The effect of concomitant hysterectomy on complications following pelvic organ prolapse surgery.

PURPOSE: Pelvic organ prolapse (POP) surgery is performed with and without concomitant hysterectomy depending on a variety of factors. The objective was to compare 30-day major complications following POP surgery with and without concomitant hysterectomy. METHODS: This was a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) multicenter database to compare 30-day complications using Current Procedural Terminology (CPT) codes for POP with or without concomitant hysterectomy. Patients were grouped by procedure: Vaginal prolapse repair (VAGINAL), minimally invasive sacrocolpopexy (MISC), and open abdominal sacrocolpopexy (OASC). 30-day postoperative complications and other relevant data were evaluated in patients who underwent concomitant hysterectomy compared to those who did not. Multivariable logistic regression models assessed the association of concomitant hysterectomy on 30-day major complications stratified by surgical approach. RESULTS: 60,201 women undergoing POP surgery comprised our cohort. Within 30 days of surgery, there were 1722 major complications in 1432 patients (2.4%). Prolapse surgery alone had a significantly lower overall complication rate than with concomitant hysterectomy (1.95% vs 2.81%; p < .001). Multivariable analysis revealed odds of complications following POP surgery was higher among women who underwent concomitant hysterectomy compared to those who did not have hysterectomy in VAGINAL (OR 1.53, 95% CI 1.36-1.72), OASC (OR 2.70, 95% CI 1.69-4.33), and overall (OR 1.46, 95% CI 1.31-1.62), but not in MISC (OR 0.99, 95% CI 0.67-1.46.) CONCLUSION: Concomitant hysterectomy at the time of pelvic organ prolapse (POP) surgery increases the risk of 30-day postoperative complications in comparison to prolapse surgery alone in our overall cohort.

Patient Preferences and Knowledge Regarding Hysterectomy: A Study from the Fellows' Pelvic Research Network (FPRN)®.

OBJECTIVE: The purpose of this study was to describe preference for and knowledge of hysterectomy routes in women presenting to urogynecology/gynecology clinics throughout the United States and to determine association with health literacy. Our primary aim was preference for hysterectomy route, and secondary aims were knowledge of basic pelvic structures and function, knowledge of various hysterectomy routes, and baseline health literacy level. METHODS: This multicenter, cross-sectional study was conducted through the Fellows' Pelvic Research Network. Patients' preference and knowledge for hysterectomy routes were assessed at initial presentation to the urogynecology/gynecology clinic with an anonymous, voluntary, self-administered questionnaire along with a validated health literacy test (Medical Term Recognition Test). RESULTS: Two hundred four women participated. Forty-five percent of patients were unsure which hysterectomy modality they would choose. Of patients who selected a preferred modality, 50% selected laparoscopic and 33% selected vaginal. Patients indicated that safety was considered highest priority when selecting route. The mean score for "knowledge about gynecology/hysterectomy" was 68%, with the high literacy group scoring higher compared with the low health literacy group (70% vs 60.1%, P = 0.01). More than 50% of patients incorrectly answered knowledge questions related to vaginal hysterectomy. Majority of the respondents had high health literacy (79.4%). CONCLUSIONS: Patients prefer laparoscopic hysterectomy approach, although have limited understanding of vaginal hysterectomy. Higher health literacy levels are associated with increased knowledge of gynecology and hysterectomy routes, but were not found to influence patient preference for hysterectomy route. Overall, patients have limited knowledge of vaginal hysterectomy.

Ergonomic Robotic Console Configuration in Gynecologic Surgery: An Interventional Study.

STUDY OBJECTIVE: The objectives of this study were to (1) pilot a robotic console configuration methodology to optimize ergonomic posture, and (2) determine the effect of this intervention on surgeon posture and musculoskeletal discomfort. DESIGN: This was an institutional review board-approved prospective cohort study conducted from February 2017 to October 2017. SETTING: A single tertiary care midwestern academic medical center. PARTICIPANTS: Six fellowship-trained gynecologic surgeons, proficient in robotic hysterectomy, were recruited: 3 men and 3 women. INTERVENTIONS: Each surgeon performed 3 robotic hysterectomies using their self-selected robotic console settings (preintervention). Then, a robotic console ergonomic intervention protocol was implemented by trained ergonomists to improve posture and decrease time in poor ergonomic positions. Each surgeon then performed 3 robotic hysterectomies using the ergonomic intervention settings (postintervention). All surgeries used the da Vinci Xi surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) and were the first case of the day. The surgeons wore inertial measurement unit (IMU) sensors on their head, chest, and bilateral upper arms during surgery. The IMU sensors are equipped with accelerometers, gyroscopes, and magnetometers to give objective measurements of body posture. IMU data were then analyzed to determine the percentage of time spent in ergonomically risky postures as categorized using a modified rapid upper limb assessment. Before and after each hysterectomy, the surgeons completed identical questionnaires for an assessment of musculoskeletal pain/discomfort. The outcome measurements were compared pre- versus postintervention on the basis of fitting generalized linear mixed models that handled the individual surgeon as a random effect and "setting" as a fixed effect. MEASUREMENTS AND MAIN RESULTS: With regard to the IMU posture results, there was a significant decrease in time spent in the moderate- to high-risk neck position and a decrease in average neck angle after the ergonomic intervention. The average percentage of time spent in moderate- to high-risk categories was significantly lower for the neck (mean, 54.3% vs 21.0%; p = .008) and right upper arm (mean, 15.5% vs 0.9%; p = .02) when using the intervention settings compared with the surgeons' settings. Pain score results: There were fewer reported increases in neck (4 [22%] vs 1 [6%]) and right shoulder (4 [22%] vs 2 [11%]) pain or discomfort after completion of robotic hysterectomy postintervention versus preintervention; however, these differences did not attain statistical significance (p = .12 and p = .37, respectively). CONCLUSION: An ergonomic robotic console intervention demonstrated effectiveness and improved objective surgeon posture at the console when compared with the surgeons' self-selected settings.

Management of presacral bleeding.

INTRODUCTION AND HYPOTHESIS: The objective of this video is to demonstrate a variety of available techniques that can be used in the management of acute presacral bleeding. METHODS: In this video, we demonstrate different methods for the management of presacral bleeding utilizing a fresh frozen cadaver. RESULTS: Presacral bleeding is a potentially catastrophic complication that can be encountered during pelvic surgery, particularly sacrocolpopexy. Various techniques exist to achieve hemostasis in the event of uncontrolled bleeding. This video demonstrates some of the available methods that may be employed in the management of presacral bleeding. The methods demonstrated in this video include direct pressure, pelvic packing, gelatin matrix, bone wax, thumb tack, surgical clip, suture, oxidized regenerated cellulose, omental flap, electrocautery, muscle fragment welding, gelatin matrix combined with thrombin, and microporous polysaccharide spheres. CONCLUSION: Familiarity with these techniques and product availability will aid in the management of acute presacral bleeding.

Randomized controlled trial of silver-alloy-impregnated suprapubic catheters versus standard suprapubic catheters in assessing urinary tract infection rates in urogynecology patients.

INTRODUCTION AND HYPOTHESIS: Catheter-associated urinary tract infections (UTI) are the most common health-care-related infections. We aimed to compare the UTI rate among women undergoing urogynecological procedures with a silver-alloy suprapubic catheter (SPC) and a standard SPC, and identify the risk factors predisposing patients to UTI. METHODS: Patients who were to undergo placement of an SPC as part of pelvic organ prolapse surgery were enrolled between 1 August 2011 and 30 August 2017, and randomized to either standard SPC or silver-alloy SPC. Follow-up was performed at a postoperative visit or via a phone call at 6 weeks. The primary outcome was UTI. RESULTS: Of the 288 patients who were randomized, 127 with standard SPC and 137 with silver-alloy SPC were included in the analysis. Twenty-nine out of 123 women with standard SPC (23.6%) and 24 out of 131 (18.3%) with silver-alloy SPC were diagnosed with UTI within 6 weeks postoperatively (p = 0.30). In univariate analysis, non-white race (odds ratio [OR] 5.36, 95% CI 1.16-24.73) and diabetes (OR 2.80, 95% CI 1.26-6.23) were associated with increased risk of UTI. On multivariate analysis, only diabetes remained an independent risk factor. Comparisons between groups were evaluated using two-sample t test for age, Chi-squared tests for diabetes, and Wilcoxon rank sum test for all other variables. CONCLUSION: There was only a 5% difference in 6-week UTI rates between those who received standard vs silver-alloy SPC; the study was not powered to detect such a small difference. Diabetes was identified as a risk factor for SPC-associated UTI in women undergoing pelvic reconstructive surgeries.

Robot-assisted vesicovaginal fistula repair via a transvesical approach.

OBJECTIVE: The objective of this video is to demonstrate a technique for robot-assisted vesicovaginal fistula (VVF) repair utilizing a mini cystotomy with a transvesical approach. METHODS: A 53-year-old female developed a VVF after she underwent an abdominal hysterectomy for uterine fibroids at an outside facility. She was referred to us following two failed VVF repairs (one vaginal, one abdominal with bladder bivalving and omental flap). After discussing options, she underwent a robotic VVF repair via a transvesical approach. Following port placement, the space of Retzius was mobilized. An intentional cystotomy was made and the camera and working arms advanced into the bladder. The fistula was identified and circumferentially mobilized. The fistula was closed in three layers using absorbable sutures, and care was taken to avoid the ureters. RESULTS: The patient's postoperative recovery was uncomplicated. Follow-up imaging was performed via cystogram at 4 weeks and showed resolution of the fistula. CONCLUSIONS: A robot-assisted transvesical approach using a mini cystotomy to VVF repair is a useful technique especially when previous surgical planes have been used in prior repairs and failed. It maintains a minimally invasive approach and may avoid complications associated with an open abdominal approach.

Visuospatial Aptitude Testing Differentially Predicts Simulated Surgical Skill.

OBJECTIVE: To determine whether visuospatial perception (VSP) testing is correlated to simulated or intraoperative surgical performance as rated by the American College of Graduate Medical Education (ACGME) milestones. DESIGN: (Canadian Task Force classification II-2). SETTING: Two academic training institutions. PARTICIPANTS: Forty-one residents, including 19 from Brigham and Women's Hospital and 22 from the Mayo Clinic, from 3 different specialties: obstetrics and gynecology, general surgery, and urology. INTERVENTION: Participants underwent 3 different tests: visuospatial perception testing (VSP), Fundamentals of Laparoscopic Surgery (FLS) peg transfer, and da Vinci robotic simulation peg transfer. Surgical grading from the ACGME milestones tool was obtained for each participant. Demographic and background information was also collected, including specialty, year of training, previous experience with simulated skills, and surgical interest. Standard statistical analyses were performed using Student's t test, and correlations were determined using adjusted linear regression models. MEASUREMENTS AND MAIN RESULTS: In univariate analysis, Brigham and Women's Hospital and Mayo Clinic training programs differed in times and overall scores for both the FLS peg transfer and da Vinci robotic simulation peg transfer tests (p < .05 for all). In addition, type of residency training affected time and overall score on the robotic peg transfer test. Familiarity with tasks correlated with higher score and faster task completion (p = .05 for all except VSP score). There were no differences in VSP scores by program, specialty, or year of training. In adjusted linear regression modeling, VSP testing was correlated only to robotic peg transfer skills (average time, p = .006; overall score, p = .001). Milestones did not correlate to either VSP or surgical simulation testing. CONCLUSION: VSP score was correlated with robotic simulation skills, but not with FLS skills or ACGME milestones. This suggests that the ability of VSP score to predict competence differs between tasks. Therefore, further investigation of aptitude testing is needed, especially before its integration as an entry examination into a surgical subspecialty.

Readmission and reoperation after midurethral sling.

INTRODUCTION AND HYPOTHESIS: We aimed to determine the rate of readmission and reoperation for patients undergoing midurethral sling (MUS) placement for stress urinary incontinence (SUI). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify all isolated MUS placed from 2012 through 2015 using the Current Procedural Terminology 4 (CPT-4) code for MUS with or without cystoscopy (57,288 ± 52,000). The cohort was then reviewed for unplanned, related readmissions and reoperations within 30 days of MUS placement. RESULTS: Isolated MUS was placed in 9910 patients. Fifty-eight (0.59%) patients were readmitted and 81 (0.82%) had reoperation. The most common indications for readmission were related to the urinary tract, i.e., urinary retention (27.6%), non-surgical-site-related infection (15.5%), and medical related issues (15.5%) The most common indications for reoperation were urinary tract (60.5%), gastrointestinal (7.4%), and gynecologic, i.e., examination under anesthesia (6.2%). Body mass index (BMI) was less (p = 0.001), and operative time (p = 0.014) and length of stay (LOS) (p = 0.001) longer in patients who were readmitted. Those who underwent reoperation had longer LOS than those who did not have reoperation (p < 0.001). Upon multivariate analysis, BMI <25 (all p < 0.05) and longer LOS maintained statistical significance as risk factors for those who experienced readmission or reoperation (p = 0.0406, p < 0001). CONCLUSIONS: Isolated MUS placement has low 30-day readmission and reoperation rates. Increased LOS was associated with readmission, while increased LOS and BMI <25 were associated with reoperation within 30 days.

Readmission and Reoperation After Surgery for Pelvic Organ Prolapse.

OBJECTIVES: We aimed to determine the rates of readmission and reoperation for patients undergoing surgery for pelvic organ prolapse (POP). METHODS: The American College of Surgeons National Surgical Quality Improvement Program Participant User File was used to select all surgeries performed for POP from 2012 through 2014. The cohort was then reviewed for unplanned readmissions and unplanned reoperations within 30 days of POP surgery. Patient and procedural factors associated with readmission or reoperation were compared using χ analyses and Student t test. Multivariable logistic regression determined independent risk factors for both readmission and reoperation. RESULTS: A total of 23,419 patients underwent surgery for POP. Of these, there were 435 (1.9%) readmissions and 341 (1.5%) reoperations within 30 days. Median numbers of days from index procedure to readmission or reoperation were 9 and 8 days, respectively. Those who were readmitted had higher American Society of Anesthesia (ASA) scores, longer operative times, and longer lengths of stay than those who were not readmitted (all P < 0.001). Patients who underwent unplanned reoperation also had higher ASA scores, longer operative times, and longer lengths of stay than those who did not undergo reoperation (all P < 0.01). The most common reasons for readmission were surgical site infection (SSI) (19.3%) and non-SSI (15.9%). The most common reason for reoperation was urologic (27.6%) such as cystoscopy or stent placement. CONCLUSIONS: Readmission and reoperation rates are relatively low for patients undergoing surgery for POP. Infection, both SSI and non-SSI, accounted for 35.2% of readmissions. Identification of ASA score of 3 or higher, longer total operating time, and increased length of stay is associated with unplanned readmission and reoperation.

Risk of venous thromboembolism in patients undergoing surgery for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: We sought to determine the incidence of venous thromboembolism (VTE) in patients undergoing surgery for pelvic organ prolapse (POP) based on surgical approach. METHODS: The American College of Surgeons National Quality Improvement Program (NSQIP) database was used to select all surgeries performed for POP from 2005 to 2013. CPT-4 codes were grouped based on surgical approach: vaginal (VAG), laparoscopic sacrocolpopexy (LSC), or open abdominal sacrocolpopexy (ASC). Patient demographics, preoperative American Society of Anesthesiologists (ASA) classification system scores, and 30-day postoperative complications were obtained. RESULTS: Of the 26,103 women who underwent surgery for POP, 21,311 (81.7 %) underwent VAG, 3,346 (12.8 %) LSC, and 1,426 (5.5 %) ASC. VTE occurred in 36 patients (0.17 %) in the VAG group, 8 (0.24 %) in the LSC group, and 9 (0.63 %) in the ASC group. The ASC group had a significantly higher incidence of VTE compared with the VAG group (p < 0.01). Upon multivariate analysis, factors associated with a greater incidence of VTE included BMI greater than 30 kg/m(2) (p = 0.048), ASA score of 3, 4, or 5 (p = 0.027), and length of stay above the 75th percentile (p < 0.01). The procedure group did not retain statistical significance in multivariate modeling. CONCLUSIONS: Venous thromboembolism is rare following surgery for POP. Although differences in VTE rates between procedure groups failed to maintain statistical significance after multivariate analysis, we were able to identify risk factors associated with an increased VTE risk in surgery for POP. Women with obesity, an increased length of stay, or ASA score of 3 or higher are at an increased risk for developing VTE after undergoing surgery for POP.

Rectovaginal fistula repair using a gracilis muscle flap.

INTRODUCTION AND HYPOTHESIS: This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula. METHODS: We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient's prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula. CONCLUSION: Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.

Perineal Body and Genital Hiatus in the Third Trimester and Risk of Perineal Laceration.

OBJECTIVE: We aimed to determine whether pelvic organ prolapse quantification measurements of genital hiatus (gh) or perineal body (pb) obtained in the late third trimester are predictors of obstetric perineal laceration in nulliparous women. METHODS: Nulliparous women with singleton gestation were prospectively recruited after 35-week gestation, and gh and pb measurements were obtained. After delivery, determination of the presence and degree of perineal laceration were recorded. Correlation of gh and pb measurements with risk of perineal laceration (defined as second, third, or fourth degree) was assessed using the Wilcoxon rank sum test. RESULTS: We recruited 224 patients and 133 met inclusion criteria after delivery. The mean (SD) age was 27.2 (4.0) years and mean (SD) prepregnancy body mass index was 24.1 (4.6) kg/m. Seventy patients (52.6%) had either a second-degree (n = 64) or third-degree (n = 6) laceration. No fourth-degree lacerations were recorded. We found no significant difference in the median gh (3.5 vs 3.0 cm, P = 0.34) and pb (3.5 vs 3.5 cm, P = 0.54) measurements among women with and without perineal lacerations. CONCLUSIONS: Our data suggest that antenatal measurement of gh and pb does not correlate with the risk of obstetric perineal laceration in nulliparous patients undergoing spontaneous vaginal delivery.

Health-related quality of life and outcomes after surgical treatment of complications from vaginally placed mesh.

INTRODUCTION AND HYPOTHESIS: We aimed to report on health-related quality of life after surgical excision of vaginally placed mesh for treatment of pelvic organ prolapse and to identify predictors of successful surgical management. METHODS: We identified patients who underwent surgery for treatment of complications from vaginally placed mesh from January 1, 2003, through December 31, 2011, and conducted a follow-up survey. Logistic regression models were used to identify predictors of successful treatment. RESULTS: We identified 114 patients who underwent surgery for mesh-related complications and 68 underwent mesh excision. Of the 68 patients, 44 (64.7%) completed the survey. Of the 44 responders, 41 returned their consent form and were included in the analysis. Only 22 (54%) patients reported a successful outcome after mesh excision. Of 29 (71%) sexually active patients, 23 had dyspareunia before mesh excision and only 3 patients reported resolution of dyspareunia after excision. We reported a multivariable model for predicting successful surgical outcome with an area under the curve for the receiver operator characteristic of 0.781. In this model, complete excision of mesh, new overactive bladder symptoms after mesh placement, and a body mass index higher than 30 kg/m were associated with successful patient-reported outcomes; adjusted odds ratios (95% confidence intervals) were 5.46 (1.10-41.59), 7.76 (1.18-89.55), and 8.41 (1.35-92.41), respectively. CONCLUSIONS: Only half of the patients who had surgery for vaginally placed mesh complications reported improvement after surgery, with modest improvement in dyspareunia. Patients who had complete mesh excision, new overactive bladder symptoms, and obesity were more likely to report improvement.