Linder, Brian J.

Objective The aim of this study was to perform a cost-effectiveness analysis comparing the management for ongoing voiding dysfunction after midurethral sling placement, including early sling loosening and delayed sling lysis. Methods A Markov model was created to compare the cost-effectiveness of early sling loosening (2 weeks) versus delayed sling lysis (6 weeks) for the management of persisting voiding dysfunction/retention after midurethral sling placement. A literature review provided rates of resolution of voiding dysfunction with conservative management, complications, recurrent stress urinary incontinence, or ongoing retention, as well as quality-adjusted life years (QALYs). Costs were based on 2020 Medicare reimbursement rates. Incremental cost-effectiveness ratios were compared using a willingness-to-pay threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. Results At 1 year, early sling loosening resulted in increased costs ($3,575 vs $1,836) and higher QALYs (0.948 vs 0.925) compared with delayed sling lysis. This translated to early sling loosening being the most cost-effective strategy, with an incremental cost-effectiveness ratio of $74,382/QALY. The model was sensitive to multiple variables on our 1-way sensitivity analysis. For example, delayed sling lysis became cost-effective if the rate of voiding dysfunction resolution with conservative management was greater than or equal to 57% or recurrent stress urinary incontinence after early loosening was greater than or equal to 9.6%. At a willingness-to-pay threshold of 100,000/QALY, early sling loosening was cost-effective in 82% of microsimulations in probabilistic sensitivity analysis. Conclusions Early sling loosening represents a more cost-effective management method in resolving ongoing voiding dysfunction after sling placement. These findings may favor early clinical management in patients with voiding dysfunction after midurethral sling placement.

Objective This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. Methods A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. Results A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. Conclusions For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

Objectives: To characterize 30-day morbidity of upper ureteral reconstruction (UUR) and lower ureteral reconstruction (LUR) surgery by comparing open and minimally invasive surgery (MIS) approaches using a national surgical outcomes registry. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent UUR and LUR between 2007 and 2017. Primary endpoints included 30-day complications, transfusion, readmission, return to operating room (ROR), and prolonged postoperative length of stay (LOS). Multivariable logistic regression was performed to observe the association of MIS approach on 30-day outcomes. Results: Three thousand forty-two patients were identified with 2116 undergoing UUR and 926 undergoing LUR. Of 2116 patients undergoing UUR, 1733 (82%) were performed through an MIS approach. On multivariable analysis, open approach for UUR was associated with increased odds of any 30-day complication (odds ratio (OR) 1.6 [1.1–2.4]; p = 0.014), major complication (OR 1.8 [1.04–3.0]; p = 0.034), transfusion (OR 3.7 [1.2–11.5]; p = 0.025), ROR (OR 2.0 [1.0–3.9]; p = 0.047), and prolonged LOS (OR 5.4 [3.9–7.6]; p < 0.001). Of the 926 patients undergoing LUR, 458 (49%) were performed through an MIS approach. On multivariable analysis, open approach for LUR was associated with increased odds of any 30-day complication (OR 1.5 [1.1–2.1]; p = 0.028), minor complication (OR 1.7 [1.1–2.6]; p = 0.02), transfusion (OR 8.1 [2.7–23.7]; p < 0.001), and prolonged LOS (OR 4.2 [2.4–7.3]; p < 0.001). Conclusion: Utilization of a national surgical database revealed an open approach was associated with increased 30-day morbidity across multiple postoperative outcome measures. These findings suggest an MIS approach should be considered, when feasible, for upper and lower ureteral reconstruction.

Objective To compare the perioperative outcomes of transvaginal/perineal and abdominal approaches to rectovaginal fistula (RVF) repair using a national multicenter cohort. Methods The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify women undergoing RVF repair from 2005 to 2016. Emergent cases and those with concomitant bowel diversion were excluded. Baseline patient demographics, procedure characteristics, 30-day postoperative complications, return to the operating room, and readmission were evaluated. Baseline characteristics were compared across surgical approach. Multivariable logistic regression models identified preoperative characteristics independently associated with postoperative complications. Results A total of 2288 women underwent RVF repair: 1560 (68.2%) via transvaginal/perineal approach and 728 (31.8%) via abdominal approach. Patients undergoing transvaginal/perineal repair were significantly younger (median age, 46 years vs 63 years), with lower American Society for Anesthesiologist (ASA) scores, and less frequency of diabetes mellitus, dyspnea, severe chronic obstructive pulmonary disease, hypertension, disseminated cancer, and bleeding disorders (all P < 0.01). Those undergoing abdominal repair had higher rates of major complications (25.8% vs 8.7%), minor complications (13.5% vs 6.3%), and readmission (13.2% vs 7.8%). On multivariable analyses, ASA Class 3/4, disseminated cancer, and hematocrit <30% ( P < 0.01) were associated with major complications in both groups. Conclusions Patients undergoing RVF repair via abdominal approach were older with more comorbidities and had higher postoperative complications rates, likely secondary to underlying differences in the treated populations. Irrespective of surgical approach, ASA class, disseminated cancer, and preoperative anemia were associated with higher postoperative morbidity. This may enhance preoperative counseling and allow for careful patient selection.

INTRODUCTION: In younger men, in whom organic prostate disease is uncommon, the etiology of lower urinary tract symptoms (LUTS) is frequently unclear. Studies suggest that in this young cohort voiding phase dysfunction is more common than storage phase dysfunction or normal urodynamics. Abnormal pelvic floor muscle relaxation, which can result in constipation, could potentially result in voiding dysfunction also. To date, no studies have investigated the relationship between posterior pelvic floor dysfunction and LUTS in young men. METHODS: Men who had undergone both anorectal manometry and uroflowmetry (i.e. had lower gastrointestinal and urinary symptoms) between October 2012 and September 2018 were identified. Patients >40 years old were excluded to reduce the likelihood of prostate disease. Clinical data was extracted from the electronic health records. Descriptive and comparative analyses were performed. RESULTS: Of 47 identified patients, 13 were excluded due to a history of neurogenic bowel/bladder, urethral/anal surgery or significant neurological disease. The mean age and standard deviation (SD) of the 34 men analyzed was 30 ± 6 years. Twenty patients demonstrated an abnormal balloon expulsion test (BET). The median (and interquartile range [IQR]) number of LUTS was 1.5 (1-2). An abnormal BET was not associated with symptoms of nocturia, hesitancy, incomplete emptying or the total number of LUTS (2 vs 1, P = 0.6). An abnormal balloon expulsion test was associated with a lower maximum urinary flow rate (Qmax, 14 vs 29 mls/sec, P < 0.001) but not flow duration (34 vs. 27 seconds, P = 0.2), residual urine volume (55 vs. 43 mls, P = 0.7) or urine volume (300 vs. 301 mls, P = 0.5). No correlation was seen between anal pressures at rest or during simulated evacuation and maximum urinary flow rate. No correlation was found between functional constipation and Qmax, LUTS or abnormal uroflow. No relationship between rectal sensory thresholds and urinary symptoms was identified. CONCLUSION: In this study of young men undergoing both anorectal manometry and uroflow, pelvic floor dysfunction was not associated with specific LUTS but was associated with a clinically significant reduction in maximum urinary flow rate. However an objective diagnosis of functional constipation was not associated with urologic abnormalities. Further studies will be needed to prospectively characterize this cohort and to identify whether PFD-associated LUTS and reduced flow respond to biofeedback therapy.

Objective The aim of this study was to evaluate national patterns of care for women with overactive bladder (OAB) in an administrative data set and identify potential areas for improvement. Methods We performed an analysis using the OptumLabs Data Warehouse, which contains deidentified administrative claims data from a large national US health insurance plan. The study included women, older than 18 years, with a new OAB diagnosis from January 1, 2007, to June 30, 2017. We excluded those with an underlying neurologic etiology, with interstitial cystitis/painful bladder syndrome, were pregnant, or did not have continuous enrollment for 12 months before and after OAB diagnosis. Trends in management were assessed via the Cochran-Armitage test. Time to discontinuation among medications was compared using t test. Results Of 1.4 million women in the database during the study time frame, 60,246 (4%) were included in the study. Median age was 61 years [interquartile range (IQR), 50–73], and median follow-up was 2.6 years (IQR, 1.6–4.2). Overall, 37% were treated with anticholinergics, 5% with beta-3 agonists, 7% with topical estrogen, and 2% with pelvic floor physical therapy; 26% saw a specialist; and 2% underwent third-line therapy. Median time to cessation of prescription filling was longer for beta-3 agonists versus anticholinergics [median, 4.1 months (IQR, 1–15) vs 3.6 months (IQR, 1–10); P < 0.0001]. Use of third-line therapies significantly increased over the study time frame, from 1.1% to 2.2% ( P < 0.0001). Conclusions Most of the patients do not continue filling prescriptions for OAB medications, and a minority of patients were referred for specialty evaluation. Although third-line therapy use is increasing, it is used in a small proportion of women with OAB. Given these patterns, there may be underutilization of specialist referral and other OAB therapies.

Objectives The objective of this study was to evaluate perioperative complications in women who underwent minimally invasive sacrocolpopexy (MISC) versus mesh-augmented vaginal repair (vaginal mesh) for pelvic organ prolapse. Methods We identified patients undergoing MISC and vaginal mesh via Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2016. Those undergoing concomitant hysterectomy were excluded. Univariate analyses were performed to compare baseline characteristics and 30-day complications. Multivariable logistic regression models were constructed to assess the association between surgical approach and complications, prolonged hospitalization, reoperation, and blood transfusion. A multivariable Cox proportional hazard model was used to evaluate hospital readmission. Results A total of 5722 patients were identified (2573 MISC [45%], 3149 vaginal mesh [55%]). Those undergoing MISC repairs had a significantly lower rate of urinary tract infection (3.1 vs 4.2%; P = 0.03) and blood transfusion (0.5 vs 1.4%; P < 0.001). There was no difference in reoperation rate (1.3 vs 1.6%; P = 0.35). Multivariable analysis showed no significant association of MISC with overall (odds ratio [OR], 0.91; P = 0.44), major (OR, 1.30; P = 0.31), or minor complication (OR, 0.85; P = 0.26). There were lower odds of receiving a blood transfusion (OR, 0.44; P = 0.02) and higher odds of prolonged hospitalization (>2 days; OR, 1.47; P = 0.003) for the MISC group. There was no difference in reoperation (OR, 0.79; P = 0.38) or hospital readmissions (hazard ratio, 1.25, P = 0.32). Conclusions Minimally invasive sacrocolpopexy was associated with a lower rate of blood transfusion than transvaginal mesh placement. There was no significant difference in 30-day complication rates, reoperation, or readmission between these prolapse procedures when performed without concomitant hysterectomy.