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Introduction and hypothesis: Support of the vaginal apex is paramount for a durable repair of pelvic organ prolapse (POP). Our aim is to assess national utilization of apical suspension procedures for the surgical treatment of complete POP. We hypothesize that there might be a high rate of apical suspension with advanced prolapse. Methods: The 2006–2016 National Surgical Quality Improvement Program database was queried for a primary postoperative diagnosis of complete POP. The primary outcome was type of repair. Secondary outcomes included patient characteristics associated with apical suspension or colpocleisis. Procedures were delineated using CPT codes. Chi-squared and multivariate logistic regression analyses were used to evaluate factors associated with repair type. Results: A total of 2,784 women underwent surgery for complete POP with a mean age of 64.6 ± 11.0 years. Overall, 1,300 (46.7%) patients underwent apical suspension: 487 sacrocolpopexies (17.5%), 428 extraperitoneal suspensions (15.4%), and 391 uterosacral suspensions (14.0%). 5.2% (144) underwent colpocleisis, and 47.5% (1,332) of women had a concurrent hysterectomy (CH). With CH, 38.6% (502) had apical suspension or colpocleisis versus 69.5% (940) of post-hysterectomy cases. On logistic regression, CH was inversely associated with apical suspension (adjusted odds ratio [aOR] 0.37, CI 0.32–0.44, p < 0.001). Colpocleisis was associated with older age (aOR 4.9 per 10 years, CI 3.8–6.3, p < 0.001), post-hysterectomy surgery (aOR 0.23, CI 0.1–0.4, p < 0.001 for CH), and higher comorbidity index (OR 1.7, CI 1.1–2.6, p = 0.009). Complication rates are similar with and without apical suspension (8.2% versus 7.0%, p = 0.269). Conclusions: During surgery for complete POP, an apical suspension procedure is performed in 46.7% of patients and is more common post-hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes between total laparoscopic hysterectomy and total vaginal hysterectomy with uterine weight greater than 250 g.Methods: We conducted a retrospective cohort study using data from American College of Surgeons' National Quality Improvement Project Hysterectomy Specific Database. Women with uterine weight greater than 250 g undergoing hysterectomy for benign indications by total laparoscopic hysterectomy or total vaginal hysterectomy were matched by propensity scores, which were calculated using preoperative characteristics and uterine weight. Total vaginal hysterectomy was matched to total laparoscopic hysterectomy at a ratio of 1:2. Pairwise analysis was performed using Wilcoxon rank-sum and Fisher exact tests as appropriate. Multivariable logistic regression was performed to identify the independent effect of total vaginal hysterectomy on surgical outcomes.Results: There were 1,870 total vaginal hysterectomies that were matched to 3,740 total laparoscopic hysterectomies. No differences in preoperative demographics and comorbidities were seen for the patients. Uterine weight was similar for both groups: 376 g (interquartile range 293-501) for total vaginal hysterectomy and 384 g (interquartile range 302-515) for total laparoscopic hysterectomy (odds ratio [OR] 0.98, 95% CI 0.92-1.09). The rate of composite major complications was similar between total vaginal hysterectomy and total laparoscopic hysterectomy (4.3% vs 5.3%, OR 0.80, 95% CI 0.61-1.05). Intraoperative cystotomies were higher with total vaginal hysterectomy (0.8% vs 0.3%, OR 2.74, 95% CI 1.17-6.61), and ureteral injuries were more common with total laparoscopic hysterectomy (1.2% vs 0.2%, OR 0.12, 95% CI 0.02-0.38). Total vaginal hysterectomy operating time was significantly shorter compared with total laparoscopic hysterectomy (77 minutes, interquartile range 56-111 vs 122 minutes, interquartile range 91-164; OR 0.69, 95% CI 0.42-0.89). After adjusting for confounders, total vaginal hysterectomy was not found to be independently associated with major morbidity (adjusted odds ratio [aOR] 0.95, 95% CI 0.18-5.11) and was associated with a lower probability of operating times exceeding 2.5 hours (aOR 0.31, 95% CI 0.27-0.43).Conclusion: In patients matched by uterine size and preoperative characteristics, total vaginal hysterectomy is not associated with an increased composite risk of major surgical morbidity or other adverse surgical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the hospital-realized cost difference between transvaginal mesh prolapse repair and robot-assisted sacrocolpopexy.Methods: Consecutive transvaginal mesh prolapse surgery and robot-assisted sacrocolpopexy cases from January 2012 to December 2013 were evaluated. Patient clinical and operative data were recorded. The total institutional costs (direct and indirect) for each procedure were obtained and subcategorized by area. Independent sample t tests and chi-squared analysis were performed.Results: One hundred twenty women underwent transvaginal mesh repair whereas 106 underwent robotic sacrocolpopexy. Body mass index was similar between groups (28.1 vs 27.5) as was midurethral sling placement (50% vs 59%). Robotic patients were younger (61 years vs 67 years., P < .001) and more likely to undergo concomitant hysterectomy (58.5% vs 26.7%). There were similar rates for additional compartment repairs. Amortized costs for robotic purchase and maintenance were included with all depreciated equipment and realized by all patients undergoing surgery. Overall mean robotic operative time was longer with and without hysterectomy (279 minutes vs 174 minutes, P < .001 and 201 minutes vs 91 minutes, P < .001). Mean total costs were higher with robotic technique ($9675 vs $6718, P < .001), primarily driven by anesthesia ($1141 vs $675, P < .001), and operative ($6883 vs $4487, P < .001) costs. No differences for total costs were seen in laboratory fees, recovery room, or inpatient nursing.Conclusion: Transvaginal prolapse repair is less costly than robotic sacrocolpopexy. Length of surgery and additional robotic supplies drive the majority of increased operative costs. Costs attributed to robot purchase and maintenance do not uniquely factor into the procedure costs. [ABSTRACT FROM AUTHOR]

• Genetic control of prolapse in swine appears to be very low as indicated by the heritability estimates of 0.03 or less obtain in the present study. • Pork producers should identify environmental causes to lower the incidence in herds where the prolapse incidence is high. • Similar heritability estimates for sow prolapse were obtained when two different methods were used to estimate genetic parameters. Vaginal and rectal prolapse incidence has been increasing in the U.S. commercial breeding sow population in recent years. This has resulted in increased sow breeding mortality rates in the U.S. due to both increased mortality and euthanasia. The objective of the present study was to estimate the potential role that genetics plays in the prolapse incidence of the U.S. commercial sow population. Data from 11,481 purebred Large White sows from two commercial farms were used in this study. Genetic parameters for prolapse incidence were estimated based on linear and threshold animal models utilizing AIREMLF90 and THRGIBBS1F90, respectively. Across both models, the fixed effects included contemporary group as year-month of removal and removal parity and a random effect was sow. A pedigree-based relationship matrix was included in the model. The highest prolapse incidence occurred in the 1st when compared to other parities. Heritability estimates for combined vaginal and rectal prolapse incidence were 0.03 ± 0.01 and 0.003 ± 0.003 for the linear and threshold models, respectively. The results from this study indicate that there is very little if any genetic impact on the prolapse incidence. Pork producers should focus on the environmental effects contributing to reducing prolapse incidence. [ABSTRACT FROM AUTHOR]

Objective: To analyze the association between patient characteristics and the probability of undergoing any uterine-sparing procedure (endometrial ablation, myomectomy, and uterine artery embolization) compared with hysterectomy as the first uterine leiomyoma (index) procedure and the probability of undergoing a specific uterine-sparing procedure.Methods: We conducted a retrospective analysis using a commercial insurance claims database containing more than 13 million enrollees annually. Based on the index procedure performed 2004-2009, women were classified into one of the four procedure cohorts. Eligible women were aged 25-54 years on the index date, continuously insured through 1-year baseline and 1-year follow-up, and had a baseline uterine leiomyoma diagnosis. Logistic regression was used to assess the association between patient characteristics and leiomyoma procedure.Results: The study sample comprised 96,852 patients (endometrial ablation=12,169; myomectomy=7,039; uterine artery embolization=3,835; and hysterectomy=73,809). Patient characteristics associated with undergoing any uterine-sparing procedure compared with hysterectomy included health maintenance organization health plan enrollment, Northeast region residence, the highest income and education quintiles based on zip code, an age-race interaction, and baseline diagnoses including menstrual disorders, pelvic pain, anemia, endometriosis, genital prolapse, and infertility. Among those who had a uterine-sparing procedure, characteristics associated with undergoing uterine artery embolization or endometrial ablation compared with myomectomy included increasing age, being from the Midwest relative to the Northeast, and certain baseline conditions including menstrual disorder, pelvic pain, endometriosis, and infertility.Conclusion: Both clinical and nonclinical factors were associated with the receipt of alternatives to hysterectomy for uterine leiomyomas in commercially insured women. [ABSTRACT FROM AUTHOR]

Background: Prophylactic midurethral sling placement at the time of prolapse repair significantly reduces the risk for de novo stress urinary incontinence, but it is associated with some small but significant morbidities. Because there has not been a standardized approach to midurethral sling utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying midurethral sling placement strategies in addressing the risk for de novo stress urinary incontinence.Objective: We aimed to compare the cost effectiveness of the 3 midurethral sling utilization strategies in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. The 3 approaches are (1) staged strategy in which prolapse repair is done without prophylactic midurethral sling placement, (2) universal sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement, and (3) selective sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement only in patients with a positive prolapse-reduced cough stress test.Study Design: We created a decision analysis model to compare staged strategy, universal sling placement, and selective sling placement. We modeled probabilities of de novo stress urinary incontinence, patients choosing subsequent midurethral sling surgery for de novo stress urinary incontinence, and outcomes related to midurethral sling placement. De novo stress urinary incontinence rates were determined for each strategy from published data. The likelihood of patients with de novo stress urinary incontinence choosing midurethral sling surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic midurethral sling placement at their index prolapse repair. Finally, outcomes related to midurethral sling placement, including recurrent or persistent stress urinary incontinence, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications, were all derived from publicly available data. All midurethral sling placement procedures were assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or from previous literature with convertion to 2020 equivalent US dollar prices using the Consumer Price Index. The primary outcome was modeled as the incremental cost-effectiveness ratio. We performed multiple 1-way sensitivity analyses to assess model robustness.Results: The lowest-cost strategy was the staged strategy, which cost $1051.70 per patient, followed by $1093.75 for selective sling placement and $1125.54 for universal sling placement. The selective sling approach, however, had the highest health utility value; therefore, universal sling placement was dominated by selective sling placement because it is both less costly and more effective. When compared with the staged strategy, selective sling placement was cost effective with an incremental cost-effectiveness ratio of $2664 per quality adjusted life-years, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent midurethral sling surgery for de novo stress urinary incontinence after the index surgery. Only when this proportion exceeded 62% did universal sling placement become the cost-effective option because selective sling placement surpassed the predetermined incremental cost-effectiveness ratio threshold and became dominated.Conclusion: Selective sling placement was the preferred and cost-effective strategy in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo stress urinary incontinence after prolapse repair, as well as on the benefits and risks of prophylactic midurethral sling placement surgery. [ABSTRACT FROM AUTHOR]

The article discusses the results of a randomized controlled study which compared the outcomes between a vaginal prolapse surgery without mesh and one with mesh. The study noted that about five of the 32 patients in the group of vaginal prolapse with mesh had developed erosions. The U.S. Food and Drug Administration (FDA) has released a notification in October 2008 about the complications from using mesh such as infection, incontinence and visceral injury. Also noted is the benefit and disadvantage of using synthetic interpositional polypropylene mesh.

Abstract: The primary aims of this trial are: 1) to compare surgical outcomes following sacrospinous ligament fixation to uterosacral vaginal vault suspension in women undergoing vaginal surgery for apical or uterine pelvic organ prolapse and stress urinary incontinence and 2) to examine the effects of a structured perioperative program consisting of behavioral techniques and pelvic floor muscle training compared to usual care. This trial is performed through the Pelvic Floor Disorders Network (PFDN), which is funded by National Institute of Child Health and Human Development. Subjects will be enrolled from hospitals associated with seven PFDN clinical centers across the United States. A centralized biostatistical coordinating center will oversee data collection and analysis. Two approaches will be investigated simultaneously using a 2×2 randomized factorial design: a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (behavioral and pelvic floor muscle training versus usual care). Surgeons have standardized essential components of each surgical procedure and have met specific standards of expertise. Providers of the behavioral intervention have undergone standardized training. Anatomic, functional, and health-related quality of life outcomes will be assessed using validated measures by researchers blinded to all randomization assignments. Cost-effectiveness analysis will be performed using prospectively collected data on health care costs and resource utilization. The primary surgical endpoint is a composite outcome defined by anatomic recurrence, recurrence of bothersome vaginal prolapse symptoms and/or retreatment and will be assessed 2 years after the index surgery. Endpoints for the behavioral intervention include both short-term (6-month) improvement in urinary symptoms and long-term (2-year) improvement in anatomic outcomes and prolapse symptoms. This article describes the rationale and design of this randomized trial, focusing on several key design features of potential interest to researchers in the field of female pelvic floor disorders and others conducting randomized surgical trials. [Copyright &y& Elsevier]

Uterine prolapse impacts animal welfare and reduces sow farm profitability. In general, the incidence of uterine prolapse is higher in the United States than in other countries. Some suspected causes of uterine prolapse include water quality, vitamin deficiency, mycotoxins, and genetics. The objectives of this study were to: 1.) estimate the heritability of uterine prolapse; and 2.) to validate estimated breeding values (EBVs) for uterine prolapse in an independent, related population. Prolapse records collected from purebred females at a commercial multiplier (n = 16,434) and nucleus farm (n = 4,096) were used for training and validation, respectively. Phenotypes were recorded as the presence/absence of uterine prolapse at the sow level. Heritability estimates were derived from the training dataset by fitting year-season of insemination and parity at removal of the sow as fixed effects and animal as a random effect. Using the same model, validation was performed by regressing corrected offspring performance on sire EBV in the validation dataset. A pedigree- and a genomics-based relationship matrix were used for parameter estimation and the validation analysis, respectively. Incidence of uterine prolapse was heritable at 0.15 ± 0.02 and 0.22 ± 0.02 when analyzed using a linear vs. threshold model, respectively. Regression of corrected offspring performance on sire EBV resulted in a slope parameter of 0.40 (95%-CI; 0.27 - 0.54, including the expected value of 0.5), indicating that sire EBV is predictive of uterine prolapse among his offspring. In conclusion, these results show that uterine prolapse is lowly-to-moderately heritable, and therefore, mainly due to environmental factors. Higher incidence of uterine prolapse within the United States vs. other geographic locations confirms the existence of a strong environmental component. Genetic selection can be used to address genetic factors, but identifying/mitigating environmental triggers remains critical to reducing the incidence of uterine prolapse within the U.S. swine industry. [ABSTRACT FROM AUTHOR]

The article evaluates the effect of a high-fiber diet on constipation in women with pelvic floor disorders. According to the authors, increasing fiber intake gradually to the amount recommended by the U.S. National Academy of Sciences Institute of Medicine improves constipation and its associated symptoms. They add that reducing the incidence and severity of straining in constipated women may help a risk factor for the onset, progression or recurrence of prolapse.

The author focuses on the implications of drugs for vaginal mesh due to inconsistence and prolapse in the U.S. It is noted that drugs introduced in the market with the approval of the Food and Drug Administration had undergone several safety and efficacy trials, thus do not exist to test new surgical devices. It is suggested that people should demand higher standards and should not agree to use a product based on small and short studies.

Objective: The purpose of this study was to identify indications for and complications of abdominal or vaginal surgical removal of the cervical stump after previous supracervical hysterectomy. Study design: This was a retrospective chart review of trachelectomy patients at Mayo Clinic, Rochester, Minnesota, or Mayo Clinic, Scottsdale, Arizona, between January 1974 and December 2003. Results: Of 335 patients with a history of supracervical hysterectomy who subsequently required trachelectomy, 25 were excluded from study. Half of the remaining 310 patients had trachelectomy between 1974 and 1983, an average of 26 years after hysterectomy. The indication in three quarters of trachelectomies performed vaginally was prolapse. The vaginal approach had significantly fewer complications than the abdominal approach. Conclusion: Removal of the cervical stump is infrequent and has declined over a 30-year period. The decline in trachelectomy may be because of a decreasing number of supracervical hysterectomies performed. When trachelectomy is performed vaginally, prolapse is the most common indication, and there are few complications. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, and enterocele, is a common group of clinical conditions affecting millions of American women. This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse. The evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often challenging for the clinician to determine which symptoms are attributable to the prolapse itself and will therefore improve or resolve once the prolapse is treated. When treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; and surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms require additional management. Virtually all women with prolapse can be treated and their symptoms improved, even if not completely resolved. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to describe the prevalence of and correlates for pelvic organ prolapse.Study Design: This was a cross-sectional analysis of women who enrolled in the Women's Health Initiative Hormone Replacement Therapy Clinical Trial (n = 27,342 women). Baseline questionnaires ascertained demographics and personal habits. A baseline pelvic examination assessed uterine prolapse, cystocele, and rectocele. Descriptive statistics and logistic regression models were used to investigate factors that were associated with pelvic organ prolapse.Results: In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. After controlling for age, body mass index, and other health/physical variables, African American women demonstrated the lowest risk for prolapse. Hispanic women had the highest risk for uterine prolapse. Parity and obesity were strongly associated with increased risk for uterine prolapse, cystocele, and rectocele.Conclusion: Pelvic organ prolapse is a common condition in older women. The risk for prolapse differs between ethnic groups, which suggests that the approaches to risk-factor modification and prevention may also differ. These data will help address the gynecologic needs of diverse populations. [ABSTRACT FROM AUTHOR]

Examines sexual function in women before and after surgery for pelvis organ prolapse or urinary incontinence in Cleveland, Ohio. Changes in sexual functions related to vaginal dimensions; Satisfaction of operated women in terms of sexual relations; Evidence of dyspareunia after Burch colposusupension and posterior colporrhaphy.

Vaginal and rectal prolapse incidence has been increasing in the commercial breeding sow population in the U.S. This has resulted in increased sow breeding mortality rates in the U.S. in recent years. The objective of the present study was to estimate the potential role that genetics plays in the prolapse incidence of the U.S. commercial sow population. Data from 22,577 LW x LR crossbred sows from commercial breeding herds were used in this study. Genetic parameters for prolapse incidence were estimated using AIREMLF90 and THRGIBBS1F90 where an animal and threshold models were implemented. The fixed effects in the models included: contemporary group as farm and year-month of removal and removal parity. A random effect for sow and pedigree based relationship matrix was also included in the model. The highest rectal and reproductive tract prolapse incidence were observed in the 1st and 2nd parities. Moreover, sows born in 2013 were investigated greatest incidence of both prolapse incidence. Heritability estimates for prolapse incidence were 0.03 and 0.003 by using the animal and threshold models. The results from this study indicated that there is very little of any genetic impact on the prolapse incidence. Pork producers identify the environmental effects contributing to prolapse incidence. [ABSTRACT FROM AUTHOR]

Background: Given the accelerating opioid crisis in the United States and evidence that patients use fewer opioid tablets than prescribed, surgeons may choose to decrease prescribed quantities. The effect this may have on patient satisfaction with pain control after hospital discharge is unknown.Objective: The primary objective of this study was to compare patient satisfaction with postoperative pain control between patients receiving a routine or reduced quantity opioid prescription after prolapse repair. Secondary objectives included a comparison of opioid-related side-effects, the number of opioid tablets used, and the number of excess tablets prescribed between these groups.Study Design: This was a single-center, unmasked, 2-arm, randomized controlled noninferiority trial of women who underwent a prolapse repair with a planned overnight hospitalization. Patients were assigned randomly to 1 of 2 study arms: routine (28 tablets of oxycodone 5 mg) or reduced (5 tablets) prescription of opioid tablets. Patients were eligible if they were at least 18 years of age and undergoing a prolapse repair with an anticipated overnight hospital stay. Exclusion criteria included a history of chronic pain, preoperative opioid use, intolerance to study medication, or a score of ≥30 on the Pain Catastrophizing Scale. In addition to their opioid prescription, all patients received multimodal pain medications at discharge. Patients were asked to complete 6 weeks of diaries to record pain and medication use. The primary outcome (patient satisfaction) was collected as part of a postoperative survey completed at patients' routine postoperative visit 6 weeks after surgery. The sample size for noninferiority was calculated at 59 patients per group for a total of 118 patients.Results: One hundred eighteen patients were assigned randomly; the primary outcome was available for 116. The majority of patients were white, postmenopausal, and nonsmokers; the mean age was 62±10.4 years. The most common surgery was a hysterectomy with native tissue repair (n=71; 60%). One hundred ten patients (93%) were satisfied with postoperative pain control. Statistical analysis constructed for noninferiority showed that the difference between the groups was <15% (93% vs 93%; P=.005). Subjects in the reduced arm reported requiring an additional opioid prescription more frequently than in the routine arm (15% vs 2%; P=.01). Patients in the routine arm used more opioid tablets than the reduced arm (median, 3 [interquartile range, 0-14] vs 1 [interquartile range, 0-3]), but overall opioid utilization was low. As such, patients in the routine arm had significantly more unused opioid tablets (median, 26 [interquartile range, 15-28] vs 4 [interquartile range, 2-5]).Conclusion: Patient satisfaction with pain control was noninferior in patients who received a reduced quantity of opioid tablets after prolapse repair compared with those who received a routine prescription. A large quantity of excess opioid tablets was seen in both groups. Surgeons should consider prescribing 5-10 opioid tablets after prolapse repair surgery and consider applying these findings to postoperative prescribing after other gynecologic procedures. [ABSTRACT FROM AUTHOR]

Background: Occult uterine cancer at the time of benign hysterectomy poses unique challenges in patient care. There is large variability and uncertainty in estimated risk of occult uterine cancer in the literature and prior research often did not differentiate/include all subtypes.Objectives: To thoroughly examine the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications and to identify associated risk factors.Study Design: Using the New York Statewide Planning and Research Cooperative System database, we identified 229,536 adult women who underwent an inpatient or outpatient hysterectomy for benign indications during the period October 1, 2003 to December 31, 2013 at civilian hospitals and ambulatory surgery centers throughout the state. Diagnosis of corpus uteri cancer within 28 days after the index hysterectomy was determined using linked state cancer registry data. We estimated the prevalence of occult uterine cancer (overall and by subtype) and developed and validated risk prediction models using a random split sample approach.Results: Overall, 0.96% (95% confidence interval: 0.92-1.00%) of the women had occult uterine cancer, including 0.75% (95% confidence interval: 0.71-0.78%) with endometrial carcinoma and 0.22% (95% confidence interval: 0.20-0.23%) with uterine sarcoma. The prevalence of leiomyosarcoma was 0.15% (95% confidence interval: 0.13-0.17%). Seventy-one percent of the endometrial carcinomas and 58.0% of the uterine sarcomas were at localized stage. The risk for occult uterine cancer ranged from 0.10% in women aged 18-29 years to 4.40% in women aged ≥75 years; and varied from 0.14% in women undergoing hysterectomy for endometriosis to 0.62% for uterine fibroids and 8.43% for postmenopausal bleeding. The risk of occult uterine cancer was also significantly associated with race/ethnicity, obesity, comorbidity, and personal history of malignancy. Prediction models incorporating these risk factors had high negative predictive values (99.8% for endometrial carcinoma and 99.9% for uterine sarcoma) and good rule-out accuracy despite low positive predictive value.Conclusions: In women undergoing hysterectomy for presumed benign indications, 0.96% had unexpected uterine cancer. Patient characteristics such as age, surgical indication, and medical history may help guide risk stratification. [ABSTRACT FROM AUTHOR]

The article "Impact of surgeon experience on routine prolapse operations", written by Emil Nüssler, Jacob Kjær Eskildsen, Emil Karl Nüssler, Marie Bixo, and Mats Löfgren, was originally published without open access. [ABSTRACT FROM AUTHOR]

Background: Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports reestablishment of apical support at time of hysterectomy, regardless of whether the hysterectomy is performed for prolapse. National rates of apical support procedure performance at time of inpatient hysterectomy have not been well described.Objective: We sought to estimate trends and factors associated with use of apical support procedures at time of inpatient hysterectomy for benign indications in a large national database.Study Design: The National (Nationwide) Inpatient Sample was used to identify hysterectomies performed from 2004 through 2013 for benign indications. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to select both procedures and diagnoses. The primary outcome was performance of an apical support procedure at time of hysterectomy. Descriptive and multivariable analyses were performed.Results: There were 3,509,230 inpatient hysterectomies performed for benign disease from 2004 through 2013. In both nonprolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (P < .0001). There were 2,790,652 (79.5%) hysterectomies performed without a diagnosis of prolapse, and an apical support procedure was performed in only 85,879 (3.1%). There was a significant decrease in the proportion of hysterectomies with concurrent apical support procedure (high of 4.0% in 2004 to 2.5% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically assisted vaginal) were associated with performance of an apical support procedure. During the study period, 718,578 (20.5%) inpatient hysterectomies were performed for prolapse diagnoses and 266,743 (37.1%) included an apical support procedure. There was a significant increase in the proportion of hysterectomies with concurrent apical support procedure (low of 31.3% in 2005 to 49.3% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (medium and large), and hysterectomy type (total laparoscopic and laparoscopic supracervical) were associated with performance of an apical support procedure.Conclusion: This national database study demonstrates that apical support procedures are not routinely performed at time of inpatient hysterectomy regardless of presence of prolapse diagnosis. Educational efforts are needed to increase awareness of the importance of reestablishing apical vaginal support at time of hysterectomy regardless of indication. [ABSTRACT FROM AUTHOR]

Background: Puerperal uterine inversion is a rare, potentially life-threatening obstetrical emergency. The current literature consists of small case series and a single nationwide study from Europe with only 15 cases.Objective: We aimed to define the incidence, temporal trends, and outcomes in women with uterine inversion using a nationally representative US cohort.Study Design: We used the Nationwide Inpatient Sample, a 20% sample of US hospital admissions, to identify all deliveries from 2004 through 2013. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify cases of uterine inversion and associated adverse outcomes (maternal death, blood transfusion, maternal shock, need for surgical correction, and length of hospital stay). The incidence of uterine inversion overall and for each year of the study period was calculated with 95% confidence intervals. The case fatality and incidence of other adverse outcomes among women with a uterine inversion were also estimated.Results: Among 8,294,279 deliveries in 2004 through 2013, there were 2427 cases of puerperal uterine inversion, corresponding to an incidence of 2.9 per 10,000 deliveries (95% confidence interval, 2.8-3.0). There was 1 maternal death in our cohort (4.1 per 10,000 events). No change in the incidence of uterine inversion over the study period was detected. Among women with a uterine inversion, 37.7% (95% confidence interval, 35.8-39.6%) had an associated postpartum hemorrhage, 22.4% (95% confidence interval, 20.7-24.0%) received a blood transfusion, and 6.0% (95% confidence interval, 5.1-7.0%) required surgical management. Only 2.8% (95% confidence interval, 2.1-3.5%) underwent a hysterectomy. The median length of hospital stay was 3 days.Conclusion: This study provides the largest population-based results on puerperal uterine inversion to date and highlights the high likelihood of adverse maternal outcomes associated with the condition. The results inform the optimization of clinical management, by preparing for possible postpartum hemorrhage, need for blood products, and surgical management in the rare event of uterine inversion. [ABSTRACT FROM AUTHOR]

Background: It has been shown that addressing apical support at the time of hysterectomy for pelvic organ prolapse (POP) reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse.Objective: The objectives of this study were to: (1) determine rates of concomitant procedures for POP in hysterectomies performed with POP as an indication, (2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and (3) identify the influence of surgical complexity on perioperative complication rates.Study Design: This is a retrospective cohort study of hysterectomies performed for POP from Jan. 1, 2013, through May 7, 2014, in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications.Results: POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% confidence interval [CI], 40.6-45.6) of cases, 32.8% (95% CI, 30.4-35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI, 22-26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age >40 years, POP as the only indication for surgery (odd ratio [OR], 1.6; 95% CI, 1.185-2.230), laparoscopic surgery (OR, 3.2; 95% CI, 2.860-5.153), and a surgeon specializing in urogynecology (OR, 8.2; 95% CI, 5.156-12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR, 2.3; 95% CI, 1.088-4.686), with the use of a colpopexy procedure (OR, 3.1; 95% CI, 1.840-5.194), and by a surgeon specializing in urogynecology (OR, 2.2; 95% CI, 1.144-4.315).Conclusion: Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study. [ABSTRACT FROM AUTHOR]

The article reports on the study by John DeLancey and colleagues about the occurrence of muscle damage during vaginal birth and pelvic organ prolapse. It shows that women with prolapse were significantly more likely to have major levator ani defects than women in the control group. It also states that women with prolapse generated significantly less vaginal closure force than controls.