Readmissions and perioperative outcomes for same-day versus next-day discharge after prolapse surgery.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the safety of same-day discharge (SDD) compared with next-day discharge (NDD) after prolapse surgery on a national level hypothesizing that readmission and complication rates after SDD would not be higher than NDD. METHODS: We performed a retrospective cohort study using the National Surgical Quality Improvement Program database including 2014-2018. Current Procedural Terminology (CPT) codes were used to identify minimally invasive apical suspensions or obliterative procedures. Exclusion criteria were length of stay > 1 day, unrelated concomitant procedures, serious medical comorbidities, American Society of Anesthesiologists (ASA) Class >2, and complication during index admission. The primary outcome was 30-day readmission, and secondary outcomes included 30-day complications. RESULTS: 12,583 were included in analysis. SDD rate was 16.7%. The majority of women were white (91%) with a mean age of 59 years and mean body mass index of 28 kg/m². Medical comorbidities were similar between the SDD and NDD groups. Overall incidence of 30-day readmission was 1.7%. SDD had lower odds of 30-day readmission than NDD (aOR 0.63, 95% CI 0.41-0.98). SDD had lower odds of 30-day complications but this failed to reach statistical significance (aOR 0.67, 95% CI 0.44-1.03). CONCLUSIONS: In this cohort, 30-day readmission and complication rates were not higher after SDD compared to NDD in women undergoing minimally-invasive apical suspension or obliterative procedures. We interpret these findings carefully given study limitations but believe our findings support the safety of SDD after minimally invasive apical suspension or obliterative procedures in a low-risk population.

A randomized trial comparing continence pessary to continence device (Poise Impressa®) for stress incontinence.

INTRODUCTION AND HYPOTHESIS: To conduct a multi-centered randomized trial evaluating stress urinary incontinence (SUI) treatment based on the Patient Global Impression of Improvement score after 4 weeks using a continence pessary (CP) or a disposable intravaginal continence device (DICD). The null hypothesis is no difference in treatment success between cohorts. METHODS: This parallel group, active treatment comparative effectiveness trial randomized women with SUI to either CP or DICD for 4 weeks in a 1:1 allocation ratio. Exclusion criteria included pregnancy, UTI, postmenopausal bleeding, neurogenic bladder, urinary retention, prolapse, contraindication to or prior treatment with CP/DICD, and prior SUI surgery. Assuming an 80% power, an alpha of 5% and 20% dropout, we needed 138 participants to detect 50% success with CP versus 25% with DICD. Due to slow enrollment, the study was stopped after 16 months with 50 participants enrolled. RESULTS: Of the 50 women enrolled, 25 (50%) were randomized to CP and 25 (50%) to DICD. Thirty-five of 50 (70%) completed a fitting, and 22/50 (44%) completed 4-week and 17/50 (34%) completed 6-month follow-up. Baseline characteristics were similar, and there was high treatment success in each cohort [80% (8/10) CP vs. 75% (9/12) DICD; p = 1.0]. DICD patients showed improvement on all questionnaires but had higher use of other therapies over 6 months. CP patients showed improvements except for lower sexual function scores at 4 weeks. No serious adverse events occurred. CONCLUSIONS: Most women fitted with a CP/DICD experienced treatment success after 4 weeks without serious adverse events.

Mode of anesthesia and major perioperative outcomes associated with vaginal surgery.

INTRODUCTION AND HYPOTHESIS: The primary aim was to compare the incidence of major perioperative complications in women undergoing vaginal reconstructive surgery with general, regional, and monitored anesthesia care using a national database. The secondary aim was to compare length of hospital stay, 30-day readmission rates, urinary tract infections, and reoperation rates between anesthesia types. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was used to study women undergoing vaginal surgery for pelvic floor disorders from 2006 to 2015 via Current Procedural Terminology codes. Demographic and clinical variables were abstracted. The incidence of major perioperative complications was defined as the occurrence of any of the following within 30 days of surgery: death, surgical-site infection, pneumonia, venous thromboembolism, intensive care unit admission, stroke, transfusion, sepsis, and myocardial infarction. Regression analysis was used to estimate the relative risks (RR) associated with anesthesia type for each outcome. RESULTS: From the database, we gathered data on 37,426 women who underwent vaginal reconstructive surgery between 2006 and 2015; 87.2% (n = 32,623) underwent general, 6.9% (n = 2565) regional, and 5.9% (n = 2238) monitored anesthesia care. Major perioperative complications occurred in 560 women (1.5%). Relative to general anesthesia, the adjusted risk of major perioperative complications was not significantly different in those receiving monitored or regional anesthesia [monitored vs. general, adjusted RR 0.74, 95% confidence interval (CI) 0.45-1.20; regional vs. general, adjusted RR 1.23, 95% CI 0.92-1.65]. DISCUSSION: Major perioperative complications in vaginal reconstructive surgery were uncommon, and no differences were observed between monitored, regional, and general anesthesia outcomes.

The incidence of transfusion and associated risk factors in pelvic reconstructive surgery.

BACKGROUND: Almost 400,000 female pelvic reconstructive operations were performed in 2010 for urinary incontinence and pelvic organ prolapse in the United States, and it is likely that this will continue to increase each year. There is a lack of population-based data evaluating the risk of blood transfusion after urogynecologic procedures. OBJECTIVE: We sought to assess the incidence of blood transfusion related to pelvic reconstructive surgery in a large national surgical quality database and to identify transfusion-associated risk factors. STUDY DESIGN: This retrospective cohort study was performed using the National Surgical Quality Improvement Program database from the years 2010 through 2014. All women undergoing surgery for pelvic floor disorders were identified by Current Procedural Terminology code. Demographic and clinical variables were abstracted. The incidence of blood transfusion was determined. A multivariate logistic regression analysis was performed to identify clinical factors independently associated with blood transfusion. RESULTS: A total of 54,387 women underwent pelvic reconstructive surgery from 2010 through 2014 in the National Surgical Quality Improvement Program database. Of these subjects, 686 (1.26%) received a blood transfusion. The median age was 57 (range 28-89) years. Of the population, 0.81% was underweight (body mass index <18.5), 27.0% was normal weight (body mass index 18.5-24.9), 35.6% was overweight (body mass index 25-29.9), and 36.7% was obese (body mass index ≥30). The majority of subjects in the study cohort were Caucasian (91.4%) followed by African Americans (4.6%); the remainder included Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander. Hispanic ethnicity was reported in 9.3% of the population. American Society of Anesthesiologists class 1 and 2 represented a majority of the sample (76.5%). Concomitant hysterectomy was performed in 20,735 (38.1%) of the population. In the multivariate analysis, preoperative hematocrit <30% (odds ratio, 13.68; 95% confidence interval, 10.65-17.59), history of coagulopathy (odds ratio, 3.74; 95% confidence interval, 2.50-5.60), and concomitant hysterectomy (odds ratio, 1.77; 95% confidence interval, 1.49-2.12) were factors independently associated with receiving blood transfusion (all P < .05). When compared to American Society of Anesthesiologists class 1, patients who were class 3 (odds ratio, 2.82, P < .01; 95% confidence interval, 2.02-3.93) or class 4 (odds ratio, 6.56, P < .01; 95% confidence interval, 3.65-11.78) were more likely to require a transfusion. When compared to Caucasians, African Americans (odds ratio, 1.73, P < .01; 95% confidence interval, 1.27-2.36) and Hispanics (odds ratio, 1.92, P < .01; 95% confidence interval, 1.54-2.40) were more likely to require a transfusion. In this cohort, overweight (odds ratio, 0.75; 95% confidence interval, 0.62-0.93) and obese (odds ratio, 0.61; 95% confidence interval, 0.49-0.75) subjects were less likely to receive a transfusion. When compared to a vaginal approach, patients who had a minimally invasive approach (odds ratio, 0.63; 95% confidence interval, 0.49-0.83) were less likely to receive a transfusion, while those with an open approach were more likely to receive a transfusion (odds ratio, 5.43; 95% confidence interval, 4.49-6.56). Age was not a risk factor for transfusion. CONCLUSION: Transfusion after pelvic reconstructive surgery is uncommon. The variables associated with transfusion are preoperative hematocrit <30%, American Society of Anesthesiologists class, bleeding disorders, nonwhite race, Hispanic ethnicity, and concomitant hysterectomy. Recognition of these factors can help guide preoperative counseling regarding transfusion risk after pelvic reconstructive surgery and individualize preoperative preparation.

Comparison of Readmission Rates for Same-Day Versus Next-Day Discharge After Benign Vaginal Hysterectomy.

IMPORTANCE: Same-day discharge (SDD) for laparoscopic hysterectomy is shown to be safe and acceptable, but data for vaginal hysterectomy (VH) are lacking. OBJECTIVE: The aim of this study was to compare 30-day readmission rates, timing, and reasons for readmission for SDD versus next-day discharge (NDD) after VH. STUDY DESIGN: This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Cases of VH with or without prolapse repair were identified by Current Procedural Terminology codes. The primary outcome was 30-day readmissions after SDD versus NDD. Secondary outcomes included reasons for and time to readmission and a subanalysis evaluating 30-day readmissions for those with prolapse repair. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analyses. RESULTS: There were 24,277 women included; 4,073 (16.8%) were SDD. The 30-day readmission rate was low (2.0%; 95% confidence interval [CI], 1.8-2.2%), with no difference in odds of readmission for SDD versus NDD after VH in multivariate analysis (SDD adjusted odds ratio [aOR], 0.9; 95% CI, 0.7-1.2). Results were similar in our subanalysis of VH with prolapse surgery (SDD aOR, 0.94; 95% CI, 0.55-1.62). Median time to readmission was 11 days and did not differ (SDD interquartile range, 5, 16 [range, 0-29] vs NDD, 7, 16 [range, 1-30]; Z = -1.30; P = 0.193). The most common reasons for readmission were bleeding (15.9%), infection (11.6%), bowel obstruction (8.7%), pain (6.8%), and nausea/emesis (6.8%). CONCLUSIONS: Same-day discharge after VH did not have an increased odds of 30-day readmission compared with NDD. This study, with preexisting data, supports the practice of SDD after benign VH in low-risk patients.

Perioperative Outcomes for Same- Versus Next-Day Discharge After Benign Vaginal Hysterectomy.

IMPORTANCE: While same-day discharge (SDD) after laparoscopic hysterectomy is well supported, studies for vaginal hysterectomy (VH) are lacking. OBJECTIVE: The aim of the study was to compare 30-day complications for SDD versus next-day discharge (NDD) after benign VH. STUDY DESIGN: This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Vaginal hysterectomy with or without urogynecology procedures was identified by Current Procedural Terminology codes. The primary outcome was 30-day composite complications of SDD versus NDD after VH. Secondary outcomes compared reoperations rates, time to and reasons for reoperation, and complications between the groups. Composite complications included death, major infection or wound complication, thromboembolism, transfusion, cardiopulmonary complication, renal insufficiency/failure, stroke, or reoperation. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analysis. RESULTS: Of 24,277 people included, 4,073 (16.8%) were SDD, which were more likely to be younger ( P < 0.001), less likely to have hypertension (23.4 vs 18.3%, P < 0.0001) or diabetes (4.5 vs 3.3%, P = 0.001), and had shorter surgical procedures (100.7 ± 47.5 vs 111.2 ±57.5 minutes, P < 0.0001). There was no difference in composite complications after SDD versus NDD and this remained true in multivariate analysis (2.0 vs 2.3%, P = 0.30, SDD; adjusted odds ratio, 0.9; 95% confidence interval, 0.7-1.1). There was no difference in reoperation rates (0.9 vs 0.9%, P = 0.94) or reasons for reoperation. Time to first complication was shorter for SDD versus NDD (11 vs 13 days, P = 0.47). CONCLUSION: In our cohort of low-risk patients, SDD after VH with or without urogynecology procedures did not have an increased odds of 30-day composite complications.

Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050.

OBJECTIVE: We sought to estimate the number of women who will undergo inpatient and outpatient surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP) in the United States from 2010 through 2050. STUDY DESIGN: Using the 2007 Nationwide Inpatient Sample and the 2006 National Survey of Ambulatory Surgery, we calculated the rates for inpatient and outpatient SUI and POP surgery. We applied the surgery rates to the US Census Bureau population projections from 2010 through 2050. RESULTS: The total number of women who will undergo SUI surgery will increase 47.2% from 210,700 in 2010 to 310,050 in 2050. Similarly, the total number of women who will have surgery for prolapse will increase from 166,000 in 2010 to 245,970 in 2050. CONCLUSION: If the surgery rates for pelvic floor disorders remain unchanged, the number of surgeries for urinary incontinence and POP will increase substantially over the next 40 years.

Vaginal agglutination: chronic graft-versus-host disease mimics lichen planus.

BACKGROUND: Graft-versus-host (GVH) disease is a common problem in transplant patients, whereas vulvovaginal gingival syndrome is an uncommon and severe variant of lichen planus characterized by erosions of characteristic mucosal surfaces, with frequent vaginal involvement, resulting in scarring or stricture formation. Both conditions have the potential to present with similar clinical pictures. CASE: We report the history, evaluation, and treatment of a woman who had recently undergone stem cell transplant for acute lymphoblastic leukemia who presented with vaginal agglutination. A clinical diagnosis of erosive lichen planus versus chronic GVH disease was considered. CONCLUSIONS: Lichen planus and GVH disease are both inflammatory processes, which can present with a range of clinical conditions. Each may result in the development of irritative symptoms and erosive lesions on mucosal surfaces. Although lichen planus is a well-defined dermatosis, GVH disease is an iatrogenic process. We report the case history of a patient with erosive vulvovaginal lesions with scarring, likely caused by GVH disease, which mimicked erosive vulvovaginal lichen planus. Although the clinical presentation and treatment of these 2 entities are similar, this case demonstrates the subtle diagnostic difference between the 2 diseases.

Evaluating the Quality and Readability of Online Resources for Labiaplasty.

OBJECTIVES: The aim of this study was to evaluate the quality, readability, and accuracy of Web-based information regarding labiaplasty and to characterize the types of Web sites providing this information. METHODS: Investigators used 3 major search engines to query the internet using the search terms labiaplasty, labia reduction, and vaginal rejuvenation. Two validated tools were used to evaluate Web sites: the JAMA benchmark tool and the DISCERN instrument. Three physicians independently reviewed each Web site. Interrater agreement was assessed, and reviewer scores were averaged. Flesch-Kincaid reading ease and Flesch-Kincaid grade level of each site were assessed. Data were analyzed using Stata 14.0 (College Station, TX). RESULTS: Of the 112 Web sites reviewed, 100 Web sites were from North America, 9 from Europe, 2 from Australia, and 1 from Asia. The median score using the JAMA tool was 1.0 (0.33-4.0), indicating low accountability, whereas the median score using the DISCERN tool was 28 (18.7-77) of 80 with higher scores indicating higher quality. Cohen's weighted κ statistic (0.81) demonstrated near perfect agreement among reviewers for DISCERN scores. The median reading level was 11.9 (6.4-19.5). A majority of the Web sites (92) were for-profit businesses or blogs. CONCLUSIONS: The internet enables patients to research sensitive topics and seek answers without worry of social stigma. Online health-related information is a widely used yet poorly studied source of medical information. The majority of Web sites reviewed lack balanced, evidence-based information. Given the wide variation in the quality of information, physicians should guide patients to reputable online resources.

Engaging Women in Pelvic Floor Disorders Research Using the Internet.

OBJECTIVES: The objective of this study were (1) to assess the feasibility of using online platforms as recruitment tools for pelvic floor disorder studies and (2) to compare the prevalence of symptoms of incontinence and care-seeking behavior by online platform to previously published prevalence estimates. METHODS: We conducted a cross-sectional study among women to assess the prevalence of incontinence symptoms, level of bother, and care-seeking behavior. Participants were recruited through Facebook ads, ResearchMatch, or Reddit. The effectiveness of Facebook ads was assessed using the click through rate and an overall completion rate (number of completes over number of times an ad was shown). A nontargeted ad was posted to a Reddit thread in which research opportunities are advertised. For ResearchMatch, investigators sent a recruitment email. Effectiveness of this method was assessed by observing how many women completed the survey compared with the number of women who received it. RESULTS: Among the 7361 women who initiated the questionnaire, 6650 (90%) completed it. A majority of participants were recruited through ResearchMatch. Online platforms were successful in recruiting women across a wide age range (ages, 18-93 years). The overall prevalence of incontinence was 46.1% with women 45 years and older having the highest prevalence (64.6%). Common reasons for not seeking care included "not bothersome enough," "other health problems," and "being unsure about treatment." CONCLUSIONS: Internet-based recruitment was found to be feasible. The prevalence of incontinence was higher than has been reported in other population-based samples. Significant barriers to care exist, and further studies should focus on educational strategies.

Perioperative Outcomes for Combined Ventral Rectopexy With Sacrocolpopexy Compared to Perineal Rectopexy With Vaginal Apical Suspension.

OBJECTIVES: To describe and compare perioperative complications in women undergoing combined ventral rectopexy with sacrocolpopexy compared with perineal rectopexy with vaginal apical suspension. METHODS: Current Procedural Terminology codes were used to identify women in the National Surgical Quality Improvement Program database who underwent ventral rectopexy with sacrocolpopexy or perineal rectopexy with vaginal apical suspension from 2006 to 2015. Perioperative complication was defined as any of the following within 30 days of surgery: death, return to the operating room, transfusion, or vascular, wound, respiratory, infectious, or renal morbidity. Secondary outcomes included length of hospital stay, operative time, blood loss, readmission, and rate of urinary tract infections. Modified Poisson regression was used to estimate the adjusted relative risks of complication associated with surgical approach, abdominal versus perineal. RESULTS: Of the 273 women included, 240 (88%) underwent surgery with an abdominal approach, and 33 (12%) underwent surgery with a perineal approach. Perioperative complications occurred in 24 (9%) patients; 19 (8%) in the abdominal group and 5 (15%) in the perineal group. The age-adjusted risk of perioperative complications was not significantly different between those with a perineal approach compared with those with an abdominal approach (adjusted relative risk, 1.78; 95% confidence interval, 0.73-4.33). CONCLUSIONS: Patients in this database who underwent surgery with a vaginal/perineal approach were not more likely to have a postoperative complication after adjusting for age compared with those undergoing an abdominal approach. Larger studies are needed to determine a more precise estimate of the impact of surgical approach on rates of perioperative complications.

Is There an Association Between Bothersome Urinary Symptoms and Postpartum Depression?

OBJECTIVE: Bothersome urinary symptoms are often present postpartum. The objective of this study was to examine the association between bothersome urinary symptoms and screening positive for postpartum depression. METHODS: Women presenting at the routine 6-week postpartum visit were screened for risk of depression with the Edinburgh Postnatal Depression Scale. A questionnaire comprising delivery characteristics and demographics, 20-item Postpartum Symptom Inventory (PSI), Urinary Distress Inventory (UDI) short form, Incontinence Impact Questionnaire (IIQ) short form, and history of depression and antidepressant use was completed. Scores were then compared. RESULTS: Data from 104 women were analyzed, with 89% reporting excellent or good health; 73% delivered vaginally; 22% reported a history of depression, and 7% were taking an antidepressant. Twelve percent were classified as at risk of depression. Median UDI score was 5.6 (range, 0-44.4). Median IIQ score was 0 (range, 0-85.7). There was no statistically significant association between bothersome urinary symptoms and the odds of screening positive for depression using either the UDI (adjusted odds ratio [OR], 2.9; 95% confidence interval [CI], 0.7-12.5) or the IIQ (adjusted OR, 0.5; 95% CI, 0.1-2.9). The UDI score was associated with elevated PSI scores as PSI scores increased by 5.4 points if a woman had a UDI score that was greater than zero versus a UDI score of zero, controlling for education level, age, and whether the patient had a cesarean delivery (95% CI, 2.2-8.6; P = 0.001). The UDI score was not associated with antidepressant use (OR, 2.4; 95% CI, 0.5-13.2). The IIQ score had no associations with PSI score (adjusted difference in means, 2.9; 95% CI, -0.9 to 6.8; P = 0.13) or antidepressant use (OR, 1.9; 95% CI, 0.4-9.3). CONCLUSIONS: No statistically significant association between bothersome urinary symptoms and the odds of screening positive for increased risk of postpartum depression was found. Future work in this area is needed.

Utility of Preoperative Laboratory Testing in Women Undergoing Suburethral Sling.

OBJECTIVE: The aim of the study was to examine current patterns and factors associated with preoperative testing in patients undergoing midurethral sling and to compare 30-day outcomes in subjects. METHODS: This retrospective cohort study was performed using the National Surgery Quality Improvement Program database from 2005 to 2014. All women undergoing midurethral slings were identified by Current Procedural Terminology code. Clinical variables were abstracted and the incidence of preoperative serum labs was determined. Multivariable logistic regression was used to estimate associations between clinical factors and collection of preoperative serum labs and between 30-day outcomes and collection of labs. RESULTS: A total of 12,368 women underwent midurethral sling in the National Surgery Quality Improvement Program database during the study period. Preoperative serum testing within 30 days before surgery was observed in 9172 (74.2%) women. Age, American Society of Anesthesiologists class, diabetes, and hypertension were strongly associated with preoperative testing when modeling together in multivariable regression. Of the 543 women who had any complication, 410 (75.5%) received preoperative testing. Urinary tract infection was the most frequent complication (66.1%). Age, American Society of Anesthesiologists class, body mass index, and presence of any comorbidity were associated with the presence of any complication at 30 days. Adjusting for these factors, the odds of complications were not significantly different between those who did and did not have preoperative testing (adjusted odds ratio = 0.98, 95% confidence interval = 0.78-1.24). CONCLUSIONS: Most women who underwent midurethral sling procedures had preoperative testing. Major postoperative complications were uncommon, and there was no substantial difference in outcomes between women who underwent preoperative testing and those who did not. In the future, surgeons may consider eliminating preoperative testing in low-risk patients.

Gene expression in the rectus abdominus muscle of patients with and without pelvic organ prolapse.

OBJECTIVE: The objective of the study was to compare gene expression in a group of actin and myosin-related proteins in the rectus muscle of 15 patients with pelvic organ prolapse and 13 controls. STUDY DESIGN: Six genes previously identified by microarray GeneChip analysis were examined using real-time quantitative reverse transcriptase-polymerase chain reaction analysis, including 2 genes showing differential expression in pubococcygeus muscle. Samples and controls were run in triplicate in multiplexed wells, and levels of gene expression were analyzed using the comparative critical threshold method. RESULTS: One gene, MYH3, was 3.2 times overexpressed in patients with prolapse (P = .032), but no significant differences in expression were seen for the other genes examined. An age-matched subset of 9 patients and controls showed that MYH3 gene expression was no longer significantly different (P = .058). CONCLUSION: Differential messenger ribonucleic acid levels of actin and myosin-related genes in patients with pelvic organ prolapse and controls may be limited to skeletal muscle from the pelvic floor.

von Brunn's Nests and Follicular Cystitis Following Intradetrusor OnabotulinumtoxinA Injections for Overactive Bladder.

A 67-year-old female with refractory OAB was treated with intradetrusor Botox. She subsequently developed multiple papillary bladder lesions with tissue biopsy showing Von Brunn's nests. Von Brunn's nests are benign bladder lesions similar in appearance to a rare urothelial tumor called Nested Variant of Urothelial Carcinoma (NVUC). It is critical that patients with these findings undergo evaluation to rule out the presence of carcinoma. This finding suggests the possibility of a previously unreported adverse reaction in association with intradetrusor Botox.

Skeletal muscle heavy-chain polypeptide 3 and myosin binding protein H in the pubococcygeus muscle in patients with and without pelvic organ prolapse.

OBJECTIVE: The purpose of this study was to compare gene expression of skeletal muscle heavy-chain polypeptide 3 (MYH3) and myosin binding protein H (MyBP-H) in the pubococcygeus muscle of patients with pelvic organ prolapse and controls. STUDY DESIGN: Genes previously identified by microarray genechip analysis of pubococcygeus muscle biopsies were examined using real-time quantitative reverse transcriptase polymerase chain reaction (RT-PCR) analysis. Specimens were obtained from 17 patients with stage III or IV pelvic organ prolapse and 23 controls with minimal to no prolapse. Glyceraldehyde 3-phosphate dehydrogenase (GAPDH) was used as the housekeeping gene. Samples and controls were run in triplicate in separate wells, and the levels of gene expression were analyzed quantitatively using the comparative critical threshold (Ct) method. Differences in gene expression were analyzed using Wilcoxon rank-sum testing. RESULTS: Significant differences in gene expression were observed between patients with prolapse and controls for both genes. Skeletal muscle myosin heavy-chain polypeptide 3 was 6.5 times underexpressed in patients with pelvic organ prolapse compared to controls (P = .028). Similarly, myosin binding protein H was 3.2 times underexpressed in patients with prolapse (P = .042). Overall, patients had a mean age of 62.4 +/- 6.5 years compared with controls with a mean age of 45.3 +/- 7.4 years (P < .001), so analysis was also performed on an age-matched subset of 8 patients and controls (mean ages of 58.1 +/- 5.4 years and 53.3 +/- 5.0 years, respectively, P = .02) with similar results. Prolapse patients in this subset were similar in parity and race to controls but had lower body mass index (23.2 vs 29.9, P = .04). MYH3 was 10.9 times underexpressed in patients with pelvic organ prolapse compared to controls (P = .027). MyBP-H was 10.4 times underexpressed in patients with prolapse (P = .036). CONCLUSION: These findings suggest that the differences between patients with advanced pelvic organ prolapse and controls may be related to differential gene expression of structural proteins related to myosin. Specifically, advanced pelvic organ prolapse may be related to down-regulation of skeletal muscle heavy-chain polypeptide 3 and myosin binding protein H.

Microscopic hematuria as a predictive factor for detecting bladder cancer at cystoscopy in women with irritative voiding symptoms.

OBJECTIVE: The purpose of this study was to assess microscopic hematuria as a predictive factor for detecting bladder cancer at cystoscopy in women with irritative voiding symptoms. STUDY DESIGN: We conducted a retrospective cohort analysis of women with irritative voiding symptoms who presented for urodynamic testing and cystoscopy. Irritative voiding symptoms were defined as urgency, urge incontinence, frequency, dysuria, and/or nocturia. Patient demographics, risk factors for bladder cancer, presence of microscopic hematuria, urodynamic findings, and cystoscopy and biopsy results were recorded. RESULTS: Of 735 patients with irritative voiding symptoms, 264 (35.9%) had microscopic hematuria and 471 (64.1%) had no hematuria. Bladder cancer was detected in 3 women, for an overall detection rate of 0.4%. Microscopic hematuria, urgency, frequency, dysuria, nocturia, age, and tobacco use were not significantly associated with bladder cancer. CONCLUSION: In this cohort of women with irritative voiding symptoms, microscopic hematuria was not predictive for bladder cancer.

Mesh erosion in abdominal sacral colpopexy with and without concomitant hysterectomy.

OBJECTIVE: The purpose of this study was to examine risk factors for mesh erosion, including concomitant hysterectomy, in abdominal sacral colpopexies. STUDY DESIGN: We conducted a retrospective cohort study of 313 women who underwent an abdominal sacral colpopexy. Data regarding patient demographics, operative techniques, length of follow-up, postoperative complications, and mesh erosion were collected. RESULTS: Of 313 subjects, 101 (32.3%) had concomitant hysterectomies and 212 (67.7%) had had previous hysterectomies. The overall rate of mesh erosion was 5.4%. In bivariate analysis, concomitant hysterectomy was not associated with erosion (6.9% vs 4.7% previous hysterectomy, P = .42); however, estrogen therapy was an effect modifier. In women on estrogen, hysterectomy (OR 4.9, CI 1.2-19.7) and anterior imbrication (OR 5.6, CI 1.1-28.6) were associated with mesh erosion. No risk factors were identified in women not on estrogen. CONCLUSION: In women on estrogen therapy, hysterectomy was associated with mesh erosion in abdominal sacral colpopexy.

Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists.

OBJECTIVE: To compare the attitudes of urogynecology and maternal-fetal medicine specialists in the United States regarding elective primary cesarean delivery. METHODS: A Web-based questionnaire was sent by e-mail to members of the American Urogynecologic Society (AUGS) and the Society for Maternal-Fetal Medicine (SMFM) who reside in the United States. The first e-mail was sent in October 2003, and 2 additional e-mails were sent to nonresponders over the next month. The survey included questions about demographics, practice patterns, and opinions about different clinical scenarios regarding elective primary cesarean delivery. RESULTS: Of 1,479 surveys sent to functioning e-mail addresses, 782 were completed (52.9% response rate). American Urogynecologic Society and Society for Maternal-Fetal Medicine members were similar in response rate (53.0% versus 52.8%, respectively). Overall, 65.4% of physicians would perform an elective cesarean delivery, but AUGS members were significantly more likely to agree to perform an elective cesarean than SMFM members (80.4% versus 55.4%, respectively, P < .001). In a logistic regression model that included age, sex, having no children, years in practice, and subspecialty (urogynecology or maternal-fetal medicine), AUGS members were 3.4 times (95% confidence interval 2.3-4.9, P < .001) more likely to agree to perform an elective cesarean. CONCLUSION: Among respondents, a majority of urogynecology and maternal-fetal medicine specialists surveyed would perform an elective primary cesarean delivery. Urogynecologists were significantly more likely to support elective cesareans. LEVEL OF EVIDENCE: II-3.

Value of routine urine culture in the assessment of preterm labor.

OBJECTIVE: To assess the utility and expense of routine urine culture in women evaluated for preterm labor. STUDY DESIGN: A retrospective study of 1,429 patients evaluated for preterm labor over a calendar year. Patients evaluated for preterm labor were identified using the hospital's admissions database and then cross-referenced with the hospital microbiology laboratory's database to identify those who had urine cultures sent as part of their evaluation. The charts of patients with a positive urine culture were further reviewed to evaluate the diagnosis and outcome. RESULTS: Five hundred twelve urine cultures were sent for analysis of preterm labor, and 6 (1.2%) reported growth of > 100,000 colonies of a single bacterium. Of these 6 patients, 5 reported symptoms consistent with a urinary tract infection, while the 6th was asymptomatic. Fisher's exact test showed no clinical significance for a positive urine culture as a predictor of preterm delivery (P = .68). Sensitivity was 0.7% (95% CI, 0.0-4.3), and specificity was 98.6% (95% CI, 96.7-99.5). A cost difference of $29,676 existed between charges and reimbursements. A positive culture was not a significant risk factor for preterm delivery. The 1 patient who delivered preterm with a positive culture probably had cervical incompetence as the cause of preterm delivery. CONCLUSION: The routine use of urine cultures in the assessment of preterm labor is costly and adds little value to obtaining a diagnosis except in the presence of specific complaints at our institution. Urine culture identified a single patient with asymptomatic bacteriuria being evaluated for preterm labor, and she probably had another etiology for her advanced cervical examination.