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Objectives: The objective of this study was to describe national practice patterns of hysterectomy type performed with concurrent sacrocolpopexy and determine clinical factors associated with surgical route., Methods: We used the National Surgical Quality Improvement Program database with hysterectomy data for this retrospective cohort study. We identified sacrocolpopexy cases from 2014 to 2016 with concurrent hysterectomy and stratified patients into supracervical hysterectomy (SCH) or total hysterectomy (TH). As a secondary analysis, we compared the laparoscopic subset of cases. We performed χ2 and backward stepwise logistic regression analyses to identify factors associated with hysterectomy type and compare complication rates., Results: A total of 4,615 women underwent SCP with hysterectomy: 55.8% TH and 44.2% SCH. Mean ± SD age was 56.5 ± 11.7 years. Gynecologists represent 96.3% of surgeons; 51.2% were urogynecologists. Urogynecologists were more likely than generalists to perform SCH (58.4% vs 41.6%, P < 0.001). Total hysterectomy was associated with younger age (adjusted odds ratio [aOR], 0.98 per year [0.97-0.99]), greater uterine weight (aOR, 1.05 per 10 g [1.03-1.06]), and non-Caucasian race (aOR, 0.73 [0.58-0.92]). Complication rates were equivalent between hysterectomy type (SCH, 6.2% vs TH, 6.2%; P = 0.956). Laparoscopy was used for 84.4% of surgical procedures. In this subgroup, TH was associated with greater uterine weight (aOR, 1.06 per 10 g [1.04-1.08]) and younger age (aOR, 0.97 per year [0.96-0.98]). Complication rates were similar (SCH, 5.1% vs TH, 5.0%; P = 0.824)., Conclusions: At the time of sacrocolpopexy, TH is more common than SCH and is associated with younger age and greater uterine weight, although urogynecologists more commonly perform SCH. The overall risk of complications was low and similar between hysterectomy type., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Introduction: Malpractice litigations have significant implications for patients and physicians. Studies have investigated mesh litigations in female pelvic reconstructive surgery, but none on nonmesh pelvic organ prolapse (POP) surgery. Our purpose is to determine the reasons for and outcomes of medical malpractice after nonmesh POP surgery., Methods: Westlaw (Thompson Reuters, New York, New York) is a legal research database of US court records. We identified completed POP litigations from 1987 to 2018 using the following: "pelvic organ prolapse," "enterocele," "rectocele," "cystocele," "uterine prolapse," and "vaginal wall prolapse." Mesh-related cases were excluded. Outcomes included reasons for litigation, verdict, injury, and payments. Statistical analysis was performed with nonparametric tests and χ2 independence test., Results: Ninety-one litigations were included. The median plaintiff age was 53 years (range, 36-85 years). The leading allegation was negligence of surgery (n = 59; 65%). The jury sided with the defendant physician in 67% of cases (n = 61). There was no association between case verdict and patient age (P = 0.781), geographic region (P = 0.824), or allegation (P = 0.904). The primary complications were urinary tract injury (n = 24; 26%), need for additional surgery (n = 22; 24%), and new postoperative urinary symptoms (n = 22; 24%). The median payout was $280,000 (interquartile range, $137,250-$1,300,000), with no difference between plaintiff awards or settlements (P = 0.659)., Conclusion: The leading allegation of malpractice litigations for nonmesh POP surgery is negligence of surgery, whereas the most common complication was urinary tract injury. A verdict in favor of the physician defendant was the most likely outcome. Plaintiff awards and settlements were not statistically different with no variation by region or time., Competing Interests: Dr David Sheyn is a consultant for AristaMD. Drs Adonis K. Hijaz and Sangeeta T. Mahajan are members of the Astellas, Inc. Speaker’s Bureau. In addition, Dr Mahajan receives grant funding from Allergan, Inc, and is on their speaker’s bureau. The authors have no additional disclosures or conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Evaluate structural differences in brains of responders (R) and nonresponders (NR) to anticholinergic (AC) therapy for overactive bladder (OAB)., Materials and Methods: This was a retrospective cohort study of age matched women treated with an AC medication for OAB and underwent magnetic resonance imaging within 12 months before treatment. Data on pretreatment demographic and clinical variables and symptom severity was also collected.T1-weighted magnetic resonance images of the brain for each subject were segmented using FreeSurfer software. Structures included for analysis were cerebral cortex, white matter, subcortical gray matter, cerebellum, and brain stem.Nonresponders were defined as patients who reported less than 50% improvement after a minimum of 4 weeks on the maximum dose of the prescribed medication. Pairwise analysis between groups was performed using the Wilcoxon-Rank Sum test and Fisher exact test where appropriate. Spearman ρ was used to evaluate for correlations between neurologic structures and symptom severity., Results: There were no differences in pretreatment characteristics or symptom severity between the 21 R and 18 NR. Nonresponders had lower volumes of the right caudal anterior cingulate gyrus white matter (1919 mm3 vs 2416 mm3, P = 0.008) and right parahippocampal gyrus white matter (1008 mm3 vs 1469 mm3, P = 0.001). Incontinence episode frequency showed a negative moderate correlation with the anterior cingulate gyrus white matter volume (ρ = -0.4228, P = 0.007). The right and left cerebellar cortices showed weak and moderate negative correlations to frequency of nocturia (ρ = -0.384, P = 0.02 and ρ -0.443, P = 0.005, respectively)., Conclusion: There are measurable volumetric differences in brain structures in R and NR to AC therapy., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objective: This study aimed to determine whether levels of choline (Ch) and acetylcholine (Ach) differ between responders and nonresponders to anticholinergic therapy., Methods: Patients prescribed an anticholinergic were evaluated using the Overactive Bladder Symptom Score; Medical, Epidemiologic and Social Aspects of Aging and Incontinence Questionnaire; and Incontinence Impact Questionnaire-7. A 1-day voiding diary and a urine sample were collected. After treatment for 12 weeks, the questionnaires were administered and 1-day voiding diary was completed. Levels of Ach and Ch were measured by liquid chromatography with tandem mass spectrometry. Subjects were divided into responders and nonresponders. Wilcoxon rank sum test and Fisher exact test were used to express differences between groups. Spearman ρ correlation coefficient was used to determine the relationship between Ach and Ch and symptom severity, patient demographics, and questionnaire scores., Results: Thirty-one women were included in the analysis. The treatment response rate was 48.8%. The median age was 67 years (interquartile range, 50-76 years), and median body mass index was 32.3 kg/m2 (27.5-40.6 kg/m2), with 41.2% having an additional complaint of stress incontinence. There were no significant differences in symptom severity or questionnaire scores between groups.The median Ch and Ach levels were higher in responders (28.6 vs 9.2 μL, P = 0.04) and (83.1 vs 18.7 nL, P = 0.02), respectively. Levels of both Ch and Ach had moderate positive correlations with the Medical, Epidemiologic and Social Aspects of Aging and Incontinence Questionnaire urgency urinary incontinence score (ρ = 0.533 [P = 0.002] and ρ = 0.453 [P = 0.01], respectively)., Conclusion: In women with overactive bladder, urinary Ach and Ch levels are higher in responders to anticholinergic therapy compared with nonresponders., Competing Interests: The authors have declared they have no conflicts of interest and no funding source., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to determine the effect of tamsulosin on postoperative urinary retention in female patients after pelvic reconstructive surgery., Methods: Data were obtained from a retrospective, matched cohort of female patients who were admitted after pelvic reconstructive surgery at a single academic institution. Patients who received tamsulosin were compared with those who did not at a 1:4 ratio, matched by surgical procedure. Patients were excluded if they were discharged on the day of surgery or if an intraoperative complication necessitated prolonged postoperative bladder drainage. Information on demographics, preoperative diagnoses, prolapse stage, preoperative voiding dysfunction, urodynamic findings, intraoperative details, postoperative complications, and voiding outcomes up to 6 weeks after surgery was gathered. The primary outcome was postoperative urinary retention, defined by failure of an active voiding trial., Results: Patients underwent surgery between January 2016 and March 2018. We identified 35 patients who received tamsulosin and matched to 140 controls. Patients in the tamsulosin group were younger; groups were otherwise similar. Patients who received tamsulosin after surgery were less likely to develop postoperative urinary retention (2.9% vs 24.3%, P = 0.004). After controlling for confounders, multivariable logistic regression identified tamsulosin use as the only independent predictor of postoperative urinary retention with a significant protective effect (odds ratio, 0.09; 95% confidence interval, 0.01-0.67; P = 0.03)., Conclusions: Prophylactic tamsulosin use may be effective in preventing postoperative urinary retention in female patients undergoing pelvic reconstructive surgery.

Objective: The objective of this study was to determine whether levels of choline (Ch) differ in women with and without overactive bladder (OAB) symptoms., Methods: New patients were evaluated using the overactive bladder symptom score; Medical, Epidemiologic, and Social Aspects of Aging (MESA) urgency incontinence questionnaire; and Impact Questionnaire 7 and provided a urine sample. Patients were stratified into asymptomatic controls, scoring 0 on overactive bladder symptom score and the MESA questionnaire, and patients with OAB and urgency incontinence (OAB-wet). Patients with conditions predisposing to OAB or had a history of OAB treatment were excluded. Choline detection was accomplished using a commercially available kit. Wilcoxon rank sum test and Fisher exact test were used to express differences between groups. Spearman ρ correlation was used to determine the relationship between Ch and questionnaire scores. Logistic regression was used to identify significant variables associated with OAB., Results: Sixty-three women were included in the final analysis. Patients with OAB-wet were older (P = 0.001), more likely to be obese (P = 0.04), had greater apical descent (P = 0.02), were more likely to be postmenopausal (P = 0.01), and were more likely to have stress incontinence (P = 0.005). Choline was 34.8% lower in OAB compared with the controls (P = 0.014). Lower Ch levels were associated with higher MESA (Spearman ρ = -0.311, P = 0.03). After logistic regression, lower Ch (adjusted odds ratio [aOR], 0.97; 95% confidence interval [CI], 0.96-0.98), age (aOR, 1.12; 95% CI, 1.08-1.18), and body mass index (aOR, 1.09; 95% CI, 1.01-1.18) were significantly associated with OAB-wet., Conclusions: Choline levels are significantly decreased in women complaining of OAB with urgency incontinence, and lower levels are associated with higher MESA scores.

Objective: To determine if women with human immunodeficiency virus (HIV) undergoing pelvic reconstructive surgery (PRS) have an increased risk of perioperative and postoperative complications compared with HIV-negative controls., Study Design: Multicenter, retrospective matched cohort study of patients with and without HIV infection who underwent PRS between 2006 and 2016. Cases were identified using International Classification of Disease, 9th edition Clinical Modification and 10th edition Clinical Modification and current procedural terminology (CPT) codes encompassing HIV diagnoses and pelvic reconstructive surgeries. Controls were identified as patients without HIV who underwent similar procedures, performed by the same surgeon during the same 1-year period as surgeries performed on patients with HIV. Cases were matched to controls at a ratio of 1:3. The primary outcome was composite complication rate within 1 year of surgery., Results: Sixty-three patients with HIV and 187 controls were identified. There was no difference in the composite complication rate between women with HIV and HIV-negative women (36.5% vs 30.0%, P = 0.15) over 1 year. However, 19.1% of patients with HIV compared with 5.4% controls had Clavien Dindo Grade I complications (P = 0.002), and 11.1% of HIV patients had urinary retention within 6 weeks of surgery compared with 3.2% of controls (P = 0.02). After multivariable logistic regression used to adjust for confounders, living with HIV was not associated with an increased risk of complications., Conclusions: Patients living with HIV are not at an increased risk of complications within 1 year of PRS compared with patients without HIV.

Objective: To evaluate whether utilization of apical suspension procedures at the time of vaginal hysterectomy for pelvic organ prolapse varies with surgeon specialty., Methods: This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. International Classification of Diseases, Ninth Revision, Clinical Modification with a diagnosis of pelvic organ prolapse who underwent vaginal hysterectomy with any combination of pelvic reconstructive procedures. Propensity score matching using available preoperative clinical data was used to ameliorate selection bias by specialty at a ratio of 1 female pelvic reconstructive surgeon (FPMRS) surgeon to 2 obstetrician-gynecologists (OBG). Descriptive statistics were reported as means with standard deviations. Pairwise analysis using Student t test and Fisher exact test was performed where appropriate., Results: After propensity score matching, there were 901 cases performed by FPMRS and 1802 performed by OBG. The overall utilization rate of apical suspension in the matched cohort was 81.7% for FPMRS and 19.8% for OBG (P < 0.001). Obstetrician-gynecologists were more likely to perform vaginal hysterectomy without apical suspension compared with FPMRS (44.3% vs 5.8%; P < 0.001) and were also more likely to perform nonapical vaginal repair without also performing an apical suspension, (17.7% vs 9.3%, P < 0.001), compared to urogynecologists. On multivariable logistic regression, having surgery performed by FPMRS was the only significant variable associated with an increased likelihood of undergoing apical suspension (adjusted odds ratio, 5.34; 95% confidence interval, 4.48-6.36)., Conclusions: The FPMRS physicians are more likely to perform apical suspension with vaginal hysterectomy for prolapse repair compared with OBG.