Elisabeth A. Erekson

Ambulatory procedures for female pelvic floor disorders in the United States

OBJECTIVE The aim of this study was to estimate the number of women undergoing ambulatory surgical procedures for female pelvic floor disorders (PFDs) in the United States and to compare age-adjusted ambulatory surgical case rates between 1996 and 2006. STUDY DESIGN We analyzed data from the 1996 and 2006 National Survey of Ambulatory Surgery, a federal public access de-identified database. Procedures for PFDs were identified using International Classification of Diseases-9th revision Clinical Modification procedure codes for urinary incontinence, fecal incontinence, and pelvic organ prolapse. RESULTS The number of women undergoing ambulatory surgical procedures for urinary incontinence increased from 34,968 (95% confidence interval, 25,583-44,353) in 1996 to 105,656 (95% confidence interval, 79,033-132,279) in 2006. The age-adjusted ambulatory surgical case rates for all PFDs increased from 7.91 per 10,000 in 1996 to 12.10 per 10,000 in 2006 (P = .0006). CONCLUSION Ambulatory procedures for urinary incontinence increased between 1996 and 2006, as well as the age-adjusted ambulatory case rate for all PFDs.

Effect of body mass index on the risk of anal incontinence and defecatory dysfunction in women

OBJECTIVE The primary objective was to estimate the effect of body mass index on the risk of anal incontinence and defecatory dysfunction in a tertiary referral urogynecologic population. STUDY DESIGN This was a cross-sectional study, including 519 new patients. Exposure was defined as body mass index. The primary outcome was any reported anal incontinence. The secondary outcome was any defecatory dysfunction. We used multiple logistic regression to estimate odds ratios and 95% confidence intervals for the effect of body mass index on anal incontinence and defecatory dysfunction. RESULTS After adjusting for confounders, every 5 unit increase in body mass index was associated with a significantly increased odds of anal incontinence (odds ratio 1.25; 95% confidence interval, 1.09 to 1.44) and a trend toward an increased odds of defecatory dysfunction (odds ratio 1.13; 95% confidence interval, 0.98 to 1.31), although this was not statistically significant. CONCLUSION Increasing body mass index is significantly associated with anal incontinence, but not defecatory dysfunction in women.

Postoperative Complications After Gynecologic Surgery

OBJECTIVE: To estimate the association of age, medical comorbidities, functional status, and unintentional weight loss (as a marker of frailty) with postoperative complications in women undergoing major gynecologic surgery. METHODS: We conducted a cross-sectional analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005–2009 participant use data files to analyze gynecologic procedures. The primary outcome was a composite of 30-day major postoperative complications. RESULTS: A total of 22,214 women were included in our final analysis. The overall prevalence of composite 30-day major postoperative complications was 3.7% (n=817). Age 80 years or older (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.25–2.58), dependent functional status (adjusted OR 2.37, 95% CI 1.53–3.68), and unintentional weight loss (adjusted OR 2.49, 95% CI 1.48–4.17) were significantly associated with postoperative morbidity after adjusting for diabetes mellitus (adjusted OR 1.44, 95% CI 1.15–1.79), known bleeding disorder (adjusted OR 2.29, 95% CI 1.49–3.52), morbid obesity (adjusted OR 1.77, 95% CI 1.45–2.17), ascites (adjusted OR 3.27, 95% CI 2.18–4.90), preoperative systemic infection (adjusted OR 3.02, 95% CI 2.03–4.48), procedures for gynecologic cancer (adjusted OR 1.60, 95% CI 1.27–2.0), disseminated cancer (adjusted OR 2.57, 95% CI 1.64–4.03), emergency procedures (adjusted OR 1.82, 95% CI 1.18–2.79), operative time more than 4 hours compared with less than 1 hour (adjusted OR 2.91, 95% CI 2.18–3.89), and wound class 4 compared with wound class 1 (adjusted OR 4.28, 95% CI 1.82–10.1). CONCLUSION: Age 80 years or older, medical comorbidities, dependent functional status, and unintentional weight loss are associated with increased major postoperative complications after gynecologic procedures. LEVEL OF EVIDENCE: III

The association between urinary and fecal incontinence and social isolation in older women

OBJECTIVE To describe the association between social isolation and urinary incontinence and fecal incontinence in older women. METHODS We conducted a secondary database analysis of the National Social Life, Health and Aging Project for women aged 57 to 85 years old. Our primary outcome was self-report of often feeling isolated. We explored self-report of daily urinary incontinence and weekly fecal incontinence. Two logistic regression analyses were performed to assess the association between often feeling isolated and (1) daily urinary incontinence and (2) weekly fecal incontinence. RESULTS A total of 1412 women were included in our analysis. Daily urinary incontinence was reported by 12.5% (177/1412) of community-dwelling older women. More women with daily urinary incontinence reported often feeling isolated (6.6%; 95% confidence interval [CI], 1.3-11.9 vs 2.6%; 95% CI, 1.7-3.5; P = .04) compared with women without daily urinary incontinence. Women with daily urinary incontinence had 3.0 (95% CI, 1.1-7.6) increased odds of often feeling isolated after adjusting for depressive symptoms, age, race, education, and overall health. Weekly fecal incontinence was reported by 2.9% (41/1412) of women. Weekly fecal incontinence and often feeling isolated were associated on univariable analysis (crude odds ratio, 4.6; 95% CI, 1.4-15.1). However, after adjusting for depressive symptoms, age, race, education, and overall health the association between weekly fecal incontinence and often feeling isolated was not significant (adjusted odds ratio, 0.65; 95% CI, 0.1-5.3; P = .65). CONCLUSION After adjusting for confounders, daily urinary incontinence was significantly associated with often feeling isolated. Weekly fecal incontinence was not found to be associated with often feeling isolated on multivariable logistic regression.

Surgical site infection after hysterectomy.

OBJECTIVE Our objective was to estimate the occurrence of surgical site infections (SSI) after hysterectomy and the associated risk factors. STUDY DESIGN We conducted a cross-sectional analysis of the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze hysterectomies. Different routes of hysterectomy were compared. The primary outcome was to identify the occurrence of 30-day superficial SSI (cellulitis) after hysterectomy. Secondary outcomes were the occurrence of deep and organ-space SSI after hysterectomy. Logistic regression models were conducted to further explore the associations of risks factors with SSI after hysterectomy. RESULTS A total of 13,822 women were included in our final analysis. The occurrence of postoperative cellulitis after hysterectomy was 1.6% (n = 221 women). Risk factors that were associated with cellulitis were route of hysterectomy with an adjusted odds ratio (AOR) of 3.74 (95% confidence interval [CI], 2.26-6.22) for laparotomy compared with the vaginal approach, operative time >75th percentile (AOR, 1.84; 95% CI, 1.40-2.44), American Society of Anesthesia class ≥ 3 (AOR, 1.79; 95% CI, 1.31-2.43), body mass index ≥40 kg/m(2) (AOR, 2.65; 95% CI, 1.85-3.80), and diabetes mellitus (AOR, 1.54; 95% CI, 1.06-2.24) The occurrence of deep and organ-space SSI was 1.1% (n = 154 women) after hysterectomy. CONCLUSION Our finding of the decreased occurrence of superficial SSI after the vaginal approach for hysterectomy reaffirms the role for vaginal hysterectomy as the route of choice for hysterectomy.

Urinary symptoms and impact on quality of life in women after treatment for endometrial cancer

The primary objective of our study is to describe urinary symptoms in women treated for endometrial cancer. We performed a cross-sectional survey of women who had undergone surgical treatment for endometrial cancer. Three validated questionnaires were utilized: the Sandvik Severity Index, the Urinary Distress Inventory-6 (UDI-6), and Incontinence Impact Questionaire-7 (IIQ-7). Our study included 70 women treated for endometrial cancer; 35.7% (25/70) of women reported adjuvant radiation therapy after surgical staging. Urinary incontinence was reported in over 80% of women. Mean UDI-6 and IIQ-7 scores for women treated with adjuvant radiation therapy were higher compared to women with no adjuvant radiation therapy [47(±26.8) vs. 35.6(±21.7; p = 0.05)] and [24.4(±28.5) vs. 8.1(±16.4; p = 0.004)], respectively. Treatment with adjuvant radiation therapy was associated with more severe incontinence symptoms and impact on quality of life.

The association between obesity and stage II or greater prolapse

OBJECTIVE We sought to evaluate the association between obesity and vaginal prolapse as well as pelvic organ prolapse symptoms. STUDY DESIGN This was a cross-sectional study of women referred for urogynecologic care. The exposure was obesity and outcome, stage>or=II prolapse. Secondary outcomes were symptom bother and disease-specific quality of life. RESULTS Our study included 721 women. No difference in stage>or=II prolapse was observed between obese (n/N 58/721 [35.8%]) and nonobese (n/N=463/721 [64.2%]) women (50.8% vs 52.7%; P=.62). Obesity was associated with increased distress on the Pelvic Floor Distress Inventory-20 (100 [+/-57.3] vs 87.4 [+/-53.1]; P=.003) due to higher scores on the Colorectal-Anal Distress Inventory-8 (22.9 [+/-21.5] vs 18.3 [+/-19.7]; P=.003) and the Urinary Distress Inventory-6 (48.8 [+/-27] vs 42.4 [+/-26.1]; P=.002). CONCLUSION Obesity was not associated with stage>or=II prolapse but was associated with increased pelvic floor symptoms secondary to urinary and anal incontinence subscales.

Morbidity of appendectomy and cholecystectomy in pregnant and nonpregnant women.

OBJECTIVE: To use the data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program to estimate major postoperative morbidity after 1) appendectomy in pregnant compared with nonpregnant women; and 2) cholecystectomy in pregnant compared with nonpregnant women. METHODS: We selected a cohort of reproductive-aged women undergoing appendectomy and cholecystectomy between 2005 and 2009 from the data files of the ACS National Surgical Quality Improvement Program. Outcomes in pregnant women were compared with those in nonpregnant women. The primary outcome was composite 30-day major postoperative complications. Pregnancy-specific complications were not assessed and thus not addressed. RESULTS: Pregnant and nonpregnant women had similar composite 30-day major morbidity after appendectomy (3.9% [33 of 857] compared with 3.1% [593 of 19,172], P=.212) and cholecystectomy (1.8% [eight of 436] compared with 1.8% [584 of 32,479], P=.954). Pregnant women were more likely to have preoperative systemic infections before each procedure. In logistic regression analysis, pregnancy status was not predictive of increased postoperative morbidity for appendectomy (adjusted odds ratio 1.26, 95% confidence interval 0.87–1.82). CONCLUSION: Pregnancy does not increase the occurrence of postoperative maternal morbidity related to appendectomy and cholecystectomy. LEVEL OF EVIDENCE: II

Oophorectomy: the debate between ovarian conservation and elective oophorectomy

AbstractOvarian cancer remains the fifth deadliest cancer among women because of its early asymptomatic nature and lack of efficacious screening methods, leading to frequent late-stage diagnosis. Elective oophorectomy is an option for women undergoing benign hysterectomy as a means of reducing their ovarian cancer risk. Benefits also include reduced risk of repeat surgical operation due to adnexal masses and reduced anxiety related to perceived risk of ovarian and breast cancer. The potential negative side effects of elective oophorectomy, such as decreased cognition and sexual function and increased risk of osteoporosis and cardiac mortality, offer support for ovarian conservation. The implications of this elective procedure and the possible consequences without it require physicians to review the pros and cons with patients in light of the patient’s individual circumstances and ovarian cancer risk.

Maternal postoperative complications after nonobstetric antenatal surgery

Objective: Our primary objective is to estimate the occurrence of major maternal 30 day postoperative complications after nonobstetric antenatal surgery. Methods: We analyzed the 2005–2009 data files from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for pregnant women undergoing nonobstetric antenatal surgery during any trimester of pregnancy as classified by CPT-4 codes. t Tests, χ2, logistic regression and other tests were used to calculate composite 30-day major postoperative complications and associations of preoperative predictors with 30 day postoperative morbidity. Results: The most common nonobstetric antenatal surgical procedure among the 1969 included women was appendectomy (44.0%). The prevalence of composite 30-day major postoperative complications was 5.8% (n = 115). This included (not exclusive categories): return to the surgical operating room within 30 days of surgery 3.6%, infectious morbidity 2.0%, wound morbidity 1.4%, 30 day respiratory morbidity 2.0%, venous thromboembolic event morbidity 0.5%, postoperative blood transfusion 0.2%, and maternal mortality 0.25%. Conclusion: Major maternal postoperative complications following nonobstetric antenatal surgery were low (5.8%). Maternal postoperative mortality was rare (0.25%).