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Obesity is a risk factor for pelvic organ prolapse (POP) and independently associated with perioperative complications following prolapse surgery. While bariatric surgery may lead to weight loss and mitigate obesity-related co-morbidities, it is associated with chronic malabsorption, which may impair post-operative healing. There have been no previous studies to evaluate the impact of prior weight loss surgery (WLS) on POP surgery outcomes. This study aims to describe the effect of WLS on complications after POP surgery. Retrospective cohort analysis. Data was procured from a U.S. National Database between January 2000 and March 2020 Patients who underwent WLS prior to surgery for POP, identified using Current Procedural Terminology codes. Comparisons were made between patients with and without a history of WLS. Of 22,363 surgeries performed for POP, 542 (2.43%) previously underwent WLS with a median interval time of 30 months (IQR 15-51). The WLS group was significantly younger, had a lower Charlson comorbidity score, and had higher rates of class II or III obesity (p <0.001), and were less likely to undergo obliterative procedures (0.74% vs 2.9%, p=0.0038). Rates of hysterectomy, sacrocolpopexy, and midurethral mesh sling did not differ between groups. The WLS group had higher rates of anemia (17% vs 9.4%, p <0.001), dumping syndrome (1.3% vs 0.049%, p<0.001), and malabsorption (12% vs 0.44%, p<0.001). The WLS group had higher rates of mesh erosion at 3 months (3% vs 1.5%, p=0.0079) and 12 months postoperatively (3.1% vs 1.8%, p=0.04) and had higher hematoma incidence (1.7% vs 0.68%, p=0.014). Time interval between surgeries did not impact rates of mesh erosion and hematoma. There was no significant difference in rates of surgical site infection between patients with and without prior WLS. Prior weight loss surgery was associated with increased rates of mesh erosion and hematoma after surgery for POP. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to determine how rates of postoperative infectious complications after pelvic organ prolapse surgery differ based on perioperative antibiotic administered. In particular, we sought to determine whether anaerobic coverage is associated with reduced rates of infectious complications., Design: This was a retrospective cohort study., Setting: Premier Healthcare U.S. national database, a comprehensive all-payer dataset capturing patients from urban and rural nonprofit, community, and teaching hospitals., Participants: Adult patients who underwent vaginal, laparoscopic, and/or abdominal prolapse surgery with or without hysterectomy from January 2000 to March 2020. Procedures with and without mesh were included., Interventions: Rates of infectious complications were compared among patients who received guideline-concordant antibiotic regimens, including those with anaerobic coverage. The primary outcome was any surgical site infection within 30 days of surgery without mesh or 90 days of surgery involving mesh., Results: Among 130,198 prolapse surgeries, the most common antibiotic regimens were cefazolin (n = 97,058, 74.5%), second-generation cephalosporin (n = 16,442, 12.6%), clindamycin + aminoglycoside (n = 8,397, 6.4%) and cefazolin + metronidazole (n = 4,328, 3.3%). On multivariable logistic regression, only clindamycin + aminoglycoside was associated with a higher rate of surgical site infections (OR = 1.37; 95% CI 1.09-1.72) and other infectious morbidity (OR = 1.26; 95% CI 1.12-1.42) when compared to cefazolin alone. The addition of metronidazole to cefazolin was not associated with reduced rates of surgical site infections (OR = 1.09; 95% CI 0.82-1.45). Obesity (OR = 1.22; 95% CI 1.03-1.43), diabetes without complication (OR = 1.30; 95% CI 1.08-1.57), Charlson comorbidity score >0 (OR = 1.24; 95% CI 1.06-1.45), and tobacco use (OR = 1.22, 95% CI 1.05-1.40) were also associated with increased composite surgical site infection., Conclusion: Compared with cefazolin alone, the use of alternative perioperative antibiotics, including those with anaerobic coverage, was not associated with reduced infectious complications after pelvic organ prolapse surgery in this U.S. national sample., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Importance: The Latina population is the largest growing ethnic group in the United States with high levels of health disparities in urinary incontinence (UI) treatment and complications rates, which may be due to disproportionately high barriers to UI care-seeking among Latinas., Objectives: The objectives of this study were to compare barriers to UI care-seeking among Latina, non-Latina Black, and non-Latina White patients by utilizing the Barriers to Incontinence Care Seeking Questionnaire (BICS-Q) total scores, and to compare specific barriers utilizing BICS-Q subscales., Study Design: In this cross-sectional study, patients accessing primary care were recruited to complete the BICS-Q, International Consultation on Incontinence Questionnaire-Short Form, and Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence. The BICS-Q total and subscale scores were compared among ethnic/racial groups., Results: A total of 298 patients were included in the study with 83 Black, 144 Latina, and 71 White participants per self-identified ethnicity/race. The total BICS-Q score was highest for Latina participants, followed by White and Black participants (11.2 vs 8.2 vs 4.9, respectively, P < 0.0001). Latina participants had significantly higher BICS-Q subscale scores compared with Black participants with no significant differences between Latina and White participants. After controlling for potential confounders, Latina ethnicity/race was still associated with a higher BICS-Q score when compared to Black ethnicity/race (P = 0.0077), and lower Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence scores remained independently associated with higher BICS-Q scores (P = 0.0078)., Conclusions: In our study population, Latina patients and patients with lower UI knowledge experience higher barriers to UI care-seeking compared with Black patients and patients with higher UI knowledge. Addressing these barriers may increase care-seeking and improve health equity in the field., Competing Interests: The authors have declared they have no conflicts of interest. A.P. received the Gender and Racial Justice Scholars Award through the Johns Hopkins University Women’s Suffrage Centennial Commemoration Committee. The authors of this paper report no conflict of interest and no further disclosures., (Copyright © 2024 American Urogynecologic Society. All rights reserved.)

Background: Postoperative pain continues to be an undermanaged part of the surgical experience. Multimodal analgesia has been adopted in response to the opioid epidemic, but opioid prescribing practices remain high after minimally invasive hysterectomy. Novel adjuvant opioid-sparing analgesia to optimize acute postoperative pain control is crucial in preventing chronic pain and minimizing opioid usage., Objective: This study aimed to determine the effect of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive (laparoscopic and robotic) hysterectomy., Study Design: This was a single-blinded, triple-arm, randomized controlled trial at an academic medical center between March 15, 2021, and April 8, 2022. The inclusion criteria were patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. The exclusion criteria were non-English-speaking patients, patients with an allergy to bupivacaine or actively using opioid medications, patients undergoing transversus abdominis plane block, and patients undergoing supracervical hysterectomy or combination cases with other surgical services. Patients were randomized in a 1:1:1 fashion to the following uterosacral administration before colpotomy: no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome was 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). The secondary outcomes were total oral morphine equivalent usage in 7 days, last day of oral morphine equivalent usage, numeric pain scores from the universal pain assessment tool, and return of bowel function. Patients reported postoperative pain scores, total opioid consumption, and return of bowel function via Qualtrics surveys. Patient and surgical characteristics and primary and secondary outcomes were compared using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the 7 days after surgery., Results: Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%) agreed to participate, and 180 were ultimately included in the final analysis after accounting for dropout. Most hysterectomies (70%) were performed laparoscopically, and the remainder were performed robotically. Most hysterectomies (94%) were outpatient. Patients randomized to bupivacaine had higher rates of former and current tobacco use, and patients randomized to the no-administration group had higher rates of previous surgery. There was no difference in first 24-hour oral morphine equivalent use among the groups (P=.10). Moreover, there was no difference in numeric pain scores (although a trend toward significance in discharge pain scores in the bupivacaine group), total 7-day oral morphine equivalent use, day of last opioid use, or return of bowel function among the groups (P>.05 for all). The predictors of increased 24-hour opioid usage among all patients included only increased postanesthesia care unit oral morphine equivalent usage. The predictors of 7-day opioid usage among all patients included concurrent tobacco use and mood disorder, history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit., Conclusion: Laparoscopic uterosacral administration of bupivacaine at the time of minimally invasive hysterectomy did not result in decreased opioid usage or change in numeric pain scores., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of obesity on clinical and financial outcomes of minimally invasive hysterectomy METHODS: This was a retrospective cohort study of 5 affiliated hospitals. We obtained demographic, operative, and financial characteristics to analyze the effects of obesity on outcomes, including operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), adverse perioperative events, and hospital charges. Obesity was stratified by the following classes: no obesity (BMI <30 kg/m 2 ), class I (BMI 30-34 kg/m 2 ), class II (BMI 35-39 kg/m 2 ), and class III (BMI >40 kg/m 2 ). Descriptive statistics and multivariate logistic and linear regressions were performed., Results: A total of 2483 women underwent benign, minimally invasive hysterectomy. Laparoscopic was the most common approach (79.8%), followed by robotic (12.2%), and vaginal (8.0%). Mean BMI was 30.13 ± 6.99 kg/m 2 , and total charges were US $13 928 ± $5954. Each additional minute in the OR increased costs by US $47.89 (P < 0.001). Compared with patients without obesity, OR time and EBL were significantly higher among patients with class I or II obesity and highest among patients with class III obesity (P < 0.001). Obesity did not affect LOS or occurrence of adverse perioperative events. Although obesity appeared to be a significant predictor of hysterectomy charges, after adjusting for covariates, charges for laparoscopic and robotic hysterectomy did not differ significantly by BMI., Conclusion: Obesity appears to have a significant effect on clinical outcomes of benign hysterectomy that is approach-dependent and most notable among patients with class III obesity. BMI was not, however, a predictor of financial outcomes., (Copyright © 2022 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Introduction: Urogynecologic disorders are highly prevalent, and many physicians across various specialties will encounter and care for patients with pelvic floor disorders. Yet most medical students have had limited to no experience in diagnosing and managing pelvic floor disorders, resulting in a gap in clinical education., Methods: Three virtual and interactive urogynecologic patient cases were developed on an e-learning platform with an overall goal of increasing clinical exposure to various pelvic floor disorders. The cases were integrated into the medical student obstetrics and gynecology clerkship during the 2020-2021 academic year ( n = 40). Participants provided feedback regarding usability, acceptability, and educational value of the cases., Results: Twenty-one students (52%) completed the survey. Ninety percent ( n = 19) agreed or strongly agreed that they were satisfied with the cases, and 71% ( n = 15) agreed or strongly agreed that they would recommend the virtual patient cases to other students. All students ( n = 21) felt that the format was easy to use and reported that the cases were appropriate for their level of learning. Most students felt that the cases increased or significantly increased their confidence regarding nonsurgical and surgical management options for pelvic floor disorders., Discussion: Our findings suggest that these interactive virtual patient cases are an acceptable, valuable, and effective tool for learners. Utilizing the cases can help mitigate existing disparities in exposure to pelvic floor disorders both highlighted by and preceding the COVID-19 pandemic., (© 2022 Kikuchi et al.)

Background: The US guidelines recommend avoiding marijuana during breastfeeding given concerns about infant's neurodevelopment. In this setting, some physicians and hospitals recommend against or prohibit breastfeeding when marijuana use is detected during pregnancy. However, breastfeeding is beneficial for infants and women, and stigmatization of substance use in pregnancy has been historically linked to punitive approaches with a disproportionate impact on minority populations. We advance an empirically informed ethical analysis of this issue., Methods: First, we performed a retrospective cross-sectional qualitative study of prenatal and postpartum records from a random sample of 150 women delivered in an academic hospital system in 2017 to provide evidence and context regarding breastfeeding management in relation to marijuana use. We then perform a scoping literature review on infant risks from breastmilk marijuana exposure and risks associated with not breastfeeding for infants and women. Finally, we analyze this issue vis-a-vis ethical principles of beneficence, autonomy, and justice., Results: (1) Medical records reveal punitive language pertaining to the medicinal use of marijuana in pregnancy and misinterpretation of national guidelines, e.g., "patient caught breastfeeding and instructed to stop." (2) Though there are plausible neurodevelopmental harms from breastmilk exposure to THC, evidence of infant effects from breastmilk exposure to marijuana is limited and largely confounded by concomitant pregnancy exposure and undisclosed exposures. By contrast, health benefits of breastfeeding for women and infants are well-established, as are harms of forgoing breastfeeding. (3) Discouraging breastfeeding for women with marijuana use in pregnancy contradicts beneficence, as it neglects women's health considerations and incorrectly assumes that risks exceed benefits for infants. Restrictive hospital practices (e.g., withholding lactation support) compromise maternal autonomy and exploit power asymmetry between birthing persons and institutions, particularly when compulsory toxicology screening prompts child welfare investigations. Finally, recommending against breastfeeding during prenatal care and imposing restrictions during postpartum hospitalization may exacerbate racial disparities in breastfeeding and related health outcomes., Conclusions: Policy interpretations which discourage rather than encourage breastfeeding among women who use of marijuana may cause net harm, compromise autonomy, and disproportionately threaten health and wellbeing of underserved women and infants., (© 2022. The Author(s).)

During the Coronavirus (COVID-19) pandemic, in-person interpreters have been deemed "nonessential," and thus eliminated to minimize viral exposure and conserve personal protective equipment. Considering alarming patterns of interpreter underuse, we evaluate how substitution for remote modalities (telephone or video) may exacerbate existing inequalities for patients with limited English proficiency. The inherent intimacy, dynamic physicality, and cultural nuances of labor and delivery pose unique communication challenges. Using clinical scenarios, we illustrate the vital role interpreters have in providing accessible obstetric care. We argue that eliminating in-person interpreters in this setting is not justified by COVID-related harms given the potential to exacerbate underlying health disparities., Competing Interests: No competing financial interests exist., (© Margot Le Neveu et al., 2020; Published by Mary Ann Liebert, Inc.)