Kris Strohbehn

Duloxetine compared with placebo for treating women with symptoms of overactive bladder

To evaluate duloxetine (a serotonin‐noradrenaline reuptake inhibitor) in women with symptoms of overactive bladder (OAB), as it has been shown to increase the bladder capacity in an animal model.

Functional disability and compromised mobility among older women with urinary incontinence.

Objective Our objective was to determine the prevalence of functional disability among older women with urinary incontinence (UI). Methods We conducted a secondary analysis of the 2005–2006 National Social Life, Health and Aging Project. Daily UI was defined as answering “daily” to the question, “How frequently…have you had difficulty controlling your bladder, including leaking small amounts of urine, leaking when you cough or sneeze, or not being able to make it to the bathroom on time?” We then explored functional status. Women were asked about 7 basic activities of daily living (ADLs). Statistical analyses with percentage estimates and 95% confidence intervals (CIs) were performed. Logistic regression was performed to assess the association between functional status and daily UI. Results In total, 1412 women were included in our analysis. Daily UI was reported by 177 (12.5%) women. Functional dependence or disability with any activities of daily living was reported in 62.1% (95% CI, 54.2%–70.1%) of women with daily UI. Among women with daily UI, 23.6% (95% CI, 16.8%–30.5%) reported specific difficulty or dependence with using the toilet, signifying functional limitations which may contribute to urine leakage. After adjusting for age category, race/ethnicity, education level, and parity, women with daily UI had 3.31 increased odds of functional difficulty or dependence compared with continent older women. Conclusions More than 60% of older women with daily UI reported functional difficulty or dependence and one fourth of women with daily UI specifically reported difficulty or dependence with using the toilet.

Major postoperative complications following surgical procedures for pelvic organ prolapse: a secondary database analysis of the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND: Surgical approaches to the correction of pelvic organ prolapse include abdominal, vaginal, and obliterative approaches. These approaches require vastly different anatomical dissections, surgical techniques, and operative times and are often selected by the patient and surgeon to match preoperative multimorbidity and ability of the patient to tolerate the stress of surgery. OBJECTIVE: We sought to describe the occurrence of postoperative complications occurring after 3 different surgical approaches to treat pelvic organ prolapse: vaginal, abdominal, and obliterative. STUDY DESIGN: We conducted a secondary database analysis of the 2006 through 2014 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze patients undergoing procedures for pelvic organ prolapse based on Current Procedural Terminology codes. Women were categorized into 3 surgical approaches to prolapse: vaginal, abdominal, and obliterative. Concomitant hysterectomy and sling were also examined. The primary outcome was a composite of 30‐day major postoperative complications. RESULTS: A total of 33,416 women were included in our final analysis: 24,928 vaginal procedures, 6834 abdominal (4461 minimally invasive) procedures, and 1654 obliterative procedures. Concomitant hysterectomies and slings were performed in 17,380 (52.0%) and 10,896 (32.6%) of prolapse procedures. The overall prevalence of composite 30‐day major postoperative complications was 3.1% (n/N = 1028/33,416). There were 13 perioperative deaths (0.04%) with no difference in the surgical approaches (P = .55). There were no differences in major postoperative complications between vaginal and abdominal procedures (3.0% vs 3.0%; P = .71). Women undergoing obliterative procedures had an occurrence of major postoperative complications of 5.0% (n/N = 83/1654), P < .001. CONCLUSION: The occurrence of major postoperative complications after prolapse surgery is rare. We did not find a significant difference in major postoperative complications between vaginal and abdominal surgeries for pelvic organ prolapse. In this well‐characterized cohort of patients who self‐selected surgical approach, women undergoing obliterative surgery had more postoperative complications, likely attributed to increased age and multimorbidity.

24: 30-day postoperative complications following surgical procedures for pelvic organ prolapse: A secondary analysis of the ACS NSQIP database

24 30-day postoperative complications following surgical procedures for pelvic organ prolapse: A secondary analysis of the ACS NSQIP database E. Erekson, R. Murchison, K. A. Gerjevic, V. T. Meljen, K. Strohbehn Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Bedford, NH OBJECTIVES: To compare the occurrence of postoperative complications, surgical site infections (SSI) and urinary tract infections (UTI) between three surgical approaches to treat pelvic organ prolapse (POP). MATERIALS AND METHODS: We conducted a secondary database analysis of the 2006-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data files to analyze women undergoing procedures for POP based on current procedural terminology (CPT) codes. Women were categorized into 3 surgical approaches to POP: vaginal, abdominal, and obliterative. Concomitant hysterectomy and sling were also examined. The primary outcome was a composite of 30-day major postoperative complications, including: death, cardiac arrest, myocardial infarction, stroke, pneumonia, sepsis, septic shock, prolonged ventilation >48 hours, unplanned re-intubation, wound dehiscence, deep/organ-space SSI, perioperative blood transfusion, and unplanned return to the operating room. Our secondary outcome was 30-day composite postoperative infection including organ-space SSI, deep would SSI, superficial SSI and UTIs. RESULTS: A total of 33,416 women were included in our final analysis: 24,928 vaginal procedures, 6,834 abdominal (4,461 minimally-invasive) procedures, and 1,654 obliterative procedures. Concomitant hysterectomies and slings were performed in 17,380 (52.0%) and 10,896 (32.6%) of POP procedures. Women undergoing obliterative procedures were older with increased preoperative multi-morbidity. Abdominal procedures had the longest mean operating times (min [ SD]) compared to vaginal and obliterative procedures (187 [ 87] vs. 105 [ 63] vs. 108 [ 67], p < 0.001). The overall prevalence of composite 30-day major postoperative complications was 3.1% (n 1⁄4 1,028). There were 13 perioperative deaths (0.04%) with no difference in the surgical approaches (p 1⁄4 0.55). There were no differences in major postoperative complications between vaginal and abdominal procedures (3.0% vs 3.0%, p 1⁄4 0.71). Women undergoing obliterative procedures had an occurrence of major postoperative complications of 5.0% (n 1⁄4 83, p < 0.001). Concomitant hysterectomies (3.5% vs 2.6%, p < 0.001) and concomitant slings (3.5% vs 2.9%, p 1⁄4 0.001) increased the occurrence of postoperative complications. Concomitant hysterectomies doubled the occurrence of 30-day SSI (0.75% vs 0.32%, p < 0.001) but did not change postoperative UTIs (4.3% vs 4.2%, p 1⁄4 0.74). Concomitant slings did not change the occurrence of 30-day SSI (0.58% vs 0.47%, p 1⁄4 0.21) but increased the occurrence of postoperative UTIs (5.5% vs 3.5%, p < 0.001). CONCLUSION: The occurrence of major postoperative complications after POP surgery is rare, but increases with increasing age category.

Frailty, Cognitive Impairment, and Functional Disability in Older Women With Female Pelvic Floor Dysfunction

Frailty is common in the elderly. It is characterized by increased vulnerability to stressors such as extreme heat or cold, falls, infection, and surgery. There are no consistent definitions of frailty, and different inclusion and exclusion criteria have been used. A large proportion of elderly develop the frailty syndrome, which is predictive for a constellation of adverse outcomes in community-dwelling individuals, including long-term nursing home stay, injurious falls, and death. It is becoming increasingly clear that frailty is also an important predictor of adverse surgical outcomes in elderly patients undergoing major procedures requiring admission to intensive care units. In addition to routine assessment prior to surgery, both the American College of Surgeons and the American Geriatrics Society have recommended that older patients be evaluated for frailty, cognitive ability, and functional status. Since the onset of female pelvic floor dysfunction (PFD) symptoms in women is age related, a high prevalence of frailty in elderly women seeking treatment for PFD could impact the risks and benefits of different treatment options. The primary aim of this prospective cross-sectional study was to determine the prevalence of frailty, cognitive impairment, and functional disability among older women seeking treatment for PFD. Community-dwelling older women, 65 years or older, were enrolled at the conclusion of their new patient consultation for PFD at a tertiary center between September 2011 and September 2012. Comprehensive geriatric screening was performed as follows: frailty was assessed using the Fried Frailty Index; cognitive screening was performed using the Saint Louis University Mental Status examination, and functional status for activities of daily living (ADLs) was evaluated according to Katz’s classification (Katz ADL score). The Fried Frailty Index score categorized 17% (n/N = 25/150) of women as frail. After adjusting the data for education level, 21.3% of women (n/N = 32/150) screened positive for dementia, and 30.7% (46/150) reported functional difficulty or dependence in performing at least 1 Katz ADL. At the conclusion of the new patient visit with a physician, 46% (64/150) of the women in the study chose surgical options for treatment of their PFD. These findings demonstrate that frailty, cognitive impairment, and functional disability are prevalent among older women seeking treatment for PFD.

Anticipating pitfalls in surgery: preparing the mind to see.

T eyes cannot see what the mind does not know” was a favorite saying of the late A. Cullen Richardson, MD. Dr. Richardson maintained a keen eye and mind throughout his career. Even late in his career, he often animatedly reported to colleagues about new discoveries during his careful prosections in the cadaver laboratory. Gynecologic surgeons and their patients face many challenges when considering complex gynecologic surgery, including procedures for pelvic support disorders. Featured in this journal are two case reports of operations performed for pelvic support disorders, describing rare events that the surgeons had not seen before (see p. 436 and p. 438).1,2 The surgeons’ training and intuition allowed them to correctly identify a solution, confirming Cullen Richardson’s favorite idiom. These case reports remind us of potential pitfalls and challenges inherent in any surgery: one report identifies the importance of understanding anatomic variation in surgery, reviewing a potentially lifethreatening anomaly of the vena cava encountered during mesh sacral colpopexy1; the second reviews potential risks of using permanent surgical materials in surgery, describing perianal fistulae that developed in two patients remote from their index procedures, after vaginal and uterine fixation to the sacrospinous ligament with permanent sutures.2 Surgeons face many challenges in their efforts to provide safe and efficacious outcomes for their patients. Optimal outcomes depend on many factors, including aligning patients’ goals with surgeons’ goals. Functional outcomes depend on many complex factors, including the integrity of patients’ connective tissues, intact neuromuscular function, and the patients’ abilities to rehabilitate. Unique to pelvic reconstructive surgery, the function of one organ, such as bladder continence, may be altered by changing the support of an adjacent organ, such as a prolapsed vagina. Recognizing these differences in condition-specific operations is important when counseling patients before taking them to the operating room. Many new strategies have recently been introduced to mitigate surgical complications. Some of these successful strategies recently have been detailed in wonderful prose by the author and surgeon Atul Gawande in his books, Complications,3 Better,4 and The Checklist Manifesto.5 Strategies include risk-reducing checklists, confirming proper site for surgery, correct patient identification, and administering appropriate prophylactic antibiotics and anticoagulation medications for high-risk procedures. These relatively simple, yet powerful strategies have been shown to reduce wrong-site surgery, perioperative infections and thromboembolic events, and improve patient safety.6 These tools reinforce the goals every surgeon strives to achieve:

Urodynamic leak point pressures weakly correlate with subjective urinary incontinence severity

To evaluate preoperative abdominal leak point pressures (ALPP) with pre‐ and postoperative Incontinence Severity Index (ISI) scores.