Urogynecology (Hagerstown, Md.)最新文献

Importance: Limited data exist on postoperative recovery among patients with chronic pain undergoing pelvic reconstructive surgical procedures.

Objective: The objective of this study was to evaluate if patients with versus without self-reported chronic pain experience different recovery after pelvic reconstructive surgery.

Study design: From September 2022 to May 2023, this prospective cohort study enrolled patients with and without chronic pain, who were undergoing vaginal or laparoscopic procedures for pelvic organ prolapse. Preoperative pain was assessed using the Brief Pain Inventory (BPI) and Pepper Assessment Tool for Disability (PAT-D). Postoperative recovery was evaluated at 2, 4, and 12 weeks using the Postdischarge Surgical Recovery (PSR) scale, Global Surgical Recovery (GSR) index, and PAT-D questionnaire. The primary outcome was PSR scores at 4 weeks postoperatively.

Results: Ninety patients were recruited, with 43 reporting chronic pain and 47 without. Demographics were similar. Patients with chronic pain had higher preoperative BPI and PAT-D scores. Perioperative outcomes and hospital stay were similar. Patients with chronic pain used more postoperative opioids in the hospital (27.0 ± 27.8 vs 24.3 ± 60.3 morphine milligram equivalents [MME]; P = 0.03) and at home (40.1 ± 54.7 vs 19.9 ± 39.0 MME; P = 0.03). The PSR scores at 4 weeks were not significantly different. No differences were observed in PSR or GSR scores at all time points. Patients with chronic pain had a higher PAT-D score at 12 weeks. Fewer chronic pain patients returned to work by 12 weeks and desired more time off work.

Conclusions: Patients with and without chronic pain had similar surgical outcomes and recovery. However, chronic pain patients required more postoperative opioid pain medication and preferred more time off work.

Importance: There is limited evidence guiding surgeons in how much mesh to resect when treating mesh complications.

Objective: The aim of the study was to compare rates of recurrent prolapse after mesh excisional surgical procedures for prolapse mesh complications.

Study design: This multicenter, retrospective cohort study included patients, identified by Current Procedural Terminology codes, who were treated surgically for prolapse mesh complications at 8 institutions between 2010 and 2019. Excisional surgical procedures were categorized as major (total vaginal, extravaginal, and total mesh excisions) or minor (partial vaginal excisions and mesh revisions). The primary outcome was prolapse recurrence 1 year after mesh excision surgery. Secondary outcomes included long-term prolapse recurrence. Prolapse recurrence was evaluated by Kaplan-Meier survival analysis and Cox proportional hazards regression.

Results: Two hundred sixty-one patients met inclusion criteria with 188 (72%) undergoing minor and 73 (28%) major excisions, with a median follow-up time of 1.0 years. Groups differed in parity, location of implant surgery, and number of vaginal compartments involved in excision. Within the first year, major excisions had a higher prolapse recurrence rate (8.7%) than minor excisions (2.9%), P < 0.05. Adjusting for mesh implant type, the hazard ratio for pelvic organ prolapse was 6.1 in the major compared to minor excision. In the entire study period, prolapse recurrence was 33.8% and did not differ between groups.

Conclusions: Patients undergoing major excision surgical procedures may have higher rates of prolapse at 1 year compared to those undergoing minor excisions. However, in long-term follow-up, recurrence rates were not different. Our findings may aid surgeons in expectation setting prior to excisional procedures.

Importance: Tobacco smoke is a modifiable risk factor that surgeons discuss with patients prior to undergoing sacrocolpopexy or mesh revision surgery.

Objective: The aim of the study was to investigate the effect of smoking on perioperative outcomes after sacrocolpopexy for pelvic organ prolapse and mesh revision repair.

Study design: This was a retrospective cohort study of data obtained from the National Surgical Quality Improvement Project's database. Women who underwent surgery for pelvic organ prolapse via abdominal sacrocolpopexy (ASCP) or minimally invasive sacrocolpopexy (MISCP) or prolapse mesh revision surgery from 2011 to 2021 were identified and compared based on current tobacco use. Demographic, medical, and surgical history, as well as intraoperative and 30-day perioperative outcomes, were compared. Multivariate analysis was performed.

Results: Overall, 21,980 women underwent MISCP (8.60% smokers) and 3,775 underwent ASCP (8.74% smokers). Postoperative wound infections were more common after sacrocolpopexy in patients who smoked. Readmission after MISCP was more common in smokers. The composite perioperative morbidity score was different between smokers and nonsmokers for MISCP (P = 0.001) and ASCP (P = 0.002). Multivariate analyses of MISCP outcomes found an association between smoking and wound infection, readmission, and composite score. Multivariate analyses of ASCP outcomes found an association between smoking and wound infection. Overall 2,160 patients underwent mesh removal by any modality (16.57% smokers), and no difference in perioperative outcomes between smokers and nonsmokers for mesh removal was found.

Conclusions: An association was found between tobacco smoking and wound infection as well as other postoperative complications. Tobacco use prior to a mesh excision procedure does not appear to increase perioperative outcomes.

Importance: The Neomedic Knotless Incontinence Mesh (KIM) sling with sterilizable trocars decreases medical waste versus midurethral slings with disposable trocars. Limited comparative data exist.

Objective: The aim of the study was to assess to the success of the retropubic KIM sling compared to the Gynecare TVT Exact sling.

Study design: This was a single-center, randomized noninferiority trial comparing outcomes of 2 retropubic slings-KIM sling and TVT Exact sling-in women with stress urinary incontinence from August 2021 to May 2023. Primary outcome was subjective success at 6 weeks defined by a composite outcome of the response to the question #17 on the The Pelvic Floor Distress Inventory-20 questionnaire and no retreatment of stress urinary incontinence. Secondary outcomes included rates of urinary retention, mesh erosion, and reoperation for mesh complications. Sample size estimate based on noninferiority margin of 14%, equal success of 90%, alpha 0.05, and 80% power with a 20% dropout was 72 per group.

Results: Among 147 patients, 74 (50.3%) were randomized to KIM sling versus 73 (49.7%) to TVT exact. The rates of 6-week success were 68.5% for the KIM sling and 83.3% for the TVT exact with a risk difference 14.8% (95% confidence interval, 1.1-28.5). The KIM sling is not noninferior to the TVT Exact sling. There were no differences in secondary outcomes.

Conclusions: The KIM sling is not noninferior to the TVT Exact sling for success at 6 weeks based on a composite outcome score. This clinical trial is ongoing to assess outcomes at 6 months and 1 year. (Clinicaltrials.gov NCT04985799).

Importance: This study quantifies the occult pathology risk among our urogynecologic patient population and highlights the importance of preoperative counseling, particularly in patients who have been underrepresented in prior studies.

Objective: The aim of the study was to estimate unexpected gynecologic pathology incidence among a low-risk, racially, and ethnically representative patient population undergoing surgery for symptomatic pelvic organ (POP) prolapse.

Study design: This was a retrospective study of patients undergoing hysterectomy for POP at an urban academic medical center. Patients with abnormal preoperative pathologic evaluation were excluded. Data were abstracted from the electronic health record, including demographic and clinical history, preoperative laboratory evaluation, and clinical risk factors for gynecologic malignancy.

Results: Two hundred ninety-nine nononcologic patients who underwent POP repair with hysterectomy were assessed. Thirty-six percent of patients identified as Hispanic, 17% as non-Hispanic Black, and 38% as non-Hispanic White. Twenty-three percent of patients reported abnormal uterine bleeding, 36% underwent a preoperative ultrasound examination, and 15% underwent endometrial biopsy. Two patients (0.9%) were diagnosed with endometrial carcinoma. Two patients (0.9%) were diagnosed with cervical dysplasia. No patients with concurrent oophorectomy or salpingectomy had ovarian or tubal pathology. The overall incidence of unexpected gynecologic pathology at the time of hysterectomy for prolapse was 1.7%.

Conclusions: The rate of endometrial cancer in our cohort is on the higher end of previously published data, although absolute rates of unanticipated malignancy remain low. Future studies should examine the pathological findings of larger, racially, and ethnically diverse cohorts of patients undergoing POP surgery with hysterectomy, which can aid in providing relevant estimates for preoperative counseling.

Importance: The U.S. health care system has an enormous carbon footprint made worse by the escalating use of single-use supplies. Emerging evidence suggests that smaller surgical fields ("green" draping) may represent a safe alternative to traditional draping.

Objectives: The aim of the study was to determine if the proportion of cases treated for culture-proven urinary tract infection (UTI) within 2 weeks of operating room cystoscopy after the green draping protocol implementation is noninferior to preprotocol cases. Secondary objectives included risk factors for UTI and waste and cost savings.

Study design: A pre-post implementation noninferiority study was performed from 2021 to 2023 in a urogynecology division at an academic medical center. The green draping protocol eliminated the use of top drapes, leg drapes, and gowns; blue towels were permitted per the surgeon's discretion. All minor cystoscopy cases were included.

Results: The cohort included 240 patients. Treatment of culture-proven UTI in the green cohort was noninferior to the preprotocol group (9 [7.5%] vs 7 [5.8%], P < 0.05). The odds of a culture-proven UTI were higher with history of recurrent UTI (odds ratio = 7.02), interstitial cystitis/bladder pain syndrome (odds ratio = 4.33), and older age (odds ratio per 5-year increase = 1.21). Approximately $1,403.92 (2023 USD) was saved, and 165 pounds of waste was diverted from the landfill.

Conclusions: A green draping protocol is noninferior to standard draping with respect to rates of postoperative culture-positive UTIs. Clinicians may use a smaller operating room field to decrease the carbon footprint without compromising quality of care.

Importance: Sacral neuromodulation (SNM) is an effective treatment for fecal incontinence (FI). Previous studies found that Black women undergo SNM for urinary incontinence less than White women, but there is less known about racial disparities for FI.

Objective: This study assessed differences in Black and White patients' FI treatment; SNM counseling was the primary outcome.

Study design: This was a retrospective cohort study of adult non-Hispanic Black and White patients who received FI treatment at an academic institution from 2011 to 2021. Medical records were queried for treatments, testing, and treating specialties for a 2:1 age-matched cohort of White:Black patients.

Results: Four hundred forty-seven women were included: 149 Black women and 298 age-matched White women. A total of 24.4% (109) of patients had documented SNM counseling, significantly fewer in Black patients (14.8% vs 29.2%, P < 0.001). A total of 5.1% (23) of patients received SNM, less frequent in Black patients (2.7% vs 6.4%, P = 0.003). Among patients with SNM counseling, there was no difference between cohorts. Black patients were less likely to be referred for physical therapy (59.7% vs 77.2%, P < 0.001), sphincter imaging (0.7% vs 5.7%, P = 0.011), and defecography (8.1% vs 17.1%, P = 0.009). Different specialties managed the 2 cohorts. Black patients were less likely to see urogynecology and colorectal surgery (21.5% vs 34.6%, P = 0.004; 9.4% vs 15.4%, P = 0.077). Patients seen by these surgeons were more likely to discuss SNM (48.6% vs 8.5%, P < 0.001).

Conclusions: There were differences between Black and White patients' FI treatment, including counseling about SNM. Multidisciplinary work is needed to provide equitable education for this life-altering condition.

Importance: Urinary incontinence (UI) occurs in 40-50% of nulliparous female elite athletes. However, causative factors, management, and perceptions of UI in this population are suboptimally understood.

Objectives: The objectives of this study were to (1) identify factors that precipitate UI in nulliparous female elite athletes and (2) explore management strategies for UI and its effect on sports performance and quality of life.

Study design: This was a cross-sectional, mixed-methods study in Division 1, college-aged nulliparous female athletes. Surveys assessed demographics, sport characteristics, relevant medical history, bladder symptoms during exercise, and validated genitourinary symptom questionnaires (Lower Urinary Tract Dysfunction Network Symptom Index-29, Female Genitourinary Pain Index). Data were compared between symptomatic athletes (who had ever experienced urinary leakage during exercise) and asymptomatic athletes. Symptomatic athletes discussed their experiences with UI in focus groups.

Results: Symptomatic athletes (33/67, 49%) had more asthma (21% vs. 2.9%, P = 0.027) and constipation (15% vs. 0%, P = 0.025), were more sexually active (76% vs. 44%, P = 0.008), and had worse overall urinary symptoms and genitourinary pain than asymptomatic athletes. They described both stress and urgency incontinence precipitated by various factors, including running, jumping, sustained efforts, and stressful situations. Many described voiding frequently before and during exercise. Despite increasing normalization of UI in the female athlete population since the onset of adolescence and variable degrees of bother, interest in improving symptom management was common.

Conclusions: Urinary incontinence in nulliparous female elite athletes may be multifactorial given its association with medical, behavioral, exercise-specific, and environmental conditions, which may be explored longitudinally to inform prevention and treatment strategies.

Importance: Feasibility of home urogenital microbiome specimen collection is unknown.

Objectives: This study aimed to evaluate successful sample collection rates from home and clinical research centers.

Study design: Adult women participants enrolled in a multicentered cohort study were recruited to an in-person research center evaluation, including self-collected urogenital samples. A nested feasibility substudy evaluated home biospecimen collection prior to the scheduled in-person evaluation using a home collection kit with written instructions, sample collection supplies, and a Peezy™ urine collection device. Participants self-collected samples at home and shipped them to a central laboratory 1 day prior to and the day of the in-person evaluation. We defined successful collection as receipt of at least one urine specimen that was visibly viable for sequencing.

Results: Of 156 participants invited to the feasibility substudy, 134 were enrolled and sent collection kits with 89% (119/134) returning at least 1 home urine specimen; the laboratory determined that 79% (106/134) of these urine samples were visually viable for analysis. The laboratory received self-collected urine from the research center visit in 97% (115/119); 76% (91/119) were visually viable for sequencing. Among 401 women who did not participate in the feasibility home collection substudy, 98% (394/401) self-collected urine at the research center with 80% (321/401) returned and visibly viable for sequencing.

Conclusions: Home collection of urogenital microbiome samples for research is feasible, with comparable success to clinical research center collection. Sample size adjustment should plan for technical and logistical difficulties, regardless of specimen collection site.

Importance: Women are a growing cohort within the U.S. military. Pelvic floor health is a component of health maintenance for which support needs vary by sex. The American Journal of Obstetrics & Gynecology reports that 1 in 4 women is affected by moderate to severe pelvic floor dysfunction (PFD). Understanding the specific experience of female service members is warranted for health care optimization and preservation of force readiness.

Objective: We aimed to identify the prevalence, incidence, and risk factors associated with incident PFD in active-duty females during an 11-year window.

Study design: We used the Medical Assessment and Readiness System at Womack Army Medical Center, which includes medical record and personnel data from 2011 to 2022. Pelvic floor dysfunction diagnoses were identified using diagnosis codes and analyzed with respect to demographic parameters.

Results: Between 2011 and 2022, 32,996 of 550,303 active-duty females were diagnosed with PFD (period prevalence: 6.00%). Using 2011-2012 as a washout period, 27,046 of 486,558 participants were diagnosed during 1,879,990.90 person-years of follow-up (incidence rate: 14.39 cases per 1,000 person-years). The incidence rate of PFD increased in both new and established active-duty females. Increasing time since service entry was the strongest, statistically significant independent predictor of PFD. Three or more deployments and specific physical fitness scoring were also predictors of PFD.

Conclusions: The incidence rate of PFD among female service members is increasing, and multiple military-specific factors predict PFD. As the percentage of women in active-duty service continues to grow, additional investigation is needed to confirm PFD trends, illuminate other predictors, and prevent adverse outcomes.