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Objective: SinceMarch 2020, the COVID-19 pandemic has catalyzed rapid integration of telemedicine services into clinical practice. Our primary aim was to assess patient satisfaction with telehealth care in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). Our secondary aim was to assess patient access to technology for telehealth visits. Methods: This was an IRB-approved, single-institution, survey study of a convenience sample of patients presenting for telehealth visits within the Division of FPMRS from July 22, 2020 to January 15, 2021. We invited new and established patients to complete a single survey regarding reason for visit, overall satisfaction, access to technology, previous use of telemedicine, and preference for future visits. We present data as mean ± standard deviation or proportion. Results: Of 227 patients offered the survey, 142 (62.6%) responded;84 (59.2%) completed the survey following a video visit, and 58 (40.9%) completed the survey following a telephone visit. Respondents had a mean age of 51.5 ± 15.4 years, and most were Non-Hispanic White (70.4%) and had at least a Bachelor's degree (64.8%). The most common primary diagnoses were sexual dysfunction (26.1%), overactive bladder (21.8%), and urinary incontinence (14.1%). Most patients in both the video and phone groups were completely satisfied (62.4% and 56.0%, respectively) or moderately satisfied (24.4% and 39.3%, respectively). Patient-reported advantages of telehealth included saving travel time (93.0%), waiting room time (59.2%), parking fees (50.0%), time off work (43.7%), and public transit fees (22.5%). Patients also reported greater overall convenience (60.6%) and feeling that they had more time with the provider (21.8%). Patient-cited disadvantages were concern about the provider's ability to make a diagnosis (69.0%) or see something of concern remotely (64.1%). Only 5.6% of patients expressed concern about difficulty building rapport with a provider virtually. Regarding access to telehealth visits, 8.5% cited a poor internet connection and 7.0% felt that setting up a virtual platform could be challenging. In anticipation of post-COVID FPMRS visits, most respondents (79.6%) preferred a combination of virtual and in-person visits. Only 2.1% indicated a preference for all future visits to be virtual, while 10.6% preferred only inperson visits, and 7.7% did not express a preference. Among respondents who preferred at least some virtual visits, 73.3% preferred video, whereas 25.9% preferred telephone visits. Conclusions: This study demonstrates high patient satisfaction with virtual telehealth visits at our FPMRS Division during the COVID-19 pandemic. Saving travel time and overall convenience were themost highly cited advantages of telehealth by patients. Patients prefer receiving a combination of telehealth and in-person visits post-pandemic. This study underscores an important role for telehealth in future FPMRS practice and should inform future studies to explore which conditions, visit types, and patient characteristics are best served by virtual versus in-person visits.

Objectives Although racial disparities are well documented for common gynecologic surgical procedures, few studies have assessed racial disparities in the surgical treatment of vaginal prolapse. This study aimed to compare the use of obliterative procedures for the treatment of vaginal prolapse across racial and ethnic groups. Study design This is a retrospective cohort study of surgical cases from 2010 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program, a nationally validated database. Cases were identified by Current Procedural Terminology codes. Modified Poisson regression was used to calculate risk ratios and 95% confidence intervals, adjusting for potential confounders selected a priori. Results We identified 45,865 surgical cases, of which 10% involved an obliterative procedure. In the unadjusted model, non-Hispanic Asian and non-Hispanic Black patients were more likely to undergo an obliterative procedure compared with non-Hispanic White patients (risk ratio [95% confidence interval], 2.4 [2.1-2.7] and 1.2 [1.03-1.3], respectively). These relative risks were largely unchanged when controlling for age, body mass index, diabetes, American Society of Anesthesiologists classification, and concurrent hysterectomy. Conclusions Although both obliterative and reconstructive procedures have their respective risks and benefits, the proportion of patients undergoing each procedure differs by race and ethnicity. It is unclear whether such disparities may be attributable to differences in preference or inequity in care.

PURPOSE: We evaluate the cost-effectiveness of prophylactic antibiotic use to prevent catheter-associated urinary tract infections. MATERIALS AND METHODS: A decision tree model was used to assess the cost-effectiveness of prophylactic antibiotics in preventing catheter-associated urinary tract infections for patients with a short-term indwelling urinary catheter. The model accounted for incidence of urinary tract infections with and without the use of prophylactic antibiotics, incidence of antibiotic-resistant urinary tract infections, as well as costs associated with diagnosis and treatment of urinary tract infections and antibiotic-resistant urinary tract infections. Costs were calculated from the healthcare system’s perspective. We conducted one-way sensitivity analyses. RESULTS: The base case analysis showed that the use of prophylactic antibiotics is cost saving in preventing catheter-associated urinary tract infections. The use of prophylactic antibiotics resulted in lower costs and higher quality-adjusted life-years compared to no prophylactic antibiotics. Sensitivity analyses showed that the optimal strategy changes to no prophylactic antibiotics when the incidence of urinary tract infections after prophylactic antibiotics exceeds 22% or the incidence of developing urinary tract infections without prophylactic antibiotics is less than 12%. Varying the costs of prophylactic antibiotics, urinary tract infection treatment, or antibiotic-resistant urinary tract infection treatment within a reasonable range did not change the optimal strategy. CONCLUSIONS: Prophylactic antibiotic use to prevent catheter-associated urinary tract infections is cost effective under most conditions. These results were sensitive to the likelihood of developing catheter-associated urinary tract infections with and without prophylactic antibiotics. Our results are limited to the cost-effectiveness perspective on this clinical practice.

Objective This study aimed to assess whether the use of visual aids to augment the consent process for pelvic floor surgeries affects patient understanding and satisfaction. Methods We conducted a single-blind, randomized controlled trial. Adults planning robotic sacrocolpopexy or suburethral sling surgeries were eligible. All participants received standard preoperative consent counseling. Participants randomized to the intervention also viewed slides with visual aids that paralleled standard counseling; participants randomized to the control group received only standard counseling. All participants completed surveys after their preoperative visit, the day of surgery, and at their postoperative visit. Each survey contained 12 true-false questions about risks, benefits, and alternatives of surgery, and expectations during recovery. The primary outcome was the percentage of correct true-false questions. We conducted an intention-to-treat analysis. Results We randomized 32 participants undergoing robotic sacrocolpopexy and 32 undergoing suburethral sling surgeries, yielding 16 in the intervention group and 16 in the control group for each procedure. The intervention and control groups for both surgeries were similar in age, body mass index, race, education, and previous surgery for similar symptoms.Among participants undergoing robotic sacrocolpopexies, median knowledge scores at the preoperative visit were similar between the intervention (92% [interquartile range {IQR}, 86%-100%]) and control (86% [IQR, 75%-94%]) groups (P = 0.21). Similar results were seen for participants undergoing suburethral sling procedures in the intervention (83.3% [IQR, 71%-92%]) and control (83% [IQR, 75%-88%]) groups (P = 0.64). Conclusions We found that using visual aids during the consent process for patients undergoing robotic sacrocolpopexy or suburethral sling surgeries did not improve knowledge.

Objective The aim of this study was to evaluate the cost-effectiveness of retrograde voiding trials in the management of postoperative voiding dysfunction. Methods We developed a disease simulation model to assess under which conditions routine retrograde voiding trial is the optimal strategy in terms of cost per quality-adjusted life-year and cost per case of chronic voiding dysfunction avoided. We varied the incidence of voiding dysfunction between 2% and 60%. We discounted future costs and utilities at 3% annually. We conducted 1- and 2-way sensitivity analyses on uncertain model parameters. Results The lifetime analysis showed that when the incidence of postoperative voiding dysfunction exceeded 12.2%, retrograde voiding trials were cost-effective, assuming a willingness-to-pay (WTP) for health of $100,000/quality-adjusted life-year. When the incidence exceeded 31.1%, retrograde voiding trials became the dominant strategy (less costly and more effective). For a simple hysterectomy with voiding dysfunction incidence of approximately 10%, lifetime cost is $230,069/case of chronic voiding dysfunction avoided; for a midurethral sling with voiding dysfunction incidence of approximately 20%, lifetime cost is $60,449/case avoided. Sensitivity analyses showed that WTP for health, the incidence of presentation to the emergency department (ED) for urinary retention and the incidence of chronic urinary retention following treatment in the ED had the greatest impact on the cost-effectiveness results. Conclusions Routine retrograde voiding trials following pelvic surgery can be cost-effective compared with expectant management when the incidence of voiding dysfunction exceeds 12.2%. These results were sensitive to WTP for health, incidence of ED visits for urinary retention, and incidence of chronic urinary retention following ED visits.

The objective was to compare postoperative urinary retention using the Babcock and Kelly clamps for retropubic midurethral sling (RPS) tensioning. This was a retrospective cohort of isolated RPS procedures from December 2010 through April 2016 by five fellowship-trained surgeons at two institutions. Slings were tensioned with a Babcock clamp by grasping a 3-mm midline fold of mesh (RPS-B) or a Kelly clamp as a spacer between the sling and suburethral tissue (RPS-K). Assessment of urinary retention included the primary outcome of postoperative catheterization and several secondary outcomes, including discharge home with a catheter, within 1 year of surgery. Analysis of covariance was used to compute the mean difference in duration of catheterization and log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI). We included 240 patients. The RPS-B group had a lower body mass index and was more likely to be menopausal, have had pelvic organ prolapse surgery, and have a lower maximum urethral closure pressure than the RPS-K group. The mean duration of catheterization was similar, as demonstrated by the crude (0.21 days [−0.30–0.71]) and BMI-adjusted (0.07 days [−0.41–0.55]) mean difference in duration of catheterization. The incidence of postoperative OAB symptoms was comparable between the groups (BMI-adjusted RR: 0.95 (0.80–1.1)), and the incidence of revision did not differ (p = 0.7). The Babcock and Kelly clamp tensioning techniques appear comparable, with a low incidence of prolonged postoperative catheterization. Most catheters were removed on the day of the surgery. It is reasonable to tension retropubic midurethral slings with either method.

Our aim was to identify predictors of postoperative voiding trial failure among patients who had a pelvic floor repair without a concurrent incontinence procedure in order to identify low-risk patients in whom postoperative voiding trials may be modified.We conducted a retrospective cohort study of women who underwent pelvic floor repair without concurrent incontinence procedures at two institutions from 1 November 2011 through 13 October 2013 after abstracting demographic and clinical data from medical records. The primary outcome was postoperative retrograde voiding trial failure. We used modified Poisson regression to calculate the risk ratio (RR) and 95 % confidence interval (CI).Of the 371 women who met eligibility criteria, 294 (79.2 %) had complete data on the variables of interest. Forty nine (16.7 %) failed the trial, and those women were less likely to be white (p = 0.04), more likely to have had an anterior colporrhaphy (p = 0.001), and more likely to have had a preoperative postvoid residual (PVR) ≥150 ml (p = 0.001). After adjusting for race, women were more likely to fail their voiding trial if they had a preoperative PVR of ≥150 ml (RR: 1.9; 95 % CI: 1.1-3.2); institution also was associated with voiding trial failure (RR: 3.0; 95 % CI: 1.6-5.4).Among our cohort, postoperative voiding trial failure was associated with a PVR of ≥150 ml and institution at which the surgery was performed.

Background Urinary voiding dysfunction is reported in many patients with complex regional pain syndrome (CRPS). However, there is a gap in the literature for treating patients with CRPS who develop incontinence symptoms. Case We report a case describing the use of sacral neuromodulation therapy in a patient with urgency urinary and fecal incontinence who had a previously implanted spinal cord stimulator for type 1 CRPS, formerly known as reflex sympathetic dystrophy. Despite initial hesitation and treatment delay, sacral neuromodulation therapy was successful and effective in controlling both fecal and urgency urinary incontinence symptoms for the patient. This intervention continues to provide her with an improved quality of life 10 months after her procedure. Conclusions In this case, there was significant hesitation from the provider and patient to use invasive treatments for incontinence symptoms when the patient's pain symptoms have been well controlled with an existing spinal device. However, in this patient with type 1 CRPS, even in the setting of an existing spinal cord stimulator, sacral neuromodulation therapy was an effective treatment.

To estimate the association between urinary incontinence and glycemic control in women ages 20 to 85 years.We included 7270 women from the 2005 to 2010 National Health and Nutrition Examination Survey, stratified into three groups of glycemic control defined by hemoglobin A1c (HbA1c): (i) those below the diagnostic threshold (HbA1c6.5%), (ii) those with relatively controlled diabetes (HbA1c, 6.5-8.5%), and (iii) those with poorly controlled diabetes (HbA1c8.5%) to allow for a different relationship between glycemic control and urinary incontinence within each group. The primary outcomes were the presence of any, only stress, only urgency, and mixed urinary incontinence. We calculated adjusted risk ratios using Poisson regressions with robust variance estimates.The survey-weighted prevalence was 52.9% for any, 27.2% for only stress, 9.9% for only urgency, and 15.8% for mixed urinary incontinence. Among women with relatively controlled diabetes, each one-unit increase in HbA1c was associated with a 13% (95% confidence interval, 1.03-1.25) increase for any urinary incontinence and a 34% (95% confidence interval, 1.06-1.69) increase in risk for only stress incontinence but was not significantly associated with only urgency and mixed incontinence. Other risk factors included body mass index, hormone replacement therapy, smoking, and physical activity.Worsening glycemic control is associated with an increased risk for stress incontinence for women with relatively controlled diabetes. For those either below the diagnostic threshold or with poorly controlled diabetes, the risk may be driven by other factors. Further prospective investigation of HbA1c as a modifiable risk factor may motivate measures to improve continence in women with diabetes.

We aimed to determine if the use of permanent suture for the apical fixation during traditional anterior colporrhaphy results in improved outcomes compared to delayed absorbable suture. A retrospective case-control study was performed in patients who underwent traditional non-grafted anterior colporrhaphy with reattachment of the anterior endopelvic fascia to the apex/cervix comparing permanent (group 1) or absorbable suture (group 2). Patients were matched based on age, body mass index, and presenting stage of prolapse. The primary outcome assessed was anterior wall vaginal prolapse recurrence defined as Pelvic Organ Prolapse Quantification (POP-Q) points Aa or Ba ≥ −1 cm. Secondary outcome measures included overall prolapse stage, subjective reporting of satisfaction, and any healing abnormalities or complications resulting from suture type. A total of 230 patients were reviewed (80 in group 1 and 150 in group 2) and median follow-up was 52 (24–174) weeks. A statistically significant improvement in anterior wall anatomy was seen in group 1 compared to group 2 [(Aa −2.70 ± 0.6 cm vs −2.5 ± 0.75 cm, p = 0.02) and Ba (−2.68 ± 0.65 cm vs −2.51 ± 0.73 cm, p = 0.03), respectively]. Comparing prolapse stage, there were no observed differences between the groups. Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure. Reattachment of endopelvic fascia to the apex at the time of anterior colporrhaphy results in low recurrence rates. Use of permanent suture for apical fixation is associated with improved anatomic correction at the expense of increased suture exposures.

This study aims to evaluate clinical outcomes of concomitant suburethral sling with LeFort colpocleisis including its effect on postoperative voiding.We performed a retrospective review of all LeFort colpocleisis procedures from our institution. We reviewed demographics, symptoms of stress urinary incontinence, incontinent events/day, pads usage/day, urodynamic parameters, and presence of voiding dysfunction.Two hundred ten patients underwent colpocleisis during the study period. Mean age was 82.2 ± 4.9 and median follow-up was 22 weeks (2-169). Preoperatively, 73 (35%) complained of stress urinary incontinence (SUI) symptoms, and an additional 105 (50%) were diagnosed with occult SUI. One hundred sixty-one (77%) patients underwent concurrent suburethral sling. Overall, sling placement resulted in a 92.5% subjective stress continent rate. Fifty-six patients presented with voiding dysfunction (VD). Postoperatively, VD resolved in 91%. De novo VD occurred in two patients (1.9%) and one (0.6%) required sling revision.Sling placement at time of colpocleisis is associated with high continence rates with minimal risk of postoperative voiding dysfunction.

The objective of this study was to compare the results of the Pelvic Organ Prolapse Quantification (POP-Q) examination by visual estimation to measurement.Women with pelvic organ prolapse underwent both "eyeball"/estimated and measured POP-Q examinations by two trained examiners in a randomized order. POP-Q points and stage were analyzed using the paired t test, chi-square, Pearson's correlation, and kappa statistics.Fifty subjects had a mean age of 60, mean BMI 27.8, and median parity of 2. The POP-Q stages by the measured technique were 18% (9/50) stage 1, 38% (19/50) stage 2, 44% (22/50) stage 3, and 0% (0/50) stage 4. The POP-Q stages based on estimation and measurement were highly associated (p0.05). Individual points did not differ significantly between the techniques and did not differ significantly between examiners (all p0.05).Among examiners who routinely perform POP-Q examinations, there is no significant difference between "eyeball"/estimated and measured POP-Q values and stage.