Urogynecology (Hagerstown, Md.)最新文献

Importance: Narcotic use after retropubic suburethral sling surgery is not unusual. Surgeons may consider using topical analgesics to minimize narcotic use.

Objectives: The aim of the study was to determine if using bupivacaine-meloxicam (Zynrelef) reduces narcotic use in the first 3 days after surgery, measured as morphine milligram equivalents (MME). Secondary aims were to compare, postoperatively, average and worst pain, satisfaction with pain control and quality of recovery between groups.

Study design: This was a single-center prospective single-blinded randomized controlled trial for women undergoing retropubic sling surgery. The intervention arm received Zynrelef at the suprapubic incisions, no placebo was used in controls. Participants tracked pain levels, medication use, satisfaction with pain control and Quality of Recovery surveys in the first 3 postoperative days. Appropriate statistical analyses were applied.

Results: A total of 119 women were randomized. For primary outcome, totalmedian MME from postoperative days 0-3, the control group used 37.5 MME compared to 30 MME in the Zynrelef group (interquartile range [IQR] 5.63-71.25; P = 0.61). Pain scores were low in both groups, participants were satisfied or very satisfied with pain control. Quality of recovery scores were similar between groups, with improvement by postoperative day 3 to near baseline scores. Patients with anxiety/depression used more oxycodone; 10 mg (IQR 0-30) vs 0 mg (IQR 0-15), P = 0.0027.

Conclusions: Use of Zynrelef during retropubic sling surgery does not reduce narcotic use in the first 3 days postoperatively. Patients can be reassured that pain and narcotic use after surgery are low and recovery is quick.

Importance: As the volume of medical literature continues to expand, the provision of artificial intelligence (AI) to produce concise, accessible summaries has the potential to enhance the efficacy of content review.

Objectives: This project assessed the readability and quality of summaries generated by ChatGPT in comparison to the Plain Text Summaries from Cochrane Review, a systematic review database, in incontinence research.

Study design: Seventy-three abstracts from the Cochrane Library tagged under "Incontinence" were summarized using ChatGPT-3.5 (July 2023 Version) and compared with their corresponding Cochrane Plain Text Summaries. Readability was assessed using Flesch Kincaid Reading Ease, Flesch Kincaid Grade Level, Gunning Fog Score, Smog Index, Coleman Liau Index, and Automated Readability Index. A 2-tailed t test was used to compare the summaries. Each summary was also evaluated by 2 blinded, independent reviewers on a 5-point scale where higher scores indicated greater accuracy and adherence to the abstract.

Results: Compared to ChatGPT, Cochrane Review's Plain Text Summaries scored higher in the numerical Flesch Kincaid Reading Ease score and showed lower necessary education levels in the 5 other readability metrics with statistical significance, indicating better readability. However, ChatGPT earned a higher mean accuracy grade of 4.25 compared to Cochrane Review's mean grade of 4.05 with statistical significance.

Conclusions: Cochrane Review's Plain Text Summaries provide clearer summaries of the incontinence literature when compared to ChatGPT, yet ChatGPT generated more comprehensive summaries. While ChatGPT can effectively summarize the medical literature, further studies can improve reader accessibility to these summaries.

Objective: The aim of the study was to synthesize the current literature and provide surgeons with data to inform counseling of eligible patients for uterine-preserving prolapse surgery (UPPS).

Methods: We compared UPPS to similar techniques incorporating hysterectomy, including native-tissue repairs by vaginal, laparoscopic, or open approach; mesh-reinforced repairs by vaginal, laparoscopic, or open approach; obliterative repairs; and the Manchester procedure. Reviewed outcomes include surgical and patient-reported outcomes, complications, uterine pathology, and sexual function. We conducted a structured literature search of English language articles published 1990-2023, combining MeSH terms for pelvic organ prolapse and UPPS. Data were categorized by procedure and approach, and evaluated to provide recommendations and strength of evidence based on group consensus.

Results: Patient counseling on prolapse surgery should follow a benefit/risk assessment related to techniques that preserve the uterus. The discussion should include the benefits of hysterectomy for cancer detection and prevention and acknowledgment that patients should continue cervical cancer screening and evaluation of abnormal uterine bleeding following UPPS. The rate of hysterectomy after UPPS is low and most commonly for recurrent prolapse. If cervical elongation is present, trachelectomy should be considered at the time of UPPS. There is no difference in sexual function between UPPS and prolapse repair with hysterectomy. Data on pregnancy outcomes following UPPS are limited.

Conclusions: Uterine-preserving prolapse surgery should be a surgical option for all patients considering surgical treatment for symptomatic pelvic organ prolapse unless contraindications exist. Uterine-preserving prolapse surgery should be offered using an individualized benefit and risk discussion of both approaches to help patients make an informed decision based on their own values.

Importance: Autonomic nerves and ganglia that affect bladder sensation and detrusor contractility are present below the proximal urethra and trigone. Radiofrequency energy has been shown to potentially ablate/modulate these nerves in overactive bladder (OAB) patients.

Objective: In this study, we intended to establish the safety and efficacy of transvaginal radiofrequency energy delivered via a vaginal Morpheus (Inmode) microneedling device in female patients with OAB.

Study design: Women with known OAB, both primary and refractory as well as urge-predominant mixed urinary incontinence, were treated in the office setting using transvaginal detrusor nerve radiofrequency ablation to a depth of 7 mm.The primary outcome was the change in urge incontinence episodes on a 3-day voiding diary at 3 months after procedure. Secondary outcomes were the following at 1 and 3 months: the change in urinary frequency and incontinence, Incontinence Impact Questionnaire-7 (IIQ-7), Urinary Distress Inventory-6 (UDI-6), and Patient's Perception of Bladder Condition (PPBC). A pain assessment was collected immediately after the procedure and a Patient Global Impression of Improvement questionnaire was collected at 3 months.

Results: From 07/2023 to 02/2024, 32 were enrolled and 31 were followed for 3 months after treatment. Episodes of urgency incontinence, IIQ-7, UDI-6, PPBC, urinary frequency, and episodes of severe urinary urgency, had statistically significant improvement. Significant Analysis of Variance (ANOVA) testing (P < 0.001) was encountered with the IIQ-7, UDI-6, PPBC, urinary frequency, and urgency incontinence. No adverse events were encountered.

Conclusions: Across all outcome metrics, the transvaginal detrusor nerve radiofrequency ablation for treatment of overactive bladder showed statistically significant improvements.

Importance: Little is known regarding the publication rate of abstracts presented at the American Urogynecologic Society (AUGS) Pelvic Floor Disorder Week (PFD).

Objective: Our aims were to determine contemporary publication rates of AUGS PFD oral and poster presentation abstracts and factors associated with publication.

Study design: In this retrospective study, we reviewed short and long oral and poster abstracts from 2019 and 2020 AUGS PFD. Article publication rates were calculated. Statistical analysis was performed with Kruskal-Wallis and χ2 tests. Multivariable logistic regression was used to assess factors associated with likelihood of publication.

Results: We identified 831 abstracts from the 2019 and 2020 PFD. Publication rates were 23.5%, 45.4%, and 53.3% at 1, 2, and 3 years (55.1% overall) with median time to publication of 16 months. For published abstracts, median journal impact factor was 2 with median principal investigator H-index of 15. Long and short podium presentations were 4 (95% confidence interval [CI], 2.2-7.6) and 1.8 times (CI, 1.2-2.5), respectively, as likely to be published than poster presentations (both P < 0.01). Resident/fellow (odds ratio [OR] 1.7, [95% CI, 1.2-2.4], P < 0.01) and female first-authorship (OR 1.4, [95% CI, 1.0-2.0], P = 0.04) and randomized control trials (OR 2.33, [95% CI, 1.2-4.7], P = 0.02) were predictive of publication.

Conclusions: Nearly half the abstracts from AUGS PFD 2019 and 2020 are unpublished. Abstracts with oral presentations, female and trainee first authors, and randomized control trials were more likely to be published. Ultimately, timely publication is critical for ensuring reliability of evidence.

Importance: Genitourinary fistula is a rare complication of obstetric cerclage with limited evidence to guide prevention and management.

Objective: The aim of the study was to describe 5 new cases of vesicovaginal fistula (VVF) after cerclage and evaluate existing cases, including shared features, to generate hypothesis for future etiologic research.

Study design: Case series and scoping review.

Results: Five patients presented with VVF symptoms after cerclage placement; 4 were diagnosed during pregnancy, 1 postpartum. Two patients had prior cervical procedures and were noted to have difficult cerclage placements. Three cerclages remained until delivery, 1 was removed antepartum, and another was replaced. All VVFs were diagnosed by cystoscopy and were repaired postpartum transvaginally. In the scoping review, 14 studies met inclusion criteria, and 19 cases were identified. Compiled cases had a history of cervical procedure(s), shortened cervix, McDonald technique, anterior knot placement, and Mersilene tape use. Fistulas were identified by cystoscopy when performed. Most reports described VVFs near the bladder trigone and midline of the vagina. All VVFs required surgical repair.

Conclusions: Genitourinary fistula after cerclage is rare but may be more common after prior cervical surgery, shortened cervix, and McDonald cerclage. Methods to mitigate morbidity associated with fistula after cerclage placement include cystoscopy if bladder injury is suspected at the time of cerclage placement and consideration of abdominal cerclage when intravaginal access to the cervix is limited. Patients with urinary leakage after cerclage should be evaluated for genitourinary fistula, not just incontinence. Postpartum surgical repair remains the primary treatment for VVF, ideally by a vaginal approach.

Importance: Ileus and small bowel obstructions are known but rare complications associated with minimally invasive sacrocolpopexy that can result in variable management.

Objectives: The objectives of this study were to describe the clinical presentation, management and outcomes of ileus or small bowel obstructions after minimally invasive sacrocolpopexy.

Study design: This was a multicenter retrospective case series of postoperative ileus or small bowel obstruction after minimally invasive sacrocolpopexy. Demographics, clinical, surgical, and complication characteristics were manually abstracted. Descriptive statistics were performed via SPSS along with associative and comparative analyses.

Results: Ileus or small bowel obstruction was diagnosed in 2.5%, 95% CI = 1.8,3.3%, of all minimally invasive sacrocolpopexy cases across institutions. Presentation for small bowel complication ranged from 1 to 2,432 days after surgery with 70% presenting within 14 days of the index surgery. Remoteness from the surgery was associated with whether the index team was involved in the management of the bowel complication. Patients who were conservatively managed were admitted for a significantly shorter amount of time with a mean length of stay of 4.52 (±3) days compared to 10.3 (±6, P < 0.001) days for those who were surgically managed.

Conclusions: Small bowel complication is a known rare risk following minimally invasive sacrocolpopexy. Conservative management resolves the majority of cases and should be considered to reduce the risk of surgical morbidity or disruption of the mesh. Given that multiple clinical teams may encounter and manage these complications, our study highlights the importance of keeping a high index of suspicion and thoughtful communication about these events.

Importance: Strong evidence demonstrates long-term cognitive decline associated with anticholinergics. While prevalent among older populations, medical management of overactive bladder (OAB) is dictated by insurance coverage rather than medical provider and patient preferences.

Objective: The aim of this study was to assess Medicare insurance plan coverage for select OAB medications and evaluate coverage of preferred medications to medications with a greater risk of cognitive dysfunction.

Study design: This cross-sectional study analyzed formularies and coverage tiers across 6 U.S. insurers for the following OAB medications: oxybutynin instant-release (IR) 5 mg, oxybutynin extended-release (ER) 5 mg, tolterodine IR 1 mg, tolterodine ER 2 mg, fesoterodine ER 4 mg, darifenacin 7.5 mg, solifenacin 5 mg, trospium IR 20 mg, trospium ER 60 mg, mirabegron 25 mg, and vibegron 75 mg. Coverage was compared between nonpreferred (oxybutynin, tolterodine, fesoterodine, darifenacin, solifenacin) and preferred medications (trospium, mirabegron, vibegron). Coverage scores, a weighted distribution based on coverage tier frequency relative to the number of plans investigated, were generated with a lower score indicating better coverage (range, 0.2-1.0).

Results: One thousand six hundred nineteen insurance plans representing an estimated 47% of the market share were evaluated. Oxybutynin IR had the best coverage score across insurers (0.4), whereas trospium ER had the worst (0.89). Preferred medications had worse coverage versus nonpreferred medications ( P < 0.001). Centene had the best overall coverage and lowest initiation cost, whereas Aetna/CVS had the best coverage and initiation cost for preferred medications.

Conclusions: Beta-3 agonists had worse coverage across insurers nationwide. Current trends in Medicare coverage reveal a need for improved coverage of preferred OAB medications for an aging population already at risk of cognitive dysfunction.

Importance: Obstructive sleep apnea (OSA) is common but likely underdiagnosed in urogynecology patients with nocturia, and OSA treatment has the potential to improve nocturia symptoms.

Objective: The aim of the study was to assess the effect of implementing a universal screening protocol for OSA in a urogynecology clinic on screening rates, OSA prevalence among patients with nocturia, and symptom improvement following treatment.

Study design: This was an observational quality improvement study at a urogynecology clinic at a safety-net hospital. Health care providers were asked to screen all new patients with nocturia using the STOP-BANG questionnaire. We assessed screening rates over an 18-month period and followed patients referred for sleep study to determine the percentage who completed evaluation, were identified as having OSA and, if necessary, prescribed treatment, as well as improvement in nocturia symptoms after treatment.

Results: Seventy-eight percent of eligible patients were screened, and screening rates increased substantially over the course of the study. Overall, 20.2% of patients screened positive and were referred for sleep study, and 80.6% of those were ultimately diagnosed with OSA. There were low levels of adherence to the recommended OSA treatment, but patients with OSA who were using the treatment reported better improvement in their symptoms.

Conclusions: Initiation of OSA screening in a urogynecology clinic is a significant and feasible way to address nocturia and has the potential to improve symptoms. Improving rates of OSA testing and adherence to OSA treatment will require a multidisciplinary approach, while systems-level changes are needed to address inequities and other barriers to accessing treatment.