Gebhart, John B.

ABSTRACT Objective To evaluate long‐term failure rates and complications after retropubic and transobturator midurethral sling procedures for primary stress urinary incontinence (SUI). Design Retrospective cohort study. Setting Academic medical centre. Population A previously described cohort of patients ( n = 1881) who underwent midurethral sling procedures (2002–2012) and a covariate‐matched cohort of patients with retropubic ( n = 570) or transobturator ( n = 317) slings. Methods Health record review with follow‐up extended by 9 years (through December 31, 2022). Main Outcome Measures Treatment failure (reoperation for recurrent SUI) and procedure‐associated complications. Results The duration of assessment was extended by 6.9 years for the retropubic group and by 6.4 years for the transobturator group. The median (IQR) follow‐up was 11.1 (5.1–14.5) years (retropubic, 11.4 [5.9–14.6]; transobturator, 9.6 [2.6–13.7]). Higher risk of reoperation was observed with transobturator (8.8%) than retropubic (4.4%) slings (unadjusted hazard ratio [HR], 2.29 [95% CI, 1.49–3.54]; p < 0.001; covariate‐matched analysis HR, 1.91 [95% CI, 1.15–3.17]; p = 0.01). The increased risk of reoperation with a transobturator sling was higher when the procedure was combined with prolapse repair (unadjusted HR, 6.34 [95% CI, 3.09–13.02]; p < 0.001; covariate‐matched analysis HR, 3.96 [95% CI, 1.35–11.58]; p = 0.01). Higher rates of reoperation for urinary retention were observed for the retropubic group than for the transobturator group (covariate‐matched analysis HR, 8.39 [95% CI, 1.11–63.22]; p = 0.04). Conclusion In this long‐term follow‐up study, midurethral slings had a low failure rate. Women with SUI undergoing transobturator sling placement plus prolapse repair had a greater risk of reoperation. However, women with retropubic slings had a greater risk of urinary retention requiring intervention.

ABSTRACTIntroduction and ObjectiveProcedural therapies for overactive bladder (OAB) most often include intradetrusor onabotulinumtoxinA (BTX) injections, sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS). Despite their proven efficacy, real‐world data on therapy continuation and crossover rates between these modalities remain limited. This study aimed to evaluate longitudinal patterns of treatment continuation and therapy crossover among women receiving procedural OAB treatments.MethodsWe conducted a multi‐institutional retrospective cohort study of women with idiopathic OAB who underwent index BTX, SNM, or PTNS between 2014 and 2022. Patients were identified using electronic medical records, and follow‐up data were collected through December 31, 2023. The primary outcomes included duration of maintenance treatments and crossover to another procedural therapy for OAB. Kaplan–Meier survival analysis estimated rates of continued treatment, and a log‐rank test assessed differences in crossover rates among treatment groups.ResultsA total of 506 women met inclusion criteria: 266 (52.6%) received BTX, 114 (22.5%) underwent SNM, and 126 (24.9%) received PTNS. Ongoing treatment rates were lowest for PTNS, with only 17.1% maintaining therapy between 3 and 5 years and 26.1% crossing over to another procedure within 3 years. Among BTX patients, 65.2% underwent repeat treatment within 3 years, and 9.5% of patients crossed over to another procedure within 3 years. Of those with 5 or more years of follow‐up, 39.1% of patients continued with BTX procedures in the 3–5‐year follow‐up timeframe. Among SNM patients, the cumulative revision rates were 7.6% at 1 year and 10.9% at 2 years. 13.1% of patients crossed over from SNM to another procedure within 3 years (the vast majority to BTX).ConclusionsPTNS had the lowest ongoing therapy rates and the highest crossover rates. BTX and SNM demonstrated similar crossover rates. These findings underscore the importance of individualized patient counseling and treatment selection based on expectations of therapy persistence. Future research should focus on optimizing patient selection, improving long‐term adherence strategies, and evaluating novel or combined therapeutic approaches for OAB management.

Importance Improving opioid stewardship is important, given the common use of opioids and resultant adverse events. Evidence-based prescribing recommendations for surgeons may help reduce opioid prescribing after specific procedures. Objective The aim of this study was to assess longitudinal prescribing patterns for patients undergoing pelvic organ prolapse surgery in the 2 years before and after implementing evidence-based opioid prescribing recommendations. Study Design In December 2017, a 3-tiered opioid prescribing recommendation was created based on prospective data on postoperative opioid use after pelvic organ prolapse surgery. For this follow-up study, prescribing patterns, including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates, were retrospectively compared for patients undergoing prolapse surgery before (November 2015–November 2017; n = 238) and after (December 2017–December 2019; n = 361) recommendation implementation. Univariate analysis was performed using the Wilcoxon rank sum and χ 2 tests. Cochran-Armitage trend tests and interrupted time-series analysis tested for significance in the change in OMEs prescribed before versus after recommendation implementation. Results After recommendation implementation, the quantity of postoperative opioids prescribed decreased from median 225 mg OME (interquartile range, 225, 300 mg OME) to 71.3 mg OME (interquartile range, 0, 112.5 mg OME; P < 0.0001). Decreases also occurred within each subgroup of prolapse surgery: native tissue vaginal repair (P < 0.0001), robotic sacrocolpopexy (P < 0.0001), open sacrocolpopexy (P < 0.0001), and colpocleisis (P < 0.003). The proportion of patients discharged following prolapse surgery without opioids increased (4.2% vs 36.6%; P < 0.0001), and the rate of opioid refills increased (2.1% vs 6.0%; P = 0.02). Conclusions With 2 years of postimplementation follow-up, the use of procedure-specific, tiered opioid prescribing recommendations at our institution was associated with a significant, sustained reduction in opioids prescribed. This study further supports using evidence-based recommendations for opioid prescribing.

Importance Data comparing perioperative outcomes between transvaginal, transabdominal, and laparoscopic/robotic vesicovaginal fistula (VVF) repair are limited but are important for surgical planning and patient counseling. Objective This study aimed to assess perioperative morbidity of VVF repair performed via various approaches. Study Design The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent transvaginal, transabdominal, or laparoscopic/robotic VVF repair from 2009 to 2020. Associations of surgical approach with baseline characteristics, blood transfusion, prolonged hospitalization (>4 days), and 30-day outcomes (any major or minor complication or return to the operating room) were evaluated with χ2, Fisher exact, and Kruskal-Wallis tests. Multivariable logistic regression models assessed the adjusted association of approach with 30-day complications and prolonged hospitalization. Results Overall, 449 women underwent VVF repair, including 252 transvaginal (56.1%), 148 transabdominal (33.0%), and 49 laparoscopic/robotic procedures (10.9%). Abdominal repair was associated with a longer length of hospitalization (median, 3 days vs 1 day transvaginal and laparoscopic/robotic; P < 0.001), higher risk of prolonged length of stay (abdominal, 21.1%; transvaginal, 4.0%; laparoscopic/robotic, 2.0%; P < 0.001), major complications (abdominal, 4.7%; transvaginal, 0.8%; laparoscopic/robotic, 0.0%; P = 0.03), and perioperative transfusion (abdominal, 5.0%; transvaginal, 0.0%; laparoscopic/robotic, 2.1%; P = 0.01). On multivariable analysis, the abdominal approach was independently associated with an increased risk of prolonged hospitalization compared with laparoscopic/robotic (odds ratio, 12.3; 95% confidence interval, 1.63–93.21; P = 0.02) and transvaginal (odds ratio, 6.09; 95% confidence interval, 2.87–12.92; P < 0.001) but not with major/minor complications (P = 0.76). Conclusion Transvaginal and laparoscopic/robotic approaches to VVF repair are associated with lower rates of prolonged hospitalization, major complications, and readmission compared with a transabdominal approach.

AbstractObjectiveTo compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway.MethodsThe present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost‐to‐charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30.ResultsFor the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331–$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P = 0.754), 30‐day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P = 0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P = 0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001).ConclusionsDecreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.

AbstractObjectiveTo assess the effect of Enhanced Recovery After Surgery (ERAS) with and without liposomal bupivacaine (LB) on opioid use, hospital length of stay (LOS), costs, and morbidity of women undergoing sacrocolpopexy.MethodsRetrospective cohort of women who underwent abdominal sacrocolpopexy between April 1, 2009 and November 30, 2017. Costs for relevant healthcare services were determined by assigning 2017 charges multiplied by 2017 Medicare Cost Report's cost to charge ratios. Outcomes were compared among periods with multivariable regression models adjusted for age, American Society of Anesthesiologists score, and concurrent hysterectomy and posterior repair.ResultsPatients were subdivided into pre‐ERAS (G1, n = 128), post‐ERAS (G2, n = 83), and post‐ERAS plus LB (G3, n = 91). The proportion of patients needing opioids during postoperative days 0–2 was significantly less for G3 (75.8%) compared with G1 (97.7%) and G2 (92.8%); P < 0.001). The median morphine equivalent units (MEU) with interquartile ranges, mean LOS, and adjusted mean standardized costs were significantly lower in G3 compared with the other two groups (35 [20–75] vs. 67 [31–109], and 60 [30–122] MEUs; 1.8 vs. 2.3 vs. 2.9 days; and $2391, $2975, and $3844, for G3, G2, and G1, respectively; P < 0.001).ConclusionImplementation of an ERAS pathway led to significant decreases in opioid use, LOS, and costs. Supplementation with LB further improved these measures.