SGS 2014

SCOTTSDALE, ARIZ. – Rates of perioperative complications among women undergoing hysterectomy for benign indications vary according to the route, an ancillary analysis of a retrospective cohort study found.

Analyses were based on 1,440 women who underwent hysterectomy at four teaching hospitals, with procedures about evenly split between the eras before and after introduction of robotic surgery, lead author Dr. Salma Rahimi of Mount Sinai Hospital, New York, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

In the prerobot era, the rate of intraoperative complications – injury of the ureter, bladder, or bowel, or transfusion – was lowest at 3.7% for laparoscopic hysterectomy, about half that for abdominal procedures, and roughly the same as that for vaginal ones. The rate of postoperative complications – infection requiring antibiotics, transfusion, small bowel obstruction, or ileus – was 1.8% with laparoscopic hysterectomy, roughly a third of that seen with the other approaches.

In the postrobot era, the rate of intraoperative complications was 2.8% with vaginal hysterectomy, the lowest value for any approach, including the robotic one. The rate of postoperative complications was 3.0% for robotic hysterectomy, about a quarter of that for abdominal procedures and roughly on a par with that for vaginal and laparoscopic ones.

"Our data demonstrate that a vaginal hysterectomy is associated with fewer intraoperative complications in both the pre- and postrobot period," Dr. Rahimi commented. However, "vaginal hysterectomy was associated with more postoperative infections in the prerobot period."

"The highest complications were noted in the abdominal group, mostly due to transfusions, infections, small bowel obstructions, and ileus," she added.

Introducing the study, she noted that the American College of Obstetricians and Gynecologists recommends vaginal hysterectomy as a first choice over other routes given its relatively better outcomes and lower rates of complications (Obstet. Gynecol. 2009;114:1156-8). "Despite this, most are performed by laparotomy, and there is an increasing trend toward the use of minimally invasive abdominal approaches. Only about 20% are performed by the vaginal approach," she said.

The investigators studied women undergoing hysterectomy identified through the Fellows’ Pelvic Research Network. All of the operations were performed at hospitals with an obstetrics and gynecology residency and had a fellow belonging to the network. Women were excluded if their hysterectomy was performed by a gynecologic oncologist, was for a suspected malignancy, or was done emergently (including cesarean hysterectomies).

Analyses were based on 732 women in the prerobot era (the year before introduction of robotics at each hospital) and 708 in the postrobot era (2011). Characteristics of the women from the two eras were essentially the same, Dr. Rahimi reported at the meeting, jointly sponsored by the American College of Surgeons.

In the prerobot era, the rate of intraoperative complications was 3.9% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P less than .05) and 3.7% for laparoscopic hysterectomy (P not significant).

The rate of postoperative complications was 8.3% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P not significant) and 1.8% for laparoscopic hysterectomy (P = .001). These differences were mainly driven by higher rates of infection with the vaginal and abdominal approaches, and a higher rate of small bowel obstruction and ileus with the abdominal approach.

In the postrobot era, the rate of intraoperative complications was 2.8% for vaginal hysterectomy, compared with 10.8% for abdominal hysterectomy (P = .003), 4.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences were mainly due to a higher rate of transfusion with the abdominal approach.

The rate of postoperative complications was 5.1% for vaginal hysterectomy, compared with 13.9% for abdominal hysterectomy (P = .008), 3.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences again were mainly due to a higher rate of transfusion when surgery was done abdominally.

Dr. Rahimi disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Rates of perioperative complications among women undergoing hysterectomy for benign indications vary according to the route, an ancillary analysis of a retrospective cohort study found.

Analyses were based on 1,440 women who underwent hysterectomy at four teaching hospitals, with procedures about evenly split between the eras before and after introduction of robotic surgery, lead author Dr. Salma Rahimi of Mount Sinai Hospital, New York, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

In the prerobot era, the rate of intraoperative complications – injury of the ureter, bladder, or bowel, or transfusion – was lowest at 3.7% for laparoscopic hysterectomy, about half that for abdominal procedures, and roughly the same as that for vaginal ones. The rate of postoperative complications – infection requiring antibiotics, transfusion, small bowel obstruction, or ileus – was 1.8% with laparoscopic hysterectomy, roughly a third of that seen with the other approaches.

In the postrobot era, the rate of intraoperative complications was 2.8% with vaginal hysterectomy, the lowest value for any approach, including the robotic one. The rate of postoperative complications was 3.0% for robotic hysterectomy, about a quarter of that for abdominal procedures and roughly on a par with that for vaginal and laparoscopic ones.

"Our data demonstrate that a vaginal hysterectomy is associated with fewer intraoperative complications in both the pre- and postrobot period," Dr. Rahimi commented. However, "vaginal hysterectomy was associated with more postoperative infections in the prerobot period."

"The highest complications were noted in the abdominal group, mostly due to transfusions, infections, small bowel obstructions, and ileus," she added.

Introducing the study, she noted that the American College of Obstetricians and Gynecologists recommends vaginal hysterectomy as a first choice over other routes given its relatively better outcomes and lower rates of complications (Obstet. Gynecol. 2009;114:1156-8). "Despite this, most are performed by laparotomy, and there is an increasing trend toward the use of minimally invasive abdominal approaches. Only about 20% are performed by the vaginal approach," she said.

The investigators studied women undergoing hysterectomy identified through the Fellows’ Pelvic Research Network. All of the operations were performed at hospitals with an obstetrics and gynecology residency and had a fellow belonging to the network. Women were excluded if their hysterectomy was performed by a gynecologic oncologist, was for a suspected malignancy, or was done emergently (including cesarean hysterectomies).

Analyses were based on 732 women in the prerobot era (the year before introduction of robotics at each hospital) and 708 in the postrobot era (2011). Characteristics of the women from the two eras were essentially the same, Dr. Rahimi reported at the meeting, jointly sponsored by the American College of Surgeons.

In the prerobot era, the rate of intraoperative complications was 3.9% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P less than .05) and 3.7% for laparoscopic hysterectomy (P not significant).

The rate of postoperative complications was 8.3% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P not significant) and 1.8% for laparoscopic hysterectomy (P = .001). These differences were mainly driven by higher rates of infection with the vaginal and abdominal approaches, and a higher rate of small bowel obstruction and ileus with the abdominal approach.

In the postrobot era, the rate of intraoperative complications was 2.8% for vaginal hysterectomy, compared with 10.8% for abdominal hysterectomy (P = .003), 4.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences were mainly due to a higher rate of transfusion with the abdominal approach.

The rate of postoperative complications was 5.1% for vaginal hysterectomy, compared with 13.9% for abdominal hysterectomy (P = .008), 3.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences again were mainly due to a higher rate of transfusion when surgery was done abdominally.

Dr. Rahimi disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Rates of perioperative complications among women undergoing hysterectomy for benign indications vary according to the route, an ancillary analysis of a retrospective cohort study found.

Analyses were based on 1,440 women who underwent hysterectomy at four teaching hospitals, with procedures about evenly split between the eras before and after introduction of robotic surgery, lead author Dr. Salma Rahimi of Mount Sinai Hospital, New York, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

In the prerobot era, the rate of intraoperative complications – injury of the ureter, bladder, or bowel, or transfusion – was lowest at 3.7% for laparoscopic hysterectomy, about half that for abdominal procedures, and roughly the same as that for vaginal ones. The rate of postoperative complications – infection requiring antibiotics, transfusion, small bowel obstruction, or ileus – was 1.8% with laparoscopic hysterectomy, roughly a third of that seen with the other approaches.

In the postrobot era, the rate of intraoperative complications was 2.8% with vaginal hysterectomy, the lowest value for any approach, including the robotic one. The rate of postoperative complications was 3.0% for robotic hysterectomy, about a quarter of that for abdominal procedures and roughly on a par with that for vaginal and laparoscopic ones.

"Our data demonstrate that a vaginal hysterectomy is associated with fewer intraoperative complications in both the pre- and postrobot period," Dr. Rahimi commented. However, "vaginal hysterectomy was associated with more postoperative infections in the prerobot period."

"The highest complications were noted in the abdominal group, mostly due to transfusions, infections, small bowel obstructions, and ileus," she added.

Introducing the study, she noted that the American College of Obstetricians and Gynecologists recommends vaginal hysterectomy as a first choice over other routes given its relatively better outcomes and lower rates of complications (Obstet. Gynecol. 2009;114:1156-8). "Despite this, most are performed by laparotomy, and there is an increasing trend toward the use of minimally invasive abdominal approaches. Only about 20% are performed by the vaginal approach," she said.

The investigators studied women undergoing hysterectomy identified through the Fellows’ Pelvic Research Network. All of the operations were performed at hospitals with an obstetrics and gynecology residency and had a fellow belonging to the network. Women were excluded if their hysterectomy was performed by a gynecologic oncologist, was for a suspected malignancy, or was done emergently (including cesarean hysterectomies).

Analyses were based on 732 women in the prerobot era (the year before introduction of robotics at each hospital) and 708 in the postrobot era (2011). Characteristics of the women from the two eras were essentially the same, Dr. Rahimi reported at the meeting, jointly sponsored by the American College of Surgeons.

In the prerobot era, the rate of intraoperative complications was 3.9% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P less than .05) and 3.7% for laparoscopic hysterectomy (P not significant).

The rate of postoperative complications was 8.3% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P not significant) and 1.8% for laparoscopic hysterectomy (P = .001). These differences were mainly driven by higher rates of infection with the vaginal and abdominal approaches, and a higher rate of small bowel obstruction and ileus with the abdominal approach.

In the postrobot era, the rate of intraoperative complications was 2.8% for vaginal hysterectomy, compared with 10.8% for abdominal hysterectomy (P = .003), 4.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences were mainly due to a higher rate of transfusion with the abdominal approach.

The rate of postoperative complications was 5.1% for vaginal hysterectomy, compared with 13.9% for abdominal hysterectomy (P = .008), 3.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences again were mainly due to a higher rate of transfusion when surgery was done abdominally.

Dr. Rahimi disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Obstetric risk factors for stage II anterior and posterior pelvic organ prolapse are essentially the same, but symptoms differ, according to a cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Investigators led by Dr. MaryAnn Wilbur of the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, analyzed data from women who were 5-10 years out from a first delivery, comparing 85 women with posterior prolapse (with or without concomitant anterior prolapse), 334 women with isolated anterior prolapse, and 1,078 women with no prolapse.

The results showed that having had a vaginal delivery was a risk factor for both posterior and anterior prolapse. But the women with posterior prolapse were significantly more likely to report a loss of gas from the rectum, having to push on the vagina to complete a bowel movement, having a sensation of bulge, and having asked a physician for help because of their symptoms.

"Not surprisingly, prolapse was associated with vaginal delivery, but when we compare anterior versus posterior prolapse, there were no differences in terms of obstetric risk factors, at least that we could perceive in this study," Dr. Wilbur commented. "But the symptomatology was different between those two groups," although the reasons for this difference were not readily apparent.

The investigators analyzed data collected at enrollment, 5-10 years after a first delivery, from women in the Mothers’ Outcomes After Delivery cohort. Most had had their delivery at Greater Baltimore Medical Center, a large community hospital.

The women’s obstetric history was reviewed, they underwent examination including the pelvic organ prolapse quantification (POP-Q) system assessment, and they completed validated measures of symptoms, including the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Colorectal-Anal Impact Questionnaire (CRAIQ).

The investigators categorized the women as having posterior prolapse (with a point A posterior value on the POP-Q greater than or equal to –1) with or without anterior prolapse, isolated anterior prolapse (with a point A anterior value greater than or equal to –1), or no prolapse.

It was not possible to study isolated posterior prolapse because only 20 women had posterior prolapse without concomitant anterior prolapse, Dr. Wilbur explained at the meeting, which was jointly sponsored by the American College of Surgeons.

Compared with the no-prolapse group, both the posterior and anterior prolapse groups were more likely to have completed the first stage of labor (85% and 76% vs. 53%) and to have had a vaginal delivery (79% and 70% vs. 40%), she reported.

The two prolapse groups were similar with respect to these and a variety of other obstetric factors, such as having a prolonged second stage of labor, having an infant weighing at least 4,000 g, having an operative delivery, having an episiotomy, and experiencing perineal tears.

But relative to their counterparts with anterior prolapse, women with posterior prolapse were more likely to report a loss of gas from the rectum (odds ratio, 1.79), having to push on the vagina to complete a bowel movement (1.72), having a sensation of bulge (2.58), and having asked a physician for help because of prolapse symptoms (3.24).

Women with anterior prolapse were similar to women with no prolapse on most of these measures. The exception was that women without prolapse were, not surprisingly, less likely to have asked a physician for help (odds ratio, 0.27).

"We are following these women over time. So those 1,497 women came in for the first visit, but as of today we have 3,840 person-visits, and in the final manuscript, we did do generalized estimating equations where we followed those trends over time," Dr. Wilbur commented. "They are actually very similar to the enrollment data."

The study’s main shortcoming is its potential lack of generalizability, she said. "Greater Baltimore Medical Center does deliver women who are mostly white and relatively affluent in comparison to the general American population."

Dr. Wilbur disclosed no relevant conflicts of interest

SCOTTSDALE, ARIZ. – Obstetric risk factors for stage II anterior and posterior pelvic organ prolapse are essentially the same, but symptoms differ, according to a cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Investigators led by Dr. MaryAnn Wilbur of the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, analyzed data from women who were 5-10 years out from a first delivery, comparing 85 women with posterior prolapse (with or without concomitant anterior prolapse), 334 women with isolated anterior prolapse, and 1,078 women with no prolapse.

The results showed that having had a vaginal delivery was a risk factor for both posterior and anterior prolapse. But the women with posterior prolapse were significantly more likely to report a loss of gas from the rectum, having to push on the vagina to complete a bowel movement, having a sensation of bulge, and having asked a physician for help because of their symptoms.

"Not surprisingly, prolapse was associated with vaginal delivery, but when we compare anterior versus posterior prolapse, there were no differences in terms of obstetric risk factors, at least that we could perceive in this study," Dr. Wilbur commented. "But the symptomatology was different between those two groups," although the reasons for this difference were not readily apparent.

The investigators analyzed data collected at enrollment, 5-10 years after a first delivery, from women in the Mothers’ Outcomes After Delivery cohort. Most had had their delivery at Greater Baltimore Medical Center, a large community hospital.

The women’s obstetric history was reviewed, they underwent examination including the pelvic organ prolapse quantification (POP-Q) system assessment, and they completed validated measures of symptoms, including the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Colorectal-Anal Impact Questionnaire (CRAIQ).

The investigators categorized the women as having posterior prolapse (with a point A posterior value on the POP-Q greater than or equal to –1) with or without anterior prolapse, isolated anterior prolapse (with a point A anterior value greater than or equal to –1), or no prolapse.

It was not possible to study isolated posterior prolapse because only 20 women had posterior prolapse without concomitant anterior prolapse, Dr. Wilbur explained at the meeting, which was jointly sponsored by the American College of Surgeons.

Compared with the no-prolapse group, both the posterior and anterior prolapse groups were more likely to have completed the first stage of labor (85% and 76% vs. 53%) and to have had a vaginal delivery (79% and 70% vs. 40%), she reported.

The two prolapse groups were similar with respect to these and a variety of other obstetric factors, such as having a prolonged second stage of labor, having an infant weighing at least 4,000 g, having an operative delivery, having an episiotomy, and experiencing perineal tears.

But relative to their counterparts with anterior prolapse, women with posterior prolapse were more likely to report a loss of gas from the rectum (odds ratio, 1.79), having to push on the vagina to complete a bowel movement (1.72), having a sensation of bulge (2.58), and having asked a physician for help because of prolapse symptoms (3.24).

Women with anterior prolapse were similar to women with no prolapse on most of these measures. The exception was that women without prolapse were, not surprisingly, less likely to have asked a physician for help (odds ratio, 0.27).

"We are following these women over time. So those 1,497 women came in for the first visit, but as of today we have 3,840 person-visits, and in the final manuscript, we did do generalized estimating equations where we followed those trends over time," Dr. Wilbur commented. "They are actually very similar to the enrollment data."

The study’s main shortcoming is its potential lack of generalizability, she said. "Greater Baltimore Medical Center does deliver women who are mostly white and relatively affluent in comparison to the general American population."

Dr. Wilbur disclosed no relevant conflicts of interest

SCOTTSDALE, ARIZ. – Obstetric risk factors for stage II anterior and posterior pelvic organ prolapse are essentially the same, but symptoms differ, according to a cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Investigators led by Dr. MaryAnn Wilbur of the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, analyzed data from women who were 5-10 years out from a first delivery, comparing 85 women with posterior prolapse (with or without concomitant anterior prolapse), 334 women with isolated anterior prolapse, and 1,078 women with no prolapse.

The results showed that having had a vaginal delivery was a risk factor for both posterior and anterior prolapse. But the women with posterior prolapse were significantly more likely to report a loss of gas from the rectum, having to push on the vagina to complete a bowel movement, having a sensation of bulge, and having asked a physician for help because of their symptoms.

"Not surprisingly, prolapse was associated with vaginal delivery, but when we compare anterior versus posterior prolapse, there were no differences in terms of obstetric risk factors, at least that we could perceive in this study," Dr. Wilbur commented. "But the symptomatology was different between those two groups," although the reasons for this difference were not readily apparent.

The investigators analyzed data collected at enrollment, 5-10 years after a first delivery, from women in the Mothers’ Outcomes After Delivery cohort. Most had had their delivery at Greater Baltimore Medical Center, a large community hospital.

The women’s obstetric history was reviewed, they underwent examination including the pelvic organ prolapse quantification (POP-Q) system assessment, and they completed validated measures of symptoms, including the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Colorectal-Anal Impact Questionnaire (CRAIQ).

The investigators categorized the women as having posterior prolapse (with a point A posterior value on the POP-Q greater than or equal to –1) with or without anterior prolapse, isolated anterior prolapse (with a point A anterior value greater than or equal to –1), or no prolapse.

It was not possible to study isolated posterior prolapse because only 20 women had posterior prolapse without concomitant anterior prolapse, Dr. Wilbur explained at the meeting, which was jointly sponsored by the American College of Surgeons.

Compared with the no-prolapse group, both the posterior and anterior prolapse groups were more likely to have completed the first stage of labor (85% and 76% vs. 53%) and to have had a vaginal delivery (79% and 70% vs. 40%), she reported.

The two prolapse groups were similar with respect to these and a variety of other obstetric factors, such as having a prolonged second stage of labor, having an infant weighing at least 4,000 g, having an operative delivery, having an episiotomy, and experiencing perineal tears.

But relative to their counterparts with anterior prolapse, women with posterior prolapse were more likely to report a loss of gas from the rectum (odds ratio, 1.79), having to push on the vagina to complete a bowel movement (1.72), having a sensation of bulge (2.58), and having asked a physician for help because of prolapse symptoms (3.24).

Women with anterior prolapse were similar to women with no prolapse on most of these measures. The exception was that women without prolapse were, not surprisingly, less likely to have asked a physician for help (odds ratio, 0.27).

"We are following these women over time. So those 1,497 women came in for the first visit, but as of today we have 3,840 person-visits, and in the final manuscript, we did do generalized estimating equations where we followed those trends over time," Dr. Wilbur commented. "They are actually very similar to the enrollment data."

The study’s main shortcoming is its potential lack of generalizability, she said. "Greater Baltimore Medical Center does deliver women who are mostly white and relatively affluent in comparison to the general American population."

Dr. Wilbur disclosed no relevant conflicts of interest

SCOTTSDALE, ARIZ. – The extent of stretching of the perineal body during the second stage of labor is not helpful in predicting which women will experience adverse obstetric and postpartum outcomes, new data show.

Short perineal body length is known to increase the risk of severe perineal laceration at the time of delivery as well as postpartum functional disorders, noted presenting author Dr. Jill Alldredge. Maternal expulsive efforts during the second stage of labor that stretch the pelvic floor may also damage the pelvic floor muscles.

She and her colleagues performed a planned secondary analysis of the APPLE cohort (Alterations in the Pelvic Floor in Pregnancy, Labor and Ensuing Years), analyzing data from 448 nulliparous women who had a vaginal birth attended by a certified nurse-midwife, had repeated perineal measurements over time, and were followed prospectively to 12 months post partum.

On average, perineal body length increased by about 2.4 cm in the cohort between the antepartum period and the maximal length during the second stage of labor, according to data reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

However, neither perineal body length nor change in this length at any time point was associated with perineal lacerations, or with urinary or anal incontinence or not being sexually active at 6 months post partum.

"We can see that the perineum is dynamic and does stretch during labor. However, measurement of the perineal body length and change in perineal body length between the antepartum, intrapartum, and post partum time periods does not predict perineal trauma or postpartum pelvic floor dysfunction," commented Dr. Alldredge, an obstetrics-gynecology resident at the University of New Mexico in Albuquerque.

APPLE participants had measurement of the perineal body length during the antepartum period, at the onset of labor, at the onset of and every 10 minutes during the second stage, and at 6 and 12 months post partum. The anal opening and the genital hiatus also were measured during the second stage of labor.

At 6 months, the women completed a set of questionnaires assessing pelvic floor function: the Incontinence Severity Index, the Wexner Fecal Incontinence Scale, and the Female Sexual Function Index.

The mean perineal body length was 3.7 cm during the antepartum period, and the mean maximal perineal body length during the second stage of labor was 6.1 cm, she said at the meeting, jointly sponsored by the American College of Surgeons.

During the second stage of labor, the maximal anal opening was 2.0 cm on average. The genital hiatus had an anterior-posterior maximal diameter of 7.5 cm, a maximal transverse diameter of 4.7 cm, and a maximal introital area of 119.4 cm².

Overall, 35% of women experienced a second-degree or worse perineal tear. And at 6 months post partum, 72% had at least mild urinary incontinence, 68% had at least mild anal incontinence, and 13% were not sexually active.

However, analyses showed that neither perineal body length nor stretch at any of the time points assessed was significantly associated with any of these outcomes.

Dr. Alldredge disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The extent of stretching of the perineal body during the second stage of labor is not helpful in predicting which women will experience adverse obstetric and postpartum outcomes, new data show.

Short perineal body length is known to increase the risk of severe perineal laceration at the time of delivery as well as postpartum functional disorders, noted presenting author Dr. Jill Alldredge. Maternal expulsive efforts during the second stage of labor that stretch the pelvic floor may also damage the pelvic floor muscles.

She and her colleagues performed a planned secondary analysis of the APPLE cohort (Alterations in the Pelvic Floor in Pregnancy, Labor and Ensuing Years), analyzing data from 448 nulliparous women who had a vaginal birth attended by a certified nurse-midwife, had repeated perineal measurements over time, and were followed prospectively to 12 months post partum.

On average, perineal body length increased by about 2.4 cm in the cohort between the antepartum period and the maximal length during the second stage of labor, according to data reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

However, neither perineal body length nor change in this length at any time point was associated with perineal lacerations, or with urinary or anal incontinence or not being sexually active at 6 months post partum.

"We can see that the perineum is dynamic and does stretch during labor. However, measurement of the perineal body length and change in perineal body length between the antepartum, intrapartum, and post partum time periods does not predict perineal trauma or postpartum pelvic floor dysfunction," commented Dr. Alldredge, an obstetrics-gynecology resident at the University of New Mexico in Albuquerque.

APPLE participants had measurement of the perineal body length during the antepartum period, at the onset of labor, at the onset of and every 10 minutes during the second stage, and at 6 and 12 months post partum. The anal opening and the genital hiatus also were measured during the second stage of labor.

At 6 months, the women completed a set of questionnaires assessing pelvic floor function: the Incontinence Severity Index, the Wexner Fecal Incontinence Scale, and the Female Sexual Function Index.

The mean perineal body length was 3.7 cm during the antepartum period, and the mean maximal perineal body length during the second stage of labor was 6.1 cm, she said at the meeting, jointly sponsored by the American College of Surgeons.

During the second stage of labor, the maximal anal opening was 2.0 cm on average. The genital hiatus had an anterior-posterior maximal diameter of 7.5 cm, a maximal transverse diameter of 4.7 cm, and a maximal introital area of 119.4 cm².

Overall, 35% of women experienced a second-degree or worse perineal tear. And at 6 months post partum, 72% had at least mild urinary incontinence, 68% had at least mild anal incontinence, and 13% were not sexually active.

However, analyses showed that neither perineal body length nor stretch at any of the time points assessed was significantly associated with any of these outcomes.

Dr. Alldredge disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The extent of stretching of the perineal body during the second stage of labor is not helpful in predicting which women will experience adverse obstetric and postpartum outcomes, new data show.

Short perineal body length is known to increase the risk of severe perineal laceration at the time of delivery as well as postpartum functional disorders, noted presenting author Dr. Jill Alldredge. Maternal expulsive efforts during the second stage of labor that stretch the pelvic floor may also damage the pelvic floor muscles.

She and her colleagues performed a planned secondary analysis of the APPLE cohort (Alterations in the Pelvic Floor in Pregnancy, Labor and Ensuing Years), analyzing data from 448 nulliparous women who had a vaginal birth attended by a certified nurse-midwife, had repeated perineal measurements over time, and were followed prospectively to 12 months post partum.

On average, perineal body length increased by about 2.4 cm in the cohort between the antepartum period and the maximal length during the second stage of labor, according to data reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

However, neither perineal body length nor change in this length at any time point was associated with perineal lacerations, or with urinary or anal incontinence or not being sexually active at 6 months post partum.

"We can see that the perineum is dynamic and does stretch during labor. However, measurement of the perineal body length and change in perineal body length between the antepartum, intrapartum, and post partum time periods does not predict perineal trauma or postpartum pelvic floor dysfunction," commented Dr. Alldredge, an obstetrics-gynecology resident at the University of New Mexico in Albuquerque.

APPLE participants had measurement of the perineal body length during the antepartum period, at the onset of labor, at the onset of and every 10 minutes during the second stage, and at 6 and 12 months post partum. The anal opening and the genital hiatus also were measured during the second stage of labor.

At 6 months, the women completed a set of questionnaires assessing pelvic floor function: the Incontinence Severity Index, the Wexner Fecal Incontinence Scale, and the Female Sexual Function Index.

The mean perineal body length was 3.7 cm during the antepartum period, and the mean maximal perineal body length during the second stage of labor was 6.1 cm, she said at the meeting, jointly sponsored by the American College of Surgeons.

During the second stage of labor, the maximal anal opening was 2.0 cm on average. The genital hiatus had an anterior-posterior maximal diameter of 7.5 cm, a maximal transverse diameter of 4.7 cm, and a maximal introital area of 119.4 cm².

Overall, 35% of women experienced a second-degree or worse perineal tear. And at 6 months post partum, 72% had at least mild urinary incontinence, 68% had at least mild anal incontinence, and 13% were not sexually active.

However, analyses showed that neither perineal body length nor stretch at any of the time points assessed was significantly associated with any of these outcomes.

Dr. Alldredge disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Certain factors portend a rockier course for women who have serious obstetric anal sphincter injuries, a cohort study has found.

In the study, known as FORCAST (For Optimal Recovery, Care After Severe Tears), researchers prospectively followed 180 women who sustained a third- or fourth-degree injury during a term vaginal delivery between 2011 and 2013.

Overall, 18% developed a postpartum wound infection, 24% developed postpartum wound breakdown, and 9% developed postpartum depression, Dr. Kimberly Kenton reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

None of a variety of factors assessed independently predicted the development of wound infections. But women had a sharply elevated risk of wound breakdown if they had an operative vaginal delivery (relative risk, 3.07; P = .04), which was mainly via forceps in the cohort, and a sharply elevated risk of postpartum depression if they had a fourth-degree tear (relative risk, 4.59; P = .01).

"Obstetric anal sphincter injury is associated with high rates of wound complications and postpartum depression," she commented. The investigators hope that this new information can be applied to improve outcomes in this patient population, added Dr. Kenton, a urogynecologist and pelvic reconstructive surgeon at Northwestern Memorial Hospital in Chicago.

Session attendee Dr. Rebecca Rogers of the University of New Mexico in Albuquerque said, "I’m wondering how we can use these data to try to influence the pressure on training programs to support forceps delivery with their residencies, because I think we have a growing body of evidence that this can cause serious sequelae for our patients."

"The Accreditation Council for Graduate Medical Education still tracks forceps and vacuum deliveries, but then they collapse them into a combined category," Dr. Kenton replied. "So [a training program] won’t get a citation as long as you have the right number of operative vaginal deliveries, but it can be either forceps or vacuum."

Attendee Dr. Mikio Nihira of the University of Oklahoma in Oklahoma City noted that he and his colleagues are also studying severe perineal lacerations after obstetric delivery. "One finding that I found very interesting about your presentation was this association with depression, because we are getting this feeling when we work with these patients that it may actually interfere with their bonding with their children," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

"Anecdotally, based on my clinical experience, I think that makes a lot of sense," Dr. Kenton commented. "I have seen a lot of these women and had to take a lot of them back to the OR. When you finally see them back 3 or 4 months later when they are healed, one of the first things they tell you is how much better they are doing and how they can finally get on with their lives and enjoy their baby."

Attendee Dr. Carl Zimmerman, director of female pelvic medicine and reconstructive surgery at Vanderbilt University in Nashville, asked which service repaired the lacerations.

"We have actively reached out to the obstetrical service and invited them to consult us for severe lacerations – sulcus tears, fourth degrees, and so on. And we believe that it has resulted in a better initial repair," he commented.

Dr. Kenton said that the obstetric service performed the laceration repairs and noted that practice variation may have some role in outcomes. "One of the biggest things that we have found is, surprisingly, nobody gives antibiotics around the time of the third- or fourth-degree tear. So maybe there is room for obtaining some level 1 evidence about randomizing women to antibiotics or no antibiotics to see if that would improve healing rates," she commented.

"Right, there are multiple things that just haven’t been looked at here," Dr. Zimmerman agreed. "And this really seems like a window of opportunity to address some of these issues at the front end rather than waiting till 20 or 30 years down the road."

Providing some background to the research, Dr. Kenton noted that each year, about 37,500 women in the United States develop anal incontinence after experiencing sphincter injury during childbirth, underscoring the importance of this complication.

The women in FORCAST had clinical follow-up in the urogynecology clinic at 1, 2, 6, and 12 weeks post partum and annually thereafter, with perineal evaluation, completion of the Patient Health Questionnaire as a depression screen, and assessment of pain on a visual analog scale.

On average, they were 32 years old and had a body mass index of 29 kg/m², according to Dr. Kenton. The majority were primiparous (87%) and had an operative delivery (72%).

In addition to identifying operative delivery as a risk factor for wound breakdown and identifying fourth-degree tear as a risk factor for depression, analyses showed that the women experiencing wound infection or breakdown had significantly higher levels of pain than did peers with an intact perineum (mean, 35 vs. 23 points on a scale from 0 to 100; P = .03).

Dr. Kenton disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Certain factors portend a rockier course for women who have serious obstetric anal sphincter injuries, a cohort study has found.

In the study, known as FORCAST (For Optimal Recovery, Care After Severe Tears), researchers prospectively followed 180 women who sustained a third- or fourth-degree injury during a term vaginal delivery between 2011 and 2013.

Overall, 18% developed a postpartum wound infection, 24% developed postpartum wound breakdown, and 9% developed postpartum depression, Dr. Kimberly Kenton reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

None of a variety of factors assessed independently predicted the development of wound infections. But women had a sharply elevated risk of wound breakdown if they had an operative vaginal delivery (relative risk, 3.07; P = .04), which was mainly via forceps in the cohort, and a sharply elevated risk of postpartum depression if they had a fourth-degree tear (relative risk, 4.59; P = .01).

"Obstetric anal sphincter injury is associated with high rates of wound complications and postpartum depression," she commented. The investigators hope that this new information can be applied to improve outcomes in this patient population, added Dr. Kenton, a urogynecologist and pelvic reconstructive surgeon at Northwestern Memorial Hospital in Chicago.

Session attendee Dr. Rebecca Rogers of the University of New Mexico in Albuquerque said, "I’m wondering how we can use these data to try to influence the pressure on training programs to support forceps delivery with their residencies, because I think we have a growing body of evidence that this can cause serious sequelae for our patients."

"The Accreditation Council for Graduate Medical Education still tracks forceps and vacuum deliveries, but then they collapse them into a combined category," Dr. Kenton replied. "So [a training program] won’t get a citation as long as you have the right number of operative vaginal deliveries, but it can be either forceps or vacuum."

Attendee Dr. Mikio Nihira of the University of Oklahoma in Oklahoma City noted that he and his colleagues are also studying severe perineal lacerations after obstetric delivery. "One finding that I found very interesting about your presentation was this association with depression, because we are getting this feeling when we work with these patients that it may actually interfere with their bonding with their children," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

"Anecdotally, based on my clinical experience, I think that makes a lot of sense," Dr. Kenton commented. "I have seen a lot of these women and had to take a lot of them back to the OR. When you finally see them back 3 or 4 months later when they are healed, one of the first things they tell you is how much better they are doing and how they can finally get on with their lives and enjoy their baby."

Attendee Dr. Carl Zimmerman, director of female pelvic medicine and reconstructive surgery at Vanderbilt University in Nashville, asked which service repaired the lacerations.

"We have actively reached out to the obstetrical service and invited them to consult us for severe lacerations – sulcus tears, fourth degrees, and so on. And we believe that it has resulted in a better initial repair," he commented.

Dr. Kenton said that the obstetric service performed the laceration repairs and noted that practice variation may have some role in outcomes. "One of the biggest things that we have found is, surprisingly, nobody gives antibiotics around the time of the third- or fourth-degree tear. So maybe there is room for obtaining some level 1 evidence about randomizing women to antibiotics or no antibiotics to see if that would improve healing rates," she commented.

"Right, there are multiple things that just haven’t been looked at here," Dr. Zimmerman agreed. "And this really seems like a window of opportunity to address some of these issues at the front end rather than waiting till 20 or 30 years down the road."

Providing some background to the research, Dr. Kenton noted that each year, about 37,500 women in the United States develop anal incontinence after experiencing sphincter injury during childbirth, underscoring the importance of this complication.

The women in FORCAST had clinical follow-up in the urogynecology clinic at 1, 2, 6, and 12 weeks post partum and annually thereafter, with perineal evaluation, completion of the Patient Health Questionnaire as a depression screen, and assessment of pain on a visual analog scale.

On average, they were 32 years old and had a body mass index of 29 kg/m², according to Dr. Kenton. The majority were primiparous (87%) and had an operative delivery (72%).

In addition to identifying operative delivery as a risk factor for wound breakdown and identifying fourth-degree tear as a risk factor for depression, analyses showed that the women experiencing wound infection or breakdown had significantly higher levels of pain than did peers with an intact perineum (mean, 35 vs. 23 points on a scale from 0 to 100; P = .03).

Dr. Kenton disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Certain factors portend a rockier course for women who have serious obstetric anal sphincter injuries, a cohort study has found.

In the study, known as FORCAST (For Optimal Recovery, Care After Severe Tears), researchers prospectively followed 180 women who sustained a third- or fourth-degree injury during a term vaginal delivery between 2011 and 2013.

Overall, 18% developed a postpartum wound infection, 24% developed postpartum wound breakdown, and 9% developed postpartum depression, Dr. Kimberly Kenton reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

None of a variety of factors assessed independently predicted the development of wound infections. But women had a sharply elevated risk of wound breakdown if they had an operative vaginal delivery (relative risk, 3.07; P = .04), which was mainly via forceps in the cohort, and a sharply elevated risk of postpartum depression if they had a fourth-degree tear (relative risk, 4.59; P = .01).

"Obstetric anal sphincter injury is associated with high rates of wound complications and postpartum depression," she commented. The investigators hope that this new information can be applied to improve outcomes in this patient population, added Dr. Kenton, a urogynecologist and pelvic reconstructive surgeon at Northwestern Memorial Hospital in Chicago.

Session attendee Dr. Rebecca Rogers of the University of New Mexico in Albuquerque said, "I’m wondering how we can use these data to try to influence the pressure on training programs to support forceps delivery with their residencies, because I think we have a growing body of evidence that this can cause serious sequelae for our patients."

"The Accreditation Council for Graduate Medical Education still tracks forceps and vacuum deliveries, but then they collapse them into a combined category," Dr. Kenton replied. "So [a training program] won’t get a citation as long as you have the right number of operative vaginal deliveries, but it can be either forceps or vacuum."

Attendee Dr. Mikio Nihira of the University of Oklahoma in Oklahoma City noted that he and his colleagues are also studying severe perineal lacerations after obstetric delivery. "One finding that I found very interesting about your presentation was this association with depression, because we are getting this feeling when we work with these patients that it may actually interfere with their bonding with their children," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

"Anecdotally, based on my clinical experience, I think that makes a lot of sense," Dr. Kenton commented. "I have seen a lot of these women and had to take a lot of them back to the OR. When you finally see them back 3 or 4 months later when they are healed, one of the first things they tell you is how much better they are doing and how they can finally get on with their lives and enjoy their baby."

Attendee Dr. Carl Zimmerman, director of female pelvic medicine and reconstructive surgery at Vanderbilt University in Nashville, asked which service repaired the lacerations.

"We have actively reached out to the obstetrical service and invited them to consult us for severe lacerations – sulcus tears, fourth degrees, and so on. And we believe that it has resulted in a better initial repair," he commented.

Dr. Kenton said that the obstetric service performed the laceration repairs and noted that practice variation may have some role in outcomes. "One of the biggest things that we have found is, surprisingly, nobody gives antibiotics around the time of the third- or fourth-degree tear. So maybe there is room for obtaining some level 1 evidence about randomizing women to antibiotics or no antibiotics to see if that would improve healing rates," she commented.

"Right, there are multiple things that just haven’t been looked at here," Dr. Zimmerman agreed. "And this really seems like a window of opportunity to address some of these issues at the front end rather than waiting till 20 or 30 years down the road."

Providing some background to the research, Dr. Kenton noted that each year, about 37,500 women in the United States develop anal incontinence after experiencing sphincter injury during childbirth, underscoring the importance of this complication.

The women in FORCAST had clinical follow-up in the urogynecology clinic at 1, 2, 6, and 12 weeks post partum and annually thereafter, with perineal evaluation, completion of the Patient Health Questionnaire as a depression screen, and assessment of pain on a visual analog scale.

On average, they were 32 years old and had a body mass index of 29 kg/m², according to Dr. Kenton. The majority were primiparous (87%) and had an operative delivery (72%).

In addition to identifying operative delivery as a risk factor for wound breakdown and identifying fourth-degree tear as a risk factor for depression, analyses showed that the women experiencing wound infection or breakdown had significantly higher levels of pain than did peers with an intact perineum (mean, 35 vs. 23 points on a scale from 0 to 100; P = .03).

Dr. Kenton disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – A simple model may help individualize the ordering of blood work after an uncomplicated hysterectomy done for benign indications, according to Dr. Carolyn W. Swenson.

Weight, preoperative hematocrit, and race independently predicted a higher hematocrit on postoperative day 1. Estimated blood loss, volume of intraoperative crystalloid used, preoperative platelet count, and use of intraoperative crystalloid as a dichotomous variable independently predicted a lower hematocrit, she said at the annual meeting of the Society of Gynecologic Surgeons.

Using a mathematical model based on the seven variables accurately predicted hematocrit on postoperative day 1 in 91% of cases, where accuracy was defined as a predicted hematocrit that fell within 4 percentage points of the actual value. "This may support the selective ordering of postoperative labs after hysterectomy, which not only would limit unnecessary lab tests for patients, but also increase the cost effectiveness of our medical care, which could lead to considerable cost savings," Dr. Swenson said at the meeting, jointly sponsored by the American College of Surgeons.

"At this conference, we have heard a lot about the importance of resource utilization in practice and cost-effective medical care," said lead investigator Dr. Swenson of the University of Michigan, Ann Arbor. "So if I told you there was an easy way to have one less thing to follow up on after a hysterectomy, there would be one less procedure for patients to undergo, and this simple thing could potentially save the health care system over $7 million a year, hopefully many of you would be interested."

Dr. Swenson and her colleagues analyzed data from 1,918 women who had hysterectomies in 2012 and validated the model in 366 comparable women operated on in 2013. The data came from the Michigan Surgical Quality Collaborative, which includes 49 community and academic hospitals. The researchers excluded patients with cancer or sepsis, those with obstetric or emergent indications, and patients receiving perioperative blood transfusions. The database included patients who had hysterectomies done for prolapse.

"In order to facilitate the use of this model, we are in the process of developing an iPhone app so that at the end of a case, a surgeon can easily and quickly calculate [the patient’s] predicted postop day 1 hematocrit, and then use that value along with their clinical judgment to decide whether or not to order this lab test," she said. "It’s just seven variables. You don’t need an iPhone app to be able to do it, but it just makes it a lot easier."

A complete blood cell count often is routinely ordered after a hysterectomy, yet "the literature shows that in the absence of any clinical suspicion, routine postoperative labs after gynecologic surgery essentially never affect clinical outcomes."

On average, the women studied were 47 years old and had a body mass index of 31 kg/m², reported Dr. Swenson. More than three-fourths were white, and about one-fourth were smokers. Hysterectomies were done by a variety of routes, with the largest share, roughly 40%, done laparoscopically.

Dr. Swenson disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – A simple model may help individualize the ordering of blood work after an uncomplicated hysterectomy done for benign indications, according to Dr. Carolyn W. Swenson.

Weight, preoperative hematocrit, and race independently predicted a higher hematocrit on postoperative day 1. Estimated blood loss, volume of intraoperative crystalloid used, preoperative platelet count, and use of intraoperative crystalloid as a dichotomous variable independently predicted a lower hematocrit, she said at the annual meeting of the Society of Gynecologic Surgeons.

Using a mathematical model based on the seven variables accurately predicted hematocrit on postoperative day 1 in 91% of cases, where accuracy was defined as a predicted hematocrit that fell within 4 percentage points of the actual value. "This may support the selective ordering of postoperative labs after hysterectomy, which not only would limit unnecessary lab tests for patients, but also increase the cost effectiveness of our medical care, which could lead to considerable cost savings," Dr. Swenson said at the meeting, jointly sponsored by the American College of Surgeons.

"At this conference, we have heard a lot about the importance of resource utilization in practice and cost-effective medical care," said lead investigator Dr. Swenson of the University of Michigan, Ann Arbor. "So if I told you there was an easy way to have one less thing to follow up on after a hysterectomy, there would be one less procedure for patients to undergo, and this simple thing could potentially save the health care system over $7 million a year, hopefully many of you would be interested."

Dr. Swenson and her colleagues analyzed data from 1,918 women who had hysterectomies in 2012 and validated the model in 366 comparable women operated on in 2013. The data came from the Michigan Surgical Quality Collaborative, which includes 49 community and academic hospitals. The researchers excluded patients with cancer or sepsis, those with obstetric or emergent indications, and patients receiving perioperative blood transfusions. The database included patients who had hysterectomies done for prolapse.

"In order to facilitate the use of this model, we are in the process of developing an iPhone app so that at the end of a case, a surgeon can easily and quickly calculate [the patient’s] predicted postop day 1 hematocrit, and then use that value along with their clinical judgment to decide whether or not to order this lab test," she said. "It’s just seven variables. You don’t need an iPhone app to be able to do it, but it just makes it a lot easier."

A complete blood cell count often is routinely ordered after a hysterectomy, yet "the literature shows that in the absence of any clinical suspicion, routine postoperative labs after gynecologic surgery essentially never affect clinical outcomes."

On average, the women studied were 47 years old and had a body mass index of 31 kg/m², reported Dr. Swenson. More than three-fourths were white, and about one-fourth were smokers. Hysterectomies were done by a variety of routes, with the largest share, roughly 40%, done laparoscopically.

Dr. Swenson disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – A simple model may help individualize the ordering of blood work after an uncomplicated hysterectomy done for benign indications, according to Dr. Carolyn W. Swenson.

Weight, preoperative hematocrit, and race independently predicted a higher hematocrit on postoperative day 1. Estimated blood loss, volume of intraoperative crystalloid used, preoperative platelet count, and use of intraoperative crystalloid as a dichotomous variable independently predicted a lower hematocrit, she said at the annual meeting of the Society of Gynecologic Surgeons.

Using a mathematical model based on the seven variables accurately predicted hematocrit on postoperative day 1 in 91% of cases, where accuracy was defined as a predicted hematocrit that fell within 4 percentage points of the actual value. "This may support the selective ordering of postoperative labs after hysterectomy, which not only would limit unnecessary lab tests for patients, but also increase the cost effectiveness of our medical care, which could lead to considerable cost savings," Dr. Swenson said at the meeting, jointly sponsored by the American College of Surgeons.

"At this conference, we have heard a lot about the importance of resource utilization in practice and cost-effective medical care," said lead investigator Dr. Swenson of the University of Michigan, Ann Arbor. "So if I told you there was an easy way to have one less thing to follow up on after a hysterectomy, there would be one less procedure for patients to undergo, and this simple thing could potentially save the health care system over $7 million a year, hopefully many of you would be interested."

Dr. Swenson and her colleagues analyzed data from 1,918 women who had hysterectomies in 2012 and validated the model in 366 comparable women operated on in 2013. The data came from the Michigan Surgical Quality Collaborative, which includes 49 community and academic hospitals. The researchers excluded patients with cancer or sepsis, those with obstetric or emergent indications, and patients receiving perioperative blood transfusions. The database included patients who had hysterectomies done for prolapse.

"In order to facilitate the use of this model, we are in the process of developing an iPhone app so that at the end of a case, a surgeon can easily and quickly calculate [the patient’s] predicted postop day 1 hematocrit, and then use that value along with their clinical judgment to decide whether or not to order this lab test," she said. "It’s just seven variables. You don’t need an iPhone app to be able to do it, but it just makes it a lot easier."

A complete blood cell count often is routinely ordered after a hysterectomy, yet "the literature shows that in the absence of any clinical suspicion, routine postoperative labs after gynecologic surgery essentially never affect clinical outcomes."

On average, the women studied were 47 years old and had a body mass index of 31 kg/m², reported Dr. Swenson. More than three-fourths were white, and about one-fourth were smokers. Hysterectomies were done by a variety of routes, with the largest share, roughly 40%, done laparoscopically.

Dr. Swenson disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The number of apical pelvic organ prolapse repairs done each year in the United States has increased, but less invasive approaches have become the norm, a cross-sectional study spanning a 15-year period found.

Using data from the Medstat MarketScan database, which captures information on commercially insured individuals, researchers identified 53,980 women aged 18-65 years who underwent surgery for apical prolapse between 1996 and 2010.

The results showed that the number of procedures done each year rose steadily during the study period, first author Dr. Vani Dandolu reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

At the same time, there was a decrease in the proportion of procedures done abdominally, from 49% to 12%, and increases in the proportions done laparoscopically (including robotically), from 0% to 21%, and done vaginally, from 51% to 67%.

Among all vaginal procedures, the proportion in which mesh was used increased steadily after its approval in 2002, peaked in 2007, and fell thereafter with the first safety warning about this product by the Food and Drug Administration in 2008. As of 2010, about 18% of vaginal procedures were done with mesh.

"Surgical advances have brought new evolution in the repair of apical prolapse in the past decade," commented Dr. Dandolu, who is professor and chair of obstetrics and gynecology at the University of Nevada in Las Vegas. "Up until 2002, the data was fairly simple: About half the procedures performed were open sacrocolpopexies, and the other half were extraperitoneal vaginal suspensions, mainly sacrospinous fixations. Things changed in the second half of the study period – it became more complex, there was more variety of procedures.

"The proportion of abdominal sacrocolpopexies decreased sharply between 1996 and 2010. This corresponded to an increase in laparoscopic sacrocolpopexy and vaginal procedures, as well as the mesh repairs," she said.

A key advantage of the MarketScan database over other national databases is its high-quality coding, which permits precise categorization of the various types of prolapse repair, noted Dr. Dandolu.

"When you are looking at procedures, probably this is the most robust dataset because it gathers information both from the providers as well as the facilities. The providers typically record the procedures based on CPT [Current Procedural Terminology] procedure codes that are more precise than the facilities’ report based on ICD [International Classification of Diseases] procedure codes," she added.

Session attendee Dr. William Hurd of the Duke Fertility Center in Durham, N.C., asked, "Do you think the increased number of procedures is related to the aging population or to more people trained to do these procedures?"

"I think it’s a combination of several things – the two factors you mentioned, as well as more and more commercial insurers are reporting data into this dataset," Dr. Dandolu replied.

Attendee Dr. John Riggs of the University of Texas in Houston wondered if the CPT codes had changed in any way during the study period.

"The CPT codes for the laparoscopic sacrocolpopexies were introduced around 2003 and the mesh codes were introduced around 2005," Dr. Dandolu replied. "Otherwise, for the traditional procedures, the CPT procedural codes have not changed."

Finally, attendee Dr. Lisa Peacock of Louisiana State University Health Sciences Center in New Orleans asked, "Could you tell in your increase in laparoscopic procedures what proportion of that may be robotic?"

That information was not available as the database did not split out the robotic procedures until 2011, Dr. Dandolu said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Dandolu reported no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The number of apical pelvic organ prolapse repairs done each year in the United States has increased, but less invasive approaches have become the norm, a cross-sectional study spanning a 15-year period found.

Using data from the Medstat MarketScan database, which captures information on commercially insured individuals, researchers identified 53,980 women aged 18-65 years who underwent surgery for apical prolapse between 1996 and 2010.

The results showed that the number of procedures done each year rose steadily during the study period, first author Dr. Vani Dandolu reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

At the same time, there was a decrease in the proportion of procedures done abdominally, from 49% to 12%, and increases in the proportions done laparoscopically (including robotically), from 0% to 21%, and done vaginally, from 51% to 67%.

Among all vaginal procedures, the proportion in which mesh was used increased steadily after its approval in 2002, peaked in 2007, and fell thereafter with the first safety warning about this product by the Food and Drug Administration in 2008. As of 2010, about 18% of vaginal procedures were done with mesh.

"Surgical advances have brought new evolution in the repair of apical prolapse in the past decade," commented Dr. Dandolu, who is professor and chair of obstetrics and gynecology at the University of Nevada in Las Vegas. "Up until 2002, the data was fairly simple: About half the procedures performed were open sacrocolpopexies, and the other half were extraperitoneal vaginal suspensions, mainly sacrospinous fixations. Things changed in the second half of the study period – it became more complex, there was more variety of procedures.

"The proportion of abdominal sacrocolpopexies decreased sharply between 1996 and 2010. This corresponded to an increase in laparoscopic sacrocolpopexy and vaginal procedures, as well as the mesh repairs," she said.

A key advantage of the MarketScan database over other national databases is its high-quality coding, which permits precise categorization of the various types of prolapse repair, noted Dr. Dandolu.

"When you are looking at procedures, probably this is the most robust dataset because it gathers information both from the providers as well as the facilities. The providers typically record the procedures based on CPT [Current Procedural Terminology] procedure codes that are more precise than the facilities’ report based on ICD [International Classification of Diseases] procedure codes," she added.

Session attendee Dr. William Hurd of the Duke Fertility Center in Durham, N.C., asked, "Do you think the increased number of procedures is related to the aging population or to more people trained to do these procedures?"

"I think it’s a combination of several things – the two factors you mentioned, as well as more and more commercial insurers are reporting data into this dataset," Dr. Dandolu replied.

Attendee Dr. John Riggs of the University of Texas in Houston wondered if the CPT codes had changed in any way during the study period.

"The CPT codes for the laparoscopic sacrocolpopexies were introduced around 2003 and the mesh codes were introduced around 2005," Dr. Dandolu replied. "Otherwise, for the traditional procedures, the CPT procedural codes have not changed."

Finally, attendee Dr. Lisa Peacock of Louisiana State University Health Sciences Center in New Orleans asked, "Could you tell in your increase in laparoscopic procedures what proportion of that may be robotic?"

That information was not available as the database did not split out the robotic procedures until 2011, Dr. Dandolu said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Dandolu reported no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The number of apical pelvic organ prolapse repairs done each year in the United States has increased, but less invasive approaches have become the norm, a cross-sectional study spanning a 15-year period found.

Using data from the Medstat MarketScan database, which captures information on commercially insured individuals, researchers identified 53,980 women aged 18-65 years who underwent surgery for apical prolapse between 1996 and 2010.

The results showed that the number of procedures done each year rose steadily during the study period, first author Dr. Vani Dandolu reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

At the same time, there was a decrease in the proportion of procedures done abdominally, from 49% to 12%, and increases in the proportions done laparoscopically (including robotically), from 0% to 21%, and done vaginally, from 51% to 67%.

Among all vaginal procedures, the proportion in which mesh was used increased steadily after its approval in 2002, peaked in 2007, and fell thereafter with the first safety warning about this product by the Food and Drug Administration in 2008. As of 2010, about 18% of vaginal procedures were done with mesh.

"Surgical advances have brought new evolution in the repair of apical prolapse in the past decade," commented Dr. Dandolu, who is professor and chair of obstetrics and gynecology at the University of Nevada in Las Vegas. "Up until 2002, the data was fairly simple: About half the procedures performed were open sacrocolpopexies, and the other half were extraperitoneal vaginal suspensions, mainly sacrospinous fixations. Things changed in the second half of the study period – it became more complex, there was more variety of procedures.

"The proportion of abdominal sacrocolpopexies decreased sharply between 1996 and 2010. This corresponded to an increase in laparoscopic sacrocolpopexy and vaginal procedures, as well as the mesh repairs," she said.

A key advantage of the MarketScan database over other national databases is its high-quality coding, which permits precise categorization of the various types of prolapse repair, noted Dr. Dandolu.

"When you are looking at procedures, probably this is the most robust dataset because it gathers information both from the providers as well as the facilities. The providers typically record the procedures based on CPT [Current Procedural Terminology] procedure codes that are more precise than the facilities’ report based on ICD [International Classification of Diseases] procedure codes," she added.

Session attendee Dr. William Hurd of the Duke Fertility Center in Durham, N.C., asked, "Do you think the increased number of procedures is related to the aging population or to more people trained to do these procedures?"

"I think it’s a combination of several things – the two factors you mentioned, as well as more and more commercial insurers are reporting data into this dataset," Dr. Dandolu replied.

Attendee Dr. John Riggs of the University of Texas in Houston wondered if the CPT codes had changed in any way during the study period.

"The CPT codes for the laparoscopic sacrocolpopexies were introduced around 2003 and the mesh codes were introduced around 2005," Dr. Dandolu replied. "Otherwise, for the traditional procedures, the CPT procedural codes have not changed."

Finally, attendee Dr. Lisa Peacock of Louisiana State University Health Sciences Center in New Orleans asked, "Could you tell in your increase in laparoscopic procedures what proportion of that may be robotic?"

That information was not available as the database did not split out the robotic procedures until 2011, Dr. Dandolu said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Dandolu reported no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Patients giving consent to undergo midurethral sling surgery are more likely to remember being advised of the risks of surgical mesh if their surgeon speaks at a lower grade level.

This was among the key findings of a longitudinal cohort study of 71 women reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

Analysis of the consent discussions, which lasted an average of 15 minutes, showed that surgeons were significantly more likely to mention the immediate risks of mesh than the long-term risks, reported first author Dr. Brook L. McFadden, a urogynecologist at the Ohio State University Wexner Medical Center in Columbus. But patients were equally likely to remember both groups of risks.

Neither the specific term surgeons used to refer to the midurethral sling implant – mesh, tape, or graft – nor the number of times they used the term during the discussion affected patients’ recall of mesh risks 6 weeks after surgery. The length of the discussion also had no significant impact.

However, the lower the grade level at which the surgeon spoke, the greater patients’ recall of risks, even though the cohort was fairly well educated. On average, the surgeons spoke at about the 6th- to 7th-grade level.

"This was a homogeneous, young, educated population, which may not be generalizable," Dr. McFadden noted. "And we cannot account for counseling that occurred prior to or after the surgical consent session that may have impacted recall."

Invited discussant Dr. Bela Kudish, a urogynecologist at the Winnie Palmer Hospital Center for Advanced Gynecologic Surgery and Pelvic Medicine in Orlando, noted, "As providers, many of us are trying to balance the principles of nonmaleficence, beneficence, and autonomy of the patient in an attempt to improve the counseling process, to emphasize the shared responsibility in decision making in patients who undergo this procedure."

"How are you planning to improve the study design to identify factors specific to the consent process that may influence the recall, since this was a study that was done in four centers with a nonstandardized consent process?" she asked the investigators.

"I think at this point, the surgical consent process is not limited to that moment that you sign papers. It starts in the first moment when you meet the patient. So I think we need to start broadening our understanding and our evaluation of the consent process to include the very beginning counseling that’s occurring from day 1. And I also think we need to spend more time trying to reconcile what patients want to know and what they think is important with what we want them to remember, maybe what the lawyers want them to remember, and try to make that more patient centered," Dr. McFadden replied at the meeting, which was jointly sponsored by the American College of Surgeons.

"In your opinion, what is the ideal way of counseling patients to increase the recall of risk?" Dr. Kudish further queried.

"I do try to spend time asking the patient, ‘How do you best learn? Is it written, is it verbal? Do you like pictures?’ And try to incorporate what works best for them. And I think that the utility of decisional aids, while we have presented work that did not show great use recently, that is where this is going to go: using decisional aids starting from the very beginning, day 1, up until surgery, and even beyond this," Dr. McFadden maintained.

Session cochair Dr. Andrew Cassidenti of St. Joseph Hospital, Orange, Calif., commented, "Your point is excellent. I think the informed consent is really your relationship with the patient. It’s not a document, it’s a relationship and it’s an understanding of your confidence, your capabilities, your experience, what you can do for them, your results, and an honest discussion. I think that really is the key to keeping lawyers at bay."

The study enrolled patients who could read and write English and were undergoing only midurethral sling surgery. "At these four centers, we did not specify specifically how the surgeons were to [address] consent. They did this all in their normal way, so that had variation," Dr. McFadden noted.

Consent discussions were audio recorded and transcribed, and the transcripts were analyzed for their content and grade level of the surgeon’s speech according to the Flesch-Kincaid scale.

Patients completed a 21-item recall checklist. Their recall score was calculated as the number of items recalled divided by the number the surgeon actually mentioned, multiplied by 100.

The patients’ mean age was 53 years; 83% were white and 66% had some college education or more, reported Dr. McFadden. On average, they had almost 15 years of education.

The percentage of physicians who mentioned various immediate risks of mesh ranged from 94% for bleeding to 97% for organ damage (mean, 95%). Patient recall scores at 6 weeks after surgery ranged from 71% for bleeding to 90% for the need for a catheter (mean, 80%).

The percentage of physicians who mentioned the long-term risks of mesh ranged from 30% for continued leakage and groin pain to 92% for mesh erosion, a notable high outlier (mean, 58%). Patient recall scores ranged from 33% for chronic urinary tract infection to 95% for continued leakage (mean, 68%).

Surgeons were significantly more likely to mention the immediate risks than the long-term risks (95% vs. 58%; P less than .01), but patients were similarly likely to recall these two groups of risks.

When referring to the midurethral sling implant, surgeons most commonly used the terms mesh (87%) and tape (81%), and less commonly used the term graft (14%). On average, there were 5.9 uses of mesh per consent session, 7.4 uses of tape, and 0.5 uses of graft.

A variety of sociodemographic factors (patient age, education, race/ethnicity, and health literacy score) and consent-related factors (duration of the discussion, mesh term used, and number of uses) were not significantly associated with patients’ recall of risks.

But the lower the grade level at which the surgeon spoke, the greater patients’ recall was (r = –0.26, P less than .05).

Dr. McFadden disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Patients giving consent to undergo midurethral sling surgery are more likely to remember being advised of the risks of surgical mesh if their surgeon speaks at a lower grade level.

This was among the key findings of a longitudinal cohort study of 71 women reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

Analysis of the consent discussions, which lasted an average of 15 minutes, showed that surgeons were significantly more likely to mention the immediate risks of mesh than the long-term risks, reported first author Dr. Brook L. McFadden, a urogynecologist at the Ohio State University Wexner Medical Center in Columbus. But patients were equally likely to remember both groups of risks.

Neither the specific term surgeons used to refer to the midurethral sling implant – mesh, tape, or graft – nor the number of times they used the term during the discussion affected patients’ recall of mesh risks 6 weeks after surgery. The length of the discussion also had no significant impact.

However, the lower the grade level at which the surgeon spoke, the greater patients’ recall of risks, even though the cohort was fairly well educated. On average, the surgeons spoke at about the 6th- to 7th-grade level.

"This was a homogeneous, young, educated population, which may not be generalizable," Dr. McFadden noted. "And we cannot account for counseling that occurred prior to or after the surgical consent session that may have impacted recall."

Invited discussant Dr. Bela Kudish, a urogynecologist at the Winnie Palmer Hospital Center for Advanced Gynecologic Surgery and Pelvic Medicine in Orlando, noted, "As providers, many of us are trying to balance the principles of nonmaleficence, beneficence, and autonomy of the patient in an attempt to improve the counseling process, to emphasize the shared responsibility in decision making in patients who undergo this procedure."

"How are you planning to improve the study design to identify factors specific to the consent process that may influence the recall, since this was a study that was done in four centers with a nonstandardized consent process?" she asked the investigators.

"I think at this point, the surgical consent process is not limited to that moment that you sign papers. It starts in the first moment when you meet the patient. So I think we need to start broadening our understanding and our evaluation of the consent process to include the very beginning counseling that’s occurring from day 1. And I also think we need to spend more time trying to reconcile what patients want to know and what they think is important with what we want them to remember, maybe what the lawyers want them to remember, and try to make that more patient centered," Dr. McFadden replied at the meeting, which was jointly sponsored by the American College of Surgeons.

"In your opinion, what is the ideal way of counseling patients to increase the recall of risk?" Dr. Kudish further queried.

"I do try to spend time asking the patient, ‘How do you best learn? Is it written, is it verbal? Do you like pictures?’ And try to incorporate what works best for them. And I think that the utility of decisional aids, while we have presented work that did not show great use recently, that is where this is going to go: using decisional aids starting from the very beginning, day 1, up until surgery, and even beyond this," Dr. McFadden maintained.

Session cochair Dr. Andrew Cassidenti of St. Joseph Hospital, Orange, Calif., commented, "Your point is excellent. I think the informed consent is really your relationship with the patient. It’s not a document, it’s a relationship and it’s an understanding of your confidence, your capabilities, your experience, what you can do for them, your results, and an honest discussion. I think that really is the key to keeping lawyers at bay."

The study enrolled patients who could read and write English and were undergoing only midurethral sling surgery. "At these four centers, we did not specify specifically how the surgeons were to [address] consent. They did this all in their normal way, so that had variation," Dr. McFadden noted.

Consent discussions were audio recorded and transcribed, and the transcripts were analyzed for their content and grade level of the surgeon’s speech according to the Flesch-Kincaid scale.

Patients completed a 21-item recall checklist. Their recall score was calculated as the number of items recalled divided by the number the surgeon actually mentioned, multiplied by 100.

The patients’ mean age was 53 years; 83% were white and 66% had some college education or more, reported Dr. McFadden. On average, they had almost 15 years of education.

The percentage of physicians who mentioned various immediate risks of mesh ranged from 94% for bleeding to 97% for organ damage (mean, 95%). Patient recall scores at 6 weeks after surgery ranged from 71% for bleeding to 90% for the need for a catheter (mean, 80%).

The percentage of physicians who mentioned the long-term risks of mesh ranged from 30% for continued leakage and groin pain to 92% for mesh erosion, a notable high outlier (mean, 58%). Patient recall scores ranged from 33% for chronic urinary tract infection to 95% for continued leakage (mean, 68%).

Surgeons were significantly more likely to mention the immediate risks than the long-term risks (95% vs. 58%; P less than .01), but patients were similarly likely to recall these two groups of risks.

When referring to the midurethral sling implant, surgeons most commonly used the terms mesh (87%) and tape (81%), and less commonly used the term graft (14%). On average, there were 5.9 uses of mesh per consent session, 7.4 uses of tape, and 0.5 uses of graft.

A variety of sociodemographic factors (patient age, education, race/ethnicity, and health literacy score) and consent-related factors (duration of the discussion, mesh term used, and number of uses) were not significantly associated with patients’ recall of risks.

But the lower the grade level at which the surgeon spoke, the greater patients’ recall was (r = –0.26, P less than .05).

Dr. McFadden disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Patients giving consent to undergo midurethral sling surgery are more likely to remember being advised of the risks of surgical mesh if their surgeon speaks at a lower grade level.

This was among the key findings of a longitudinal cohort study of 71 women reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

Analysis of the consent discussions, which lasted an average of 15 minutes, showed that surgeons were significantly more likely to mention the immediate risks of mesh than the long-term risks, reported first author Dr. Brook L. McFadden, a urogynecologist at the Ohio State University Wexner Medical Center in Columbus. But patients were equally likely to remember both groups of risks.

Neither the specific term surgeons used to refer to the midurethral sling implant – mesh, tape, or graft – nor the number of times they used the term during the discussion affected patients’ recall of mesh risks 6 weeks after surgery. The length of the discussion also had no significant impact.

However, the lower the grade level at which the surgeon spoke, the greater patients’ recall of risks, even though the cohort was fairly well educated. On average, the surgeons spoke at about the 6th- to 7th-grade level.

"This was a homogeneous, young, educated population, which may not be generalizable," Dr. McFadden noted. "And we cannot account for counseling that occurred prior to or after the surgical consent session that may have impacted recall."

Invited discussant Dr. Bela Kudish, a urogynecologist at the Winnie Palmer Hospital Center for Advanced Gynecologic Surgery and Pelvic Medicine in Orlando, noted, "As providers, many of us are trying to balance the principles of nonmaleficence, beneficence, and autonomy of the patient in an attempt to improve the counseling process, to emphasize the shared responsibility in decision making in patients who undergo this procedure."

"How are you planning to improve the study design to identify factors specific to the consent process that may influence the recall, since this was a study that was done in four centers with a nonstandardized consent process?" she asked the investigators.

"I think at this point, the surgical consent process is not limited to that moment that you sign papers. It starts in the first moment when you meet the patient. So I think we need to start broadening our understanding and our evaluation of the consent process to include the very beginning counseling that’s occurring from day 1. And I also think we need to spend more time trying to reconcile what patients want to know and what they think is important with what we want them to remember, maybe what the lawyers want them to remember, and try to make that more patient centered," Dr. McFadden replied at the meeting, which was jointly sponsored by the American College of Surgeons.

"In your opinion, what is the ideal way of counseling patients to increase the recall of risk?" Dr. Kudish further queried.

"I do try to spend time asking the patient, ‘How do you best learn? Is it written, is it verbal? Do you like pictures?’ And try to incorporate what works best for them. And I think that the utility of decisional aids, while we have presented work that did not show great use recently, that is where this is going to go: using decisional aids starting from the very beginning, day 1, up until surgery, and even beyond this," Dr. McFadden maintained.

Session cochair Dr. Andrew Cassidenti of St. Joseph Hospital, Orange, Calif., commented, "Your point is excellent. I think the informed consent is really your relationship with the patient. It’s not a document, it’s a relationship and it’s an understanding of your confidence, your capabilities, your experience, what you can do for them, your results, and an honest discussion. I think that really is the key to keeping lawyers at bay."

The study enrolled patients who could read and write English and were undergoing only midurethral sling surgery. "At these four centers, we did not specify specifically how the surgeons were to [address] consent. They did this all in their normal way, so that had variation," Dr. McFadden noted.

Consent discussions were audio recorded and transcribed, and the transcripts were analyzed for their content and grade level of the surgeon’s speech according to the Flesch-Kincaid scale.

Patients completed a 21-item recall checklist. Their recall score was calculated as the number of items recalled divided by the number the surgeon actually mentioned, multiplied by 100.

The patients’ mean age was 53 years; 83% were white and 66% had some college education or more, reported Dr. McFadden. On average, they had almost 15 years of education.

The percentage of physicians who mentioned various immediate risks of mesh ranged from 94% for bleeding to 97% for organ damage (mean, 95%). Patient recall scores at 6 weeks after surgery ranged from 71% for bleeding to 90% for the need for a catheter (mean, 80%).

The percentage of physicians who mentioned the long-term risks of mesh ranged from 30% for continued leakage and groin pain to 92% for mesh erosion, a notable high outlier (mean, 58%). Patient recall scores ranged from 33% for chronic urinary tract infection to 95% for continued leakage (mean, 68%).

Surgeons were significantly more likely to mention the immediate risks than the long-term risks (95% vs. 58%; P less than .01), but patients were similarly likely to recall these two groups of risks.

When referring to the midurethral sling implant, surgeons most commonly used the terms mesh (87%) and tape (81%), and less commonly used the term graft (14%). On average, there were 5.9 uses of mesh per consent session, 7.4 uses of tape, and 0.5 uses of graft.

A variety of sociodemographic factors (patient age, education, race/ethnicity, and health literacy score) and consent-related factors (duration of the discussion, mesh term used, and number of uses) were not significantly associated with patients’ recall of risks.

But the lower the grade level at which the surgeon spoke, the greater patients’ recall was (r = –0.26, P less than .05).

Dr. McFadden disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Women with asymptomatic stage 2 pelvic organ prolapse can be reassured that it rarely progresses, according to the results of a study reported at the annual meeting of the Society of Gynecologic Surgery.

Investigators led by Dr. Peggy A. Norton, chief of urogynecology and pelvic reconstructive surgery at the University of Utah in Salt Lake City, performed a secondary analysis of the 597 women undergoing surgery for stress urinary incontinence in the randomized TOMUS (Trial of Mid-Urethral Slings) study. Analyses were based on the 291 women (49%) who also had stage 2 prolapse – a group for whom the need for repair has been a gray area.

The results showed that among the 189 women who had asymptomatic prolapse and did not have concomitant repair at the time of continence surgery, just 2% experienced progression to stage 3 prolapse after 6 years of follow-up. Moreover, none underwent surgery for the prolapse during that time.

This very low rate of progression was surprising, according to Dr. Norton, and noteworthy in that these women were being rigorously followed up in a trial.

"We would conclude that surgeons may counsel women with asymptomatic stage 2 prolapse that their prolapse is unlikely to progress or even unlikely to require surgery in the next 5-7 years. Said another way, it is not necessary to perform concomitant anterior prolapse surgery for asymptomatic stage 2 anterior prolapse when performing a mid-urethral sling for stress incontinence," she said at the annual scientific meeting of the Society of Gynecologic Surgeons, jointly sponsored by the American College of Surgeons.

In additional findings, among the 47 women who had symptomatic prolapse and did have concomitant repair at the time of their continence surgery, just 6% underwent another prolapse repair during follow-up (2 at 36 months and 1 at 48 months). The women who underwent another repair typically had a repeated anterior prolapse or an apical prolapse, but the numbers were too small to definitively pin down any pattern.

Invited discussant Dr. Jeffrey Mangel, director of the division of urogynecology and pelvic reconstructive surgery at the Metrohealth Medical Center, Cleveland, noted, "This is a very common clinical scenario; we see this every week – patients who have primary stress incontinence who have some mild degree of anterior wall prolapse – and the question is how to manage that."

"This was an impressive long-term surgical follow-up," he commented. However, "the surgical bias is there; that is, we know how we counsel patients can influence what patients decide to do or not to do in response to these milder degrees of symptoms and findings on anatomy.

"Were the patients in the TOMUS trial who had concurrent prolapse surgery (or not) evenly distributed across all the study sites, and were there any differences in stress incontinence outcomes in patients who had their prolapse repaired and those who didn’t?" Dr. Mangel asked.

There were some differences in surgical intervention across institutions, as might be expected in a multicenter trial, Dr. Norton said. The results for the whole trial population at 2 years of follow-up, previously reported, showed that concomitant repair did not adversely affect continence outcomes (N. Engl. J. Med. 2010;362:2066-76). "Doing a concomitant procedure didn’t increase the number of [adverse events]; it just changed the type of [adverse events] that we saw. But it didn’t change the primary outcome for stress urinary incontinence.

"I think we would all agree it is hard to improve in an asymptomatic patient, but how, given these findings, would you counsel a patient about symptomatic stage 2 anterior wall prolapse who is a candidate for a sling procedure with regard to concurrent repair of the prolapse?" Dr. Mangel asked.

"It has to be an individual discussion between the surgeon and the patient," Dr. Norton replied. "We have always told patients, have everything repaired at the time, while we are in there anyway. I think what’s changed for me is the minute we saw these results, I was able to say to patients, if we repair this stage 2 prolapse, you have about a 6%-7% chance that over the next couple of years, we’ll have to repair it again. And it seems like for patients who don’t have any bother, that none of them go on [to need repair]. So it may be that there’s a difference in patients feeling that stage 2 prolapse that may be one of the critical issues."

The decision to perform concomitant prolapse repair in women undergoing continence surgery is typically clear-cut if the prolapse is stage 0 or 1 (no) or stage 3 or 4 (yes), according to Dr. Norton. "But it’s more difficult to counsel patients on defects that have some intermediate anatomy or intermediate levels of bother or even no bother."

The total 575 women in TOMUS underwent either a retropubic or transobturator continence procedure. Concomitant vaginal procedures to repair pelvic organ prolapse were allowed at the surgeon’s discretion after discussion with the patient.

The women were assessed at baseline and annually for 5-7 years after surgery with the Urinary Distress Inventory (UDI) and the Pelvic Organ Prolapse Quantification System (POP-Q).

About a quarter of women with stage 2 prolapse had symptoms according to responses on the UDI. As expected, 70% of those who were symptomatic, but only 15% of those who were asymptomatic, had a concomitant repair at the time of their continence surgery.

"These findings are not generalizable to women with higher stages of prolapse since we really only had sufficient power to be looking at stage 2’s," said Dr. Norton. "Also, this was a primary randomized trial of stress incontinence, and patients were not randomized to receive or not receive concomitant prolapse repair, so it really limits our ability to [control for] selection bias or surgeon bias."

Dr. Norton disclosed no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Women with asymptomatic stage 2 pelvic organ prolapse can be reassured that it rarely progresses, according to the results of a study reported at the annual meeting of the Society of Gynecologic Surgery.

Investigators led by Dr. Peggy A. Norton, chief of urogynecology and pelvic reconstructive surgery at the University of Utah in Salt Lake City, performed a secondary analysis of the 597 women undergoing surgery for stress urinary incontinence in the randomized TOMUS (Trial of Mid-Urethral Slings) study. Analyses were based on the 291 women (49%) who also had stage 2 prolapse – a group for whom the need for repair has been a gray area.

The results showed that among the 189 women who had asymptomatic prolapse and did not have concomitant repair at the time of continence surgery, just 2% experienced progression to stage 3 prolapse after 6 years of follow-up. Moreover, none underwent surgery for the prolapse during that time.

This very low rate of progression was surprising, according to Dr. Norton, and noteworthy in that these women were being rigorously followed up in a trial.

"We would conclude that surgeons may counsel women with asymptomatic stage 2 prolapse that their prolapse is unlikely to progress or even unlikely to require surgery in the next 5-7 years. Said another way, it is not necessary to perform concomitant anterior prolapse surgery for asymptomatic stage 2 anterior prolapse when performing a mid-urethral sling for stress incontinence," she said at the annual scientific meeting of the Society of Gynecologic Surgeons, jointly sponsored by the American College of Surgeons.

In additional findings, among the 47 women who had symptomatic prolapse and did have concomitant repair at the time of their continence surgery, just 6% underwent another prolapse repair during follow-up (2 at 36 months and 1 at 48 months). The women who underwent another repair typically had a repeated anterior prolapse or an apical prolapse, but the numbers were too small to definitively pin down any pattern.

Invited discussant Dr. Jeffrey Mangel, director of the division of urogynecology and pelvic reconstructive surgery at the Metrohealth Medical Center, Cleveland, noted, "This is a very common clinical scenario; we see this every week – patients who have primary stress incontinence who have some mild degree of anterior wall prolapse – and the question is how to manage that."

"This was an impressive long-term surgical follow-up," he commented. However, "the surgical bias is there; that is, we know how we counsel patients can influence what patients decide to do or not to do in response to these milder degrees of symptoms and findings on anatomy.

"Were the patients in the TOMUS trial who had concurrent prolapse surgery (or not) evenly distributed across all the study sites, and were there any differences in stress incontinence outcomes in patients who had their prolapse repaired and those who didn’t?" Dr. Mangel asked.

There were some differences in surgical intervention across institutions, as might be expected in a multicenter trial, Dr. Norton said. The results for the whole trial population at 2 years of follow-up, previously reported, showed that concomitant repair did not adversely affect continence outcomes (N. Engl. J. Med. 2010;362:2066-76). "Doing a concomitant procedure didn’t increase the number of [adverse events]; it just changed the type of [adverse events] that we saw. But it didn’t change the primary outcome for stress urinary incontinence.

"I think we would all agree it is hard to improve in an asymptomatic patient, but how, given these findings, would you counsel a patient about symptomatic stage 2 anterior wall prolapse who is a candidate for a sling procedure with regard to concurrent repair of the prolapse?" Dr. Mangel asked.

"It has to be an individual discussion between the surgeon and the patient," Dr. Norton replied. "We have always told patients, have everything repaired at the time, while we are in there anyway. I think what’s changed for me is the minute we saw these results, I was able to say to patients, if we repair this stage 2 prolapse, you have about a 6%-7% chance that over the next couple of years, we’ll have to repair it again. And it seems like for patients who don’t have any bother, that none of them go on [to need repair]. So it may be that there’s a difference in patients feeling that stage 2 prolapse that may be one of the critical issues."

The decision to perform concomitant prolapse repair in women undergoing continence surgery is typically clear-cut if the prolapse is stage 0 or 1 (no) or stage 3 or 4 (yes), according to Dr. Norton. "But it’s more difficult to counsel patients on defects that have some intermediate anatomy or intermediate levels of bother or even no bother."

The total 575 women in TOMUS underwent either a retropubic or transobturator continence procedure. Concomitant vaginal procedures to repair pelvic organ prolapse were allowed at the surgeon’s discretion after discussion with the patient.

The women were assessed at baseline and annually for 5-7 years after surgery with the Urinary Distress Inventory (UDI) and the Pelvic Organ Prolapse Quantification System (POP-Q).

About a quarter of women with stage 2 prolapse had symptoms according to responses on the UDI. As expected, 70% of those who were symptomatic, but only 15% of those who were asymptomatic, had a concomitant repair at the time of their continence surgery.

"These findings are not generalizable to women with higher stages of prolapse since we really only had sufficient power to be looking at stage 2’s," said Dr. Norton. "Also, this was a primary randomized trial of stress incontinence, and patients were not randomized to receive or not receive concomitant prolapse repair, so it really limits our ability to [control for] selection bias or surgeon bias."

Dr. Norton disclosed no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Women with asymptomatic stage 2 pelvic organ prolapse can be reassured that it rarely progresses, according to the results of a study reported at the annual meeting of the Society of Gynecologic Surgery.

Investigators led by Dr. Peggy A. Norton, chief of urogynecology and pelvic reconstructive surgery at the University of Utah in Salt Lake City, performed a secondary analysis of the 597 women undergoing surgery for stress urinary incontinence in the randomized TOMUS (Trial of Mid-Urethral Slings) study. Analyses were based on the 291 women (49%) who also had stage 2 prolapse – a group for whom the need for repair has been a gray area.

The results showed that among the 189 women who had asymptomatic prolapse and did not have concomitant repair at the time of continence surgery, just 2% experienced progression to stage 3 prolapse after 6 years of follow-up. Moreover, none underwent surgery for the prolapse during that time.

This very low rate of progression was surprising, according to Dr. Norton, and noteworthy in that these women were being rigorously followed up in a trial.

"We would conclude that surgeons may counsel women with asymptomatic stage 2 prolapse that their prolapse is unlikely to progress or even unlikely to require surgery in the next 5-7 years. Said another way, it is not necessary to perform concomitant anterior prolapse surgery for asymptomatic stage 2 anterior prolapse when performing a mid-urethral sling for stress incontinence," she said at the annual scientific meeting of the Society of Gynecologic Surgeons, jointly sponsored by the American College of Surgeons.

In additional findings, among the 47 women who had symptomatic prolapse and did have concomitant repair at the time of their continence surgery, just 6% underwent another prolapse repair during follow-up (2 at 36 months and 1 at 48 months). The women who underwent another repair typically had a repeated anterior prolapse or an apical prolapse, but the numbers were too small to definitively pin down any pattern.

Invited discussant Dr. Jeffrey Mangel, director of the division of urogynecology and pelvic reconstructive surgery at the Metrohealth Medical Center, Cleveland, noted, "This is a very common clinical scenario; we see this every week – patients who have primary stress incontinence who have some mild degree of anterior wall prolapse – and the question is how to manage that."

"This was an impressive long-term surgical follow-up," he commented. However, "the surgical bias is there; that is, we know how we counsel patients can influence what patients decide to do or not to do in response to these milder degrees of symptoms and findings on anatomy.

"Were the patients in the TOMUS trial who had concurrent prolapse surgery (or not) evenly distributed across all the study sites, and were there any differences in stress incontinence outcomes in patients who had their prolapse repaired and those who didn’t?" Dr. Mangel asked.

There were some differences in surgical intervention across institutions, as might be expected in a multicenter trial, Dr. Norton said. The results for the whole trial population at 2 years of follow-up, previously reported, showed that concomitant repair did not adversely affect continence outcomes (N. Engl. J. Med. 2010;362:2066-76). "Doing a concomitant procedure didn’t increase the number of [adverse events]; it just changed the type of [adverse events] that we saw. But it didn’t change the primary outcome for stress urinary incontinence.

"I think we would all agree it is hard to improve in an asymptomatic patient, but how, given these findings, would you counsel a patient about symptomatic stage 2 anterior wall prolapse who is a candidate for a sling procedure with regard to concurrent repair of the prolapse?" Dr. Mangel asked.

"It has to be an individual discussion between the surgeon and the patient," Dr. Norton replied. "We have always told patients, have everything repaired at the time, while we are in there anyway. I think what’s changed for me is the minute we saw these results, I was able to say to patients, if we repair this stage 2 prolapse, you have about a 6%-7% chance that over the next couple of years, we’ll have to repair it again. And it seems like for patients who don’t have any bother, that none of them go on [to need repair]. So it may be that there’s a difference in patients feeling that stage 2 prolapse that may be one of the critical issues."

The decision to perform concomitant prolapse repair in women undergoing continence surgery is typically clear-cut if the prolapse is stage 0 or 1 (no) or stage 3 or 4 (yes), according to Dr. Norton. "But it’s more difficult to counsel patients on defects that have some intermediate anatomy or intermediate levels of bother or even no bother."

The total 575 women in TOMUS underwent either a retropubic or transobturator continence procedure. Concomitant vaginal procedures to repair pelvic organ prolapse were allowed at the surgeon’s discretion after discussion with the patient.

The women were assessed at baseline and annually for 5-7 years after surgery with the Urinary Distress Inventory (UDI) and the Pelvic Organ Prolapse Quantification System (POP-Q).

About a quarter of women with stage 2 prolapse had symptoms according to responses on the UDI. As expected, 70% of those who were symptomatic, but only 15% of those who were asymptomatic, had a concomitant repair at the time of their continence surgery.

"These findings are not generalizable to women with higher stages of prolapse since we really only had sufficient power to be looking at stage 2’s," said Dr. Norton. "Also, this was a primary randomized trial of stress incontinence, and patients were not randomized to receive or not receive concomitant prolapse repair, so it really limits our ability to [control for] selection bias or surgeon bias."

Dr. Norton disclosed no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Applying a paracervical block before laparoscopic supracervical hysterectomy improves some operative outcomes but not others, Dr. Rachel L. Barr said at the annual scientific meeting of the Society of Gynecologic Surgeons.

The 132 women undergoing scheduled ambulatory surgery for presumed benign indications were randomized evenly to receive paracervical injection of bupivacaine plus epinephrine or paracervical injection of normal saline as a placebo control, each in addition to standard anesthesia.

Overall, about one-third of women were admitted to the hospital after the surgery – the trial’s primary outcome – with no significant difference between groups, reported lead investigator Dr. Rachel L. Barr, an obstetrician-gynecologist at Mount Sinai Hospital in New York. The findings were similar when restricted to women admitted specifically for pain management.

The paracervical-block group consumed about one-tenth of a tablet less of narcotics per day after surgery. They also had significantly lower estimated blood loss, although the median value was identical at 100 mL.

"The paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy is recommended to decrease the number of postoperative narcotic tablets consumed. It has the additional benefit of decreased blood loss and was found to be safe," Dr. Barr commented. "However, it was not effective at decreasing admissions for pain control."

"My first question for the authors relates to the clinical vs. statistical significance of the estimated blood loss and its variability in measurement and whether the authors considered using hematocrit in the study design," said invited discussant Dr. Clifford Wai of the division of female pelvic medicine and reconstructive surgery, University of Texas Southwestern Medical Center, Dallas.

The attending surgeon who performed all of the hysterectomies was very experienced, which likely helped achieve fairly low estimated blood loss in general, according to Dr. Barr. "So within this population, maybe the 50-mL difference between the two groups [in interquartile ranges] may not be that clinically significant."

"However, if you were to generalize this to other surgeons who maybe don’t do quite as many laparoscopic supracervical hysterectomies or on average have a higher blood loss, there may be a role for the paracervical block in helping decrease their blood loss, and you may see a larger decrease in blood loss when using the block," she added. "In addition, I think the block can be used as a tool to reduce blood loss in cases where, based on uterine size or pathology, you might predict there would be a higher blood loss, or in patients who have a lower hematocrit to begin with and refuse transfusions; this might decrease their blood loss and improve their recovery."

The investigators did not use hematocrit because they expected many patients to go home after surgery, and they do not routinely obtain a complete blood cell count in the postanesthesia care unit unless there is a clinical indication, she said at the meeting jointly sponsored by the American College of Surgeons.

"My second question is, given the limitations of the study, do the authors feel the conclusions justify a change in clinical practice?" Dr. Wai asked.

"We do now use the paracervical block with bupivacaine and epinephrine for all of our patients prior to laparoscopic supracervical hysterectomy," Dr. Barr replied.

Session attendee Dr. William W. Hurd, professor of obstetrics and gynecology at Duke University, Durham, N.C., and director of the division of reproductive endocrinology and infertility at the Duke Fertility Center, wondered, "Do you think that tiny change in pain medication would be clinically significant?"

"I do," Dr. Barr answered. "Maybe it’s not clinically significant just looking at that one value. But when you are talking to your patients preoperatively and they are asking, ‘Doctor, am I going to be taking tons of narcotics after? Am I going to get addicted?’ I think you can reassure them that over their postoperative course they might only need to take one or two tablets instead of two or three over several days. This might not seem like a lot to us, but I think that difference is reassuring to our patients."

The investigators studied patients undergoing laparoscopic supracervical hysterectomy at Mount Sinai Hospital between 2011 and 2013.

"In designing our study, we had noted that many patients at our institution were staying overnight electively in the hospital for pain management despite otherwise being stable for discharge home following laparoscopic hysterectomy," noted Dr. Barr.

The paracervical injection was performed after intubation but before the uterine manipulator was inserted or the abdominal incision was made. Admission was defined as at least one overnight stay in the hospital.

Results showed that the paracervical block and control groups were statistically indistinguishable with respect to the overall admission rate (41% vs. 28%) and the unplanned admission rate (34% vs. 27%). In the subset with an unplanned admission, 21 women were admitted for pain management: 10 in the paracervical-block group and 11 in the control group.

Use of fentanyl and use of oxycodone while in the postanesthesia care unit did not differ significantly between groups. However, in the first 14 days after surgery, the paracervical block group consumed fewer tablets of narcotics per day (0.58 vs. 0.71) and more tablets of over-the-counter analgesics per day (1.02 vs. 0.77). Mean pain scores during the first 2 postoperative days were essentially the same.

"Maybe the patients who didn’t have the block were using narcotics more to achieve a lower pain score. That’s one way to think about it," Dr. Barr proposed.

The two groups had similar rates of perioperative outcomes such as operative time and complications. Estimated median blood loss was generally low, but significantly lower in the paracervical block group.

"Out of all 132 patients, we only had 7 patients who had a blood loss greater than or equal to 500 mL, and the largest blood loss was 900 mL. Also, there were no transfusions," she pointed out.

Three patients – two in the paracervical block group and one in the control group – developed a cervical infection after surgery. All were successfully treated with oral antibiotics.

"The hysterectomies were all supracervical so the results may not apply to total hysterectomies, and we did not control for additional procedures performed at the same time," Dr. Barr noted.

Dr. Barr disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Applying a paracervical block before laparoscopic supracervical hysterectomy improves some operative outcomes but not others, Dr. Rachel L. Barr said at the annual scientific meeting of the Society of Gynecologic Surgeons.

The 132 women undergoing scheduled ambulatory surgery for presumed benign indications were randomized evenly to receive paracervical injection of bupivacaine plus epinephrine or paracervical injection of normal saline as a placebo control, each in addition to standard anesthesia.

Overall, about one-third of women were admitted to the hospital after the surgery – the trial’s primary outcome – with no significant difference between groups, reported lead investigator Dr. Rachel L. Barr, an obstetrician-gynecologist at Mount Sinai Hospital in New York. The findings were similar when restricted to women admitted specifically for pain management.

The paracervical-block group consumed about one-tenth of a tablet less of narcotics per day after surgery. They also had significantly lower estimated blood loss, although the median value was identical at 100 mL.

"The paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy is recommended to decrease the number of postoperative narcotic tablets consumed. It has the additional benefit of decreased blood loss and was found to be safe," Dr. Barr commented. "However, it was not effective at decreasing admissions for pain control."

"My first question for the authors relates to the clinical vs. statistical significance of the estimated blood loss and its variability in measurement and whether the authors considered using hematocrit in the study design," said invited discussant Dr. Clifford Wai of the division of female pelvic medicine and reconstructive surgery, University of Texas Southwestern Medical Center, Dallas.

The attending surgeon who performed all of the hysterectomies was very experienced, which likely helped achieve fairly low estimated blood loss in general, according to Dr. Barr. "So within this population, maybe the 50-mL difference between the two groups [in interquartile ranges] may not be that clinically significant."

"However, if you were to generalize this to other surgeons who maybe don’t do quite as many laparoscopic supracervical hysterectomies or on average have a higher blood loss, there may be a role for the paracervical block in helping decrease their blood loss, and you may see a larger decrease in blood loss when using the block," she added. "In addition, I think the block can be used as a tool to reduce blood loss in cases where, based on uterine size or pathology, you might predict there would be a higher blood loss, or in patients who have a lower hematocrit to begin with and refuse transfusions; this might decrease their blood loss and improve their recovery."

The investigators did not use hematocrit because they expected many patients to go home after surgery, and they do not routinely obtain a complete blood cell count in the postanesthesia care unit unless there is a clinical indication, she said at the meeting jointly sponsored by the American College of Surgeons.

"My second question is, given the limitations of the study, do the authors feel the conclusions justify a change in clinical practice?" Dr. Wai asked.

"We do now use the paracervical block with bupivacaine and epinephrine for all of our patients prior to laparoscopic supracervical hysterectomy," Dr. Barr replied.

Session attendee Dr. William W. Hurd, professor of obstetrics and gynecology at Duke University, Durham, N.C., and director of the division of reproductive endocrinology and infertility at the Duke Fertility Center, wondered, "Do you think that tiny change in pain medication would be clinically significant?"

"I do," Dr. Barr answered. "Maybe it’s not clinically significant just looking at that one value. But when you are talking to your patients preoperatively and they are asking, ‘Doctor, am I going to be taking tons of narcotics after? Am I going to get addicted?’ I think you can reassure them that over their postoperative course they might only need to take one or two tablets instead of two or three over several days. This might not seem like a lot to us, but I think that difference is reassuring to our patients."

The investigators studied patients undergoing laparoscopic supracervical hysterectomy at Mount Sinai Hospital between 2011 and 2013.

"In designing our study, we had noted that many patients at our institution were staying overnight electively in the hospital for pain management despite otherwise being stable for discharge home following laparoscopic hysterectomy," noted Dr. Barr.

The paracervical injection was performed after intubation but before the uterine manipulator was inserted or the abdominal incision was made. Admission was defined as at least one overnight stay in the hospital.

Results showed that the paracervical block and control groups were statistically indistinguishable with respect to the overall admission rate (41% vs. 28%) and the unplanned admission rate (34% vs. 27%). In the subset with an unplanned admission, 21 women were admitted for pain management: 10 in the paracervical-block group and 11 in the control group.

Use of fentanyl and use of oxycodone while in the postanesthesia care unit did not differ significantly between groups. However, in the first 14 days after surgery, the paracervical block group consumed fewer tablets of narcotics per day (0.58 vs. 0.71) and more tablets of over-the-counter analgesics per day (1.02 vs. 0.77). Mean pain scores during the first 2 postoperative days were essentially the same.

"Maybe the patients who didn’t have the block were using narcotics more to achieve a lower pain score. That’s one way to think about it," Dr. Barr proposed.

The two groups had similar rates of perioperative outcomes such as operative time and complications. Estimated median blood loss was generally low, but significantly lower in the paracervical block group.

"Out of all 132 patients, we only had 7 patients who had a blood loss greater than or equal to 500 mL, and the largest blood loss was 900 mL. Also, there were no transfusions," she pointed out.

Three patients – two in the paracervical block group and one in the control group – developed a cervical infection after surgery. All were successfully treated with oral antibiotics.

"The hysterectomies were all supracervical so the results may not apply to total hysterectomies, and we did not control for additional procedures performed at the same time," Dr. Barr noted.

Dr. Barr disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Applying a paracervical block before laparoscopic supracervical hysterectomy improves some operative outcomes but not others, Dr. Rachel L. Barr said at the annual scientific meeting of the Society of Gynecologic Surgeons.

The 132 women undergoing scheduled ambulatory surgery for presumed benign indications were randomized evenly to receive paracervical injection of bupivacaine plus epinephrine or paracervical injection of normal saline as a placebo control, each in addition to standard anesthesia.

Overall, about one-third of women were admitted to the hospital after the surgery – the trial’s primary outcome – with no significant difference between groups, reported lead investigator Dr. Rachel L. Barr, an obstetrician-gynecologist at Mount Sinai Hospital in New York. The findings were similar when restricted to women admitted specifically for pain management.

The paracervical-block group consumed about one-tenth of a tablet less of narcotics per day after surgery. They also had significantly lower estimated blood loss, although the median value was identical at 100 mL.

"The paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy is recommended to decrease the number of postoperative narcotic tablets consumed. It has the additional benefit of decreased blood loss and was found to be safe," Dr. Barr commented. "However, it was not effective at decreasing admissions for pain control."

"My first question for the authors relates to the clinical vs. statistical significance of the estimated blood loss and its variability in measurement and whether the authors considered using hematocrit in the study design," said invited discussant Dr. Clifford Wai of the division of female pelvic medicine and reconstructive surgery, University of Texas Southwestern Medical Center, Dallas.

The attending surgeon who performed all of the hysterectomies was very experienced, which likely helped achieve fairly low estimated blood loss in general, according to Dr. Barr. "So within this population, maybe the 50-mL difference between the two groups [in interquartile ranges] may not be that clinically significant."

"However, if you were to generalize this to other surgeons who maybe don’t do quite as many laparoscopic supracervical hysterectomies or on average have a higher blood loss, there may be a role for the paracervical block in helping decrease their blood loss, and you may see a larger decrease in blood loss when using the block," she added. "In addition, I think the block can be used as a tool to reduce blood loss in cases where, based on uterine size or pathology, you might predict there would be a higher blood loss, or in patients who have a lower hematocrit to begin with and refuse transfusions; this might decrease their blood loss and improve their recovery."

The investigators did not use hematocrit because they expected many patients to go home after surgery, and they do not routinely obtain a complete blood cell count in the postanesthesia care unit unless there is a clinical indication, she said at the meeting jointly sponsored by the American College of Surgeons.

"My second question is, given the limitations of the study, do the authors feel the conclusions justify a change in clinical practice?" Dr. Wai asked.

"We do now use the paracervical block with bupivacaine and epinephrine for all of our patients prior to laparoscopic supracervical hysterectomy," Dr. Barr replied.

Session attendee Dr. William W. Hurd, professor of obstetrics and gynecology at Duke University, Durham, N.C., and director of the division of reproductive endocrinology and infertility at the Duke Fertility Center, wondered, "Do you think that tiny change in pain medication would be clinically significant?"

"I do," Dr. Barr answered. "Maybe it’s not clinically significant just looking at that one value. But when you are talking to your patients preoperatively and they are asking, ‘Doctor, am I going to be taking tons of narcotics after? Am I going to get addicted?’ I think you can reassure them that over their postoperative course they might only need to take one or two tablets instead of two or three over several days. This might not seem like a lot to us, but I think that difference is reassuring to our patients."

The investigators studied patients undergoing laparoscopic supracervical hysterectomy at Mount Sinai Hospital between 2011 and 2013.

"In designing our study, we had noted that many patients at our institution were staying overnight electively in the hospital for pain management despite otherwise being stable for discharge home following laparoscopic hysterectomy," noted Dr. Barr.

The paracervical injection was performed after intubation but before the uterine manipulator was inserted or the abdominal incision was made. Admission was defined as at least one overnight stay in the hospital.

Results showed that the paracervical block and control groups were statistically indistinguishable with respect to the overall admission rate (41% vs. 28%) and the unplanned admission rate (34% vs. 27%). In the subset with an unplanned admission, 21 women were admitted for pain management: 10 in the paracervical-block group and 11 in the control group.

Use of fentanyl and use of oxycodone while in the postanesthesia care unit did not differ significantly between groups. However, in the first 14 days after surgery, the paracervical block group consumed fewer tablets of narcotics per day (0.58 vs. 0.71) and more tablets of over-the-counter analgesics per day (1.02 vs. 0.77). Mean pain scores during the first 2 postoperative days were essentially the same.

"Maybe the patients who didn’t have the block were using narcotics more to achieve a lower pain score. That’s one way to think about it," Dr. Barr proposed.

The two groups had similar rates of perioperative outcomes such as operative time and complications. Estimated median blood loss was generally low, but significantly lower in the paracervical block group.

"Out of all 132 patients, we only had 7 patients who had a blood loss greater than or equal to 500 mL, and the largest blood loss was 900 mL. Also, there were no transfusions," she pointed out.

Three patients – two in the paracervical block group and one in the control group – developed a cervical infection after surgery. All were successfully treated with oral antibiotics.

"The hysterectomies were all supracervical so the results may not apply to total hysterectomies, and we did not control for additional procedures performed at the same time," Dr. Barr noted.

Dr. Barr disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The advent of robotic technology has shifted both the approach used for hysterectomies and the involvement of residents in this surgery, suggest results of a retrospective cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Researchers studied women undergoing hysterectomy at four hospitals that had both residents and fellows, comparing 732 surgeries from the pre-robot era (the year before the first robotic hysterectomy at the hospital) with 709 from the postrobot era (2011).

Results showed a significant decrease in the proportion of all hysterectomies that were total vaginal hysterectomies from 43% to 31%. Meanwhile, robotic hysterectomies accounted for 23% of the total by 2011.

In other findings, there was no significant change in the proportion of all hysterectomies having at least some resident involvement, according to operative reports: That value stood at 81% before robotic hysterectomy began and 82% afterward. However, in the postrobot era, residents were involved in nearly 89% of all nonrobotic hysterectomies, but only about 59% of robotic ones.

"These data provide early data on potential implications for robotic implementation," commented first author Dr. Peter C. Jeppson, a urogynecology fellow at Brown University, Providence, R.I. "At this point, the impact of the increasing diversity of hysterectomy approaches on resident education warrants further study."

"Resident involvement was based on dictated operative reports, so we do not know how much of each case was actually performed by the resident," he acknowledged at the meeting jointly sponsored by the American College of Surgeons. "However, one could argue that observing or assisting in more surgical cases provides important educational experience."

Invited discussant Dr. Shawn A. Menefee, an obstetrician-gynecologist at Kaiser Permanente, San Diego, noted, "While the rates of vaginal hysterectomy decreased in the postrobotic period, they still remained above what has been reported in the past. ... Given that resident training often reflects what technique is performed over a surgeon’s career, what impact do you believe this decrease in TVH [total vaginal hysterectomy] rates will have in the United States?"

"At this point, it’s a little bit speculative to state how this will impact the future global rates within the United States," Dr. Jeppson replied. "But I think that it is certainly possible that as the numbers decrease in training, that those numbers also decrease for postgraduates because it seems unlikely to me that residents in training, after graduating, would choose to do a procedure that they weren’t trained to do well."

Dr. Menefee noted that about one-fifth of cases were done by attendings who were urogynecologists. "Is vaginal hysterectomy becoming a procedure performed by subspecialists, and if you remove the urogynecologists at the sites, what would be the percentage of transvaginal hysterectomies performed?" he asked.

Urogynecologists performed about 40% of all hysterectomies in both eras, according to Dr. Jeppson. When these hysterectomies were removed from analyses, the share of the total that were done vaginally still fell, from 31% to 22%.

"While robotic hysterectomy offers limited-to-no benefits for benign hysterectomy, compared with other minimally invasive approaches, it does appear to impact residents’ already limited exposure. Can we adequately teach residents to safely perform multiple approaches, or do we have to choose which ones to teach?" Dr. Menefee wondered.

"My personal opinion is that we should be training residents to perform what’s best for the patients. So different patients may need a different type of surgery," Dr. Jeppson replied. "But with the restrictions placed on duty work hours and with the increasing diversity of the approaches that can be used, that may be difficult. But time will tell."

Session attendee Dr. Hal C. Lawrence III, executive vice president and CEO of the American Congress of Obstetricians and Gynecologists, asked, "What do you think we need to do as a specialty to get people back to doing vaginal surgery, which is just as effective, a whole lot less expensive, and has fewer complications?"

"I think that that will be something that we will have to address on the national level," Dr. Jeppson commented. "But having a commitment to vaginal surgery would be the place to start – there are other modalities that are important and useful, but to not abandon the proven approaches that have been established over a long period of time."

For the study, the researchers analyzed hysterectomies captured by the Fellows’ Pelvic Research Network, excluding those performed in the oncology setting and those done for emergent indications.

The women undergoing hysterectomy in the pre- and postrobot eras did not differ significantly with respect to age, body mass index, prior abdominal or pelvic surgery, insurance type, or mean uterine weight, reported Dr. Jeppson. Also, dysfunctional uterine bleeding was the most common indication for hysterectomy in both groups.

In addition to the observed decrease in vaginal hysterectomies and increase in robotic hysterectomies, there was also a significant reduction in the proportion of total abdominal hysterectomies, from 22% to 17%.

Dr. Jeppson disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The advent of robotic technology has shifted both the approach used for hysterectomies and the involvement of residents in this surgery, suggest results of a retrospective cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Researchers studied women undergoing hysterectomy at four hospitals that had both residents and fellows, comparing 732 surgeries from the pre-robot era (the year before the first robotic hysterectomy at the hospital) with 709 from the postrobot era (2011).

Results showed a significant decrease in the proportion of all hysterectomies that were total vaginal hysterectomies from 43% to 31%. Meanwhile, robotic hysterectomies accounted for 23% of the total by 2011.

In other findings, there was no significant change in the proportion of all hysterectomies having at least some resident involvement, according to operative reports: That value stood at 81% before robotic hysterectomy began and 82% afterward. However, in the postrobot era, residents were involved in nearly 89% of all nonrobotic hysterectomies, but only about 59% of robotic ones.

"These data provide early data on potential implications for robotic implementation," commented first author Dr. Peter C. Jeppson, a urogynecology fellow at Brown University, Providence, R.I. "At this point, the impact of the increasing diversity of hysterectomy approaches on resident education warrants further study."

"Resident involvement was based on dictated operative reports, so we do not know how much of each case was actually performed by the resident," he acknowledged at the meeting jointly sponsored by the American College of Surgeons. "However, one could argue that observing or assisting in more surgical cases provides important educational experience."

Invited discussant Dr. Shawn A. Menefee, an obstetrician-gynecologist at Kaiser Permanente, San Diego, noted, "While the rates of vaginal hysterectomy decreased in the postrobotic period, they still remained above what has been reported in the past. ... Given that resident training often reflects what technique is performed over a surgeon’s career, what impact do you believe this decrease in TVH [total vaginal hysterectomy] rates will have in the United States?"

"At this point, it’s a little bit speculative to state how this will impact the future global rates within the United States," Dr. Jeppson replied. "But I think that it is certainly possible that as the numbers decrease in training, that those numbers also decrease for postgraduates because it seems unlikely to me that residents in training, after graduating, would choose to do a procedure that they weren’t trained to do well."

Dr. Menefee noted that about one-fifth of cases were done by attendings who were urogynecologists. "Is vaginal hysterectomy becoming a procedure performed by subspecialists, and if you remove the urogynecologists at the sites, what would be the percentage of transvaginal hysterectomies performed?" he asked.

Urogynecologists performed about 40% of all hysterectomies in both eras, according to Dr. Jeppson. When these hysterectomies were removed from analyses, the share of the total that were done vaginally still fell, from 31% to 22%.

"While robotic hysterectomy offers limited-to-no benefits for benign hysterectomy, compared with other minimally invasive approaches, it does appear to impact residents’ already limited exposure. Can we adequately teach residents to safely perform multiple approaches, or do we have to choose which ones to teach?" Dr. Menefee wondered.

"My personal opinion is that we should be training residents to perform what’s best for the patients. So different patients may need a different type of surgery," Dr. Jeppson replied. "But with the restrictions placed on duty work hours and with the increasing diversity of the approaches that can be used, that may be difficult. But time will tell."

Session attendee Dr. Hal C. Lawrence III, executive vice president and CEO of the American Congress of Obstetricians and Gynecologists, asked, "What do you think we need to do as a specialty to get people back to doing vaginal surgery, which is just as effective, a whole lot less expensive, and has fewer complications?"

"I think that that will be something that we will have to address on the national level," Dr. Jeppson commented. "But having a commitment to vaginal surgery would be the place to start – there are other modalities that are important and useful, but to not abandon the proven approaches that have been established over a long period of time."

For the study, the researchers analyzed hysterectomies captured by the Fellows’ Pelvic Research Network, excluding those performed in the oncology setting and those done for emergent indications.

The women undergoing hysterectomy in the pre- and postrobot eras did not differ significantly with respect to age, body mass index, prior abdominal or pelvic surgery, insurance type, or mean uterine weight, reported Dr. Jeppson. Also, dysfunctional uterine bleeding was the most common indication for hysterectomy in both groups.

In addition to the observed decrease in vaginal hysterectomies and increase in robotic hysterectomies, there was also a significant reduction in the proportion of total abdominal hysterectomies, from 22% to 17%.

Dr. Jeppson disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – The advent of robotic technology has shifted both the approach used for hysterectomies and the involvement of residents in this surgery, suggest results of a retrospective cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Researchers studied women undergoing hysterectomy at four hospitals that had both residents and fellows, comparing 732 surgeries from the pre-robot era (the year before the first robotic hysterectomy at the hospital) with 709 from the postrobot era (2011).

Results showed a significant decrease in the proportion of all hysterectomies that were total vaginal hysterectomies from 43% to 31%. Meanwhile, robotic hysterectomies accounted for 23% of the total by 2011.

In other findings, there was no significant change in the proportion of all hysterectomies having at least some resident involvement, according to operative reports: That value stood at 81% before robotic hysterectomy began and 82% afterward. However, in the postrobot era, residents were involved in nearly 89% of all nonrobotic hysterectomies, but only about 59% of robotic ones.

"These data provide early data on potential implications for robotic implementation," commented first author Dr. Peter C. Jeppson, a urogynecology fellow at Brown University, Providence, R.I. "At this point, the impact of the increasing diversity of hysterectomy approaches on resident education warrants further study."

"Resident involvement was based on dictated operative reports, so we do not know how much of each case was actually performed by the resident," he acknowledged at the meeting jointly sponsored by the American College of Surgeons. "However, one could argue that observing or assisting in more surgical cases provides important educational experience."

Invited discussant Dr. Shawn A. Menefee, an obstetrician-gynecologist at Kaiser Permanente, San Diego, noted, "While the rates of vaginal hysterectomy decreased in the postrobotic period, they still remained above what has been reported in the past. ... Given that resident training often reflects what technique is performed over a surgeon’s career, what impact do you believe this decrease in TVH [total vaginal hysterectomy] rates will have in the United States?"

"At this point, it’s a little bit speculative to state how this will impact the future global rates within the United States," Dr. Jeppson replied. "But I think that it is certainly possible that as the numbers decrease in training, that those numbers also decrease for postgraduates because it seems unlikely to me that residents in training, after graduating, would choose to do a procedure that they weren’t trained to do well."

Dr. Menefee noted that about one-fifth of cases were done by attendings who were urogynecologists. "Is vaginal hysterectomy becoming a procedure performed by subspecialists, and if you remove the urogynecologists at the sites, what would be the percentage of transvaginal hysterectomies performed?" he asked.

Urogynecologists performed about 40% of all hysterectomies in both eras, according to Dr. Jeppson. When these hysterectomies were removed from analyses, the share of the total that were done vaginally still fell, from 31% to 22%.

"While robotic hysterectomy offers limited-to-no benefits for benign hysterectomy, compared with other minimally invasive approaches, it does appear to impact residents’ already limited exposure. Can we adequately teach residents to safely perform multiple approaches, or do we have to choose which ones to teach?" Dr. Menefee wondered.

"My personal opinion is that we should be training residents to perform what’s best for the patients. So different patients may need a different type of surgery," Dr. Jeppson replied. "But with the restrictions placed on duty work hours and with the increasing diversity of the approaches that can be used, that may be difficult. But time will tell."

Session attendee Dr. Hal C. Lawrence III, executive vice president and CEO of the American Congress of Obstetricians and Gynecologists, asked, "What do you think we need to do as a specialty to get people back to doing vaginal surgery, which is just as effective, a whole lot less expensive, and has fewer complications?"

"I think that that will be something that we will have to address on the national level," Dr. Jeppson commented. "But having a commitment to vaginal surgery would be the place to start – there are other modalities that are important and useful, but to not abandon the proven approaches that have been established over a long period of time."

For the study, the researchers analyzed hysterectomies captured by the Fellows’ Pelvic Research Network, excluding those performed in the oncology setting and those done for emergent indications.

The women undergoing hysterectomy in the pre- and postrobot eras did not differ significantly with respect to age, body mass index, prior abdominal or pelvic surgery, insurance type, or mean uterine weight, reported Dr. Jeppson. Also, dysfunctional uterine bleeding was the most common indication for hysterectomy in both groups.

In addition to the observed decrease in vaginal hysterectomies and increase in robotic hysterectomies, there was also a significant reduction in the proportion of total abdominal hysterectomies, from 22% to 17%.

Dr. Jeppson disclosed no relevant conflicts of interest.