Postprocedural Pain Associated With 5 Versus 20 Intradetrusor Injections of onabotulinumtoxinA for Treatment of Overactive Bladder: A Multicenter Randomized Clinical Trial.

IMPORTANCE: Intradetrusor injection of onabotulinumtoxinA is performed via varying injection paradigms but no studies have studied the various effects of these paradigms on patient experience with the procedure. OBJECTIVES: This randomized clinical trial aims to compare pain and procedure time between patients receiving a 100-unit dose of onabotulinumtoxinA in 5 injections compared to 20 injections for the treatment of idiopathic overactive bladder or urgency urinary incontinence. STUDY DESIGN: Patients presenting with refractory overactive bladder or urgency urinary incontinence at 2 clinical sites were identified and randomized to undergo onabotulinumtoxinA treatment with 5 injections versus 20 injections. Patients rated their pain level on a 10-point visual analog scale at procedure completion. The procedure duration was recorded with a stopwatch. Patients were followed up 6 weeks postprocedure, at which time they completed a Global Response Assessment to determine subjective efficacy of treatment. Participants were additionally monitored for incidence of adverse events in the follow-up period. RESULTS: The average pain score was not statistically significant between groups (2; interquartile range, 1-4 for the 5 injection group vs 3; interquartile range, 2-4 for the 20 injection group; P = 0.27). Patients who received 5 injections experienced significantly shorter mean procedure time as compared with patients who received 20 injections (76 seconds vs 176 seconds; P < 0.001). There were no differences in subjective efficacy or adverse events between groups. CONCLUSIONS: Perceived pain, efficacy, and postprocedure complications did not significantly differ between patients receiving 5 injections and 20 injections, but procedure time was significantly shorter.

Estimated Levator Ani Subtended Volume: A Predictive Biomarker for Surgical Outcomes Following Native Tissue Apical Repair.

OBJECTIVE: The aim of the study was to investigate the clinical utility of estimated levator ani subtended volume (eLASV) as a prospective preoperative biomarker for prediction of surgical outcomes. STUDY DESIGN: This is a prospective case-control pilot study. Patients were recruited and gave consent between January 2018 and December 2020. Surgical failure was defined by composite score. The eLASV was calculated for each patient based on a previously published algorithm. Descriptive statistics, Fisher exact test, log-binomial regression, area under a receiver operating characteristics, Bland-Altman plot, Lin coefficient, and κ coefficient were all performed for analysis. RESULTS: Fifty-one patients gave consent, 31 completed preoperative magnetic resonance imaging, 27 underwent surgery (uterosacral ligament suspension), and 19 followed up for 1-year examination. Five patients (26.3%) were defined as surgical failure with median eLASV volume of 57.0 (interquartile range, 50.1-66.2). Fourteen patients (73.7%) were defined as surgical success with median eLASV of 28.2 (interquartile range, 17.2-24.3). Eighty percent of the surgical failure group (4/5) had elevated volume of eLASV, where only 14.3% of the success group (2/14) had an elevated volume (P = 0.0173). No confounders were found and unadjusted log-binomial regression suggested that patients with a high eLASV were 8.7 (95% confidence interval, 1.2-61.9) times more likely to experience surgical failure compared with those with low eLASV. The c-statistic (area under a receiver operating characteristics) was high at 0.829 along with Lin concordance coefficient of 0.949 (95% confidence interval, 0.891-0.977) for continuous data between the 2 interrater observer teams. CONCLUSIONS: In this small prospective pilot study, patients with elevated eLASV on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure at 1 year regardless of age, body mass index, stage, or parity.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT03534830.

A Retrospective Cohort Study to Identify the Risk Factors for Urinary Tract Infection After Office Procedures.

OBJECTIVE: The objective of this study is to identify the incidence of and risk factors for urinary tract infection (UTI) after office cystoscopy and urodynamic studies (UDS) in a female population. METHODS: This was a retrospective cohort study investigating incidence of and risk factors for UTI after office testing. Inclusion criteria included women presenting for either cystoscopy or UDS from September 2019 to February 2020. Modified Poisson regression with robust error variance was used to identify risk factors for UTI after cystoscopy and UDS in a female population. RESULTS: A total of 274 patients met inclusion criteria. One hundred eighty-five patients underwent office cystoscopy. Nine (4.8%) had a postcystoscopy UTI. Significant risk factors for postcystoscopy UTI included recurrent UTI (relative risk, 7.51; 95% confidence interval, 1.66-34.05) and a history of interstitial cystitis (relative risk, 4.56; 95% confidence interval, 1.52-13.73). Of those with recurrent UTI, 13.7% had a postcystoscopy UTI. Among patients with interstitial cystitis, 25% had a postcystoscopy UTI. One hundred ninety-two patients underwent UDS. Ten (5.2%) developed a post-UDS UTI. No risk factors were identified. CONCLUSIONS: Patients with recurrent UTI were 7.51 times more likely to develop a UTI after cystoscopy, whereas those with interstitial cystitis were 4.56 times more likely to develop a UTI after cystoscopy. The incidence of UTI after UDS was low overall. Understanding who is at higher risk of postprocedural UTIs may help identify subpopulations that may benefit from prophylactic strategies.

Vesicovaginal fistula repair at the time of colpocleisis.

INTRODUCTION AND HYPOTHESIS: The objectives of this video are to discuss the presentation, evaluation, and surgical management of a patient with a vesicovaginal fistula at the time of colpocleisis. METHOD: We present the case of an 83-year-old woman with a history of stage IV prolapse who had had a pessary device removed. Urine had been noted to be in the vaginal vault, leading to suspicion of a vesicovaginal fistula. Following evaluation, the patient decided to proceed with surgical management. The patient underwent a vesicovaginal fistula repair with concomitant colpocleisis. A cystoscopy was performed at the conclusion of the case where the bilateral ureteral stents were removed and a strong efflux was noted at both ureteral orifices. RESULTS: At the patient's 1-month follow-up, she had no complaints of prolapse or vaginal leaking. CONCLUSION: Neglect of a vaginal pessary can lead to serious complications, indicating the importance of patient education and careful follow-up. Surgical planning is a key component in effectively managing a vesicovaginal fistula with ureteral presentation in order to preserve ureteral integrity. Concomitant vesicovaginal repair and colpocleisis can be performed safely with effective cure of a vesicovaginal fistula and stage IV prolapse.

Concomitant laparoscopic and vaginal excision of duplicated collecting system.

INTRODUCTION AND HYPOTHESIS: A duplicated collecting system is the most common birth defect related to the urinary tract and is more common in women. Approximately 0.7% of the healthy adult population and 2-4% of patients with urinary tract symptoms have duplicated ureters. This video discusses the presentation, evaluation, and treatment of duplicated urinary collecting systems, and presents a case of duplicated collecting system with ectopic ureteral implantation at the vaginal introitus. METHODS: We present the case of a 56-year-old presenting with a history of incontinence and recurrent urinary tract infections starting in adolescence and her workup for a duplicated collecting system, as well as subsequent surgical management with narrated footage. The patient was counseled that a distal ectopic ureter remnant could serve as a nidus for infection and the patient elected to undergo complete excision of the distal ectopic ureter. CONCLUSION: Duplicated urinary collecting systems are the most common birth defect related to the urinary tract and can be frequently encountered by the pelvic surgeon. Knowledge of the presentation and workup of a suspected duplicated collecting system is important in carrying out appropriate treatment.

Adnexal surgery at the time of hysterectomy in women 65 years and older undergoing hysterectomy for prolapse: do practice trends differ by route of surgery?

INTRODUCTION AND HYPOTHESIS: The objective was to determine whether the rate of adnexal surgery varies by route of hysterectomy in women over the age of 65 undergoing hysterectomy for prolapse. We hypothesized that women undergoing vaginal hysterectomy would be less likely to undergo bilateral salpingo-oophorectomy (BSO) at the time of their hysterectomy for prolapse. METHODS: This was a cross-sectional analysis using the National Inpatient Sample (NIS) database. Our primary outcome was concomitant adnexal surgery performed at the time of hysterectomy, classified into five groups: BSO, unilateral salpingo-oophorectomy (USO), bilateral salpingectomy (BS), other adnexal surgery, and no adnexal surgery. The study sample included women aged 65 years and older who underwent hysterectomy between 1 January 2009 and 31 December 2014 and with a diagnosis of genital prolapse. RESULTS: Of the 91,292 patients over the age of 65 who underwent a hysterectomy for prolapse, the majority of hysterectomies were vaginal (69%), followed by abdominal (13%), laparoscopic (11%), and robotic (7%). The number of women having a hysterectomy and undergoing a BSO was much lower for vaginal than for other hysterectomy types; 20.3% of women undergoing vaginal hysterectomies had a BSO, compared with 79.2% in abdominal, 81.8% in laparoscopic, and 73.8% in robotic-assisted procedures. Women who received vaginal hysterectomies were five times as likely (RR: 5.02, 95% CI: 4.70-5.35) to have no concomitant adnexal procedure compared with other routes of hysterectomy. CONCLUSIONS: Women over the age of 65 undergoing hysterectomy for prolapse are significantly less likely to have adnexal surgery if undergoing hysterectomy via vaginal route compared with the other routes.

Vaginal Estrogen as First-Line Therapy for Recurrent Urinary Tract Infections in Postmenopausal Women and Risk Factors for Needing Additional Therapy.

OBJECTIVES: This retrospective cohort study aims to determine the proportion of postmenopausal women with recurrent urinary tract infections (rUTIs) who improve with vaginal estrogen cream alone and to identify risk factors for those who go on to require additional therapies. METHODS: Postmenopausal women presenting with rUTIs seen at a single institution over a 29-month period were identified. Patients who had not undergone previous treatment and were started on vaginal estrogen cream alone as first-line therapy were included in the study. Descriptive statistics were used to compare demographic and clinical characteristics between therapy groups. Log-binomial regression was used to explore the association between treatment failure (ie, the need for additional therapy for rUTIs) and patient sociodemographic and clinical characteristics. RESULTS: During the study period, 167 patients with rUTIs met inclusion criteria. Of these, 67.7% noted improvement or resolution in their symptoms with vaginal estrogen cream alone. Women with a concomitant diagnosis of urinary incontinence, as defined as subjective report of bothersome stress or urgency urinary incontinence, were 2.3 times more likely to need additional therapy compared with women not reporting urinary incontinence (relative risk, 2.28; 95% confidence interval, 1.06-4.90). CONCLUSIONS: Sixty-eight percent of postmenopausal women with rUTIs treated with vaginal estrogen alone did not go on to receive additional therapy. A risk factor for needing additional therapy in our study population is the presence of urinary incontinence.

A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling.

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.

Cost-effectiveness of a preoperative pelvic MRI in pelvic organ prolapse surgery.

OBJECTIVE: To investigate the cost-effectiveness of preoperative pelvic magnetic resonance imaging (MRI) in identifying women at high risk of surgical failure following apical repair for pelvic organ prolapse (POP). METHODS: A decision tree (TreeAgePro Healthcare software) was designed to compare outcomes and costs of screening with a pelvic MRI versus no screening. For the strategy with MRI, expected surgical outcomes were based on a calculated value of the estimated levator ani subtended volume (eLASV) from previously published work. For the alternative strategy of no MRI, estimates for surgical outcomes were obtained from the published literature. Costs for surgical procedures were estimated using the 2008-2014 National Inpatient Sample (NIS). A cost-effectiveness analysis from a third-party payer perspective was performed with the primary measure of effectiveness defined as avoidance of surgical failure. Deterministic and probabilistic sensitivity analyses were performed to assess how robust the calculated incremental cost-effectiveness ratio was to uncertainty in decision tree estimates and across a range of willingness-to-pay values. RESULTS: A preoperative MRI resulted in a 17% increased chance of successful initial surgery (87% vs. 70%) and a decreased risk of repeat surgery with an ICER of $2298 per avoided cost of surgical failure. When applied to annual expected women undergoing POP surgery, routine screening with preoperative pelvic MRI costs $90 million more, but could avoid 39,150 surgical failures. CONCLUSION: The use of routine preoperative pelvic MRI appears to be cost-effective when employed to identify women at high risk of surgical failure following apical repair for pelvic organ prolapse.

Fenestrated/Branched Endovascular Aortic Aneurysm Repair Using a Supraceliac Aortic Proximal Seal Zone Versus an Infraceliac Aortic Proximal Seal Zone.

BACKGROUND: Fenestrated/branched endovascular aneurysm repair (F/B-EVAR) achieves more extensive proximal seal than conventional infrarenal devices, thereby increasing aneurysm exclusion durability. Optimal seal zone length remains undefined. We assessed relative risks and benefits of extending the proximal seal above the celiac artery. METHODS: The prospective database of all complex endovascular aortic aneurysm repairs at a single institution (institutional review board-approved, physician-sponsored investigational device exemption trial, 10/2010-6/2017) was used to classify repairs according to the number of target visceral-renal arteries incorporated: 4-vessel versus <4-vessel. Comparisons of aneurysm characteristics, perioperative details, and postoperative complications were performed, stratified by repair type. One-year survival, target artery patency, freedom from type 1 or 3 endoleak, and freedom from reintervention were estimated with Kaplan-Meier analysis. RESULTS: Among 175 F/B-EVARs, 38% (n = 67) were 4-vessel and 62% (n = 108) were <4-vessel. Intraoperatively, there was no difference in mean contrast use (76 mL vs. 74 mL, P = non significant [NS]) or dose area product (63,428 mGy cm2 vs. 96,015 mGy cm2), but there was increased median procedure time (4.8 hr, interquartile range [IQR] = 4.1-5.8 versus 3.6 hr, IQR = 2.9-4.1, P < 0.0001) and mean operating room direct costs ($52,532, standard deviation [SD] = 18,640 versus $40,128, SD = 15,135, P < 0.0001) in 4-vessel repairs. There were no differences in mortality (1.9% vs. 4.5%), paraparesis (0% vs. 3.0%), or paralysis (0.9% vs. 0%), all P = NS. There were no differences in one-year survival, target artery patency, or freedom from reintervention. There was a lower 1-year freedom from type 1 or 3 endoleak with 4-vessel repairs (82% vs. 94%, log-rank P = 0.02), driven by an increased rate of type 3 endoleaks. Endoleak resolution after treatment was equivalent in both groups (4-vessel, 10 of 12, 83% resolved; <4-vessel, 7 of 7, 100% resolved, P = NS). CONCLUSIONS: With F/B-EVAR, utilization of a supraceliac seal zone, compared with an infraceliac seal zone, is associated with statistical differences in operative characteristics/resource utilization, but with negligible clinical significance. Further innovation to eliminate type 3 endoleaks at fenestrations/branches remains an unmet need. To achieve adequate F/B-EVAR proximal seal zone length, one should have a low threshold to incorporate the celiac artery.

Levator ani muscle (LAM) anatomical volume compared to age and body mass index (BMI) of patients.

INTRODUCTION AND HYPOTHESIS: The levator ani muscle (LAM) plays an important role in pelvic support. Estimated levator ani subtended volume (eLASV) is an objective measurement of the anatomical volume of the LAM obtained from pelvic MRIs. The aim of this study was to assess the relationship between the anatomical volume of LAM to the age and body mass index (BMI) of a surgical patient based on our previous published cutoff value of increased LAM volume as measured by pelvic MRIs (eLASV > 38.5). We hypothesize that increasing age and BMI will both be correlated with the increasing volumes of LAM. METHODS: We conducted a secondary analysis of an Institutional Review Board-approved retrospective cohort study. Standard protocol pelvic MRI measurements, including the pubococcygeal line, H-line, and M-line, were collected along with the calculated width of the levator ani hiatus (eLASV = - 72.838 + 0.598H-line + 1.217 M-line + 1.136WLH). Comparison to patients' age and BMI was assessed using the Wilcoxon-Mann-Whitney (continuous) and chi-square test (group). Spearman's correlation analysis was used to explore the relationship between age and BMI to eLASV. RESULTS: Patients with elevated LAM volumes of eLASV were more likely to be older than patients with low volume of LAM, with median age 65 (37, 83) vs. 49.5 (28, 72), respectively (p < 0.001). We observed no difference in median BMI between patients with elevated volumes of eLASV compared with patients with low volumes of eLASV. CONCLUSIONS: Increasing age of women appears to be directly related to elevated volumes for levator ani muscle morphology when measured with eLASV.

A 10-Year Case Series of Surgically Managed Periurethral Masses at a Single Tertiary Care Institution.

OBJECTIVE: This study aimed to present the evaluation, diagnoses, and surgical management of symptomatic periurethral masses of women at an academic institution. METHODS: This study is an institutional review board-approved retrospective case series of women who presented with a symptomatic periurethral mass and scheduled for surgery within the Department of Urology and Female Pelvic Medicine and Reconstructive Surgery over a 10-year period (October 2003-July 2014). RESULTS: Fifty-nine women (mean age, 46 years; range, 22-73 years) were evaluated during the study period. Final pathology revealed 38 (64%) urethral diverticula and 21 (36%) from other benign etiologies. Of the 38 urethral diverticula, 2 (5%) were associated with adenocarcinoma and 4 (11%) with previous bulking agents. Of the 21 nondiverticula, there were 7 (12%) Skene duct cysts/abscesses, 3 (5%) Gartner duct cysts, 2 (3%) vaginal wall inclusion cysts, 2 (3%) bulking agents, 2 (3%) urethral polyps, and one (2%) of each of the following: leiomyoma, angiomyofibroblastoma, redundant vaginal mucosa epithelium, suture abscess, and encapsulated mesh remnant. Fifty-seven women underwent surgical excision (97%), and 2 elected observation. Most (78%) reported resolution of symptoms after excision. Of the patients surgically managed, 7% had postoperative stress urinary incontinence and 12% had persistent lower urinary tract symptoms. Of the 38 women with urethral diverticula, 17% had recurrence and were more likely to have multiple diverticula (44% vs 8%, P = 0.03). CONCLUSION: Although urethral diverticulum was the most common cause of a periurethral mass, final pathology revealed a variety of benign diagnoses in more than one-third of cases, demonstrating the importance of a thorough investigation for accurate diagnosis.

Carotid Duplex Velocity Criteria Recommended by the Society of Radiologists in Ultrasound and Endorsed by the Intersocietal Accreditation Commission Lack Predictive Ability for Identifying High-Grade Carotid Artery Stenosis.

BACKGROUND: Carotid duplex is the first-line imaging modality for characterizing degree of carotid stenosis. The Intersocietal Accreditation Commission (IAC), in published guideline documents, has endorsed use of the Society of Radiologists in Ultrasound (SRU) criteria to characterize ≥70% stenosis: peak systolic velocity (PSV) ≥230 cm/s. We sought to perform a validation of the SRU criteria using computed tomography (CT) angiography as a gold standard imaging modality and to perform a sensitivity analysis to determine optimal velocity criteria for identifying ≥80% stenosis. METHODS: We queried all carotid duplex examinations performed at our institution between 2008 and 2017. Patients with ≥70% carotid stenosis, based on previous criteria, were identified. Of these patients, those who also had a CT angiogram of the neck within one year formed the study cohort. Patients who underwent carotid revascularization between the 2 imaging dates were excluded. Degree of stenosis, as reported from the CT angiogram, was considered the true degree of stenosis. Receiver operating characteristic (ROC) curves were generated to evaluate the SRU criteria and to identify the optimal discrimination threshold for high-grade carotid stenosis. RESULTS: Of 37,204 carotid duplex examinations, 3,478 arteries met criteria for ≥70% stenosis. Of these, 344 patients had a CT angiogram within 1 year of the carotid duplex (mean time between studies, 55 days, SD 6.5) and 240 (69.8%) were consistent with ≥80% carotid stenosis. The predictive ability of the SRU criteria to identify ≥70% stenosis was poor, with an area under the ROC curve (AUC) of 0.51. A sensitivity analysis to identify ≥80% stenosis demonstrated the optimal discrimination threshold to be PSV ≥450 cm/s or end diastolic velocity (EDV) ≥120 cm/s, with an AUC of 0.66. CONCLUSIONS: In this validation study, the SRU criteria, endorsed by the IAC, to identify ≥70% carotid stenosis had no predictive value. For detection of ≥80% stenosis, the optimal criteria are a PSV ≥450 cm/s or EDV ≥120 cm/s. This study demonstrates the critical importance of carotid duplex examination validation.

Furosemide Use and Time to Confirmation of Ureteral Patency During Intraoperative Cystoscopy: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of intravenous administration of furosemide on the time to confirmation for ureteral patency during intraoperative cystoscopy. METHODS: In a double-blind randomized controlled trial, intravenous administration of furosemide 10 mg was compared with placebo (normal saline) to investigate the effect of furosemide on the time to confirmation for ureteral patency during intraoperative cystoscopy. The primary outcome was time to confirmation of ureteral patency. Secondary outcomes included adverse reaction to study medication and delayed diagnosis of ureteric injury. A sample size of 72 per group (N=144) was powered to detect a 3-minute difference in time to confirmation of ureteral patency between groups. RESULTS: From May 2017 to March 2018, 215 patients were eligible for inclusion and 150 were randomized, with 145 available for final evaluation. The two groups were similar in regard to baseline characteristics. The administration of intravenous furosemide 10 mg in a routine cystoscopy resulted in a shorter time to confirmation compared with the administration of the placebo (86.5 seconds, interquartile range 55.0-137.0 vs 165.0 seconds, interquartile range 77.0-280.0; P<.05). Furthermore, at any given time period, patients receiving intravenous administration of furosemide 10 mg were 2.3 times more likely to have ureteral patency confirmed compared with patients receiving normal saline (95% CI 1.59-3.23). There were no adverse events related to administration of intravenous furosemide and no delayed diagnoses of ureteric injury. CONCLUSION: Compared with placebo, intravenous administration of 10 mg furosemide at time of intraoperative cystoscopy resulted in a statistically significantly shorter time to confirmation of ureteral patency, though the clinical significance of this finding is small. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02960412.

Risks factors for significant injury after geriatric falls.

Elderly falls are a healthcare epidemic. We aimed to identify risk factors of serious falls by linking data on functional status from the Global Longitudinal Study of Osteoporosis in Women (GLOW) and our institutional trauma registry. 124 of 5,091 local women enrolled in GLOW were evaluated by our trauma team for injuries related to a fall during the study period. Median injury severity score was 9. The most common injuries were intertrochanteric femur fracture (n = 25, 9.8%) and skin contusion/hematoma to face (n = 12, 4.7%). Injured women were older than the uninjured cohort (median 80 versus 68 years), more likely to have cardiovascular disease and osteoarthritis, and less likely to have high cholesterol. Prospectively collected Short Form 36 (SF-36) baseline activity status revealed greater limitation in all assessed activities in women evaluated for fall-related injuries in our trauma center. In multivariable analysis, age (per 10 year increase) and two or more self-reported falls in the baseline survey were the strongest predictors of falling (both HR 2.4, p <0.0001 and p<0.001 respectively), followed by history of osteoarthritis (HR 1.6, p= 0.01). Functional status was no longer associated with risk of fall when adjusting for these factors. Functional status appears to be a surrogate marker for frailty. With the aging of the US population and long lifespan of American women, this finding has important implications for both fall prevention strategies and research intended to better understand why aging women fall as burdensome validated metrics may not be the best indicators of fall risk.

External Use of an Oxidized Regenerated Cellulose Agent in the Treatment of Labial Agglutination in Postmenopausal Women.

BACKGROUND: Vulvovaginal diseases affect women of all ages. Vaginal atrophy and vulvar lichen sclerosus are common etiologies for chronic vulvovaginal pruritus and labial agglutination in both prepubertal and postmenopausal women. CASES: We present two cases of a novel approach in management of symptomatic labial agglutination in postmenopausal women. At the time of surgical intervention, an oxidized regenerated cellulose gauze was sutured in place within the operative field of separation of the labia minora and clitoral hood adhesions. At more than 18-months' follow-up, no recurrence of agglutination has been noted. CONCLUSION: The use of an oxidized regenerated cellulose agent may create an effective barrier to recurrence of labial agglutination in postmenopausal women.

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial.

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

A Simplified Novel Approach for Total Laparoendoscopic Single-Site (LESS) Hysterectomy.

Total laparoendoscopic single-site (LESS) hysterectomy is a technically challenging minimally-invasive gynecologic procedure. Multiple technological innovations assist surgeons to overcome the challenges that are usually encountered during this advanced approach. Simplifying the steps of this advanced surgery is an invaluable addition in overcoming associated challenges with this procedure. We present our novel technique for a total laparoscopic hysterectomy that will optimize a single-site approach (LESS) for surgeons.

Outpatient beta-blockers and survival from sepsis: Results from a national cohort of Medicare beneficiaries.

BACKGROUND: Elderly Americans suffer increased mortality from sepsis. Given that beta-blockers have been shown to be cardioprotective in critical care, we investigated outpatient beta-blocker prescriptions and mortality among Medicare beneficiaries admitted for sepsis. METHODS: We queried a 5% random sample of Medicare beneficiaries for patients admitted with sepsis. We used in-hospital and outpatient prescription drug claims to compare in-hospital and 30-day mortality based on pre-admission beta-blocker prescription and class of beta-blocker prescribed using univariate tests of comparison and multivariable logistic regression models and another class of medications for control. RESULTS: Outpatient beta-blocker prescription was associated with a statistically significant decrease in in-hospital and 30-day mortality. In multivariable modeling, beta-blocker prescription was associated with 31% decrease in in-hospital mortality and 41% decrease in 30-day mortality. Both cardioselective and non-selective beta-blockers conferred mortality benefit. CONCLUSIONS: Our data suggests that there may be a role for preadmission beta-blockers in reducing sepsis-related mortality.

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension.

AIM: We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery. MATERIAL AND METHODS: We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse. CONCLUSION: This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.