Amie Kawasaki

Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050

OBJECTIVE We sought to estimate the number of women who will undergo inpatient and outpatient surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP) in the United States from 2010 through 2050. STUDY DESIGN Using the 2007 Nationwide Inpatient Sample and the 2006 National Survey of Ambulatory Surgery, we calculated the rates for inpatient and outpatient SUI and POP surgery. We applied the surgery rates to the US Census Bureau population projections from 2010 through 2050. RESULTS The total number of women who will undergo SUI surgery will increase 47.2% from 210,700 in 2010 to 310,050 in 2050. Similarly, the total number of women who will have surgery for prolapse will increase from 166,000 in 2010 to 245,970 in 2050. CONCLUSION If the surgery rates for pelvic floor disorders remain unchanged, the number of surgeries for urinary incontinence and POP will increase substantially over the next 40 years.

Long-Term Outcomes After Stress Urinary Incontinence Surgery

OBJECTIVES: To compare the long-term risk of repeat stress urinary incontinence (SUI) surgery after different types of initial SUI surgery and to identify predictors of time to repeat SUI surgery in a large, population-based cohort. METHODS: We used de-identified, adjudicated health care claims data from approximately 100 employer-based plans across the United States from 2000 to 2009. We identified the index SUI surgery in women aged 18 to 64 years. Kaplan-Meier survival curves were used to estimate cumulative incidence of repeat surgery through 9 years. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with recurrent SUI surgery. RESULTS: Over 10 years, we identified 155,458 eligible women who underwent one or more SUI surgeries, with a total of 294,855 person-years of follow-up. Of these index surgeries, 127,848 (82.2%) were slings. The 9-year cumulative incidence of repeat surgery after any SUI surgery was 14.5% (95% CI 13.4–15.5). As expected, bulking agents had the highest cumulative incidence of repeat surgery (61.2%, 95% CI 56.3–66.0) followed by needle suspension (22.2%, 95% CI 16.5–27.9); the lowest 9-year incidences were for Burch (10.8%, 95% CI 9.3–12.3) and sling (13.0%, 95% CI 11.7–14.3). In a Cox proportional hazards model that adjusted for age, year of index surgery, and region of the United States, the rate of repeat surgery was 28% higher for slings compared with Burch (adjusted HR 1.28, 95% CI 1.19–1.37). CONCLUSION: In this population-based analysis of women aged 18 to 64 years, Burch procedures had the lowest 9-year cumulative incidence of repeat SUI surgery.

Do urodynamic parameters predict persistent postoperative stress incontinence after midurethral sling? A systematic review

Introduction and hypothesisIt is unclear whether preoperative urodynamic study (UDS) values are predictive of outcomes after midurethral sling.Materials and methodsWe systematically reviewed multiple databases from January 1989 to October 2011 for English-language studies correlating UDS data with postoperative outcomes after midurethral slings. We performed random effects model meta-analyses, as indicated. Relative risk (RR) ratios for the outcome of stress urinary incontinence (SUI) cure were calculated using high maximum urethral closure pressure (MUCP) and Valsalva leak point pressure (VLPP) values as the reference group.ResultsHigh preoperative MUCP was associated with cure after retropubic [RR 0.67; 95% confidence interval (CI) 0.47–0.97)] and transobturator slings (RR 0.65; 95% CI 0.49–0.90). High preoperative VLPP was also associated with cure after retropubic sling (RR 0.89; 95% CI 0.82–0.96), but this relationship did not achieve statistical significance for cure after transobturator sling (RR 0.86; 95% CI 0.74–1.00).ConclusionsPreoperative MUCP and VLPP values may add insight into postoperative outcomes after surgical treatment for SUI.

Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial.

OBJECTIVE: To evaluate whether nitrofurantoin prophylaxis prevents postoperative urinary tract infection (UTI) in patients receiving transurethral catheterization after pelvic reconstructive surgery. METHODS: In a randomized, double-blind, placebo-controlled trial, participants undergoing pelvic reconstructive surgery were randomized to 100 mg nitrofurantoin or placebo once daily during catheterization if they were: 1) discharged with a transurethral Foley or performing intermittent self-catheterization; or 2) hospitalized overnight with a transurethral Foley. Our primary outcome was treatment for clinically suspected or culture-proven UTI within 3 weeks of surgery. Statistical analysis was performed by &khgr;2 and logistic regression. Assuming 80% power at a P value of .05, 156 participants were needed to demonstrate a two-thirds reduction in UTI. RESULTS: Of 159 participants, 81 (51%) received nitrofurantoin and 78 (49%) received placebo. There were no significant differences in baseline demographics, intraoperative characteristics, duration and type of catheterization, or postoperative hospitalization, except a lower rate of hysterectomy in the nitrofurantoin group. Nitrofurantoin prophylaxis did not reduce the risk of UTI treatment within 3 weeks of surgery (22% UTI with nitrofurantoin compared with 13% UTI with placebo, relative risk 1.73, 95% confidence interval 0.85–3.52, P=.12). Urinary tract infection treatment was higher in premenopausal women, lower in diabetics, and increased with longer duration of catheterization. In logistic regression adjusting for menopause, diabetes, preoperative postvoid residual volume, creatinine clearance, hysterectomy, and duration of catheterization, there was still no difference in UTI with nitrofurantoin as compared with placebo. CONCLUSION: Prophylaxis with daily nitrofurantoin during catheterization does not reduce the risk of postoperative UTI in patients receiving short-term transurethral catheterization after pelvic reconstructive surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01450800. LEVEL OF EVIDENCE: I

Do Mixed-Flora Preoperative Urine Cultures Matter?

Objectives To determine whether mixed-flora preoperative urine cultures, as compared with no-growth preoperative urine cultures, are associated with a higher prevalence of postoperative urinary tract infections (UTIs). Methods This was a retrospective cohort study. Women who underwent urogynecologic surgery were included if their preoperative clean-catch urine culture result was mixed flora or no growth. Women were excluded if they received postoperative antibiotics for reasons other than treatment of a UTI. Women were divided into two cohorts based on preoperative urine culture results—mixed flora or no growth; the prevalence of postoperative UTI was compared between cohorts. Baseline characteristics were compared using &khgr;2 or Student t tests. A logistic regression analysis then was performed. Results We included 282 women who were predominantly postmenopausal, white, and overweight. There were many concomitant procedures; 46% underwent a midurethral sling procedure and 68% underwent pelvic organ prolapse surgery. Preoperative urine cultures resulted as mixed flora in 192 (68%) and no growth in 90 (32%) patients. Overall, 14% were treated for a UTI postoperatively. There was no difference in the proportion of patients treated for a postoperative UTI between the two cohorts (25 mixed flora vs 13 no growth, P = 0.77). These results remained when controlling for potentially confounding variables in a logistic regression model (adjusted odds ratio 0.92, 95% confidence interval 0.43–1.96). Conclusions In women with mixed-flora compared with no-growth preoperative urine cultures, there were no differences in the prevalence of postoperative UTI. The clinical practice of interpreting mixed-flora cultures as negative is appropriate.

Robotic-Assisted Sacrocolpopexy: Early Postoperative Outcomes after Surgical Reduction of Enlarged Genital Hiatus

BACKGROUND Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic‐assisted sacrocolpopexy is not standardized. OBJECTIVE We sought to compare anatomic failure after robotic‐assisted sacrocolpopexy among 3 groups of patients categorized by their preoperative and postoperative genital hiatus size. STUDY DESIGN We performed a retrospective cohort study of women who underwent robotic‐assisted sacrocolpopexy, from January 2013 through September 2016. We defined a wide genital hiatus as ≥4 cm and a normal genital hiatus as <4 cm. We compared 3 groups: (1) wide preoperative and postoperative genital hiatus (persistently wide); (2) wide preoperative and normal postoperative genital hiatus (improved); and (3) normal preoperative and postoperative genital hiatus (stably normal). Our primary outcome was composite anatomic failure defined as either recurrent prolapse in any compartment past the hymen or retreatment for prolapse with either surgery or pessary. Our data were analyzed using 1‐way analysis of variance and χ2 test. Logistic regression was performed to evaluate for independent risk factors for anatomic failure among the 3 groups. P < .05 was considered significant. RESULTS Our study population consisted of 452 women with a mean age of 59.3 ± 10.0 years and a mean body mass index of 27.8 ± 5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The genital hiatus groups were distributed as follows: 57 (12.6%) were persistently wide, 296 (65.5%) were improved, and 99 (21.9%) were stably normal. The stably normal group had less advanced preoperative prolapse (stage ≥3) than the other groups (P < .01). A similar percentage of patients among groups had a concomitant posterior repair/perineoplasty (P = .09) with a total of 84 (18.6%) women undergoing this procedure. There was a statistically significant difference in overall composite anatomic failure among the groups (P = .03). There was an increase in failure in the persistently wide group (14.0%) compared to the improved group (5.7%, P = .04) and compared to the stably normal group (4.0%, P = .03). In a logistic regression model, controlling for number of vaginal deliveries and posterior repair/perineoplasty, there was a 5.3‐fold increased odds of composite anatomic failure in the persistently wide group (adjusted odds ratio, 5.3; 95% confidence interval, 1.4–19.1; P = .01) compared to the stably normal group. In a subanalysis of failure by compartment, there was an increase in failure of the posterior compartment in the persistently wide group compared to the improved group (8.8% vs 2.0%, P < .01), but not the stably normal group (3.0%, P = .12). There was not a statistically significant difference in failure of the combined apical and anterior compartments among groups (P = .29). CONCLUSION Surgical reduction of an enlarged preoperative genital hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of genital hiatus to postoperative genital hiatus are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic‐assisted sacrocolpopexy.