General Versus Regional Anesthesia in Sacrospinous Ligament Fixation for Pelvic Organ Prolapse: Assessment of a National Database.

IMPORTANCE: Sacrospinous ligament fixation is a prolapse repair surgical procedure that can be performed under general or regional anesthesia. Little is known about the impact of anesthesia on postoperative outcomes. OBJECTIVES: The primary objective of this study was to compare 30-day complication rates for patients undergoing sacrospinous ligament fixation by anesthesia type. Secondary objectives were to assess factors associated with type of anesthesia selected. STUDY DESIGN: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program for the years of 2015 to 2020. Cases were selected based on procedural codes for sacrospinous ligament fixation and diagnostic codes for prolapse. Complications, readmissions, and reoperations were compared between general versus regional anesthesia cohorts. RESULTS: A total of 2,984 cases were included with 2,742 (91.9%) performed under general and 242 (8.1%) performed under regional anesthesia. The regional anesthesia cohort was older (69.2 vs 65.4 years old; P < 0.001) with no differences in medical history variables. Fewer patients in the regional anesthesia cohort were Hispanic (0.4% in regional vs 10.8% in general cohorts, P < 0.001). More superficial surgical site infections (2.5% vs 0.8%, P = 0.026) and cardiac complications (0.8% vs 0.1%, P = 0.035) were noted in the regional anesthesia cohort. However, multivariable regression analysis showed that anesthesia type was not associated with increased rates of minor or major complications. CONCLUSIONS: Mode of anesthesia was not a significant predictor of minor or major complications. Racial and ethnic differences in mode of anesthesia warrant further investigation to reduce racial disparities.

Money Matters: Anticipated Expense of In-Person Obstetrics and Gynecology Fellowship Interviews Has Greater Impact for Underrepresented in Medicine and Women Applicants.

Background: Much of the expense of pursuing subspecialty training in obstetrics and gynecology (ObGyn) is due to in-person fellowship interviews. Although interviews were converted to a virtual platform for the 2020 fellowship interview season in response to the COVID-19 pandemic, candidates anticipated in-person interview expenses at the time of their application. It is unknown whether financial considerations influenced candidates' decision to pursue fellowship training. This study aimed to evaluate the financial impact of anticipated in-person fellowship interviews among applicants of ObGyn subspecialties. Materials and Methods: This was a planned secondary analysis of a survey administered during the 2020 interview season to evaluate the effectiveness of virtual ObGyn fellowship subspecialty interviews in creating a rank list. Information was obtained about anticipated and actual interview costs, the need for securing additional funding and whether financial considerations influenced the decision to apply for fellowship. Results: In total, 158 participants enrolled in the 2020 National Resident Matching Program for ObGyn fellowship programs (48%) completed the web-based survey. Women and Black fellowship applicants were more likely than men (p = 0.044) and White applicants (p = 0.014) to endorse a need to secure additional funding for in-person fellowship interviews. In addition, Hispanic and Black applicants were more likely than White applicants to report that the financial impact of fellowship interviews influenced the decision to apply "somewhat" or "to a great extent" (p = 0.025 and p < 0.001, respectively). Conclusions: The costs of applying to ObGyn fellowship programs may disproportionately affect women and underrepresented in medicine applicants. By reducing a financial barrier, virtual interviews may help promote greater gender and racial and ethnic diversity in ObGyn subspecialty pursuit.

Virtual Interviews Improve Equity and Wellbeing: Results of a Survey of Applicants to Obstetrics and Gynecology Subspecialty Fellowships.

BACKGROUND: Nationwide restrictions and recommendations from the Association of American Medical Colleges mandated program directors to conduct all graduate medical education interviews virtually in the Spring of 2020 in response to the COVID-19 pandemic. This study was conducted to assess the impact of virtual interviews on a candidates' ability to effectively create a rank list. OBJECTIVE: The primary objective of this study was to evaluate Obstetrics and Gynecology (ObGyn) subspecialty fellowship applicants' perspectives regarding the effectiveness of virtual interviews for creating a rank list. Secondary outcomes included perceived advantages and disadvantages of the process and costs of the process. METHODS: This was a cross-sectional IRB-exempt study, using an electronic survey administered to a convenience sample of applicants to ObGyn subspecialty fellowship programs. The survey was administered via RedCap between the rank list submission deadline and the Match. Descriptive statistics were used. RESULTS: Response rate was 158/330 (48%). Overall, 129/158 (82%) percent of respondents felt confident in making their rank list based on the virtual interviews, and 146/158 (92%) were "very satisfied" or "somewhat satisfied" with the process. Of those who expressed an interview style preference, 65/149(44%) of respondents preferred virtual interviews; 49/149(33%) had no preference or were not sure. Nearly all 146/148(99%) applicants cited cost-savings as a distinct advantage of virtual interviews. CONCLUSION: Applicants to ObGyn subspecialty fellowships felt comfortable to create a rank list based on the virtual interview. This study indicates that the virtual format is effective, less stressful and less costly for ObGyn subspecialty interviews and should be considered beyond the pandemic to remove barriers and burdens for applicants.

Postoperative complications and pelvic organ prolapse recurrence following combined pelvic organ prolapse and rectal prolapse surgery compared with pelvic organ prolapse only surgery.

BACKGROUND: There is a growing interest in combined pelvic organ prolapse and rectal prolapse surgery for concomitant pelvic floor prolapse despite a paucity of data regarding complications and clinical outcomes of combined repair. OBJECTIVE: The primary objective of this study was to compare the <30-day postoperative complication rate in women undergoing combined POP + RP surgery with that of women undergoing pelvic organ prolapse-only surgery. The secondary objectives were to describe the <30-day postoperative complications, compare the pelvic organ prolapse recurrence between the 2 groups, and determine the preoperative predictors of <30-day postoperative complications and predictors of pelvic organ prolapse recurrence. STUDY DESIGN: This was a multicenter, retrospective cohort study at 5 academic hospitals. Patients undergoing combined pelvic organ prolapse and rectal prolapse surgery were matched by age, pelvic organ prolapse stage by leading compartment, and pelvic organ prolapse procedure compared with those undergoing pelvic organ prolapse-only surgery from March 2003 to March 2020. The primary outcome measure was <30-day complications separated into Clavien-Dindo classes. The secondary outcome measures were (1) subsequent pelvic organ prolapse surgeries and (2) pelvic organ prolapse recurrence, defined as patients who complained of vaginal bulge symptoms postoperatively. RESULTS: Overall, 204 women underwent combined surgery for pelvic organ prolapse and rectal prolapse, and 204 women underwent surgery for pelvic organ prolapse only. The average age (59.3±1.0 vs 59.0±1.0) and mean parity (2.3±1.5 vs 2.6±1.8) were similar in each group. Of note, 109 (26.7%) patients had at least one <30-day postoperative complication. The proportion of patients who had a complication in the combined surgery group and pelvic organ prolapse-only surgery group was similar (27.5% vs 26.0%; P=.82). The Clavien-Dindo scores were similar between the groups (grade I, 10.3% vs 9.3%; grade II, 11.8% vs 12.3%; grade III, 3.9% vs 4.4%; grade IV, 1.0% vs 0%; grade V, 0.5% vs 0%). Patients undergoing combined surgery were less likely to develop postoperative urinary tract infections and urinary retention but were more likely to be treated for wound infections and pelvic abscesses than patients undergoing pelvic organ prolapse-only surgery. After adjusting for combined surgery vs pelvic organ prolapse-only surgery and parity, patients who had anti-incontinence procedures (adjusted odds ratio, 1.85; 95% confidence interval, 1.16-2.94; P=.02) and perineorrhaphies (adjusted odds ratio, 1.68; 95% confidence interval, 1.05-2.70; P=.02) were more likely to have <30-day postoperative complications. Of note, 12 patients in the combined surgery group and 15 patients in the pelvic organ prolapse-only surgery group had subsequent pelvic organ prolapse repairs (5.9% vs 7.4%; P=.26). In the combined surgery group, 10 patients (4.9%) underwent 1 repair, and 2 patients (1.0%) underwent 2 repairs. All patients who had recurrent pelvic organ prolapse surgery in the pelvic organ prolapse-only surgery group had 1 subsequent pelvic organ prolapse repair. Of note, 21 patients in the combined surgery group and 28 patients in the pelvic organ prolapse-only surgery group reported recurrent pelvic organ prolapse (10.3% vs 13.7%; P=.26). On multivariable analysis adjusted for number of previous pelvic organ prolapse repairs, combined surgery vs pelvic organ prolapse-only surgery, and perineorrhaphy at the time of surgery, patients were more likely to have a subsequent pelvic organ prolapse surgery if they had had ≥2 previous pelvic organ prolapse repairs (adjusted odds ratio, 6.06; 95% confidence interval, 2.10-17.5; P=.01). The average follow-up times were 307.2±31.5 days for the combined surgery cohort and 487.7±49.9 days for the pelvic organ prolapse-only surgery cohort. Survival curves indicated that the median time to recurrence was not statistically significant (log-rank, P=.265) between the combined surgery group (4.2±0.4 years) and the pelvic organ prolapse-only surgery group (5.6±0.4 years). CONCLUSION: In this retrospective cohort study, patients undergoing combined pelvic organ prolapse and rectal prolapse surgery had a similar risk of <30-day postoperative complications compared with patients undergoing pelvic organ prolapse-only surgery. Furthermore, patients who underwent combined surgery had a similar risk of recurrent pelvic organ prolapse and subsequent pelvic organ prolapse surgery compared with patients who underwent pelvic organ prolapse-only surgery.

Trends in Apical Suspension at the Time of Hysterectomy for Pelvic Organ Prolapse: Impact of American College of Obstetricians and Gynecologists Recommendations.

OBJECTIVE: The aim of the study was to compare national surgical practice patterns of performing apical suspension procedures (ASPs) at the time of hysterectomy for pelvic organ prolapse (POP) before and after the publication of the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on POP. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for hysterectomy cases performed for POP indications for the years 2015-2016 and 2018-2019. The primary outcome was the use of ASP at the time of hysterectomy for POP. Secondary outcomes included the use of anterior, posterior, and paravaginal prolapse repair procedures. Multivariable regression analysis was performed to identify factors associated with performing a hysterectomy without an ASP. RESULTS: A total of 11,336 cases were included, and apical prolapse was the primary POP diagnosis in 86.3% of these cases. There was no statistically significant change in the utilization of ASPs in 2018-2019 compared with 2015-2016 (51.4% vs 49.8%, P = 0.081). Urogynecologists were significantly more likely than general gynecologists to perform ASPs (65.6% vs 37.5%, P < 0.001), which was confirmed on multivariable logistic regression analysis (adjusted odds ratio, 3.257; P < 0.001). The use of concomitant anterior repairs (44.1% vs 39.5%, P < 0.001) and posterior repairs (47.5% vs 41.3%, P < 0.001) increased in the 2018-2019 cohort. CONCLUSIONS: There was no overall increase in the utilization of concomitant ASPs at the time of hysterectomy done for POP indications despite the 2017 American College of Obstetricians and Gynecologists practice bulletin. Urogynecologists were more likely to perform ASPs than general gynecologists.

Complications After Vesicovaginal Fistula Repair Based on Surgeon Specialty in the United States: Analysis of a National Database.

OBJECTIVES: This study aimed to compare the rates of major and minor complications for vesicovaginal fistula (VVF) repair based on surgeon specialty and to identify risk factors for adverse outcomes. METHODS: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program between the years 2014 and 2019. Cases were identified using Current Procedural Terminology codes for VVF repair. Minor and major complication rates for VVF repair were compared between 2 cohorts defined by surgeon specialty: gynecology versus urology. Additional outcomes included readmissions and reoperations. Multivariable logistic regression analysis was performed to investigate risk factors for complications. RESULTS: A total of 319 VVF repairs were included in the analysis, of which 115 (36.1%) were performed by gynecologists and 204 (63.9%) by urologists. There were no significant differences in the demographic or medical characteristics between the gynecology and urology cohorts except for race. Gynecologists performed more concomitant hysterectomies (10.4% vs 1.0%, P < 0.001) and apical suspension procedures (6.1% vs 0%, P < 0.001). There were no differences in minor (7.8% vs 6.4%, P = 0.623) or major (2.6% vs 3.4%, P = 1.000) complications between the cohorts. The overall readmission rate was 4.7%, and the reoperation rate was 2.2% with no differences between specialties. On multivariable logistic regression analysis, body mass index and concurrent hysterectomy were risk factors for major or minor complications with no increased risk associated with surgeon specialty or route of surgery. CONCLUSIONS: Complication rates did not differ for VVF repairs performed by gynecologists compared with urologists. Readmission and reoperation rates were low for both groups.

Virtual Interviews During COVID-19 Pandemic: A Survey of Applicants to Fellowships in Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVES: The objective was to assess female pelvic medicine and reconstructive surgery (FPMRS) fellowship applicants' perspectives on the effectiveness of the virtual interview format for creating their rank lists. METHODS: This was an anonymous internet-based survey study of applicants to the FPMRS fellowships in the United States, conducted from July 21, 2020, to August 5, 2020. A 34-item questionnaire queried applicants on satisfaction with interviews, comfort with creating a rank list and time, and financial cost of interviews. Applicants were invited to complete the survey via standardized emails distributed via the REDCap secure database. RESULTS: Forty-two (56.7%) of 74 applicants completed the survey. The majority of respondents were somewhat satisfied or very satisfied (92.9%) with the virtual interview process and felt comfortable ranking the programs (83.3%). A total of 9.8% of respondents found virtual interviews somewhat or much better than in-person interviews with regards to being informative and helpful, whereas 61% found them to be about the same. A majority (75.6%) found virtual interviews somewhat or much less stressful compared with in-person interviews. The majority (97.5%) spent less than $2,000 during the application process compared with more than $4,000 (87.8%) that they had anticipated spending if the interviews were in person. CONCLUSIONS: Our data revealed that FPMRS applicants overall had a positive experience with the virtual interview platform and felt comfortable creating a rank list of programs based on those interviews.

Virtual Interviews During COVID-19: Perspectives of Female Pelvic Medicine and Reconstructive Surgery Program Directors.

OBJECTIVE: The aim of the study was to evaluate female pelvic medicine and reconstructive surgery (FPMRS) fellowship program directors' opinions regarding the effectiveness of virtual interviews for selecting fellows and their future interview mode preferences. METHODS: This was a cross-sectional online survey of all FPMRS program directors in the United States conducted from April 29, 2020, to May 30, 2020. At the time of this study, there were 73 program directors and 69 obstetrics and gynecology and urology-accredited FPMRS programs nationwide. The primary outcome was to subjectively assess the effectiveness of virtual interviews as compared with in-person interviews for evaluating applicants. RESULTS: Fifty seven (82.6%) of the program directors completed the survey. A total of 80.7% (46/57) of the respondents had participated in interviews for the active match cycle. Of the programs that participated in the interview process, almost all conducted interviews using virtual platforms (97.8%, 45/46). Program directors who conducted interviews virtually found them effective in evaluating applicants (88.9%, 40/45) and were satisfied with the virtual interview process (86.7%, 39/45). A total of 31.1% of respondents (14/45) preferred a virtual platform to an in-person setting for future interviews, and 60% (27/45) reported that they will likely perform future interviews virtually. CONCLUSIONS: Although the pandemic resulted in a sudden reformatting of FPMRS fellowship interviews, most program directors nationally were satisfied with the process and found virtual interviews effective for assessing applicants. More than 50% of FPMRS program directors are likely to consider the virtual format for future interviews.

Human Embryo Morphokinetics Correlation with Obstetric Outcomes and Antepartum Biomarkers.

OBJECTIVE: To evaluate the correlation between em-bryo morphology and antepartum biomarker levels and obstetric outcomes following single embryo transfers (SETs). STUDY DESIGN: In vitro fertilization patients who delivered at the study site's partnering hospital were included. Embryo morphology was compared to antepartum biomarkers and pregnancy outcomes. RESULTS: At a single academic reproductive endocrinology/infertility center, 2,882 SETs (day 3, 5, or 6) were performed from July 1, 2001, to June 30, 2013. Embryologic, serologic, and obstetric outcomes were available for 78 patients (cleavage [n=23]; blastocyst [n=55]). Embryos with a lower quality inner cell mass (ICM) demonstrated higher second trimester maternal serum alpha-fetoprotein (AFP) (p=0.0241) and AFP multiple of median (MoM) (p= 0.0036). After adjusting for age, body mass index, parity, and smoking status, this statistical significance remained (p=0.0319 for AFP; p=0.0026 for AFP MoM). CONCLUSION: Embryo morphokinetics did not correlate with perinatal outcome or a majority of placental biomarkers. A low ICM score was associated with higher second trimester maternal serum AFP values. This warrants further investigation, especially due to the risks of potential adverse obstetric outcomes associated with high AFP levels. Despite these findings, no difference in obstetric outcomes between low and high ICM scores was observed after controlling for maternal confounding variables. Patients should be reassured that embryo implantation, regardless of morphological score, results in similar obstetric outcomes.

Health Care and Human Trafficking: We are Seeing the Unseen.

OBJECTIVES: This study aimed to build the evidence base around human trafficking (HT) and health in the U.S. by employing a quantitative approach to exploring the notion that health care providers encounter this population. Furthermore, this study sought to describe the health care settings most frequented by victims of human trafficking. METHODS: This was an anonymous, retrospective study of survivors of U.S.-based human trafficking. RESULTS: One hundred and seventy-three participants who endured U.S.-based human trafficking were surveyed. The majority (68%, n=117) of participants were seen by a health care provider while being trafficked. Respondents most frequently reported visiting emergency/urgent care practitioners (56%), followed by primary care providers, dentists, and obstetricians/gynecologists (OB/GYNs). CONCLUSIONS: While health care providers are serving this patient population, they do not consistently identify them as victims of human trafficking.