Publications by authors named "Sherif A El-Nashar"

75 Publications

Counseling, contraception, and conception rates in patients undergoing bariatric surgery: A retrospective review.

Contraception 2021 Feb 28. Epub 2021 Feb 28.

Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.

Objectives: To determine conception rates, contraceptive use patterns, and frequency of counseling regarding pregnancy recommendations in patients undergoing bariatric surgery.

Study Design: Using a database of bariatric surgery patients at our institution, we identified female patients aged 18 to 45 who underwent surgery from 2013 to 2018. Patient charts were reviewed for demographic information, documentation of counseling regarding pregnancy recommendations, conception during the postoperative period, and pre and postoperative contraception use. We examined rates of contraception use and used standard statistical tests to compare conception rates between groups.

Results: Of the 460 patients that met inclusion criteria and did not have a history of permanent contraception, 54% (95% CI 49-58) had documented postoperative contraception use, most commonly the levonorgestrel-releasing intrauterine device followed by combination oral contraceptive pills. In the 18 months following bariatric surgery, 6% of patients (95% CI 4-8) had a documented pregnancy. Over 50% (95% CI 35-71) of pregnancies occurred in patients without documented postoperative contraception.

Conclusions: For bariatric surgery patients at risk of pregnancy, postoperative contraception use patterns and conception rates are not consistent with the recommendation to refrain from pregnancy for 18 months.

Implications: Individualized contraceptive counseling that includes a discussion of fertility and weight loss goals, planned bariatric procedure type, and patient preference should be implemented as part of standard preoperative care for patients at risk of pregnancy undergoing bariatric surgery.
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http://dx.doi.org/10.1016/j.contraception.2021.02.012DOI Listing
February 2021

Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis.

Int Urogynecol J 2021 Feb 27. Epub 2021 Feb 27.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.

Introduction And Hypothesis: It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly.

Methods: The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications.

Results: A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications.

Conclusion: ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.
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http://dx.doi.org/10.1007/s00192-021-04673-6DOI Listing
February 2021

Perioperative Complications of Laparoscopic versus Open Surgery for Pelvic Inflammatory Disease.

J Minim Invasive Gynecol 2020 Sep 4. Epub 2020 Sep 4.

Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio (all authors).

Study Objective: To compare complications in patients undergoing laparoscopic vs open surgery for acute pelvic inflammatory disease (PID).

Design: We performed a retrospective cohort study of patients who underwent surgery for PID, using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2015. Propensity score matching was used to balance baseline characteristics and compare complications in patients who underwent laparoscopic vs open surgery.

Setting: Surgical management of acute PID.

Patients: Patients with a preoperative diagnosis of PID were identified using International Classification of Diseases, Ninth Revision, codes. We excluded patients with chronic PID, gynecologic malignancy, and those for whom the surgical route was unknown.

Interventions: Surgery for acute PID.

Measurements And Main Results: The study included 367 patients. The mean age was 43.0 ± 11.1 years, body mass index was 30.9 ± 11.2 kg/m, and American Society of Anesthesiology class was 2 (interquartile range 2-3). Preoperative signs of sepsis were noted in 33.8% of the patients, and septic shock was present in 1.4%. Hysterectomy was performed in 67.6%, oophorectomy in 12.0%, and salpingectomy in 4.6%. Complications were experienced by 114 patients (31.1%), 11 (3.0%) of which were potentially life-threatening. Multivariate logistic regression identified the following to be independently associated with complications: laparoscopy (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI], 0.3-0.8; p <.01), operative time (aOR 1.01; 95% CI, 1.00-1.01; p <.01), appendectomy (aOR 2.36; 95% CI, 1.0-5.4; p = .04), elevated international normalized ratio (aOR 2.30; 95% CI, 1.3-4.2; p <.01), and low hematocrit level (aOR 2.53; 95% CI, 1.4-4.5; p <.01). Propensity scores were calculated and used to generate a matched cohort of patients who underwent laparoscopic vs open surgery; the groups were similar, with p <.05 for all covariates. After balancing confounding variables, a laparoscopic approach to surgery remained significantly associated with a lower risk of complications (coefficient -0.07; 95% CI, -0.11 to -0.02; p = .008).

Conclusion: Laparoscopy was associated with lower complication rates than open surgery in this well-matched cohort of patients who underwent surgery for acute PID.
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http://dx.doi.org/10.1016/j.jmig.2020.08.488DOI Listing
September 2020

Cystoscopy with antibiotic irrigation during pelvic reconstruction and minimally invasive gynecologic surgery: A double-blind randomized controlled trial.

Neurourol Urodyn 2020 11 4;39(8):2386-2393. Epub 2020 Sep 4.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA.

Aims: After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI.

Methods: This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ and multivariable logistic regression analyses were performed.

Results: We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569).

Conclusion: When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.
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http://dx.doi.org/10.1002/nau.24499DOI Listing
November 2020

Adjusting to the new reality: Evaluation of early practice pattern adaptations to the COVID-19 pandemic.

Gynecol Oncol 2020 08 23;158(2):256-261. Epub 2020 May 23.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.

Objective: We aim to define national practice patterns to assess current clinical practice, anticipated delays and areas of concern that potentially could lead to deviations from the normal standard of care.

Methods: Anonymous surveys were emailed to members of the Society of Gynecologic Oncology (SGO). The spread of COVID-19 and its impact on gynecologic oncology care in terms of alterations to normal treatment patterns and anticipated challenges were assessed. The Wilcoxon rank sum test was performed to determine risk factors for COVID-19 infection.

Results: We analyzed the responses of 331 gynecologic oncology providers. COVID-19 is present in 99.1% of surveyed communities with 99.7% reporting mitigation efforts in effect. The infection rate differs significantly between regions (p≪0.001) with the Northeast reporting the highest number of COVID-19 cases. Practice volume has dropped by 61.6% since the start of the pandemic with most cancellations being provider initiated. A majority of responders (52.8%) believed that ovarian cancer will be the most affected cancer by COVID-19. >94% of responders are proceeding with gynecologic cancer surgeries with exception of grade 1, endometrioid endometrial adenocarcinoma (36.3%). Surgical backlog (58.6%), delayed cancer diagnosis (43.2%) and re-establishing normal care with delayed patient (37.8%) were identified as the top 3 challenges after COVID-19 has abated.

Conclusions: COVID-19 is widespread and has radically altered normal practice patterns. Despite COVID-19 related concerns, most gynecologic oncology care is proceeding. However, the steep decline in clinical volume shows there is a large group of patients who are not being diagnosed or are deferring care.
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http://dx.doi.org/10.1016/j.ygyno.2020.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245245PMC
August 2020

Perioperative Safety of Surgery for Pelvic Organ Prolapse in Elderly and Frail Patients.

Obstet Gynecol 2020 03;135(3):599-608

Case Western Reserve University, University Hospitals Cleveland Medical Center, and MetroHealth Medical Center, Cleveland, Ohio.

Objective: To evaluate the effects of old age and frailty on complication rates after surgery for pelvic organ prolapse.

Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for prolapse from 2010 to 2017. We compared our control group (45-64 years, index population) to those aged 65-79 years (elderly) and 80 years and older (very elderly). Frailty was assessed using the National Surgical Quality Improvement Program Modified Frailty Index-5. The primary outcome was the composite rate of serious complications and mortality.

Results: We analyzed 27,403 patients in the index population, 20,567 in the elderly group, and 3,088 in the very elderly group. The composite rate of serious complications in the index population was 4.5%, compared with 4.7% in the elderly group (odds ratio [OR] 1.0, 95% CI 0.9-1.1) and 9.0% in the very elderly group (OR 2.1, 95% CI 1.8-2.4). Compared with the index group, the very elderly group had notably elevated risks of cardiac complications (OR 11.9, 95% CI 6.2-23.0), stroke (OR 26.6, 95% CI 5.4-131.8), and mortality (OR 39.9, 95% CI 8.6-184.7). On multivariate logistic regression, the only age group independently associated with serious complications was the very elderly group (adjusted odds ratio [aOR] 2.01, 95% CI 1.8-2.3). The Modified Frailty Index-5 score was independently predictive of complications (aOR 1.4, 95% CI 1.1-2.0). Stratified analysis using interaction terms revealed the Modified Frailty Index-5 score to be predictive of complications in the elderly age group (aOR 2.5, 95% CI 1.3-4.6), but not in the very elderly group.

Conclusion: Serious complications surrounding prolapse surgery increase substantially in the cohort of patients older than 80 years of age, independent of frailty and medical or surgical risk factors.
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http://dx.doi.org/10.1097/AOG.0000000000003682DOI Listing
March 2020

Gene expression in stress urinary incontinence: a systematic review.

Int Urogynecol J 2020 01 16;31(1):1-14. Epub 2019 Jul 16.

Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Introduction: A contribution of genetic factors to the development of stress urinary incontinence (SUI) is broadly acknowledged. This study aimed to: (1) provide insight into the genetic pathogenesis of SUI by gathering and synthesizing the available data from studies evaluating differential gene expression in SUI patients and (2) identify possible novel therapeutic targets and leads.

Methods: A systematic literature search was conducted through September 2017 for the concepts of genetics and SUI. Gene networking connections and gene-set functional analyses of the identified genes as differentially expressed in SUI were performed using GeneMANIA software.

Results: Of 3019 studies, 4 were included in the final analysis. A total of 13 genes were identified as being differentially expressed in SUI patients. Eleven genes were overexpressed: skin-derived antileukoproteinase (SKALP/elafin), collagen type XVII alpha 1 chain (COL17A1), plakophilin 1 (PKP1), keratin 16 (KRT16), decorin (DCN), biglycan (BGN), protein bicaudal D homolog 2 (BICD2), growth factor receptor-bound protein 2 (GRB2), signal transducer and activator of transcription 3 (STAT3), apolipoprotein E (APOE), and Golgi SNAP receptor complex member 1 (GOSR1), while two genes were underexpressed: fibromodulin (FMOD) and glucocerebrosidase (GBA). GeneMANIA revealed that these genes are involved in intermediate filament cytoskeleton and extracellular matrix organization.

Conclusion: Many genes are involved in the pathogenesis of SUI. Furthermore, whole-genome studies are warranted to identify these genetic connections. This study lays the groundwork for future research and the development of novel therapies and SUI biomarkers in clinical practice.
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http://dx.doi.org/10.1007/s00192-019-04025-5DOI Listing
January 2020

Reoperation for Urinary Incontinence After Retropubic and Transobturator Sling Procedures.

Obstet Gynecol 2019 08;134(2):333-342

Division of Urogynecology, the Division of Biomedical Statistics and Informatics, and the Department of Urology, Mayo Clinic, Rochester, Minnesota; the Clinical Pharmacology Division, Vanderbilt University, Vanderbilt, Tennessee; and the Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio.

Objective: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures.

Methods: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure.

Results: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups.

Conclusion: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.
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http://dx.doi.org/10.1097/AOG.0000000000003356DOI Listing
August 2019

What Is New in Chronic Pelvic Pain Research?: Best Articles From the Past Year.

Obstet Gynecol 2019 08;134(2):413-415

Dr. El-Nashar is from the Case Western Reserve University School of Medicine and the Division of Female Pelvic Medicine and Reconstructive Surgery at University Hospitals Cleveland Medical Center, Cleveland, Ohio; email:

This month we focus on current research in chronic pelvic pain. Dr. El-Nashar discusses four recent publications, which are concluded with a "bottom-line" that is the take-home message. A complete reference for each can be found on on this page along with direct links to abstracts.
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http://dx.doi.org/10.1097/AOG.0000000000003387DOI Listing
August 2019

Multimodal opioid-sparing postoperative pain regimen compared with the standard postoperative pain regimen in vaginal pelvic reconstructive surgery: a multicenter randomized controlled trial.

Am J Obstet Gynecol 2019 11 12;221(5):511.e1-511.e10. Epub 2019 Jun 12.

Division of Urogynecology and Pelvic Reconstructive Surgery, MetroHealth Medical Center, Cleveland, OH.

Background: Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use.

Objective: The objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery.

Study Design: This was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power).

Results: Thirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P < .001) and received fewer narcotics during the entire hospitalization (55.7 vs 91.2, P < .001). At 96 hour follow up, patients in the ice packs, Tylenol, and Toradol group used 4.9 ketorolac tablets compared with 4.6 oxycodone/acetaminophen tablets in the standard group (P = .81); however, ice packs, Tylenol, and Toradol patients required more acetaminophen than ibuprofen by patients in the standard arm (10.7 vs 6.2 tablets, P = .012). There were no differences in Quality of Recovery Questionnaire or satisfaction scores either in the morning after surgery or at 96 hour follow up.

Conclusion: The ice packs, Tylenol, and Toradol multimodal pain regimen offers improved pain control the morning after surgery and 96 hours postoperatively compared with the standard regimen with no differences in patient satisfaction and quality of recovery. Ice packs, Tylenol, and Toradol can significantly limit postoperative inpatient narcotic use and eliminate outpatient narcotic use in patients undergoing vaginal pelvic reconstructive surgery.
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http://dx.doi.org/10.1016/j.ajog.2019.06.002DOI Listing
November 2019

Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature.

Int Urogynecol J 2019 07 14;30(7):1023-1035. Epub 2019 Mar 14.

Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Mailstop MAC 5034, Cleveland, OH, 44106, USA.

Introduction And Hypothesis: Sacral neuromodulation (SNM) is gaining popularity as a treatment option for chronic pelvic pain (CPP). Our hypothesis is that SNM is effective in improving CPP.

Methods: A systematic search was conducted through September 2018. Peer-reviewed studies using pre- and postpain intensity scores were selected. The primary outcome was pain improvement on a 10-point visual analog scale (VAS) (adjusted or de novo) in patients with CPP. Secondary outcomes included comparing SNM approaches and etiologies and evaluating lower urinary tract symptoms (LUTS).

Results: Fourteen of 2175 studies, evaluating 210 patients, were eligible for further analysis. The overall VAS pain score improvement was significant [weighted mean difference (WMD) -4.34, 95% confidence interval (CI) = -5.22, to-3.64, p < 0.0001)]. Regarding SNM approach, both standard and caudal approaches had significant reduction in pain scores: WMD -4.32, CI 95% = -5.32, to -3.31 (p < 0.001) for the standard approach, compared with WMD -4.63, 95% CI = -6.57 to -2.69 (P < 0.001), for the caudal approach (p = 0.75). While significant improvement in pain was observed both in patients with and without interstitial cystitis/bladder pain syndrome (IC/BPS), the observed improvement was lower in patients with (WMD -4.13, CI 95% -5.36 to -2.90 versus without (WMD -5.72, CI 95% = -6.18, to-5.27) IC/BPS (p = 0.02). SNM was effective in treating voiding symptoms (frequency, urgency, nocturia) associated with IC/BPS (all p < 0.01).

Conclusions: SNM is an effective therapy for CPP in both IC/BSP and non-IC/BSP patients, with better results in non-IC/BSP patients. Outcomes of the antegrade caudal approach were comparable with the standard retrograde approach.
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http://dx.doi.org/10.1007/s00192-019-03898-wDOI Listing
July 2019

Urinary Tract Infection After Hysterectomy for Benign Gynecologic Conditions or Pelvic Reconstructive Surgery.

Obstet Gynecol 2018 12;132(6):1347-1357

Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: To report rates and identify risk factors for urinary tract infection (UTI) after hysterectomy for benign conditions or combined with pelvic reconstructive surgery.

Methods: This is a cohort study that included women who underwent hysterectomy either for benign gynecologic conditions or hysterectomy combined with pelvic reconstructive surgery from January 1, 2012, through June 30, 2014, at a single institution. The primary outcome was UTI within 8 weeks of surgery. Logistic regression modeling was used to develop a model for predicting UTI after surgery.

Results: Of 1,156 women included in the study, 136 (11.8%, 95% CI 10.0-13.8) developed UTI within 8 weeks. Women who underwent hysterectomy for a benign gynecologic condition that was not combined with pelvic reconstructive surgery had an overall UTI rate of 7.3% (95% CI 5.6-9.3) vs 21.7% (95% CI 17.6-26.4) after hysterectomy combined with pelvic reconstructive surgery. After adjusting for hormone therapy use, the following were independent variables associated with postoperative UTI: premenopausal status with an adjusted odds ratio (OR) of 1.80 (95% CI 1.11-2.99), anterior vaginal wall prolapse with an adjusted OR of 4.39 (95% CI 2.77-6.97), and postvoid residual greater than 150 mL with an adjusted OR of 2.38 (95% CI 1.12-4.36). Using this model, postoperative UTI rates ranged from 4.3% to 59.4% with high postvoid residual and presence of anterior prolapse having the strongest association.

Conclusion: There are wide variations in the rate of UTI after hysterectomy for begin disease including pelvic reconstructive surgery. These variations can be explained with a model based on available preoperative data.
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http://dx.doi.org/10.1097/AOG.0000000000002931DOI Listing
December 2018

Chlorhexidine-Alcohol Compared with Povidone-Iodine Preoperative Skin Antisepsis for Cesarean Delivery: A Systematic Review and Meta-Analysis.

Am J Perinatol 2019 01 5;36(2):118-123. Epub 2018 Sep 5.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Objective: To compare chlorhexidine-alcohol with povidone-iodine solutions for skin antisepsis prior to cesarean delivery for the prevention of surgical site infection.

Study Design: Electronic databases MEDLINE, Embase, Scopus, and Clinicaltrials.gov were searched from inception to August 2017. Eligible studies included randomized controlled trials comparing chlorhexidine-alcohol with povidone-iodine skin preparation solutions for women undergoing cesarean delivery. The primary outcome was surgical site infection including superficial or deep wound infection. Meta-analysis was performed, and risk ratios (RRs) with 95% confidence interval (CI) were calculated using the Mantel-Haenszel random effects model. Statistical heterogeneity was assessed using Higgin's .

Results: Of 61 abstracts identified in the primary search, four studies (3,059 women) met the eligibility criteria. The risk of surgical site infection was significantly reduced with chlorhexidine-alcohol (RR: 0.72; 95% CI: 0.52-0.98). No heterogeneity across studies was observed with  = 0%. Subgroup analysis of superficial infection only or deep infection only showed no statistically significant difference (RR: 0.76, 95% CI: 0.54-1.08; and RR: 0.50, 95% CI: 0.23-1.10, respectively).

Conclusion: Preoperative skin cleansing prior to cesarean delivery with chlorhexidine-alcohol reduces surgical site infection as compared with povidone-iodine solutions.
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http://dx.doi.org/10.1055/s-0038-1669907DOI Listing
January 2019

Body fat index: A novel alternative to body mass index for prediction of gestational diabetes and hypertensive disorders in pregnancy.

Eur J Obstet Gynecol Reprod Biol 2018 Sep 6;228:243-248. Epub 2018 Jul 6.

Division of Maternal Fetal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Objectives: To evaluate the association of ultrasound measurement of maternal abdominal subcutaneous and pre-peritoneal fat thickness in relation to the subsequent diagnosis of gestational diabetes (GDM), and to assess the association of body fat index (BFI), compared to conventional body mass index (BMI), with respect to the development of some obstetric related complications.

Study Design: A prospective study included non-diabetic pregnant women who were scheduled for fetal anatomic survey. Women underwent fat measurements and BFI (pre-peritoneal fat x subcutaneous fat/height) was calculated. They underwent routine glucose screening and diagnostic tests for GDM. Obstetric complications, mode of delivery, and delivery related events were reported. Multivariable logistic regression was used to test potential predictors for development of obesity-related complications. Primary outcome was development of GDM. Secondary outcomes included development of hypertensive disorders during pregnancy and need for cesarean delivery due to labor dystocia. The optimal cut-off points for continuous variables were obtained using a receiver operating characteristic (ROC) curve analyses.

Results: 389 women met study criteria. Median gestational age at time of ultrasound evaluation was 19.1 weeks. Positive family history of diabetes (adjusted odds ratio "OR" 2.30, 95% CI 1.35-3.92), history of GDM (adjusted OR 6.87, 95% CI 3.03-15.61), subcutaneous fat≥13 mm (adjusted OR 4.63, 95% CI 1.60-13.38) and pre-peritoneal fat≥12 mm (adjusted OR 3.32, 95% CI 1.06-10.42) were significant predictors for development of GDM. ROC analysis demonstrated that a BFI > 0.5 was statistically superior to a BMI > 25 or 30 as a predictor of gestational diabetes (adjusted OR 6.24, 95% CI 1.86-20.96). A Similar ROC analysis demonstrated that a BFI > 0.8 was associated with a higher risk for the development of hypertensive disorders of pregnancy (adjusted OR 2.70 [95% CI 1.60-4.55]), and need for cesarean delivery (adjusted OR 2.01[95% CI 1.23-3.28]) than a BMI > 25 or 30.

Conclusion: Values obtained by ultrasound measurement of subcutaneous and pre-peritoneal fat are associated with development of GDM and hypertensive disorders in pregnancy. Our data suggest that BFI was a better predictor than BMI for development of GDM and hypertensive disorders in pregnancy and should be studied further.
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http://dx.doi.org/10.1016/j.ejogrb.2018.07.001DOI Listing
September 2018

National survey of urogynecological practice patterns among United States OB/GYN oral board examinees in different practice settings.

Int Urogynecol J 2019 07 13;30(7):1153-1161. Epub 2018 Apr 13.

Department of Female Pelvic Medicine & Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Introduction And Hypothesis: The current urogynecological surgical experience of recent OB/GYN graduates in different practice settings is unclear. The aim of this study was to evaluate differences in urogynecological surgical care between private practitioners (PPs) and other generalist OB/GYN oral board examinees.

Methods: A total of 699 OB/GYN oral board examination examinees were administered a survey during board preparatory courses with a 70.7% response rate. The primary outcome was to determine differences in subjective reported performance of urogynecological surgery with and without apical support procedures (female pelvic medicine and reconstructive surgery, FPMRS, ± apical) between PP and generalists in other practice models (academic, managed care, other). Secondary outcomes included urogynecological case list reporting, referral patterns, and residency training.

Results: A total of 473 surveys were completed; after excluding subspecialists, 210 surveys were completed by PP and 162 by individuals in other settings. 6.7% of PPs subjectively reported that they perform FPMRS + apical surgery compared with 4.3% of those in other practice settings (p = 0.33). Although 29.2% of PPs reported adequate FPMRS training in residency compared with 39.7% of those in other practice settings (p = 0.04), 53.6% of PPs reported that they refer patients with pelvic organ prolapse (POP), compared with 66.5% of those in other practice settings (p = 0.013). 38.9% of PPs report that they performed POP surgery compared with 27.8% of non-PPs (p = 0.014).

Conclusions: Regardless of practice setting, surgical volumes are low and few general OB/GYN board examinees report that they perform comprehensive FPMRS ± apical support surgery. The practice environment may affect providers' management of patients with pelvic floor disorders.
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http://dx.doi.org/10.1007/s00192-018-3636-0DOI Listing
July 2019

Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: a case-controlled study.

BMC Pregnancy Childbirth 2017 Dec 11;17(1):415. Epub 2017 Dec 11.

Department of Obstetrics and Gynecology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA.

Background: Neonatal encephalopathy (NE) affects 2-4/1000 live births with outcomes ranging from negligible neurological deficits to severe neuromuscular dysfunction, cerebral palsy and death. Hypoxic ischemic encephalopathy (HIE) is the sub cohort of NE that appears to be driven by intrapartum events. Our objective was to identify antepartum and intrapartum factors associated with the development of neonatal HIE.

Methods: Hospital databases were searched using relevant diagnosis codes to identify infants with neonatal encephalopathy. Cases were infants with encephalopathy and evidence of intrapartum hypoxia. For each hypoxic ischemic encephalopathy case, four controls were randomly selected from all deliveries that occurred within 6 months of the case.

Results: Twenty-six cases met criteria for hypoxic ischemic encephalopathy between 2002 and 2014. In multivariate analysis, meconium-stained amniotic fluid (aOR 12.4, 95% CI 2.1-144.8, p = 0.002), prolonged second stage of labor (aOR 9.5, 95% CI 1.0-135.3, p = 0.042), and the occurrence of a sentinel or acute event (aOR 74.9, 95% CI 11.9-infinity, p < 0.001) were significantly associated with hypoxic ischemic encephalopathy. The presence of a category 3 fetal heart rate tracing in any of the four 15-min segments during the hour prior to delivery (28.0% versus 4.0%, p = 0.002) was more common among hypoxic ischemic encephalopathy cases.

Conclusion: Prolonged second stage of labor and the presence of meconium-stained amniotic fluid are risk factors for the development of HIE. Close scrutiny should be paid to labors that develop these features especially in the presence of an abnormal fetal heart tracing. Acute events also account for a substantial number of HIE cases and health systems should develop programs that can optimize the response to these emergencies.
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http://dx.doi.org/10.1186/s12884-017-1610-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725836PMC
December 2017

History of cervical insufficiency increases the risk of pelvic organ prolapse and stress urinary incontinence in parous women.

Maturitas 2018 Jan 16;107:63-67. Epub 2017 Oct 16.

University Hospitals Cleveland Medical Center, Division of Female Pelvic Medicine and Reconstructive Surgery, USA; Case Western Reserve University School of Medicine, USA.

Objective: A likely contributor to pelvic floor disorders is injury and degradation of connective tissue components such as collagen and elastin, leading to weakening of the pelvic floor. Prior studies have found similar connective tissue component changes in women with cervical insufficiency (CI). However, the connection between pelvic floor disorders and cervical insufficiency has not previously been evaluated. Our objective was to determine whether a history of cervical insufficiency is associated with an increased risk of pelvic organ prolapse and stress urinary incontinence after controlling for confounders.

Study Design: The study used de-identified clinical data from a large multi-institution electronic health records HIPAA-compliant data web application, Explorys Inc. (Cleveland, Ohio, USA). Women with a history of at least one prior delivery after at least 20 weeks' gestation between the years 1999 and 2016 were identified. Logistic regression models were used to identify risk factors and adjust for confounders.

Main Outcome Measures: The primary outcome was subsequent development of either stress incontinence or pelvic organ prolapse.

Results: A total of 1,182,650 women were identified, of whom 30,890 (2.6%) had a history of cervical cerclage or insufficiency. A history of cervical insufficiency was associated with an increased risk of either pelvic organ prolapse or stress urinary incontinence (aOR=1.93, 95%CI: 1.84-2.02). A history of cervical insufficiency was more strongly associated with an increased risk of pelvic organ prolapse (aOR=2.06, 95%CI: 1.91-2.21) than with stress urinary incontinence (aOR=1.91, 95%CI: 1.80-2.02).

Conclusion: A history of cervical insufficiency is associated with an increased risk of development of pelvic organ prolapse and stress urinary incontinence.
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http://dx.doi.org/10.1016/j.maturitas.2017.10.009DOI Listing
January 2018

Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis.

PLoS One 2017 15;12(11):e0188176. Epub 2017 Nov 15.

Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America.

Background: Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB.

Methods: We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months.

Results: Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089).

Conclusion: For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care.

Clinical Trial Registration: NCT01165307.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0188176PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5687740PMC
December 2017

Long-term outcomes and predictors of failure after surgery for stage IV apical pelvic organ prolapse.

Int Urogynecol J 2018 Jun 18;29(6):803-810. Epub 2017 Sep 18.

Departments of Obstetrics and Gynecology (BJL, SAE, AAM, JBG, CJK, JAO, ECT), Internal Medicine (DJR), and Health Science Research (ALW, MEM), Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Introduction And Hypothesis: The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of prolapse recurrence.

Methods: The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan-Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence.

Results: Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p < 0.001) and less likely to have a prior hysterectomy (39.7 vs 86.4%; p < 0.001) or prior apical prolapse repair (8.2 38.6%; p < 0.001). Median follow-up was 4.3 years [interquartile range (IQR) 1.1-7.7]. Survival free of recurrence was similar between USLS and sacrocolpopexy (p = 0.43), with 5-year rates of 88.7 and 97.6%, respectively. Younger age [adjusted hazard ratio (aHR) 1.55, 95% confidence interval (CI) 1.12-2.13; p = 0.008] and prior hysterectomy (aHR 2.8, 95% CI 1.39-5.64; p = 0.004) were associated with the risk of prolapse recurrence, whereas type of surgery approached statistical significance (aHR 2.76, 95% CI 0.80-9.60; p = 0.11).

Conclusions: Younger age and history of prior hysterectomy were associated with an increased risk of recurrent prolapse symptoms. Notably, excellent survival free of prolapse recurrence were obtained with both surgical techniques.
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http://dx.doi.org/10.1007/s00192-017-3482-5DOI Listing
June 2018

Geographic Variance of Cost Associated With Hysterectomy.

Obstet Gynecol 2017 05;129(5):844-853

Department of Obstetrics and Gynecology and Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals Cleveland Medical Center, and Case Western Reserve University School of Medicine, Cleveland, Ohio.

Objective: To estimate whether the cost of hysterectomy varies by geographic region.

Methods: This was a cross-sectional, population-based study using the 2013 Healthcare Cost and Utilization Project National Inpatient Sample of women older than 18 years undergoing inpatient hysterectomy for benign conditions. Hospital charges obtained from the National Inpatient Sample database were converted to actual costs using cost-to-charge ratios provided by the Healthcare Cost and Utilization Project. Multivariate regression was used to assess the effects that demographic factors, concomitant procedures, diagnoses, and geographic region have on hysterectomy cost above the median.

Results: Women who underwent hysterectomy for benign conditions were identified (N=38,414). The median cost of hysterectomy was $13,981 (interquartile range $9,075-29,770). The mid-Atlantic region had the lowest median cost of $9,661 (interquartile range $6,243-15,335) and the Pacific region had the highest median cost, $22,534 (interquartile range $15,380-33,797). Compared with the mid-Atlantic region, the Pacific (adjusted odds ratio [OR] 10.43, 95% confidence interval [CI] 9.44-11.45), South Atlantic (adjusted OR 5.39, 95% CI 4.95-5.86), and South Central (adjusted OR 2.40, 95% CI 2.21-2.62) regions were associated with the highest probability of costs above the median. All concomitant procedures were associated with an increased cost with the exception of bilateral salpingectomy (adjusted OR 1.03, 95% CI 0.95-1.12). Compared with vaginal hysterectomy, laparoscopic and robotic modes of hysterectomy were associated with higher probabilities of increased costs (adjusted OR 2.86, 95% CI 2.61-3.15 and adjusted OR 5.66, 95% CI 5.11-6.26, respectively). Abdominal hysterectomy was not associated with a statistically significant increase in cost compared with vaginal hysterectomy (adjusted OR 1.01, 95% CI 0.91-1.09).

Conclusion: The cost of hysterectomy varies significantly with geographic region after adjusting for confounders.
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http://dx.doi.org/10.1097/AOG.0000000000001966DOI Listing
May 2017

The effect of sacral neuromodulation on pregnancy: a systematic review.

Int Urogynecol J 2017 Sep 3;28(9):1357-1365. Epub 2017 Feb 3.

Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA.

Introduction And Hypothesis: To evaluate the effects of sacral neuromodulation (SNM) on pregnancy and the impact of delivery on SNM function.

Methods: A systematic search was conducted through January 2016. We selected studies including women who had SNM and a subsequent pregnancy.

Results: Out of 2,316, eight studies were included, comprising 22 patients (26 pregnancies). SNM indications were Fowler's syndrome in 11, urinary retention in 6, fecal incontinence in 1, fecal and urinary urgency in 1, overactive bladder in 1, intractable interstitial cystitis in 1, and myelodysplasia in 1. SNM stayed on in 8 pregnancies. In the remaining 18 pregnancies in which the device was deactivated, 7 had recurrent urinary tract infections, including 1 with pyelonephritis and 2 who requested reactivation owing to recurrent symptoms. Outcomes were reported in 25 pregnancies, 16 had Cesarean section (CS) and 9 had vaginal delivery, including 2 operative deliveries. Out of 25, two infants had pilonidal sinus and motor tic disorder (exhibited at the age of 2 years), both from the same mother. After delivery, SNM was functioning in 15 (60%), 4 required reprogramming, and 3 required replacement (1 had recurrence of fecal incontinence after her operative delivery with evidence of displaced leads and 1 patient reported decreased SNM effects after her two CS), and 3 decided to remove the device (2 out of 3 patients were free of symptoms after SNM deactivation and requested removal).

Conclusion: Within the current limited evidence, the decision regarding SNM activation or deactivation should be individualized. A registry for those patients is recommended.
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http://dx.doi.org/10.1007/s00192-017-3272-0DOI Listing
September 2017

Abnormal Uterine Bleeding Is Associated With Increased BMP7 Expression in Human Endometrium.

Reprod Sci 2017 05 7;24(5):671-681. Epub 2016 Oct 7.

1 Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.

Abnormal uterine bleeding (AUB), a common health concern of women, is a heterogeneous clinical entity that is traditionally categorized into organic and nonorganic causes. Despite varied pharmacologic treatments, few offer sustained efficacy, as most are empiric, unfocused, and do not directly address underlying dysregulated molecular mechanisms. Characterization of such molecular derangements affords the opportunity to develop and use novel, more successful treatments for AUB. Given its implication in other organ systems, we hypothesized that bone morphogenetic protein (BMP) expression is altered in patients with AUB and hence comprehensively investigated dysregulation of BMP signaling pathways by systematically screening 489 samples from 365 patients for differences in the expression of BMP2, 4, 6, and 7 ligands, BMPR1A and B receptors, and downstream SMAD4, 6, and 7 proteins. Expression analysis was correlated clinically with data abstracted from medical records, including bleeding history, age at procedure, ethnicity, body mass index, hormone treatment, and histological diagnosis of fibroids, polyps, adenomyosis, hyperplasia, and cancer. Expression of BMP7 ligand was significantly increased in patients with AUB (H-score: 18.0 vs 26.7; P < .0001). Patients reporting heavy menstrual bleeding (menorrhagia) as their specific AUB pattern demonstrated significantly higher BMP7 expression. Significantly, no differences in the expression of any other BMP ligands, receptors, or SMAD proteins were observed in this large patient cohort. However, expression of BMPR1A, BMPR1B, and SMAD4 was significantly decreased in cancer compared to benign samples. Our study demonstrates that BMP7 is a promising target for future investigation and pharmacologic treatment of AUB.
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http://dx.doi.org/10.1177/1933719116671218DOI Listing
May 2017

Risk Factors, Clinical Presentation, and Outcomes for Abdominal Wall Endometriosis.

J Minim Invasive Gynecol 2017 Mar - Apr;24(3):478-484. Epub 2017 Jan 16.

Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.

Study Objective: To evaluate the risk factors, presentation, and outcomes in cases of abdominal wall endometriosis.

Design: A case-control study (Canadian Task Force classification II-2).

Setting: An academic medical center.

Patients: A total of 102 (34 cases and 68 controls) were included.

Interventions: Surgical resection of abdominal wall endometriosis.

Measurements And Main Results: Cases underwent surgical excision for abdominal wall endometriosis at Mayo Clinic from January 1, 2000, through December 31, 2013. For each case, 2 controls were randomly selected from a list of women who had surgery in the same year with minimal (American Society for Reproductive Medicine stage I-II) endometriosis. A chart review was completed for variables of interest. Regression models were used to identify independent risk factors associated with abdominal wall endometriosis.

Results: In 14 years, 2539 women had surgery for endometriosis at Mayo Clinic. Of these, only 34 (1.34%) had abdominal wall endometriosis. The mean age was 35.2 ± 5.9 years, and the median parity was 2 (range, 0-5). Clinical examination diagnosed abdominal wall endometriosis in 41% of cases, with the cesarean delivery scar being the most common site (59%). There was a strong correlation between the size of the lesion on clinical examination compared with the size of the pathology specimen (r = 0.74, p < .001). When compared with controls, cases had significantly higher parity and body mass index, more cyclic localized abdominal pain, less dysmenorrhea, longer duration from the start of symptoms to surgery, and more gynecologic surgeries for symptoms without cure. In the final multivariable model, cyclic localized abdominal pain, absence of dysmenorrhea, and previous laparotomy were independently associated with abdominal wall endometriosis with adjusted odds ratios of 10.6 (95% CI 1.85-104.4, p < .001), 12.4 (95% CI 1.64-147.1, p < .001), and 70.1 (95% CI 14.8-597.7, p < .001), respectively, with an area under the curve for the receiver operating characteristic of 0.94 (95% CI, 0.87-0.98). After excision of the disease, repeat surgery was needed in 2 (5.9%) patients with a median time to recurrence of 50.5 (range, 36-65) months.

Conclusions: Abdominal wall endometriosis is a rare but unique form of endometriosis. Careful history and clinical examination can provide accurate diagnosis and avoid unnecessary delay before surgical intervention. Localized cyclic abdominal pain with the absence of dysmenorrhea and a history of prior laparotomy are independent risk factors with very high accuracy for diagnosis.
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http://dx.doi.org/10.1016/j.jmig.2017.01.005DOI Listing
July 2017

Loop Electrosurgical Excision Procedure Instead of Cold-Knife Conization for Cervical Intraepithelial Neoplasia in Women With Unsatisfactory Colposcopic Examinations: A Systematic Review and Meta-Analysis.

J Low Genit Tract Dis 2017 Apr;21(2):129-136

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.

Objectives: This meta-analysis compared loop electrosurgical excision procedure (LEEP) with cold-knife conization (CKC) for treating cervical intraepithelial neoplasia (CIN) in patients with unsatisfactory colposcopic examinations.

Material And Methods: A literature search on MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases was conducted from inception until April 2015. We included clinical trials and cohort studies comparing CKC with LEEP for treating CIN. The primary outcome was a combined end point of persistent CIN (<6 months after conization) and recurrent CIN (>6 months). Secondary outcomes included procedural, pathologic, and long-term outcomes. Pooled relative risk (RR) and weighted mean difference (WMD) were used to report binary and continuous outcomes, respectively.

Results: Among 26 studies, the incidence of persistent and recurrent disease after LEEP was comparable with that after CKC (15.6% vs 7.38%; RR = 1.35; 95% CI = 1.00-1.81). Loop electrosurgical excision procedure was faster, caused less intraoperative bleeding, and resulted in shorter hospital stay (WMD, 9.5 minutes [95% CI = 6.4-12.6 minutes]; WMD, 42.4 mL [95% CI = 21.3-106 mL]; and WMD, 1.5 days [95% CI = 1.1-1.8 days], respectively). Loop electrosurgical excision procedure cones were shallower with overall less volume and weight than CKC (WMD, 5.1 mm [95% CI = 3.2-7.1 mm]; 2.6 mm [95% CI = 0.6-5.7 mm]; and 2.6 g [95% CI = 1.4-3.7 g], respectively). During follow-up, LEEP was associated with less cervical stenosis and fewer unsatisfactory examinations; however, this was not statistically significant (RR, 0.5 [95% CI = 0.1-1.5]; RR, 0.7 [95% CI = 0.4-1.2], respectively).

Conclusions: Loop electrosurgical excision procedure is an acceptable alternative to CKC in women with CIN and unsatisfactory colposcopic examinations. Close follow-up is necessary for prompt detection and treatment of persistent or recurrent disease.
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http://dx.doi.org/10.1097/LGT.0000000000000287DOI Listing
April 2017

Female Urethral Diverticulum: Presentation, Diagnosis, and Predictors of Outcomes After Surgery.

Female Pelvic Med Reconstr Surg 2016 Nov/Dec;22(6):447-452

From the *Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN; †Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals, Cleveland, OH; ‡Department of Obstetrics and Gynecology, Michigan State University, Sparrow Hospital, Lansing, MI; and §Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.

Introduction And Hypothesis: To report on clinical presentation, diagnosis, and outcomes after treatment of female urethral diverticulum (UD).

Methods: Using a record linkage system, women with a new diagnosis of UD at Mayo Clinic from January 1, 1980, through December 31, 2011, were identified. The presenting symptoms, clinical characteristics, diagnosis, and management of women presenting with UD were recorded. Outcomes after surgery were assessed using survival analysis. All statistical analyses were 2-sided and P values less than 0.05 were considered significant. Statistical analysis was done using SAS version 9.2 and JMP version 9.0 (SAS Institute Inc.).

Results: A total of 164 cases were identified. Median age at diagnosis was 46 years (range, 21-83). The most common presenting symptom was recurrent urinary tract infection (98, 59.8%), followed by urinary incontinence (81, 49.4%), dysuria (62, 37.8%), dyspareunia (37, 22.6%), and hematuria (15, 9.1%). Examination revealed vaginal mass in 55 (33.5%) of the women. A significant trend was noted toward an increase in use of both magnetic resonance imaging and computed tomography (P < 0.001) along with a progressive decrease in use of urethrogram (P < 0.001) for diagnosis of UD over the years. Among 114 women who underwent surgical treatment for UD, 14(12.3%) women presented with recurrent UD and the 5-year recurrence rate after surgery for UD was 23.4% (95% confidence interval, 13.9-37.0) and a reoperation rate of 17.0% (95% confidence interval, 8.8-30.2) at 5 years.

Conclusions: Female UD is a rare and unique condition. Clinical presentation is usually nonspecific, and magnetic resonance imaging is commonly used for confirming the diagnosis. Recurrence is not uncommon, and repeat surgical intervention might be needed.
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http://dx.doi.org/10.1097/SPV.0000000000000312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367903PMC
November 2017

Management of Abnormal Uterine Bleeding with Emphasis on Alternatives to Hysterectomy.

Obstet Gynecol Clin North Am 2016 Sep;43(3):415-30

Department of Obstetrics and Gynecology and Reproductive Biology, University Hospitals, Case Medical Center, Cleveland, OH, USA; Department of Reproductive Biology, University Hospitals, Case Medical Center, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt. Electronic address:

Abnormal uterine bleeding (AUB) is a common problem that negatively impacts a woman's health-related quality of life and activity. Initial medical treatment includes hormonal and nonhormonal medications. If bleeding persists and no structural abnormalities are present, a repeat trial of medical therapy, a levonorgestrel intrauterine system, or an endometrial ablation can be used dependent on future fertility wishes. The levonorgestrel intrauterine system and endometrial ablation are effective, less invasive, and safe alternatives to a hysterectomy in women with AUB. A hysterectomy is the definitive treatment of AUB irrespective of the suspected cause when alternative treatments fail. Future studies should focus on detection of predictors for treatment outcomes.
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http://dx.doi.org/10.1016/j.ogc.2016.04.002DOI Listing
September 2016

Association of the Duration of Active Pushing With Obstetric Outcomes.

Obstet Gynecol 2016 08;128(2):406-407

Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1097/AOG.0000000000001543DOI Listing
August 2016

Expected probability of congenital heart disease and clinical utility of fetal echocardiography in pregnancies with pre-gestational diabetes.

Eur J Obstet Gynecol Reprod Biol 2016 Jun 28;201:121-5. Epub 2016 Feb 28.

Division of Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.

Objectives: To establish a prediction model for fetal congenital heart disease (CHD) that could facilitate selective fetal echocardiography screening for diabetic women, and to provide cost analysis of selective versus global screening of these women.

Study Design: A historical cohort study included women with pre-gestational diabetes who received perinatal care at Mayo Clinic, Minnesota from 2007 through 2013. Anatomical scans and fetal echocardiograms were reviewed and charts for postnatal outcomes were abstracted. Logistic regression models were utilized to identify predictors of CHD. Cost of global versus selective screening was estimated using cost per case detected.

Results: A cohort of 152 women was included. Abnormal anatomy scan was reported in five (3.3%). Among 51 (33.6%) who had fetal echocardiography, eight (15.7%) had abnormal findings. Postnatal echocardiography was conducted in 36 neonates, 12 had abnormalities. Only first trimester HbA1c was independent predictor with observed incidence of CHD of 1.8, 14.3, and 40% and HbA1c of <8, 8-10, and >10% respectively. Global screening strategy missed 22% of fetal cardiac abnormalities, while selective screening missed 33%.

Conclusions: According to our probability model, selective screening based on HbA1c and/or anatomic surveys seems to be an accurate and cost effective strategy for prenatal diagnosis of CHD among diabetic pregnancies.
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http://dx.doi.org/10.1016/j.ejogrb.2016.02.036DOI Listing
June 2016

Impact of Simple Ovarian Cysts on the Interpretation of Endometrial Thickness in Women with Postmenopausal Bleeding.

J Womens Health (Larchmt) 2016 09 11;25(9):889-96. Epub 2016 Apr 11.

1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota.

Background: There is evidence that premenopausal hormones may persist for variable time after menopause. Histological specimens from postmenopausal women support the presence of follicular growth at that age. Residual ovarian function may explain postmenopausal bleeding (PMB), which is not associated with endometrial pathology. Our objective was to evaluate the effect of sonographic diagnosis of simple ovarian cysts on the association between thickened endometrium and endometrial pathology in women with PMB.

Materials And Methods: Data were retrospectively collected from medical records of women who underwent office hysteroscopy for PMB between January 2007 and October 2011. Women with sonographic reports within 3 months of presentation were included. Endometrial thickness and the presence of a simple ovarian cyst (≤5 cm) were documented by reviewing sonographic reports. Diagnosis of endometrial pathology was abstracted according to pathology reports or hysteroscopic impression. Endometria with hyperplasia, cancer, or polyps were considered pathological.

Results: Of 836 women with PMB, 356 had recent transvaginal sonography and were included in the analysis. Pathological endometrium was documented in 129 (36.2%) women, including 29 (8.2%) with endometrial cancer. In women with PMB and no evidence of a simple ovarian cyst, endometrial thickness was an independent predictor of endometrial pathology and endometrial cancer with adjusted OR = 1.13 (95% CI = 1.07-1.19) and 1.16 (95% CI = 1.07-1.25), respectively. In the presence of simple ovarian cysts, the adjusted ORs for endometrial thickness as a predictor of endometrial pathology were 1.06 (95% CI = 0.90-1.25) and 0.84 (95% CI = 0.62-1.14), respectively.

Conclusion: The presence of simple ovarian cysts (≤5 cm) tempers the value of endometrial thickness in predicting endometrial pathology in women with PMB.
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http://dx.doi.org/10.1089/jwh.2015.5644DOI Listing
September 2016

Intraoperative Predictors of Long-term Outcomes After Radiofrequency Endometrial Ablation.

J Minim Invasive Gynecol 2016 May-Jun;23(4):582-9. Epub 2016 Feb 9.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.

Study Objective: To identify intraoperative predictors of radiofrequency ablation (RFA) failure after adjusting for clinical risk factors.

Design: A cohort study (Canadian Task Force II-2).

Setting: An academic institution in the Upper Midwest.

Patients: Data were retrospectively collected from medical records of women who underwent RFA and who had a postprocedure gynecologic assessment between April 1998 and December 2011.

Interventions: RFA.

Measurements And Main Results: The primary outcome was RFA failure, which was defined as hysterectomy, repeat ablation, synechiolysis, or treatment with gonadotropin-releasing hormone analogue for postablation pain or bleeding. Cox proportional hazards regression was used to test the predictability of intraoperative variables on RFA failure with adjustment for baseline predictors. We created an RFA index to capture the procedure duration divided by the uterine surface area. One thousand one hundred seventy-eight women were eligible. The median age at ablation was 44 years (interquartile range, 40-48 years), and the median parity was 2 (interquartile range, 2-3). Dysmenorrhea and prior tubal ligation were reported in 37.1% and 37.2% of women, respectively. After adjustment for baseline characteristics, intraoperative predictors of failure were uterine sounding length >10.5 cm (adjusted hazard ratio [HR] = 2.58; 95% confidence interval [CI], 1.31-5.05), uterine cavity length >6 cm (adjusted HR = 2.06; 95% CI, 1.30-3.27), uterine width >4.5 cm (adjusted HR = 2.06; 95% CI, 1.29-3.28), surface area >25 cm(2) (adjusted HR = 2.02; 95% CI, 1.26-3.23), procedure time <93 seconds (adjusted HR = 2.61; 95% CI, 1.25-5.47), and RFA index <3.6 (adjusted HR = 3.14; 95% CI, 1.70-5.77).

Conclusion: Intraoperative parameters are predictive of long-term adverse outcomes of RFA independent of patient clinical characteristics. Uterine length, procedure duration, and RFA index are associated with unfavorable outcomes and thus could be used to optimize postprocedure patient counseling.
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http://dx.doi.org/10.1016/j.jmig.2016.02.002DOI Listing
July 2017