Prediction of Postoperative Urinary Tract Infection Following Benign Gynecologic Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to develop a prediction model for urinary tract infection (UTI) after pelvic surgery. METHODS: We utilized data from three tertiary care centers of women undergoing pelvic surgery. The primary outcome was a UTI within 8 weeks of surgery. Additional variables collected included procedural data, severity of prolapse, use of mesh, anti-incontinence surgery, EBL, diabetes, steroid use, estrogen use, postoperative catheter use, PVR, history of recurrent UTI, operative time, comorbidities, and postoperative morbidity including venous thromboembolism, surgical site infection. Two datasets were used for internal validation, whereas a third dataset was used for external validation. Algorithms that tested included the following: multivariable logistic regression, decision trees (DTs), naive Bayes (NB), random forest (RF), gradient boosting (GB), and multilayer perceptron (MP). RESULTS: For the training dataset, containing both University of British Columbia and Mayo Clinic Rochester data, there were 1,657 patients, with 172 (10.4%) UTIs; whereas for the University of Calgary external validation data, there were a total of 392 patients with a UTI rate of 16.1% (n = 63). All models performed well; however, the GB, DT, and RF models all had an area under the curve (AUC) > 0.97. With external validation the model retained high discriminatory ability, DT: AUC = 0.88, RF: AUC = 0.88, and GB: AUC = 0.90. CONCLUSIONS: A model with high discriminatory ability can predict UTI within 8 weeks of pelvic surgery. Future studies should focus on prospective validation and application of randomized trial models to test the utility of this model in the prevention of postoperative UTI.

A Pilot Study in Fatigue Risk Management Among Obstetrics and Gynaecology Residents at the University of Alberta.

OBJECTIVES: Combatting fatigue is an ongoing challenge in surgical residency programs impacting both patient care and resident well-being. There is a gap in understanding the nuances of fatigue perpetuation, especially where it relates to specific on-call duties. This pilot study seeks to explore the extent of sleep deprivation among Obstetrics and Gynecology (OBGYN) residents and identify obstacles to obtaining adequate rest. METHODS: A survey was sent out to all OBGYN residents at the University of Alberta, collecting demographic and baseline sleep information and assessing perceived barriers to sleep. Residents then self-selected for participation in the second portion which involved recording all pages in a 12-hour shift and assigning an acuity rating to them. Mixed methods were used including thematic analysis of the page acuity survey and descriptive statistics for the primary survey. RESULTS: In total, 21 residents completed the initial survey (67.7%) and 17 12-hour shifts were recorded. While junior residents (postgraduate year 1-2) and those carrying the low-risk pager slept less on call and had less sleep on days without call, barriers to sleep were not different when compared to senior residents and those carrying the high-risk pager. While low-risk and high-risk shifts had different primary contributors to fatigue (volume and acuity, respectively) both groups attributed fatigue to non-urgent pages. On review of pages, 49.4% were perceived as non-urgent. A total of 81% of residents supported the development of problem boards to reduce the number of non-urgent pages. CONCLUSIONS: This pilot study demonstrated residents, regardless of seniority or shift, found non-urgent pages to be a significant contributor to on-call fatigue and supported the use of problem boards to reduce pages. Our approach can provide a framework for other institutions to learn more about resident fatigue and non-urgent paging in their program.

Barriers to Surgical Innovation Research: A Canadian Study on Public Funding Trends.

BACKGROUND: A decline in research funding has been cited as a potential cause for limited surgical innovation in the United States. We aim to understand if this is a North American phenomenon and explore whether a lack of public funding is a barrier to surgical innovation in Canada. METHODS: Publicly available funding data from Canadian Institutes of Health Research (CIHR) were reviewed from 2008 to 2019 to determine the yearly funding distributed to surgical departments. Surgical innovation studies were identified and total yearly funding was calculated. All amounts were adjusted for inflation to reflect 2019 Canadian dollar value. RESULTS: From 2008 to 2019, surgical departments were granted 1.82-4.70% of total CIHR funding. In total, 902 grants were allocated to surgical departments and 126 (14.0%) met criteria for surgical innovation. Surgical innovation research was allocated a total annual amount ranging from 1.52 to 9.01 million CAD. There appears to be an upward trend in public funding for surgical innovation over this time period. DISCUSSION: Contrary to the landscape in the United States, there is no evidence of decreasing trends in public funding for surgical innovation in Canada. Considerations should be given to other potential barriers precluding surgeons from participating in innovation. CONCLUSION: Only a small percentage of research dollars to departments in Canada are spent on innovation research, despite an overall increasing trend in total public research funding over the past 10 years. We need to foster an environment in which surgical innovation is encouraged through medical curriculum changes, multidisciplinary collaboration opportunities, and dedicated faculty resources.

Regional Variation and Temporal Trends in Surgery for Pelvic Organ Prolapse in Canada, 2004-2014.

OBJECTIVES: We sought to examine temporal trends in pelvic organ prolapse (POP) surgery in Canada. METHODS: In this observational cross-sectional study, we used diagnostic and procedure codes from all hospitalizations and outpatient clinic visits in Canada (excluding Québec) from 2004 to 2014 to identify and analyze data on POP surgery. RESULTS: There were 204 301 POP surgery visits from 2004 to 2014, and the rate of POP surgery declined from 19.3 to 16.0 per 10 000 women during this period. The rates of "native tissue reconstructive repair" and "hysterectomy without other procedure" declined from 15.0 to 12.8 per 10 000 women and 2.6 to 1.6 per 10 000 women, respectively. The rate of obliteration increased from 0.1 to 0.3 per 10 000 women (all P values for trend <0.01). Mesh procedures increased from 1.6 per 10 000 women in 2004 to 2.4 per 10 000 women in 2007 and 2008, and then declined to 1.3 per 10 000 women in 2014. Reconstructive mesh surgery using an abdominal open approach declined, while laparoscopic procedures increased over the period examined. CONCLUSION: The rates of POP surgery declined in Canada between 2004 and 2014. An increase was observed in obliteration procedures and in laparoscopic vaginal suspension and fixation with mesh.

Diagnosis and Management of an Unusual Cyst 3 Years After Sacrocolpopexy.

BACKGROUND: Peritoneal inclusion cysts (PICs) are uncommon tumours that can pose diagnostic challenges. This report describes an unusual etiology and management of recurrent pelvic organ prolapse. CASE: A 48-year-old premenopausal woman presented with recurrent prolapse and urinary frequency after total abdominal hysterectomy and synthetic mesh sacrocolpopexy. On examination, a stage II rectoenterocele was noted. Her post-void residual was 760 mL as measured by bladder scanner, discrepant with in-and-out catheterization. Pelvic ultrasound revealed a 19-cm cystic pelvic mass. At laparoscopy a PIC was identified, and cystectomy, uterosacral plication, and Moschcowitz culdoplasty were performed. Complete symptom resolution was documented at 4 weeks and 3 months postoperatively. CONCLUSION: PICs should be included in the differential diagnosis of recurrent prolapse. Prolapse symptoms attributable to PICs can be treated with laparoscopic cystectomy.

Urinary tract infection after clean-contaminated pelvic surgery: a retrospective cohort study and prediction model.

INTRODUCTION AND HYPOTHESIS: Postoperative urinary tract infection (UTI) leads to increased patient morbidity and health care costs. A prediction model may identify patients at highest risk for UTI development. Our primary objective was to determine the rate of UTI in the first 6 weeks after benign gynecologic surgery. Our secondary objective was to identify risk factors and build a predictive model for postoperative UTI. METHODS: We reviewed 310 patient records, which represent all patients who underwent clean-contaminated surgery at a tertiary center (2016-2017). UTI was defined as positive urine culture (> 100,000,000 CFU/l) in a symptomatic patient. Pre-, intra- and postoperative variables were collected. The relation between these variables and UTI was assessed through logistic regression. A clinical prediction model was built. RESULTS: Patients' mean age was 58.5 years and mean body mass index was 27.5 kg/m2. Most were inpatients (65.8%) and 269 had urogynecologic procedures, with the remainder undergoing pelvic surgery for other indications. The most common operation was vaginal reconstruction for prolapse (59.7%), associated with concomitant synthetic midurethral sling in 1/3 cases. Forty patients (12.9%) developed UTI. Multivariate prediction modeling showed increasing age (OR 1.33, CI 1.01-1.75), increasing number of procedures (OR 1.42, CI 1.14-1.78) and prolonged voiding dysfunction (OR 3.78, CI 1.66-8.60) to be significant UTI predictors. CONCLUSIONS: Urinary tract infection in the first 6 weeks after complex pelvic surgery is common. Our prediction model identifies that patients who are older women, have prolonged voiding dysfunction and have a greater number of concomitant pelvic floor surgeries have higher risk of postoperative UTI.

Graduating Obstetrics and Gynaecology Residents' Readiness for Practice: A Cross-Sectional Survey Study.

OBJECTIVE: This study sought to evaluate the self-reported and program director-reported comfort of graduating Canadian obstetrics and gynaecology residents in independently performing various surgical skills. METHODS: A Web-based survey was distributed to four cohorts of graduating obstetrics and gynaecology residents across Canada (2014-2017). Residents were asked to indicate their comfort level with independently performing 34 core surgical procedures by using a five-point Likert-type scale. A similar survey was sent to program directors. Comfort scores for residents and program directors were compared using quantitative and qualitative methods as appropriate (Canadian Task Force Classification II-3). RESULTS: Resident and program director survey response rates were 168 of 320 (52.5%) and 20 of 48 (41.7%), respectively. Residents were "comfortable" or "very comfortable" performing 7 of 13 (54%) gynaecology and 4 of 6 (67%) obstetrics List A procedures independently. Program directors reported that residents were "comfortable" or "very comfortable" performing 10 of 13 (77%) gynaecology and 4 of 6 (67%) obstetrics List A procedures. Compared with program directors, residents reported lower comfort with certain minimally invasive and obstetrics List A procedures (P < 0.05). Differences in comfort when performing several List A procedures were related to training program size and plans to pursue fellowship. Qualitative analysis revealed several major and minor themes supporting the dichotomy between residents' lack of comfort and program directors' expectation of comfort. CONCLUSION: Graduating residents were not comfortable performing many core surgical procedures independently. Additionally, program directors believed that trainees were more comfortable than they reported, and comfort varied according to program size and future fellowship plans. The new competency-based curriculum is an opportunity to address this gap.

Urinary tract infection prevention after midurethral slings in pelvic floor reconstructive surgery: A systematic review and meta-analysis.

INTRODUCTION: Synthetic midurethral slings are the most common procedures currently performed for stress urinary incontinence in women. Infection is a frequent complication of urogynecologic surgery. We performed a systematic review and meta-analysis to identify interventions that successfully prevent infections, including urinary tract infection (UTI) and/or bacteriuria, compared with no intervention, in women undergoing midurethral sling surgery with or without concomitant pelvic reconstructive procedures for prolapse. MATERIAL AND METHODS: The primary outcome was the development of any infection post-midurethral sling placement in women. MEDLINE, Embase, CINAHL and the Cochrane Library were searched for comparative studies from inception to July 2017, with no language restrictions. We used search terms related to midurethral sling, infections and infection-reduction interventions. Two independent reviewers abstracted data and assessed study quality. Pooled effect size estimates were calculated. We conducted meta-analysis of eligible studies. A protocol for this review has been registered and can be accessed online (http://hdl.handle.net/2429/64731). RESULTS: We identified seven eligible studies of infection risk-reducing interventions; all focused on UTIs. Only one study assessed preoperative antibiotics with midurethral sling alone and was halted early because of low UTI rates. All other studies (three randomized control trials and three observational studies) examined whether postoperative antibiotics decrease UTI/bacteriuria rates after midurethral sling with or without reconstructive procedures for pelvic organ prolapse and using bladder catheterization postoperatively. Due to considerable clinical heterogeneity, we only combined four studies for meta-analysis. Postoperative oral prophylactic nitrofurantoin showed no significant benefit in reducing UTI/bacteriuria in women post-midurethral sling with or without concomitant reconstructive pelvic surgery and the need for bladder catheterization, when compared with the reference group (pooled relative risk 0.73, 95% confidence interval [CI] 0.42-1.25). CONCLUSIONS: Based on the best available evidence, postoperative oral nitrofurantoin is not effective at reducing UTI/bacteriuria rates in catheterized women after midurethral sling with or without concomitant pelvic reconstructive surgery for prolapse. For midurethral sling alone, preoperative antibiotic prophylaxis may not be needed for UTI prevention.

Optimizing resident operative self-confidence through competency-based surgical education modules: are we there yet?

INTRODUCTION AND HYPOTHESIS: Self-confidence is the belief in one's ability to perform and can be enhanced by training. Surgical education should aim to optimize trainee confidence. We designed three procedure-specific competency-based modules to teach vaginal hysterectomy (VH), anterior (AR) and posterior repair (PR) to novice gynecology residents. We hypothesized each module would improve self-confidence and satisfaction during index procedure performance in the operating room. METHODS: This was an ancillary analysis of a larger randomized-controlled trial of gynecologic educational interventions. Residents at three Canadian universities were included if they had previously performed fewer than five index procedures independently. Intervention residents received educational modules; controls engaged in self-directed learning. All residents performed one or more of the three surgeries and filled out a validated Self-Confidence Scale and a Satisfaction Scale. Scores were compared between groups. Correlations were sought between self-confidence and various variables. RESULTS: Forty-six residents at three Canadian universities were randomized (21 intervention, 25 control). Most residents had never performed the index procedure. Overall, self-confidence was significantly higher (p = 0.021) in the intervention group for VH, but not for AR and PR (p = 0.94 and p = 0.12, respectively). Compared with controls, self-confidence was also significantly higher in intervention residents who had never performed VH (p = 0.026) or PR (p = 0.027) and in first and second year intervention residents. There was a positive correlation between self-confidence and satisfaction. CONCLUSIONS: Surgical modules improved self-confidence preferentially in the most junior residents and for more complicated procedures. The wide self-confidence ranges observed suggest that optimization should be an important goal for surgical educators.

Pelvic floor hypertonicity in women with pelvic floor disorders: A case control and risk prediction study.

AIM: Myofascial pelvic pain is a chronic and debilitating condition, sometimes associated with pelvic floor disorders (PFD) such as urinary incontinence, defecatory dysfunction or pelvic organ prolapse. Our aim was to identify risk factors in women with PFD and hypertonic pelvic floor, compared to controls without hypertonicity. METHODS: Case control study (2009-2017) of patients with PFD and a diagnosis of hypertonic pelvic floor. Cases were matched with patients who presented with the same PFD but without pelvic floor hypertonicity. Postoperative patients with hypertonic pelvic floor were matched with patients who underwent surgery for the same PFD but did not develop pain. Risk factors were compared between groups. RESULTS: Ninety-five cases were matched; 71% had urogynecologic surgery as a possible trigger for myofascial pain. Most were post-menopausal. Overall, case patients were younger than controls (mean 54 vs 59, P = 0.002). Multivariate logistic regression identified risk factors of younger age (OR 1.45, 95%CI 1.04-2.07), history of depression (OR 3, 95%CI 1.03-9.09), musculoskeletal spine injury (OR 4.32, 95%CI 1.01-21.26) and transobturator midurethral sling (OR 8.36, 95%CI 2.68-31.32). Retropubic midurethral sling was protective against pelvic floor hypertonicity (OR 0.37, 95%CI 0.15-0.86). A clinical prediction model including depression, endometriosis, irritable bowel, spine injury and type of midurethral sling was developed to estimate the probability for myofascial pain after urogynecologic surgery. CONCLUSIONS: Specific risk factors predispose women with PFD to chronic pelvic floor hypertonicity. Knowledge of these can help with patient counselling and choice of midurethral sling prior to PFD surgery.

Patient-targeted websites on overactive bladder: What are our patients reading?

AIMS: Patients often turn to the Internet for information on medical conditions. We sought to evaluate the quality and readability of highly visible websites on overactive bladder (OAB). METHODS: A survey of 42 consecutive patients attending outpatient urogynecology clinics was performed to identify the most commonly used Internet search engines and search terms for information on OAB. The three most commonly used search engines (Google, Bing, and Yahoo!) were then queried using the three most commonly used search terms. The first 20 relevant websites from each search were reviewed. After excluding duplicates, 35 websites were analyzed. Website quality of information on OAB was evaluated using the DISCERN score, JAMA benchmark criteria, and Health on the Net code (HONcode) accreditation status. Readability was assessed using the Simplified Measure of Gobbledygook (SMOG) and Dale-Chall indices. RESULTS: Websites were classified as advertisement/commercial (31%), health portal (29%), professional (26%), patient group (6%), and other (9%). The overall mean DISCERN score was 44 ± 18 (maximum possible score of 80). Three websites (9%) met all four JAMA benchmark criteria. Seventeen percent of websites provided adequate information on content authorship and contributions. Median SMOG and Dale-Chall indices were 9.9 (IQR 9.3-11.2) and 9.0 (IQR 8.1-9.4), respectively. Nine websites (26%) were HONcode certified. CONCLUSIONS: Popular websites on OAB are of low quality, written for a high school to college-level readership, and often lack adequate information to assess the potential for commercial bias. Patients should be cautioned that incomplete and potentially biased information on OAB is prevalent online.

Management of patients with stress urinary incontinence after failed midurethral sling.

Surgical failure rates after midurethral sling (MUS) procedures are variable and range from approximately 8-57% at five years of followup. The disparity in long-term failure rates is explained by a lack of long-term followup and lack of a clear definition of what constitutes failure. A recent Cochrane review illustrates that no high-quality data exists to recommend or refute any of the different management strategies for recurrent or persistent stress urinary incontinence (SUI) after failed MUS surgery. Clinical evaluation requires a complete history, physical examination, and establishment of patient goals. Conservative treatment measures include pelvic floor physiotherapy, incontinence pessary dish, commercially available devices (Uresta®, Impressa®), or medical therapy. Minimally invasive therapies include periurethral bulking agents (bladder neck injections) and sling plication. Surgical options include repeat MUS with or without mesh removal, salvage autologous fascial sling or Burch colposuspension, or salvage artificial urinary sphincter insertion. In this paper, we present the available evidence to support each of these approaches and include the management strategy used by our review panel for patients that present with SUI after failed midurethral sling.

The art of medicine: arts-based training in observation and mindfulness for fostering the empathic response in medical residents.

Empathy is an essential attribute for medical professionals. Yet, evidence indicates that medical learners' empathy levels decline dramatically during medical school. Training in evidence-based observation and mindfulness has the potential to bolster the acquisition and demonstration of empathic behaviours for medical learners. In this prospective cohort study, we explore the impact of a course in arts-based visual literacy and mindfulness practice (Art of Seeing) on the empathic response of medical residents engaged in obstetrics and gynaecology and family medicine training. Following this multifaceted arts-based programme that integrates the facilitated viewing of art and dance, art-making, and mindfulness-based practices into a practitioner-patient context, 15 resident trainees completed the previously validated Interpersonal Reactivity Index, Compassion, and Mindfulness Scales. Fourteen participants also participated in semistructured interviews that probed their perceived impacts of the programme on their empathic clinical practice. The results indicated that programme participants improved in the Mindfulness Scale domains related to self-confidence and communication relative to a group of control participants following the arts-based programme. However, the majority of the psychometric measures did not reveal differences between groups over the duration of the programme. Importantly, thematic qualitative analysis of the interview data revealed that the programme had a positive impact on the participants' perceived empathy towards colleagues and patients and on the perception of personal and professional well-being. The study concludes that a multifaceted arts-based curriculum focusing on evidence-based observation and mindfulness is a useful tool in bolstering the empathic response, improving communication, and fostering professional well-being among medical residents.

Asthma associated with incontinentia pigmenti and Fanconi anemia: variable airflow limitation without cellular bronchitis.

Airway inflammation is considered a central component of asthma and, therefore, international guidelines recommend antiinflammatory medications. We describe the clinical history of a 34-year-old woman with airway hyperresponsiveness and asthma who had a reduced ability to mount an inflammatory response due to two unrelated and rare genetic conditions: Fanconi anemia and incontinentia pigmenti. Absence of eosinophils in blood and sputum led to a successful reduction in the dose of corticosteroids without loss of asthma control demonstrating the clinical utility of monitoring treatment using biomarkers and the importance of recognizing the components of airway diseases that contribute to symptoms.