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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.

It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly. The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications. A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), “other race” (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications. ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

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.

To determine if graft augmentation with anterior colporrhaphy (AC+G) is associated with higher complication rates compared to native tissue repair (AC). Retrospective cohort study using data from the ACS-NSQIP database between 2010 and 2017. CPT codes were used to identify women undergoing AC+G and AC. Propensity scores for the likelihood of undergoing AC+G were calculated and were used to match to women undergoing native tissue repair at a ratio of 1:2. The primary outcome was the composite complication rate. Descriptive statistics are reported as means with standard deviations for parametric data and as medians and interquartile ranges for non-parametric data. Pairwise comparisons were performed using Fisher’s exact test, Wilcoxon rank-sum and Student’s t test as appropriate. Multivariable logistic regression was then used to adjust for confounders to identify statistically significant factors associated with the likelihood of experiencing a complication after prolapse repair. 582 women met inclusion criteria for AC+G and were matched with 1164 women undergoing AC. There were no differences in preoperative characteristics between groups. There was no difference in the composite complication rate, (10.8% vs. 8.5%, p = 0.13) between groups. Dependent functional status (aOR 4.31, 95% CI 1.96–13.58) was the strongest predictor of the likelihood of a complication: other significant predictors were operating time greater than 20 min (aOR 1.68, 95% CI 1.19–2.38) and ASA class greater than 2 (aOR 1.44, 95% CI 1.01–2.05). There is no increase in 30-day complication rates in women undergoing AC+G compared to a matched cohort of those undergoing AC alone.

The purpose of this study was to evaluate the accuracy of the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) surgical risk calculator in predicting postoperative complications in patients undergoing pelvic organ prolapse surgery. We performed a retrospective review of 354 patients who underwent surgery for pelvic organ prolapse from 2013 to 2017 at a single academic institution. Patient medical information and surgical procedure were entered into the calculator to obtain predicted complication rates, which were compared with observed complications. Logistic regression, C-statistic, and Brier score were used to assess the accuracy of the calculator. Of 354 patients included in the analysis, 79.7% were under the age of 75, and 41.5% were classified as American Society of Anesthesiologists class ≥3. The majority of patients underwent robotic sacrocolpopexy (40.7%) or uterosacral ligament suspension (36.4%), followed by colpocleisis, abdominal sacrocolpopexy, and extraperitoneal suspension. Complications were experienced by 100 patients (28.3%). Most common complications were urinary tract infection (n = 57), surgical site infection (n = 42), and readmission (n = 16); other complications were rare. The surgical risk calculator displayed poor predictive ability for experiencing a complication (C-statistic = 0.547, Brier score = 0.25). The NSQIP surgical risk calculator displayed poor predictive ability in our cohort of patients undergoing surgery for pelvic organ prolapse, suggesting that this tool might have limited clinical applicability to individual patients in this population.

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. 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. 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

Objective To evaluate the effects of old age and frailty on complication rates after surgery for pelvic organ prolapse. Methods The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for prolapse from 2010 to 2017. We compared our control group (45-64 years, index population) to those aged 65-79 years (elderly) and 80 years and older (very elderly). Frailty was assessed using the National Surgical Quality Improvement Program Modified Frailty Index-5. The primary outcome was the composite rate of serious complications and mortality. Results We analyzed 27,403 patients in the index population, 20,567 in the elderly group, and 3,088 in the very elderly group. The composite rate of serious complications in the index population was 4.5%, compared with 4.7% in the elderly group (odds ratio [OR] 1.0, 95% CI 0.9-1.1) and 9.0% in the very elderly group (OR 2.1, 95% CI 1.8-2.4). Compared with the index group, the very elderly group had notably elevated risks of cardiac complications (OR 11.9, 95% CI 6.2-23.0), stroke (OR 26.6, 95% CI 5.4-131.8), and mortality (OR 39.9, 95% CI 8.6-184.7). On multivariate logistic regression, the only age group independently associated with serious complications was the very elderly group (adjusted odds ratio [aOR] 2.01, 95% CI 1.8-2.3). The Modified Frailty Index-5 score was independently predictive of complications (aOR 1.4, 95% CI 1.1-2.0). Stratified analysis using interaction terms revealed the Modified Frailty Index-5 score to be predictive of complications in the elderly age group (aOR 2.5, 95% CI 1.3-4.6), but not in the very elderly group. Conclusion Serious complications surrounding prolapse surgery increase substantially in the cohort of patients older than 80 years of age, independent of frailty and medical or surgical risk factors.

This study aimed to determine factors associated with prolonged hospital admission following outpatient female pelvic reconstructive surgery (FPRS) and associated adverse clinical outcomes.Using the National Surgical Quality Improvement Program database, we identified outpatient FPRS performed 2011-2016. Isolated hysterectomy without concurrent prolapse repair was excluded. Surgeries were classified as major or minor for analysis. The primary outcome was prolonged length of stay (LOS), defined as admission of ≥2 days. Secondary outcomes included complications, readmission and reoperation associated with prolonged LOS. We abstracted data on covariates, and following univariable analysis, performed backward stepwise regression analysis.A total of 29645 women were included: 12311 (41.5%) major and 17334 (58.5%) minor procedures. A total of 6.9% (2033) had a prolonged LOS. On full cohort multivariable regression analysis, patient characteristics associated with prolonged LOS were older age (odds ratio [OR]: 1.1 per 10 years, confidence interval [CI]: 1.06-1.1, p 0.001), frailty (OR: 1.8, 95% CI: 1.3-2.6, p = 0.001), and Caucasian race (OR: 1.2, CI: 1.02-1.3, p = 0.024). Associated surgical factors included having a major surgical procedure (OR: 1.3, CI: 1.2-1.4, p 0.001), use of general anesthesia (OR: 2.0, CI: 1.5-2.6, p 0.001) and longer operative time (OR: 2.0, CI: 1.8-2.2, p 0.001). The occurrence of any complication (10.3% vs. 4.7%, p 0.001), hospital readmission (4.3% vs. 1.7%, p 0.001), and reoperation (2.7% vs. 1.0%, p 0.001) were more likely with prolonged LOS.After outpatient FPRS, 6.9% of patients experience an admission of ≥2 days. Prolonged LOS is more common in patients who are older, frail and Caucasian, and in those who have major surgery with long operative time and general anesthesia.

Despite an estimated 10% prevalence of endometriosis among reproductive-age women, surgical population-based data are limited.We sought to investigate racial and ethnic disparities in surgical interventions and complications among patients undergoing endometriosis surgery across the United States.We performed a retrospective cohort study of American College of Surgeons National Surgical Quality Improvement Program data from 2010 to 2018 identifying International Classification of Diseases, Ninth/Tenth Revision codes for endometriosis We compared procedures, surgical routes (laparoscopy vs laparotomy), and 30-day postoperative complications by race and ethnicity.We identified 11,936 patients who underwent surgery for endometriosis (65% White, 8.2% Hispanic, 7.3% Black or African American, 6.2% Asian, 1.0% Native Hawaiian or Pacific Islander, 0.6% American Indian or Alaska Native, and 11.5% of unknown race). Perioperative complications occurred in 9.6% of cases. After adjusting for confounders, being Hispanic (adjusted odds ratio, 1.31; 95% confidence interval, 1.06-1.64), Black or African American (adjusted odds ratio, 1.71; confidence interval, 1.39-2.10), Native Hawaiian or Pacific Islander (adjusted odds ratio, 2.08; confidence interval, 1.28-3.37), or American Indian or Alaska Native (adjusted odds ratio, 2.34; confidence interval, 1.32-4.17) was associated with surgical complications. Hysterectomies among Hispanic (adjusted odds ratio, 1.68; confidence interval, 1.38-2.06), Black or African American (adjusted odds ratio, 1.77; confidence interval, 1.43-2.18), Asian (adjusted odds ratio, 1.87; confidence interval, 1.43-2.46), Native Hawaiian or Pacific Islander (adjusted odds ratio, 4.16; confidence interval, 2.14-8.10), and patients of unknown race or ethnicity (adjusted odds ratio, 2.07; confidence interval, 1.75-2.47) were more likely to be open. Being Hispanic (adjusted odds ratio, 1.64; confidence interval, 1.16-2.30) or Black or African American (adjusted odds ratio, 2.64; confidence interval, 1.95-3.58) was also associated with receipt of laparotomy for nonhysterectomy procedures. The likelihood of undergoing oophorectomy was increased for Hispanic and Black women (adjusted odds ratio, 2.57; confidence interval, 1.96-3.37 and adjusted odds ratio, 2.06; confidence interval, 1.51-2.80, respectively), especially at younger ages.Race and ethnicity were independently associated with surgical care for endometriosis, with elevated complication rates experienced by Hispanic, Black or African American, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native patients.

Objectives The aim of this study was to compare the risk of complications associated with obliterative surgery versus reconstructive surgery in elderly and frail patients undergoing surgery for pelvic organ prolapse. Methods We performed a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2017. We compared characteristics and perioperative complications in patients aged 80 years or older who underwent obliterative surgery versus reconstructive surgery. Multivariate logistic regression and propensity score matching were used to control for confounding. A subanalysis was performed that included patients who were considered frail as defined by the National Surgical Quality Improvement Program Modified Frailty Index 5. Results Of 1,654 total patients, reconstructive surgery was performed in 56.9% of patients, and obliterative surgery was performed in 43.1%. The respective composite complication rates were 9.2% and 9.8% (P = 0.69), whereas severe complications were experienced by 1.9% in the reconstructive group versus 0.8% in the obliterative group (P = 0.07). On multivariate logistic regression, reconstructive surgery was not significantly associated with the composite complication rate (adjusted odds ratio, 1.0; 95% confidence interval, 0.7-1.4; P = 0.80). After propensity score matching, composite complications did not differ between groups, but the rate of severe complications was significantly higher in patients who underwent reconstructive surgery compared with obliterative surgery (2.1% vs 0.8%; odds ratio, 2.53; 95% confidence interval, 1.01-6.36; P = 0.05). In frail patients only, complication rates did not differ between groups. Conclusions In patients aged 80 years or older, the overall rate of complications did not differ between those who underwent reconstructive surgery versus obliterative surgery. However, propensity score matching identified an increased risk of the most severe complications in patients who underwent reconstructive surgery.

To determine if the presence of cerebral white matter disease (WMD) affects the response to anti-cholinergic medications. 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. 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). WMD is independently associated with anti-muscarinic treatment failure in women with overactive bladder symptoms.

Objective: The primary objective of our study was to identify predictors of goal achievement in patients undergoing simple hysterectomy for benign indications. We also sought to describe the goals of patients in this population. Study Design: This was a prospective cohort study of patients undergoing hysterectomy for benign indications performed at a single academic institution. We documented patient-reported goals of treatment prior to undergoing hysterectomy in 57 patients, and assessed goal achievement and other patient-centered outcomes three months after surgery in 47 of the patients (82.5%). We compared patients who met all of their goals to those who did not, and used multivariate regression to identify predictors of goal achievement. We also characterized the general profile of goals for patients undergoing hysterectomy. Results: We identified the primary surgical diagnosis of abnormal uterine bleeding (OR 6.5, 1.7–30.1, p = 0.006), as well as an increased feeling of being prepared for postoperative discharge (OR 11.9, 2.1–104.4, p = 0.005), to be independent predictors of patient goal achievement. Goal achievement was correlated with other patient-centered outcomes, including a higher sense of satisfaction and greater patient global impression of improvement. Goals related to symptoms were more commonly stated and more commonly achieved than functional goals. Conclusion: Goal achievement in patients undergoing hysterectomy depends on the preoperative diagnosis and the patient’s feeling of preparedness for postoperative discharge. Goal achievement should be considered as a useful patient-centered outcome. Patients undergoing hysterectomy have a unique profile of goals which should be considered and addressed in preoperative counseling.

OBJECTIVE To evaluate national trends in major adverse cardiovascular and cerebrovascular events (MACCE) in female pelvic reconstructive surgery (FPRS). METHODS Data from the National Inpatient Sample was used to identify women undergoing FPRS between 2012 and 2016. Demographic, procedural, and comorbidity data were collected. Patients were stratified into those with and without MACCE (defined as all-cause mortality, cardiac arrest, myocardial infarction (MI) and acute ischemic stroke). Descriptive statistics are expressed as medians and interquartile ranges. Pairwise analysis was performed using Wilcoxon rank-sum or Fisher exact test as appropriate. Multivariable logistic regression was used to identify independent risk factors for MACCE. RESULTS During the study period, 53,540 patients underwent FPRS. The rate of MACCE was 4.8 per 1000 surgeries; MI, 3.7; acute ischemic stroke, 0.6; cardiac arrest, 0.4; and all-cause mortality, 0.3. Patients experiencing MACCE were more likely to have major preexisting cardiovascular comorbidities, coagulopathy, neurologic disease (ND), and diabetes and were more likely to undergo robotic colpopexy (20.7% vs 9.6%, P < 0.001), vaginal colpopexy (32.0% vs 28.5%, P = 0.04), and to receive a blood transfusion (8.2% vs 2.5%, P < 0.001).On logistic regression, preexisting coagulopathy was the strongest predictor of MACCE (adjusted odds ratio [aOR], 5.53; 95% confidence interval [CI], 2.39-12.78), followed by blood transfusion (aOR, 4.84; 95% CI, 1.89-12.45), congestive heart failure (aOR, 3.61; 95% CI, 1.56-8.37), ND (aOR, 3.14; 95% CI, 1.23-8.06), and electrolyte abnormalities (aOR, 1.99; 95% CI, 1.05-3.99). CONCLUSION Major adverse cardiovascular and cerebrovascular events after FPRS is a rare event, with MI being the most common manifestation. Preexisting ND, congestive heart failure, coagulopathy, electrolyte disturbances, and perioperative transfusions are strongly associated with MACCE.

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.

It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly.The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications.A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age 85 years (aOR 1.98), operative time 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications.ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

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.

Background As transmasculine persons utilize androgen gender affirming hormone therapy as a part of transition, guidance has been lacking on the effects of the therapy on the ovaries, especially for those who may desire retention. Aim To describe the ovarian histopathology of transmasculine persons on testosterone therapy following oophorectomy at the time of hysterectomy performed for gender affirmation. Methods This was a multicenter case series study of transmasculine patients on testosterone therapy who underwent hysterectomy with oophorectomy for gender affirmation between January 2015 and December 2017 at 5 tertiary care referral centers. Patients were identified by their current procedural and International Classification of Diseases codes. Outcomes Pre-, perioperative, and pathologic data were obtained from the electronic medical records and ovarian tissue descriptions from pathology reports were grouped into the following classifications: (i) simple/follicular cysts; (ii) polycystic ovaries; (iii) complex cysts; (iv) endometriomas; (v) other masses; (vi) atrophy; and (vii) normal. Results 85 patients were included in the study. At the time of oophorectomy, the mean age and body mass index of the cohort were 30.4 ± 8.4 years and 30.2 ± 7.3 kg/m2, respectively, and the average interval from the initiation of testosterone to oophorectomy was 36 0.3 ± 37.9 months. On examination of ovarian histopathology, 49.4% (42) of specimens were found to have follicular/simple cysts, 5.9% (5) were polycystic, and 38.8% (33) had normal pathology. For those specimens with volume documented (n = 41), the median volume was 9.6 (range 1.5–82.5) cm3. There was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries. Clinical Implications The results of this study reported benign histopathology in ovaries of a large cohort of transmasculine persons on testosterone which should be included when counseling patients on ovarian retention, as transmasculine patients may choose to retain their ovaries while on testosterone for a variety of reasons (including no desire to undergo surgery, desire for backup sex steroids, and potential use for future fertility). Strengths & Limitations This is a large multicenter study seeking to address the uncertainty in present counseling surrounding ovarian conservation in transmasculine persons on testosterone therapy. Its limitations included its retrospective nature and inability to address ovarian function after testosterone discontinuance. Conclusion In this cohort of transmasculine patients on testosterone therapy undergoing hysterectomy with oophorectomy for gender affirmation, ovarian histopathology was benign in all the specimens.

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.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.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).During surgery for complete POP, an apical suspension procedure is performed in 46.7% of patients and is more common post-hysterectomy.

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.

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.

To evaluate whether utilization of apical suspension procedures at the time of vaginal hysterectomy for pelvic organ prolapse varies with surgeon specialty.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.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 (P0.001). Obstetrician-gynecologists were more likely to perform vaginal hysterectomy without apical suspension compared with FPMRS (44.3% vs 5.8%; P0.001) and were also more likely to perform nonapical vaginal repair without also performing an apical suspension, (17.7% vs 9.3%, P0.001), 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).The FPMRS physicians are more likely to perform apical suspension with vaginal hysterectomy for prolapse repair compared with OBG.

Preoperative counseling about salpingectomy with pelvic surgery is recommended by the American College of Obstetrics and Gynecology for ovarian cancer risk reduction. Our objective was to determine recent practice patterns and patient factors associated with salpingectomy with vaginal hysterectomy (VH) for pelvic organ prolapse (POP) in the USA. We hypothesize that salpingectomy might have become more common in recent years. We queried the 2014–2016 National Surgical Quality Improvement Program database for women with a postoperative diagnosis of POP who underwent VH with any combination of pelvic reconstructive procedures. CPT codes do not differentiate salpingectomy from salpingo-oophorectomy, so subjects were stratified by whether concurrent adnexectomy was performed. Chi-squared and multivariate logistic regression analyses were used to evaluate characteristics associated with adnexectomy. Propensity score matching was utilized when evaluating postoperative complication rates. Of 5,344 women who underwent VH, 2019 (37.8%) had adnexectomy. Adnexectomy rate increased from 34.4% in 2014 to 46.8% in 2016 (p

STUDY OBJECTIVE To compare complications in patients undergoing laparoscopic vs open surgery for acute pelvic inflammatory disease (PID). DESIGN We performed a retrospective cohort study of patients who underwent surgery for PID, using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2015. Propensity score matching was used to balance baseline characteristics and compare complications in patients who underwent laparoscopic vs open surgery. SETTING Surgical management of acute PID. PATIENTS Patients with a preoperative diagnosis of PID were identified using International Classification of Diseases, Ninth Revision, codes. We excluded patients with chronic PID, gynecologic malignancy, and those for whom the surgical route was unknown. INTERVENTIONS Surgery for acute PID. MEASUREMENTS AND MAIN RESULTS The study included 367 patients. The mean age was 43.0 ± 11.1 years, body mass index was 30.9 ± 11.2 kg/m2, and American Society of Anesthesiology class was 2 (interquartile range 2-3). Preoperative signs of sepsis were noted in 33.8% of the patients, and septic shock was present in 1.4%. Hysterectomy was performed in 67.6%, oophorectomy in 12.0%, and salpingectomy in 4.6%. Complications were experienced by 114 patients (31.1%), 11 (3.0%) of which were potentially life-threatening. Multivariate logistic regression identified the following to be independently associated with complications: laparoscopy (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI], 0.3-0.8; p

Study Objective To determine if tamsulosin is effective in reducing the risk of postoperative urinary retention in women undergoing pelvic reconstructive surgery. Design We performed a multicenter double-blind randomized controlled trial. Setting Surgery for pelvic organ prolapse with or without a concomitant incontinence procedure. Patients or Participants All patients undergoing surgery for pelvic organ prolapse from August 2018 to March 2020 at two academic institutions were screened. Patients with a history of urinary retention requiring catheterization, sulfa allergy, or a preoperative post-void residual volume of greater than 100ml were not eligible. Participants who experienced cystotomy were excluded from analysis. A total of 132 patients were enrolled. Interventions Using permuted block randomization, participants were allocated to receive a 10-day course of either tamsulosin 0.4mg or placebo, beginning 3 days prior to surgery. Both patients and providers were blinded to treatment group. A standardized voiding trial was performed on postoperative day one. Measurements and Main Results An intention-to-treat analysis of 118 patients was performed. Patients received either tamsulosin (n=57) or placebo (n=61). Mean age was 61.2 ± 10.2 years, 86.4% were Caucasian, and 71.2% had stage 2 or 3 prolapse. Procedures included vaginal prolapse repair in 85.6%, abdominal prolapse repair in 49.2%, hysterectomy in 66.9%, and midurethral sling in 60.2%. Groups were similar in regards to demographics, pelvic organ prolapse quantification scores, baseline urinary symptoms, urodynamic parameters, and surgical details. Tamsulosin users had a significantly lower rate of urinary retention compared to placebo (8.7% vs 24.6%, p=0.03). Postoperative urinary tract infection and prolonged urinary retention requiring reoperation did not differ between groups. Variables associated with the development of postoperative urinary retention included tamsulosin use (OR 0.29, 95%CI 0.10-0.85) and American Urological Association Symptom Index score (OR 0.90, 95%CI 0.82-0.98). Conclusion This study supports the prophylactic use of tamsulosin to reduce the risk of postoperative urinary retention following female pelvic reconstructive surgery.

Study Objective To develop a visual tool to predict the risk of perioperative complications in surgery for pelvic inflammatory disease (PID). Design We retrospectively analyzed the risk of complications within 30 days of surgery for PID using the National Surgical Quality Improvement Program database. Multivariate logistic regression was used to identify preoperative variables associated with complications, and to develop a corresponding nomogram to estimate an individual patient's preoperative risk of morbidity. The nomogram was internally validated using K-fold cross validation. A separate dataset was used to externally validate the model. Setting N/A. Patients or Participants Patients who underwent surgical management of PID from 2010 to 2015 were analyzed, providing a total study population of 761 patients. Patients from 2010 to 2014 were used to create the model. Patients from 2015 were used to externally validate the model. Interventions N/A. Measurements and Main Results The mean age was 43.5 years, mean BMI was 30.6kg/m2, and 60.1% were ASA class 2. Sepsis or septic shock was present in 149 patients (19.5%). Surgery was performed laparoscopically in 40.7% of patients. The composite complication rate was 23.3%. Multivariate logistic regression identified the following preoperative variables to be most strongly predictive of complications: laparoscopy, ASA class, BMI, wound class, septic shock, hematocrit 1.2, and creatinine>1.2. Mean cross-validated AUC-ROC was 0.7120. This regression model was then used to generate a predictive nomogram. Using preoperative patient information, the nomogram was used to provide a predicted probability of complications for each individual patient in the validation cohort. The nomogram-predicted probability was similar to the true rate of experiencing a complication (24.0% vs 24.5%, p=0.9). The AUC-ROC value of this nomogram-predicted probability in the validation cohort (0.7010) did not differ from that of the initial nomogram model (p=0.7). Conclusion This validated tool can be used to estimate the risk of perioperative morbidity prior to proceeding with surgical management of PID.

Background Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use. Objective The objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery. Study Design This was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power). Results Thirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P Conclusion The ice packs, Tylenol, and Toradol multimodal pain regimen offers improved pain control the morning after surgery and 96 hours postoperatively compared with the standard regimen with no differences in patient satisfaction and quality of recovery. Ice packs, Tylenol, and Toradol can significantly limit postoperative inpatient narcotic use and eliminate outpatient narcotic use in patients undergoing vaginal pelvic reconstructive surgery.

Study Objective Primary objective was to evaluate risk of perioperative complications when performing concomitant urogynecologic surgery at time of minimally invasive hysterectomy for large uterus (>250gm). Design Retrospective cohort study of existing national database. Patients were followed for complications 30 days after hysterectomy. Setting Data was extracted from the NSQIP database. Patients or Participants Patients were included who underwent laparoscopic or vaginal hysterectomy for benign indications with uterine weight of at least 250gm from 2014-2017. Patients with gynecologic malignancy and those who underwent abdominal hysterectomy were excluded. The total cohort included 7,428 patients. Interventions We assessed the effect of concomitant urogynecologic procedure on 30 day complication rates after laparoscopic or vaginal hysterectomy for large uterus (>250gm). Measurements and Main Results Chi-square analysis and Student's t-test were used to describe the population and compare groups. Primary outcome was composite rate of all 30 day complications. Stepwise backward multivariate logistic regression was used to control for confounders of the primary outcome. 301 of the 7,428 total patients (4.1%) underwent concomitant urogynecologic procedures. This population was older (49.7 vs 46.6 years, p Conclusion In this retrospective analysis of a large national cohort, the 30 day complication rate was greater than 50% higher when concomitant urogynecologic procedure was performed at the time of minimally invasive hysterectomy for a uterus >250gm.

Study Objective To report rates and identify risk factors for urinary tract infection (UTI) following hysterectomy for benign conditions. Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients or Participants Women undergoing benign hysterectomy by any modality between 2010 and 2017. Interventions Abdominal hysterectomy (AH), total laparoscopic hysterectomy (TLH), laparoscopic supracervical hysterectomy, laparoscopic assisted vaginal hysterectomy (LAVH), vaginal hysterectomy (TVH). Measurements and Main Results 67,243 women included in the analysis with 1,310 postoperative UTIs identified, at a rate of 19.5 per 1000 hysterectomies. Women who developed UTIs were more likely to smoke (19.6% vs 15.7%, p= Procedures complicated by UTI were longer (148.1min +/-79.4 vs 135.5min +/-65.6, p= Following regression analysis, cystotomy (aOR=4.16, 95%CI=2.57-6.73) and TVH (aOR=2.45, 95%CI=1.99-2.99) were significant independent predictors of associated with an increased risk of post-hysterectomy UTI. Conclusion The risk of UTI after hysterectomy is low. Intraoperative cystotomy and vaginal hysterectomy are the most significant predictors of subsequent urinary tract infection.

Background As part of transition, transmasculine persons often use testosterone gender-affirming hormone therapy; however, there is limited data on its long-term effects. The impact of exogenous testosterone on uterine pathology remains unclear. While testosterone achieves amenorrhea in the majority of this population, persistence of abnormal uterine bleeding can be difficult to manage. Excess androgens in cisgender females are associated with pathologic uterine processes such as polycystic ovary syndrome, endometrial hyperplasia, or cancer. There are no guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population. Objective The aim of this study was to describe the characteristics of uterine pathology after the initiation of testosterone in transmasculine persons. Materials and Methods A retrospective, multicenter case series was performed. Uterine pathology reports of transmasculine persons who received testosterone and subsequently underwent hysterectomy were reviewed. The endometrial phase and endometrial thickness were recorded. Results A total of 94 subjects met search criteria. The mean age of participants was 30 ± 8.6 years, and the mean interval from initiation of testosterone to hysterectomy was 36.7 ± 36.6 months. Active endometrium was found in the majority of patients (n = 65; 69.1%). One patient had complex hyperplasia without atypia. There were no cases of endometrial cancer. Conclusion Despite amenorrhea in the majority of transmasculine persons on testosterone, endometrial activity persists with predominantly proliferative endometrium on histopathology. Individualized counseling for abnormal uterine bleeding is encouraged in this patient population.

Abstract 3061 Poster Board II-1037 At the onset of a wound, injured blood vessels and degranulating platelets release a number of growth factors and cytokines, and the blood clot forms of cross-linked fibrin and extracellular matrix proteins. Peripheral blood monocytes play a central role in angiogenesis. Monocyte migration toward injured tissue depending on a chemotactic gradient, as well as the activation and adherence of monocytes to the endothelial cell layer. Endothelial cells provide adhesion molecules and secreted proteins acting as monocyte chemoattractants and monocyte activators leading to transendothelial migration. Studies examined direct endothelial cell-monocyte interactions and cytokines produced by monocytes that enhance angiogenesis during wound healing, but the precise analyses of factors secreted by vascular endothelial cells in response to hypoxia have not been examined. This report identifies proteins that contribute to enhanced monocyte migration. To determine whether umbilical cord blood (UCB)-derived monocytes may serve to augment endothelial cell function, Matrigel experiments were conducted. HUVEC tubule formation in Matrigel in basal media was compared with HUVEC alone and HUVEC + UCB monocytes. We compared the kinetics and stability of enclosed endothelial cell networks formed by HUVEC. CD14+ monocytes were isolated via magnetic bead-labeling (AutoMACS) with purity >80% and cultured in RPMI 1640 medium with 5% FBS. UCB-derived monocytes significantly enhanced HUVEC tubule formation in Matrigel assays (e.g., with the addition of monocyte-conditioned media (CM) (137 networks) compared to non-CM (80 networks)). UCB monocyte-CM also improved the stability of the enclosed cell networks in culture as structures persisted beyond 24h, while none were present in the non-CM matrigel cultures. To determine whether UCB-derived monocytes respond to factors elicited by injured vascular endothelial cells, we measured UCB-derived monocyte chemotaxis to HUVEC-CM in hypoxic conditions (5% O2) using Transwell plates (8.0 μm pores). Monocytes migrated for four hours to either media alone or HUVEC-CM. We observed a 3.3 fold increase in the migration of the monocytes to HUVEC-CM over that of basal media. To characterize the protein expression profiles and identify the molecules associated with monocyte migration response to endothelial cells maintained in a hypoxic environment, cellular proteins secreted by HUVEC in response to hypoxia were analyzed using mass spectrometry proteomics. Proteins were run on SDS-PAGE gels and after Coomassie staining, gel regions corresponding to MW < 25 KDa were excised and subjected to in-gel-trypsin-digestion. Peptides were analyzed by liquid chromatography mass spectroscopy (LC-MS). The mass spectrometer was operated in a data-dependant mode in which every high resolution FT full scan (resolution=60,000). Mass spectrometry raw files were searched against the Swiss-Prot human database and peptides with P values less than 0.01 were reported. The activity of every protein was determined through literature review, with an emphasis on roles pertaining to angiogenesis, inflammation, monocyte activation and chemotaxis, and transendothelial migration. Of 206 differentially expressed proteins, six were further studied and were Cyclophilin A, Cyr61 (CCN1), connective tissue growth factor (CCN2), pancreatic RNase A, macrophage migration inhibitory factor (MIG), and. Higher expression of all proteins (except thioredoxin) was confirmed by Western blot and ELISA. The exact mechanisms by which monocytes promote formation of new vasculature is not elucidated, but there is evidence of both direct contact in the activation of endothelial cells and by paracrine mechanisms secreting proangiogenic factors (VEGF, bFGF, PDGF, and TNFαa). We have identified other factors that may play a role. Our results support reported increased vascularization in a limb ischemia murine model treated with human CD14+ monocytes and support with molecular evidence that CD14+ monocytes increase the kinetics of collateral artery growth after acute femoral artery occlusion in animal models. In conclusion, these in vitro analyses confirm that UCB-derived monocytes significantly augment HUVEC function and the precise identification of proteins regulated in hypoxic HUVEC CM enhancing monocyte chemotaxis may have implications in diverse processes including wound healing. Disclosures No relevant conflicts of interest to declare.

Currently, PRP is used clinically as a topical application to augment healing of both surgical and chronic, non-healing wounds. PRP exerts its efficacy by releasing growth factors that enhance clot formation and vasculogenesis. We conducted in vitro functional analyses comparing PRP and/or UCB-derived monocytes including cytokine production, cell migration, and HUVEC tubule formation in standard matrigel assays to test the hypothesis whether topical concurrent application of PRP and UCB-derived monocytes may serve to augment wound healing beyond the ability of topical PRP alone. UCB was obtained according to institutional guidelines and collected into bags with citrate dextrose (Allegiance). MNC were separated on a Histopaque-1077 (Sigma) density gradient. UCB CD14+ monocytes were isolated using AutoMACS magnetic cell sorter (Miltenyi), and cultured in RPMI with 1% HSA. PRP was isolated from adult peripheral blood by centrifugation. To determine if the addition of UCB monocytes may improve the wound healing effects of PRP alone, VEGF, bFGF, and PDGF secreted by monocytes alone, PRP alone, and monocytes supplemented with 3% PRP, were measured by ELISA (RayBiotech) daily over 4 days. PRP alone elicited no measurable secretion of VEGF. UCB-derived monocytes alone showed a low, constant production of VEGF over the four days of 0.868ng/ml. PRP supplemented with UCB-derived monocytes secreted VEGF at a 7.6-fold increase over either PRP or UCB monocytes alone, with a peak production at day three of 6.638ng/ml. PRP alone produced no measurable secretion of bFGF over the four day time course. UCB monocytes alone secreted bFGF in an increasing manner during the same time course. During days one to four, bFGF secreted by UCB monocytes was 33.8, 27.9, 115.4, and 452.1pg/ml, respectively. The presence of PRP suppressed this secretion, as PRP combined with UCB monocytes constantly secreted bFGF at an average of 39.9pg/ml throughout days one to four. Finally, secretion of PDGF was highest in conditions including PRP combined with UCB monocytes. PRP alone constantly produced PDGF at an average of 3,144pg/ml over a 4 day time course. Monocytes alone secreted PDGF constantly at a lower average of 597pg/ml. PRP supplemented with UCB monocytes secreted PDGF at a concentration 5.9-fold higher than PRP alone, producing an average of 18,534pg/ml over four days. To determine whether UCB-derived monocytes respond to cytokines elicited by injured vascular endothelial cells, we measured UCB-derived monocyte chemotaxis to HUVEC conditioned media in hypoxic conditions (5% O2). Migration experiments were conducted using Transwell plates with 8.0 μm pores. Monocytes were cultured in RPMI with 5% FBS at a concentration of 5×106/ml and were allowed to migrate for four hours to either: media alone, PRP, HUVEC-conditioned media, or HUVEC-conditioned media supplemented with PRP. We observed a 3.3 fold increase in the migration of the monocytes to HUVECconditioned media over that of basal media. Experiments with PRP alone showed no significant difference in monocyte migration compared to basal medium. To determine whether UCB-derived monocytes may serve to augment endothelial cell function beyond that elicited by PRP alone, matrigel experiments were conducted by adding HUVEC in endothelial cell basal medium. HUVEC tubule formation in matrigel in basal media was compared in three conditions including media conditioned with: 1) PRP alone, 2) UCB monocytes alone, or 3) a combination of PRP + UCB monocytes. We compared the kinetics and stability of enclosed endothelial cell networks formed by HUVEC. No significant benefit was seen with addition of PRP conditioned media. The number of enclosed endothelial cell networks reached a higher maximum with the addition of monocyte conditioned media (137 networks) as well as PRP + monocyte conditioned media (142 networks), compared to non-conditioned media (80 networks). UCB monocyte and PRP + UCB monocyte conditioned media also improved the stability of the enclosed cell networks in culture as structures persisted beyond 24h, while none were present in the PRP-conditioned or non-conditioned media matrigel cultures. Figure Figure In summary, these in vitro analyses support the hypothesis that UCB-derived monocytes significantly improve efficacy of PRP alone in augmentation of vasculogenesis and cell migration to vascular endothelial injury, thereby supporting potential concurrent topical application of UCB-derived monocytes to PRP in wound healing.

In vitro expansion of UCB using cytokines has been pursued to overcome the limited stem cell content of a single UCB graft. We have previously demonstrated that a feeder layer of huMSC inhibits UCB HSC differentiation during short-term cytokine-driven expansion in vitro. The protein LIF has been shown to inhibit the differentiation of neurosphere stem cells during 3 week culture over a monolayer of murine stromal cells (C. Shih, et al., 2001). We sought to investigate the hypothesis that LIF secreted by bone marrow (BM) derived huMSCs is involved in inhibition of UCB HSC differentiation during short-term cytokine-driven expansion in vitro. BM derived huMSCs (third passage) were cultured at 2x10^6/ml in DMEM supplemented with 10% FBS. Supernatant was collected at 24, 36, 48, and 72 hours and analyzed for LIF secretion levels by ELISA (Quantikine). LIF secreted by huMSC was noted at all four time points, with peak secretion at 48 h (mean 52.1±3.3 pg/ml) (n=3). UCB was obtained according to institutional guidelines after normal full-term deliveries, collected into bags with citrate dextrose (Allegiance), and MNC were separated on a Histopaque-1077 (Sigma) density gradient. UCB CD133+ cells were isolated using AutoMACS magnetic cell sorter (Miltenyi) and surface stained for LIF receptor (LIF-R). Surface expression of LIF-R on gated CD133+ cells was 2.61%. Total LIF-R expression in isolated CD133+ cells was further confirmed by Western blot (n=3) using anti-LIF-R antibody (Chemicon). Isolated UCB CD133+ were plated in 24 well plates at 3.3x10^3/ml and cultured in StemPro™ media supplemented with 10% FBS, L-glutamine, penicillin, streptomycin and amphotericin B (Gibco). UCB CD133+ were culture-expanded for 96h with or without the addition of recombinant human LIF (Chemicon) (10ng/ml) in a combination of cytokines including: IL-3 (20 ng/mL), IL-6 (20 ng/mL), Flt-3L (100 ng/mL) (R&D), SCF (100 ng/mL), G-CSF (20 ng/mL), and EPO (0.1 U/mL) (Amgen Inc.). At 0, 48, and 96 h cell counts were obtained and flow analysis was performed including surface staining for: CD133, CD34, CD38, HLA-DR, CD33, CD71, and CD41B (Becton Dickinson). At 48 hours, higher cell counts in cultures without LIF were noted 6.3x10^4 ± 0.9/ml, compared with cultures with LIF 4.4x10^4 ± 0.8/ml. However, at 96 h cell counts equalized when comparing cultures with or without LIF at 7.510x10^4 ± 0.9/ml, and 7.8x10^4±0.9/ml respectively (n=6). Surface expression of differentiation markers on gated CD133+ cells did not differ when comparing cultures (n=3). In summary, we observed LIF secretion by MSC peaks at 48 h at a concentration 3 logs lower than that previously used to inhibit stem cell differentiation (10 ng/ml). Although LIF-R is expressed on CD133+ HSC, no difference in cell expansion nor surface phenotype of UCB 133+ cells was observed at early time points (96h) during expansion in cytokines with or without the addition of LIF. Taken together, huMSC mediated inhibition of cytokine-driven UCB HSC differentiation is not attributable to LIF secretion alone and may require direct cell contact between UCB CD133 HSC and huMSC. Studies are ongoing to determine whether LIF may augment huMSC-based UCB CD133 expansion.