Does a Preoperative Bowel Regimen Change Time to Bowel Movement? A Randomized Clinical Trial.

IMPORTANCE: This study is important because it aimed to assess an intervention to decrease patient discomfort after a robotic sacral colpopexy. OBJECTIVE: Our primary outcome was to determine whether preoperative use of polyethylene glycol decreases time to first bowel movement postoperatively. Secondary outcomes include degree of pain with first bowel movement and stool consistency. STUDY DESIGN: This was a randomized controlled trial. The experimental group was assigned polyethylene glycol daily for 7 days before surgery and the control group was not. All patients received polyethylene glycol postoperatively. RESULTS: There was no statistically significant reduction in the time to first postoperative bowel movement when preoperative polyethylene glycol was used (mean [SD] in days for the control and experimental groups of 2.32 [0.99] and 1.96 [1.00], P = 0.21). There was a statistically significant reduction in pain levels with the first postoperative bowel movement in the experimental group (median [IQR] of 4 [2-5] vs 1 [0-2], P = 0.0007). Postoperative day 1 pain levels were also significantly lower in the experimental group (median [IQR] of 4 [3-6] vs 2 [0-4], P = 0.0484). In addition, patients had decreased average postoperative pain levels over 7 days with an estimated difference in the median pain levels of 1.88 units (95% confidence interval, 0.64-3.12; P = 0.0038). CONCLUSIONS: Preoperative administration of polyethylene glycol did not decrease time to first postoperative bowel movement. Patients in the experimental group exhibited less pain with their first postoperative bowel movement and had improved pain levels on postoperative day 1.

Dynamic, High-Fidelity, 3-Dimensional Pelvic Model Improves Education on Pelvic Organ Prolapse and the Pelvic Organ Prolapse Quantification System and Interest in Urogynecology.

IMPORTANCE: Pelvic organ prolapse (POP) affects millions of women globally. Still, medical students and obstetrics and gynecology residents gain minimal exposure to POP during training. OBJECTIVES: Our goal was to increase exposure to POP by creating a high-fidelity, dynamic, 3-dimensional pelvic model of prolapse and using it to teach through didactic learning sessions. STUDY DESIGN: This was a prospective cohort study from November 2021 to July 2022. Presession and postsession surveys were administered to assess for change in POP knowledge both subjectively and objectively. Statistical analysis was performed using the Wilcoxon signed-rank test with a P value of 0.05 denoting significance. RESULTS: Thirty-three learners participated in the study, including 18 residents and 15 medical students. Most participants had interacted with urogynecologists and had seen at least 1 patient with POP. Fewer participants had received prior education on POP and the Pelvic Organ Prolapse Quantification (POP-Q) examination, witnessed or performed a POP-Q examination, or participated in POP surgical procedures. After learning with the model, comfort with identifying POP doubled (P < 0.001), the ability to understand the POP-Q examination quadrupled (P < 0.001), the ability to perform a POP-Q examination tripled (P < 0.001), and the ability to teach a POP-Q examination doubled (P < 0.001). The median score on a multiple-choice knowledge assessment increased by 40% (P < 0.001). Learners felt that the pelvic model was an effective teaching tool that increased interest in the field of urogynecology. CONCLUSIONS: Using a high-fidelity, dynamic model in didactic sessions enhances education about POP and the POP-Q system and should be used to improve learner exposure and experience.

A robotic approach to management of failed sacrocolpopexy and sacrocolpopexy complications: a case series.

INTRODUCTION AND HYPOTHESIS: Approximately 5% of patients pursue reoperation after sacrocolpopexy (SCP). Reasons for re-operation include recurrence of prolapse, mesh erosion, bowel and bladder dysfunction, and pain. We aim to describe patient presentation, intraoperative findings, and subsequent robotic approach to management of SCP failures and complications. METHODS: This is a case series of patients who underwent abdominal re-exploration after SCP over 7 years at a single institution. Demographic data, previous prolapse surgery, presenting complaint, prolapse stage, operative notes, and outcomes were reviewed. Nineteen patients were identified by CPT codes; ten met inclusion criteria. RESULTS: Seven of the ten patients presented with vaginal bulge, urinary frequency and urgency; four also had stress urinary incontinence. Two patients presented with vaginal bleeding and another with vaginal pain. Operative findings on reoperation for patients who had vaginal bulge included detachment from the vagina or cervix (n = 4, 57%) and the anterior longitudinal ligament (n = 3, 43%). Of these, two had their SCP mesh reattached, and five had SCP mesh removal and replacement. The patients with vaginal bleeding and pain underwent mesh excisions. All ten patients had uncomplicated postoperative courses with resolution of symptoms in most cases. CONCLUSIONS: Prolapse recurrence and complications after SCP have a significant impact on patient quality of life. Recurrent prolapse after SCP theoretically occurs because of mesh detachment from the cervix/vagina, the anterior longitudinal ligament, or disruption/stretching of the mesh. Our case series demonstrates that abdominal re-exploration is feasible and valuable in these rare cases.

Rates of Pessary Self-Care and the Characteristics of Patients Who Perform it.

OBJECTIVE: The aims of this study were to determine the percentage of patients who opt to undergo pessary self-care versus those who return to the office for care and to identify any differences in the characteristics between the 2 groups. METHODS: This study is a retrospective chart review conducted at a tertiary care center. Demographic data; details regarding pessary use; body weight; pelvic organ prolapse stage; and medical, surgical, and obstetrical histories were evaluated. Variables were compared between groups of patients using the t test, Wilcoxon rank sum test, χ2 test, and Fisher exact test. RESULTS: The rate of patients choosing to perform pessary self-care was 31%. The patients in the self-care group were significantly younger (65.0 vs 75.0 years, P < 0.001). Those who were performing self-care were more likely to be premenopausal (6.9% vs 1.5%, P = 0.003), have a lower stage of pelvic organ prolapse (61.3% vs 42.1%, P < 0.001), and more likely to be sexually active (40.5% vs 9.6%, P < 0.001). Those not performing self-care had higher rates of vaginal bleeding (26.0% vs 16.4%, P = 0.012) and erosion (23.5% vs 9.9%, P < 0.001). Self-care patients predominantly used the ring with support pessary, whereas those in the non-self-care group were mostly using the Gellhorn. CONCLUSIONS: Only one third of patients who use a pessary chose to perform self-care. Patients who use self-care are younger, premenopausal, sexually active, and have lower degrees of prolapse. These data can help educate patients on the characteristics more often seen in those choosing self-care. This study highlights the importance of further exploring pessary care preferences and using this information for counseling.

Comparison of strength of sacrocolpopexy mesh attachment using barbed and nonbarbed sutures.

INTRODUCTION AND HYPOTHESIS: We aimed to assess the pull-out strength of barbed and nonbarbed sutures used in sacrocolpopexy mesh fixation. We hypothesized there are no differences in the force needed to dislodge mesh from tissue using barbed and nonbarbed sutures of similar size. METHODS: Using the rectus fascia of three unembalmed cadavers, a 6 × 3 cm strip of polypropylene mesh was anchored to the fascia with sutures. The barbed sutures investigated were 2-0 V-Loc 180 (nine trials) and 3-0 bidirectional Quill™ SRS PDO (five trials). The nonbarbed sutures included 2-0 PDS (nine trials), CV-2 GORE-TEX (nine trials) and 2-0 Prolene (nine trials). The free-end of the mesh was anchored to a pulley system fixed to a tensiometer to measure the peak force applied at the moment of mesh dislodgement (termed the pull-out force). The pull-out force was recorded. Continuous variables are presented as medians and interquartile ranges (IQR). Analysis of variance was used to compare the forces across the suture types. RESULTS: The highest pull-out force observed was with GORE-TEX (median 65.14 N, IQR 53.37-68.77 N) followed by Prolene (median 58.98 N, IQR 54.64-62.59 N), V-Loc (median 55.23 N, IQR 51.60-58.57 N), PDS (53.96 N, IQR 51.60-57.88 N), and Quill (44.44 N, IQR 17.27-47.38 N). All 2-0 and CV-2 caliber sutures had greater pull-out forces than 3-0 Quill sutures (p < 0.01). No significant differences in pull-out forces were observed between 2-0 and CV-2 caliber sutures (p > 0.05). In 35 of the 41 trials (85%), the mesh sheared from the tissue. CONCLUSION: CV-2 ad 2-0 barbed and nonbarbed sutures had similar pull-out forces in an assessment of mesh fixation strength.

Establishing the Learning Curve of Robotic Sacral Colpopexy in a Start-up Robotics Program.

STUDY OBJECTIVE: To determine the learning curve of the following segments of a robotic sacral colpopexy: preoperative setup, operative time, postoperative transition, and room turnover. DESIGN: A retrospective cohort study to determine the number of cases needed to reach points of efficiency in the various segments of a robotic sacral colpopexy (Canadian Task Force II-2). SETTING: A university-affiliated community hospital. PATIENTS: Women who underwent robotic sacral colpopexy at our institution from 2009 to 2013 comprise the study population. INTERVENTIONS: Patient characteristics and operative reports were extracted from a patient database that has been maintained since the inception of the robotics program at Winthrop University Hospital and electronic medical records. Based on additional procedures performed, 4 groups of patients were created (A-D). MEASUREMENTS AND MAIN RESULTS: Learning curves for each of the segment times of interest were created using penalized basis spline (B-spline) regression. Operative time was further analyzed using an inverse curve and sequential grouping. A total of 176 patients were eligible. Nonparametric tests detected no difference in procedure times between the 4 groups (A-D) of patients. The preoperative and postoperative points of efficiency were 108 and 118 cases, respectively. The operative points of proficiency and efficiency were 25 and 36 cases, respectively. Operative time was further analyzed using an inverse curve that revealed that after 11 cases the surgeon had reached 90% of the learning plateau. Sequential grouping revealed no significant improvement in operative time after 60 cases. Turnover time could not be assessed because of incomplete data. CONCLUSIONS: There is a difference in the operative time learning curve for robotic sacral colpopexy depending on the statistical analysis used. The learning curve of the operative segment showed an improvement in operative time between 25 and 36 cases when using B-spline regression. When the data for operative time was fit to an inverse curve, a learning rate of 11 cases was appreciated. Using sequential grouping to describe the data, no improvement in operative time was seen after 60 cases. Ultimately, we believe that efficiency in operative time is attained after 30 to 60 cases when performing robotic sacral colpopexy. The learning curve for preoperative setup and postoperative transition, which is reflective of anesthesia and nursing staff, was approximately 110 cases.

Reoperation After Robotic and Vaginal Mesh Reconstructive Surgery: A Retrospective Cohort Study.

OBJECTIVES: Our primary objective was to compare reoperations after robotic-assisted sacrocolpopexy and transvaginal mesh for apical prolapse repair. Our secondary aim was to record perioperative complications after robotic and vaginal surgeries. METHODS: We reviewed medical records of women who underwent vaginal apical mesh support procedures or robotic sacrocolpopexy at Winthrop University Hospital between August 2009 and August 2013. We compared reoperations and perioperative complications between the 2 groups. RESULTS: There were 245 eligible cases during the 4-year study period. One hundred eighty-one women underwent robotic-assisted sacrocolpopexy and 64 women underwent transvaginal mesh. Women who underwent robotic surgery were younger and had decreased blood loss. Patients were followed up for a median of 3 months after robotic surgery and 11.5 months after transvaginal mesh. We found no difference in overall rate of reoperation between robotic and transvaginal mesh repair for apical prolapse. Specifically, there was no difference in the rate of reoperation for mesh exposure. CONCLUSIONS: Despite recent controversies, transvaginal mesh offers the benefit of an effective minimally invasive procedure with shorter operative times, and may not pose additional risk for reoperation when compared to robotic-assisted sacrocolpopexy.

Delayed small bowel obstruction after robotic-assisted sacrocolpopexy.

We report 2 unusual cases of partial bowel obstruction resulting from adherence to a barbed suture presenting 3 to 4 weeks after robotic-assisted sacrocolpopexy for uterovaginal prolapse. Both patients underwent an uncomplicated robotic-assisted supracervical hysterectomy and sacrocolpopexy. Immediate postoperative recovery was uncomplicated. Three to four weeks after surgery, both patients presented with symptoms of nausea, vomiting, and abdominal pain and were found to have small bowel obstructions requiring a return to the operating room. Upon surgical exploration, a loop of small bowel was found to be adhered to a segment of the barbed suture at the sacral promontory, which had been used to close the peritoneum over the mesh. Subsequent to release, both patients had an uneventful recovery.

Patient safety in clinical research articles.

Patient safety has remained one of the most important priorities over the past decade, particularly in hospital settings. Implementation of patient safety measures has focused not only on reducing medication and surgical errors but also on the development of a culture of safety, including enhanced communication among all healthcare stakeholders. Academic medicine may further contribute to the culture of safety if all relevant clinical article submissions address patient safety. In order to improve communication between the authors of clinical research articles and practicing physicians, we propose that each clinical research article may be accompanied by a clear statement from the authors regarding practice implications and patient safety.

Inclusion of body mass index in the history of present illness.

OBJECTIVE: To estimate the degree of association between body mass index (BMI) and some of the most common adverse outcomes and conditions in obstetrics and gynecology, and to compare it with the traditional descriptors such as age, gravidity, parity, history of preterm births, history of abortions or miscarriages, and race and ethnic status. METHODS: Using a PubMed search, abstracts were identified that dealt with the associations between each of the descriptors (age, gravidity, parity, history of preterm births, history of abortions, racial and ethnic identification, and BMI) and a variety of adverse outcomes and conditions in both obstetrics and in gynecology. RESULTS: Body mass index had the highest association with the most common adverse outcomes and conditions in obstetrics and in gynecology (53 of 57 [93%]) as compared with the traditional descriptors (age, 39 of 57 [88%]; gravidity, 19 of 57 [33%]; parity, 24 of 57 [42%]; previous preterm births, 22 of 57 [39%]; abortions, 14 of 57 [25%]; and race and ethnic status, 26 of 57 [46%]). CONCLUSION: This study underscores the prominence BMI plays regarding its frequently cited associations with an array of obstetric and gynecologic conditions. Body mass index should be included in the opening statement of the history of present illness and in all communications of health care providers regarding obstetric and gynecologic patients.

Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison.

UNLABELLED: Does local injection with lidocaine plus epinephrine prior to vaginal reconstructive surgery with synthetic mesh affect exposure rates? A retrospective comparison. PURPOSE: To determine if local injection, prior to incision with lidocaine plus epinephrine (L + E) influences the rate of mesh exposure in the early postoperative period following synthetic mesh augmented vaginal reconstructive surgery (MAVR). METHODS: We performed a chart review over an 18-month period of patients who underwent MAVR. The presence of mesh exposure at the 3-month postoperative visit, demographic data and whether or not L + E was used to hydrodissect was recorded. Statistical analysis was performed to determine whether hydrodissection influenced erosion rates. RESULTS: A total of 143 meshes were placed, hydrodissection with L + E was used in 78 cases and was not in the remaining 65 cases. There were 10 (7.0% 10/143) total erosions at the 3-month postoperative visit, 6 (7.7%; 6/78) in the group that got L + E and 4 (6.2%; 4/65) in the group that did not get local injection. This difference was not significant (p = 0.740, OR 1.54 95% CI 0.41-5.76). There was no difference between the two groups in terms of age, presence of diabetes, concurrent incontinence repair or estimated blood loss. CONCLUSION: Mesh exposure is a known complication of MAVR. Our study suggests that local injection with L + E prior to vaginal surgery does not influence exposure rates.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery. METHODS: The charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial. RESULTS: Forty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3-9.8). CONCLUSIONS: A higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Characteristics of physicians who choose fellowship training in obstetrics and gynecology.

INTRODUCTION: : To determine the attributes and motivation of physicians who pursue fellowship training in the subspecialties of Obstetrics and Gynecology (Ob/Gyn). METHODS: : We surveyed current fellows and recent graduates from the ABOG recognized subspecialties in Ob/Gyn. Demographics and reasons for pursuing fellowship training were obtained. Significant differences between and among groups were determined using the Mann-Whitney U test and Pearson χ test. RESULTS: : Forty-two percent of those sent a survey responded. The majority were between ages 30 to 35 (65.7%), female (60.5%), married (74.5%), and White (68.8%). Over 55% in each subspecialty cited interest in subject area as the primary reason for choosing their fellowship. CONCLUSION: : Interest in subject remains the primary motivation for the majority of physicians choosing subspecialty fellowship training in Ob/Gyn. There is considerably more variation regarding what physicians' secondary motivation is and these reasons appear to vary according to the particular subspecialty.

Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs.

INTRODUCTION AND HYPOTHESIS: Our objective was to establish the overall graft erosion rate in a synthetic graft-augmented repair 3 months postoperatively. METHODS: A retrospective chart review was performed on a cohort of subjects who underwent mesh-augmented vaginal reconstructive surgery during an 18-month period. We defined graft erosion as exposure of any mesh upon visual inspection of the entire vagina at the 3-month postoperative visit. Statistical tests performed to evaluate proportional differences were the Pearson chi square and Fisher exact tests. Independent t test was performed to compare mean differences. RESULTS: A total of 124 grafts were implanted. The overall erosion rate was 11.3%. There was a significantly lower erosion rate when using "commercial kits" vs. our traditional repairs (1.4% [one out of 69] vs. 23.6% [13 out of 55]; p < 0.001). CONCLUSIONS: Our study demonstrates a significantly lower erosion rate when using a "commercial kit" to repair pelvic organ prolapse compared to our traditional synthetic graft-augmented repair.

Anatomic relationships of the "top-down" mid-urethral sling.

OBJECTIVE: To determine the anatomic relationships between the "top-down" mid-urethral sling (MUS) and pelvic structures. STUDY DESIGN: Placement of the sling needle delivery device was performed in 10 cadaveric hemi-pelves. The distances between major structures in the pelvis and the needle delivery device were recorded. RESULTS: The mean distances are as follows: mid pubis 1.71 (+/- 0.25) cm, bladder neck 1.66 (+/- 0.37) cm, urethral orifice 3.96 (+/- 0.52) cm, obturator foramen 3.90 (+/- 0.43) cm, inferior epigastric vessels 3.50 (+/- 0.62) cm, accessory obturator vessels 3.53 (+/- 0.36) cm and external iliac vein 4.02 (+/- 0.42) cm. CONCLUSION: Major pelvic structures are in close proximity to the needle delivery device in a top-down mid-urethral sling.

Mirror syndrome associated with sacrococcygeal teratoma: a case report.

BACKGROUND: Mirror syndrome is associated with both nonimmune and immune hydrops fetalis. The clinical manifestations are quite varied, and the pathophysiology is poorly understood. We describe a case of mirror syndrome associated with afetus that had a rapidly growing sacrococcygeal teratoma (SCT) without overt hydrops. CASE: At 30 weeks' gestational age a fetus with SCT began to show early sonographic evidence of right heart failure, placentomegaly and polyhydramnios without overt fetal hydrops. Shortly after these findings were noted, the mother began to develop hypertension, epigastric pain, proteinuria and thrombocytopenia. These findings were all reversed after delivery of the fetus. Subsequent surgery on the infant was successful. CONCLUSION: Mirror syndrome has been linked with SCT and is usually associated with severe fetal hydropic changes. In our case the development of mirror syndrome preceded the manifestations of overt hydrops. Identification of early signs of fetal compromise or hydrops may help to predict patients who will develop mirror syndrome and improve outcomes with earlier intervention.

Social concerns of women undergoing infertility treatment.

OBJECTIVE: Our study was undertaken to determine [1] what women are disclosing to their employer with regard to their infertility, [2] what demographic characteristics are associated with women who are more likely to disclose, and [3] if there is an association between disclosure and lowering one's stress. We hypothesize that, in certain women, disclosure may lower stress, and therefore increase success rate of in vitro fertilization. DESIGN: Cross-sectional questionnaire. SETTING: University Infertility Treatment Center. PATIENT(S): We handed out a questionnaire to patients being evaluated and treated for infertility over a 6-month period. A total of 267 questionnaires were handed out and all were collected. MAIN OUTCOME MEASURE(S): We collected demographic data as well as information regarding privacy, disclosure, and stress. We then compared women who disclose to their employer that they are being seen by an infertility specialist to those women who do not disclose. We also measured stress and determined if higher stress level was associated with disclosure or nondisclosure. RESULT(S): Most women who did disclose did so because they needed a reason to leave work for frequent doctor visits. Among women who did not disclose, the main reason for nondisclosure was to protect their privacy. Women with a high school education were more likely to disclose compared with those with a college and postgraduate education. African American/Caribbean American women were least likely to disclose. Those who were out of work more often because of their infertility were more likely to disclose. There was not an association with disclosure and decreasing stress level. CONCLUSION(S): Women who did or did not disclose their infertility status to their employer were different with regard to level of education, race/ethnicity, and number of visits per month to the doctor. The decision to disclose does not seem to have a significant impact on stress.