Lisa Rogo-Gupta

The effect of surgeon volume on outcomes and resource use for vaginal hysterectomy.

OBJECTIVE: To estimate the effect of surgical volume on outcomes and resource use in women undergoing vaginal hysterectomy. METHODS: Women who underwent total vaginal hysterectomy and were registered in the Perspective database were examined. Perspective is a nationwide database developed to measure quality and resource use. Procedure-associated intraoperative, perioperative, and postoperative medical complications as well as hospital readmission, length of stay, intensive care unit (ICU) use, operating time, and cost were analyzed. Based on the overall gynecologic surgical volume and vaginal surgical volume of their surgeons, patients were stratified into tertiles. Complications were compared using adjusted generalized estimating equations and reported as odds ratios (ORs). RESULTS: A total of 77,109 patients operated on by 6,195 gynecologic surgeons were identified. After adjustment for the effects of other demographic variables and concomitant procedures, patients operated on by high-volume vaginal surgeons were 31% (OR 0.69; 95% confidence interval [CI] 0.59–0.80) less likely to experience an operative injury, whereas perioperative complications were reduced by 19% (OR 0.81; 95% CI 0.72–0.92), medical complications decreased by 24% (OR 0.76; 95% CI 0.67–0.86), ICU admission reduced by 46% (OR 0.56; 95% CI 0.43–0.73), and the transfusion rate decreased by 28% (OR 0.72; 95% CI 0.61–0.85) in patients treated by high-volume vaginal surgeons, whereas rates of readmission were higher (OR 1.24; 95% CI 1.04–1.47) in patients treated by high-volume surgeons. Operative times were lower in patients operated on by high-volume surgeons (P<.001). Although total gynecologic surgical volume had no effect on cost, patients treated by high-volume vaginal surgeons had lower costs (P<.001). CONCLUSION: Perioperative morbidity and resource use are lower in women undergoing vaginal hysterectomy when the procedure is performed by high-volume vaginal surgeons. LEVEL OF EVIDENCE: II

Trends in surgical mesh use for pelvic organ prolapse from 2000 to 2010.

OBJECTIVE: To describe trends in and predictors of surgical mesh use for pelvic organ prolapse (POP) repair and to estimate the influence of safety advisories on mesh use. METHODS: Analysis of women aged 18 years and older recorded in a health care quality and resource utilization database who underwent POP repair from 2000 to 2010, identified by International Classification of Diseases, 9th Revision, Clinical Modification procedure codes, and stratified by mesh use. Odds ratios were calculated with adjustments for patient, physician, and hospital-level characteristics. RESULTS: Among 273,275 women in the cohort, 64,968 (23.8%) underwent a mesh-augmented repair. Concurrent incontinence surgery was a strong predictor of mesh use (odds ratio [OR] 9.95; 95% confidence interval [CI] 9.70–10.21). Mesh use increased from 7.9% in 2000 to a peak of 32.1% in 2006, and declined slightly to 27.5% in 2010. Among women without incontinence, mesh use increased from 3.3% in 2000 to 13.5% in 2006, and remained stable at 12.8% in 2010. Intermediate-volume (OR 1.53; 95% CI 1.44–1.62) and high-volume (OR 2.74; 95% CI 2.58–2.92) surgeons were more likely to use mesh than low-volume surgeons. Compared with women who underwent operation by gynecologists, those treated by urologists were more than three times more likely to undergo mesh-augmented prolapse repair (OR 3.36; 95% CI 3.09–3.66). Black women were 27% less likely to undergo mesh repair (OR 0.73; 95% CI 0.66–0.82). CONCLUSIONS: Mesh-augmented prolapse repairs increased substantially over the past decade, and this increase was most pronounced in the years before the publication of safety advisories. Physician specialty and surgical volume are important factors underlying mesh use. Additional measures must ensure evidence-based use of mesh for pelvic reconstruction. LEVEL OF EVIDENCE: II

Symptom Improvement After Prolapse and Incontinence Graft Removal in a Case Series of 306 Patients.

Objectives We report our experience with removal of synthetic and biologic implants used in pelvic reconstruction in a tertiary referral center from 2005 to 2012. Methods We performed a retrospective cohort study of all consecutive patients who underwent surgical implant removal for treatment of implant-related complications. Symptoms were determined by patient self-assessment including validated questionnaires. One hundred seventy-nine patients completed follow-up. Results Three hundred six patients underwent removal for exposure or erosion (57%), pain (46%), and urinary symptoms or incontinence (54%). Ninety patients (29%) had previous revision. Eleven percent had pelvic organ prolapse (POP) implants, 48% had sling implants, and 41% had both implants. Mean time from removal to follow-up was 2 years (median, 2 years; range, <1–7). The majority of patients experienced symptom improvement after implant removal. Seventy-eight percent of those with pain reported pain improvement, 9% reported no change, and 14% experienced worsening. Symptom improvement was reported by 79% of those who underwent removal of a POP implant alone, 79% of those who underwent removal of POP and sling implants, and 83% of those who underwent removal of a sling alone. Quality of life was significantly improved after implant removal overall (P < 0.05) for those who underwent removal of POP and slings, and slings alone, but not for those with POP removal only. Conclusions Pain is among the most common symptoms reported in women referred to our institution for implant-related complications. In a series of 306 complex patients with a range of implants and symptoms, removal improved implant-related pain in the majority of patients.

Long-Term Durability of the Distal Urethral Polypropylene Sling for the Treatment of Stress Urinary Incontinence: Minimum 11-Year Followup

PURPOSE We report on the long-term outcomes of the distal urethral polypropylene sling for stress urinary incontinence in a patient cohort that was closely followed and whose outcomes were reported at 1 and 5 years after surgery. MATERIALS AND METHODS We performed a prospective study of all consecutive patients who underwent a distal urethral polypropylene sling procedure between November 1999 and April 2000. The 1 and 5-year outcomes for this particular patient cohort were previously reported. At the minimum 11-year followup, outcome was determined by patient self-assessment including validated questionnaires. RESULTS A total of 69 patients were followed prospectively and followup was obtained for 30. Of those lost to followup 10 were deceased and 5 were cognitively impaired. Mean patient age at followup was 73 years (range 40 to 97). More than 11 years after surgery 48% of patients reported no stress urinary incontinence symptoms and 63% were never bothered by stress urinary incontinence. Patients reported a mean overall symptom improvement of 64% compared to 81% at 5 years. Overall 82% of patients met the criteria for treatment success by symptom scores and 80% met the criteria by bother scores. CONCLUSIONS The distal urethral polypropylene sling procedure has excellent long-term durability in the treatment of stress urinary incontinence, in addition to low morbidity and low cost as previously described. Eleven years after the procedure the majority of patients report symptom improvement. Nevertheless, many older patients are unable to participate in followup. When choosing an anti-incontinence procedure, durability should be considered in light of patient age given that the theoretical advantages of long-term durability are limited by cognitive decline and mortality.

Long-term symptom improvement and overall satisfaction after prolapse and incontinence graft removal.

Objectives We report long-term symptom improvements and overall satisfaction in patients after removal of grafts used in pelvic reconstruction in a tertiary referral center. Methods We analyzed patients who underwent graft removal for treatment of related complications and who were followed for at least 2 years. Symptoms were determined by patient self-assessment questionnaires. Results Seventy-nine patients underwent partial or complete graft removal from 2005 to 2011 and met inclusion criteria. The mean follow-up time was 4.0 years (median, 3.4 years; range, 2.0–7.6 years). Forty-seven percent (37 patients) had implants for both prolapse and incontinence, 40% (32 patients) had incontinence implants only, and 13% (10 patients) had prolapse implants only. Thirty percent of those with both implants presented with multiple symptoms compared to 50% of those with prolapse implants and 44% of those with incontinence implants only. At follow-up, 75% (56 patients) reported that their symptoms were better and 15% (11 patients) reported that their symptoms were worse. Of patients who underwent graft removal for pain alone, 74% (17 patients) improved whereas17% (4 patients) were worse. When asked about spending the rest of their lives with their current symptoms, 49% (38 patients) reported positively whereas 44% (34 patients) reported negatively. Forty-one patients underwent one or more additional treatments. Conclusions Graft-related complications are often treated with surgical excision. In a cohort of 79 patients in whom implants were removed an average of 4 years earlier, 75% still report symptom improvement and 49% report good quality of life. However, many patients still feel dissatisfied and sought additional treatment during long-term follow-up. These data can be used to counsel patients considering removal of pelvic reconstruction grafts.

Current trends in surgical repair of pelvic organ prolapse.

PURPOSE OF REVIEW Over the past decade, surgical prolapse correction has evolved significantly, taking a sharp turn in 2011 when the USFDA publicly questioned synthetic graft safety. This controversy has been widely publicized and debated amongst laymen and experts alike. This review summarizes current trends in mesh implantation for prolapse repair, highlighting the impact of the current controversy. RECENT FINDINGS Recent studies revealed nonmesh prolapse repair may have better outcomes than previously reported; the USFDA states there is insufficient evidence to support vaginal mesh for apical or posterior compartment prolapse; mesh prolapse repair increased over the past decade, 75% of which was placed vaginally; approximately 30% of mesh prolapse repair is performed with hysterectomy and approximately 40% is performed with concomitant incontinence repair. Anterior and apical prolapse are most likely to include mesh and of apical repair procedures, minimally invasive approaches exceed laparotomy. SUMMARY This years population-based studies describe the impact of surgeon experience, prolapse compartment, and national trends in surgical technique on mesh prolapse repair. The impact of the recent investigation on future mesh use remains unknown.

Missed diagnosis of complete urethral transection after sling: the case for translabial ultrasound.

Abstract Patients with complications of urethral sling placement for stress urinary incontinence are often treated for recurrent symptoms for years after initial reassuring evaluation. Translabial ultrasound is a noninvasive modality with minimal risks that can clearly diagnose urethral mesh complications. We present a 47-year-old premenopausal woman referred for treatment of urethral stricture and diverticulum 8 years after mesh sling placement. The diagnosis was made at an outside institution by voiding cystourethrogram and cystoscopy. However, translabial ultrasound confirmed the diagnosis of complete urethral transection, and the patient underwent a complex urethral reconstruction. Ultrasound should be used to evaluate patients with a history of urethral sling and persistent lower urinary tract symptoms. Referral to a center with advanced pelvic reconstruction services may be required.

Foreign body in the bladder 11 years after intravaginal pessary

Vaginal pessaries used for symptomatic pelvic organ prolapse (POP) rarely develop complications when regularly monitored. However, many reports of complications of neglected pessaries have been described. Patients presenting with pessary complications report a variety of symptoms ranging from malodorous discharge or recurrent infections to more severe symptoms such as vaginal bleeding, complete urinary incontinence, or defecatory obstruction. Complete pessary encapsulation within the bladder is rare. We present the case of a 79-year-old postmenopausal woman referred to a tertiary care center for treatment of a large intravesical foreign body 11 years after pessary placement. The patient successfully underwent minimally invasive surgery to remove the foreign body and repair the bladder defect. Physicians should have a low threshold for diagnostic imaging in patients presenting with unclear history. Large intravesical foreign bodies can be removed by a vaginal approach with good outcomes.

Where do Women go for Revision Surgeries? Geographic Migration Patterns after Urethral Sling Placement in California

Introduction: Although long‐term rates of sling revision after urethral sling placement have been well studied, details of these revisions have not been addressed. In this study we explore the timing, location and migration of patients from one facility to another for revision procedures. Methods: Using data from the Office of Statewide Health Planning and Development (OSHPD) for the state of California (2005 to 2011), all females who underwent index outpatient urethral sling procedures at nonfederal facilities were identified (CPT 57288). Cases requiring eventual sling revision or urethrolysis were subsequently identified. Location, distance traveled and factors associated with seeking a new facility for revision were explored. Results: Of the 44,605 patients undergoing urethral sling surgery 842 (1.9%) underwent sling revision, with 178 (22.5%) at a new facility. Facilities in the top 10% of surgical volume placed 41% of the slings and performed more than 50% of revisions. Patient proximity to multiple facilities and increased time between procedures were associated with an increased odds of changing facilities for revision (OR 2.11, p <0.0001 and OR 1.05 per month, p <0.0001, respectively). Placement at a high volume center was associated with decreased odds of changing facilities for revision (OR 0.32, p <0.0001). Patients migrated toward larger centers in urban areas for revision. Conclusions: Overall 78% of sling revisions are performed at the facility where the initial placement was performed. This suggests that the majority of facilities where urethral slings are placed also have the capability of sling revision surgery.

How Dry is “OAB-Dry”?: Perspectives from Patients and Physician Experts

PURPOSE Overactive bladder is subtyped into overactive bladder-wet and overactive bladder-dry, based on the presence or absence, respectively, of urgency incontinence. To better understand patient and physician perspectives on symptoms among women with overactive bladder-wet and overactive bladder-dry, we performed patient focus groups and interviews with experts in urinary incontinence. MATERIALS AND METHODS Five focus groups totaling 33 patients with overactive bladder symptoms, including 3 groups of overactive bladder-wet and 2 groups of overactive bladder-dry patients, were conducted. Topics addressed patient perceptions of overactive bladder symptoms, treatments and outcomes. A total of 12 expert interviews were then done in which experts were asked to describe their views on overactive bladder-wet and overactive bladder-dry. Focus groups and expert interviews were transcribed verbatim. Qualitative data analysis was performed using grounded theory methodology, as described by Charmaz. RESULTS During the focus groups sessions, women screened as overactive bladder-dry shared the knowledge that they would probably leak if no toilet were available. This knowledge was based on a history of leakage episodes in the past. Those few patients with no history of leakage had a clinical picture more consistent with painful bladder syndrome than overactive bladder. Physician expert interviews revealed the belief that many patients labeled as overactive bladder-dry may actually be mild overactive bladder-wet. CONCLUSIONS Qualitative data from focus groups and interviews with experts suggest that a spectrum exists between very mild overactive bladder-wet and severe overactive bladder-wet. Scientific investigations are needed to determine whether urgency without fear of leakage constitutes a unique clinical entity.