Urogynecology (Hagerstown, Md.)最新文献

Importance: Individuals with non-English primary language (NEPL) have difficulty accessing subspecialty care, and communication barriers can result in suboptimal counseling. Studies investigating the association between primary spoken language (PSL) and pelvic organ prolapse (POP) stage and treatment are lacking.

Objective: The objective of this study was to determine the association between primary language and degree and management of POP.

Study design: This was a retrospective cohort analysis of patients evaluated for POP between 2015 and 2023 at 2 tertiary care centers. Chart review identified patients with a NEPL, and a cohort of English primary language (EPL) patients was randomly selected. Data regarding demographics, Pelvic Organ Prolapse Quantification examination, and treatment within 6 months of initial presentation were collected.

Results: The total cohort included 114 patients (57 per group). The groups were well-matched except that the NEPL group had a significantly higher mean gravidity and parity (4.6 vs 2.8, P < 0.001; 3.8 vs 2.4, P <0.001). The NEPL group had higher rate of Medicaid/Medicare/Self-pay insurance (47 vs 26, P < 0.001) and more diabetes mellitus (19 vs 5, P = 0.002). The rate of advanced-stage POP (stage 3-4) was similar between groups (49.1% vs 56.1%, P = 0.45). The NEPL group had statistically significant higher rates of apical (78.6% vs 59.6%, P = 0.03), anterior (90.9% vs 66.7%, P = 0.002), and posterior prolapse (81.8% vs 45.6%, P < 0.001). The EPL group had statistically significant higher rates of surgical management (43.9% vs 22.8%, P = 0.02). These findings persisted after controlling for age, body mass index, insurance, parity, and diabetes mellitus.

Conclusions: This study highlights inequity in the treatment of POP by primary language. The NEPL population had a similar rate of advanced POP and significantly higher rates of all the subcategories of prolapse. However, they were significantly less likely to undergo surgery. This suggests bias toward conservative measures in those with NEPL.

Importance: The onset of symptom improvement following intravesical onabotulinum toxinA for urgency urinary incontinence is not well known.

Objective: The objective of this study was to evaluate the early efficacy of intradetrusor onabotulinumtoxinA for the treatment of urgency urinary incontinence.

Study design: We performed a prospective observational study of women undergoing intradetrusor onabotulinumtoxinA for the treatment of urgency urinary incontinence. Adult women receiving an initial or subsequent injection of 100 units of intradetrusor onabotulinumtoxinA were included. Participants completed 3-day baseline voiding diaries, the Urinary Distress Inventory-6, and Incontinence Impact Questionnaire-7 before the procedure. Voiding diaries, Urinary Distress Inventory-6, and Incontinence Impact Questionnaire-7 were repeated daily for 14 days postprocedure. Statistical analysis of paired data (preprocedure and postprocedure) was performed using the Wilcoxon signed-rank test.

Results: Thirty-one participants completed baseline and follow-up questionnaires. The median (range) baseline Urinary Distress Inventory-6 was 33 (8-71) and the Incontinence Impact Questionnaire-7 was 38 (0-100). The median baseline daily voids, urgency urinary incontinence episodes, urgency episodes, and nocturia episodes were 13 (8-20), 5 (2-15), 8 (3-17), and 4 (0-6), respectively. For all measures, day 1 outcomes were significantly improved from baseline. Day 1 median Urinary Distress Inventory-6 was 25 (0-67), Incontinence Impact Questionnaire-7 was 24 (0-81), daily voids were 10 (5-20), daily urgency urinary incontinence episodes were 2 (0-15), daily urgency episodes were 3 (0-20), and daily nocturia episodes were 2 (0-4). Significant improvement persisted over the 14-day follow-up.

Conclusions: Women undergoing intradetrusor onabotulinumtoxinA for urgency urinary incontinence had significant subjective and objective improvement 1 day postprocedure.

Importance: Urine samples are part of urogynecologic evaluation, but limited data exist on the optimal urine collection technique in obese female patients.

Objective: The objective of this study was to compare dipstick urinalysis and culture results obtained from obese females via midstream clean-catch and straight catheterization.

Study design: We performed a prospective cross-sectional study of obese females aged ≥18 years with a body mass index (BMI) ≥30 presenting for urogynecologic consult. Women with symptoms of acute urinary tract infection were excluded. Midstream clean-catch and straight catheterization urine samples were collected from all participants. Dipstick urinalysis and urine cultures were performed on both specimens to compare results using contingency tables, Cohen's Kappa, and logistic regression.

Results: Two hundred one patients were included with a mean age of 59.61±13.42 years and a median (IQR) BMI of 35.8 (33.0-40.3). Agreement between collection methods was moderate for nitrites (κ=0.65). There was weak agreement between the collection methods for blood, leukocytes, and bacteria (all κ<0.60). Nearly half of the midstream clean-catch cultures were contaminated with ≥3 mixed bacteria versus catheterized specimens (42.3% vs 3.5% respectively, P<0.001). Culture contamination was not more likely with increasing BMI for clean-catch or catheterized specimens (odds ratio [OR]=1.0, 95% CI, 0.96-1.10 and OR=1.0, 95% CI, 0.94-1.16, respectively). Culture contamination was not associated with age by decade in clean-catch or catheterized specimens (OR=1.0, 95% CI, 0.83-1.27 and OR=1.3, 95% CI, 0.72-2.40, respectively).

Conclusions: Agreement between midstream clean-catch and catheterized specimens among obese female patients is poor. Midstream clean-catch urine cultures were more likely to be contaminated, though increasing BMI does not appear to influence the odds of contamination among obese patients.

Importance: Current literature insufficiently identifies the optimal preoperative vaginal antiseptic to reduce rates of surgical site infection (SSI) after gynecologic surgery.

Objective: The objective of this study was to determine the rate of chlorhexidine vaginal preparation use in gynecologic surgery with and without postoperative SSI compared with iodine.

Study design: We performed a retrospective case-control study of women undergoing any gynecologic surgery between January 2010 and December 2023 at an urban academic medical center. Adult women diagnosed with and treated for a postoperative SSI within 30 days of gynecologic surgery were identified as cases and matched 1:4 to the 2 preceding and 2 subsequent gynecologic surgical procedures performed on the same day without postoperative SSI. Additional SSI risk factors were analyzed as secondary objectives. Standard group comparisons were performed. A multivariable logistic regression was used to assess factors associated with SSI.

Results: SSI cases (n=101) were matched to controls (n=404). Cases and controls differed on numerous baseline and intraoperative characteristics, including insurance type, American Society of Anesthesiologists physical status, comorbidities, malignancy, surgical route, major/minor surgery, estimated blood loss, intraoperative complications, and operative time. Cases were less likely to undergo chlorhexidine vaginal preparation (11% vs 26%, P<0.01) and more likely to have a non-SSI postoperative complication (32.7% vs 7.0%, P<0.01), readmission (17.0% vs 4.3%, P<0.01), and reoperation (17.2% vs 0%, P<0.01). In a backwards regression, chlorhexidine vaginal preparation was associated with significantly lowered odds (adjusted odds ratio, 0.4, 0.17-0.89) of SSI after gynecologic surgery.

Conclusion: Patients undergoing chlorhexidine vaginal preparation before gynecologic surgery had a 60% decreased odds of SSI within 30 days of surgery.

Importance: The effect of a short interpregnancy interval (IPI) on pelvic floor disorders is unknown.

Objectives: We investigated the relationship between a short IPI and the development of stress incontinence (SUI), pelvic organ prolapse (POP), and anal incontinence (AI) in the decade after the first delivery.

Study design: We performed a secondary analysis of the Mothers' Outcomes After Delivery study-a prospective cohort of women recruited 5-10 years following their first delivery and followed annually between 2008 and 2018. A short IPI was defined as ≤18 months, calculated as the number of months between deliveries minus the length of the second pregnancy. SUI, POP, and AI were identified by annual validated questionnaires, examination, or history of treatment. Data were analyzed in SAS. Variables significant on bivariate analysis were entered into multivariable logistic regression models predicting each outcome using the generalized estimating equations approach for repeated measures.

Results: Of 1,127 women, the majority (671, 59%) never had a short IPI, 395 (35%) had 1 short IPI, and 61 (6%) had 2 or more. Within 10-15 years, 219 women (19%) reported SUI, 156 (14%) reported POP, and 251 (22%) reported AI. We found that a short IPI was not associated with SUI (P=0.69), POP (P=0.71), or AI (P=0.95). When restricting the cohort to women with only nonoperative vaginal deliveries (n=440), there remained no difference in the presence of SUI, POP, or AI (P = 0.88, 0.84, 0.78, respectively).

Conclusions: A short IPI is not associated with pelvic floor disorders in the decade following the first delivery. This should be reassuring to women at risk of PFDs who elect to become pregnant within 18 months of childbirth.

Importance: Asymptomatic bacteriuria (ASB) is common, particularly among women as they age, yet awareness is low and patient education materials are often limited in quality.

Objectives: We conducted a qualitative study to assess patient feedback on existing ASB information and identify gaps in understanding to guide future educational efforts.

Study design: We convened 5 focus groups among postmenopausal women with previous experience of treatment for urinary tract infections. Participants were asked to describe their experiences of urinary symptoms, reflect on a handout describing ASB, and make recommendations on how to improve patient education. Three team members read deidentified transcripts of the focus groups, developed a thematic codebook following Conventional Content Analysis guidelines, and coded the data using NVivo software.

Results: Twenty women participated in 5 focus groups. The average age of participants was 69.1 years (SD 10.8). Three participants (15.0%) identified as Black and the remaining participants identified as White. Many had postsecondary education, 12 with some college (60.0%) and 7 with graduate-level education (35.0%). Five overarching themes emerged: (1) ASB confusion, (2) presence of bacteria must indicate infection, (3) diagnosis requires treatment, (4) antibiotics as a "cure-all," and (5) in favor of antimicrobial stewardship. Quotations illustrated both persistent misconceptions and openness to learning, highlighting opportunities to improve communication and reduce inappropriate antibiotic use.

Conclusions: Among postmenopausal women, there is a lack of awareness surrounding ASB and the concept that bacteriuria could exist without requiring antibiotics. While misconceptions are common, willingness to learn suggests potential for targeted, plain-language educational materials as we seek to improve understanding of ASB and support antibiotic stewardship.

Importance: Midurethral sling (MUS) is a common procedure to correct stress urinary incontinence but carries a risk of postoperative urinary retention (POUR).

Objective: The objective of this study was to evaluate the efficacy of perioperative tamsulosin for reducing the incidence of POUR in patients undergoing MUS placement, with or without concomitant pelvic organ prolapse (POP) surgery.

Study design: This was a retrospective cohort study of female patients who underwent MUS placement, with or without concomitant gynecologic surgery. Patients were excluded if they underwent transobturator or autologous sling placement or had an intraoperative injury requiring prolonged catheterization. Patients who received perioperative tamsulosin were compared with those who did not. Multivariable logistic regression was performed to assess factors associated with POUR. The primary outcome was the incidence of POUR.

Results: A total of 423 patients who underwent MUS placement were eligible for analysis. Of these, 131 (31.0%) patients received perioperative tamsulosin and 292 (69.0%) did not. In the unadjusted analysis, the incidence of POUR was significantly higher in the no-tamsulosin group (18.8% vs 10.6%, P=0.04). However, the multivariable logistic model demonstrated that perioperative tamsulosin was not significantly associated with decreased POUR (OR, 0.61; 95% CI, [0.29-1.28], P=0.19). Patients with a higher body mass index had a reduced likelihood of POUR (OR, 0.94; 95% CI, [0.89-0.99], P=0.02), while patients who underwent a concomitant POP surgical procedure trended toward increased likelihood of POUR (OR, 2.15; 95% CI, [0.97-4.73], P=0.06).

Conclusions: These findings suggest that patient and procedural characteristics may play a more significant role in POUR risk than perioperative tamsulosin use for patients undergoing MUS placement.

Importance: Urinary tract infections (UTIs) are common yet preventable complications after pelvic organ prolapse (POP) surgery.

Objective: The objective of this study was to compare hospital-based postoperative UTI rates among patients undergoing POP surgery by perioperative antibiotic regimen received: cefazolin (C), gentamicin + clindamycin (GC), or cefazolin + metronidazole (CM).

Study design: This was a retrospective cohort analysis of patients undergoing POP surgery from 2000 to 2022 using a U.S. national database. The primary outcome was UTIs within 30 days postoperatively. Secondary outcomes included emergency department (ED) visits, inpatient admissions, and UTIs within 90 days postoperatively. Inverse probability of treatment weighting (IPTW) was performed to balance on potential confounding preoperative characteristics.

Results: Of 166,673 POP surgery patients, 3.0% (n=4,953) were diagnosed with a 30-day postoperative UTI. The UTI rate differed by perioperative antibiotic regimen: C 2.9% (n=4,197), CM 2.5% (n=295), and GC 3.8% (n=461), P<0.001. GC was associated with a higher 90-day UTI rate (4.9%, n=601, P<0.001), UTI-related ED visits (1.8%, n=219, P<0.001), and UTI-related hospitalization (0.73%, n=89, P=0.0014) compared with cefazolin-based antibiotic cohorts. After IPTW, cefazolin-based regimens remained associated with decreased odds of postoperative UTI-related complications compared with GC. Compared with cefazolin, GC was associated with increased odds of 30-day UTIs (OR, 1.27; 95% CI, 1.14-1.42), 90-day UTIs (OR, 1.30; 95% CI, 1.18-1.43), UTI-related ED visits (OR, 1.40; 95% CI, 1.19-1.63), and UTI-related inpatient admissions (OR, 1.36; 95% CI, 1.06-1.74).

Conclusions: Among patients undergoing POP surgery, cefazolin-based antibiotic regimens were associated with a lower probability of hospital-based UTI-related complications compared with the group receiving GC.

Importance: A cost analysis model of supracervical (SCH) versus total hysterectomy (TH) at the time of minimally invasive sacrocolpopexy (SCP) has not been established.

Objectives: Minimally invasive sacrocolpopexy (SCP), a mesh-augmented pelvic organ prolapse (POP) repair, is frequently performed with concomitant hysterectomy, either a supracervical hysterectomy (SCH) or total hysterectomy (TH), with comparable POP outcomes with either approach. However, for SCH versus TH, there are important implications on cervical cancer screening and reported complication rates. Clinical outcomes data have not identified a clear preferred hysterectomy type at the time of SCP. This study aimed to perform a cost analysis to compare SCH versus TH at the time of SCP for POP.

Study design: A health care sector-perspective analysis was performed using a 10-year time horizon. Our model assumes that there is similar efficacy and patient satisfaction for SCH and TH, and that the age of patients undergoing SCP is 55 years (median age in the literature). The average cost of procedures and complications were estimated from publicly available data sources. Base-case probabilities for various complications were estimated through a PubMed literature search.

Results: TH-SCP is $654 less costly per treatment case compared with SCH-SCP ($26,101 vs. $26,754). Three model variables have the potential to reverse this cost advantage when varied across their ranges: SCH-SCP surgery, TH-SCP surgery, and the cost of cervical screening. Based on our model assumptions, SCH-SCP was 2.5% more costly than TH-SCP in relative terms.

Conclusion: SCH-SCP was found to be more costly over a 10-year time horizon than TH-SCP in our study population.

Importance: Colpocleisis is an obliterative procedure for pelvic organ prolapse commonly offered to medically complex patients who may not be candidates for reconstructive surgery. Although frailty is a well-established predictor of surgical morbidity, its effect on colpocleisis outcomes is not well defined. The 5-factor Modified Frailty Index (mFI-5) is a validated tool for surgical risk prediction.

Objective: This study evaluated the association between mFI-5 and 30-day postoperative complications after colpocleisis.

Study design: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2006 to 2022. We defined frailty as an mFI-5 score ≥2 based on 5 ACS NSQIP-captured items: (1) functional dependence, (2) diabetes, (3) chronic obstructive pulmonary disease, (4) congestive heart failure, and (5) hypertension. Demographic, perioperative variables, and postoperative complications were compared between frail and nonfrail patients. The primary outcome was a composite of any 30-day complication. Secondary outcomes included individual complications, reoperation, and length of stay. Multivariable logistic regression adjusted for prespecified clinical covariates.

Results: Of 5,213 patients undergoing colpocleisis, 93 (1.8%) were frail. Overall, 495 (9.3%) experienced a postoperative complication. More frail patients were Black, had higher body mass index, smoked tobacco, and were assigned American Society of Anesthesiologists classification 3-4. In adjusted models, frailty was independently associated with composite complications (adjusted odds ratio [aOR], 2.04; 95% CI, 1.21-3.48), pneumonia (aOR,15.94; 95% CI, 4.51-56.37), and stroke (aOR, 14.72; 95% CI, 2.74-79.08).

Conclusion: Frailty is an independent predictor of morbidity after colpocleisis with disproportionately elevated risks of pulmonary and cerebrovascular events. Incorporating frailty screening into preoperative evaluation may improve perioperative counseling, stratification, and management.