Amandeep Mahal

Inappropriate oophorectomy at time of benign premenopausal hysterectomy

Objective: We assessed rates of oophorectomy during benign hysterectomy around the release of the American College of Obstetricians and Gynecologists 2008 practice bulletin on prophylactic oophorectomy, and evaluated predictors of inappropriate premenopausal oophorectomy. Methods: A cross-sectional administrative database analysis was performed utilizing the California Office of Statewide Health Planning Development Patient Discharge Database for years 2005 to 2011. After identifying all premenopausal women undergoing hysterectomy for benign conditions, International Classification of Diseases (ICD)-9 diagnosis codes were reviewed to create a master list of indications for oophorectomy. We defined appropriate oophorectomy as cases with concomitant coding for ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses. Using patient demographics and hospital characteristics to predict inappropriate oophorectomy, a logistic regression model was created. Results: We identified 57,776 benign premenopausal hysterectomies with oophorectomies during the period studied. Of the premenopausal oophorectomies, 37.7% (21,783) were deemed “inappropriate” with no documented reason for removal. The total number of premenopausal inpatient hysterectomies with oophorectomy decreased yearly (12,227/y in 2005 to 5,930/y in 2011). However, the percentage of inappropriate oophorectomies remained stable. In multivariate analysis, Hispanic and African American ethnicity/race associated with increased odds of inappropriate oophorectomy (P < 0.001). Urban and at low Medi-Cal utilization hospitals showed increased odds of inappropriate oophorectomy. Conclusions: In premenopausal women undergoing benign hysterectomy, over one-third undergo oophorectomy without an appropriate indication documented. The rate of inappropriate oophorectomy in California has not changed since the 2008 American College of Obstetricians and Gynecologists guidelines. Whereas the absolute number of inpatient hysterectomies for benign indications has decreased, our work suggests persistent utilization of oophorectomy in premenopausal women, despite well-documented long-term adverse health implications.

Necrotizing postsurgical infection complicating midurethral sling procedure with unrecognized cystotomy.

A 39-year-old woman with stress urinary incontinence underwent a retropubic midurethral sling procedure. On postoperative day 1, she presented with persistent abdominal pain and fever. A computed tomographic scan showed subcutaneous lower abdominal wall edema and gas above the fascia suggesting a necrotizing soft tissue infection. She was surgically debrided twice, which included removal of the mesh sling on postoperative day 4. Cystoscopy suggested unrecognized bladder perforation had occurred during the initial procedure, and record rerevealed untreated bacteriuria before sling placement. The patient required wound vacuum therapy and a later secondary wound closure procedure. Six months after the initial surgery, she was reevaluated for stress urinary incontinence and underwent a transobturator midurethral sling procedure with resolution of these symptoms. Necrotizing postsurgical infection is a rarely described complication of midurethral slings. Treatment for this potentially life-threatening complication includes aggressive surgical debridement, administration of broad-spectrum antibiotic, removal of infected implants, and supportive therapy. Unrecognized bladder injury and preoperative bacteriuria are discussed as potential risk factors for postsling necrotizing infection.

Peroxisome proliferator-activated receptor gamma agonist as a novel treatment for interstitial cystitis: A rat model

Purpose To understand the therapeutic potential of pioglitazone, a peroxisome proliferator-activated receptor gamma (PPAR-γ) agonist with a propensity to cause bladder mucosal proliferation, on interstitial cystitis (IC) in a rat model. Materials and Methods Using a previously described animal model for IC, Sprague-Dawley rats were treated with biweekly cyclophosphamide injections (35 mg/kg) to induce cystitis. Animals were divided into 4 groups (n=6 for each group): IC plus daily sham saline gavage (IC+Pio−), IC plus daily pioglitazone gavage (15 mg/kg) (IC+Pio+), normal rats with daily pioglitazone (IC−Pio+), and normal rats with neither IC nor pioglitazone (IC−Pio− or Control). At the end of four weeks, urinary frequency and bladder capacity were measured. Histologic examination of urothelial integrity was also performed. Results Average voids per hour were significantly lower in IC+Pio+ (4.0±1.9) vs. IC+Pio− (10.0±2.4) rats (p<0.01) and were similar to IC−Pio+ (6.0±1.4) and IC−Pio− (6.0±1.5) controls. Cystometric capacity was significantly higher in IC+Pio+ (0.945±0.122 mL) vs. IC+Pio− rats (0.588±0.165 mL, p=0.01) and was comparable to IC−Pio− capacity (0.817±0.196 mL) and IC−Pio+ capacity (0.941±0.188 mL). Urothelial structural integrity was improved in IC+Pio+ rats versus IC+Pio− rats upon histologic observation. Conclusions Pioglitazone, a PPAR-γ agonist, improved bladder function in cyclophosphamide-induced cystitis by both observed urinary frequency and measured cystometric capacity. Urothelial structural integrity was also improved. Pioglitazone, due to a propensity to cause bladder mucosal proliferation, may prove useful for treating IC, and deserves further investigation.

PD09-08 SACRAL NEUROMODULATION IN CALIFORNIA FROM 2005 TO 2011: WHAT ARE THE REAL-WORLD SUCCESS RATES?

INTRODUCTION AND OBJECTIVES: Sacral neuromodulation (SNS) is approved by the Food and Drug Administration for the treatment of refractory urge urinary incontinence, frequency/urgency, idiopathic urinary retention and fecal incontinence. Prior to placement of an implantable pulse generator, all patients must undergo a trial stimulation to ensure improvement in their condition. The success rate for staged SNS implantation of a pulse generator (defined as > 50% improvement) varies greatly in the literature (ranging from 40 to 90%). We sought to determine success rates in California using a statewide registry. METHODS: We accessed non-public records from the California Office of Statewide Health Planning and Development (OSHPD) Ambulatory Surgery Database for the years 2005 to 2011. This dataset captures all non-federal ambulatory surgical visits within the state. Appropriate Current Procedural Terminology, 4th edition (CPT) procedure codes and International Classification of Disease, 9th edition (ICD-9) diagnosis codes were used to analyze all SNS procedures and their indication. Patients were followed longitudinally using unique patient record linkage numbers. Staged success was defined as the proportion of patients who received a stage 2 SNS generator implantation after their stage 1 tined lead trial. RESULTS: We identified 4,098 patients with SNS procedure codes. After excluding patients who only underwent generator exchange, lead revision or lead explantation, our final cohort included 2,765 patients. The majority of patients were female (77%), over 60 years of age (68%), Caucasian (74%) and had Medicare (60%). A total of 1,396 patients underwent a stage 1 trial of tined-lead implantation, of which 962 subsequently underwent stage 2 pulse generator placement (staged success rate of 69%). Staged success rates were 72% for urge urinary incontinence, 69% for urgency/frequency, 57% for urinary retention, 68% for interstitial cystitis and 67% for neurogenic bladder. Success rates were similar after stratification by race/ethnicity and insurance coverage. CONCLUSIONS: While the success rates for staged SNS implantation in the state of California were less than that observed in many single center academic series; they are better than previously reported for Medicare patients, and suggestive of a success rate of greater than two thirds.

Persistent postoperative granulation tissue following vaginal prolapse repair

This retrospective cohort study used procedure codes to identify all patients who underwent vaginal-approach reconstructive prolapse surgery over a 3-year period. Demographic, medical history, medications, operative details and follow-up data were obtained via chart review. Surgical procedures, suture and implant types were abstracted from operative notes. Rates of pre-specified outcomes, including persistent GT (GT on exam > 2 months after surgery) and reoperation for GT, were calculated by procedure. Associations were studied between potential risk factors and GT outcomes.