Urogynecology (Hagerstown, Md.)最新文献

Importance: Use of the publicly available Large Language Model, Chat Generative Pre-trained Transformer (ChatGPT 3.5; OpenAI, 2022), is growing in health care despite varying accuracies.

Objective: The aim of this study was to assess the accuracy and readability of ChatGPT's responses to questions encompassing surgical informed consent in urogynecology.

Study design: Five fellowship-trained urogynecology attending physicians and 1 reconstructive female urologist evaluated ChatGPT's responses to questions about 4 surgical procedures: (1) retropubic midurethral sling, (2) total vaginal hysterectomy, (3) uterosacral ligament suspension, and (4) sacrocolpopexy. Questions involved procedure descriptions, risks/benefits/alternatives, and additional resources. Responses were rated using the DISCERN tool, a 4-point accuracy scale, and the Flesch-Kinkaid Grade Level score.

Results: The median DISCERN tool overall rating was 3 (interquartile range [IQR], 3-4), indicating a moderate rating ("potentially important but not serious shortcomings"). Retropubic midurethral sling received the highest overall score (median, 4; IQR, 3-4), and uterosacral ligament suspension received the lowest (median, 3; IQR, 3-3). Using the 4-point accuracy scale, 44.0% of responses received a score of 4 ("correct and adequate"), 22.6% received a score of 3 ("correct but insufficient"), 29.8% received a score of 2 ("accurate and misleading information together"), and 3.6% received a score of 1 ("wrong or irrelevant answer"). ChatGPT performance was poor for discussion of benefits and alternatives for all surgical procedures, with some responses being inaccurate. The mean Flesch-Kinkaid Grade Level score for all responses was 17.5 (SD, 2.1), corresponding to a postgraduate reading level.

Conclusions: Overall, ChatGPT generated accurate responses to questions about surgical informed consent. However, it produced clearly false portions of responses, highlighting the need for a careful review of responses by qualified health care professionals.

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: Literature surrounding conservative management of voiding dysfunction (VD) due to pelvic organ prolapse (POP) is limited.

Objective: The objective of this study was to evaluate the effect of pessaries on VD in women with symptomatic POP.

Study design: This was a retrospective case series of adult women who underwent a pessary fitting for POP and VD between January 2010 to December 2022 at 2 tertiary care centers. Voiding dysfunction was defined as a composite outcome of participant report of obstructive voiding symptoms and postvoid residual volume (PVR) ≥150 mL prior to pessary fitting. Obstructive voiding symptoms were determined by positive response on the Pelvic Floor Distress Inventory-20 to items 5, 6, 19, and/or 20.

Results: Sixty-one participants with POP and VD underwent successful pessary fitting at 2 large academic institutions. Median (range) age was 75 years (35-89) and body mass index of 26.5 (18.0-46.3). Participant reports of "difficult bladder emptying" and "sensation of incomplete bladder emptying" were the most reported symptoms of obstructive voiding. Advanced staged prolapse (prolapse ≥ stage 3) was documented for 84% of participants. Median point C, Ba, and genital hiatus were -2 cm, +3 cm, and 4 cm, respectively, on examination. Median PVR prior to pessary fitting was 263 mL (150-810). Voiding dysfunction resolved in 60 out of 61 participants (98%). Median repeat PVR after pessary placement was 50 mL (0-250).

Conclusion: Pessary placement resolved VD due to POP in 98% of participants. Clinicians can offer pessary placement as nonsurgical management for participants with VD due to POP.

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.

Importance: There are limited data to guide practices to reduce surgical site infections following sacral neuromodulation; however, many surgeons prescribe prophylactic postoperative antibiotics after device implantation.

Objective: The aim of the study was to compare the proportion of patients with sacral neuromodulation device-associated surgical site infections after use of prophylactic postoperative antibiotics versus none.

Study design: This was a multicenter retrospective cohort study of patients undergoing sacral neuromodulation device implantation at 11 institutions from January 2014 to December 2023, comparing outcomes in patients who did versus did not receive prophylactic postoperative antibiotic treatment. The primary outcome was surgical site infection within 90 days. The proportions of surgical site infections were compared, and regression analyses were performed to identify variables associated with surgical site infection.

Results: A total of 1,798 patients met inclusion criteria. Within this population, 67 surgical site infections (3.7%) were identified. Patients who received postoperative antibiotics (898/1798, 49.9%) were older (63.2 years vs 61.0 years, P < 0.001), and a greater proportion had staged procedures (57.9% vs 49.8%, P < 0.001). The proportion of surgical site infections and device explantations were not different between groups (3.6% vs 3.9%, P = 0.8) and (2.0% vs 2.8%, P = 0.2), respectively. After adjusting for age in a multivariate analysis, prophylactic postoperative antibiotic use was not associated with surgical site infections (0.98, 95% CI: 0.61-1.61, P = 0.94).

Conclusions: Rates of surgical site infection following device implantation are low. Our findings suggest that the use of prophylactic postoperative antibiotics has minimal effect on reducing infection after device implantation. Further research is needed to explore underlying factors influencing this relationship.

Abstract: Importance: The most used overactive bladder (OAB) medications are anticholinergics, which professional societies recommend avoiding in older patients given dementia risk. Cost prevents patients from switching to preferred beta-3 agonists. Mirabegron was the only beta-3 agonist eligible for the Centers for Medicare/Medicaid Services (CMS) 2023 Drug Negotiation Program (DNP). While mirabegron's price would be markedly reduced by inclusion in the DNP, only ten drugs were chosen in its first year.Objectives: We sought to explain mirabegron's absence from CMS's 2023 DNP and estimate the percentage of anticholinergic to mirabegron conversions needed to merit DNP inclusion.Study design: We modeled CMS's 2023 selection process using publicly available dashboards from 2017-2021. Among the 20 costliest drugs, we excluded ineligible drugs and categorized the remainder as DNP chosen/not chosen. For drugs not chosen, we used price inflation and beneficiary utilization trends to project total 2023 costs.Results: In 2021, mirabegron was the 14th most costly drug overall-9th when excluding ineligibles-and the only top-20 drug eligible but not selected for the 2023 DNP. We estimated mirabegron to be 96.7% the cost of the 10th most costly drug. Switching 1.2% of 2021 anticholinergic prescriptions to mirabegron would have led to DNP inclusion, presenting an interesting dilemma where more patients would use mirabegron if it were cheaper, but insufficient patients used it for DNP inclusion to make it cheaper.Conclusions: Mirabegron came exceedingly close to DNP selection in 2023, and its future inclusion in the DNP would likely herald a massive shift of Medicare patients away from anticholinergics.

Importance: The Pelvic Organ Prolapse Quantification (POP-Q) stages do not correlate with symptoms or characterize important prolapse subtypes.

Objectives: We hypothesize that clinically meaningful prolapse "phenotypes" utilizing POP-Q measurements can be defined. The primary aim was to define the phenotypes and their frequency. Secondary aims were to compare demographics, medical characteristics, and symptoms between phenotypes.

Study design: Patients who previously underwent prolapse surgery were retrospectively categorized into 1 of 8 phenotypes based on 2 principles: (1) prolapse exists when the anterior or posterior vaginal wall descend to the hymen or the apex descends half total vaginal length, and (2) prolapse may exist in anterior, posterior, and/or apical compartments. Demographics, medical characteristics, and Pelvic Floor Distress Inventory-20 (PFDI-20) responses were compared. Linear and logistic regression models were used for comparisons.

Results: The AC (anterior-predominant and apical) phenotype was most common (231 of 501 patients, 46.1%) and served as the reference for comparisons. The no prolapse, P (isolated posterior), C (isolated apical), and PC (posterior-predominant and apical) phenotypes were younger. The A (isolated anterior) phenotype was older. P, PC, and APC (anterior and posterior and apical) phenotypes had greater body mass index. The P phenotype Colorectal-Anal Distress Inventory scores were higher. Similarly, the PC phenotype had higher scores for bowel splinting and rectal prolapse. Conversely, the C phenotype total PFDI-20 scores were lower (P = 0.01). Only the APC phenotype had no significant differences in any PFDI-20 question compared with the AC phenotype.

Conclusion: These phenotypes may allow for improved understanding, communication, and counseling about prolapse and prolapse treatment.

Importance: Postoperative urinary retention (POUR) is common after reconstructive pelvic surgery. Little is known about the relationship between older age (≥70 years) and POUR after pelvic organ prolapse surgery.

Objectives: We aimed to investigate the relationship between age ≥70 years and POUR. Secondarily, we aimed to determine if duration of urinary catheterization differed by age in women with POUR.

Study design: This was a secondary analysis of a dual-center retrospective study on perioperative adverse events in biologic females aged ≥61 years undergoing prolapse surgery. The primary outcome was POUR, defined as a failed retrograde voiding trial requiring bladder catheterization. The secondary outcome was duration of temporary bladder catheterization. We developed a stepwise multivariable logistic regression model, which included relevant variables with P < 0.10 on univariate analyses and a forced age variable.

Results: In this cohort of 2,665 women, mean ± standard deviation age was 71.2 ± 6.7 years, and 54.6% were ≥70 years, POUR occurred in 830 (31.1%) patients. Women with POUR had a lower body mass index and were more likely to have undergone a vaginal prolapse surgery and concomitant hysterectomy/incontinence procedure (P < 0.05). They had higher estimated blood loss (75 vs 50 mL, P < 0.001). On multivariable logistic regression, age ≥70 years was not associated with POUR (adjusted odds ratio 1.02, 95% CI [0.83-1.26]). Age ≥70 years was associated with longer duration of catheterization (5 vs 4 days, P < 0.01).

Conclusion: Age was not associated with POUR when controlling for other clinical factors (body mass index, surgical approach, concomitant hysterectomy/incontinence surgery, and estimated blood loss). These factors may affect POUR in older women and should be considered in perioperative management.