The PSR13, a tool for evaluating patient-perceived recovery after vaginal prolapse repair surgery
INTRODUCTION AND HYPOTHESIS/OBJECTIVE:Surgical recovery is the return to preoperative functional, psychologic, and social activity, or a return to normalcy. To date, little is known about the global post-surgical recovery experience from the patients' perspective. The aim of this study was to validate the Post-Discharge Surgical Recovery scale 13 (PSR13) in women undergoing vaginal prolapse repair procedures and evaluate the patient-perceived postoperative recovery experience over a 12-week period. METHODS:Fifty women undergoing vaginal prolapse repairs completed the PSR13 and global surgical recovery scale (GSR) at 1, 2, 4, 6, and 12 weeks post-surgery. Validity, the minimal clinically important difference (MCID), and responsiveness to change over time of the PSR13 was evaluated using descriptive statistics and linear regression models. The proportion of patients deemed fully recovered at each time point (defined as PSR13 score â‰¥ 80) was also assessed. RESULTS:The PSR13 correlated significantly (p < 0.001) with the single-item recovery scale and showed excellent internal consistency reliability (Cronbach Î± = 0.91, range 0.77 to 0.93). The MCID was estimated at 7.0 points. The PSR13 scores improved at varying rates over time, with the greatest amount of patient-perceived recovery occurring between 4 and 6 weeks after surgery. The proportion of patients deemed fully recovered at 6- and 12- weeks postoperatively was 37% and 56%, respectively. CONCLUSIONS:The PSR13 is a useful instrument to assess overall return to normalcy from the patient's perspective and can be applied to evaluate the recovery experience among women undergoing vaginal prolapse repairs, in both the research and clinical setting.
Defining Bladder Outlet Obstruction in Women
Purpose of Review: The goal of this paper is to provide the reader with an understanding of the definition of bladder outlet obstruction (BOO) in females and guidance on the diagnostic work-up of this condition. Recent Findings: Our understanding of female BOO is continuing to evolve. Urodynamics and fluoroscopy can aid in the diagnosis of this condition. Several new definitions of BOO in females have been studied and provide more clarity for female BOO. However, no one definition has proved to be superior. Therefore, there is no replacement for looking at the entire clinical picture including patient history, examination and urodynamic data if available. Summary: Recent studies have further contributed to the body of literature on how to define bladder outlet obstruction in women, but no current consensus exists on the best way to define this condition.
Estimation of urinary frequency: does question phrasing matter?
PURPOSE/OBJECTIVE:To evaluate if question phrasing and patient numeracy impact estimation of urinary frequency. MATERIALS AND METHODS/METHODS:We conducted a prospective study looking at reliability of a patient interview in assessing urinary frequency. Prior to completing a voiding diary, patients estimated daytime and nighttime frequency in 3 ways: 1) how many times they urinated 2) how many hours they waited in between urinations 3) how many times they urinated over the course of 4 hours. Numeracy was assessed using the Lipkus Numeracy Scale. RESULTS:Seventy-one patients completed the study. Correlation of estimates from questions 1, 2 and 3 to the diary were not statistically different. Prediction of nighttime frequency was better than daytime for all questions (correlation coefficients 0.751, 0.754 and 0.670 vs 0.596, 0.575, and 0.460). When compared to the diary, Question 1 underestimated (8.5 vs 9.7, p=0.014) while Question 2 overestimated (11.8 vs 9.7, p=0.027) recorded voids on a diary. All questions overpredicted nighttime frequency with 2.6, 2.9 and 3.9 predicted vs 1.6 recorded voids (p <0.001). Although not statistically significant, for each question, the predicted frequency of numerate patients was more correlated to the diary than those of innumerate patients. CONCLUSIONS:When compared to a voiding diary for daytime urinary frequency, asking patients how many times they urinated underestimated, and asking patients how many hours they waited between urinations overestimated the number recorded voids. Regardless of phrasing, patients overestimated nighttime urination. Patients in our functional urology population have limited numeracy, which may impact accuracy of urinary frequency estimation.
Vaginal Estrogen-What a Urologist Should Know
The implications of estrogen depletion on the lower urinary tract and vagina are relevant to the urologist treating women with genitourinary symptoms. The main symptoms of vaginal estrogen depletion that affect women are dyspareunia and vaginal dryness, recurrent UTIs and lower urinary tract symptoms. Vaginal estrogen can be used to effectively treat these conditions. Vaginal estrogen is available in a variety of formulations. Each formulation has different considerations regarding its use and patients should be actively involved in choosing the right product for them. Contrary to concerns over the risks of oral estrogen, vaginal estrogen has a low risk profile. In terms of contra-indications for use, there are relatively few absolute contraindications for vaginal estrogen. A thorough understanding of vaginal estrogen's safety, efficacy and correct use is essential to the urologist treating the post-menopausal female.
Rethinking Second-Line Therapy for Overactive Bladder to Improve Patient Access to Treatment Options
Idiopathic overactive bladder (OAB) is a chronic condition that negatively affects quality of life, and oral medications are an important component of the OAB treatment algorithm. Recent literature has shown that anticholinergics, the most commonly prescribed oral medication for the treatment of OAB, are associated with cognitive side effects including dementia. Î²3-adrenoceptor agonists, the only alternative oral treatment for OAB, are similar in efficacy to anticholinergics with a more favorable side effect profile without the same cognitive effects. However, there are marked cost variations and barriers to access for OAB medications, resulting in expensive copays and medication trial requirements that ultimately limit access to Î²3-adrenoceptor agonists and more advanced procedural therapies. This contributes to and perpetuates health care inequality by burdening the patients with the least resources with a greater risk of dementia. When prescribing these medications, health care professionals are caught in a delicate balancing act between cost and patient safety. Through multilevel collaboration, we can help disrupt health care inequalities and provide better care for patients with OAB.
The impact of concomitant mid-urethral sling surgery on patients undergoing vaginal prolapse repair
INTRODUCTION AND HYPOTHESIS/OBJECTIVE:The aim of this study was to assess whether mid-urethral sling (MUS) placement at the time of vaginal prolapse repair compared to vaginal prolapse repair alone is associated with an increase in 30-day postoperative complications. METHODS:Using the American College of Surgeons National Surgical Quality Improvement Database, Current Procedural Terminology codes were used to identify cases of vaginal prolapse repair with and without concomitant MUS from 2012 to 2017. Student's t-test and chi-square test were used to compare differences between the groups. RESULTS:A total of 1469 cases of vaginal prolapse repair with sling were compared to 4566 cases without sling. There was no difference between prolapse repair with sling compared to without sling in mean hospital length of stay (LOS) (1.42 versus 1.32Â days, pÂ =â€‰0.65), postoperative urinary tract infection (UTI) (6.1% versus 5.8%, pÂ =â€‰0.670), perioperative blood transfusion (1.1% versus 1.2%, pÂ =â€‰0.673), readmission (2.7% versus 2.6%, pÂ =â€‰0.884) and postoperative wound infection (0.5% versus 0.7%, pÂ =â€‰0.51). There was a higher rate of reoperation (2.2% versus 1.5%, pÂ =â€‰0.049) and venous thromboembolism (VTE) (0.4% versus 0.1%, pÂ =â€‰0.030) in patients undergoing concomitant MUS compared to those undergoing prolapse repair alone. CONCLUSIONS:Compared to prolapse repair alone, the addition of a sling did not increase hospital LOS, UTI, perioperative blood transfusions, readmission or postoperative wound infections. However, concomitant sling was found to be associated with a higher risk of reoperation and VTE.
"First, Do No Harm"-Trainees' Observation of Risk Reduction in the Treatment of Overactive Bladder
Venous thromboembolism prophylaxis in vaginal surgery for pelvic organ prolapse: Predictors of high risk in a low-risk population
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:Â tests for categorical variables. Multivariate logistic regression was performed to identify factors independently associated with VTE. RESULTS:Of 44â€‰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 (pâ€‰=â€‰.616 andÂ .216, respectively). Multivariate analysis demonstrated predictors for postoperative VTE to be ASA physical status classificationâ€‰â‰¥â€‰3 (aOR, 1.99; pâ€‰=â€‰.014), length of stay >75th percentile (aOR, 2.01; pâ€‰=â€‰.007), operative time >3â€‰hÂ (aOR, 2.24; pâ€‰=â€‰.007), and dyspnea (aOR, 3.26, pâ€‰=â€‰.004). CONCLUSION/CONCLUSIONS:Despite the low incidence of VTE after vaginal POP repair, patients with ASA physical status classificationâ€‰â‰¥â€‰3, length of stayÂ >75th percentile, operative timeÂ >3â€‰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.
Non-adherence to labor guidelines in cesarean sections done for failed induction and arrest of dilation
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.
Prolapse repair in the elderly patient: contemporary trends and 30-day perioperative 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 75Â 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 (pâ€‰<â€‰0.001, pâ€‰=â€‰0.03). No difference was observed in complications across the three approaches, but length of stay was shorter (1.2Â days vs 1.7Â days, pâ€‰=â€‰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.