Sarah F. Faris

The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes

OBJECTIVE To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs. METHODS We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs. RESULTS There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%). CONCLUSION Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.

30-Day Morbidity and Reoperation Following Midurethral Sling: Analysis of 8772 Cases Using a National Prospective Database

OBJECTIVE To determine 30-day complications, risk of readmission, and reoperation for midurethral slings (MUS). METHODS The National Surgical Quality Improvement Program database from 2006 to 2013 was queried for MUS alone by excluding concurrent reconstructive, urologic, or gynecologic procedures. We assessed baseline characteristics, 30-day perioperative outcomes and 30-day readmission. Logistic regression analysis identified risk factors for the frequent complications. RESULTS There were 8772 women who underwent MUS, of which 3830 (43.7%) and 4942 (56.3%) were performed by urologists and gynecologists, respectively. Patients of urologists were older, had higher frailty, and were more likely diabetic (all P < .05). Patients of gynecologists were more likely to have resident involvement compared to urologists (16.4% vs 11.2%, P < .001). Mean operative time was shorter for urologists compared to gynecologists (35.6 ± 29.2 minutes vs 38.1 ± 34.3 minutes, P < .001). The overall 30-day rate of any complication was 3.52%. Urinary tract infection (UTI) occurred in 2.2% vs 3.5% of the urologic and gynecologic patients, respectively (P=.001). After adjusting for frailty, body mass index, steroid use, age, operative time, and residency involvement, gynecologic performed surgery incurred an increased risk of UTI (OR 1.67, 95% CI 1.27-2.19; P=.001). Sixty-five (0.90%) patients were readmitted within 30 days, most commonly due to urinary symptoms. Sling revision for urinary obstruction occurred in 15 patients; 10 underwent repair of the bladder, urethra, or vagina. CONCLUSION To our knowledge, we present the largest American cohort of MUS 30-day outcomes to date, stratified by specialty of performing surgeon. Overall, morbidity is low. UTI is the most common complication, and occurs at increased frequency for patients of gynecologists.

Open Vs Minimally Invasive Adult Ureteral Reimplantation: Analysis of 30-day Outcomes in the National Surgical Quality Improvement Program (NSQIP) Database

OBJECTIVE To examine 30-day outcomes of robotic-assisted and pure laparoscopic ureteral reimplantation (LUR) vs open ureteral reimplantation (OUR) in adult patients for benign disease. METHODS We identified adult patients undergoing LUR or OUR by urologists between 2006 and 2013 using the American College of Surgeons National Surgical Quality Improvement Program database, excluding those with concomitant partial cystectomy or ureterectomy. Multivariable regression modeling was used to assess for the independent association of minimally invasive surgery (MIS) with 30-day complications, reoperations, or readmissions. RESULTS Of 512 patients identified, 300 underwent LUR and 212 underwent OUR. Baseline characteristics including age, race, body mass index, and cardiovascular comorbidities were similar between LUR and OUR (all P > .05). Patients who underwent LUR had higher median preoperative serum creatinine (1.1 mg/dL vs 1.0 mg/dL, P = .03), increased presence of a resident (51% vs 34%, P < .01), and shorter hospitalization (1 [interquartile range 0-3] days vs 4 [interquartile range 3-6] days, P < .01) compared to patients who underwent OUR. LUR had lower overall complications (9% vs 28%, P < .01), especially with regard to transfusions (1% vs 11%, P < .01), superficial wound infections (0% vs 5%, P < .01), and urinary tract infections (5% vs 11%, P = .03). On multiple regression analyses, MIS was an independent predictor of lower overall complication rate (odds ratio [OR] 0.24 [0.14-0.40], P < .01), but was not predictive of readmission (OR 0.93 [0.44-1.98], P = .16) or reoperation (OR 2.09 [0.90-4.82], P = .10). CONCLUSION In the largest current series assessing the impact of MIS on adult ureteral reimplantation, data from the National Surgical Quality Improvement Program demonstrate that LUR results in decreased 30-day complications.

Thirty-day Morbidity of Abdominal Sacrocolpopexy Is Influenced by Additional Surgical Treatment for Stress Urinary Incontinence

OBJECTIVE To assess the impact of concurrent anti-incontinence procedure (AIP) at time of abdominal sacrocolpopexy (ASC) on 30-day complications, readmission, and reoperation. METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 was queried to identify patients who underwent ASC with or without AIP. We assessed baseline characteristics and 30-day perioperative outcomes including complications, readmission, and reoperation. RESULTS There were 4793 patients who underwent ASC, of whom 1705 underwent concurrent AIP (35.6%). The majority of patients (4414, 92.1%) were treated by a gynecologist, but those treated by a urologist were older, had higher American Society of Anesthesiologists (ASA) class, and had increased frailty. Rates of 30-day postoperative urinary tract infection (UTI) and overall complication were higher among women who underwent concurrent AIP (4.75% vs 2.33%, P <.001; 7.74% vs 6.02%, P = .02). On multivariate analysis controlling for age, body mass index, approach, ASA physical status, modified frailty index, resident involvement, and surgeon specialty, AIP was associated with increased odds of UTI (odds ratio 2.20, 95% confidence interval 1.14-4.13, P = .02) and increased odds of overall complication (odds ratio 1.80, 95%confidence interval 1.10-2.93, P = .02). Thirty-day readmission and reoperation rates did not differ between the groups. CONCLUSION AIP performed at the time of ASC are associated with higher rates of 30-day postoperative UTI but do not impact 30-day readmission or reoperation. The decision to perform AIP at the time of ASC should be made following a thorough discussion of the risks and benefits, including the potential for increased UTI with concurrent AIP.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

OBJECTIVE To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. MATERIALS AND METHODS We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. RESULTS We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. CONCLUSION Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

MP46-13 EVALUATING THE ROLE OF PERIOPERATIVE ANTIBIOTICS IN PREVENTING ARTIFICIAL URINARY SPHINCTER EXPLANTATION: ANALYSIS OF A LARGE NATIONAL PROSPECTIVE DATABASE

p1⁄40.543 (UTI)], patient satisfaction [p1⁄40.913, 0.863, 0.913, 0.552], pain rates [p1⁄40.389, 0.389, 0.637, 0.160], and IQOL scores [p1⁄40.522]. Regarding the surgical procedure, duration of perioperative antibiotics prophylaxis significantly effected long-term pain rates (p1⁄40.036), patient satisfaction rates (p1⁄40.007), and correlated significantly with reduced IQOL scores (R1⁄4-0.531, p<0.001). Surgical approach, catheter size and indwelling time, and intraoperative complications had no significant effect on the analyzed endpoints. CONCLUSIONS: This is the first study to analyze long-term effects of perioperative complications on favorable outcomes after AUS implantation. We show that perioperative morbidity does not lead to less favorable long-term results and therefore reassure both implanting surgeon and patient. Since duration of antibiotic prophylaxis had a negative effect on AUS outcomes, our results advocate a more restrictive use of perioperative antibiotics.

MP25-15 FACTORS ASSOCIATED WITH INFLATABLE PENILE PROSTHESIS (IPP) EXPLANTATION: EVALUATING THE ROLE FOR POSTOPERATIVE ORAL ANTIBIOTICS ADMINISTRATION

initial implanter (26% vs 11%, p1⁄40.004), and when reoperation was performed by a high volume implanter (p<0.001). On multivariate analysis, salvage was less common when the operation for infection was not performed by the original implanter (OR 0.42, p1⁄40.04) or was performed by a low volume implanter ( 2/year vs >20/year, OR 0.21, p1⁄40.01). CONCLUSIONS: Men treated for infected IPPs with salvage procedures are far more likely to end up with a prosthesis than those treated with explant. Despite these favorable functional outcomes, salvage of infected IPPs is an underutilized strategy. We identified surgeon factors that may partially explain this suboptimal practice pattern. Proactive referral of patients with IPP infections to their original surgeons or to experienced implanters could improve functional outcomes for affected patients.

PD17-02 THE IMPACT OF CONCURRENT PROCEDURES ON PERIOPERATIVE OUTCOMES AMONG WOMEN UNDERGOING ABDOMINAL SACROCOLPOPEXY: MIDURETHRAL SLING PLACEMENT IS ASSOCIATED WITH INCREASED RISK OF COMPLICATION

for total vaginal length at least 7 cm. Secondary outcomes included complication rate, operating time, intra-operative blood loss, hospitalstay length, functional results and satisfaction (PGI-I scores). Statistical analysis : The Mann-Whitney, McNemar, X2 test. RESULTS: 121 consecutive women were included in the RCT (60 AS, 61 LS). In this sub-analysis we compared 3 surgical subgroups: Group 1 (28): 14 AS, 14 LS; Group 2 (45): 24 AS, 21 LS; Group 3 (47): 22 AS, 25 LS. The groups were comparable for demographic and clinical characteristics. Mean follow-up was of 45.4 months. There was a statistical functional and anatomical improvement in all subgroups in both groups. The recurrences (stage I or II) in anterior compartment were significantly more common in the LS group (in particular in group3) (p1⁄40.015), while in posterior compartment was more frequently but not significantly present in the AS group (p1⁄40.736). Intra-operative median blood loss(p<0.001), hospital stay (p<0.0001) and median operating time (group 3 p<0.0001 and group 2 p1⁄40.022) were lower in LS in all the 3 subgroups. There were no significant differences in the grade of complications among surgical subgroups in both groups (AS p1⁄40.845, LS p1⁄40.250). The majority of complications were observed in group 2 (16/24 in AS and 9/21 in LS, p1⁄40.193). There were 3 mesh exposure in LS (2 group 2 and 1 group 1) and 1 in AS (group 2). CONCLUSIONS: LS can be considered an excellent option in patients with severe urogenital prolapse,with functional and anatomical outcomes and patient’s satisfaction as good as AS in all the subgroups. The recurrence rate of anterior compartment is higher in LS especially when uterus is preserved. LS had best intraoperative and peri operative results compared to AS group.

Functional Outcomes of Bladder Reconstruction Secondary to Trauma and Ureteral Injury

Injury to the ureter and bladder are relatively rare occurrences and provoke significant diagnostic dilemmas. Etiologies include external trauma, such as automobile accidents or gunshot wounds, and iatrogenic injuries during pelvic surgery or endoscopy. When lower urinary tract injury goes unrecognized, presenting symptoms can be vague and often delay diagnosis. Such delays may result in prolonged hospital stays and deterioration of renal function and have significant impact on a patient’s quality of life. Reconstruction of these injuries can be challenging depending on the mechanism and location of injury. Overall functional outcomes of reconstruction for ureteral or bladder injuries is excellent, but there is limited data on post-operative voiding function. One unique injury worth mentioning is mesh erosion into the genitourinary tract where patients may have persistent lower urinary tract symptoms after reconstruction.