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Study Objective To describe the incidence of pelvic pain in transgender men undergoing hysterectomy for gender affirmation and to describe the incidence of endometriosis found at the time of surgery. Design Retrospective chart review of transgender men presenting for gender-affirming hysterectomy between 2010 and 2019. Patients were identified by Current Procedural Terminology codes and documented male gender in the medical record, which was queried for perioperative data. Setting All patients underwent minimally invasive hysterectomy under general anesthesia by 2 surgeons at 2 institutions. Patients Patients were individuals assigned female at birth identifying as male who met the criteria for gender-affirming hysterectomy. Interventions Hysterectomy performed using preferred techniques by the surgeons in this study. Measurements and Main Results Sixty-seven (N = 67) patients underwent hysterectomy: 98.5% (66) total laparoscopic with salpingo-oophorectomy and 1.5% (1) total laparoscopic with ovarian preservation. Mean age and body mass index were 29(±8) years and 28.6(±6.7) kg/m2, respectively. Of the patients, 89.5% (60) were on testosterone for a median of 36 (12–300) months: 59.7% (40) were amenorrheic, 43.2% (29) had dysmenorrhea, 17.9% (12) reported heavy menses, and 14.9% had irregular menses. Furthermore, 50.7% (34) complained of pelvic pain (35.3% constant, 64.7% cyclic). Intraoperative endometriosis was diagnosed in 26.9% (18) of the patients: in 32.3% of the patients who reported pelvic pain and in 21.9% of the patients without pain. There were no differences between patients with endometriosis compared with those without endometriosis except for those with endometriosis were more likely to report irregular bleeding (27.8% vs 8.3%, p = .04) and were also more likely to complain of heavy menses (66.7% vs 35.4%, p = .03). Conclusion Of the transgender men who presented for hysterectomy, 50% reported pelvic pain, but only 1 in 3 with pain had findings of endometriosis. Patients found to have endometriosis were more likely to report irregular bleeding and/or heavy menses.

STUDY OBJECTIVE The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. DESIGN Retrospective propensity-score matched cohort study. SETTING American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. INTERVENTIONS We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. MEASUREMENTS AND MAIN RESULTS The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p

Aims After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI. Methods This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ2 and multivariable logistic regression analyses were performed. Results We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ2 (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569). Conclusion When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.

Postoperative urinary retention is common after female pelvic reconstructive surgery. Alpha receptor antagonists can improve dysfunctional voiding by relaxing the bladder outlet and may be effective in reducing the risk of postoperative urinary retention.This study aimed to determine whether tamsulosin is effective in preventing postoperative urinary retention in women undergoing surgery for pelvic organ prolapse.This was a multicenter, double-blind, randomized controlled trial between August 2018 and June 2020, including women undergoing surgery for pelvic organ prolapse. Patients were excluded from recruitment if they had elevated preoperative postvoid residual volume, history of postoperative urinary retention, or a contraindication to tamsulosin. Those who experienced cystotomy were excluded from analysis. Participants were randomized to a 10-day perioperative course of tamsulosin 0.4 mg vs placebo, beginning 3 days before surgery. A standardized voiding trial was performed on postoperative day 1. The primary outcome was the development of postoperative urinary retention, as defined by the failure of the voiding trial or subsequent need for catheterization to empty the bladder. Secondary outcomes included the rate of urinary tract infection and the impact on lower urinary tract symptoms as measured by the American Urological Association Symptom Index.Of 119 patients, 57 received tamsulosin and 62 received placebo. Groups were similar in regard to demographics, preoperative prolapse and voiding characteristics, and surgical details. Tamsulosin was associated with a lower rate of postoperative urinary retention than placebo (5 patients [8.8%] vs 16 patients [25.8%]; odds ratio, 0.28; 95% confidence interval, 0.09-81; P=.02). The number needed to treat to prevent 1 case of postoperative urinary retention was 5.9 patients. The rate of urinary tract infection did not differ between groups. American Urological Association Symptom Index scores significantly improved after surgery in both groups (median total score, 14 vs 7; P.01). Scores related to urinary stream improved more in the tamsulosin group than in placebo (P=.03).In this placebo-controlled trial, tamsulosin use was associated with a reduced risk of postoperative urinary retention in women undergoing surgery for pelvic organ prolapse.

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 To describe the rate and 30-day outcomes after gender affirmation surgery in transgender men. Methods We conducted a cross-sectional population-based study. Patients with male gender who underwent hysterectomy for benign indications between 2013 and 2016 in the American College of Surgeons' National Surgical Quality Improvement database were identified. Propensity score matching was performed to ameliorate selection bias. Student t test and Mann-Whitney tests were used to compare continuous variables between two groups where appropriate. The χ and Fisher exact tests were used where appropriate to compare categorical variables across groups. Logistic regression models were used to evaluate factors associated with any postoperative adverse event. Results Of 159,736 hysterectomies performed during the study period, 521 (0.3%) were performed in transgender men. The mean age was 23.9±13.8 years, and the median body mass index was 29.0 (range 24.8-34.2). The majority of patients were white (64.5%). The most common specified diagnosis associated with hysterectomy was gender identity disorder (20.9%). Laparoscopy was the most common route (57.2%) followed by laparoscopic-assisted vaginal hysterectomy (20.0%) and abdominal hysterectomy (15.2%). After propensity matching was performed, the composite rate of postoperative complications was similar between the transgender male and control groups (3.4% vs 3.3%, P=.92). On multivariate logistic regression controlling for age, presence of a major medical comorbidity, and primary mode of surgery, transgender male status and presence of a major medical comorbidity were not significantly associated with complications (adjusted odds ratio [OR] 1.11, 95% CI 0.56-2.10 and adjusted OR 1.16, 95% CI 0.58-2.27, respectively). Age remained weakly associated with postoperative complications (adjusted OR 1.04, 95% CI 1.01-1.06), whereas minimally invasive approaches to hysterectomy were significantly associated with lower incidences of complications (vaginal, adjusted OR 0.04, 95% CI 0.002-0.17; laparoscopic adjusted OR 0.09, 95% CI 0.04-0.18; and laparoscopic-assisted vaginal hysterectomy, adjusted OR 0.07, 95% CI 0.02-0.20). Conclusion Less than 1% of hysterectomies performed annually are for transgender male patients. Postoperative complications after hysterectomy in this patient population are similar to the complication rates found in cisgender women.

The cough stress test is a common and accepted tool to evaluate stress urinary incontinence but there is no agreement on how the test should be performed. We assessed the diagnostic ability of different cough stress tests performed when varying patient position and bladder volume using urodynamic stress urinary incontinence as the gold standard. The 24-hour pad test was also evaluated.We recruited women who presented to specialty outpatient clinics with the complaint of urinary incontinence and who were recommended to undergo urodynamic testing. A total of 140 patients were randomized to 4 cough stress test groups, including group 1-a comfortably full bladder, group 2-an empty bladder, group 3- a bladder infused with 200 cc saline and group 4-a bladder filled to half functional capacity. The sequence of standing and sitting was randomly assigned. The groups were compared by 1-way ANOVA or the generalized Fisher exact test. The κ statistic was used to evaluate agreement between the sitting and standing positions. The 95% CIs of sensitivity and specificity were calculated using the Wilson method. ROC analysis was done to evaluate the performance of the 24-hour pad test.The cough stress test performed with a bladder filled to half functional capacity was the best performing test with 83% sensitivity and 90% specificity. There was no statistically significant evidence that the sensitivity or specificity of 1 cough stress test differed from that of the others. The pad test had no significant predictive ability to diagnose urodynamic stress urinary incontinence (AUC 0.60, p = 0.08).Cough stress tests were accurate to diagnose urodynamic stress urinary incontinence. The 24-hour pad test was not predictive of urodynamic stress urinary incontinence and not helpful when used in conjunction with the cough stress test.

Study Objective To determine if there is a difference in readmission rates after same-day discharge compared with postoperative day 1 discharges after laparoscopic hysterectomy. Design A retrospective cohort study with 1:2 propensity score matching (Canadian Task Force classification II-2). Setting American College of Surgeons National Surgical Quality Improvement Program database. Patients Women undergoing benign laparoscopic total or supracervical hysterectomy or laparoscopic-assisted vaginal hysterectomy with or without adnexal surgery between the years 2010 to 2015. Interventions Three thousand thirty-two low-risk women discharged on postoperative day 0 and 6064 women discharged on postoperative day 1 were included in the analysis. Measurements and Main Results The overall readmission rate was 1.8%; after same-day discharge, the readmission rate was 2.2%, and after postoperative day 1 discharge the readmission rate was 1.7% (p = .10). After logistic regression analysis, smoking (adjusted odds ratio [aOR] = 2.06; 95% confidence interval [CI], 1.49–2.88), nonwhite race (aOR = 1.53; 95% CI, 1.1007–2.14), and cystoscopy (aOR = 2.05; 95% CI, 1.49–2.82) were associated with an increased risk of readmission. Conclusion There was no statistically significant difference in readmission rates after laparoscopic hysterectomy between women discharged on the day of surgery or postoperative day 1.