Christine A. Heisler

Determining Perioperative Complications Associated With Vaginal Hysterectomy: Code Classification Versus Chart Review

BACKGROUND Improvement in outcomes after vaginal hysterectomy (VH) requires accurate identification of complications. We hypothesized that coded data, commonly used to determine morbidity, would miss more complications than chart review would. STUDY DESIGN Medical records of women who underwent VH from January 2004 through December 2005 were reviewed for cardiac or respiratory arrest, congestive heart failure, pulmonary edema, pulmonary embolism, urinary tract infection, ureteral obstruction, hemorrhage, and delirium. Complications were identified with use of coded data, in which diagnoses were classified with a modification of the Hospital Adaptation of the International Classification of Diseases. RESULTS Records of 712 patients were reviewed. Of the 161 complications identified, 158 (98.1%) were identified through chart review and 48 (29.8%) through coded data. Codes captured all diagnoses of cardiac arrest, respiratory arrest, and pulmonary embolism but missed other complications. CONCLUSIONS Codes captured life-threatening complications, but other complications were underestimated or missed entirely. Reliance on coded data for outcomes assessments can be misleading and should be combined with other methods to maximize validity.

Effect of Additional Reconstructive Surgery on Perioperative and Postoperative Morbidity in Women Undergoing Vaginal Hysterectomy

OBJECTIVE: To estimate the risk of perioperative and postoperative morbidity among women undergoing vaginal hysterectomy with and without reconstructive pelvic surgery. METHODS: We collected patient demographics, baseline medical status, perioperative and postoperative findings, and surgical procedures for women aged 18 years or older who had vaginal hysterectomy for a benign indication at Mayo Clinic, Rochester, Minnesota, between January 2004 and December 2005. The main outcome measure was any complication, defined by intensive care unit (ICU) admission, reoperation, readmission, or medical intervention within 9 weeks after surgery. RESULTS: Of 736 patients who met the study criteria, 712 had complete follow-up information. Overall, more women undergoing vaginal hysterectomy with reconstructive pelvic surgery had complications than did those without reconstructive pelvic surgery (147 of 336 [43.8%] compared with 77 of 376 [20.5%], odds ratio [OR] 3.0, 95% confidence interval [CI] 2.2–4.2, P<.001). This association was significant (OR 3.0, 95% CI 1.5–6.2, P=.003) even after adjusting for factors that were significantly different between groups (age, surgical indication, and change in hemoglobin). Specifically, urinary tract infection, pulmonary edema, and unplanned ICU admissions were more common among those undergoing reconstructive pelvic surgery. Disregarding urinary tract infections, the overall complication rate was still higher among the women with concomitant reconstructive pelvic surgery (22.9% compared with 16.5%, OR 1.5, 95% CI 1.04–2.2, P=.03). CONCLUSION: Women having vaginal hysterectomy with additional reconstructive pelvic surgery were more likely to have a perioperative complication than were women undergoing vaginal hysterectomy alone. LEVEL OF EVIDENCE: II

Subpubic cartilaginous cyst presenting as acute urinary retention: a report and review of the literature.

Introduction A subpubic cartilaginous cyst is a rare and therefore poorly understood pathologic process involving the symphysis pubis. We describe a case of a postmenopausal female with acute urinary retention secondary to a periurethral cyst, and provide a literature review of previously reported cases of women with presenting complaints of a vulvar mass or pain. The differential diagnoses of a subpubic cartilaginous cyst, as well as management options, are discussed. Case A 68-year-old woman presented with acute urinary retention. Physical examination revealed a 4-cm tender cystic mass palpated along the anterior vaginal wall traversing toward the posterior pubic ramus. A pelvic magnetic resonance imaging showed a 4.4 × 3.5 × 4.2-cm3 well-circumscribed, cystic lesion at the anterior aspect of the lower urethra with no intrinsic contrast enhancement. The cyst was surgically excised through a transvaginal approach with no recurrence to date. Conclusions A subpubic cartilaginous cyst is an uncommon lesion thought to originate from the symphysis pubis and to be a result of degenerative changes. Patients have presented with pain, a vulvar/vaginal mass, or both. This case describes a patient who presented with acute urinary retention. In patients with suspected subpubic cartilaginous cyst, the lesion may be excised in symptomatic patient or observed in those who are asymptomatic. Standard of care has not yet been determined regarding management due to the rarity of the lesion.

Importance of adequate gross anatomy education: The impact of a structured pelvic anatomy course during gynecology fellowship

Medical education underwent standardization at the turn of the 20th century and remained fairly consistent until recently. Incorporation of a patient‐centered or case‐based curriculum is believed to reinforce basic science concepts. One negative aspect is a reduction in hours spent with cadaveric dissection in the gross anatomy laboratory. For those entering a surgical career, limited anatomical exposure leaves knowledge deficits that must be corrected during further education during residency training. The benefit of providing formal anatomy education to residents and surgical fellows is described in the literature, specifically noting improvement in written test scores and surgical application. Anat Sci Educ.

Improving quality of care: development of a risk-adjusted perioperative morbidity model for vaginal hysterectomy

OBJECTIVE We sought to develop and evaluate a risk-adjusted perioperative morbidity model for vaginal hysterectomy. STUDY DESIGN Medical records of women who underwent vaginal hysterectomy during 2004 and 2005 were retrospectively reviewed. Morbidity included hospital readmission, reoperation, and unplanned medical intervention or intensive care unit admission; urinary tract infections were excluded. Multivariate logistic regression identified factors associated with perioperative morbidity (adjusted for urinary tract infection). The resulting model was validated using a random 2006 sample. RESULTS Of 712 patients, 139 (19.5%) had morbidity associated with congestive heart failure or prior myocardial infarction, perioperative hemoglobin decrease >3.1 g/dL, preoperative hemoglobin <12.0 g/dL, and prior thrombosis (c-index = 0.68). Predicted morbidity was similar to observed rates in the validation sample. CONCLUSION History of congestive heart failure or myocardial infarction, prior thrombosis, perioperative hemoglobin decrease >3.1 g/dL, or preoperative hemoglobin <12.0 g/dL were associated with increased perioperative complications. Quality improvement efforts should modify these variables to optimize outcomes.

Validation of a visual analog scale form of the pelvic organ prolapse/urinary incontinence sexual function questionnaire 12.

Objective: This study aimed to validate a visual analog scale (VAS) form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). Methods: This was a planned secondary analysis of a vaginal anatomy and sexual function study. All women undergoing vaginal reconstruction between October 2008 and December 2009 were asked to participate. We planned for an analysis of 30 women for this validation. Preoperatively, sexually active participants completed a questionnaire containing a PISQ-12 in Likert (0-4) and VAS (0-10) format. Within 30 days, participants completed a PISQ-12 in VAS form only for evaluation of test-retest reliability. At 6 months after surgery, participants completed the PISQ-12 in both the Likert and VAS forms. For each item on the PISQ-12, the Spearman rank correlation coefficient was used to estimate the correlation between the Likert and VAS formats using the responses from the same assessment period (before or after surgery). The intraclass correlation coefficient was estimated to assess the test-retest agreement. Results: A total of 43 women completed the preoperative questionnaire, 25 completed the retest, and 37 completed the postoperative questionnaire. When PISQ-12 scores were compared between the Likert and VAS forms, correlation values were 0.88 preoperatively and 0.91 postoperatively. Test-retest reliability was high with an intraclass correlation coefficient of 0.87. Most women preferred the Likert version (71.4% preoperatively and 55.0% postoperatively). Conclusions: The VAS form of the PISQ-12 is both reliable and reproducible and avoids the limitations of the Likert scale.

Complication Rates Between Local and Referral Patients Undergoing Vaginal Hysterectomy at an Academic Medical Center

OBJECTIVE To explore the influence of referral bias on complication rates after vaginal hysterectomy. PATIENTS AND METHODS Community-based (local) and referral patients had benign indications and underwent vaginal hysterectomy from January 1, 2004, through December 31, 2005. We retrospectively evaluated patient characteristics, surgical procedures, and complications that occurred within 9 weeks after the index surgery. Complications were defined as admission to the intensive care unit, reoperation, hospital readmission, or medical intervention. RESULTS Of 736 patients, 361 (49.0%) were referred from outside the immediate 7-county area. Compared with local patients, referral patients were older (mean age, 54.5 vs 49.3 years; P<.001) and had lower body mass index (mean, 27.6 vs 28.7 kg/m2; P=.02). More referral patients had cardiovascular disease (4.2% vs 0.5%; P=.001) and prior myocardial infarctions (1.9% vs 0%; P=.007). Referral patients also had higher American Society of Anesthesiologists scores (score of 3 or 4, 12.6% vs 7.0%; P=.01) and longer length of hospitalization (mean, 2.6 vs 2.2 days; P<.001), and more underwent pelvic reconstruction (52.1% vs 41.3%; P=.004). Fewer referral patients had private insurance (74.5% vs 89.6%; P<.001). Despite these differences, overall complication rates were similar for referral and local patients (33.4% vs 29.7%; P=.28). CONCLUSION Although referral patients had more comorbid conditions than local patients, the groups had similar complication rates after vaginal hysterectomy.

Ureteral injury during vaginal mesh excision: role of prevention and treatment options

Vaginal mesh kits are increasingly used in vaginal prolapse repair. Mesh erosion, infection, and pain may necessitate removal, which can lead to urinary tract injury. We describe 2 cases of ureteral injury at the time of mesh excision. Surgeons must recognize the possibility of ureteral injury and treatment modalities available.

Utility of intraoperative cystoscopy in detecting ureteral injury during vaginal hysterectomy.

Objectives The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy. Methods We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury. Results In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58–6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19–9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were

Hysterectomy and perioperative morbidity in women who have undergone renal transplantation

10,686 (95% CI,