RESUMEN

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate if botox alters the urinary microbiome of patients with overactive bladder and whether this alteration is predictive of treatment response. METHODS: This multicenter prospective cohort study included 18-89-year-old patients undergoing treatment for overactive bladder with 100 units of botox. Urine samples were collected by straight catheterization on the day of the procedure (S1) and again 4 weeks later (S2). Participants completed the Patient Global Impression of Improvement form at their second visit for dichotomization into responders and nonresponders. The microbiome was sequenced using 16s rRNA sequencing. Wilcoxon signed rank and Wilcoxon rank sum were used to compare the microbiome, whereas chi-square, Wilcoxon rank sum, and the independent t-test were utilized for clinical data. RESULTS: Sixty-eight participants were included in the analysis. The mean relative abundance and prevalence of Beauveria bassiana, Xerocomus chrysenteron, Crinipellis zonata, and Micrococcus luteus were all found to increase between S1 and S2 in responders; whereas in nonresponders the mean relative abundance and prevalence of Pseudomonas fragi were found to decrease. The MRA and prevalence of Weissella cibaria, Acinetobacter johnsonii, and Acinetobacter schindleri were found to be greater in responders than nonresponders at the time of S1. Significant UM differences in the S1 of patients who did (n = 5) and did not go on to develop a post-treatment UTI were noted. CONCLUSIONS: Longitudinal urobiome differences may exist between patients who do and do not respond to botox.

Asunto(s)

Toxinas Botulínicas Tipo A , Microbiota , Vejiga Urinaria Hiperactiva , Humanos , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Toxinas Botulínicas Tipo A/uso terapéutico , Vejiga Urinaria Hiperactiva/tratamiento farmacológico , Estudios Prospectivos , ARN Ribosómico 16S

RESUMEN

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median. METHODS: This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery. RESULTS: One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review. CONCLUSIONS: Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.

Asunto(s)

Trastornos del Suelo Pélvico , Cirugía Plástica , Humanos , Femenino , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/uso terapéutico , Estudios Prospectivos , Trastornos del Suelo Pélvico/cirugía , Trastornos del Suelo Pélvico/complicaciones , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Pautas de la Práctica en Medicina

RESUMEN

BACKGROUND: Postoperative urinary retention is common after female pelvic reconstructive surgery. Alpha receptor antagonists can improve dysfunctional voiding by relaxing the bladder outlet and may be effective in reducing the risk of postoperative urinary retention. OBJECTIVE: This study aimed to determine whether tamsulosin is effective in preventing postoperative urinary retention in women undergoing surgery for pelvic organ prolapse. STUDY DESIGN: This was a multicenter, double-blind, randomized controlled trial between August 2018 and June 2020, including women undergoing surgery for pelvic organ prolapse. Patients were excluded from recruitment if they had elevated preoperative postvoid residual volume, history of postoperative urinary retention, or a contraindication to tamsulosin. Those who experienced cystotomy were excluded from analysis. Participants were randomized to a 10-day perioperative course of tamsulosin 0.4 mg vs placebo, beginning 3 days before surgery. A standardized voiding trial was performed on postoperative day 1. The primary outcome was the development of postoperative urinary retention, as defined by the failure of the voiding trial or subsequent need for catheterization to empty the bladder. Secondary outcomes included the rate of urinary tract infection and the impact on lower urinary tract symptoms as measured by the American Urological Association Symptom Index. RESULTS: Of 119 patients, 57 received tamsulosin and 62 received placebo. Groups were similar in regard to demographics, preoperative prolapse and voiding characteristics, and surgical details. Tamsulosin was associated with a lower rate of postoperative urinary retention than placebo (5 patients [8.8%] vs 16 patients [25.8%]; odds ratio, 0.28; 95% confidence interval, 0.09-81; P=.02). The number needed to treat to prevent 1 case of postoperative urinary retention was 5.9 patients. The rate of urinary tract infection did not differ between groups. American Urological Association Symptom Index scores significantly improved after surgery in both groups (median total score, 14 vs 7; P<.01). Scores related to urinary stream improved more in the tamsulosin group than in placebo (P=.03). CONCLUSION: In this placebo-controlled trial, tamsulosin use was associated with a reduced risk of postoperative urinary retention in women undergoing surgery for pelvic organ prolapse.

Asunto(s)

Prolapso de Órgano Pélvico/cirugía , Complicaciones Posoperatorias/prevención & control , Tamsulosina/uso terapéutico , Retención Urinaria/prevención & control , Método Doble Ciego , Femenino , Humanos , Persona de Mediana Edad , Agentes Urológicos/uso terapéutico

RESUMEN

STUDY OBJECTIVE: The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. DESIGN: Retrospective propensity-score matched cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. INTERVENTIONS: We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1-3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1-2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7-2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0-2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7-2.8; p = .3). CONCLUSION: In this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.

Asunto(s)

Histerectomía Vaginal , Histerectomía , Laparoscopía , Prolapso de Órgano Pélvico/cirugía , Complicaciones Posoperatorias/epidemiología , Anciano , Ligamento Ancho/patología , Ligamento Ancho/cirugía , Estudios de Cohortes , Femenino , Humanos , Histerectomía/efectos adversos , Histerectomía/métodos , Histerectomía/estadística & datos numéricos , Histerectomía Vaginal/efectos adversos , Histerectomía Vaginal/métodos , Histerectomía Vaginal/estadística & datos numéricos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Laparoscopía/estadística & datos numéricos , Ligamentos/cirugía , Persona de Mediana Edad , Morbilidad , Readmisión del Paciente/estadística & datos numéricos , Prolapso de Órgano Pélvico/epidemiología , Periodo Perioperatorio , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Estudios Retrospectivos , Estados Unidos/epidemiología , Útero/cirugía , Vagina/cirugía

RESUMEN

BACKGROUND: As transmasculine persons utilize androgen gender affirming hormone therapy as a part of transition, guidance has been lacking on the effects of the therapy on the ovaries, especially for those who may desire retention. AIM: To describe the ovarian histopathology of transmasculine persons on testosterone therapy following oophorectomy at the time of hysterectomy performed for gender affirmation. METHODS: This was a multicenter case series study of transmasculine patients on testosterone therapy who underwent hysterectomy with oophorectomy for gender affirmation between January 2015 and December 2017 at 5 tertiary care referral centers. Patients were identified by their current procedural and International Classification of Diseases codes. OUTCOMES: Pre-, perioperative, and pathologic data were obtained from the electronic medical records and ovarian tissue descriptions from pathology reports were grouped into the following classifications: (i) simple/follicular cysts; (ii) polycystic ovaries; (iii) complex cysts; (iv) endometriomas; (v) other masses; (vi) atrophy; and (vii) normal. RESULTS: 85 patients were included in the study. At the time of oophorectomy, the mean age and body mass index of the cohort were 30.4 ± 8.4 years and 30.2 ± 7.3 kg/m2, respectively, and the average interval from the initiation of testosterone to oophorectomy was 36 0.3 ± 37.9 months. On examination of ovarian histopathology, 49.4% (42) of specimens were found to have follicular/simple cysts, 5.9% (5) were polycystic, and 38.8% (33) had normal pathology. For those specimens with volume documented (n = 41), the median volume was 9.6 (range 1.5-82.5) cm3. There was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries. CLINICAL IMPLICATIONS: The results of this study reported benign histopathology in ovaries of a large cohort of transmasculine persons on testosterone which should be included when counseling patients on ovarian retention, as transmasculine patients may choose to retain their ovaries while on testosterone for a variety of reasons (including no desire to undergo surgery, desire for backup sex steroids, and potential use for future fertility). STRENGTHS & LIMITATIONS: This is a large multicenter study seeking to address the uncertainty in present counseling surrounding ovarian conservation in transmasculine persons on testosterone therapy. Its limitations included its retrospective nature and inability to address ovarian function after testosterone discontinuance. CONCLUSION: In this cohort of transmasculine patients on testosterone therapy undergoing hysterectomy with oophorectomy for gender affirmation, ovarian histopathology was benign in all the specimens. Grimstad FW, Fowler KG, New EP, et al. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020;17:1807-1818.

Asunto(s)

Ovario/patología , Testosterona , Personas Transgénero , Adulto , Andrógenos , Femenino , Humanos , Estudios Retrospectivos , Adulto Joven

RESUMEN

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.

Asunto(s)

Acetaminofén/uso terapéutico , Crioterapia , Procedimientos Quirúrgicos Ginecológicos , Ketorolaco Trometamina/uso terapéutico , Dolor Postoperatorio/prevención & control , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Terapia Combinada , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Hidromorfona/uso terapéutico , Ketorolaco/uso terapéutico , Persona de Mediana Edad , Satisfacción del Paciente , Escala Visual Analógica

Asunto(s)

Humanos , Masculino , Femenino , Testosterona/efectos adversos , Transexualidad/complicaciones , Personas Transgénero , Útero/patología , Endometrio/fisiopatología , Endometrio/patología

RESUMEN

BACKGROUND: As part of transition, transmasculine persons often use testosterone gender-affirming hormone therapy; however, there is limited data on its long-term effects. The impact of exogenous testosterone on uterine pathology remains unclear. While testosterone achieves amenorrhea in the majority of this population, persistence of abnormal uterine bleeding can be difficult to manage. Excess androgens in cisgender females are associated with pathologic uterine processes such as polycystic ovary syndrome, endometrial hyperplasia, or cancer. There are no guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population. OBJECTIVE: The aim of this study was to describe the characteristics of uterine pathology after the initiation of testosterone in transmasculine persons. MATERIALS AND METHODS: A retrospective, multicenter case series was performed. Uterine pathology reports of transmasculine persons who received testosterone and subsequently underwent hysterectomy were reviewed. The endometrial phase and endometrial thickness were recorded. RESULTS: A total of 94 subjects met search criteria. The mean age of participants was 30 ± 8.6 years, and the mean interval from initiation of testosterone to hysterectomy was 36.7 ± 36.6 months. Active endometrium was found in the majority of patients (n = 65; 69.1%). One patient had complex hyperplasia without atypia. There were no cases of endometrial cancer. CONCLUSION: Despite amenorrhea in the majority of transmasculine persons on testosterone, endometrial activity persists with predominantly proliferative endometrium on histopathology. Individualized counseling for abnormal uterine bleeding is encouraged in this patient population.

Asunto(s)

Andrógenos/efectos adversos , Hiperplasia Endometrial/inducido químicamente , Endometrio/patología , Procedimientos de Reasignación de Sexo/efectos adversos , Testosterona/efectos adversos , Personas Transgénero , Adolescente , Adulto , Andrógenos/uso terapéutico , Hiperplasia Endometrial/diagnóstico , Hiperplasia Endometrial/patología , Hiperplasia Endometrial/cirugía , Endometrio/efectos de los fármacos , Femenino , Humanos , Histerectomía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Testosterona/uso terapéutico , Resultado del Tratamiento , Adulto Joven

RESUMEN

PURPOSE: The cough stress test is a common and accepted tool to evaluate stress urinary incontinence but there is no agreement on how the test should be performed. We assessed the diagnostic ability of different cough stress tests performed when varying patient position and bladder volume using urodynamic stress urinary incontinence as the gold standard. The 24-hour pad test was also evaluated. MATERIALS AND METHODS: We recruited women who presented to specialty outpatient clinics with the complaint of urinary incontinence and who were recommended to undergo urodynamic testing. A total of 140 patients were randomized to 4 cough stress test groups, including group 1-a comfortably full bladder, group 2-an empty bladder, group 3- a bladder infused with 200 cc saline and group 4-a bladder filled to half functional capacity. The sequence of standing and sitting was randomly assigned. The groups were compared by 1-way ANOVA or the generalized Fisher exact test. The κ statistic was used to evaluate agreement between the sitting and standing positions. The 95% CIs of sensitivity and specificity were calculated using the Wilson method. ROC analysis was done to evaluate the performance of the 24-hour pad test. RESULTS: The cough stress test performed with a bladder filled to half functional capacity was the best performing test with 83% sensitivity and 90% specificity. There was no statistically significant evidence that the sensitivity or specificity of 1 cough stress test differed from that of the others. The pad test had no significant predictive ability to diagnose urodynamic stress urinary incontinence (AUC 0.60, p = 0.08). CONCLUSIONS: Cough stress tests were accurate to diagnose urodynamic stress urinary incontinence. The 24-hour pad test was not predictive of urodynamic stress urinary incontinence and not helpful when used in conjunction with the cough stress test.

Asunto(s)

Tos , Técnicas de Diagnóstico Urológico , Incontinencia Urinaria de Esfuerzo/diagnóstico , Urodinámica , Adulto , Anciano , Instituciones de Atención Ambulatoria , Femenino , Humanos , Pañales para la Incontinencia , Persona de Mediana Edad , Estudios Prospectivos , Curva ROC , Vejiga Urinaria/fisiopatología , Incontinencia Urinaria de Esfuerzo/fisiopatología

RESUMEN

OBJECTIVE: The objective of the study was to determine whether transversus abdominis plane (TAP) block improves the early postoperative quality of recovery (QoR-40). The secondary objectives measured postoperative pain, length of stay, and narcotic use. STUDY DESIGN: This was a randomized, single-blinded trial of TAP block versus no block on women undergoing laparoscopic hysterectomy. TAP block patients received 20 mL of 0.5% ropivacaine with epinephrine 1:200,000 placed under ultrasound guidance on each side. The outcomes were measured using validated quality of recovery questionnaires (QoR-40), visual analog scales (VAS) for pain, and documented narcotic use in the electronic medical record. RESULTS: In 58 women, no differences in demographics were noted between groups. Comparisons of pain and recovery between the 2 groups showed no differences. There was no decrease in narcotic use or length of stay among those who received the TAP block. CONCLUSIONS: TAP block does not improve postoperative QoR-40 scores or VAS pain scores following laparoscopic hysterectomy, nor does it decrease narcotic pain medication use.

Asunto(s)

Analgesia/métodos , Histerectomía/métodos , Laparoscopía/métodos , Bloqueo Nervioso/métodos , Recuperación de la Función/efectos de los fármacos , Músculos Abdominales/diagnóstico por imagen , Músculos Abdominales/efectos de los fármacos , Adulto , Amidas/uso terapéutico , Anestésicos Locales/uso terapéutico , Femenino , Humanos , Tiempo de Internación , Persona de Mediana Edad , Dimensión del Dolor , Ropivacaína , Resultado del Tratamiento , Ultrasonografía

RESUMEN

BACKGROUND: The objective was to evaluate the cytotoxic effect and mechanism of action of vitamins C (VC) and K3 (VK3) on ovarian carcinoma. MATERIALS AND METHODS: Cytotoxicity assays were performed on ovarian cancer cell lines with VC, VK3 or a VC/VK3 combination. FIC index was employed to evaluate synergism. Flow cytometry was accomplished at 90% cytotoxic doses. Light, transmission electron microscopy and DNA isolation were performed. RESULTS: Antitumor activity was exhibited by both VC, VK3 and VC/VK3. VC/VK3 demonstrated synergistic activity. VC/VK3 may induce a G1 block in the cell cycle. Combined vitamin treatment resulted in cells that maintain apparently intact nuclei while extruding pieces of organelle-free cytoplasm. Degradation of chromosomal DNA was observed. CONCLUSION: Cell death (autoschizis) displayed characteristics of both apoptosis and necrosis. The cytotoxic effects observed may enable vitamins C and K3 to play an adjuvant role in the treatment of ovarian cancer.

Asunto(s)

Protocolos de Quimioterapia Combinada Antineoplásica/farmacología , Ácido Ascórbico/farmacología , Neoplasias Ováricas/tratamiento farmacológico , Vitamina K 3/farmacología , Ácido Ascórbico/administración & dosificación , División Celular/efectos de los fármacos , ADN de Neoplasias/aislamiento & purificación , ADN de Neoplasias/metabolismo , Sinergismo Farmacológico , Femenino , Citometría de Flujo , Humanos , Microscopía Electrónica , Neoplasias Ováricas/genética , Neoplasias Ováricas/patología , Células Tumorales Cultivadas , Vitamina K 3/administración & dosificación