Faculty Bibliography

AIM/OBJECTIVE:Venous thromboembolism (VTE) rates in vaginal pelvic organ prolapse (POP) repair are low. Our aim is to evaluate specific risk factors for VTE in patients undergoing vaginal POP repair. METHODS: tests for categorical variables. Multivariate logistic regression was performed to identify factors independently associated with VTE. RESULTS:Of 44 207 women who underwent vaginal POP repair, there were 69 cases of VTE (0.16%). VTE rates for obliterative (0.15%) and functional (0.16%) vaginal POP repair, as well as for repairs with hysterectomy (0.17%) and without hysterectomy (0.12%) were not significantly different (p = .616 and .216, respectively). Multivariate analysis demonstrated predictors for postoperative VTE to be ASA physical status classification ≥ 3 (aOR, 1.99; p = .014), length of stay >75th percentile (aOR, 2.01; p = .007), operative time >3 h (aOR, 2.24; p = .007), and dyspnea (aOR, 3.26, p = .004). CONCLUSION/CONCLUSIONS:Despite the low incidence of VTE after vaginal POP repair, patients with ASA physical status classification ≥ 3, length of stay >75th percentile, operative time >3 h, and dyspnea were at higher risk for VTE. Vaginal POP repair may have independent VTE risk factors not captured in standard risk assessment tools.

Objectives/UNASSIGNED:In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes. Methods/UNASSIGNED:Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes. Results/UNASSIGNED:Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003). Conclusions/UNASSIGNED:Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

INTRODUCTION AND HYPOTHESIS:Pelvic organ prolapse is common and increases with age. Although conservative options exist for management, surgery remains a mainstay of treatment. Understanding how surgical repair affects the elderly is increasingly important as the population ages. We set out to describe current treatment patterns for prolapse repair in the elderly. Our main goal was to compare perioperative morbidity and mortality for elderly patients who undergo surgical repair of pelvic organ prolapse with colpocleisis, vaginal repair or sacrocolpopexy. METHODS:Women 75 years and older who underwent prolapse repair from 2014 to 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using Current Procedural Terminology (CPT) codes for colpocleisis, vaginal prolapse repair, and abdominal sacrocolpopexy. Variables including demographics, comorbidities, concomitant hysterectomy or stress urinary incontinence procedure, hospital length of stay, morbidity, and mortality were evaluated. A regression model was used to analyze risk factors for perioperative complications. RESULTS:We identified 764 women who underwent prolapse repair. The largest proportion of patients (334, 43.7%) underwent transvaginal repair, closely followed by colpocleisis (323, 42.3%), and the remainder (107, 14%) sacrocolpopexy. Older age and higher ASA class were significantly associated with colpocleisis (p < 0.001, p = 0.03). No difference was observed in complications across the three approaches, but length of stay was shorter (1.2 days vs 1.7 days, p = 0.03) for colpocleisis. CONCLUSIONS:In current practice, patients undergoing colpocleisis compared with transvaginal repair or sacrocolpopexy are older with more comorbidities. Despite this, length of stay remains shorter for these patients and complications rates equivalent.

BACKGROUND:Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling. OBJECTIVE:The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling. STUDY DESIGN:This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05. RESULTS:We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups. CONCLUSION:This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

OBJECTIVE:To compare perioperative and functional outcomes of autologous fascia lata versus rectus fascia pubovaginal sling in female patients with stress urinary incontinence (SUI). METHODS:The charts of all patients undergoing pubovaginal sling for SUI from 2012 to 2017 at a single center were retrospectively reviewed. Patients were divided into 2 groups: those with the sling harvested from the fascia lata (FL group) and those with the sling harvested from the rectus fascia (RF group). RESULTS:Between 2012 and 2017, 105 women underwent pubovaginal slings: 21 using FL and 84 using RF. Operative time did not differ significantly between the FL and RF groups (84 vs 81.9 minutes; P = 0.68). Estimated blood loss was lower in the FL group (91.7 vs 141.6 mL; P = 0.04). There were more wound complications in the RF group, although this was not statistically significant (0% vs 14.3%; P = 0.12). Overall complications were comparable between FL and RF groups (52.4% vs 48.9%; P = 0.81), but the proportion of Clavien grade 2 or greater were higher in the RF group (4.8% vs 20.2%; P = 0.11). Overall, wound complications accounted for 29.3% of postoperative complications in the RF group (12/41). Functional outcomes were comparable between FL and RF groups, with similar rates of patients without SUI symptoms after 1 month (82.4% vs 76.4%; P = 0.74), 1 year (55.6% vs 63.8%; P = 0.76), and at the latest follow-up (66.7% vs 65.8%; P = 0.87). CONCLUSIONS:When compared with rectus fascia for pubovaginal sling, fascia lata may decrease perioperative morbidity, especially wound complications, without compromising functional outcomes.

Purpose of Review: The goal of this paper is to provide the reader with three distinct definitions of midurethral sling failure and provide guidance on the work up and management of each definition. Recent Findings: The definition of sling failure should include not only patients with recurrent and persistent stress urinary incontinence but also those with de novo voiding symptoms and overactive bladder as a result of their midurethral sling. Urodynamics are less commonly performed for the straightforward patient with stress urinary incontinence prior to a midurethral sling. However, there is evidence that urodynamics studies can help with diagnosis and guide management in the patient with a failed midurethral sling. Summary: When a patient experiences abnormalities of urinary storage or emptying after a midurethral sling, a comprehensive workup can help guide thoughtful and effective management of symptoms.

OBJECTIVES/OBJECTIVE:To investigate trends in stress urinary incontinence (SUI) surgery before and after the 2011 FDA notification and the 2014 AUGS/SUFU position statement. METHODS:A retrospective chart review was performed to identify patients presenting for evaluation of SUI by two Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialists between June 1, 2010 and May 31, 2017. Rates of surgical treatment modality (synthetic midurethral slings (MUS) vs. autologous fascial pubovaginal sling (AFPVS) vs. bulking agents) were analyzed at 6 month intervals. RESULTS:Over 14 six-month intervals, the number of new patients presenting for evaluation of SUI increased consistently. There was a decrease in the proportion of new patients who underwent anti-incontinence surgical procedures, specifically MUS, between December 2011 and December 2013. After the integration of the 2014 AUGS/SUFU position statement in patient counseling, this trend reverted and we noted a sustained increase in the proportion of patients electing surgical management. This paralleled an increase in new patient visits for SUI and MUS. The number AFPVS remained stable throughout the study period. Conversely, MUS composed the highest proportion of procedures performed, accounting for 60 % to 87.2% off all anti-incontinence procedures. CONCLUSION/CONCLUSIONS:After the FDA Public Health Notification in 2011, we observed a decline in the number of new patients presenting with SUI electing surgical management, specifically MUS. However, after the AUGS/SUFU position statement publication and integration into counseling, we observed a reversal in the previous year's trends, noting a resurgence of MUS utilization.