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Objective: The COVID-19 pandemic has altered health care. The aim of this study was to evaluate changes in gynecology practice patterns in response to the pandemic. Materials and Methods: A survey ...

Objective: The goal of this research was to evaluate trends in gynecologic surgical reimbursement and to determine the factors affecting compensation. Materials and Methods: Procedure codes represe...

Objective: To assess the volume and temporal trends in utilization of gynecologic surgery codes between 2010 and 2015. Study design: The American College of Surgeons National Surgical Quality Impro...

Objectives To determine conception rates, contraceptive use patterns, and frequency of counseling regarding pregnancy recommendations in patients undergoing bariatric surgery. Study Design Using a database of bariatric surgery patients at our institution, we identified female patients aged 18 to 45 who underwent surgery from 2013 to 2018. Patient charts were reviewed for demographic information, documentation of counseling regarding pregnancy recommendations, conception during the postoperative period, and pre and postoperative contraception use. We examined rates of contraception use and used standard statistical tests to compare conception rates between groups. Results Of the 460 patients that met inclusion criteria and did not have a history of permanent contraception, 54% (95% CI 49–58) had documented postoperative contraception use, most commonly the levonorgestrel-releasing intrauterine device followed by combination oral contraceptive pills. In the 18 months following bariatric surgery, 6% of patients (95% CI 4–8) had a documented pregnancy. Over 50% (95% CI 35–71) of pregnancies occurred in patients without documented postoperative contraception. Conclusions For bariatric surgery patients at risk of pregnancy, postoperative contraception use patterns and conception rates are not consistent with the recommendation to refrain from pregnancy for 18 months. Implications Individualized contraceptive counseling that includes a discussion of fertility and weight loss goals, planned bariatric procedure type, and patient preference should be implemented as part of standard preoperative care for patients at risk of pregnancy undergoing bariatric surgery.

While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse. A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2. Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2–2.4; P = 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P = 0.58 and P = 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33–1.70; P = 0.02) and better POP-Q Ba scores [MD = −0.23; 95% CI = −0.37; −0.10; P = 0.01]. ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.

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.

Purpose of review To review current evidence on gene expression in women with urinary incontinence and pelvic organ prolapse (POP). Recent findings Our literature review revealed numerous genes that are associated with urinary incontinence and POP. For overactive bladder and urge urinary incontinence, four genes were highlighted: adrenergic receptor β3, Rho guanine nucleotide exchange factor 10, Rho-associated coiled-coil containing protein kinase 2, and potassium two pore domain channel subfamily K member-1. For Stress Urinary incontinence (SUI), 13 genes were included: skin-derived antileukoproteinase, collagen type XVII alpha 1 chain, plakophilin 1, keratin 16, decorin, biglycan, protein bicaudal D homolog 2, growth factor receptor-bound protein 2, signal transducer and activator of transcription 3, apolipoprotein E, Golgi SNAP receptor complex member 1, fibromodulin, and glucocerebrosidase. For POP seven genes were identified: homeobox A13, matrix metallopeptidase 9, estrogen receptor 2, collagen type XIV alpha 1 chain, collagen type V alpha 1 chain, collagen type IV alpha 2 chain, and catenin beta 1. Summary The current review highlights many genes which are potential biomarkers and targets for drug development.

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.

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

Objective To evaluate 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.

Study Objective To evaluate whether there are differences in complication rates between laparoscopic myomectomy (LM) and total laparoscopic hysterectomy (TLH) for the treatment of uterine leiomyoma in perimenopausal women. Design A retrospective cohort study using 1:2 propensity score matching (Canadian Task Force classification II-2). Setting American College of Surgeons National Surgical Quality Improvement Program database. Patients Women between the ages of 40 and 60 years undergoing surgical laparoscopic surgery for uterine leiomyoma between the years 2010 and 2016. Interventions Women were stratified to either LM or TLH at a ratio of 1:2 using propensity score matching. Descriptive statistics were reported as means with standard deviations. Pairwise analysis using the Student t test and chi-square test was performed where appropriate. Multivariable logistic regression was used to identify factors associated with the presence of a complication. Measurements and Main Results After propensity score matching, there were 631 myomectomies and 1262 hysterectomies. The operating time was slightly longer for LM compared with TLH (166.8 ± 90.3 minutes vs 157.9 ± 70.9 minutes, p = .03). The overall complication rate was 6.3%. There were no differences in complications between the LM and TLH groups (5.9% vs 6.6%, p = .54). Urinary tract infections were more common in the TLH group (2.3% vs 0.6%, p = .01). There were no other differences in the rates of specific complications between the 2 groups. On logistic regression, wound class greater than 3 was most strongly associated with a risk of complications (adjusted odds ratio [aOR] = 8.89; 95% confidence interval [CI], 1.28–15.87). Other variables associated with an increased risk of complications were conversion to hysterectomy (aOR = 5.91; 95% CI, 1.7–9.63), total operating time (aOR = 1.05; 95% CI, 1.02–1.07), and length of stay over 1 day (aOR = 3.67; 95% CI, 2.31–5.8). Conclusion LM is not associated with an increased risk of complications compared with TLH in women over the age of 40 years undergoing treatment for uterine leiomyomata.

A contribution of genetic factors to the development of stress urinary incontinence (SUI) is broadly acknowledged. This study aimed to: (1) provide insight into the genetic pathogenesis of SUI by gathering and synthesizing the available data from studies evaluating differential gene expression in SUI patients and (2) identify possible novel therapeutic targets and leads. A systematic literature search was conducted through September 2017 for the concepts of genetics and SUI. Gene networking connections and gene-set functional analyses of the identified genes as differentially expressed in SUI were performed using GeneMANIA software. Of 3019 studies, 4 were included in the final analysis. A total of 13 genes were identified as being differentially expressed in SUI patients. Eleven genes were overexpressed: skin-derived antileukoproteinase (SKALP/elafin), collagen type XVII alpha 1 chain (COL17A1), plakophilin 1 (PKP1), keratin 16 (KRT16), decorin (DCN), biglycan (BGN), protein bicaudal D homolog 2 (BICD2), growth factor receptor-bound protein 2 (GRB2), signal transducer and activator of transcription 3 (STAT3), apolipoprotein E (APOE), and Golgi SNAP receptor complex member 1 (GOSR1), while two genes were underexpressed: fibromodulin (FMOD) and glucocerebrosidase (GBA). GeneMANIA revealed that these genes are involved in intermediate filament cytoskeleton and extracellular matrix organization. Many genes are involved in the pathogenesis of SUI. Furthermore, whole-genome studies are warranted to identify these genetic connections. This study lays the groundwork for future research and the development of novel therapies and SUI biomarkers in clinical practice.

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.

Sacral neuromodulation (SNM) is gaining popularity as a treatment option for chronic pelvic pain (CPP). Our hypothesis is that SNM is effective in improving CPP. A systematic search was conducted through September 2018. Peer-reviewed studies using pre- and postpain intensity scores were selected. The primary outcome was pain improvement on a 10-point visual analog scale (VAS) (adjusted or de novo) in patients with CPP. Secondary outcomes included comparing SNM approaches and etiologies and evaluating lower urinary tract symptoms (LUTS). Fourteen of 2175 studies, evaluating 210 patients, were eligible for further analysis. The overall VAS pain score improvement was significant [weighted mean difference (WMD) −4.34, 95% confidence interval (CI) = −5.22, to−3.64, p

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.

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.

While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse.A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2.Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2-2.4; P = 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P = 0.58 and P = 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33-1.70; P = 0.02) and better POP-Q Ba scores [MD = -0.23; 95% CI = -0.37; -0.10; P = 0.01].ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.

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.

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

Objective To develop and externally validate a prediction model for anticholinergic response in patients with overactive bladder (OAB). Methods A machine learning model to predict the likelihood of anticholinergic treatment failure was constructed using a retrospective data set (n=559) of female patients with OAB who were treated with anticholinergic medications between January 2010 and December 2017. Treatment failure was defined as less than 50% improvement in frequency, urgency, incontinence episodes, and nocturia, and the patient's subjective impression of symptomatic relief. Patients were stratified by age (younger than 40 years, 40-60 years, and older than 60 years), and number of previously failed medications. K-fold stratified cross-validation was performed on each stratum using machine learning algorithms. Of these, the random forest model was the most accurate. This model was refined using internal cross validation within each stratum. The area under the curve (AUC) was calculated for each stratum and used to identify the optimal operating points for prediction of treatment failure. The random forest model was then externally validated using a prospectively collected data set (n=82) of women treated with anticholinergic medications at a different clinical site between January 2018 and December 2018. Results The global accuracy of the final model was 80.3% (95% CI 79.1-81.3), and the AUC was 0.77 (95% CI 0.74-0.79). Using the external validation data set, the model's sensitivity and specificity was 80.4% (95% CI 66.5-89.7%) and 77.4% (95% CI 58.6-89.7%), respectively. The model performed best in women aged younger than 40 years (AUC 0.84, 95% CI 0.81-0.84) and worst in women aged older than 60 years who had previously failed medication (AUC 0.71, 95% CI 0.67-0.75). Conclusion Our externally validated machine learning prediction model can predict anticholinergic treatment failure during the standard 3-month treatment trial period with greater than 80% accuracy. The model can be accessed at https://oabweb.herokuapp.com/app/pre/.

Objective To report rates and identify risk factors for urinary tract infection (UTI) after hysterectomy for benign conditions or combined with pelvic reconstructive surgery. Methods This is a cohort study that included women who underwent hysterectomy either for benign gynecologic conditions or hysterectomy combined with pelvic reconstructive surgery from January 1, 2012, through June 30, 2014, at a single institution. The primary outcome was UTI within 8 weeks of surgery. Logistic regression modeling was used to develop a model for predicting UTI after surgery. Results Of 1,156 women included in the study, 136 (11.8%, 95% CI 10.0-13.8) developed UTI within 8 weeks. Women who underwent hysterectomy for a benign gynecologic condition that was not combined with pelvic reconstructive surgery had an overall UTI rate of 7.3% (95% CI 5.6-9.3) vs 21.7% (95% CI 17.6-26.4) after hysterectomy combined with pelvic reconstructive surgery. After adjusting for hormone therapy use, the following were independent variables associated with postoperative UTI: premenopausal status with an adjusted odds ratio (OR) of 1.80 (95% CI 1.11-2.99), anterior vaginal wall prolapse with an adjusted OR of 4.39 (95% CI 2.77-6.97), and postvoid residual greater than 150 mL with an adjusted OR of 2.38 (95% CI 1.12-4.36). Using this model, postoperative UTI rates ranged from 4.3% to 59.4% with high postvoid residual and presence of anterior prolapse having the strongest association. Conclusion There are wide variations in the rate of UTI after hysterectomy for begin disease including pelvic reconstructive surgery. These variations can be explained with a model based on available preoperative data.

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

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

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

Objective A likely contributor to pelvic floor disorders is injury and degradation of connective tissue components such as collagen and elastin, leading to weakening of the pelvic floor. Prior studies have found similar connective tissue component changes in women with cervical insufficiency (CI). However, the connection between pelvic floor disorders and cervical insufficiency has not previously been evaluated. Our objective was to determine whether a history of cervical insufficiency is associated with an increased risk of pelvic organ prolapse and stress urinary incontinence after controlling for confounders. Study design The study used de-identified clinical data from a large multi-institution electronic health records HIPAA-compliant data web application, Explorys Inc. (Cleveland, Ohio, USA). Women with a history of at least one prior delivery after at least 20 weeks’ gestation between the years 1999 and 2016 were identified. Logistic regression models were used to identify risk factors and adjust for confounders. Main outcome measures The primary outcome was subsequent development of either stress incontinence or pelvic organ prolapse. Results A total of 1,182,650 women were identified, of whom 30,890 (2.6%) had a history of cervical cerclage or insufficiency. A history of cervical insufficiency was associated with an increased risk of either pelvic organ prolapse or stress urinary incontinence (aOR = 1.93, 95%CI: 1.84–2.02). A history of cervical insufficiency was more strongly associated with an increased risk of pelvic organ prolapse (aOR = 2.06, 95%CI: 1.91–2.21) than with stress urinary incontinence (aOR = 1.91, 95%CI: 1.80–2.02). Conclusion A history of cervical insufficiency is associated with an increased risk of development of pelvic organ prolapse and stress urinary incontinence.

The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of prolapse recurrence. The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan–Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence. Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p

To estimate whether the cost of hysterectomy varies by geographic region.This was a cross-sectional, population-based study using the 2013 Healthcare Cost and Utilization Project National Inpatient Sample of women older than 18 years undergoing inpatient hysterectomy for benign conditions. Hospital charges obtained from the National Inpatient Sample database were converted to actual costs using cost-to-charge ratios provided by the Healthcare Cost and Utilization Project. Multivariate regression was used to assess the effects that demographic factors, concomitant procedures, diagnoses, and geographic region have on hysterectomy cost above the median.Women who underwent hysterectomy for benign conditions were identified (N=38,414). The median cost of hysterectomy was $13,981 (interquartile range $9,075-29,770). The mid-Atlantic region had the lowest median cost of $9,661 (interquartile range $6,243-15,335) and the Pacific region had the highest median cost, $22,534 (interquartile range $15,380-33,797). Compared with the mid-Atlantic region, the Pacific (adjusted odds ratio [OR] 10.43, 95% confidence interval [CI] 9.44-11.45), South Atlantic (adjusted OR 5.39, 95% CI 4.95-5.86), and South Central (adjusted OR 2.40, 95% CI 2.21-2.62) regions were associated with the highest probability of costs above the median. All concomitant procedures were associated with an increased cost with the exception of bilateral salpingectomy (adjusted OR 1.03, 95% CI 0.95-1.12). Compared with vaginal hysterectomy, laparoscopic and robotic modes of hysterectomy were associated with higher probabilities of increased costs (adjusted OR 2.86, 95% CI 2.61-3.15 and adjusted OR 5.66, 95% CI 5.11-6.26, respectively). Abdominal hysterectomy was not associated with a statistically significant increase in cost compared with vaginal hysterectomy (adjusted OR 1.01, 95% CI 0.91-1.09).The cost of hysterectomy varies significantly with geographic region after adjusting for confounders.

Study Objective To evaluate the risk factors, presentation, and outcomes in cases of abdominal wall endometriosis. Design A case-control study (Canadian Task Force classification II-2). Setting An academic medical center. Patients A total of 102 (34 cases and 68 controls) were included. Interventions Surgical resection of abdominal wall endometriosis. Measurements and Main Results Cases underwent surgical excision for abdominal wall endometriosis at Mayo Clinic from January 1, 2000, through December 31, 2013. For each case, 2 controls were randomly selected from a list of women who had surgery in the same year with minimal (American Society for Reproductive Medicine stage I–II) endometriosis. A chart review was completed for variables of interest. Regression models were used to identify independent risk factors associated with abdominal wall endometriosis. Results In 14 years, 2539 women had surgery for endometriosis at Mayo Clinic. Of these, only 34 (1.34%) had abdominal wall endometriosis. The mean age was 35.2 ± 5.9 years, and the median parity was 2 (range, 0–5). Clinical examination diagnosed abdominal wall endometriosis in 41% of cases, with the cesarean delivery scar being the most common site (59%). There was a strong correlation between the size of the lesion on clinical examination compared with the size of the pathology specimen ( r 2 = 0.74, p Conclusions Abdominal wall endometriosis is a rare but unique form of endometriosis. Careful history and clinical examination can provide accurate diagnosis and avoid unnecessary delay before surgical intervention. Localized cyclic abdominal pain with the absence of dysmenorrhea and a history of prior laparotomy are independent risk factors with very high accuracy for diagnosis.

Study Objective Instagram is a social media platform that provides education and support for endometriosis patients. The objective of our study was to analyze the authorship and content of Instagram posts utilizing endometriosis related hashtags. Design 15 hashtags were identified utilizing the ACOG Endometriosis FAQ and a hashtag finder program. Hashtags included: endometriosis, endo, endowarrior, endometriosisawareness, endosisters, endometriosiswarrior, pelvicpain, chronicpelvicpain, painfulperiod, painfulsex, invisibleillness, fatigue, uterus, hysterectomy, and laparoscopy. The authorship and content of the “top 9” and most recent 30 posts were evaluated for each hashtag and categorized by authorship and content. We also analyzed groups of hashtags. Non-English posts were excluded. Setting NA Patients or Participants NA Interventions NA Measurements and Main Results 585 posts were analyzed. Authorship: patients (54.2%), health professional (16.2%), for-profit group (9.6%), holistic provider (8.7%), and non-profit group (4.6%). Regarding content: support (33.5%), personal post (21.2%), advertisement (17.8%) and education (13.5%). Endometriosis specific group: patient (74.8%), for-profit commercial group (6%), holistic provider (5.1%), health professional (3.8%), support (40.6%), personal post related to endometriosis (23.5%), personal post unrelated to endometriosis (20.9%), education (6.4%). General symptoms group: patient (47.4%), holistic provider (14.1%), for-profit commercial group (12.8%), health professional (2.6%), support (34.6%), advertisement (21.8%), personal post related to diagnosis (20.5%), personal post unrelated to diagnosis (15.4%), education (7.7%). Pain group: health professional (34%), patient (32.7%), for-profit commercial group (15.4%), holistic provider (12.8%), non-profit organization (4.5%), support (27.6%), education (25.6%), personal post related to diagnosis (10.9%), personal post unrelated to diagnosis (7.1%). Procedure group: patient (59%), health professional (29.5%), non-profit organization (3.8%), personal post related to diagnosis (42.3%), support (20.5%), education (14.1%), personal post unrelated to diagnosis (10.3%). Conclusion When analyzing the hashtags, endometriosis specific and general symptoms groups, the majority of posts were authored by patients with education being the least represented content. When grouping into pain and procedure, more posts were authored by health professionals with more educational content.

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.

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

Objective To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures. Methods We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure. Results We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups. Conclusion Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.

This month we focus on current research in chronic pelvic pain. Dr. El-Nashar discusses four recent publications, which are concluded with a "bottom-line" that is the take-home message. A complete reference for each can be found on on this page along with direct links to abstracts.

Disorders of micturition result from a wide variety of conditions and evaluation often involves multiple diagnostic modalities. However, the sensitivity and specificity of these techniques are highly variable and may not always yield a diagnosis. Novel imaging techniques such as ultrasound shear wave elastography may help to improve diagnostic accuracy. Continent women were recruited from outpatient gynecology offices from a tertiary medical system. Participants underwent ultrasound evaluation with measurement of the shear wave velocity (SWV) of the bladder neck (BN). SWV was used to determine the Young’s modulus of the bladder neck. The median bladder neck stiffness was calculated and univariate and step-wise and backward multivariate logistic regression analyses were used to identify significant patient characteristics associated with bladder neck stiffness above or below the median. Fifty-seven women underwent SWE of the bladder; 12 were excluded, and 45 were included in the analysis. The median bladder neck stiffness of the study population was 22 (17.1–28.2) kPa. Age greater than 45 years was associated with a bladder neck stiffness above the median, OR 8.39, p

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

Abnormal uterine bleeding (AUB) is a common problem that negatively impacts a woman's health-related quality of life and activity. Initial medical treatment includes hormonal and nonhormonal medications. If bleeding persists and no structural abnormalities are present, a repeat trial of medical therapy, a levonorgestrel intrauterine system, or an endometrial ablation can be used dependent on future fertility wishes. The levonorgestrel intrauterine system and endometrial ablation are effective, less invasive, and safe alternatives to a hysterectomy in women with AUB. A hysterectomy is the definitive treatment of AUB irrespective of the suspected cause when alternative treatments fail. Future studies should focus on detection of predictors for treatment outcomes.

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.

Objectives To establish a prediction model for fetal congenital heart disease (CHD) that could facilitate selective fetal echocardiography screening for diabetic women, and to provide cost analysis of selective versus global screening of these women. Study design A historical cohort study included women with pre-gestational diabetes who received perinatal care at Mayo Clinic, Minnesota from 2007 through 2013. Anatomical scans and fetal echocardiograms were reviewed and charts for postnatal outcomes were abstracted. Logistic regression models were utilized to identify predictors of CHD. Cost of global versus selective screening was estimated using cost per case detected. Results A cohort of 152 women was included. Abnormal anatomy scan was reported in five (3.3%). Among 51 (33.6%) who had fetal echocardiography, eight (15.7%) had abnormal findings. Postnatal echocardiography was conducted in 36 neonates, 12 had abnormalities. Only first trimester HbA1c was independent predictor with observed incidence of CHD of 1.8, 14.3, and 40% and HbA1c of 10% respectively. Global screening strategy missed 22% of fetal cardiac abnormalities, while selective screening missed 33%. Conclusions According to our probability model, selective screening based on HbA1c and/or anatomic surveys seems to be an accurate and cost effective strategy for prenatal diagnosis of CHD among diabetic pregnancies.