Sallie S. Oliphant

Trends in stress urinary incontinence inpatient procedures in the United States, 1979-2004

OBJECTIVE The purpose of this study was to describe national trends in surgery for female stress urinary incontinence (SUI). STUDY DESIGN We used data from the National Hospital Discharge Survey, a federal dataset sampling patient discharges from US inpatient hospitals. We analyzed patient and hospital demographics and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) diagnostic and procedures codes for 1979-2004. Age-adjusted rates per 1000 women were calculated with 1990 US Census population data. RESULTS The number of women who have undergone SUI surgery each year increased from 48,345 in 1979 to 103,467 in 2004. In women > or = 52 years old, the age-adjusted rate more than doubled from 0.64-1.60 procedures per 1000 women; in women < 52 years old, the age-adjusted rate fell from 0.57-0.47. Age-adjusted rates for retropubic urethral suspension (ICD-9-CM, 59.5) fell from 0.37 in 1979 to 0.14 in 2004. For suprapubic sling procedures (ICD-9-CM, 59.4), the age-adjusted rates rose from 0.02 in 1979 to a peak of 0.10 in 1997 and then fell to 0.03 in 2004. Age-adjusted rates for other repair of urinary stress incontinence (ICD-9-CM, 59.79) rose from 0.06 in 1979 to 0.64 in 2004. CONCLUSION The number of women who have undergone SUI surgery increased significantly from 1979-2004. Because the National Hospital Discharge Survey data do not include ambulatory procedures, accurate information on same-day surgeries is unavailable. Currently no ICD-9-CM procedure code exists specifically for midurethral sling procedures. Both missed sampling of same-day procedures and nonspecific or inaccurate coding may explain the surprising decline in suprapubic sling procedures and the rise in rates of other repair of SUI. A national ambulatory surgical database and a specific code for midurethral sling are needed to capture these important data.

Trends in inpatient prolapse procedures in the United States, 1979-2006.

OBJECTIVE We sought to describe national trends for inpatient procedures for pelvic organ prolapse from 1979-2006. STUDY DESIGN The National Hospital Discharge Survey was analyzed for patient and hospital demographics, as were International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedures codes from 1979-2006. Age-adjusted rates (AARs) per 1000 women were calculated using the 1990 US Census data. RESULTS There was a significantly decreasing trend in the AARs for inpatient prolapse procedures, from 2.93-1.52 per 1000 women from 1979-2006. AARs for hysterectomy decreased from 8.39-4.55 per 1000 women from 1979-2006. Over the study period, AARs remained at about the 1979 level among the women>or=52 years old (2.73-2.86; P=.075). In women<52 years old, AARs declined to less than one-third of the 1979 rate (3.03-0.84; P<.001). CONCLUSION AARs for inpatient procedures for prolapse in the United States remained stable for women aged>or=52 years from 1979-2006; rates declined by two-thirds for women aged<52 years.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures.

OBJECTIVES: To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a womans lifespan. METHODS: Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed. RESULTS: More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a womans lifetime. CONCLUSION: Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women. LEVEL OF EVIDENCE: III

Prophylactic bilateral oophorectomy or removal of remaining ovary at the time of hysterectomy in the United States, 1979-2004

OBJECTIVE The purpose of this study was to describe national rates and trends of prophylactic bilateral oophorectomy or remaining oophorectomy (BO/RO) at hysterectomy in women without specific gynecologic disease. STUDY DESIGN Data from the National Hospital Discharge Survey were analyzed for 1979-2004. Hysterectomies were divided into 2 groups: (1) hysterectomy with BO/RO and (2) hysterectomy alone (> or =1 ovary remaining). Age-adjusted rates (AARs) were calculated with 2000 US census data. RESULTS Approximately 3,686,000 hysterectomies with BO/RO were performed from 1979-2004. AARs of hysterectomy with BO/RO decreased during this period; the AARs in women > or =50 years old increased. The number of hysterectomies alone was 5,461,100, and AARs of hysterectomy alone decreased significantly from 2.9 per 1000 women in from 1979-1981 to 1.1 per 1000 women in 2001 (P < .001). The proportion of women who underwent hysterectomy with BO/RO increased from 29% in 1979 to 45% in 2004. CONCLUSION Although AARs of prophylactic BO/RO decreased from 1979-2004, the actual proportion of BO/RO at hysterectomy increased.

Management of recurrent stress urinary incontinence after burch and sling procedures

To examine treatment options selected for recurrent stress urinary incontinence (rSUI) in follow‐up after Burch, autologous fascial and synthetic midurethral sling (MUS) procedures.

Effect of a preoperative self-catheterization video on anxiety: a randomized controlled trial

Introduction and hypothesisThe purpose of this study was to determine if a clean intermittent self-catheterization (CISC) instructional video could improve anxiety in women undergoing prolapse and/or incontinence surgery.MethodsA total of 199 women were randomized to preoperative CISC video or routine counseling prior to prolapse/incontinence surgery. Patient anxiety, satisfaction, and concerns about CISC were evaluated using the State-Trait Anxiety Inventory-State (STAI-S) and study-specific visual analog scale (VAS) questions at four perioperative time points.ResultsSTAI-S and VAS anxiety measures were similar at baseline between groups; no significant differences were seen by group at any time point. STAI-S scores varied considerably over time, with highest scores at voiding trial failure and lowest scores at postoperative visit. Women in the video group had improved STAI-S scores and reported less worry and more comfort with CISC immediately following video viewing. Women with anxiety/depression had higher STAI-S scores at voiding trial failure and discharge and reported less anxiety reduction following video viewing compared to non-anxious/non-depressed peers.ConclusionsWomen undergoing prolapse/incontinence surgery have significant perioperative anxiety, which is exacerbated by voiding trial failure. Preoperative CISC video viewing decreases anxiety scores immediately following viewing, but this effect is not sustained at voiding trial failure. Women with baseline anxiety/depression exhibit less anxiety score improvement after video viewing and have overall higher anxiety scores perioperatively.

Midurethral sling for treatment of occult stress urinary incontinence at the time of colpocleisis: a decision analysis.

Objective The objective of this study was to estimate optimal timing for treatment of occult stress urinary incontinence in women undergoing colpocleisis using decision analysis methodology. Methods A decision tree was constructed comparing concomitant versus staged midurethral slings (MUSs). Simple roll-back methodology was used to determine average 1-year utilities of the compared approaches. Results One-year overall utility favored the staged approach to treating occult incontinence (0.945 vs 0.908) at time of colpocleisis. However, this difference was less than the accepted minimally important difference for utilities. Multiple 1-way sensitivity analyses of all utilities and probabilities identified few thresholds, confirming model robustness. In our model, only 22.5% of women in the staged group ultimately underwent MUS. Conclusions Staged and concomitant MUSs have similar overall utilities. Both strategies are clinically reasonable, and surgical decision making should be tailored to individual patient needs and preferences. In our model, a staged approach greatly reduces the number of MUS performed.

Sleep quality in women seeking care for pelvic organ prolapse

OBJECTIVES To identify the prevalence of sleep disturbance in women seeking treatment for pelvic organ prolapse (POP) and identify correlates of poor sleep quality in this population by using a validated sleep scale. STUDY DESIGN This is a cohort study of female patients with pelvic organ prolapse. MAIN OUTCOME MEASURES Pittsburgh Sleep Quality Index (PSQI), Pelvic Floor Disorders Inventory (PFDI), and Pelvic Floor Impact Questionnaire (PFIQ) measures were completed. Demographic data, medical comorbidities, medications, and physical examinations were also recorded. RESULTS 407 Women were enrolled. Analysis was performed on the 250 subjects who completed all PSQI components. Subjects were predominantly white, with a mean age of 61 ± 11 years and mean BMI of 28 ± 5 kg/m(2). The majority (71%) had Stage III prolapse. Half (N=127) had poor sleep quality (PSQI > 5). Women with poor sleep quality were younger, had more medical comorbidities, more pelvic floor symptoms, more nocturia, more depressive symptoms, and took more time to fall asleep. Factors associated with sleep quality were evaluated using multivariable linear regression models. Worse sleep scores were associated with each of the PFDI subscores (urinary, prolapse, bowel), depressive symptoms, severe nocturia symptoms, and number of comorbidities. CONCLUSIONS Poor sleep is prevalent in women with prolapse. Pelvic floor symptoms as measured by PFDI sub-scales, were associated with poor sleep quality. Future studies are needed to better understand how sleep disturbances may contribute to the impact of pelvic floor symptoms on quality of life.

Feasibility of prophylactic salpingectomy during vaginal hysterectomy

BACKGROUND: The American Congress of Obstetricians and Gynecologists recommends that “the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy,” resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy. OBJECTIVE: The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms. STUDY DESIGN: This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow‐up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and χ2 test when appropriate. Questionnaire scores were compared using paired t tests. RESULTS: Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5–5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5–22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001). CONCLUSION: Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible.

Body Image in the Pelvic Organ Prolapse Questionnaire: development and validation

OBJECTIVE The purpose of this study was to develop and validate a prolapse-specific body image questionnaire. STUDY DESIGN Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability. RESULTS Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbachs α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high. CONCLUSION We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.