The Response of the Urinary Microbiome to Botox.

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate if botox alters the urinary microbiome of patients with overactive bladder and whether this alteration is predictive of treatment response. METHODS: This multicenter prospective cohort study included 18-89-year-old patients undergoing treatment for overactive bladder with 100 units of botox. Urine samples were collected by straight catheterization on the day of the procedure (S1) and again 4 weeks later (S2). Participants completed the Patient Global Impression of Improvement form at their second visit for dichotomization into responders and nonresponders. The microbiome was sequenced using 16s rRNA sequencing. Wilcoxon signed rank and Wilcoxon rank sum were used to compare the microbiome, whereas chi-square, Wilcoxon rank sum, and the independent t-test were utilized for clinical data. RESULTS: Sixty-eight participants were included in the analysis. The mean relative abundance and prevalence of Beauveria bassiana, Xerocomus chrysenteron, Crinipellis zonata, and Micrococcus luteus were all found to increase between S1 and S2 in responders; whereas in nonresponders the mean relative abundance and prevalence of Pseudomonas fragi were found to decrease. The MRA and prevalence of Weissella cibaria, Acinetobacter johnsonii, and Acinetobacter schindleri were found to be greater in responders than nonresponders at the time of S1. Significant UM differences in the S1 of patients who did (n = 5) and did not go on to develop a post-treatment UTI were noted. CONCLUSIONS: Longitudinal urobiome differences may exist between patients who do and do not respond to botox.

Rare Variant of Meigs Syndrome Associated With Pericardial Effusion.

Meigs syndrome is an uncommon entity associated with benign ovarian tumor, pleural effusion, and ascites. Its association with pericardial effusion is extremely rare. We report a case of Meigs syndrome associated with recurrent pericardial effusion that resolved after surgical resection of the ovarian tumor. (Level of Difficulty: Beginner.).

Pudendal Nerve Block Analgesia at the Time of Vaginal Surgery: A Randomized, Double-Blinded, Sham-Controlled Trial.

IMPORTANCE: Effective opioid-sparing postoperative analgesia requires a multimodal approach. Regional nerve blocks augment pain control in many surgical fields and may be applied to pelvic floor reconstruction. OBJECTIVE: This study aimed to evaluate the impact of pudendal nerve block on postoperative pain control and opioid consumption after vaginal surgery. STUDY DESIGN: In this randomized, double-blind, sham-controlled trial, we enrolled women undergoing pelvic reconstruction, excluding patients with chronic pelvic pain or contraindications to nonnarcotic analgesia. Patients were randomized to transvaginal pudendal nerve block (9 mL 0.25% bupivacaine and 1 mL 40 mg/mL triamcinolone) or sham injection (10 mL normal saline). Primary outcomes were pain scores and opioid requirements. Sixty patients were required to show a 20-mm difference on a 100-mm visual analog scale (VAS). RESULTS: We randomized 71 patients: 36 pudendal block and 35 sham. Groups were well matched in baseline characteristics and surgery type. Prolapse repairs were most common (n = 63 [87.5%]), and there was no difference in anesthetic dose or operative time. Pain scores were equivalent in the postanesthesia care unit (mean VAS, 53.1 [block] vs 56.4 [sham]; P = 0.517) and on postoperative day 4 (mean VAS, 26.7 [block] vs 35.5 [sham]; P = 0.131). On postoperative day 1, the intervention group reported less pain, but this did not meet our 20 mm goal for clinical significance (mean VAS, 29.2 vs 42.5; P = 0.047). A pudendal block was associated with lower opioid consumption at all time points, but this was not statistically significant. CONCLUSIONS: Surgeon-administered pudendal nerve block at the time of vaginal surgery may not significantly improve postoperative pain control or decrease opioid use.

Opioid use following pelvic reconstructive surgery: a predictive calculator.

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median. METHODS: This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery. RESULTS: One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review. CONCLUSIONS: Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.

Understanding Intimate Partner Violence Perpetration Involving the Deaf Population.

There has been an increase in intimate partner violence (IPV) research regarding the deaf population; however, no studies to date obtained data directly from members of the deaf population who disclose IPV perpetration. This community-based participatory research study explored the social context of IPV perpetration involving the deaf population through interviews with deaf or hard-of-hearing individuals who self-identified as perpetrating either physical or sexual abuse in an intimate relationship where at least one partner was deaf. Through semi-structured interviews using video relay, an interdisciplinary research team, which included deaf investigators, explored questions which included IPV triggers, types of IPV, weapon use, childhood victimization, and interactions with first responders and response systems (e.g., criminal justice, medical). The types of IPV abuse, resulting injuries, and systems used are discussed. The team collectively identified key elements of abuse and their relationships to each other through concept mapping of each interview. Through a method of constant comparison, we identified several themes: intergenerational transmission of violence, fund of information concerns, communication barriers with family and friends and resulting frustration, and help-seeking challenges. Many of these themes are specific to the deaf population, illustrating the need for continued research to understand IPV in diverse communities. Findings are compared with IPV trends in the general (hearing) population, and prompt concerns that universal IPV interventions may not effectively address the needs of the deaf population. Recommendations for diversifying screening efforts, modifying screening tools, and tailoring interventions to better address IPV involving deaf and hard-of-hearing populations are discussed.

Tamsulosin vs placebo to prevent postoperative urinary retention following female pelvic reconstructive surgery: a multicenter randomized controlled trial.

BACKGROUND: Postoperative urinary retention is common after female pelvic reconstructive surgery. Alpha receptor antagonists can improve dysfunctional voiding by relaxing the bladder outlet and may be effective in reducing the risk of postoperative urinary retention. OBJECTIVE: This study aimed to determine whether tamsulosin is effective in preventing postoperative urinary retention in women undergoing surgery for pelvic organ prolapse. STUDY DESIGN: This was a multicenter, double-blind, randomized controlled trial between August 2018 and June 2020, including women undergoing surgery for pelvic organ prolapse. Patients were excluded from recruitment if they had elevated preoperative postvoid residual volume, history of postoperative urinary retention, or a contraindication to tamsulosin. Those who experienced cystotomy were excluded from analysis. Participants were randomized to a 10-day perioperative course of tamsulosin 0.4 mg vs placebo, beginning 3 days before surgery. A standardized voiding trial was performed on postoperative day 1. The primary outcome was the development of postoperative urinary retention, as defined by the failure of the voiding trial or subsequent need for catheterization to empty the bladder. Secondary outcomes included the rate of urinary tract infection and the impact on lower urinary tract symptoms as measured by the American Urological Association Symptom Index. RESULTS: Of 119 patients, 57 received tamsulosin and 62 received placebo. Groups were similar in regard to demographics, preoperative prolapse and voiding characteristics, and surgical details. Tamsulosin was associated with a lower rate of postoperative urinary retention than placebo (5 patients [8.8%] vs 16 patients [25.8%]; odds ratio, 0.28; 95% confidence interval, 0.09-81; P=.02). The number needed to treat to prevent 1 case of postoperative urinary retention was 5.9 patients. The rate of urinary tract infection did not differ between groups. American Urological Association Symptom Index scores significantly improved after surgery in both groups (median total score, 14 vs 7; P<.01). Scores related to urinary stream improved more in the tamsulosin group than in placebo (P=.03). CONCLUSION: In this placebo-controlled trial, tamsulosin use was associated with a reduced risk of postoperative urinary retention in women undergoing surgery for pelvic organ prolapse.

Preoperative Pain Symptoms and the Incidence of Endometriosis in Transgender Men Undergoing Hysterectomy for Gender Affirmation.

STUDY OBJECTIVE: To describe the incidence of pelvic pain in transgender men undergoing hysterectomy for gender affirmation and to describe the incidence of endometriosis found at the time of surgery. DESIGN: Retrospective chart review of transgender men presenting for gender-affirming hysterectomy between 2010 and 2019. Patients were identified by Current Procedural Terminology codes and documented male gender in the medical record, which was queried for perioperative data. SETTING: All patients underwent minimally invasive hysterectomy under general anesthesia by 2 surgeons at 2 institutions. PATIENTS: Patients were individuals assigned female at birth identifying as male who met the criteria for gender-affirming hysterectomy. INTERVENTIONS: Hysterectomy performed using preferred techniques by the surgeons in this study. MEASUREMENTS AND MAIN RESULTS: Sixty-seven (N = 67) patients underwent hysterectomy: 98.5% (66) total laparoscopic with salpingo-oophorectomy and 1.5% (1) total laparoscopic with ovarian preservation. Mean age and body mass index were 29(±8) years and 28.6(±6.7) kg/m2, respectively. Of the patients, 89.5% (60) were on testosterone for a median of 36 (12-300) months: 59.7% (40) were amenorrheic, 43.2% (29) had dysmenorrhea, 17.9% (12) reported heavy menses, and 14.9% had irregular menses. Furthermore, 50.7% (34) complained of pelvic pain (35.3% constant, 64.7% cyclic). Intraoperative endometriosis was diagnosed in 26.9% (18) of the patients: in 32.3% of the patients who reported pelvic pain and in 21.9% of the patients without pain. There were no differences between patients with endometriosis compared with those without endometriosis except for those with endometriosis were more likely to report irregular bleeding (27.8% vs 8.3%, p = .04) and were also more likely to complain of heavy menses (66.7% vs 35.4%, p = .03). CONCLUSION: Of the transgender men who presented for hysterectomy, 50% reported pelvic pain, but only 1 in 3 with pain had findings of endometriosis. Patients found to have endometriosis were more likely to report irregular bleeding and/or heavy menses.

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension.

STUDY OBJECTIVE: The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. DESIGN: Retrospective propensity-score matched cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. INTERVENTIONS: We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1-3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1-2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7-2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0-2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7-2.8; p = .3). CONCLUSION: In this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.

Cystoscopy with antibiotic irrigation during pelvic reconstruction and minimally invasive gynecologic surgery: A double-blind randomized controlled trial.

AIMS: After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI. METHODS: This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ2 and multivariable logistic regression analyses were performed. RESULTS: We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ2 (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569). CONCLUSION: When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.

Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series.

BACKGROUND: As transmasculine persons utilize androgen gender affirming hormone therapy as a part of transition, guidance has been lacking on the effects of the therapy on the ovaries, especially for those who may desire retention. AIM: To describe the ovarian histopathology of transmasculine persons on testosterone therapy following oophorectomy at the time of hysterectomy performed for gender affirmation. METHODS: This was a multicenter case series study of transmasculine patients on testosterone therapy who underwent hysterectomy with oophorectomy for gender affirmation between January 2015 and December 2017 at 5 tertiary care referral centers. Patients were identified by their current procedural and International Classification of Diseases codes. OUTCOMES: Pre-, perioperative, and pathologic data were obtained from the electronic medical records and ovarian tissue descriptions from pathology reports were grouped into the following classifications: (i) simple/follicular cysts; (ii) polycystic ovaries; (iii) complex cysts; (iv) endometriomas; (v) other masses; (vi) atrophy; and (vii) normal. RESULTS: 85 patients were included in the study. At the time of oophorectomy, the mean age and body mass index of the cohort were 30.4 ± 8.4 years and 30.2 ± 7.3 kg/m2, respectively, and the average interval from the initiation of testosterone to oophorectomy was 36 0.3 ± 37.9 months. On examination of ovarian histopathology, 49.4% (42) of specimens were found to have follicular/simple cysts, 5.9% (5) were polycystic, and 38.8% (33) had normal pathology. For those specimens with volume documented (n = 41), the median volume was 9.6 (range 1.5-82.5) cm3. There was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries. CLINICAL IMPLICATIONS: The results of this study reported benign histopathology in ovaries of a large cohort of transmasculine persons on testosterone which should be included when counseling patients on ovarian retention, as transmasculine patients may choose to retain their ovaries while on testosterone for a variety of reasons (including no desire to undergo surgery, desire for backup sex steroids, and potential use for future fertility). STRENGTHS & LIMITATIONS: This is a large multicenter study seeking to address the uncertainty in present counseling surrounding ovarian conservation in transmasculine persons on testosterone therapy. Its limitations included its retrospective nature and inability to address ovarian function after testosterone discontinuance. CONCLUSION: In this cohort of transmasculine patients on testosterone therapy undergoing hysterectomy with oophorectomy for gender affirmation, ovarian histopathology was benign in all the specimens. Grimstad FW, Fowler KG, New EP, et al. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020;17:1807-1818.

A review of mentoring deaf and hard-of-hearing scholars.

Diversification of the scientific workforce usually focuses on recruitment and retention of women and underrepresented racial and ethnic minorities but often overlooks deaf and hard-of hearing (D/HH) persons. Usually classified as a disability group, such persons are often members of their own sociocultural linguistic minority and deserve unique support. For them, access to technical and social information is often hindered by communication- and/or language-centered barriers, but securing and using communication access services is just a start. Critical aspects of training D/HH scientists as part of a diversified workforce necessitates: (a) educating hearing persons in cross-cultural dynamics pertaining to deafness, sign language, and Deaf culture; (b) ensuring access to formal and incidental information to support development of professional soft skills; and (c) understanding that institutional infrastructure change may be necessary to ensure success. Mentorship and training programs that implement these criteria are now creating a new generation of D/HH scientists.

Tamsulosin to Prevent Postoperative Urinary Retention After Female Pelvic Reconstructive Surgery.

OBJECTIVE: This study aimed to determine the effect of tamsulosin on postoperative urinary retention in female patients after pelvic reconstructive surgery. METHODS: Data were obtained from a retrospective, matched cohort of female patients who were admitted after pelvic reconstructive surgery at a single academic institution. Patients who received tamsulosin were compared with those who did not at a 1:4 ratio, matched by surgical procedure. Patients were excluded if they were discharged on the day of surgery or if an intraoperative complication necessitated prolonged postoperative bladder drainage. Information on demographics, preoperative diagnoses, prolapse stage, preoperative voiding dysfunction, urodynamic findings, intraoperative details, postoperative complications, and voiding outcomes up to 6 weeks after surgery was gathered. The primary outcome was postoperative urinary retention, defined by failure of an active voiding trial. RESULTS: Patients underwent surgery between January 2016 and March 2018. We identified 35 patients who received tamsulosin and matched to 140 controls. Patients in the tamsulosin group were younger; groups were otherwise similar. Patients who received tamsulosin after surgery were less likely to develop postoperative urinary retention (2.9% vs 24.3%, P = 0.004). After controlling for confounders, multivariable logistic regression identified tamsulosin use as the only independent predictor of postoperative urinary retention with a significant protective effect (odds ratio, 0.09; 95% confidence interval, 0.01-0.67; P = 0.03). CONCLUSIONS: Prophylactic tamsulosin use may be effective in preventing postoperative urinary retention in female patients undergoing pelvic reconstructive surgery.

Three Synchronous Primary Extranodal Mantle Cell Lymphomas Involving Torus Tubarius, Posterior Nasopharynx, and Base of the Tongue 65 Years After Treatment of Chronic Sinusitis with Nasopharyngeal Radium Irradiation.

BACKGROUND Radiation, specifically ionizing radiation, causes broad-spectrum gene damage, including double-strand DNA breaks, single DNA strand breaks, cross links, and individual base lesions, thus causing chromosomal translocations, deletions, point mutations, and, consequently, various types of cancer. Radiation also causes genomic instability in cells, which enhances the rate of mutations in the descendants of the irradiated cell after many generations of normal replications. CASE REPORT We report the first case of mantle cell lymphoma of the torus tubarius, and the first CD10-positive mantle cell lymphoma of the Waldeyer's ring. Mantle cell lymphoma appeared 65 years after treatment of chronic sinusitis with nasopharyngeal radium irradiation. CONCLUSIONS On the basis of the medical literature about atomic bomb survivors, nuclear plant workers, and radiologists exposed to radiation, and our case, we conclude that radiation can, in a very small percentage of exposed individuals, cause non-Hodgkin lymphoma: in 0.24% of atomic bomb survivors and in at least 0.13% of the patients treated with nasopharyngeal radium irradiation. Non-Hodgkin lymphoma can occur many decades after radiation exposure, and individuals treated with nasopharyngeal radium irradiation, usually in their childhood, need continuing follow-up.

Multimodal opioid-sparing postoperative pain regimen compared with the standard postoperative pain regimen in vaginal pelvic reconstructive surgery: a multicenter randomized controlled trial.

BACKGROUND: Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use. OBJECTIVE: The objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery. STUDY DESIGN: This was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power). RESULTS: Thirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P < .001) and received fewer narcotics during the entire hospitalization (55.7 vs 91.2, P < .001). At 96 hour follow up, patients in the ice packs, Tylenol, and Toradol group used 4.9 ketorolac tablets compared with 4.6 oxycodone/acetaminophen tablets in the standard group (P = .81); however, ice packs, Tylenol, and Toradol patients required more acetaminophen than ibuprofen by patients in the standard arm (10.7 vs 6.2 tablets, P = .012). There were no differences in Quality of Recovery Questionnaire or satisfaction scores either in the morning after surgery or at 96 hour follow up. CONCLUSION: The ice packs, Tylenol, and Toradol multimodal pain regimen offers improved pain control the morning after surgery and 96 hours postoperatively compared with the standard regimen with no differences in patient satisfaction and quality of recovery. Ice packs, Tylenol, and Toradol can significantly limit postoperative inpatient narcotic use and eliminate outpatient narcotic use in patients undergoing vaginal pelvic reconstructive surgery.

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications.

BACKGROUND: Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. OBJECTIVE: The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. MATERIALS AND METHODS: This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. RESULTS: Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P <.001) and were more likely to smoke (21.0% vs 15.8%, P = .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P = .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P = .02), and cystotomy repair (1.0% vs 0.3%, P = .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). CONCLUSION: Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series.

BACKGROUND: As part of transition, transmasculine persons often use testosterone gender-affirming hormone therapy; however, there is limited data on its long-term effects. The impact of exogenous testosterone on uterine pathology remains unclear. While testosterone achieves amenorrhea in the majority of this population, persistence of abnormal uterine bleeding can be difficult to manage. Excess androgens in cisgender females are associated with pathologic uterine processes such as polycystic ovary syndrome, endometrial hyperplasia, or cancer. There are no guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population. OBJECTIVE: The aim of this study was to describe the characteristics of uterine pathology after the initiation of testosterone in transmasculine persons. MATERIALS AND METHODS: A retrospective, multicenter case series was performed. Uterine pathology reports of transmasculine persons who received testosterone and subsequently underwent hysterectomy were reviewed. The endometrial phase and endometrial thickness were recorded. RESULTS: A total of 94 subjects met search criteria. The mean age of participants was 30 ± 8.6 years, and the mean interval from initiation of testosterone to hysterectomy was 36.7 ± 36.6 months. Active endometrium was found in the majority of patients (n = 65; 69.1%). One patient had complex hyperplasia without atypia. There were no cases of endometrial cancer. CONCLUSION: Despite amenorrhea in the majority of transmasculine persons on testosterone, endometrial activity persists with predominantly proliferative endometrium on histopathology. Individualized counseling for abnormal uterine bleeding is encouraged in this patient population.

Complication Rates and Outcomes After Hysterectomy in Transgender Men.

OBJECTIVE: To describe the rate and 30-day outcomes after gender affirmation surgery in transgender men. METHODS: We conducted a cross-sectional population-based study. Patients with male gender who underwent hysterectomy for benign indications between 2013 and 2016 in the American College of Surgeons' National Surgical Quality Improvement database were identified. Propensity score matching was performed to ameliorate selection bias. Student t test and Mann-Whitney tests were used to compare continuous variables between two groups where appropriate. The χ and Fisher exact tests were used where appropriate to compare categorical variables across groups. Logistic regression models were used to evaluate factors associated with any postoperative adverse event. RESULTS: Of 159,736 hysterectomies performed during the study period, 521 (0.3%) were performed in transgender men. The mean age was 23.9±13.8 years, and the median body mass index was 29.0 (range 24.8-34.2). The majority of patients were white (64.5%). The most common specified diagnosis associated with hysterectomy was gender identity disorder (20.9%). Laparoscopy was the most common route (57.2%) followed by laparoscopic-assisted vaginal hysterectomy (20.0%) and abdominal hysterectomy (15.2%). After propensity matching was performed, the composite rate of postoperative complications was similar between the transgender male and control groups (3.4% vs 3.3%, P=.92). On multivariate logistic regression controlling for age, presence of a major medical comorbidity, and primary mode of surgery, transgender male status and presence of a major medical comorbidity were not significantly associated with complications (adjusted odds ratio [OR] 1.11, 95% CI 0.56-2.10 and adjusted OR 1.16, 95% CI 0.58-2.27, respectively). Age remained weakly associated with postoperative complications (adjusted OR 1.04, 95% CI 1.01-1.06), whereas minimally invasive approaches to hysterectomy were significantly associated with lower incidences of complications (vaginal, adjusted OR 0.04, 95% CI 0.002-0.17; laparoscopic adjusted OR 0.09, 95% CI 0.04-0.18; and laparoscopic-assisted vaginal hysterectomy, adjusted OR 0.07, 95% CI 0.02-0.20). CONCLUSION: Less than 1% of hysterectomies performed annually are for transgender male patients. Postoperative complications after hysterectomy in this patient population are similar to the complication rates found in cisgender women.

A Randomized Comparative Study Evaluating Various Cough Stress Tests and 24-Hour Pad Test with Urodynamics in the Diagnosis of Stress Urinary Incontinence.

PURPOSE: The cough stress test is a common and accepted tool to evaluate stress urinary incontinence but there is no agreement on how the test should be performed. We assessed the diagnostic ability of different cough stress tests performed when varying patient position and bladder volume using urodynamic stress urinary incontinence as the gold standard. The 24-hour pad test was also evaluated. MATERIALS AND METHODS: We recruited women who presented to specialty outpatient clinics with the complaint of urinary incontinence and who were recommended to undergo urodynamic testing. A total of 140 patients were randomized to 4 cough stress test groups, including group 1-a comfortably full bladder, group 2-an empty bladder, group 3- a bladder infused with 200 cc saline and group 4-a bladder filled to half functional capacity. The sequence of standing and sitting was randomly assigned. The groups were compared by 1-way ANOVA or the generalized Fisher exact test. The κ statistic was used to evaluate agreement between the sitting and standing positions. The 95% CIs of sensitivity and specificity were calculated using the Wilson method. ROC analysis was done to evaluate the performance of the 24-hour pad test. RESULTS: The cough stress test performed with a bladder filled to half functional capacity was the best performing test with 83% sensitivity and 90% specificity. There was no statistically significant evidence that the sensitivity or specificity of 1 cough stress test differed from that of the others. The pad test had no significant predictive ability to diagnose urodynamic stress urinary incontinence (AUC 0.60, p = 0.08). CONCLUSIONS: Cough stress tests were accurate to diagnose urodynamic stress urinary incontinence. The 24-hour pad test was not predictive of urodynamic stress urinary incontinence and not helpful when used in conjunction with the cough stress test.

Readmission Rates after Same-Day Discharge Compared with Postoperative Day 1 Discharge after Benign Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To determine if there is a difference in readmission rates after same-day discharge compared with postoperative day 1 discharges after laparoscopic hysterectomy. DESIGN: A retrospective cohort study with 1:2 propensity score matching (Canadian Task Force classification II-2). SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Women undergoing benign laparoscopic total or supracervical hysterectomy or laparoscopic-assisted vaginal hysterectomy with or without adnexal surgery between the years 2010 to 2015. INTERVENTIONS: Three thousand thirty-two low-risk women discharged on postoperative day 0 and 6064 women discharged on postoperative day 1 were included in the analysis. MEASUREMENTS AND MAIN RESULTS: The overall readmission rate was 1.8%; after same-day discharge, the readmission rate was 2.2%, and after postoperative day 1 discharge the readmission rate was 1.7% (p = .10). After logistic regression analysis, smoking (adjusted odds ratio [aOR] = 2.06; 95% confidence interval [CI], 1.49-2.88), nonwhite race (aOR = 1.53; 95% CI, 1.1007-2.14), and cystoscopy (aOR = 2.05; 95% CI, 1.49-2.82) were associated with an increased risk of readmission. CONCLUSION: There was no statistically significant difference in readmission rates after laparoscopic hysterectomy between women discharged on the day of surgery or postoperative day 1.