C. Carter - Academia.edu (original) (raw)

Papers by C. Carter

American Journal of Obstetrics and Gynecology, 2022

Female pelvic medicine & reconstructive surgery, Mar 1, 2022

The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cor... more The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

Female Pelvic Medicine & Reconstructive Surgery, 2020

OBJECTIVE As perioperative care pathways are developed to improve recovery, there is a need to ex... more OBJECTIVE As perioperative care pathways are developed to improve recovery, there is a need to explore the impact of age. The aim of this study was to compare the impact of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway on perioperative outcomes across 3 age categories: young, middle age, and elderly. METHODS A retrospective cohort study was conducted assessing same-day discharge, opioid administration, pain scores, and complications differences across and within 3 age categories, young (<61 years), middle age (61-75 years), elderly (>75 years), before and after ERAS implementation. RESULTS Among 98 (25.7%) young, 202 (52.9%) middle-aged, and 82 (21.5%) elderly women, distribution before and after ERAS implementation was similar. In each age category, we found a commensurate increase in same-day discharge and decrease in length of stay independent of age. Age was associated with a variable response to opioid administration after ERAS. In women who received opioids, we found there was a greater reduction in opioids in elderly. Young women received 22.5 mg more than middle-aged women, whereas elderly women received 24.3 mg less than middle-aged women (P < 0.0001, P < 0.0001) for a mean difference of 46.8 mg between the youngest and oldest group. We found no significant differences in postanesthesia care unit pain scores with ERAS implementation. Complications did not increase after ERAS implementation in any age group, although younger and elderly women were more likely to experience complications independent of ERAS. CONCLUSIONS Elderly women had similar outcomes compared with their younger counterparts after implementation of an ERAS pathway. Further research is needed to assess whether our age-related observations are generalizable.

Introduction and Hypothesis: Obstetric anal sphincter injuries (OASIs) complicate 5.8% of vaginal... more Introduction and Hypothesis: Obstetric anal sphincter injuries (OASIs) complicate 5.8% of vaginal deliveries. Our objective was to assess if the primary delivering provider, nurse-midwife versus physician obstetrician, is associated with OASIs. Methods: We performed a secondary analysis of the Consortium of Safe Labor, a multicenter, retrospective cohort study. Included were nulliparous women with singleton, vaginal delivery at ³ 37 weeks from 2002-2008. Women were excluded if delivery was complicated by shoulder dystocia or from sites without midwife deliveries. Student t-tests, chi-squared analysis and Fisher’s exact test were used as appropriate. Multivariable logistic regression and propensity score matching analyses were performed. Results: Of 228,668 births at 19 sites, 2,735 births from 3 sites met inclusion criteria: 1,551 physician and 1,184 midwife births. Of all births, 4.2% (n=116) were complicated by OASIs. Physician patients were older, more often White, privately insu...

American Journal of Obstetrics and Gynecology, 2018

American Journal of Obstetrics and Gynecology, 2018

Current Opinion in Obstetrics and Gynecology, 2021

Purpose of review To review current US literature and describe the extent, source, and impact of ... more Purpose of review To review current US literature and describe the extent, source, and impact of disparities that exist among Black, Indigenous, and people of color (BIPOC) in surgical route and outcomes for hysterectomy, myomectomy, and endometriosis surgery. Recent findings Despite the nationwide trend toward minimally invasive surgery (MIS), BIPOC women are disproportionally less likely to undergo MIS hysterectomy and myomectomy and have higher rates of perioperative complications. African American women, in particular, receive significantly disparate care. Contemporary literature on the prevalence of endometriosis in BIPOC women is lacking. Further, there is little data on the racial and ethnic differences in endometriosis surgery access and outcomes. Summary Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology exist and these differences are not fully accounted for by patient, socioeconomic, or healthcare infrastructure factors....

International Urogynecology Journal, 2021

Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ... more Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesized that patients would have increased incidence and severity of perioperative complications up to 6 weeks after surgeries for POP/SUI. Secondary objectives were to compare pre- and post-operative pelvic floor symptoms and anatomical support as well as pelvic floor disorder recurrence. In this multi-center retrospective cohort study, we identified patients with HDCTs by patient history and ICD-9 codes over an 11-year period. Controls without HDCTs were matched 2:1 to the primary POP or SUI procedure and surgeon. Demographic characteristics, perioperative pelvic floor information and complications were collected. A sample size of 65 HDCT patients and 130 controls was calculated to detect a 20% difference in complications with 80% power and alpha of 0.05. We identified 59 HDCT patients and 118 controls. Of the women with HDCTs, 49% had Ehlers–Danlos, 22% joint hypermobility syndrome, 15% Marfan syndrome, and 14% had others. Compared with controls, HDCT patients had more total perioperative complications (46% vs 22%, p = 0.002); an age-adjusted relative risk of complications was 1.4 (CI 0.7–2.6). HDCT patients had more Clavien–Dindo grades I and II complications (p = 0.02, 0.03) and more hospital readmissions (14% vs 3%, p = 0.01) than controls. There was no difference in the incidence of specific complications nor was there a difference in recurrence of POP (10%) or SUI (11%) between groups. Patients with HDCTs had more Clavien–Dindo grade I and II complications following pelvic floor reconstructive surgery and more readmissions.

Journal of Minimally Invasive Gynecology, 2020

Study Objective: Scientifically evaluate the validity and reproducibility of 2 novel surgical tri... more Study Objective: Scientifically evaluate the validity and reproducibility of 2 novel surgical triaging systems, as well as offer modifications to the Medically-Necessary, Time-Sensitive (MeNTS) criteria for improved application in gynecologic surgeries. Design: Retrospective cohort study. Setting: Academic university hospital. Patients: Ninety-seven patients with delayed benign gynecologic procedures owing to the coronavirus disease 2019 pandemic. Intervention(s): Surgical prioritization was assessed using 2 novel scoring systems, the Gynecologic Medically-Necessary Time-Sensitive (Gyn-MeNTS) and modified Elective Surgery Acuity Scale (mESAS) systems for all 93 patients included. Measurements and Main Results: The interrater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. The Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. The Gyn-MeNTS interrater reliability was tested using Spearman r and paired t tests were used to detect systematic differences between raters. Weighted k indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Spearman r's for all Gyn-MeNTS rater pairs were above 0.80 (0.84 for 1 vs 2; 0.82 for 1 vs 3; and 0.82 for 2 vs 3, all p <.001) indicating strong agreement. The weighted k for the 2 mESAS raters was 0.57 (95% confidence interval, 0.40−0.73) indicating moderate agreement. When used together, both scores were significantly independently associated with SSP, with strong discrimination (area under the curve, 0.89). Conclusion: Interrater reliability is acceptable for both scoring systems, and concurrent validity of each is moderate for predicting SSP, but discrimination improves to a high level when they are used together. Journal of Minimally Invasive Gynecology (2020) 00, 1−12.

Obstetrics & Gynecology, 2019

OBJECTIVE To evaluate the proportion of women who experienced resolution of stress urinary incont... more OBJECTIVE To evaluate the proportion of women who experienced resolution of stress urinary incontinence (SUI) symptoms after surgery for pelvic organ prolapse (POP) without a concomitant incontinence procedure. METHODS We conducted a retrospective observational study of women with preoperative subjective and objective SUI who underwent minimally invasive sacrocolpopexy or uterosacral ligament suspension from 2009 to 2015. We excluded cases with incontinence procedures. The primary outcome was the proportion of women with subjective resolution of SUI postoperatively, defined as the absence of patient reported SUI symptoms during follow-up. Secondary outcomes included the proportion of women who underwent a subsequent staged midurethral sling (MUS) procedure and factors associated with resolution of SUI and staged MUS placement. RESULTS Of 93 women, most were white (n=90, 98%) with stage III POP (n=55, 59%). Mean age was 59.5±8.9 years and body mass index 28.7±4.7. Seventy-three patients (78%) underwent minimally invasive sacrocolpopexy, and 20 (22%) underwent uterosacral ligament suspension. Median follow-up was 8.3 months (interquartile range 3.4-26.7). Postoperatively, 28 (30%) patients reported resolution of SUI, and 65 (70%) reported persistent SUI. Of the 93 patients, 47 (51%) were treated for persistent SUI and 34 (37%) underwent a staged MUS procedure. Among the staged MUS procedures, 27 (79%) were placed within 12 months. Median time to staged MUS procedure was 5.5 months (interquartile range 4.2-9.9). After controlling for degree of preoperative SUI bother, obese women were less likely to experience resolution of SUI after prolapse repair (odds ratio 0.28, 95% CI 0.08-0.95). We did not identify any factors that were significantly associated with undergoing a staged MUS procedure on univariate analyses (P>.05). CONCLUSION Preoperative SUI resolved in nearly a third of women after prolapse surgery without a concomitant incontinence procedure. In a population typically offered a concomitant MUS procedure at the time of prolapse repair, a staged approach may result in nearly two-thirds fewer patients undergoing MUS procedures. This information may be helpful during preoperative shared decision making.

Obstetrics & Gynecology, 2019

Personal or nonessential information may be redacted at the editor's discretion.

American Journal of Obstetrics and Gynecology, 2019

American Journal of Obstetrics and Gynecology, 2018

Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postope... more Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postoperative recovery. Variations of the protocol are being adopted for gynecological procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate whether implementation of an enhanced recovery after surgery pathway would facilitate reduced length of admission in a urogynecology population. MATERIALS AND METHODS: In this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons, we compared same-day discharge, length of admission and postoperative complications before and after implementation of an enhanced recovery after surgery pathway

Female Pelvic Medicine & Reconstructive Surgery, 2019

Objective: To study the performance of a previously published stress urinary incontinence (SUI) r... more Objective: To study the performance of a previously published stress urinary incontinence (SUI) risk calculator in women undergoing minimally invasive or transvaginal apical suspensions. Methods: Using a database of stress continent women who underwent minimally invasive or transvaginal apical suspensions, we calculated two prediction risks for development of SUI within 12 months based upon inclusion of a 'prophylactic' midurethral sling at the time of prolapse surgery. Observed subjective and objective continence status was abstracted from medical records. Regression models were created for the outcome of de novo SUI to generate receiver operating curves. Concordance (c) indices were estimated for the overall and procedure subgroups to determine the calculator's ability to discriminate between SUI outcomes. Results: Analyses included 502 women. De novo SUI was observed in 23.5% of women. The mean calculated risk of de novo SUI if a sling was performed was 18.9% (±13.9) at 12 months compared to 36.4% (±8.3) without sling. The calculator's discriminative ability for those with a planned sling was moderate (c index 0.55, p=.037). The calculator failed to discriminate continence outcomes when a sling was not planned in the overall group (c index 0.50, p=.799) and individual apical procedures. Conclusions: The SUI Risk calculator is significantly limited in its ability to predict de novo SUI in our population of women planning minimally invasive apical suspensions. Refinements to the calculator model are needed to improve its utility in clinical practice.

Obstetrical & Gynecological Survey, 2018

Introduction and hypothesis-Studies have yet to examine the impact of day-of-surgery voiding tria... more Introduction and hypothesis-Studies have yet to examine the impact of day-of-surgery voiding trials on post-operative urinary retention in women undergoing obliterative and apical suspension procedures for pelvic organ prolapse. Our objective was to evaluate if time to spontaneous void after these procedures is shorter when a voiding trial is performed on the day of surgery compared with our standard practice of post-operative day 1. Methods-We conducted a randomized, parallel-arm trial in patients undergoing major pelvic floor reconstructive surgery. Women were randomized 1:1 to an early (4 h post-operatively on the day of surgery) or a standard (6 am on post-operative day 1) retrograde voiding trial. Results-A total of 57 women consented. Mean age and BMI were 65 ±11 and 27.9 ± 4.4. Most women had stage III pelvic organ prolapse (77.2%). Groups had similar baseline characteristics. In the intention-to-treat analysis (n = 57), there was no difference in time to spontaneous void in the early versus standard voiding trial groups (15.9 ± 3.8 vs 28.4 ± 3.1 hours, p = 0.081). In the adjusted analysis using mutlivariable linear regression, an early voiding trial decreased the time to spontaneous void (abeta −2.00 h, p = 0.031) when controlling for vaginal packing and stage IV prolapse. In the per-protocol analysis, which excluded 4 patients for crossover, spontaneous void occurred 17 hours faster in the early voiding trial group (14.6 ± 3.7 vs 31.8 ± 2.9 hours; p = 0.022). Early voiding trial patients experienced ambulation sooner and more often than the standard group (p = 0.02). Conclusions-A day-of-surgery voiding trial did not prolong catheter use after obliterative and apical suspension procedures.

Obstetrical & Gynecological Survey, 2018

This open access article is distributed under Creative Commons Attribution-NonCommercial-NoDeriva... more This open access article is distributed under Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND).

American journal of obstetrics and gynecology, Jan 6, 2018

Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fec... more Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fecal incontinence. Infection after sacral neurostimulation is costly and burdensome. Determining optimal perioperative management strategies to reduce the risk of infection is important to reduce this burden. To identify risk factors associated with sacral neurostimulator infection requiring explantation, to estimate the incidence of infection requiring explantation, and identify associated microbial pathogens. This is a multicenter retrospective case-control study of sacral neuromodulation procedures completed from January 1, 2004-December 31, 2014. We identified all sacral neuromodulation implantable pulse generator implants (IPG) as well as explants due to infection at eight participating institutions. Cases were patients who required IPG explantation for infection during the review period. Cases were included if >18 years old, follow up data > 30 days after IPG implant, and if th...

American Journal of Obstetrics and Gynecology, 2017

International Urogynecology Journal, 2017

Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolap... more Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolapse (POP) in the USA. Over the last decade, fellowship programs have increased the number of these procedures performed robotically. Currently, there is a paucity of literature exploring the impact of fellowship training on outcomes of robotic-assisted sacrocolpopexy (RASC). We sought to explore the impact of an expert surgeon operating alone versus with a fellow on operative time and perioperative morbidity associated with RASC. This is an analysis of a retrospectively collected cohort of all RASCs performed to treat POP from June 2010 to August 2015 by a single attending surgeon. Outcomes were compared by expert surgeon alone and with a fellow. We identified 208 RASCs, of which 124 (59.6%) were performed by an expert surgeon alone and 84 (40.4%) with a fellow. Eight fellows were included, with a median of 7 cases (interquartile range 5-13.5). Cases with fellows were 31.1 min longer than an expert surgeon alone (155.6 vs 124.5 min, p &lt; 0.001), a 25% increase. Increased operative time for fellows remained significant on multivariate regression (34.2 min, p &lt; 0.001) after adjusting for case order postmenopausal status, hysterectomy, mid-urethral sling, and bowel injury. Years in fellowship did not have an impact on operative time (p = 0.80). Complications were seen in 34 women (16.4%). On univariate regression, fellows did not have an impact on complications (OR 1.49, 95% CI [0.65-3.43]), which was unchanged on multivariate regression (OR 0.628, 95% CI [0.26-1.54]). Prolapse recurrence was seen in 19 women (9.5%). Fellows had no impact on prolapse recurrence (OR 0.478, 95% CI [0.17-1.38]), which was unchanged on multivariate regression (OR 0.266, 95% CI [0.17-1.49]). When an expert surgeon operated together with a fellow, operative time increased by 34 min without increasing prolapse recurrence or complications.

Female Pelvic Medicine & Reconstructive Surgery, 2017

Objective To determine the clinical utility of routine postoperative hemoglobin screening after m... more Objective To determine the clinical utility of routine postoperative hemoglobin screening after minimally invasive sacrocolpopexy. Methods This is a retrospective chart review of women undergoing minimally invasive sacrocolpopexy between 2009 and 2015 at a large academic center where postoperative hemoglobin assessment is performed as routine practice. Demographic and perioperative data, pre- and postoperative hemoglobin values, and clinical signs and symptoms of potential postoperative anemia were extracted. Hemoglobin parameters were compared between women with and without clinical evidence of potential postoperative anemia. Linear and logistic regression analyses were used to identify predictors of postoperative anemia and magnitude of hemoglobin decrease. Results Among 800 women, postoperative hemoglobin was obtained for 99.6% and prompted further testing among 23.8%. Mean postoperative hemoglobin was 11.78 ± 1.11 g/dL, and mean decrease was 1.76 ± 0.95 g/dL. More than half (56.9%) had clinical evidence of potential anemia, but few (5%) had postoperative hemoglobin of 10 g/dL or less and none required transfusion. Women with clinical evidence of potential anemia had lower postoperative hemoglobin (11.57 vs 12.19; P < 0.001) and larger mean hemoglobin decrease (1.91 vs 1.49; P < 0.001). On regression analyses, only lower body mass index was associated with larger hemoglobin decrease (&bgr; = −0.030, P < 0.001) and no factor significantly predicted postoperative hemoglobin of 10 g/dL or less. Conclusions Routine hemoglobin testing rarely benefited clinical care but lead to further testing for nearly 1 in 4 patients. Although many women demonstrated clinical evidence potentially suggestive of anemia, significant anemia was rare and no women required transfusion. Neither estimated blood loss nor other risk factors consistently predicted presence of postoperative anemia or significant postoperative decrease in hemoglobin.

American Journal of Obstetrics and Gynecology, 2022

Female pelvic medicine & reconstructive surgery, Mar 1, 2022

The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cor... more The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

Female Pelvic Medicine & Reconstructive Surgery, 2020

OBJECTIVE As perioperative care pathways are developed to improve recovery, there is a need to ex... more OBJECTIVE As perioperative care pathways are developed to improve recovery, there is a need to explore the impact of age. The aim of this study was to compare the impact of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway on perioperative outcomes across 3 age categories: young, middle age, and elderly. METHODS A retrospective cohort study was conducted assessing same-day discharge, opioid administration, pain scores, and complications differences across and within 3 age categories, young (<61 years), middle age (61-75 years), elderly (>75 years), before and after ERAS implementation. RESULTS Among 98 (25.7%) young, 202 (52.9%) middle-aged, and 82 (21.5%) elderly women, distribution before and after ERAS implementation was similar. In each age category, we found a commensurate increase in same-day discharge and decrease in length of stay independent of age. Age was associated with a variable response to opioid administration after ERAS. In women who received opioids, we found there was a greater reduction in opioids in elderly. Young women received 22.5 mg more than middle-aged women, whereas elderly women received 24.3 mg less than middle-aged women (P < 0.0001, P < 0.0001) for a mean difference of 46.8 mg between the youngest and oldest group. We found no significant differences in postanesthesia care unit pain scores with ERAS implementation. Complications did not increase after ERAS implementation in any age group, although younger and elderly women were more likely to experience complications independent of ERAS. CONCLUSIONS Elderly women had similar outcomes compared with their younger counterparts after implementation of an ERAS pathway. Further research is needed to assess whether our age-related observations are generalizable.

Introduction and Hypothesis: Obstetric anal sphincter injuries (OASIs) complicate 5.8% of vaginal... more Introduction and Hypothesis: Obstetric anal sphincter injuries (OASIs) complicate 5.8% of vaginal deliveries. Our objective was to assess if the primary delivering provider, nurse-midwife versus physician obstetrician, is associated with OASIs. Methods: We performed a secondary analysis of the Consortium of Safe Labor, a multicenter, retrospective cohort study. Included were nulliparous women with singleton, vaginal delivery at ³ 37 weeks from 2002-2008. Women were excluded if delivery was complicated by shoulder dystocia or from sites without midwife deliveries. Student t-tests, chi-squared analysis and Fisher’s exact test were used as appropriate. Multivariable logistic regression and propensity score matching analyses were performed. Results: Of 228,668 births at 19 sites, 2,735 births from 3 sites met inclusion criteria: 1,551 physician and 1,184 midwife births. Of all births, 4.2% (n=116) were complicated by OASIs. Physician patients were older, more often White, privately insu...

American Journal of Obstetrics and Gynecology, 2018

American Journal of Obstetrics and Gynecology, 2018

Current Opinion in Obstetrics and Gynecology, 2021

Purpose of review To review current US literature and describe the extent, source, and impact of ... more Purpose of review To review current US literature and describe the extent, source, and impact of disparities that exist among Black, Indigenous, and people of color (BIPOC) in surgical route and outcomes for hysterectomy, myomectomy, and endometriosis surgery. Recent findings Despite the nationwide trend toward minimally invasive surgery (MIS), BIPOC women are disproportionally less likely to undergo MIS hysterectomy and myomectomy and have higher rates of perioperative complications. African American women, in particular, receive significantly disparate care. Contemporary literature on the prevalence of endometriosis in BIPOC women is lacking. Further, there is little data on the racial and ethnic differences in endometriosis surgery access and outcomes. Summary Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology exist and these differences are not fully accounted for by patient, socioeconomic, or healthcare infrastructure factors....

International Urogynecology Journal, 2021

Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ... more Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesized that patients would have increased incidence and severity of perioperative complications up to 6 weeks after surgeries for POP/SUI. Secondary objectives were to compare pre- and post-operative pelvic floor symptoms and anatomical support as well as pelvic floor disorder recurrence. In this multi-center retrospective cohort study, we identified patients with HDCTs by patient history and ICD-9 codes over an 11-year period. Controls without HDCTs were matched 2:1 to the primary POP or SUI procedure and surgeon. Demographic characteristics, perioperative pelvic floor information and complications were collected. A sample size of 65 HDCT patients and 130 controls was calculated to detect a 20% difference in complications with 80% power and alpha of 0.05. We identified 59 HDCT patients and 118 controls. Of the women with HDCTs, 49% had Ehlers–Danlos, 22% joint hypermobility syndrome, 15% Marfan syndrome, and 14% had others. Compared with controls, HDCT patients had more total perioperative complications (46% vs 22%, p = 0.002); an age-adjusted relative risk of complications was 1.4 (CI 0.7–2.6). HDCT patients had more Clavien–Dindo grades I and II complications (p = 0.02, 0.03) and more hospital readmissions (14% vs 3%, p = 0.01) than controls. There was no difference in the incidence of specific complications nor was there a difference in recurrence of POP (10%) or SUI (11%) between groups. Patients with HDCTs had more Clavien–Dindo grade I and II complications following pelvic floor reconstructive surgery and more readmissions.

Journal of Minimally Invasive Gynecology, 2020

Study Objective: Scientifically evaluate the validity and reproducibility of 2 novel surgical tri... more Study Objective: Scientifically evaluate the validity and reproducibility of 2 novel surgical triaging systems, as well as offer modifications to the Medically-Necessary, Time-Sensitive (MeNTS) criteria for improved application in gynecologic surgeries. Design: Retrospective cohort study. Setting: Academic university hospital. Patients: Ninety-seven patients with delayed benign gynecologic procedures owing to the coronavirus disease 2019 pandemic. Intervention(s): Surgical prioritization was assessed using 2 novel scoring systems, the Gynecologic Medically-Necessary Time-Sensitive (Gyn-MeNTS) and modified Elective Surgery Acuity Scale (mESAS) systems for all 93 patients included. Measurements and Main Results: The interrater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. The Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. The Gyn-MeNTS interrater reliability was tested using Spearman r and paired t tests were used to detect systematic differences between raters. Weighted k indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Spearman r's for all Gyn-MeNTS rater pairs were above 0.80 (0.84 for 1 vs 2; 0.82 for 1 vs 3; and 0.82 for 2 vs 3, all p <.001) indicating strong agreement. The weighted k for the 2 mESAS raters was 0.57 (95% confidence interval, 0.40−0.73) indicating moderate agreement. When used together, both scores were significantly independently associated with SSP, with strong discrimination (area under the curve, 0.89). Conclusion: Interrater reliability is acceptable for both scoring systems, and concurrent validity of each is moderate for predicting SSP, but discrimination improves to a high level when they are used together. Journal of Minimally Invasive Gynecology (2020) 00, 1−12.

Obstetrics & Gynecology, 2019

OBJECTIVE To evaluate the proportion of women who experienced resolution of stress urinary incont... more OBJECTIVE To evaluate the proportion of women who experienced resolution of stress urinary incontinence (SUI) symptoms after surgery for pelvic organ prolapse (POP) without a concomitant incontinence procedure. METHODS We conducted a retrospective observational study of women with preoperative subjective and objective SUI who underwent minimally invasive sacrocolpopexy or uterosacral ligament suspension from 2009 to 2015. We excluded cases with incontinence procedures. The primary outcome was the proportion of women with subjective resolution of SUI postoperatively, defined as the absence of patient reported SUI symptoms during follow-up. Secondary outcomes included the proportion of women who underwent a subsequent staged midurethral sling (MUS) procedure and factors associated with resolution of SUI and staged MUS placement. RESULTS Of 93 women, most were white (n=90, 98%) with stage III POP (n=55, 59%). Mean age was 59.5±8.9 years and body mass index 28.7±4.7. Seventy-three patients (78%) underwent minimally invasive sacrocolpopexy, and 20 (22%) underwent uterosacral ligament suspension. Median follow-up was 8.3 months (interquartile range 3.4-26.7). Postoperatively, 28 (30%) patients reported resolution of SUI, and 65 (70%) reported persistent SUI. Of the 93 patients, 47 (51%) were treated for persistent SUI and 34 (37%) underwent a staged MUS procedure. Among the staged MUS procedures, 27 (79%) were placed within 12 months. Median time to staged MUS procedure was 5.5 months (interquartile range 4.2-9.9). After controlling for degree of preoperative SUI bother, obese women were less likely to experience resolution of SUI after prolapse repair (odds ratio 0.28, 95% CI 0.08-0.95). We did not identify any factors that were significantly associated with undergoing a staged MUS procedure on univariate analyses (P>.05). CONCLUSION Preoperative SUI resolved in nearly a third of women after prolapse surgery without a concomitant incontinence procedure. In a population typically offered a concomitant MUS procedure at the time of prolapse repair, a staged approach may result in nearly two-thirds fewer patients undergoing MUS procedures. This information may be helpful during preoperative shared decision making.

Obstetrics & Gynecology, 2019

Personal or nonessential information may be redacted at the editor's discretion.

American Journal of Obstetrics and Gynecology, 2019

American Journal of Obstetrics and Gynecology, 2018

Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postope... more Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postoperative recovery. Variations of the protocol are being adopted for gynecological procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate whether implementation of an enhanced recovery after surgery pathway would facilitate reduced length of admission in a urogynecology population. MATERIALS AND METHODS: In this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons, we compared same-day discharge, length of admission and postoperative complications before and after implementation of an enhanced recovery after surgery pathway

Female Pelvic Medicine & Reconstructive Surgery, 2019

Objective: To study the performance of a previously published stress urinary incontinence (SUI) r... more Objective: To study the performance of a previously published stress urinary incontinence (SUI) risk calculator in women undergoing minimally invasive or transvaginal apical suspensions. Methods: Using a database of stress continent women who underwent minimally invasive or transvaginal apical suspensions, we calculated two prediction risks for development of SUI within 12 months based upon inclusion of a 'prophylactic' midurethral sling at the time of prolapse surgery. Observed subjective and objective continence status was abstracted from medical records. Regression models were created for the outcome of de novo SUI to generate receiver operating curves. Concordance (c) indices were estimated for the overall and procedure subgroups to determine the calculator's ability to discriminate between SUI outcomes. Results: Analyses included 502 women. De novo SUI was observed in 23.5% of women. The mean calculated risk of de novo SUI if a sling was performed was 18.9% (±13.9) at 12 months compared to 36.4% (±8.3) without sling. The calculator's discriminative ability for those with a planned sling was moderate (c index 0.55, p=.037). The calculator failed to discriminate continence outcomes when a sling was not planned in the overall group (c index 0.50, p=.799) and individual apical procedures. Conclusions: The SUI Risk calculator is significantly limited in its ability to predict de novo SUI in our population of women planning minimally invasive apical suspensions. Refinements to the calculator model are needed to improve its utility in clinical practice.

Obstetrical & Gynecological Survey, 2018

Introduction and hypothesis-Studies have yet to examine the impact of day-of-surgery voiding tria... more Introduction and hypothesis-Studies have yet to examine the impact of day-of-surgery voiding trials on post-operative urinary retention in women undergoing obliterative and apical suspension procedures for pelvic organ prolapse. Our objective was to evaluate if time to spontaneous void after these procedures is shorter when a voiding trial is performed on the day of surgery compared with our standard practice of post-operative day 1. Methods-We conducted a randomized, parallel-arm trial in patients undergoing major pelvic floor reconstructive surgery. Women were randomized 1:1 to an early (4 h post-operatively on the day of surgery) or a standard (6 am on post-operative day 1) retrograde voiding trial. Results-A total of 57 women consented. Mean age and BMI were 65 ±11 and 27.9 ± 4.4. Most women had stage III pelvic organ prolapse (77.2%). Groups had similar baseline characteristics. In the intention-to-treat analysis (n = 57), there was no difference in time to spontaneous void in the early versus standard voiding trial groups (15.9 ± 3.8 vs 28.4 ± 3.1 hours, p = 0.081). In the adjusted analysis using mutlivariable linear regression, an early voiding trial decreased the time to spontaneous void (abeta −2.00 h, p = 0.031) when controlling for vaginal packing and stage IV prolapse. In the per-protocol analysis, which excluded 4 patients for crossover, spontaneous void occurred 17 hours faster in the early voiding trial group (14.6 ± 3.7 vs 31.8 ± 2.9 hours; p = 0.022). Early voiding trial patients experienced ambulation sooner and more often than the standard group (p = 0.02). Conclusions-A day-of-surgery voiding trial did not prolong catheter use after obliterative and apical suspension procedures.

Obstetrical & Gynecological Survey, 2018

This open access article is distributed under Creative Commons Attribution-NonCommercial-NoDeriva... more This open access article is distributed under Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND).

American journal of obstetrics and gynecology, Jan 6, 2018

Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fec... more Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fecal incontinence. Infection after sacral neurostimulation is costly and burdensome. Determining optimal perioperative management strategies to reduce the risk of infection is important to reduce this burden. To identify risk factors associated with sacral neurostimulator infection requiring explantation, to estimate the incidence of infection requiring explantation, and identify associated microbial pathogens. This is a multicenter retrospective case-control study of sacral neuromodulation procedures completed from January 1, 2004-December 31, 2014. We identified all sacral neuromodulation implantable pulse generator implants (IPG) as well as explants due to infection at eight participating institutions. Cases were patients who required IPG explantation for infection during the review period. Cases were included if >18 years old, follow up data > 30 days after IPG implant, and if th...

American Journal of Obstetrics and Gynecology, 2017

International Urogynecology Journal, 2017

Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolap... more Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolapse (POP) in the USA. Over the last decade, fellowship programs have increased the number of these procedures performed robotically. Currently, there is a paucity of literature exploring the impact of fellowship training on outcomes of robotic-assisted sacrocolpopexy (RASC). We sought to explore the impact of an expert surgeon operating alone versus with a fellow on operative time and perioperative morbidity associated with RASC. This is an analysis of a retrospectively collected cohort of all RASCs performed to treat POP from June 2010 to August 2015 by a single attending surgeon. Outcomes were compared by expert surgeon alone and with a fellow. We identified 208 RASCs, of which 124 (59.6%) were performed by an expert surgeon alone and 84 (40.4%) with a fellow. Eight fellows were included, with a median of 7 cases (interquartile range 5-13.5). Cases with fellows were 31.1 min longer than an expert surgeon alone (155.6 vs 124.5 min, p &lt; 0.001), a 25% increase. Increased operative time for fellows remained significant on multivariate regression (34.2 min, p &lt; 0.001) after adjusting for case order postmenopausal status, hysterectomy, mid-urethral sling, and bowel injury. Years in fellowship did not have an impact on operative time (p = 0.80). Complications were seen in 34 women (16.4%). On univariate regression, fellows did not have an impact on complications (OR 1.49, 95% CI [0.65-3.43]), which was unchanged on multivariate regression (OR 0.628, 95% CI [0.26-1.54]). Prolapse recurrence was seen in 19 women (9.5%). Fellows had no impact on prolapse recurrence (OR 0.478, 95% CI [0.17-1.38]), which was unchanged on multivariate regression (OR 0.266, 95% CI [0.17-1.49]). When an expert surgeon operated together with a fellow, operative time increased by 34 min without increasing prolapse recurrence or complications.

Female Pelvic Medicine & Reconstructive Surgery, 2017

Objective To determine the clinical utility of routine postoperative hemoglobin screening after m... more Objective To determine the clinical utility of routine postoperative hemoglobin screening after minimally invasive sacrocolpopexy. Methods This is a retrospective chart review of women undergoing minimally invasive sacrocolpopexy between 2009 and 2015 at a large academic center where postoperative hemoglobin assessment is performed as routine practice. Demographic and perioperative data, pre- and postoperative hemoglobin values, and clinical signs and symptoms of potential postoperative anemia were extracted. Hemoglobin parameters were compared between women with and without clinical evidence of potential postoperative anemia. Linear and logistic regression analyses were used to identify predictors of postoperative anemia and magnitude of hemoglobin decrease. Results Among 800 women, postoperative hemoglobin was obtained for 99.6% and prompted further testing among 23.8%. Mean postoperative hemoglobin was 11.78 ± 1.11 g/dL, and mean decrease was 1.76 ± 0.95 g/dL. More than half (56.9%) had clinical evidence of potential anemia, but few (5%) had postoperative hemoglobin of 10 g/dL or less and none required transfusion. Women with clinical evidence of potential anemia had lower postoperative hemoglobin (11.57 vs 12.19; P < 0.001) and larger mean hemoglobin decrease (1.91 vs 1.49; P < 0.001). On regression analyses, only lower body mass index was associated with larger hemoglobin decrease (&bgr; = −0.030, P < 0.001) and no factor significantly predicted postoperative hemoglobin of 10 g/dL or less. Conclusions Routine hemoglobin testing rarely benefited clinical care but lead to further testing for nearly 1 in 4 patients. Although many women demonstrated clinical evidence potentially suggestive of anemia, significant anemia was rare and no women required transfusion. Neither estimated blood loss nor other risk factors consistently predicted presence of postoperative anemia or significant postoperative decrease in hemoglobin.