Urogynecology (Hagerstown, Md.)最新文献

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.

Objective: This study aimed to determine the effect of a run-in period on fecal incontinence (FI) symptom severity.

Study design: This study conducted a planned secondary analysis of the run-in period to a study evaluating the effect of 12-week treatment with percutaneous tibial nerve stimulation versus sham in reducing FI severity in women. All participants completed a 4-week run-in period designed to exclude from randomization women whose symptoms reduced below the eligibility threshold after receiving education on FI and completing bowel diaries. Change in St Mark's (Vaizey) score and weekly FI episodes during the run-in period (week 1 vs week 4) was assessed.

Results: One hundred and eighty-five women completed the run-in period. The mean St Mark's (Vaizey) score was 17.8 ± 2.6 and 16.9 ± 3.5 at week 1 and week 4, respectively. There was no significant change in the St Mark's (Vaizey) score from week 1 to week 4 (mean change, -0.93 [95% CI, -1.56 to -0.31]). The average number of FI episodes per week did not change significantly between week 1 and week 4, nor did other bowel diary measures. Only 11 (6%) women became ineligible for the trial following the run-in period, all of whom had baseline St Mark's (Vaizey) scores of 18 or lower.

Conclusions: Completion of a bowel diary and receiving education on FI during the 4-week run-in period did not significantly affect symptom severity in women with FI. Only 6% of women became ineligible for participation following the run-in period, suggesting that, in a refractory population, a run-in period may have minimal effect.

Importance: Postoperative activity restrictions can affect patient satisfaction after midurethral sling (MUS) surgery.

Objective: The aim of the study was to assess the effect of a duration of postoperative activity restrictions on patient satisfaction and surgical outcomes after MUS surgery for stress urinary incontinence.

Study design: Women undergoing MUS surgery alone for stress urinary incontinence were enrolled in this provider-blinded, randomized clinical trial. Randomization to either 3- or 6-weeks' duration of activity restrictions was assigned. Restrictions included abstaining from lifting greater than 20 pounds, high-impact activity, or strenuous exercise. Primary outcome was patient satisfaction with surgery, using a 5-point Likert patient satisfaction scale. Satisfaction scores were analyzed in a "complete satisfaction" ("completely" satisfied only) and a "higher satisfaction" approach (both "completely" and "mostly" satisfied). Secondary outcomes included objective and subjective assessment of incontinence symptoms and activity assessment.

Results: Ninety-eight women underwent MUS surgery between July 2021 and September 2022, and 88 were randomized. Of them, 41 and 43 women with 3- and 6-week restrictions had patient satisfaction data, respectively. Baseline characteristics did not differ between groups. At the 6-month postoperative visit, overall patient satisfaction ("completely" and "mostly" satisfied) was very high at 92%. Complete satisfaction was significantly higher in the 3-week (73.2%) versus the 6-week restriction group (51.2%) ( P  = 0.04). "Higher satisfaction" did not reach a statically significant difference between groups ( P  = 0.11). Subjective urinary incontinence indices did not differ between groups.

Conclusions: Return to normal activities 3 weeks after MUS surgery resulted in significantly higher satisfaction scores at 6 months compared to a 6-week restriction without compromising subjective and objective surgical success.

Importance: Constipation is a common and bothersome problem for many patients with prolapse. This study attempts to understand rates of constipation following abdominal and vaginal prolapse surgical procedures.

Objective: The objective of this study was to evaluate whether sacral colpopexy increases postoperative constipation compared with vaginal prolapse surgery.

Study design: This was a prospective cohort study of participants undergoing surgery for apical prolapse at a single academic urogynecology practice. Preoperative, intraoperative, and 6-week and 6-month postoperative data were collected. The Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire was utilized to assess for constipation preoperatively and postoperatively. The primary outcome measure was the difference in PAC-SYM scores from preoperative evaluation to 6 weeks postoperatively between those who underwent sacral colpopexy (abdominal group) and those who underwent vaginal prolapse surgery (vaginal group). Unadjusted and adjusted linear regression were used to evaluate the change in PAC-SYM.

Results: Ninety-seven participants were enrolled in the study, and 6-week postoperative data were available for 91 participants (50 participants in the abdominal group and 41 participants in the vaginal group). Forty-three percent of participants had preoperative constipation. There were no statistically significant changes in total or subscale PAC-SYM scores at 6 weeks or 6 months postoperatively. At 6 weeks, more participants in the abdominal group had changes in the number of weekly bowel movements than the vaginal group.

Conclusions: Constipation is common among women with pelvic organ prolapse. Symptoms of constipation do not significantly change after prolapse surgery. Sacral colpopexy does not appear to worsen constipation postoperatively compared with vaginal prolapse surgery.

Importance: Social and structural barriers affect access to urogynecologic care for underserved patients, but few studies explore patient experiences at federally qualified health centers (FQHCs).

Objective: The objective of this study was to identify barriers to accessing urogynecologic care from the patient perspective at an FQHC affiliated with an academic medical center.

Study design: Female-identifying patients ages 18-100 years who were referred for and subsequently missed their new urogynecology appointment from October 1, 2022, through February 28, 2023, were recruited for participation in qualitative interviews. A semi-structured interview guide was used for telephone interviews. Transcripts were coded thematically using grounded theory until theoretical saturation was reached.

Results: Thematic saturation occurred with 17 participants. Participants were predominantly Hispanic, the mean age was 55 years, and most were insured by Medicaid or self-pay. The most common referral diagnosis was urinary incontinence (n=13). Major themes regarding barriers included scheduling issues, transportation, language barriers, and perceived costs. All participants identified at least 1 barrier to accessing urogynecologic care, with scheduling challenges related to poor communication from clinic staff as the most common reason. Transportation was the second most cited barrier.

Conclusions: Barriers to accessing urogynecology care are prevalent, even at FQHCs with dedicated subspecialists on site. Poor communication and transportation were the most cited barriers. These findings can inform quality improvement projects to increase access to urogynecologic care in these settings. It is imperative that women's health providers advocate for expanded access and implement changes to address these inequalities in urogynecologic care.

Importance: Single-incision slings (SIS) offer a minimally invasive option for treating stress urinary incontinence (SUI), aiming to reduce operative time, postoperative pain, and recovery compared to traditional slings. Their growing use underscores the importance of understanding their effectiveness, safety profile, and long-term outcomes to ensure optimal patient care.

Objective: The objective was to update current evidence on the safety, efficacy, and economic impact of SISs for the treatment of SUI in women.

Study design: A structured literature review was conducted using PubMed, Cochrane Library, and the U.S. Food and Drug Administration (FDA) 522 Postmarket Surveillance Studies Database up to December 2024. Inclusion criteria were randomized controlled trials, prospective observational studies, meta-analyses and the FDA summary addressing SIS outcomes. Key metrics included objective and subjective cure rates, complications, and economic evaluations.

Results: A total of 28 publications were reviewed since the most recent Cochrane review in 2023. Overall, high subjective (73.3% to 94.2%) and objective cure rates (61.5% to 94%) continue to be reported for SISs with operative times of 10.7 to 20.4 min and low adverse events of mesh complications (0% to 14.2%), reintervention procedures (0% to 16.3%) and de novo urgency urinary incontinence (0% to 15%) up to 36 months. Economic analyses revealed short-term cost savings for SISs, particularly in outpatient settings under local anesthesia, though cost-effectiveness over longer periods remains uncertain due to potential retreatment and/or complications.

Conclusions: Single-incision slings offer a minimally invasive option for SUI with comparable efficacy to full-length midurethral slings, with rare perioperative complications and short operative times. Long-term outcomes on complications and durability are needed. Future studies are needed to guide clinical decision making, particularly regarding longer-term complications and cost-effectiveness.

Importance: Antimuscarinic medications are widely used for overactive bladder (OAB). Recent studies linking antimuscarinics to dementia and cognitive impairment (DCI) have raised concerns about long-term antimuscarinic use for OAB management.

Objectives: We sought to investigate the incidence of DCI among patients with OAB and whether DCI incidence is associated with antimuscarinic use.

Study design: We conducted a retrospective cohort study of women aged 55 years or older with OAB, without a preexisting DCI diagnosis, within a managed health care system with at least 10 years of follow-up. Participants were divided into 2 groups: antimuscarinic users and nonusers for OAB. We calculated each participant's total antimuscarinic burden and identified incident DCI using International Classification of Diseases codes. We used bivariate analysis to identify factors associated with DCI and multivariate logistic regression to assess the association between antimuscarinic use and DCI.

Results: Of the 16,249 women included, 7,141 (44%) received antimuscarinics for OAB and 1,200 (7.4%) were diagnosed with DCI. Compared with those without DCI, women with DCI were older, less likely to be white, had more comorbidities, were more likely to use antimuscarinics, and had higher mean anticholinergic burden scores. Age at OAB diagnosis (OR: 1.13, CI: 1.12-1.14, P <0.001), diabetes (OR: 1.43, CI: 1.22-1.68, P <0.001), and bladder antimuscarinic use (OR: 1.27, CI: 1.12-1.44, P <0.001) were associated with incident DCI using multivariate analysis.

Conclusions: Among women with OAB, DCI is associated with bladder antimuscarinic use and with higher cumulative exposure to antimuscarinics. This association persists after controlling for age and comorbidities.

Importance: When treating pelvic organ prolapse (POP) through surgery, age may factor into joint decision making for surgeons and patients.

Objective: The objective of this study was to determine if 30-day perioperative outcomes after POP surgery vary by age.

Study design: This was a retrospective cohort study of women who underwent surgery for POP using the 2011-2022 American College of Surgeons National Surgical Quality Improvement Program database. Composite rates of adverse events were categorized as major complications (deep/organ space surgical site infection [SSI], reintubation, renal failure, wound dehiscence, pulmonary embolism, cardiac arrest, myocardial infarction, deep vein thrombosis, sepsis, septic shock, return to operating room, stroke, and death) or minor complications (pneumonia, blood transfusion, superficial SSI, or urinary tract infection). Multivariate logistic regression models were used to assess the association between patient age and perioperative complications after adjusting for relevant variables. Interaction models were created to determine if age modulates the effect of procedure type (apical, nonapical, obliterative prolapse surgery) or concomitant hysterectomy on risk of complications.

Results: We included 133,058 women (aged 18-59 years, n=60,659, 45.6%; aged 60-69 years, n=37,818, 28.4%; aged 70-79 years, n=27,598, 20.7%; aged 80 years and older, n=6,983, 5.2%) who underwent POP surgical procedures. On multivariate logistic regression, relative to patients younger than 60 years, age groups 60-69 years and 70-79 years had significantly lower rates of major complications (60-69 years: adjusted odds ratio [aOR]=0.68 [0.62-0.74]; 70-79 years: aOR=0.71 [0.64-0.78]) and patients older than 80 years had similar rates of major complications (aOR=0.98 [0.86-1.12]). In the patients younger than 60 years, the addition of a hysterectomy to a prolapse procedure carried a slightly increased risk of major complications (aOR=1.19, 95% CI=1.06-1.32). No other group carried an increased risk of major complications when adding a hysterectomy or performing an apical or obliterative repair.

Conclusion: This study shows a low risk of complications after POP procedures, even in patients older than 80 years.