos RetrospectivosRESUMO
INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy (SCP) is the gold standard surgical management of apical pelvic organ prolapse (POP), and increasingly, minimally invasive SCP is being adopted as a primary treatment for advanced uterovaginal prolapse. Patients undergoing surgery for POP consider postoperative improvement in sexual function to be a highly important outcome, and sexual dysfunction and dyspareunia severe adverse events. Therefore, it is crucial to understand the impact of minimally invasive SCP on postoperative sexual function. We aimed to analyze the current literature available to discuss the impact of minimally invasive SCP on postoperative sexual function. METHODS: We performed a narrative review of minimally invasive SCP and its impact on sexual function. PubMed and EMBASE were searched from inception through 28 January 2024 for studies that reported sexual function following surgery for POP. Baseline and postoperative sexual activity, dyspareunia, and validated questionnaire scores for sexual function were documented. RESULTS: Minimally invasive SCP is associated with improved postoperative sexual function, increased rates of postoperative sexual activity, and low rates of dyspareunia. Dyspareunia was not associated with mesh related complications. Patients with baseline dyspareunia or pain were more likely to experience persistent dyspareunia after surgery. CONCLUSION: The rates of POP are increasing in our aging population, and sexual function is very important to patients undergoing surgery for POP. Clinicians should consider all factors related to sexual function when planning surgery for POP and address dyspareunia prior to surgery. Sexual function appears to improve overall after minimally invasive SCP and de novo dyspareunia rates are low.
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INTRODUCTION AND HYPOTHESIS: The objective was to describe long-term device-related reoperations at 8 years following sacral neuromodulation (SNM) in women older than 65 years for the indications of overactive bladder (OAB), fecal incontinence (FI), and/or idiopathic urinary retention (UR). METHODS: The 2010-2019 Medicare 100% Outpatient Limited Dataset was used to identify women aged 65 years and older who underwent SNM to treat OAB, FI, and/or UR. The primary study outcome was any device-related reoperation within 8 years following initial implantable pulse generator (IPG) implantation defined as: IPG revision or removal; IPG replacement; or neuro-electrode revision or removal. Kaplan-Meier survival analysis was also performed to evaluate time to adverse event. RESULTS: The cohort included 32,454 women with a mean age of 74 years. The most common indication for SNM was OAB (71%) followed by UI and FI (13%) and FI only (8%). Staged SNM procedures were performed more frequently (60%) than percutaneous nerve evaluation/full implants. The overall rate of device-related reoperations was 24% over 8 years: 12% of patients underwent removal or revision of the neuro-electrode, 11% underwent removal or revision of the IPG, and 13% underwent replacement of the IPG. The mean follow-up was 3.9 ± 2.4 years. The cumulative incidence of any device-related reoperations was 9.4% at 1 year, 20% at 3 years, and 43% at 8 years. CONCLUSIONS: In the 8 years following SNM implantation, the rate of device-related reoperation among female Medicare beneficiaries was 43%, and staged implants were associated with a 17% lower likelihood of undergoing any device-related reoperations.
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INTRODUCTION AND HYPOTHESIS: The primary objective was to compare rates of mesh exposure in women undergoing minimally invasive sacrocolpopexy with concurrent supracervical vs total hysterectomy. We hypothesized there would be a lower risk of mesh exposure for supracervical hysterectomy. METHODS: This was a retrospective cohort study using the Premier Healthcare Database. Women undergoing sacrocolpopexy with supracervical or total hysterectomy between 2010 and 2018 were identified using Current Procedural (CPT) codes. Complications were identified using CPT and diagnosis codes; reoperations were identified using CPT codes. Mesh exposures were measured over a 2-year period. A multivariable logistic regression was performed with a priori defined predictors of mesh exposure. RESULTS: This study includes 17,111 women who underwent minimally invasive sacrocolpopexy with concomitant supracervical or total hysterectomy (6708 (39%) vs 10,403 (61%)). Women who underwent supracervical hysterectomy were older (age 60 ± 11 vs 53 ± 13, p < 0.01) and less likely to be obese (4% vs 7%, p < 0.01). Postoperative mesh exposures within 2 years were similar (supracervical n = 47, 0.7% vs total n = 65, 0.62%, p = 0.61). On logistic regression, obesity significantly reduced the odds of mesh exposure (OR 0.2, 95% CI 0.01, 0.8); concomitant slings increased odds (OR 1.91, 95% CI 1.28, 2.83). Supracervical hysterectomy was associated with higher rates of port site hernias (1.3% vs 0.65%, p < 0.01), but lower surgical site infections within 3 months (0.81% vs 1.2%, p = 0.03). Reoperation for recurrent prolapse within 24 months was similar (supracervical n = 94, 1.4% vs total n = 150, 1.4%, p = 0.88). CONCLUSIONS: Postoperative mesh exposure rates do not significantly differ based on type of concomitant hysterectomy in this dataset.
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Laparoscopia , Prolapso de Órgão Pélvico , Feminino , Humanos , Pessoa de Meia-Idade , Idoso , Vagina/cirurgia , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , Prolapso de Órgão Pélvico/cirurgia , Prolapso de Órgão Pélvico/complicações , Laparoscopia/efeitos adversos , Resultado do Tratamento , Histerectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
INTRODUCTION AND HYPOTHESIS: The objective was to assess long-term mesh complications following total hysterectomy and sacrocolpopexy. METHODS: In this second extension study, women from a multicenter randomized trial were followed for more than 36 months after surgery. Owing to COVID-19, participants were assessed through either in-person visits or telephone questionnaires. The primary outcome was the incidence of permanent suture or mesh exposure. Secondary outcomes included surgical success and late adverse outcomes. RESULTS: Out of the 200 initially enrolled participants, 82 women took part in this second extension study. Among them, 46 were in the permanent suture group, and 36 in the delayed absorbable group. The mean follow-up duration was 5.3 years, with the cumulative mesh or suture exposure of 9.9%, involving 18 cases, of which 4 were incident cases. Surgical success after more than 5 years stood at 95%, with few experiencing bothersome bulge symptoms or requiring retreatment. No serious adverse events occurred, including mesh erosion into the bladder or bowel. The most common adverse events were vaginal pain, bleeding, dyspareunia, and stress urinary incontinence, with no significant differences between suture types. CONCLUSION: The study found that mesh exposure risk gradually increased over time, reaching nearly 10% after more than 5 years post-surgery, regardless of suture type. However, surgical success remained high, and no delayed serious adverse events were reported.
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Histerectomia , Prolapso de Órgão Pélvico , Complicações Pós-Operatórias , Telas Cirúrgicas , Humanos , Feminino , Telas Cirúrgicas/efeitos adversos , Pessoa de Meia-Idade , Histerectomia/efeitos adversos , Idoso , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Seguimentos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/métodos , Suturas/efeitos adversosRESUMO
BACKGROUND: It is well known that, in general, total laparoscopic hysterectomy is associated with less perioperative morbidity compared with total abdominal hysterectomy. However, total laparoscopic hysterectomy is also associated with longer operating times, which itself is an independent predictor of morbidity. Currently, it is unknown whether there is an operative time threshold beyond which total laparoscopic hysterectomy provides a diminishing return and higher risk of morbidity than a shorter abdominal hysterectomy. OBJECTIVE: This study aimed to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy diminished compared with shorter total abdominal hysterectomy. STUDY DESIGN: Targeted hysterectomy-specific data from the National Surgical Quality Improvement Project was used to identify patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years 2014 and 2018. The primary outcomes of interest were any major morbidity, and the length of stay after surgery was analyzed using generalized linear models. The models controlled for demographic data, comorbidities, and hysterectomy-specific information, such as uterine weight, presence of endometriosis, and pelvic inflammatory disease at the time of surgery. Missing data were addressed using multiple imputation analysis. Sensitivity analyses using propensity score matching and generalized additive models were performed to assess the effect of selection bias and nonlinear interactions between covariates and the outcomes, respectively. Common Procedural Terminology codes were used to identify women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570-58,573). Conventional laparoscopy could not be differentiated from robotic surgery as there is no mechanism for doing so within the National Surgical Quality Improvement Project. Therefore, total laparoscopic hysterectomy also includes robotic-assisted surgery. Additional exclusion criteria included any surgery lasting >360 minutes, as these represent significant outliers in the data and clinical practice; pelvic reconstructive procedure; anti-incontinence surgery; lymphadenectomy; radical hysterectomy; cytoreductive surgery; a pre- or postoperative diagnostic code for gynecologic malignancy; preoperative sepsis or renal failure; emergency surgery; or any concurrent nongynecologic surgery. Patients who underwent ureteral stenting during the procedure with no additional urologic procedures were included, as this may be performed at the time of hysterectomy or to address ureteral injury. RESULTS: The mean operating time was similar for both routes, 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy (P=.45). The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (16.6% vs 7.7%; P<.001); and the median length of stay was longer for total abdominal hysterectomy (2 [interquartile range, 2-3] days vs 1 [interquartile range, 0-1] days; P<.001). After adjusting for confounders, an increase of 1 hour in operative time for hysterectomy was associated with a 45% (95% confidence interval, 41%-49%) increase in the risk of major morbidity; furthermore, total abdominal hysterectomy was associated with an additional time detriment, such that there was an additional 61% (95% confidence interval, 53%-68%) increase in the risk of a major morbidity for each additional hour of a total abdominal hysterectomy. There was no time point at which total abdominal hysterectomy was associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy, even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy. The same conclusions remained true with the propensity-matched analysis and generalized additive model analyses. CONCLUSION: Our findings showed that there is no reasonable operative time at which total laparoscopic hysterectomy is associated with a higher rate of complications or longer length of stay than total abdominal hysterectomy.
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Laparoscopia , Procedimentos Cirúrgicos Robóticos , Feminino , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Duração da Cirurgia , Histerectomia/métodos , Útero/patologia , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Estudos RetrospectivosRESUMO
OBJECTIVE: To identify the incidence and risk factors of gastrointestinal injury (GITI) related to pelvic organ prolapse (POP) surgery. METHODS: Women who underwent POP surgery between 2000 and 2020 were identified in the Premier Healthcare Database. The primary outcome was GITI, defined as small or large bowel injury or repair, and fistula or fistula repair. Differences between patients with and without GITI were evaluated, and a multivariable regression was performed to determine independent predictors of GITI. RESULTS: We identified 563,661 index POP surgeries in female patients aged 18 years and older. Of these, 4582 (0.8%) had a bowel injury code within 1 year of index POP surgery. Patients who experienced GITI were more likely to be younger (49.9 ± 12.8 vs 50.9 ± 13.7), and receive surgery with a surgeon who performed less than 12 surgeries per year (48% vs 42%). Most GITI was diagnosed in the same month (73.4%) and same hospital encounter (54%) as index POP surgery. After adjusting for confounders, lysis of adhesions (aOR = 2.03, 95% CI: 1.48-2.72) and perioperative hematoma/hemorrhage (aOR = 2.87, 95%C I: 1.70-4.59) were strongly associated with GITI, while having surgery with a surgeon performing > 50 POP surgeries per year (aOR = 0.66, 95%C I: 0.59-0.75 and concomitant obliterative procedures (aOR = 0.48, 95% CI: 0.34-0.65) were associated with a lower probability of GITI. CONCLUSIONS: The rate of GITI after POP surgery is less than 1%, and injuries are commonly diagnosed and treated in the same month as index surgery. High-volume surgeons and obliterative procedures may be protective against GITI.
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Prolapso de Órgão Pélvico , Feminino , Humanos , Prolapso de Órgão Pélvico/epidemiologia , Prolapso de Órgão Pélvico/cirurgia , Trato Gastrointestinal , Aderências Teciduais , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Symptomatic pelvic organ prolapse is common and affects 25% to 35% of women worldwide. As this growing patient need is being met by surgeons from diverse training backgrounds, it is important to both characterize the differences in surgeon practice patterns and examine postoperative outcomes to ensure optimal patient care. OBJECTIVE: To determine the association between surgeon specialty and postoperative outcomes following surgery for pelvic organ prolapse. STUDY DESIGN: This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Gynecologic reconstructive surgery targeted database between 2014 and 2018. Pelvic organ prolapse surgeries were identified using Current Procedural Terminology codes, and surgical cases performed by urogynecologists or obstetrician-gynecologists were included for analysis. The primary outcome was any 30-day postoperative complication following prolapse surgery. The secondary outcomes were any major or minor postoperative complications, genitourinary complications, reoperation, or readmission within 30-days following surgery. Descriptive statistics were used to characterize the cohort, and pairwise analyses were used to describe the differences between the cases performed by the surgeon specialties. Multivariable logistic regression was used to control for potential confounders. RESULTS: A total of 3358 women underwent prolapse surgery-68% performed by urogynecologists and 32% by obstetrician-gynecologists. The 30-day postoperative complication rate was higher for surgeries performed by obstetrician-gynecologists than for surgeries performed by urogynecologists (10.7% vs 7.0%, respectively; P<.001). There was no difference in the readmission rates between the 2 groups (2.1% vs 2.0%; P=1.000). However, the reoperation rates were higher for surgeries performed by obstetrician-gynecologists (1.8% vs 1.0%; P=.040). In a multivariable logistic regression model controlling for age, body mass index, American Society of Anesthesiology class, smoking, and type of concomitant surgery (hysterectomy, apical suspension, other prolapse surgery, obliterative procedure, or sling), prolapse surgery performed by a urogynecologist remained associated with nearly 40% lower odds of any 30-day postoperative complication (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80). CONCLUSION: Prolapse surgery performed by a urogynecologist is associated with lower odds of any 30-day postoperative complication than that performed by an obstetrician-gynecologist.
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Prolapso de Órgão Pélvico , Cirurgiões , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Prophylactic midurethral sling placement at the time of prolapse repair significantly reduces the risk for de novo stress urinary incontinence, but it is associated with some small but significant morbidities. Because there has not been a standardized approach to midurethral sling utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying midurethral sling placement strategies in addressing the risk for de novo stress urinary incontinence. OBJECTIVE: We aimed to compare the cost effectiveness of the 3 midurethral sling utilization strategies in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. The 3 approaches are (1) staged strategy in which prolapse repair is done without prophylactic midurethral sling placement, (2) universal sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement, and (3) selective sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement only in patients with a positive prolapse-reduced cough stress test. STUDY DESIGN: We created a decision analysis model to compare staged strategy, universal sling placement, and selective sling placement. We modeled probabilities of de novo stress urinary incontinence, patients choosing subsequent midurethral sling surgery for de novo stress urinary incontinence, and outcomes related to midurethral sling placement. De novo stress urinary incontinence rates were determined for each strategy from published data. The likelihood of patients with de novo stress urinary incontinence choosing midurethral sling surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic midurethral sling placement at their index prolapse repair. Finally, outcomes related to midurethral sling placement, including recurrent or persistent stress urinary incontinence, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications, were all derived from publicly available data. All midurethral sling placement procedures were assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or from previous literature with convertion to 2020 equivalent US dollar prices using the Consumer Price Index. The primary outcome was modeled as the incremental cost-effectiveness ratio. We performed multiple 1-way sensitivity analyses to assess model robustness. RESULTS: The lowest-cost strategy was the staged strategy, which cost $1051.70 per patient, followed by $1093.75 for selective sling placement and $1125.54 for universal sling placement. The selective sling approach, however, had the highest health utility value; therefore, universal sling placement was dominated by selective sling placement because it is both less costly and more effective. When compared with the staged strategy, selective sling placement was cost effective with an incremental cost-effectiveness ratio of $2664 per quality adjusted life-years, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent midurethral sling surgery for de novo stress urinary incontinence after the index surgery. Only when this proportion exceeded 62% did universal sling placement become the cost-effective option because selective sling placement surpassed the predetermined incremental cost-effectiveness ratio threshold and became dominated. CONCLUSION: Selective sling placement was the preferred and cost-effective strategy in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo stress urinary incontinence after prolapse repair, as well as on the benefits and risks of prophylactic midurethral sling placement surgery.
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Prolapso de Órgão Pélvico , Slings Suburetrais , Incontinência Urinária por Estresse , Prolapso Uterino , Idoso , Análise Custo-Benefício , Feminino , Humanos , Medicare , Prolapso de Órgão Pélvico/complicações , Prolapso de Órgão Pélvico/cirurgia , Slings Suburetrais/efeitos adversos , Estados Unidos , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/prevenção & controle , Incontinência Urinária por Estresse/cirurgia , Prolapso Uterino/complicações , Prolapso Uterino/cirurgiaRESUMO
INTRODUCTION AND HYPOTHESIS: Although vaginal hysterectomy(VH) is traditionally considered the safest route of hysterectomy, newer data suggest that laparoscopic hysterectomy (LH) might have lower risks of perioperative complications in contemporary practice. Using a large surgical database, we aimed to assess the hypothesis that there are no significant differences in rates of major and minor complications between LH and VH when performed with pelvic reconstructive surgery, controlling for the number and type of pelvic reconstructive procedures. METHODS: A total of 27,941 eligible LH and VH from the 2010-2018 National Surgical Quality Improvement Program database were identified. Concomitant pelvic reconstructive surgery was defined as either an apical suspension, enterocele repair, or colporrhaphy. Laparoscopy-assisted VH, gynecological malignancy, and concomitant nongynecological procedures were excluded. Complications within 30 days of surgery were grouped into major (Clavien-Dindo grade ≥3) or minor (grade 1-2) classifications. Bivariate analysis and inverse propensity-weighted logistic regression compared the outcomes of the VH and LH groups. Cochran-Armitage tests and multivariate regression assessed changes over time. RESULTS: The majority of hysterectomies (72%) were vaginal, although its utilization declined from 89% in 2010 to 64% in 2018 (p < 0.001). In multivariate analysis controlling for patient factors and the type and number of concomitant pelvic reconstructive procedures, LH was associated with a lower odds of major (adjusted odds ratio [aOR] 0.711, 95% confidence interval [CI]:0.639-0.791) and minor (aOR 0.659, 95% CI: 0.612-0.710) complications. CONCLUSIONS: Relative safety profiles should be considered among other patient factors when counseling women undergoing surgical prolapse repair. Our findings suggest that laparoscopic approaches can be safely utilized among older and sicker patients traditionally counseled toward a vaginal approach.
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Laparoscopia , Prolapso de Órgão Pélvico , Procedimentos de Cirurgia Plástica , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia/métodos , Histerectomia Vaginal/efeitos adversos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Estudos RetrospectivosRESUMO
INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the association of same-day discharge and outcomes following minimally invasive surgery for pelvic organ prolapse (POP). METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, we identified women undergoing POP surgery between 2014 and 2018 who were discharged on the day of surgery (same-day) or on postoperative day 1 (POD1). Patient and procedural characteristics, and 30-day outcomes including readmission, reoperation, and postoperative complications, were abstracted. Multivariate logistic regression was used to determine the association of day of discharge and complications, readmission, and reoperation while controlling for potential confounders. RESULTS: A total of 33,614 patients met the inclusion criteria: 20% patients were discharged on the same day, whereas 80% were discharged POD1. The mean ± SD age for the cohort was 61 ± 12 years, with a median (IQR) body mass index (BMI) of 28 (25-32) kg/m2. The overall postoperative complication rate was 5.4%. Patients discharged on the same day had lower rates of complications (4.8% vs 5.5%, p = 0.02) and lower rates of readmission (1.6% vs 2.0%, p = 0.03) compared with those discharged on POD1. No difference in reoperation rates (0.9% vs 1.1%, p = 0.31) were noted between groups. In multivariate logistic regression models controlling for age, race, BMI, ASA class, smoking, procedure type, and operative time, day of discharge was not associated with increased odds of postoperative complications (same-day discharge: aOR 1.00, 95% CI 0.88-1.14), reoperation (aOR 0.83, 95%CI 0.61-1.12), or readmission (aOR 0.93, 95%CI 0.74-1.16). CONCLUSIONS: Same-day discharge did not impact the rate of adverse events after minimally invasive prolapse surgery.
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Alta do Paciente , Prolapso de Órgão Pélvico , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Readmissão do Paciente , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos RetrospectivosRESUMO
INTRODUCTION AND HYPOTHESIS: To describe complications at the time of surgery, 90-day readmission and 1-year reoperation rates after minimally invasive pelvic organ prolapse (POP) in women > 65 years of age in the US using Medicare 5% Limited Data Set (LDS) Files. METHODS: Medicare is a federally funded insurance program in the US for individuals 65 and older. Currently, 98% of individuals over the age of 65 in the US are covered by Medicare. We identified women undergoing minimally invasive POP surgery, defined as laparoscopic or vaginal surgery, in the inpatient and outpatient settings from 2011-2017. Patient and surgical characteristics as well as adverse events were abstracted. We used logistic regression for complications at index surgery and Cox proportional hazards regression models for time to readmission and time to reoperations. RESULTS: A total of 11,779 women met inclusion criteria. The mean age was 72 (SD ± 8) years; the majority were White (91%). Most procedures were vaginal (76%) and did not include hysterectomy (68%). The rate of complications was 12%; vaginal hysterectomy (aOR 2.4, 95% CI 2.2-2.7) was the factor most strongly associated with increased odds of complications. The 90-day readmission rate was 7.3%. The most common reason for readmission was infection (2.0%), three quarters of which were urinary tract infections. Medicaid eligibility (aHR 1.5, 95% CI 1.3-1.8) and concurrent sling procedures (aHR 1.2, 95% CI 1.04-1.4) were associated with a higher risk of 90-day readmission. The 1-year reoperation rate was 4.5%. The most common type of reoperation was a sling procedure (1.8%). Obliterative POP surgery (aHR 0.6, 95% CI 0.4-0.9) was associated with a lower risk of reoperation than other types of surgery. CONCLUSIONS: US women 65 years and older who are also eligible to receive Medicaid are at higher risk of 90-day readmission following minimally invasive surgery for POP with the most common reason for readmission being UTI.
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Prolapso de Órgão Pélvico , Complicações Pós-Operatórias , Idoso , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Histerectomia Vaginal , Medicare , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION AND HYPOTHESIS: The objective was to compare 30-day perioperative complications in women undergoing minimally invasive sacrocolpopexy with and without a concomitant hysterectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified women undergoing minimally invasive sacrocolpopexy between 2014 and 2018. Women were then stratified into two groups: sacrocolpopexy only and sacrocolpopexy + hysterectomy. The primary outcome was the occurrence of any 30-day postoperative complication. Group comparisons were performed using Student's t test, Mann-Whitney U test, and Chi-squared test. Multivariate logistic regression was used to identify independent factors associated with the occurrence of any complication. RESULTS: A total of 8,553 women underwent laparoscopic sacrocolpopexy, 5,123 (59.9%) of whom had a concomitant hysterectomy. Median operative time was longer in women who had sacrocolpopexy + hysterectomy compared with sacrocolpopexy alone (185 [129-241] versus 172 [130-224] min, p < 0.001). The rate of any 30-day postoperative complication did not differ between groups (sacrocolpopexy + hysterectomy 5.5% versus sacrocolpopexy alone 5.8%, p = 0.34). Likewise, organ space, deep, and superficial surgical site infections did not differ between groups. There was also no difference in reoperation or readmission rates between groups. On multivariate logistic regression, sacrocolpopexy + hysterectomy were not associated with increased odds of 30-day postoperative complications relative to women who underwent sacrocolpopexy alone. CONCLUSIONS: Complication rates during the first 30 days after minimally invasive sacrocolpopexy are low and concomitant hysterectomy is not associated with increased risks of 30-day complications after surgery.
Assuntos
Laparoscopia , Melhoria de Qualidade , Feminino , Humanos , Histerectomia/efeitos adversos , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
INTRODUCTION AND HYPOTHESIS: The study objective was to examine the impact of race on inpatient complications and costs after inpatient surgery for pelvic organ prolapse (POP). METHODS: In this retrospective cohort study, we identified women who underwent surgery for POP between 2012 and 2014. Patient demographics, outcomes, hospital characteristics, and hospital costs were extracted. Demographic and clinical characteristics were compared by race using Kruskal-Wallis for continuous variables and Chi-squared test for categorical variables. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs respectively. RESULTS: A total of 29,347 women with a median age of 62 years underwent inpatient surgery for POP between 2012 and 2014. There were 4,419 women (15%) who had at least one in-hospital postoperative complication. Rates of any postoperative complication were significantly higher among Black women (20%) than among white, Hispanic, and women of other races (16%, 11%, and 13% respectively, p < 0.01). The median total cost associated with surgeries for POP was $8,267 (IQR $6,008-$11,734). After multivariate analyses controlled for potential confounders, postoperative complications remained independently associated with Black race (aOR 1.21) whereas Hispanic and other races were associated with decreased odds of complications (aOR 0.62, and aOR 0.77) relative to white race. After controlling for confounders, Hispanic women had lower associated hospital costs. CONCLUSIONS: Black women undergoing inpatient surgery for POP had a 21% increase in the odds of complications, but no difference in costs compared with white women, whereas Hispanic women had the lowest odds of complications and lowest costs.
Assuntos
Prolapso de Órgão Pélvico , População Negra , Feminino , Hispânico ou Latino , Humanos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/complicações , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
INTRODUCTION AND HYPOTHESIS: There are few studies examining patient risk factors for postoperative complications following midurethral sling (MUS) placement for stress urinary incontinence (SUI). The objective of this study was to describe 30-day postoperative complications after MUS using the National Surgical Quality Improvement Program database. Secondary objectives included rates of readmission and patient factors associated with postoperative complications and readmissions following MUS. METHODS: We identified 16,491 women who underwent MUS for SUI between 2014 and 2018. American Society of Anesthesia (ASA) classification, medical comorbidities, readmission, reoperation, and 30-day postoperative complications were extracted. Outcomes included the 30-day postoperative complications, readmission, and reoperations. Descriptive statistics, univariate analyses, and multivariate logistic regression were used. RESULTS: The majority of patients were white (66.9%) and had an ASA classification II (60.9%). Postoperative complications occurred in 4.2% of patients; 1.5% required readmission and 1.0% required reoperation. The most common complication was urinary tract infection (3.4%). Using multivariate logistic regression, older age, i.e., ≥80 years of age, was associated with increased odds of complication (aOR 1.77, 95%CI 1.14-2.72) and readmission (aOR 3.84, 95%CI 1.76-8.66). ASA class III and IV were associated with increased odds of complications (aOR 1.55, 95%CI 1.13-2.14, and aOR 3.06, 95% CI 1.48-5.86 respectively) and readmissions. Women of Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander descent ("other") were associated with increased postoperative complications (aOR 1.51, 95%CI 1.07-2.07). CONCLUSION: Postoperative complications following MUS are rare. Factors associated with complications following MUS for SUI include age, ASA class, and women of "other" race.
Assuntos
Slings Suburetrais , Incontinência Urinária por Estresse , Feminino , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Melhoria de Qualidade , Reoperação , Estudos Retrospectivos , Slings Suburetrais/efeitos adversos , Incontinência Urinária por Estresse/etiologiaRESUMO
INTRODUCTION AND HYPOTHESIS: Our objective was to compare mesh exposure rates (4 months and 1 year) after total (TLH) vs supracervical (SLH) laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy (SCP). Secondary outcomes included 30-day complications and midurethral mesh exposure rates. METHODS: This a retrospective cohort study at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes. Demographics, operative characteristics, and perioperative complications were abstracted from medical records. RESULTS: Four hundred three women met the inclusion criteria: 91 SLH+SCP and 312 TLH+SCP. Median follow-up was 52 weeks with an overall mesh exposure rate of 1.5%. Follow-up was available for 90% of patients at 4 months and 51% at 1 year. Half of patients had lightweight mesh (n = 203), and half had ultralightweight mesh (n = 200). Vaginal mesh fixation was performed with permanent suture in 86% (n = 344) and delayed absorbable suture in 14% (n = 56) of patients. At 4 months, vaginal mesh exposure rates did not differ between groups (0% SLH vs 1% TLH, p = 1.00). All mesh exposures in the study period occurred with lightweight mesh in the TLH arm. No differences were noted in 1-year mesh exposure rates, 30-day perioperative complications (p = 0.57), or midurethral mesh exposure rates at 4 months (p = 0.35) and 1 year (p = 1.00) between groups. CONCLUSIONS: Short-term mesh exposure following SCP with ultralightweight and lightweight polypropylene mesh is rare regardless of type of hysterectomy and much lower than reported in earlier studies with heavier weight mesh. These data suggest TLH at the time of SCP is a safe option in appropriately counseled patients.
Assuntos
Laparoscopia , Prolapso de Órgão Pélvico , Telas Cirúrgicas , Feminino , Humanos , Histerectomia/efeitos adversos , Laparoscopia/efeitos adversos , Prolapso de Órgão Pélvico/complicações , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , Resultado do TratamentoRESUMO
STUDY OBJECTIVES: To describe changes in length of stay and same-day discharges (SDDs) after minimally invasive hysterectomy (MIH) over the last decade and forecast anticipated utilization over the subsequent decade. DESIGN: Cross-sectional analysis. SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: All benign MIH excluding joint cases with concomitant nongynecologic surgery in the 2011 to 2019 National Surgical Quality Improvement Program datasets, identified by Current Procedural Terminology code. INTERVENTIONS: A descriptive analysis of changes in the estimated length of stay and utilization of SDD from 2011 to 2019. Multivariable negative binomial regression assessed for individual-level risk factors for prolonged hospital stay and autoregressive linear forecasting estimated the growth of SDD through 2029. MEASUREMENTS AND MAIN RESULTS: A total of 239 220 MIH were identified. Over the 9-year period, SDD increased by 10.7% across all MIH. However, in 2019, SDD represented only 29.8% of total MIH discharges and utilization varied by surgical approach (laparoscopic hysterectomy, 35.4%; vaginal hysterectomy, 18.6%; laparoscopic-assisted vaginal hysterectomy, 19.6%) and a surgical indication of pelvic organ prolapse (32.7% without and 13.9% with prolapse). Multivariable models controlling for patient characteristics showed independent associations of route and indication for MIH and length of stay (adjusted relative rate, 1.30; 95% confidence interval [CI], 1.29-1.32 for vaginal hysterectomy, and adjusted relative rate, 1.12; 95% CI, 1.11-1.14 for prolapse); however, these individual-level factors provided limited information explaining variation in the length of stay (model pseudo-R2, 0.054). Forecasting models suggest that utilization of SDD will grow to 48.5% (95% CI, 38.7-58.4) by the end of 2029. CONCLUSION: Although the estimated length of stay is decreasing among MIH over time, the utilization of SDD remained low in 2019 and was not explained by patient factors. If current trends hold, SDD utilization is not forecast to exceed 50% through 2029. Additional efforts focused on the provider and institution level are needed to encourage SDD as the standard of care for MIH.
Assuntos
Laparoscopia , Prolapso de Órgão Pélvico , Estudos Transversais , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia Vaginal/efeitos adversos , Laparoscopia/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos , Alta do Paciente , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women. OBJECTIVE: This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience. STUDY DESIGN: A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time. RESULTS: A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications. CONCLUSION: This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.