IMPORTANCE:Only a fraction of women with overactive bladder (OAB) receive effective treatment for this condition; inequities in access to OAB care must be understood. OBJECTIVE:The objective of this study was to explore features associated with intradetrusor chemodenervation treatment for OAB among female Medicare beneficiaries from different racial and ethnic groups. STUDY DESIGN:This was a retrospective cohort study of females ≥65 years old from the Center for Medicare & Medicaid Services' 5% Limited Data Set with a diagnosis of OAB between 2012 and 2020. The cumulative incidence of beneficiaries who received intradetrusor chemodenervation within 5 years following OAB diagnosis was compared between race and ethnicity groups. Cox regression analysis was performed to determine predictors for the likelihood of intradetrusor chemodenervation treatment and to adjust for potential confounders. RESULTS:In total, 232,366 females with a new OAB diagnosis were identified. The cumulative incidence of intradetrusor chemodenervation treatment within 5 years of OAB diagnosis was low at 1.4%, with lower rates among Asian (0.6%), Black (0.7%), Hispanic (0.7%), and Other groups (0.9%) ( P < 0.001). After adjustments, non-White race and Hispanic ethnicity (Asian: adjusted hazard ratio [aHR] 0.51, 95% CI: 0.33-0.80; Black: aHR 0.56, 95% CI: 0.45-0.69; Hispanic: aHR 0.62, 95% CI: 0.40-0.96; Other: aHR 0.58, 95% CI: 0.37-0.91) were associated with a lower relative hazard of receiving intradetrusor chemodenervation. CONCLUSIONS:Overall utilization of intradetrusor chemodenervation was low in this national cohort. Women from non-White racial and ethnic groups had lower rates of utilization compared with White women. Further research should evaluate barriers patients face in accessing this effective OAB treatment and explore potential interventions that facilitate access to care.

IMPORTANCE:Little is known regarding patient use of the emergency department for prolapse symptoms and the burden this use places on the health care system. OBJECTIVE:The aim of the study was to evaluate the incidence of emergency department visits in the United States for pelvic organ prolapse and associated patient and hospital demographics. STUDY DESIGN:This was a cross-sectional study of emergency department presentations from 2016 to 2018 associated with a primary diagnosis of pelvic organ prolapse. Data were obtained using International Classification of Diseases, Tenth Revision, Clinical Modification codes from the Healthcare Cost and Utilization Project Nationwide Emergency Department Samples. Descriptive analysis was used to identify sociodemographic and clinical characteristics of the population presenting to the emergency department for prolapse. RESULTS:Between 2016 and 2018, there were 14,101 annual emergency department visits for prolapse in the United States, which comprised less than 0.01% of all emergency department visits. Overall, 55.5% of patients were <65 years old and 62.5% had a household income of <50th percentile ($0-$58,999). The most common secondary diagnosis was hypertension (12.3%), and the most common secondary urogynecologic diagnosis was urinary tract infection or pyelonephritis (5.7%). No high-risk comorbidities were seen in 78.1% of patients. Most patients with prolapse were discharged (91.8%), although 5.8% were admitted and 1.5% were transferred for further care. CONCLUSIONS:Emergency department presentation for pelvic organ prolapse is uncommon. Disproportionate emergency department use was seen for patients <65 years old and with low household income. Further initiatives can optimize outpatient workflows for urogynecologic care and expand community outreach efforts on prolapse education to reduce emergency department use for nonurgent concerns.

OBJECTIVE: To explore how patient characteristics related to health care disparities are associated with access to care and clinical outcomes among patients receiving surgical treatment for pelvic floor disorders in the United States. DATA SOURCES: We searched MEDLINE, EMBASE, and ClinicalTrials.gov through March 25, 2024. METHODS OF STUDY SELECTION: Patient characteristics related to health care disparities included race, ethnicity, geographic location, and insurance status, among others. Outcomes included access to surgery, surgical outcomes, and patient-reported outcomes. Eligible studies reported multivariable regression analyses that included at least one patient characteristic related to health care disparities and an included study outcome. For each outcome, we describe the consistency (in direction), strength of association, and number of studies of the patient characteristic related to health care disparities. Meta-analysis was not performed because of study heterogeneity. This review was conducted by the Systematic Review Group of the Society of Gynecologic Surgeons. TABULATION, INTEGRATION, AND RESULTS: Of 6,853 abstracts screened, 42 studies with a total of 84 multivariable analyses were included. Characteristics associated with decreased access to apical suspension during prolapse surgery included being from a rural area or of Hispanic ethnicity, and Black racial identity was associated with decreased access to mesh augmentation. Black racial identity and Hispanic ethnicity were also associated with decreased access to reconstructive prolapse repair compared with obliterative procedures and hemorrhage during prolapse repair; older age and having Medicare insurance were associated with increased risk of overall complications. Not being from the Northeast was associated with increased risk of overall complications after prolapse surgery. Patients from a minority race were less likely to undergo reoperation after stress urinary incontinence (SUI) surgery. Black race was not associated with complications after SUI surgery. CONCLUSION: Patients in minoritized groups in the United States, those with Medicare insurance, and those not from the Northeast were more likely to have health care disparities related to surgical treatment for pelvic floor disorders. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021234511.

ImportanceUnlike other surgical specialties, obstetrics and gynecology (OB-GYN) has been predominantly female for the last decade. The association of this with gender bias and sexual harassment is not known.ObjectiveTo systematically review the prevalence of sexual harassment, bullying, abuse, and discrimination among OB-GYN clinicians and trainees and interventions aimed at reducing harassment in OB-GYN and other surgical specialties.Evidence ReviewA systematic search of PubMed, Embase, and ClinicalTrials.gov was conducted to identify studies published from inception through June 13, 2023.: For the prevalence of harassment, OB-GYN clinicians and trainees on OB-GYN rotations in all subspecialties in the US or Canada were included. Personal experiences of harassment (sexual harassment, bullying, abuse, and discrimination) by other health care personnel, event reporting, burnout and exit from medicine, fear of retaliation, and related outcomes were included. Interventions across all surgical specialties in any country to decrease incidence of harassment were also evaluated. Abstracts and potentially relevant full-text articles were double screened.: Eligible studies were extracted into standard forms. Risk of bias and certainty of evidence of included research were assessed. A meta-analysis was not performed owing to heterogeneity of outcomes.FindingsA total of 10 eligible studies among 5852 participants addressed prevalence and 12 eligible studies among 2906 participants addressed interventions. The prevalence of sexual harassment (range, 250 of 907 physicians [27.6%] to 181 of 255 female gynecologic oncologists [70.9%]), workplace discrimination (range, 142 of 249 gynecologic oncologists [57.0%] to 354 of 527 gynecologic oncologists [67.2%] among women; 138 of 358 gynecologic oncologists among males [38.5%]), and bullying (131 of 248 female gynecologic oncologists [52.8%]) was frequent among OB-GYN respondents. OB-GYN trainees commonly experienced sexual harassment (253 of 366 respondents [69.1%]), which included gender harassment, unwanted sexual attention, and sexual coercion. The proportion of OB-GYN clinicians who reported their sexual harassment to anyone ranged from 21 of 250 AAGL (formerly, the American Association of Gynecologic Laparoscopists) members (8.4%) to 32 of 256 gynecologic oncologists (12.5%) compared with 32.6% of OB-GYN trainees. Mistreatment during their OB-GYN rotation was indicated by 168 of 668 medical students surveyed (25.1%). Perpetrators of harassment included physicians (30.1%), other trainees (13.1%), and operating room staff (7.7%). Various interventions were used and studied, which were associated with improved recognition of bias and reporting (eg, implementation of a video- and discussion-based mistreatment program during a surgery clerkship was associated with a decrease in medical student mistreatment reports from 14 reports in previous year to 9 reports in the first year and 4 in the second year after implementation). However, no significant decrease in the frequency of sexual harassment was found with any intervention.Conclusions and RelevanceThis study found high rates of harassment behaviors within OB-GYN. Interventions to limit these behaviors were not adequately studied, were limited mostly to medical students, and typically did not specifically address sexual or other forms of harassment.

OBJECTIVE:To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES:PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION:In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS:Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION:Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42022326255.

Pelvic organ prolapse (POP) is a common condition, and surgical repair will take place for as many as 12.6% of women at some point in their lifetime. Though definitions vary, it is agreed that the diagnosis of POP and thus the demand for care are increasingfaster than expected; potential causes may include advancing ageand increasing prevalence of obesity, which are both associatedwith POP. Current literature predicts that severe obesity (body mass index [BMI] higher than 40) will be the most common weightclassification among women by 2030, with a prevalence as high as 1 in 4. Given that obesity also increases risks of surgical com-plications, previous studies haveexamined its role in other gynecologic surgeries, with varied outcomes. This study was designed toevaluate the association of BMI with POP surgery outcomes in the form of a systematic review and meta-analysis.

Importance Telemedicine was increasingly used to provide patients with an alternative to in-office visits during the COVID-19 pandemic. While previous studies have described the role of telemedicine for preoperative visits for other surgical specialties, the role of this modality in preoperative visits for gynecologic surgery has not been thoroughly explored. Objectives The aims of the study are to explore and compare patient experience, decision making, and satisfaction among women undergoing telemedicine or in-person preoperative visits. Study Design This was a qualitative study of women who underwent a preoperative appointment with a urogynecologic surgeon or minimally invasive gynecologic surgeon at a single academic institution from April to May of 2021. Data were collected using semistructured phone interviews, which focused on visit content, visit type decision making, surgical preparedness/confidence, and past surgical experiences. Interviews were thematically analyzed until theoretical saturation was achieved in accordance with grounded theory. Results Theoretical saturation occurred with 20 interviews. Participants were evenly divided between in-person and telemedicine visits. Major themes included visit content, experience/quality, surgeon perception, and surgical preparedness. Advantages of telemedicine visits were convenience and safety. Advantages of in-person visits were social factors, perceived medical or surgical severity, and preoperative physical examination. Disadvantages for telemedicine visits included technology concerns and difficulty accessing preoperative materials. The disadvantage of an in-person visit was the inability to have family present because of COVID hospital policy restrictions. Participants in both groups felt prepared for surgery and reported high satisfaction with their care. Conclusions Decision making for selecting an in-person or telemedicine visit is complex and involves balancing multiple advantages and disadvantages. Participant experience was similar for both visit types with high satisfaction.

Prior studies demonstrate mixed results on the impact of obesity on the success of midurethral slings (MUS), with little known about how postoperative weight change affects outcomes. We aimed to examine the effect of postoperative weight change on outcomes 12 months after MUS for stress urinary incontinence (SUI). This secondary analysis utilized data from two multicenter randomized trials of women undergoing MUS placement. Subjects were categorized into cohorts based on change in body weight at 12 months postoperatively: weight gain (≥5

OBJECTIVE:To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications.DATA SOURCES:PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022.METHODS OF STUDY SELECTION:The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies.TABULATION, INTEGRATION, AND RESULTS:Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy.CONCLUSION:Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities.SYSTEMATIC REVIEW REGISTRATION:PROSPERO, CRD42021234511.

OBJECTIVE: To estimate the national cost of pelvic organ prolapse (POP) surgery in the United States. METHODS: In this cross-sectional, population-based study, we used the 2016–2018 Healthcare Cost and Utilization Project National Inpatient Samples and National Ambulatory Surgery Samples to identify patients undergoing POP surgery using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, ICD-10 procedural codes, and Current Procedural Terminology codes. Cost-to-charge ratios and weighted estimates were used to calculate nationwide costs. Descriptive analysis was used to identify the sociodemographic, clinical, and surgical characteristics of the population undergoing POP surgery. RESULTS: Between 2016 and 2018, there were 140,762 POP surgical cases annually with an annual national cost estimated at $1.523 billion per year. The median cost per procedure increased slightly from $8,837 in 2016 to $8,958 in 2018. Overall, 82.5% of the total surgeries and 78% of the total national costs associated with POP surgery came from the ambulatory setting over this time period. Of these surgeries, 44.7% included an apical repair, and 42.3% included a concomitant hysterectomy. The average age of the population was 62 years, and 20% of the total population receiving prolapse surgery were younger than age 50 years. CONCLUSION: The annual national cost associated with surgical correction of POP is substantial, and the majority of cases occur in an ambulatory setting. These findings will contribute to enhancing cost-effectiveness analyses and decision-making processes for both health care professionals and policymakers as the national population continues to age.

Objective The aim of this study was to determine if higher artificially sweetened beverage intake is associated with higher prevalence of urinary incontinence symptoms. Methods We conducted a secondary analysis of data from the Women's Health Initiative Observational Study. Our analytic cohort included 80,388 women. Participants who answered questions about beverage consumption and urinary incontinence symptoms at a 3-year follow-up visit were included. Demographic characteristics were compared between three groups of beverage consumers: never to less than one serving per week, one to six servings per week, and greater than or equal to one serving per day. Multivariable logistic regression models were constructed to estimate odds and type of urinary incontinence and adjust for potential confounders. Results Most participants (64%) were rare consumers of artificially sweetened beverages, with 13% ( n = 10,494) consuming greater than or equal to 1 serving per day. The unadjusted odds of reporting urinary incontinence were 10% to 12% higher in women consuming one to six servings per week (odds ratio [OR], 1.10; 95% CI, 1.06-1.14) or greater than or equal to one serving per day (OR, 1.12; 95% CI, 1.07-1.18) versus never to less than one serving per week. In multivariable analyses, women consuming greater than or equal to one serving per day (ref: never to <1 serving/wk) had 10% higher odds of reporting mixed urinary incontinence (OR, 1.10; 95% CI, 1.02-1.19). There were no significant differences for stress or urgency urinary incontinence symptoms between groups. Conclusions When compared to never to less than one serving per week, women consuming greater than or equal to one serving per day of artificially sweetened beverages had 10% greater odds of reporting mixed urinary incontinence after adjustments. Amount of artificially sweetened beverage consumption was not associated with stress or urgency urinary incontinence symptoms.

Importance Diabetes is an independent risk factor for urinary incontinence, and its impact on rates of postoperative incontinence after pelvic reconstructive surgery remains unexplored. Objective The aim of the study was to compare the incidence of postoperative stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence in patients with diabetes mellitus undergoing surgery for pelvic organ prolapse (POP) with or without SUI surgery. Study Design This is a secondary analysis of a multicenter retrospective cohort study involving 10 diverse medical centers that identified a cohort of women with diabetes who had prolapse and/or anti-incontinence surgery. We compared rates of postoperative urinary incontinence among patients who had surgery for prolapse and incontinence versus surgery for prolapse only. Results Three hundred five patients had surgery for prolapse and incontinence, 330 had surgery for prolapse only, and 189 had anti-incontinence surgery only. De novo UUI was higher among those who underwent surgery for POP and SUI compared with surgery for POP alone (26.4% vs 14.1%, P < 0.01). Rates of persistent SUI (21% vs 4.9%, P < 0.01) and mixed urinary incontinence (15.9% vs 2.7%, P < 0.01) were higher for those who underwent prolapse surgery alone versus prolapse and an incontinence procedure. No differences were seen in hemoglobin A 1C levels between those who did and did not report postoperative UI. Conclusions We found that postoperative de novo UUI rates were high among patients with diabetes after pelvic reconstructive surgery, with the incidence being significantly higher for those who had surgery for prolapse and incontinence compared with surgery for prolapse only.

Importance Intradetrusor injection of onabotulinumtoxinA is performed via varying injection paradigms but no studies have studied the various effects of these paradigms on patient experience with the procedure. Objectives This randomized clinical trial aims to compare pain and procedure time between patients receiving a 100-unit dose of onabotulinumtoxinA in 5 injections compared to 20 injections for the treatment of idiopathic overactive bladder or urgency urinary incontinence. Study Design Patients presenting with refractory overactive bladder or urgency urinary incontinence at 2 clinical sites were identified and randomized to undergo onabotulinumtoxinA treatment with 5 injections versus 20 injections. Patients rated their pain level on a 10-point visual analog scale at procedure completion. The procedure duration was recorded with a stopwatch. Patients were followed up 6 weeks postprocedure, at which time they completed a Global Response Assessment to determine subjective efficacy of treatment. Participants were additionally monitored for incidence of adverse events in the follow-up period. Results The average pain score was not statistically significant between groups (2; interquartile range, 1–4 for the 5 injection group vs 3; interquartile range, 2–4 for the 20 injection group; P = 0.27). Patients who received 5 injections experienced significantly shorter mean procedure time as compared with patients who received 20 injections (76 seconds vs 176 seconds; P < 0.001). There were no differences in subjective efficacy or adverse events between groups. Conclusions Perceived pain, efficacy, and postprocedure complications did not significantly differ between patients receiving 5 injections and 20 injections, but procedure time was significantly shorter.

For treating nonneurogenic overactive bladder, female pelvic medicine and urogenital reconstruction guidelines given by the American Urological Association and Society of Urodynamics recommend that onabotulinumtoxinA (botoxA) may be used as third-line therapy following a failure of both first-line lifestyle and behavioral changes and second-line cholinergic or ss-agonist therapy. Wide variations on the acceptable number of injections per treatment episode (as much as 1 injection to 40) have been promulgated for botoxA. Few studies have been performed to assess patient-centered outcomes for repeated injection. As the goal of treatment using botoxA is to improve patient quality of life, this study aimed to assess the effect of the injection paradigm on patient perceptions of the treatment. In addition, the study sought comparisons of the patient-perceived efficacy of treatment, the duration of the procedure, and any adverse events. The authors hypothesized that receiving fewer injections will result in a patient experience with significantly less pain and a shorter procedure time than those receiving more injections. This study used a multicenter single-blind, randomized controlled trial format. It enrolled women undergoing treatment of refractory idiopathic overactive bladder via intradetrusor botoxA. For the experimental arm, participants received a 100-unit dose of botoxA in 10 mL of sodium chloride as 5 injections of 2 mL each, and participants in the control arm received 20 injections of 0.5 mL each. Participants were masked to their treatment allocation. Primary outcomes of the study were perceived overall pain on a 10-point visual analog scale (VAS) and duration of injection procedure. Secondary outcomes included a 6-week postprocedure Global Response Assessment (GRA) score measuring subjective treatment efficacy, as collected via follow-up phone call (integer scale of -3 to +3). A total of 60 patients were recruited at 2 study sites. The median VAS pain score was not significantly different between groups. However, there was a significant difference in duration of procedure, with a median of 76 seconds for 5-injection participants and 176 seconds for 20-injection participants, meaning that the procedure was almost 2 minutes shorter with the 5-injection approach. The GRA score of efficacy was not significantly different between groups, but the study did not assess additional traditional methods of measuring efficacy of treatment with botoxA such as pad counts or bladder diaries. Strengths of this study include the following: single-blind, randomized controlled design and a well-defined study population consisting of women with urgency urinary incontinence or idiopathic overactive bladder. The generalizability of the study is facilitated by its multisite nature. Furthermore, the authors' choice to utilize subjective outcome measures contributed to the strength of this patient-focused outcomes study. Limitations of the study include the inability to determine whether masking patients to their treatment assignment truly prevented bias, as patients may have had the ability to count the number of injections performed and therefore ascertain their treatment group. There may have been some variation in the procedure performance and equipment, as this was not strictly standardized. The small size of the study itself could also limit the ability of researchers to detect differences in secondary outcomes between groups. This trial showed that perception of pain from botoxAvia intradetrusor injection may not be significantly affected by decreasing the number of injection sites. That approach does significantly shorten procedure time, which likely improves the patient experience. Results such as these suggest a possibility of modifying the traditional injection paradigm to optimize the procedure experience for patients without compromising safety or efficacy.

Background:Insufficient data exist to conclude whether consumption of artificially sweetened beverages is associated with a higher risk of urinary tract cancers. Objective:We sought to investigate whether urinary tract cancer incidence differed among women who consumed various amounts of artificially sweetened beverages. Design setting and participants:This was a secondary analysis of data from the Women's Health Initiative Observational Study, a multicenter longitudinal prospective study of the health of 93 676 postmenopausal women with a mean follow-up time of 13.5 yr. Women were identified at 40 clinical centers across the USA and enrolled from 1993 to 1998. Women between the ages of 50 and 79 yr were enrolled. We included women who answered questions about artificially sweetened beverage consumption and reported no prior urinary tract cancer diagnoses. The frequency of artificially sweetened beverage consumption was categorized as follows: rare artificially sweetened beverage consumption (never to fewer than one serving per week), frequent consumption (one to six servings per week), and daily consumption (more than one servings per day). Outcome measurements and statistical analysis:The incidence of urinary tract cancer reported during subsequent visits until February 28, 2020 was recorded. Demographic characteristics were compared between those with varying levels of artificially sweetened beverage consumption. Descriptive statistics were used to report the rates of urinary tract cancer diagnosis, and Cox regression models were constructed to determine hazard ratios and adjust for potential confounders. Results and limitations:We identified 80 388 participants who met the inclusion criteria. Most participants (64%) were infrequent consumers of artificially sweetened beverages, with 13% (n = 10 494) consuming more than one servings per day. The incidence of urinary tract cancers was low, with only 804 cases identified. Cox regression models showed that frequent artificially sweetened beverage consumption was associated with a higher risk of kidney cancer (adjusted hazard ratio 1.34, 95% confidence interval 1.03-1.75). There was no significant association between artificially sweetened beverage intake and bladder cancer. Conclusions:Frequent consumption of artificially sweetened beverages may be associated with a higher risk of kidney cancer among postmenopausal women. Patient summary:A secondary analysis of the Women's Health Initiative Observational Study showed that higher consumption of artificially sweetened beverages was associated with a higher risk of kidney cancer.

OBJECTIVE To compare 30-day complication rates after prolapse repair and sling procedures across racial/ethnic groups, and evaluate trends over time. METHODS We identified female patients in a national outcomes-based database who underwent prolapse repair and/or sling procedures between January 1, 2010 and December 31, 2018, stratified by race and ethnicity, and compared 30-day postoperative complication rates. Multivariable logistic regression adjusted for confounders. Trends in complication rates over time were evaluated using a test for trend (p-trend). RESULTS We identified 70,540 prolapse repairs and 23,968 sling procedures. Following prolapse repairs, Black women had the highest complication rates (11%, vs 8% for Hispanic and 9% for both White and Other race/ethnicity women, P <0.01). Following sling procedures, there were few differences in complication rates between groups. After adjustments, Black women still experienced higher odds of any complication (aOR 1.15, 95% CI 1.03-1.29), particularly a vascular complication (venous thromboembolism or transfusion) (aOR 2.50, 95% CI 2.05-3.04) following prolapse repair procedures. Hispanic women had higher odds of vascular complications after prolapse repair (aOR 1.47, 95% CI 1.23-1.76) and slings (aOR 2.40, 95% CI 1.53-3.76). Trends from 2010-2018 showed a decrease in vascular complication rates among non-Black women after prolapse repairs, but rates among Black women did not decrease. CONCLUSION Black women have higher odds of experiencing postoperative complications after prolapse repair procedures, particularly vascular complications. Vascular complication rates after prolapse repair decreased over time for all racial/ethnic groups except Black women. Hispanic women have higher odds of vascular complications after prolapse repair and slings than other racial/ethnic groups. UROLOGY 160: 81-86, 2022. (c) 2021 Elsevier Inc.

OBJECTIVES:Poor control of diabetes mellitus is a known predictor of perioperative and postoperative complications. No literature to date has established a hemoglobin A1c (HbA1c) cutoff for risk stratification in the urogynecology population. We sought to identify an HbA1c threshold predictive of increased risk for perioperative and postoperative complications after pelvic reconstructive surgery.METHODS:This multicenter retrospective cohort study involving 10 geographically diverse U.S. female pelvic medicine and reconstructive surgery programs identified women with diabetes who underwent prolapse and/or stress urinary incontinence surgery from September 1, 2013, to August 31, 2018. We collected information on demographics, preoperative HbA1c levels, surgery type, complications, and outcomes. Sensitivity analyses identified thresholds of complications stratified by HbA1c. Multivariate logistic regression further evaluated the association between HbA1c and complications after adjustments.RESULTS:Eight hundred seven charts were identified. In this diabetic cohort, the rate of overall complications was 44.1%, and severe complications were 14.9%. Patients with an am HbA1c value of 8% or greater (reference HbA1c, <8%) had an increased rate of both severe (27.1% vs 12.8%, P < 0.001) and overall complications (57.6% vs 41.8%, P = 0.002) that persisted after multivariate logistic regression (odds ratio, 2.618; 95% confidence interval, 1.560-4.393 and odds ratio, 1.931; 95% confidence interval, 1.264-2.949, respectively). Mesh complications occurred in 4.6% of sacrocolpopexies and 1.7% of slings. The average HbA1c in those with mesh exposures was 7.5%.CONCLUSIONS:Preoperative HbA1c of 8% or higher was associated with a 2- to 3-fold increased risk of overall and severe complications in diabetic patients undergoing pelvic reconstructive surgery that persisted after adjustments.

Study Objective: To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA(1c)) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA(1c) level past which we should consider delaying surgery owing to increased risk of complications. Design: Retrospective cohort study. Setting: Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017. Patients: Women with and without a diabetes diagnosis. Interventions: Hysterectomy. Measurements and Main Results: Data on demographics, preoperative HbA(1c) values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA(1c) level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA(1c) value; group 2: no diabetes diagnosis, with HbA(1c) levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA(1c) value or HbA(1c) levels <9%; and group 4: diabetes diagnosis with HbA(1c) levels >= 9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA(1c) level >= 9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA1c levels >= 9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA(1c) levels < 9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery. Conclusion: Diabetes diagnosis and measurement of preoperative HbA(1c) levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA1c level >= 9%. (C) 2021 AAGL. All rights reserved.

Recent publications show an association between exposure to anticholinergic medications and the risk of developing dementia. We hypothesized that urogynecology providers have changed their overactive bladder syndrome treatment as a result of this literature. This was an anonymous, cross-sectional, web-based survey of American Urogynecologic Society members. Survey questions queried awareness of the referenced literature, prescribing practices, the impact of insurance on treatment plans, and demographics. Our primary outcome measured the change in prescribing practice in response to literature linking anticholinergic medications with the risk of dementia. Descriptive statistics were used. A total of 222 urogynecology providers completed the survey. Nearly all respondents (99.1%) were aware of the recent literature, and, as a result, 90.5% reported changing their practice. Prior to the publication of recent literature, a “non-CNS-sparing” anticholinergic (e.g., oxybutynin) was most commonly prescribed (64.4%), whereas after the literature was published, this shifted to ß3-adrenoceptor agonists (58.5%, p < 0.001). A majority of respondents (96.6%) reported that insurance restrictions led to a change in treatment for some patients, with 73.5% describing the prior-authorization process as difficult. Many providers (61.8%) reported that a trial of anticholinergics was required by insurance companies prior to authorizing mirabegron. The recent literature associating anticholinergic medications with the development of dementia has changed practice patterns among survey respondents, with a shift away from anticholinergic medications and toward ß3-adrenoceptor agonists. The majority of respondents report insurance barriers to non-anticholinergic therapies, resulting in alteration of their preferred practices.