Lower reproductive tract fistula repairs in inpatient US women, 1979-2006

INTRODUCTION AND HYPOTHESIS

The objective of the study was to characterize trends in lower reproductive tract fistula (LRTF) repair in inpatient US women from 1979 to 2006.

METHODS

Retrospective data was obtained from the National Hospital Discharge Survey regarding LRTF diagnoses, demographics, comorbidities, and fistula repair procedures, using ICD-9-CM diagnostic and procedure codes. Age-adjusted rates (AARs) were calculated using 1990 census data. Trends in LRTF surgical repair were evaluated using regression analysis.

RESULTS

Between 1979 and 2006, the AAR of LRTF repair declined from 7.8 to 4.8 per 100,000 women (b = -2.97, p < 0.001). The most common surgical fistula repairs were rectovaginal, vesicovaginal, and colovaginal. The AARs of colovaginal and vesicovaginal fistula repair remained stable, while the AAR of rectovaginal fistula repair declined.

CONCLUSIONS

The AAR of inpatient LRTF repair declined between 1979 and 2006, perhaps reflecting a concurrent decrease in obstetric trauma, in the context of decreasing episiotomy and operative vaginal delivery and increasing cesarean section rates.

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study

OBJECTIVE

To describe surgical complications in 597 women over a 24-month period after randomization to retropubic or transobturator midurethral slings.

STUDY DESIGN

During the Trial of Midurethral Slings study, the Data Safety Monitoring Board regularly reviewed summary reports of all adverse events using the Dindo Surgical Complication Scale. Logistic regression models were created to explore associations between clinicodemographic factors and surgical complications.

RESULTS

A total of 383 adverse events were observed among 253 of the 597 women (42%). Seventy-five adverse events (20%) were classified as serious (serious adverse events); occurring in 70 women. Intraoperative bladder perforation (15 events) occurred exclusively in the retropubic group. Neurologic adverse events were more common in the transobturator group than in retropubic (32 events vs 20 events, respectively). Twenty-three (4%) women experienced mesh complications, including delayed presentations, in both groups.

CONCLUSION

Adverse events vary by procedure, but are common after midurethral sling. Most events resolve without significant sequelae.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures

OBJECTIVES

To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a woman's lifespan.

METHODS

Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed.

RESULTS

More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a woman's lifetime.

CONCLUSION

Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women.

LEVEL OF EVIDENCE

III.

Prophylactic bilateral oophorectomy or removal of remaining ovary at the time of hysterectomy in the United States, 1979-2004

OBJECTIVE

The purpose of this study was to describe national rates and trends of prophylactic bilateral oophorectomy or remaining oophorectomy (BO/RO) at hysterectomy in women without specific gynecologic disease.

STUDY DESIGN

Data from the National Hospital Discharge Survey were analyzed for 1979-2004. Hysterectomies were divided into 2 groups: (1) hysterectomy with BO/RO and (2) hysterectomy alone (> or =1 ovary remaining). Age-adjusted rates (AARs) were calculated with 2000 US census data.

RESULTS

Approximately 3,686,000 hysterectomies with BO/RO were performed from 1979-2004. AARs of hysterectomy with BO/RO decreased during this period; the AARs in women > or =50 years old increased. The number of hysterectomies alone was 5,461,100, and AARs of hysterectomy alone decreased significantly from 2.9 per 1000 women in from 1979-1981 to 1.1 per 1000 women in 2001 (P < .001). The proportion of women who underwent hysterectomy with BO/RO increased from 29% in 1979 to 45% in 2004.

CONCLUSION

Although AARs of prophylactic BO/RO decreased from 1979-2004, the actual proportion of BO/RO at hysterectomy increased.

Lower urinary tract injury in women in the United States, 1979-2006

OBJECTIVE

We sought to determine age-adjusted rates (AARs) of lower urinary tract injury and incidence in selected inpatient gynecologic and obstetric procedures.

STUDY DESIGN

We utilized the National Hospital Discharge Survey, 1979-2006. AARs of nonobstetric bladder and ureteral injuries and incidence of lower urinary tract injury for various hysterectomy types and deliveries were calculated for women>18 years old.

RESULTS

Overall AARs of ureteral injury decreased from 0.06-0.03 per 1000 women (1979-2006). AARs of inpatient gynecologic procedures decreased from 24.9-11.8 per 1000 women (1979-2006). By hysterectomy type, bladder injury was highest in laparoscopic-assisted vaginal hysterectomy (VH) (13.8 per 1000) and VH (13.1 per 1000). Ureteral injury recognized during hysterectomy was most common with radical hysterectomy (7.7 per 1000) and least common with laparoscopic-assisted VH (0 per 1000).

CONCLUSION

Ureteral injuries at time of inpatient surgical procedures have decreased from 1979-2006. This corresponds with a sharp decrease in inpatient gynecologic procedures.

Depressive symptoms in women seeking surgery for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

To compare depressive symptoms in women with and without prolapse and evaluate impact on quality of life.

METHODS

This is a secondary analysis of a case-control study assessing the effect of prolapse on body image. Cases had prolapse and sought surgery (Pelvic Organ Prolapse Quantification stage > or = 2). Controls had stage < or = 1. Subjects completed the Pelvic Floor Impact Questionnaire (PFIQ), Pelvic Floor Distress Inventory, and the Patient Health Questionnaire-9 (PHQ-9) at baseline. Cases completed measures 6 months post-operatively. We report: (1) the comparison of cases and controls at baseline and (2) comparison of baseline and post-operative scores in cases.

RESULTS

Baseline questionnaires were completed by 75 cases and 65 controls; 57 cases completed post-operative measures. Cases were 5-fold more likely than controls to have depressive symptoms. Cases with depressive symptoms had higher PFIQ scores than cases without symptoms. PHQ-9 scores improved post-operatively.

CONCLUSIONS

Depressive symptoms are common in women with prolapse and a decrease following surgical treatment.

Episiotomy in the United States: has anything changed?

OBJECTIVE

The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice.

STUDY DESIGN

The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy.

RESULTS

The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004.

CONCLUSION

Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.

Trends in stress urinary incontinence inpatient procedures in the United States, 1979-2004

OBJECTIVE

The purpose of this study was to describe national trends in surgery for female stress urinary incontinence (SUI).

STUDY DESIGN

We used data from the National Hospital Discharge Survey, a federal dataset sampling patient discharges from US inpatient hospitals. We analyzed patient and hospital demographics and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) diagnostic and procedures codes for 1979-2004. Age-adjusted rates per 1000 women were calculated with 1990 US Census population data.

RESULTS

The number of women who have undergone SUI surgery each year increased from 48,345 in 1979 to 103,467 in 2004. In women > or = 52 years old, the age-adjusted rate more than doubled from 0.64-1.60 procedures per 1000 women; in women < 52 years old, the age-adjusted rate fell from 0.57-0.47. Age-adjusted rates for retropubic urethral suspension (ICD-9-CM, 59.5) fell from 0.37 in 1979 to 0.14 in 2004. For suprapubic sling procedures (ICD-9-CM, 59.4), the age-adjusted rates rose from 0.02 in 1979 to a peak of 0.10 in 1997 and then fell to 0.03 in 2004. Age-adjusted rates for other repair of urinary stress incontinence (ICD-9-CM, 59.79) rose from 0.06 in 1979 to 0.64 in 2004.

CONCLUSION

The number of women who have undergone SUI surgery increased significantly from 1979-2004. Because the National Hospital Discharge Survey data do not include ambulatory procedures, accurate information on same-day surgeries is unavailable. Currently no ICD-9-CM procedure code exists specifically for midurethral sling procedures. Both missed sampling of same-day procedures and nonspecific or inaccurate coding may explain the surprising decline in suprapubic sling procedures and the rise in rates of other repair of SUI. A national ambulatory surgical database and a specific code for midurethral sling are needed to capture these important data.

Prophylactic antibiotics to prevent urinary tract infection during clean intermittent self-catheterization (CISC) for management of voiding dysfunction after prolapse and incontinence surgery: a decision analysis

INTRODUCTION AND HYPOTHESIS

The objective of this study is to estimate efficacy of prophylactic antibiotics in UTI prevention during CISC for postoperative voiding dysfunction after prolapse/incontinence surgery.

METHODS

We constructed a decision tree model to evaluate risks and benefits of prophylactic antibiotics during CISC for voiding dysfunction after prolapse/incontinence surgery. The model randomized women requiring CISC to prophylactic antibiotics or no prophylaxis. Probabilities for UTI after CISC with or without prophylactic antibiotics, sequelae from antibiotic use or UTI, and utility values were obtained from published literature and practice quality assurance reviews. Main outcome was probability of experiencing no UTI or adverse event.

RESULTS

Under baseline assumptions, prophylactic antibiotics were favored in both models. In the true UTI model, prophylactic antibiotics had an 83.1% probability of no UTI or adverse events; 16.1% better than no prophylactic antibiotics.

CONCLUSIONS

Using decision analysis methods, prophylactic antibiotics are favored for prevention of UTI during CISC to manage voiding dysfunction after prolapse/incontinence surgery.

Complications in women undergoing Burch colposuspension versus autologous rectus fascial sling for stress urinary incontinence

PURPOSE

We determined the clinicodemographic factors associated with complications of continence procedures, the impact of concomitant surgery on the complication rate and the relationship between the incidence of cystitis and the method of postoperative bladder drainage.

MATERIALS AND METHODS

We reviewed serious adverse events and adverse events in the Stress Incontinence Surgical Efficacy Trial, a randomized trial comparing Burch colposuspension to the autologous rectus fascial sling. Clinicodemographic variables were analyzed to determine those associated with adverse events using logistic regression analysis. Complications were stratified based on the presence or absence of concomitant surgery. Differences in complication rates (controlling for concomitant surgery) and cystitis rates (controlling for the bladder emptying method) were compared using Fisher's exact test.

RESULTS

Blood loss (p = 0.0002) and operative time (p <0.0001) were significantly associated with an adverse event. Patients who underwent concomitant surgery had a significantly higher serious adverse event rate (14.2% vs 7.3%, p = 0.01) and adverse event rate (60.5% vs 48%, p <0.01) than patients who underwent continence surgery alone. Cystitis rates were higher in the sling vs the Burch group up to 6 weeks postoperatively regardless of concomitant surgery status (p <0.01). Intermittent self-catheterization increased the cystitis rate by 17% and 23% in the Burch and sling groups, respectively.

CONCLUSIONS

Concomitant surgery at continence surgery increased the risk of complications. Sling surgery was associated with a higher risk of cystitis within the first 6 weeks postoperatively. Intermittent self-catheterization increased the risk of cystitis in each group. Complications were associated with surgical factors and not with patient related factors.

Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery

OBJECTIVE

This study was performed to assess the effect of pregnancy, route of delivery, and parity on the risk of primary and subsequent anal sphincter laceration in women at first vaginal delivery (1st VD), vaginal birth after cesarean delivery (VBAC), or second vaginal delivery (2nd VD).

METHODS

This retrospective cohort study used data from a perinatal database that included all deliveries at Magee-Womens Hospital from 1995 to 2002. Anal sphincter laceration was the primary outcome, defined as third- and fourth-degree perineal lacerations. The adjusted odds ratio (OR) for primary and subsequent anal sphincter laceration at delivery by risk group was estimated using logistic regression models and reported with 95% confidence intervals (CIs).

RESULTS

We assessed 20,674 live, singleton, term deliveries at Magee-Womens Hospital from 1995 to 2002, including 13,183 with 1st VD, 6068 with 2nd VD, and 1423 with VBAC. Anal sphincter laceration occurred in 16% of women with 1st VD, 18% with VBAC, and 3% with 2nd VD. Multivariable logistic regression modeling for primary anal sphincter laceration showed that 1st VD had OR of 5.1 and 95% CI 4.4, 5.9, and VBAC had OR of 5.1, 95% CI 4.2, 6.2 when compared with the reference group with 2nd VD. Shown in order for 1st VD, VBAC, and 2nd VD, the following factors, adjusted for the other listed factors, were significantly related to anal sphincter laceration except as noted: forceps, ORs of 3.0, 2.6, 5.5; midline episiotomy, ORs of 2.7, 2.9, 2.9; infant birth weight 3500 g or more, ORs of 1.9, 1.9, 1.1, not significantly different from OR of 1.0; vacuum delivery, ORs of 1.7, 1.8, 1.5, not significantly different from OR of 1.0, and 2nd stage of labor 2 hours or longer, ORs of 1.8, 0.9, 0.9, last 2 not significantly different from OR of 1.0. Of women who had anal sphincter laceration in their first vaginal delivery, 7.2% (76 of 1054 women who had 2 pregnancies) had recurrent laceration in their second vaginal delivery, compared with 2.3% (123 of 5147) of women who had a primary anal sphincter laceration in their second vaginal delivery. Multivariable logistic regression modeling for recurrent anal sphincter laceration yielded the following significant factors: episiotomy, OR 8.5, 95% CI 4.1, 17.7; vertex malpresentation (primarily occiput posterior), OR 4.3, 95% CI 1.4, 12.6; shoulder dystocia, OR 2.7, 95% CI 1.2, 5.8; and infant birth weight 3500 g or greater, OR 1.7, 95% CI 1.1, 2.7.

CONCLUSION

At this institution, women undergoing VBAC are at similarly high risk of anal sphincter laceration, compared with nulliparous women. Women with prior anal sphincter laceration are at 3 times increased risk for subsequent sphincter laceration, compared with women with prior vaginal delivery without sphincter laceration. Pregnancy by itself does not appear to be an important factor in decreasing the risk of anal sphincter laceration in subsequent deliveries.

Biomechanical adaptations of the rat vagina and supportive tissues in pregnancy to accommodate delivery

OBJECTIVE

We hypothesize that in pregnancy and at the time of delivery, the vagina and supportive tissues undergo dramatic alterations to accommodate passage of the fetus. In this study, we sought to characterize these changes in the rat using an established biomechanical testing protocol.

METHODS

Seventy-four 3-month-old Long Evans rats divided into virgin, mid and late pregnant, vaginal delivery (immediate and 4-week postpartum), and abdominal delivery (immediate and 4-week postpartum) groups were killed. The biomechanical properties of the vagina and supportive tissues were tested intact as a complex under loading conditions that simulate downward distension. Data were analyzed using analysis of variance and post hoc comparisons.

RESULTS

Mean linear stiffness (ability of the specimen to resist distension) and ultimate load at failure (maximal resistance of the specimen to distension before disruption) were decreased in pregnancy and at delivery, regardless of delivery route (Ps<.001). Maximal distension was increased at time of delivery (Ps<.001). Four weeks after vaginal delivery, all biomechanical characteristics returned to at least virgin values.

CONCLUSION

In the rat, the biomechanical characteristics affording distensibility of the vagina and supportive tissues increased in pregnancy and even further at delivery. It is likely that these represent maternal tissue adaptations that facilitate delivery of the fetus(es).

Prophylactic antibiotics after urodynamics in women: a decision analysis

The objective of this paper is to compare the risks and benefits of antibiotics to prevent urinary tract infection (UTI) after urodynamics. We developed a decision analytic model to compare the use of prophylactic antibiotics with no antibiotic use after urodynamics to prevent UTI. Risks and benefits were estimated from the literature and by consensus. The main outcome measure was the occurrence of UTI. Secondary outcomes were the development of adverse events and possible sequelae. One-way sensitivity analyses estimated the effect of varying each characteristic through its range while all other characteristics were fixed at their baseline values. The effectiveness of prophylaxis after urodynamics was a reduction of UTI from 9.2 (no antibiotics) to 5.3% (antibiotics). One-way sensitivity analysis of the probability of UTI without prophylaxis yielded a threshold infection rate of 10%, below which, the strategy of no prophylaxis was favored. In this model, prophylactic antibiotics after urodynamics are not beneficial until the rate of UTI without antibiotics exceeds 10%.

A rat model to study the structural properties of the vagina and its supportive tissues

OBJECTIVE

The purpose of this study was to investigate the rat as a model for evaluating the structural properties of the vagina and its supportive tissues.

STUDY DESIGN

The in situ relationships between the vagina and its supportive tissues were studied grossly (n = 10), and in serial cross sections (n = 4). For biomechanical testing (n = 10), the lumbar spine was fixed to a testing machine while the distal vagina was gripped with a soft-tissue clamp mounted to a load-cell on the crosshead of the machine. The vagina was systematically pulled through the pelvis until failure of the supportive tissues occurred. Parameters describing the structural properties of the tissues (linear stiffness, ultimate load, ultimate elongation, and energy absorbed to failure) were determined from the resulting load-elongation curve. A coefficient of correlation (R) was used to determine experimental reproducibility.

RESULTS

The rat vagina is supported by structures analogous to those in humans. The parameters describing the structural properties of these tissues were highly correlated among specimens (R = 0.95). The mechanism of failure was similar for all specimens.

CONCLUSION

We have developed a mechanical testing protocol in which the structural properties of the vagina-supportive tissue complex can be measured. This will be a powerful tool for testing the impact of life events on vaginal support.

A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage

OBJECTIVE

The purpose of this study was to determine whether postcesarean section administration of ketorolac tromethamine reduces pain and narcotic usage.

STUDY DESIGN

A double-blinded randomized, placebo-controlled trial of ketorolac tromethamine was performed. Patients were randomly assigned to receive either ketorolac tromethamine or placebo. Patient-controlled analgesia (PCA) was used for pain control. Visual analog scales (VAS) were administered postoperatively to assess pain levels. Morphine equivalents and attempts were recorded.

RESULTS

There were 22 patients in each arm of the study. There was no significant difference between patient demographics, blood loss, and type of anesthesia. Pain scores were significantly different at 2, 3, 4, 6, 12, and 24 hours by analysis of variance (ANOVA) (P=.033). There was a significant decrease in pain medication usage (P=.008) in the study group.

CONCLUSION

Ketorolac tromethamine is efficacious in reducing postoperative pain and narcotics usage after cesarean section.