Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery. METHODS: We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP). RESULTS: For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90. CONCLUSIONS: A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.

Procedure-specific simulation for vaginal surgery training: A randomized controlled trial.

INTRODUCTION: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS: gov: Registration no. NCT05887570. RESULTS: We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS: Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Association of infertility with type and timing of menopause: a prospective cohort study.

STUDY QUESTION: What is the association between past infertility and the type and timing of menopause in midlife women? SUMMARY ANSWER: Women with a history of infertility were more likely to experience surgical menopause overall and had elevated risk of earlier surgical menopause until age 43 years but experienced no differences in the timing of natural menopause. WHAT IS KNOWN ALREADY: Infertility is experienced by 12-25% of women and is thought to reveal a propensity for poor health outcomes, such as chronic illness, later in life. However, little is known about whether infertility is linked with characteristics of the menopausal transition as women age, despite possible shared underlying pathways involving ovarian function and gynecologic disease. STUDY DESIGN, SIZE, DURATION: Secondary analysis of a prospective cohort study of 13 243 midlife females recruited in Phase 1 of the Alberta's Tomorrow Project (Alberta, Canada) and followed approximately every 4 years (2000-2022). PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were collected through standardized self-report questionnaires. History of infertility, defined as ever trying to become pregnant for more than 1 year without conceiving, was measured at baseline. Menopause characteristics were measured at each study follow-up. Menopause type was defined as premenopause, natural menopause, surgical menopause (bilateral oophorectomy), or indeterminate menopause (premenopausal hysterectomy with ovarian conservation). Timing of natural menopause was defined as the age at 1 full year after the final menstrual period, and timing of surgical and indeterminate menopause was defined as the age at the time of surgery. We used flexible parametric survival analysis for the outcome of menopause timing with age as the underlying time scale and multinomial logistic regression for the outcome of menopause type. Multivariable models controlled for race/ethnicity, education, parity, previous pregnancy loss, and smoking. Sensitivity analyses additionally accounted for birth history, menopausal hormone therapy, body mass index, chronic medical conditions, and age at baseline. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, 18.2% of women reported a history of infertility. Past infertility was associated with earlier timing of surgical menopause exclusively before age 43 years (age 35: adjusted hazard ratio 3.13, 95% CI 1.95-5.02; age 40: adjusted hazard ratio 1.83, 95% CI 1.40-2.40; age 45: adjusted hazard ratio 1.13, 95% CI 0.87-1.46) as well as greater odds of experiencing surgical menopause compared to natural menopause (adjusted odds ratio 1.40, 95% CI 1.18-1.66). Infertility was not associated with the timing of natural or indeterminate menopause. LIMITATIONS, REASONS FOR CAUTION: Information on the underlying cause of infertility and related interventions was not collected, which precluded us from disentangling whether associations differed by infertility cause and treatment. Residual confounding is possible given that some covariates were measured at baseline and may not have temporally preceded infertility. WIDER IMPLICATIONS OF THE FINDINGS: Women with a history of infertility were more likely to experience early surgical menopause and may therefore benefit from preemptive screening and treatment for gynecologic diseases to reduce bilateral oophorectomy, where clinically appropriate, and its associated health risks in midlife. Moreover, the lack of association between infertility and timing of natural menopause adds to the emerging knowledge that diminishing ovarian reserve does not appear to be a primary biological mechanism of infertility nor its downstream implications for women's health. STUDY FUNDING/COMPETING INTEREST(S): Alberta's Tomorrow Project is only possible due to the commitment of its research participants, its staff and its funders: Alberta Health, Alberta Cancer Foundation, Canadian Partnership Against Cancer and Health Canada, and substantial in-kind funding from Alberta Health Services. The views expressed herein represent the views of the author(s) and not of Alberta's Tomorrow Project or any of its funders. This secondary analysis is funded by Project Grant Priority Funding in Women's Health Research from the Canadian Institutes of Health Research (Grant no. 491439). N.V.S. is supported by a Banting Postdoctoral Fellowship from the Canadian Institutes of Health Research. H.K.B. is supported by the Canada Research Chairs Program. E.A.B. is supported by an Early Career Investigator Award in Maternal, Reproductive, Child and Youth Health from the Canadian Institutes of Health Research. A.K.S. has received honoraria from Pfizer, Lupin, Bio-Syent, and Eisai and has received grant funding from Pfizer. N.V.S., H.K.B., and E.A.B. have no conflicts of interest to report. TRIAL REGISTRATION NUMBER: N/A.

Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study.

BACKGROUND: Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking. OBJECTIVE: This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years. STUDY DESIGN: This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group. RESULTS: Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group. CONCLUSION: Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.

Impact of lifetime lactation on the risk and duration of frequent vasomotor symptoms: A longitudinal dose-response analysis.

OBJECTIVE: To examine the association between lifetime lactation and risk and duration of frequent vasomotor symptoms (VMS). DESIGN: Prospective cohort. SETTING: USA, 1995-2008. SAMPLE: 2356 parous midlife women in the Study of Women's Health Across the Nation. METHODS: Lifetime lactation was defined as the duration of breastfeeding across all births in months. We used generalised estimating equations to analyse risk of frequent VMS and Cox regression to analyse duration of frequent VMS in years. MAIN OUTCOME MEASURES: Frequent VMS (hot flashes and night sweats) were measured annually for 10 years, defined as occurring ≥6 days in the past 2 weeks. RESULTS: Overall, 57.1% of women reported hot flashes and 43.0% reported night sweats during follow-up. Lifetime lactation was inversely associated with hot flashes plateauing at 12 months of breastfeeding (6 months: adjusted odds ratio [AOR] 0.85, 95% confidence interval (CI) 0.75-0.96; 12 months: AOR 0.78, 95% CI 0.65-0.93) and was inversely associated with night sweats in a downward linear fashion (6 months: AOR 0.93, 95% CI 0.81-1.08; 18 months: AOR 0.82, 95% CI 0.67-1.02; 30 months: AOR 0.73, 95% CI 0.56-0.97). Lifetime lactation was associated with shorter duration of hot flashes and night sweats in a quadratic (bell-shaped) fashion. The association was strongest at 12-18 months of breastfeeding and significant for hot flashes (6 months: adjusted hazard ratio [AHR] 1.35, 95% CI 1.11-1.65; 18 months: AHR 1.54, 95% CI 1.16-2.03; 30 months: AHR 1.18, 95% CI 0.83-1.68). CONCLUSIONS: Longer lifetime lactation is associated with decreased risk and duration of frequent VMS.

The impact of surgeon operative volume on risk of reoperation within 5 years of mid-urethral sling: a systematic review.

INTRODUCTION AND HYPOTHESIS: Undesired outcomes after mid-urethral sling (MUS), such as mesh exposure or surgical failure, can necessitate further procedures. The objective of this review is to evaluate the association between surgeon operative volume and the risk of reoperation after MUS. METHODS: Eligible studies were selected through an electronic literature search from database and references of the studies included. Databases were searched for original studies reporting on the MUS procedure, reoperation, and operative volume. Random effects models were used to estimate the pooled OR of reoperation according to surgeon volume. Outcomes were divided into two categories: mesh removal and/or revision and subsequent surgery for treatment of SUI. RESULTS: A total of 2,304 abstracts were screened, and 51 studies were assessed through full-text reading. Seven studies were included in the systematic review. High-volume and low-volume surgeons were defined differently in various studies. The odds ratio of the mesh removal/revision procedure was 1.26 (95%CI 1.03-1.53) among those who received their surgery from a low-volume surgeon compared with those who received their surgery from a high-volume surgeon as defined by the studies. The odds ratio of repeated incontinence procedures was 1.18 (95% CI 1.01-1.37). CONCLUSIONS: The odds of a repeat incontinence procedure appear higher if the surgery is performed by a low-volume surgeon, although these results need to be interpreted with caution as the definition of low-volume vs high-volume surgeon varied between studies. As such, operative volume should be included in surgical reporting, and future research should utilize surgical volume as either a continuous exposure or a standardized value of low- vs high-volume MUS surgeons.

Age and postoperative opioid use in women undergoing pelvic organ prolapse surgery.

INTRODUCTION: Our objective was to explore the relation between patient age and postoperative opioid use up to 24 hours following pelvic organ prolapse (POP) surgery. MATERIAL AND METHODS: We conducted a prospective cohort study following 335 women ranging in age from 26 to 82 years who underwent surgery for multi-compartment POP at a tertiary center in Alberta, Canada. Patient characteristics were measured using baseline questionnaires. Perioperative data were collected from medical chart review during and up to 24 hours following surgery. We used logistic regression to analyze the odds of being opioid-free and linear regression to analyze mean differences in opioid dose, measured as total morphine equivalent daily dose, exploring for a potential non-linear effect of age. Adjusted models controlled for preoperative pain, surgical characteristics and patient health factors. RESULTS: Overall, age was positively associated with greater odds of being opioid-free in the first 24 hours after surgery (adjusted odds ratio per increasing year of age = 1.07, 95% confidence interval [CI] 1.04-1.09, n = 332 women). Among opioid users, age was inversely associated with total opioid dose (adjusted mean difference per increasing year of age = 0.71 mg morphine equivalent daily dose, 95% CI -0.99 to -0.44, n = 204 women). There was no evidence of a non-linear relation between age and postoperative opioid use or dose. CONCLUSIONS: In the context of POP surgery, we found that younger women were more likely to use opioids after surgery and to use a higher dose in the first 24 hours when compared with older women. These findings support physicians to consider age when counseling POP patients regarding pain management after surgery, and to direct resources aimed at opioid-free pain control towards younger patients.

Surgical sexism in Canada: structural bias in reimbursement of surgical care for women.

BACKGROUND: It is well established that female physicians in Canada are reimbursed at lower rates than their male counterparts. To explore if a similar discrepancy exists in reimbursement for care provided to female and male patients, we addressed this question: Do Canadian provincial health insurers reimburse physicians at lower rates for surgical care provided to female patients than for similar care provided to male patients? METHODS: Using a modified Delphi process, we generated a list of procedures performed on female patients, which we paired with equivalent procedures performed on male patients. We then collected data from provincial fee schedules for comparison. RESULTS: In 8 out of 11 Canadian provinces and territories studied, we found that surgeons were reimbursed at significantly lower rates (28.1% [standard deviation 11.1%]) for procedures performed on female patients than for similar procedures performed on male patients. CONCLUSION: The lower reimbursement of the surgical care of female patients than for similar care provided to male patients represents double discrimination against both female physicians and their female patients, as female providers predominate in obstetrics and gynecology. We hope our analysis will catalyze recognition and meaningful change to address this systematic inequity, which both disadvantages female physicians and threatens the quality of care for Canadian women.

Does Size Matter? Opioid Use after Laparoscopy for Apical Pelvic Organ Prolapse Using an 8 mm versus 10-12 mm Accessory Port.

STUDY OBJECTIVE: To determine whether a change in lateral accessory port (LAP) size from 10-"?>12 mm to 8 mm among women undergoing laparoscopic native tissue pelvic organ prolapse (POP) surgery was effective at reducing opioid use after surgery. DESIGN: Prospective cohort of women taking part in a POP surgical registry. SETTING: Tertiary academic hospital in Calgary, Canada. PATIENTS: Women undergoing laparoscopic uterosacral ligament apical suspensions for stage ≥2 POP with either uterine preservation or concomitant hysterectomy. A total of 92 women were included during a 15-month study period from June 2020 and September 2021. INTERVENTIONS: Laparoscopic apical suspension using either a 10-"?>12 mm or 8 mm LAP, with the change occurring at the midpoint of the study period. Fascial defects from 10-"?>12 mm ports were closed with a fascial closure device. Perioperative care and technique were otherwise unchanged. MEASUREMENTS AND MAIN RESULTS: Postoperative opioid use was measured by mean morphine equivalent daily dose, accounting for all oral and intravenous opioids used in the first 24 hours after surgery. A total of 50 cases (54.3%) used a 10-12 mm LAP, and 42 cases (45.7%) used an 8 mm LAP. Mean morphine equivalent daily dose after surgery with a 10-12 mm LAP was significantly higher than with an 8 mm LAP (35.3 [95% confidence interval (CI) 24.9-45.6] vs 13.6 [95% CI 8.0-19.2], p <.001). The proportion of women who did not require opioids postoperatively was higher in the 8 mm group (45.2%, n = 19) than the 10-12 mm group (18.0%, n = 9) (crude odds ratio 3.76, 95% CI 1.47-9.66). Similarly, the proportion of women who did not fill an opioid prescription after discharge was higher in the 8 mm group (35.7%, n = 15) than the 10-12 mm group (16.0%, n = 8) (crude odds ratio 2.92, 95% CI 1.09-7.81). These results remained statistically significant after adjustment for age, body mass index, race and ethnicity, length of procedure, and concomitant procedures performed. CONCLUSION: Compared with a 10-12 mm port, the use of an 8 mm LAP during laparoscopic native tissue apical POP surgery is associated with decreased opioid use in the first 24 hours after surgery.

Female Pelvic Medicine and Reconstructive Surgery challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium: managing complicated cases : Series 5: management of recurrent stress urinary incontinence after midurethral sling exposure.

This case presents the work-up and management of a patient requesting surgical intervention for recurrent stress urinary incontinence after previous excision of a portion of her midurethral sling because of mesh exposure. Four international experts provide their approach to this complex case. There is little consensus regarding further surgery in a patient who has required mesh excision. Treatment by fascial sling was commonly considered and the literature review outlines the pros and cons of autologous fascia versus donor fascia for this specific case.

A prospective study investigating the diagnostic agreement between urodynamics and dynamic cystoscopy in women presenting with mixed urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Patient history is often insufficient to identify type of urinary incontinence (UI). Multichannel urodynamic testing (UDS) is often used to clarify the diagnosis. Dynamic cystoscopy (DC) is a novel approach for testing bladder function. The primary objective of this study was to investigate the diagnostic agreement of UDS and DC in evaluating women with mixed urinary incontinence (MUI). METHODS: Women presenting with MUI were approached for enrollment if UDS and DC were planned for further investigation. Investigators were blinded to history and comparative test results. McNemar's test and kappa coefficient were calculated to assess agreement between UDS and DC. Receiver operating characteristic (ROC) analysis was used to explore the best possible filling sensation cutoffs for DC that would best predict the filling sensation cutoffs from UDS. RESULTS: Sixty participants were included, of whom, four were excluded for protocol violation. For the primary outcome measure of agreement, UDS and DC were concordant in 44/56 of stress urinary incontinence (SUI) cases (79%) with a κ= 0.54 and in 43/56 of urinary urge incontinence (UUI) cases (77%) with a κ= 0.54, indicating moderate, nearly substantial agreement. ROC analysis identified the best prediction of DC first urge to void as 148 cm3, strong urge 215 cm3, and maximum capacity at 246 cm3. These parameters were used to compare UDS UUI to DC UUI and resulted in a κ = 0.61 (p = 0.37), indicating substantial agreement. CONCLUSIONS: When compared with UDS, DC shows moderate agreement for detection of SUI and substantial agreement for detection of UUI.

Uterosacral vault suspension (USLS) at the time of hysterectomy: laparoscopic versus vaginal approach.

INTRODUCTION AND HYPOTHESIS: To compare laparoscopic and vaginal approaches to uterosacral ligament vault suspension (USLS) by perioperative data, short-term complications, rates of successful concomitant adnexal surgery and procedural efficacy. METHODS: Retrospective cohort of USLS procedures performed at the time of hysterectomy at a tertiary care center over a 3-year period. Patient demographics, surgical data, concomitant adnexal procedures and complications were abstracted from a surgical database and compared using parametric or non-parametric tests as appropriate. Validated questionnaires (POPDI-6, UDI-6, PROMIS) were used to collect information on recurrence and long-term complications. Patients were analyzed according to both intention-to-treat analysis based on the intended approach and the completed route of surgery to deal with intraoperative conversions. RESULTS: Two hundred six patients met the criteria for inclusion; 152 underwent vaginal USLS (V-USLS) and 54 laparoscopic USLS (L-USLS). No statistically significant differences in mean case time, postoperative length of stay or perioperative infection were found. While no ureteric obstructions occurred in the L-USLS group, in the V-USLS group 14 (9%) obstructions occurred (p = 0.023). Postoperative urinary retention was higher with V-USLS (31% vs. 15%, p = 0.024). Rates of successfully completed adnexal surgery differed (56% vs. 98%, p < 0.001) in favor of L-USLS. Patient-reported symptomatic recurrence of prolapse was higher in the V-USLS group (41% vs. 24%, p = 0.046); despite this, re-treatment did not differ between the groups (0% vs. 7%, p = 0.113). CONCLUSIONS: Perioperative case time and complications did not differ between approaches. However, rates of completed adnexal surgery were significantly higher in the laparoscopic group, which could influence surgical decisions concerning approaches to prolapse surgery.

Female Pelvic Medicine & Reconstructive Surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 2: management of urinary incontinence in a neurogenic patient.

Discussion and management of incontinence in a patient with spina bifida by four international experts followed by a literature review.

Urinary leakage during exercise: problematic activities, adaptive behaviors, and interest in treatment for physically active Canadian women.

INTRODUCTION AND HYPOTHESIS: Urine loss during recreational exercise is problematic. We aimed to characterize which activities are most frequently reported as causing leakage for women, adaptive management mechanisms, and awareness and interest in treatment in a cohort of physically active women. METHODS: We administered an anonymous questionnaire to 59 physically active women in Canada. Surveys were completed electronically or on paper. Demographic information was obtained. Questions about which specific activities caused leakage, adaptive behaviors to deal with urinary loss, and degree of bother were addressed, and knowledge and interest in therapies for leakage were queried. RESULTS: Activities most likely to cause leakage were skipping, trampoline, jumping jacks, and running/jogging. To decrease leakage, 93.2% voided immediately before exercise, 62.7% reported voiding breaks, and some reported fluid restriction (37.3%). Leakage impacted activity level for 50% of women. Most often, activity intensity was decreased (90.3%) or specific activities avoided (80.7%). Pad use during exercise was common (49.2%). Interest in receiving treatment for urinary incontinence (UI) was high (88.1%) despite a large proportion (35.6%) not knowing of available treatments. Interest was highest for pelvic floor physiotherapy (84.6%), although interest in both pessary and surgical management (63.5% each) was significant. CONCLUSIONS: Women experiencing UI during exercise report high-impact activities as most frequently causing loss. Adaptive behaviors are common. Physically active women are interested in treatment, and the high interest in pelvic physiotherapy presents a unique opportunity to link pelvic exercise with recreational exercise to meet both cardiovascular and continence needs in the physically active patient population.

Predictors of length of stay after urogynecological surgery at a tertiary referral center.

INTRODUCTION AND HYPOTHESIS: The primary objective of this study was to determine significant predictors of length of stay (LOS) beyond the first postoperative day after urogynecological surgery. METHODS: A single-center retrospective cohort study was conducted in 2015. Our study population included women who underwent inpatient pelvic reconstructive surgery. The primary outcome was LOS beyond the first postoperative day. A logistic regression analysis explored the relationship between 11 selected predictor variables [age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, distance from home to hospital, length of surgery, anesthesia during surgery, route of surgical approach, trial of void recordings, choice of bladder protocol, presence of concomitant sling, surgeon], and LOS. RESULTS: Two hundred and sixty-three patients were included in this study. A logistic regression analysis identified route of surgery and trial of void recordings as the two statistically significant predictors of stay beyond the first postoperative day. The odds of LOS after laparoscopic or open surgery compared with vaginal surgery increased more than fivefold [laparoscopic vs. vaginal approach odds ratio (OR) 5.04, 95 % confidence interval (CI) 1.95-13.03; laparotomy vs. vaginal OR 15.56, 95 % CI 1.77-136.77] and more than threefold for a prolonged pass of the bladder protocol compared with an immediate pass (OR 3.25, 95 % CI 1.54-6.87). CONCLUSION: Our study identified route of surgery and trial of void recordings as the two predictors with the greatest impact on LOS beyond the first postoperative day. Our results warrant a larger follow-up study.

Five years after midurethral sling surgery for stress incontinence: obesity continues to have an impact on outcomes.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the impact of preoperative body mass index ≥30 on objective and subjective cure rates 5 years after midurethral sling surgery. METHODS: Secondary analysis of the 5-year results of a randomized clinical trial evaluating tension-free vaginal tape vs transobturator tape surgery. Women (n = 176) were classified as obese or non-obese based on preoperative height and weight. Women self-reported symptoms and quality of life, and underwent standardized physical examinations and pad-testing. Categorical data were analyzed using Chi-squared or Fisher's exact tests, continuous data by Mann-Whitney U test. Primary outcome was objective cure defined as <1 g urine lost on pad-test at 5 years post-surgery. Secondary outcomes were subjective cure of incontinence, urinary urge incontinence symptoms, and quality of life scores. RESULTS: Non-obese women had a higher rate of objective cure, 87.4 % (n = 83 out of 95) compared with 65.9 % (n = 29 out of 44) in the obese group (P = 0.003, risk difference [RD] 21.5 %, 95 % CI 5.9-37.0 %). Subjectively, non-obese women also reported higher rates of cure, 76.7 % (n = 89 out of 116) compared with 53.6 % (n = 30 out of 56) of obese women (P = 0.002, RD 23.2 %, 95 % CI 8.0-38.3 %). Overall rates of urge incontinence symptoms were similar in the two groups, but rates of bothersome symptoms were higher for obese women (58.9 % vs 42.1 %, P = 0.039, RD 16.8 % 95 % CI 1.1-32.6). CONCLUSIONS: Five years after surgery, obese women continued to experience lower rates of cure compared with non-obese women.

Early voiding dysfunction after midurethral sling surgery: comparison of two management approaches.

INTRODUCTION AND HYPOTHESIS: Early voiding dysfunction (EVD) with urinary retention (UR) is a complication of midurethral sling (MUS) surgery. Management is not standardized. Our objective was to characterize management approaches at our center, and report outcomes including resolution of UR, persistent voiding dysfunction, and recurrent stress urinary incontinence (SUI). METHODS: All women requiring catheterization for ≥7 days after MUS surgery during the period March 2014 to 2016 were eligible for inclusion in this prospective study. The management plan for each patient was decided jointly by the surgeon and the patient. Questionnaires regarding urinary symptoms were administered at enrollment, and 3 and 6 months after surgery. The timing and type of any surgical intervention were recorded. RESULTS: During the 2-year period, 31 women experienced EVD for ≥7 days after MUS surgery. At 6 months, complete data were available for 30 women (97%). Two management approaches were identified: "early mobilization" to loosen the MUS intact (in 10 patients), and continued catheterization with delayed sling lysis as needed (in 21 patients). In eight of the ten women in the early mobilization group, UR resolved after one intervention. Two required a second mobilization. For all women in this group, UR resolved after one or two procedures. In 11 of the 21 women in the continued catheterization group UR resolved without intervention. The other ten women in the continued catheterization group opted for sling lysis ≤6 months after MUS surgery. None of the women in the mobilization group reported SUI at 6 months in contrast to 9 of 20 (45%) in the planned continued catheterization group (p = 0.029). Seven of the nine women experiencing recurrent SUI had undergone sling lysis. CONCLUSIONS: Patients experiencing EVD after MUS surgery can be informed that UR will resolve in 50% with continued catheterization. Mobilization should be an option for those not comfortable with prolonged catheterization. Early intervention by mobilization may be associated with a lower risk of recurrent SUI, compared to continued catheterization and delayed sling lysis.

Transobturator tape versus retropubic tension-free vaginal tape for stress urinary incontinence: 5-year safety and effectiveness outcomes following a randomised trial.

INTRODUCTION AND HYPOTHESIS: In a randomised trial comparing transobturator tape (TOT) to retropubic tension-free vaginal tape (TVT) for women with stress urinary incontinence (SUI), vaginal examination at 12 months showed that tapes were palpable for 80.0 % of the TOT group versus 26.7 % of the TVT group. We hypothesized that this difference would lead to more women in the TOT group experiencing vaginal mesh erosion or other serious adverse events compared to women in the TVT group 5 years after surgery. METHODS: All participants were invited to join the follow-up study after being randomised to receive TOT or TVT for SUI. Consenting women had a vaginal examination, a pad test for urinary incontinence (UI) and completed Health-related Quality of Life Questionnaires (HRQOL). Women unable to attend the clinic completed questionnaires only. The primary composite outcome incorporated mesh exposure, urinary retention, repeat incontinence surgery and moderate to severe pelvic pain. Assuming 80 % follow-up, our study would have 67 % power to detect a difference in primary outcome (two-sided 5 % level of significance). Comparisons between groups used chi-square tests and t tests. RESULTS: One hundred and seventy-six (88.4 %) women participated in the 5-year follow-up (83 TOT, 93 TVT). The primary composite outcome occurred in 21.8 % of the TOT and 27.6 % of the TVT groups [difference =-5.8 %, 95 % confidence interval (CI) -18.9 % to 7.3 %, p value 0.39)] Vaginal examination found more women with palpable tapes in the TOT versus the TVT group (48.5 % versus 22.4 %, p value 0.001). There were no other significant differences between groups. CONCLUSIONS: Serious adverse events and tape effectiveness did not differ between groups at 5 years. Palpable tape remains a concern for women who receive TOT for treating SUI.