Urogynecology (Hagerstown, Md.)最新文献

Importance: Women aged 90 years and older ("oldest-old") represent a small but growing population who may experience bothersome pelvic organ prolapse and opt for surgical repair.

Objective: This study aimed to compare perioperative adverse events (AEs) within 8 weeks of prolapse surgery between women ≥90 years and younger patients.

Study design: We performed a secondary analysis of a dual-center retrospective cohort study of women ≥61 years old undergoing major prolapse surgery from January 2016 to May 2023. We identified all women ≥90 years and matched them to women <90 years in a 1:4 fashion based on Charlson Comorbidity Index score and surgery type. Matching was performed without replacement. The primary outcome was a composite AE outcome, defined as all intraoperative and postoperative complications within 8 weeks of surgery.

Results: There were 24 oldest-old undergoing prolapse surgery who were matched to 96 women with mean ± standard deviation age of 77.2 ± 5.7 years. Women ≥90 years were more likely to have a lower body mass index ( P < 0.01), greater preoperative prolapse stage ( P = 0.049), and were less likely to have general anesthesia ( P < 0.01). Patients did not differ in medical comorbidities, frailty status, concomitant hysterectomy or incontinence procedure, or length of postoperative stay. The oldest-old did not experience any intraoperative complications and had low rates of readmission (8.3%) and discharge to skilled nursing facilities (4.2%). Age ≥90 was not associated with composite AEs on multivariable analysis (adjusted odds ratio 1.60, 95% confidence interval [0.39-6.55]).

Conclusions: Age ≥90 years does not appear to increase the risk of perioperative AEs in women with similar comorbidities.

Importance: Sacral neuromodulation (SNM) requires removal for infectious complications in 3-11%.

Objective: The objective of this study was to examine the effect of preoperative antibiotic choice on all-cause SNM device removal rates.

Study design: This was a retrospective cohort analysis, using the Health Facts Database, representing more than 750 hospitals. We included female patients undergoing SNM implantation from 2010 to 2018. Univariate and multivariate logistic regression identified factors associated with removal. Thirty-five comorbidities were evaluated. Those with P < 0.2 on univariate analysis were included in the multivariate analysis. We decided a priori to include prophylactic antibiotic choice in the final model.

Results: Of 1,433 patients, 170 (11.9%) had device removal. Patients were 63.0 ± 14.9 years old, predominantly Caucasian (90.0%), treated in urban hospitals (94.1%), and married (54.2%). A total of 11.8% were obese, and 18.0% smoked. Those in the removal cohort were more likely from the Northeastern United States; 52.3% received first-gen cephalosporins (CPSN), 7.4% second- or third-generation CPSNs, 9.1% vancomycin, 13.4% aminoglycosides, 4.6% clindamycin, and 13.3% fluoroquinolones. Compared to vancomycin, more removals were associated with first-generation CPSNs (odds ratio [OR] = 3.1, 95% confidence interval [1.4, 6.8]); clindamycin (OR = 3.2, [1.2, 8.4]); second/third-generation CPSNs (OR = 3.1, [1.3, 7.6]); and aminoglycosides (OR = 3.1, [1.3, 7.4]). Additionally, patients treated in the Northeast were more likely to undergo removal (OR = 1.9, [1.0, 3.7]).

Conclusions: Vancomycin as a prophylactic antibiotic was associated with fewer device removals compared to most antibiotics in this retrospective cohort analysis. While prospective trials could confirm this benefit, low removal rates may make this impractical.

Importance: Nocturia is one of the most bothersome complaints in women with overactive bladder syndrome (OAB). Although small preliminary studies have shown that intradetrusor onabotulinum toxin A (BTX) injections reduce nocturia episodes, it is not known how reduction in nighttime urination affects sleep quality and quality of life.

Objectives: We aimed to assess the effect of BTX on nocturia frequency, sleep quality, and quality of life.

Study design: This is a prospective observation study of adult women with ≥2 nocturia episodes and OAB planning to undergo treatment with BTX injections. Participants completed a 2-day bladder/sleep diary and sleep-related questionnaires at baseline and 5 weeks post-BTX.

Results: A total of 40 participants were included with a mean age of 71 ± 12 years and most (90%) undergoing 100 units of BTX injection. At baseline, the median nocturia episodes were 3.5 (IQR, 2.5-5.0), and nearly half (43%) of participants reported mild to moderate sleep disturbance. At 5 weeks post-BTX, we found a significant decrease in nocturia episodes (-2/night) and a 59% decrease in mild to moderate sleep disturbance (P = 0.006). There were significant increases in longest sleep interval (+1.5 hours), time to first awakening (+1.6 hours) and average sleep interval (+1.3 hours), and a significant increase in nocturia-related quality of life scores (P < 0.001 for all). Sixteen (40%) of participants had nocturia resolution defined as ≤1 mean nocturia episode post-BTX.

Conclusions: For women with OAB and >2 nocturia episodes/night, BTX injections reduce voids/night and improve sleep quality and nocturia-related quality of life.

Importance: Restrictive physical activity after pelvic reconstructive surgery is recommended, although the optimal duration and intensity are not standardized.

Objective: This systematic review and meta-analysis aimed to evaluate the existing literature comparing clinical outcomes for liberal postoperative physical activity versus standard of care, defined as restricted postoperative physical activity, after pelvic reconstructive surgery.

Study design: PubMed, CENTRAL, Scopus, Web of Science, and CINAHL databases were searched for observational and randomized studies comparing liberal postoperative physical activity and standard of care in women undergoing pelvic reconstructive surgery, reporting anatomic and functional outcomes. Statistical analysis was performed using RevMan software, presenting results as mean difference (MD) or odds ratio in a random-effects model, with 95% confidence intervals (CIs).

Results: Five randomized trials, representing total n = 434, were included, with 2 studies on sling surgical procedures and 3 on prolapse surgical procedures. Data from 3 studies suggest no significant difference between liberal and standard postoperative instructions in surgical outcomes, measured by Point Ba from POP-Q assessment tool, up to 3 months follow-up (MD, -0.04; 95% CI, -0.16 to 0.07; P = 0.49). Disease-specific symptom distress, measured by Pelvic Floor Distress Inventory-20, favored the liberal approach (MD, -10.09; 95% CI, -18.33 to -1.86; P = 0.02). Other domains, including Urinary Distress Inventory-6, also showed significant improvements with liberal postoperative activities (MD, -4.29; 95% CI, -7.84 to -0.74; P = 0.02).

Conclusions: Patients with liberal postoperative physical activity recommendations in prolapse repair surgical procedures had similar short-term anatomic outcomes compared with standard restrictions, with more favorable outcomes in disease-specific symptom relief and quality of life.

Importance: A patient-centered care model is needed for recurrent urinary tract infection (UTI) management.

Objective: The aim of this study was to develop a conceptual model for a digital platform to implement evidence-based guidelines for recurrent UTI management.

Study design: This was a qualitative, 3-stage mixed methods study that included (1) developing an evidence-based prototype texting platform; (2) qualitative feedback from recurrent UTI patients using the platform; and (3) quantitative data on acceptability (proportion of patients engaging with the platform), accuracy (proportion of patient messages interpreted accurately by the platform), and usability (score 0-100).

Results: Thirty-one women with recurrent UTI (median age, 71 years; range, 60-74 years) participated in testing over 4 months. The prototype platform was modified through iterative rounds of qualitative and quantitative analysis until engagement ≥85%, accuracy ≥90%, and usability score of ≥80 were achieved in 10 patients. Qualitative feedback indicated that patients valued rapid access to treatment through fewest possible health encounters during an acute episode, evidence-based education about prevention, and ability to participate in self-management with support from health care providers. Based on this feedback, a conceptual model consisting of 3 main components was developed: (1) an algorithm to triage acute symptoms, (2) educational videos emphasizing prevention strategies, and (3) supportive messages. Patient feedback identified 4 key implementation outcomes-usability, acceptability (engagement), fidelity (accuracy), and cost-and 3 clinical outcomes-self-efficacy, health care utilization, and rate of unnecessary antibiotics for testing the model.

Conclusion: The proposed model can be used to implement and test a patient-centered evidence-based digital platform for the management of recurrent UTI.

Importance: This study is important as it challenges the effectiveness of silver-coated catheters in reducing urinary tract infections (UTIs) after pelvic floor surgery (PFS).

Objective: The aim of this study was to investigate the incidence of UTIs in patients using silver-coated silicone transurethral indwelling catheters (TICs) compared with standard silicone TICs among women with postoperative urinary retention following PFS.

Study design: This was a double-blind, randomized controlled trial of women undergoing PFS between June 2022 and February 2024 with postoperative urinary retention. Participants were randomized to a silver-coated silicone TIC or a standard silicone TIC. The primary outcome was the incidence of symptomatic, culture-proven UTI within 30 days of surgery. Secondary outcomes included the categorization of uropathogens as well as adverse symptoms potentially related to the catheter. A sample size of 155 participants per arm was calculated to find a relative decrease of 47%, from 30% to 16%.

Results: Of 310 participants randomized, 303 were included in the analysis: 154 controls and 149 silver catheter. Demographics were similar for both groups. For our primary outcome, 56 patients in the control group and 52 patients in the silver catheter group were diagnosed with a UTI (36.4% vs 34.9%; P = 0.81). No adverse reactions to the silver catheter were noted. Analysis of the urinary microbiomes demonstrated Escherichia coli was the most represented uropathogen, found in 43% of the urine cultures overall.

Conclusion: There was no difference in incidence of symptomatic, culture-confirmed UTIs in patients who received silver-coated silicone TICs compared with standard silicone TICs in women undergoing PFS.

Importance: Urinary tract infection (UTI) is the most common complication of intradetrusor onabotulinumtoxinA (BTX-A) injection. Despite this, there are no evidence-based guidelines on antibiotic prophylaxis.

Objectives: Our primary aim was to determine whether antibiotic prophylaxis decreased symptomatic, culture-proven UTI rates within 6 weeks of intradetrusor BTX-A injection. Our secondary aims were to determine if there are differences between antibiotic regimens and to identify risk factors for developing a UTI.

Study design: This was a prospective, observational multicenter cohort study of female patients receiving BTX-A for idiopathic overactive bladder. We compared patients who received antibiotics (nitrofurantoin or trimethoprim-sulfamethoxazole) to those who did not. To detect a 15% difference in UTI rates between groups (80% power, alpha = 0.05), 270 participants were needed.

Results: A total of 282 participants ultimately received BTX-A and were included in the analysis. One hundred eighty-one (62.6%) were in the antibiotic cohort and 101 (35.8%) were in the no-antibiotic cohort. The overall rate of symptomatic, culture-proven UTI was 12.1%, and there was no difference between the antibiotic and no-antibiotic cohort (10.6% vs 14.9%, respectively; P = 0.29). On multivariable logistic regression, UTI was associated with older age (adjusted odds ratio [aOR], 1.07; 95% CI, 1.02-1.11), BTX-A dose of 200 units (aOR, 4.24; 95% CI, 1.45-12.35), and self-catheterization (aOR, 26.0; 95% CI, 3.62-186.5). The odds of symptomatic UTI were lower among postmenopausal participants (aOR, 0.13; 95% CI, 0.02-0.68) and participants in the Northeast United States (aOR, 0.23; 95% CI, 0.08-0.72).

Conclusions: Our study did not find a lower rate of symptomatic, culture-proven UTI among participants who took antibiotics compared with those who did not.

Importance: Overactive bladder is a distressing syndrome that significantly affects quality of life. Transcutaneous tibial nerve stimulation (TTNS) has been proposed as a home-based, patient-centered therapy that could improve access to treatment for this condition.

Objective: We aimed to determine the efficacy of 12 weeks of TTNS versus sham therapy in reducing symptomatic bother in ambulatory women with urgency urinary incontinence.

Study design: This was a double-masked, sham-controlled randomized trial. The primary outcome was the change in Overactive Bladder Questionnaire scores. Secondary outcomes included those with 50% or greater reduction in urgency incontinence episodes on 3-day voiding diaries and Patient Global Impression of Improvement.

Results: One hundred women were randomized (65 intervention, 35 sham) and included in analysis. Both groups experienced clinically meaningful improvement in Overactive Bladder Questionnaire scores postintervention from baseline, which was not significant between groups (symptom severity: intervention -19.5 ± 20.2 vs sham -19.4 ± 20.4, P = 1.0; health-related quality of life -16.6 ± 18.5 vs -13.8 ± 16.8, P = 0.5). In the TTNS group, 58.8% of women achieved 50% or greater reduction in urgency incontinence episodes versus 41.7% of women in the sham group ( P = 0.2), and 25% versus 18% were "much" or "very much improved" ( P = 0.2). A sensitivity analysis confirmed these findings.

Conclusions: Clinically meaningful reductions in overactive bladder symptoms were observed in both TTNS and sham therapy without significant differences between groups; however, a trend toward greater reduction in incontinence episodes and overall impression of improvement was noted in the active treatment. The therapeutic benefit from regularly connecting with a clinician should be considered when developing new therapies.

Importance: Evaluation of racial and ethnic differences in apical suspension during prolapse repair is crucial for equitable gynecological care.

Objective: The objective was to assess racial and ethnic disparities in apical suspension during native tissue prolapse repair.

Study design: We analyzed data from the 2019 Healthcare Cost and Utilization Project National Inpatient Sample and Nationwide Ambulatory Surgery Sample, using Current Procedural Terminology and International Classification of Diseases, Tenth Revision, codes. Bivariate analysis identified demographic and hospital-based differences between native tissue apical suspension procedures versus non-apical suspension during vaginal hysterectomy for prolapse, further analyzed with multivariable logistic regression. A separate analysis examined posthysterectomy prolapse surgical procedures.

Results: Of the 62,553 vaginal hysterectomies, 26,094 (41%) were for prolapse. Among these, 14,027 (54%) included apical suspension. The cohort's racial and ethnic identity was 73% non-Hispanic White, 5% Black, 15% Hispanic, 3% Asian, 0% Native American, and 3% other. Multivariable analysis confirmed Black patients were more likely to receive apical suspension compared to non-Hispanic White patients (adjusted odds ratio [aOR] 1.26, 95% CI: 1.04-1.53, P = 0.02), and Hispanic patients were less likely to receive apical suspension (aOR 0.74, 95% CI: 0.63-0.87, P < 0.001). Among 60,074 posthysterectomy prolapse surgical procedures, only 18% included apical suspension. Compared to non-Hispanic Whites, Black, Hispanic, and Asian patients were less likely to receive apical suspension (Black: aOR 0.8, 95% CI: 0.68-0.95, P = 0.013; Hispanic: aOR 0.89, 95% CI: 0.77-1.04, P = 0.14; Asian: aOR 0.52, 95% CI: 0.41-0.66, P < 0.001).

Conclusions: The study highlights persistent racial and ethnic disparities in apical suspension provision. There is a notable lack of apical suspension in native tissue repairs, especially after hysterectomy.