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Objective: The goal of this research was to evaluate trends in gynecologic surgical reimbursement and to determine the factors affecting compensation. Materials and Methods: Procedure codes representing a comprehensive list of gynecologic surgical procedures were used to calculate the mean annual reimbursements from 2012 to 2017. Medicare compensation trends for all gynecologic procedures and trends for hysterectomies were evaluated with and without adjustment for inflation, using data from the Bureau of Labor and Statistics. The impact of the constituent components of physician billing was evaluated using linear regression. Results: Overall gynecologic surgical billing was flat with an insignificant increase of $12–$18 (2.5%–4.0%) during the study period. While the conversion factor increased significantly (5.2%) over time, the other major inputs to billing were flat. The most important determinant of compensation was the work relative value unit (wRVU). Using a regression model, a 1-point increase in the wRVU increased billing by $36.87. Laparoscopic hysterectomy reimbursement decreased significantly over time (p = 0.001). The mean reimbursement for laparoscopic hysterectomies dropped by 14.2% after changes to the relative value assignment were adjusted for these procedures. Conclusions: Gynecologic surgical reimbursement has been essentially flat over time. Reimbursement for laparoscopic hysterectomy has declined over time significantly. This inequity will only be magnified as hysterectomies shift to minimally invasive techniques. The most-effective method to maintain or improve overall gynecologic surgical compensation is to increase the assigned relative value unit for high-volume procedures such as hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To assess the volume and temporal trends in utilization of gynecologic surgery codes between 2010 and 2015. Study design: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to determine the frequency of individual gynecologic surgical procedures from 2010 to 2015. The National Inpatient Sample was used to further define the frequency of minimally invasive hysterectomies from 2012 to 2016. Data were analyzed using linear regression and chi-squared tests. Results: Gynecologic procedures represented 6.8% (95% confidence interval 6.8–6.9) of all surgical procedures included in the NSQIP database from 2010 through 2015 and this percentage was stable during the study period. The top 10% of procedures make up ∼70% (66.5%–71.2%) of all procedures performed. The top 40% of procedures make up ∼97% (96.8%–97.5%) of all procedures. Although hysterectomy codes were consistently among the top 10 most utilized codes, significant trends were observed in utilization related to the route of hysterectomy with rise of total laparoscopic hysterectomy (TLH). This was correlated with increasing adoption of robotic-assisted laparoscopy and decline of total vaginal hysterectomy (TVH) and abdominal hysterectomy (p < 0.001). There was also a large increase in concomitant adnexal surgery at the time of TLH, which potentially mirrors the recent rise in opportunistic salpingectomy. Conclusion: In this analysis, we highlight changes in the utilization of different gynecologic procedures to inform policy makers of challenges to appropriate reimbursement for laparoscopic procedures and a potential skills loss in open and vaginal procedures. (J GYNECOL SURG 37:323) [ABSTRACT FROM AUTHOR]

Objective: To determine if the presence of cerebral white matter disease (WMD) affects the response to anti-cholinergic medications. Materials and Methods: This was a retrospective cohort of age-matched patients treated for OAB with anti-cholinergic medications between January 2010 and December 2017. Inclusion criteria were a chief complaint of OAB, never evaluated by a urogynecologist for OAB, treated with a maximum dose for a minimum of 4 weeks, and underwent head computed tomography (CT) within 12 months of starting therapy. Patients with WMD were matched 1:1 by age and number of prior failed antimuscarinics to controls with normal head CTs. Exclusion criteria included incomplete documentation of therapeutic response, non-WMD CT abnormalities, and non-idiopathic OAB. The primary outcome was anti-cholinergic treatment failure. Pairwise analysis between groups was performed using Wilcoxon rank-sum and Fisher's exact test where appropriate. Univariate logistic regression was performed, and any variable that was associated with treatment failure and a p value ≤ 0.2 was included in the multivariable regression analysis. Results: Sixty-eight cases were matched with 68 controls. Patients with WMD were more likely to have undergone hysterectomy (57.4% vs. 41.2%, p = 0.04) and to use diuretics (31.1% vs. 19.1%, p = 0.04). Patients with WMD were more likely to fail treatment compared with controls (60.7% vs. 29.4%, p = 0.004). After adjusting for confounders, WMD was strongly associated with an increased probability of failure (aOR = 7.31, 95% CI: 1.49–12.20). Additional significant risk factors for treatment failure were the previous number of failed medications (aOR = 3.65 per medication, 95% CI: 1.48–9.01) and a rising HbA1c (aOR: 1.39 per 1.0% increase, 95% CI: 1.0–1.91). Conclusion: WMD is independently associated with anti-muscarinic treatment failure in women with overactive bladder symptoms. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Disorders of micturition result from a wide variety of conditions and evaluation often involves multiple diagnostic modalities. However, the sensitivity and specificity of these techniques are highly variable and may not always yield a diagnosis. Novel imaging techniques such as ultrasound shear wave elastography may help to improve diagnostic accuracy. Methods: Continent women were recruited from outpatient gynecology offices from a tertiary medical system. Participants underwent ultrasound evaluation with measurement of the shear wave velocity (SWV) of the bladder neck (BN). SWV was used to determine the Young's modulus of the bladder neck. The median bladder neck stiffness was calculated and univariate and step-wise and backward multivariate logistic regression analyses were used to identify significant patient characteristics associated with bladder neck stiffness above or below the median. Results: Fifty-seven women underwent SWE of the bladder; 12 were excluded, and 45 were included in the analysis. The median bladder neck stiffness of the study population was 22 (17.1-28.2) kPa. Age greater than 45 years was associated with a bladder neck stiffness above the median, OR 8.39, p < 0.001. Having no vaginal deliveries was also associated with a bladder neck stiffness greater than 22 kPa, unadjusted OR 4.76 (95 % CI 1.41-20.0, p = 0.012). Bladder volume and bladder neck thickness were not significantly associated with bladder neck stiffness above or below the median. Conclusion: Trans-abdominal shear wave elastography can be used to quantitatively assess bladder neck stiffness. This technique may potentially be useful for evaluating chronic urinary retention. [ABSTRACT FROM AUTHOR]

Background: There is evidence that premenopausal hormones may persist for variable time after menopause. Histological specimens from postmenopausal women support the presence of follicular growth at that age. Residual ovarian function may explain postmenopausal bleeding (PMB), which is not associated with endometrial pathology. Our objective was to evaluate the effect of sonographic diagnosis of simple ovarian cysts on the association between thickened endometrium and endometrial pathology in women with PMB. Materials and Methods: Data were retrospectively collected from medical records of women who underwent office hysteroscopy for PMB between January 2007 and October 2011. Women with sonographic reports within 3 months of presentation were included. Endometrial thickness and the presence of a simple ovarian cyst (£5 cm) were documented by reviewing sonographic reports. Diagnosis of endometrial pathology was abstracted according to pathology reports or hysteroscopic impression. Endometria with hyperplasia, cancer, or polyps were considered pathological. Results: Of 836 women with PMB, 356 had recent transvaginal sonography and were included in the analysis. Pathological endometrium was documented in 129 (36.2%) women, including 29 (8.2%) with endometrial cancer. In women with PMB and no evidence of a simple ovarian cyst, endometrial thickness was an independent predictor of endometrial pathology and endometrial cancer with adjusted OR= 1.13 (95% CI = 1.07-1.19) and 1.16 (95% CI = 1.07-1.25), respectively. In the presence of simple ovarian cysts, the adjusted ORs for endometrial thickness as a predictor of endometrial pathology were 1.06 (95% CI = 0.90-1.25) and 0.84 (95% CI = 0.62-1.14), respectively. Conclusion: The presence of simple ovarian cysts (≤5 cm) tempers the value of endometrial thickness in predicting endometrial pathology in women with PMB. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aim of this study was to determine the feasibility of a novel biomechanical test for evaluating mesh-reinforced repair compared to suture-reinforced repair using an animal model. We hypothesized that the fatigue life of a mesh reinforced repair would be greater than that of xenograft reinforced repair and suture-only repair. Methods: Wistar rats were randomly assigned to undergo a ventral hernia repair using sutures or one of the three mesh materials representative of incorporation, encapsulation and resorption host responses (Gynemesh®, Pelvisoft® and Surgisis®, respectively). All surviving animals were killed at 90 days and specimens containing the prosthesis-tissue interface were exposed to cyclic forces. The number of cycles to failure (fatigue life) was compared between groups using a Cox regression model. Results: Of 40 randomly assigned animals, 11 died before 90 days. After randomizing an additional 5 rats, a total of 34 rats were killed at 90 days. The proportions of specimens that failed before 10,000 cycles were 25 % (2/8), 50 % (4/8), 62.5 % (5/8) and 70 % (7/10) in the Gynemesh, Surgisis, Pelvisoft, and suture control groups, respectively. In addition, the median number of cycles to failure was >10,000 in the Gynemesh group, >6,923 in the Surgisis group, 1133 in the Pelvisoft group and 741 in the control group. After adjustment for cross-sectional area, the risk of failure in the suture control group was higher than in all of the reinforced repair groups combined with an adjusted hazard ratio of 2.58 (95 % CI 0.96 - 6.97), and was statistically significantly higher than in the Gynemesh group with an adjusted hazard ratio of 6.67 (95 % CI 1.30 - 34.48). Conclusion: We present a novel biomechanical test that can be used to compare mesh materials in an animal model prior to use in humans. In this animal model, after adjusting for cross-sectional area, suture reinforced repair has a higher risk of failure than graft reinforced repair. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the efficacy and safety of endometrial ablation (EA) among obese versus non-obese women. Methods: A retrospective cohort study of 666 women who underwent EA at the Mayo Clinic, Rochester, USA, between January 1, 1998, and December 31, 2005, was conducted. Obesity was defined as a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30 or above. Outcome measures included treatment failure and amenorrhea. Regression models were used to compare outcomes and adjust for known confounders. Results: The mean BMI was 29.6±7.7; 263 women (39.5%) were classified as obese. No difference was observed in treatment failure at 5years between the obese and non-obese cohorts (11.6% vs 9.7%) with an adjusted hazard ratio of 0.96 (95% confidence interval [CI], 0.60–1.53; P =0.878). The crude 12-month amenorrhea rate was higher among non-obese than obese women (24.3% vs 17.5%); however, this difference was not significant after adjusting for known predictors of amenorrhea. The odds ratio was 1.28 (95% CI, 0.75–2.19; P =0.366). Adverse events were rare and comparable between the cohorts. Conclusion: The use of EA is a safe and effective option for women with obesity. [Copyright &y& Elsevier]