Publications

OBJECTIVES: The objective of this study was to assess long-term outcomes after the transobturator postanal sling (TOPAS) procedure for the treatment of fecal incontinence. Long-term recurrence, satisfaction and regret after transobturator postanal sling procedure support the ongoing use of this procedure for patients with fecal incontinence.

METHODS: Both a retrospective review of medical records and a prospective telephone survey were conducted. For the retrospective review of medical records, all patients who underwent the TOPAS procedure at our institution were eligible. Medical records were reviewed to assess for symptom resolution, retreatment, and complications. For the prospective telephone survey, patients who were conversant in English and had a valid contact information were eligible and were asked to complete questions on satisfaction, the Patient Global Impression of Improvement, the Wexner Symptom Severity Score, the Fecal Incontinence Qualify of Life Scale, and the modified Decision Regret Scale.

RESULTS: A total of 134 patients met the inclusion criteria for the retrospective medical record review. Patients were followed in clinic for a median of 24.0 months (interquartile range, 6.0-53.0). Overall, 75.4% reported improvement in fecal incontinence. There were 37 (27.6%) who required subsequent treatment for fecal incontinence. There were 67 patients eligible for the prospective telephone survey, of whom 46 (68.7%) agreed to participate. Median time between surgery and the telephone survey was 63.5 months (interquartile range, 36.0-98.0). Among these participants, 54.3% were satisfied and 60.9% would recommend the procedure to someone else. No adverse events were identified with long-term follow-up.

CONCLUSIONS: Our findings suggest that the TOPAS procedure remains a safe and effective therapy for the treatment of fecal incontinence with favorable long-term outcomes.

The surgery practiced today is not the same as the surgery practiced a generation ago and because of the ever-evolving nature of medicine, ongoing education, and adoption of new technology is vital for all surgeons. New technology has the potential to revolutionize the way we practice medicine; however, it is important to understand the context in which new medical devices arise and to approach new medical devices with a healthy combination of skepticism and optimism. Surgeons should feel comfortable assessing, critiquing, and adopting new technology.

OBJECTIVE: To understand the compensation differences between male and female academic urogynecologists at public institutions.

METHODS: Urogynecologists at public universities with publicly available salary data as of June 2019 were eligible for the study. We collected characteristics, including sex, additional advanced degrees, years of training, board certification, leadership roles, number of authored scientific publications, and total National Institutes of Health funding projects and number of registered clinical trials for which the physician was a principal or co-investigator. We also collected total number of Medicare beneficiaries treated and total Medicare reimbursement as reported by the Centers for Medicare & Medicaid Services. We used linear regression to adjust for potential confounders.

RESULTS: We identified 85 academic urogynecologists at 29 public state academic institutions with available salary data eligible for inclusion in the study. Males were more likely to be an associate or a full professor (81%) compared with females (55%) and were more likely to serve as department chair, vice chair, or division director (59%) compared with females (30%). The mean annual salary was significantly higher among males ($323,227 ± $97,338) than females ($268,990 ± $72,311, P = 0.004). After adjusting for academic rank and leadership roles and years since residency, the discrepancy persisted, with females compensated on average $37,955 less annually.

CONCLUSIONS: Salaries are higher for male urogynecologists than female urogynecologists, even when accounting for variables such as academic rank and leadership roles. Physician compensation is complex; the differences observed may be due to variables that are not captured in this study. Nevertheless, the magnitude of disparity found in our study warrants further critical assessment of potential biases within the field.

UNLABELLED: There are insufficient studies on long-term outcomes following colpocleisis, which limits physicians' ability to effectively counsel patients. The purpose of this study was to assess pelvic floor symptoms, recurrence, satisfaction, and regret among patients who underwent colpocleisis procedures.

METHODS: This is an ambidirectional cohort study involving patients who underwent a colpocleisis at a single institution from 2002 to 2012. Medical records were reviewed, and patients were contacted by telephone in order to complete questionnaires.

RESULTS: A total of 73 patients met inclusion criteria for our study. At the time of colpocleisis, patients were an average of 78.1 years old (range, 62-85 years). Patients were followed up in clinic for a median of 44.4 months, and the majority reported overactive bladder postoperatively. We were able to contact 33 patients by telephone. Median time between surgery and telephone follow-up was 6 years (range, 5-15 years). Among these patients, 78% were satisfied with the procedure; however, 13% reported strong feelings of regret. Regret was associated with postoperative bowel and bladder symptoms. The majority reported urinary frequency (63%) and urgency urinary incontinence (56%). Fewer than half (44%) of patients reported bowel symptoms. Only 19% reported prolapse symptoms. No patients reported regret due to loss of sexual function.

CONCLUSIONS: Colpocleisis remains an excellent surgical option for elderly patients. However, regret and dissatisfaction may increase over time as bowel and bladder symptoms may be perceived to be the result of surgery. Our findings highlight the continued need for detailed consent and expectation setting for women considering colpocleisis.

OBJECTIVES: Most surgeons recommend restriction of activities after minimally invasive gynecologic and pelvic reconstructive surgery. The goal of this study was to identify and assess the postoperative guidelines gynecologists and urogynecologists provide their patients.

METHODS: This was a cross-sectional study of physicians at a national gynecology conference in March 2018. Respondents were asked to answer questions about the typical postoperative recommendations they provide patients after gynecologic surgery as well as their postoperative prescribing habits.

RESULTS: There were 418 attendees, and 135 (32%) eligible physicians completed the survey. Of respondents, 87% were specialists in female pelvic medicine and reconstructive surgery. Most respondents (61%) were in academic practice. Most respondents (82%-86%) recommended specific postoperative lifting restrictions, and 49% to 52% recommended limiting lifting to a maximum of 10 lb after surgery with some variation depending on the surgical procedure performed. Many respondents (42%-56% depending on the surgical procedure) recommended that patients wait at least 2 weeks before returning to sedentary work. Male respondents and those who were in practice for more than 10 years recommended that patients return to work sooner compared with those who were in practice less than 10 years. Male respondents prescribed fewer opioids to patients after vaginal hysterectomy (P = 0.04) and vaginal prolapse repair (P = 0.03) compared with female respondents.

CONCLUSIONS: After minimally invasive gynecologic or pelvic reconstructive surgery, providers recommend a wide range of postoperative restrictions and prescribe significantly different quantities of opioids during the postoperative period. This study highlights some of the recommendations with the greatest variability.

INTRODUCTION AND HYPOTHESIS: Understanding patient preferences regarding provider characteristics is an under-explored area in urogynecology. This study aims to describe patient preferences for urogynecologic care, including provider gender, age, experience, and presence of medical trainees.

METHODS: This was a multicenter, cross-sectional, survey-based study assessing patient preferences with a voluntary, self-administered, anonymous questionnaire prior to their first urogynecology consult. A 5-point Likert scale addressing provider gender, age, experience, and presence of trainees was used. Descriptive statistics summarized patient characteristics and provider preferences. Chi-squared (or Fisher's exact) test was used to test for associations.

RESULTS: Six hundred fifteen women participated from eight sites including all geographic regions across the US; 70.8% identified as white with mean age of 58.5 ± 14.2 years. Urinary incontinence was the most commonly reported symptom (45.9%); 51.4% saw a female provider. The majority of patients saw a provider 45-60 years old (42.8%) with > 15 years' experience (60.9%). Sixty-five percent of patients preferred a female provider; 10% preferred a male provider. Sixteen percent preferred a provider < 45 years old, 36% preferred 45-60 years old, and 11% of patients preferred a provider > 60 years old. Most patients preferred a provider with 5-15 or > 15 years' experience (49% and 46%, respectively). Eleven percent preferred the presence of trainees while 24% preferred trainee absence.

CONCLUSION: Patient preferences regarding urogynecologic providers included female gender and provider age 45-60 years old with > 5 years' experience. Further study is needed to identify qualitative components associated with these preferences.

OBJECTIVES: The objective of this study was to determine the impact of a multimodal protocol on opiate use and postoperative pain after ambulatory urogynecologic surgery.

METHODS: This was a retrospective cohort study comparing ambulatory urogynecologic surgery patients treated under a standard perioperative pain protocol with those treated under a multimodal perioperative pain protocol. The multimodal protocol consisted of preoperative gabapentin and acetaminophen and postoperative scheduled doses of acetaminophen and nonsteroidal anti-inflammatory drugs. Pain scores were obtained from nursing records and assessed on the Numeric Rating Scale 11 per hospital protocol. All opioid dosages were converted into morphine milligram equivalents using standardized conversion tables.

RESULTS: We treated 109 patients under the standard protocol and 112 under the multimodal protocol. Patients had similar baseline characteristics. Overall, a minority of patients (39%) used postoperative opioids; this was similar in the 2 groups (P=0.45). The 2 groups also were similar with regard to the total postoperative morphine milligram equivalents (P=0.35). Postoperatively, patients treated under the standard protocol had higher mean pain scores (2.2 vs 1.4, P=0.002). Patients treated under the standard protocol were also significantly more likely to report postoperative pain (69%) than those treated under the multimodal protocol (52%; P=0.01), and the multimodal protocol was associated with a 25% lower risk of postoperative pain (risk ratio, 0.75; 95% confidence interval, 0.60-0.94) than the standard protocol.

CONCLUSIONS: Patients infrequently use opiates after ambulatory urogynecologic surgery. The use of a multimodal pain protocol was associated with lower pain scores, and patients in a multimodal pain protocol were more likely to report no pain.

OBJECTIVE: To assess the effects of the U.S. Food and Drug Administration (FDA) safety communication and the reclassification of transvaginal mesh to a class III device on national trends in the treatment of apical prolapse.

METHODS: A retrospective cohort study of surgical cases from 2008 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program was conducted. Patients were included if they underwent apical prolapse repair, as identified by Current Procedural Terminology codes.

RESULTS: We identified 36,523 eligible surgical cases. There were no clinically meaningful differences in postoperative complications when stratified by surgical approach. The use of transvaginal mesh decreased from 35.0% to 11.0% from 2008 to 2017. In the year immediately after the first FDA safety communication in 2011, there was a decrease in the proportion of apical procedures using transvaginal mesh of 4.4% per quarter (P<.001), and the proportion of intraperitoneal, extraperitoneal, and abdominal colpopexy all increased. The greatest increase was seen for abdominal colpopexy procedures, which rose by 2.6% per quarter (P<.001). In the year after the FDA reclassification of transvaginal mesh in 2016, there was no significant change in the proportion of apical procedures using transvaginal mesh (P=.56).

CONCLUSION: The first FDA safety communication in 2011 was associated with a significant decline in the use of transvaginal mesh and a concurrent rise in abdominal colpopexy procedures using transabdominal mesh. We speculate that the 2019 FDA ban of transvaginal mesh will result in an even more substantial shift toward abdominal colpopexy procedures.