Trends in Fellowship Training for Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVE: The aim of this study was to characterize distinguishing features among gynecology, urology, and combined female pelvic medicine and reconstructive surgery (FPMRS) fellowship programs and practices. METHODS: A 32-item Web-based survey was sent to fellowship directors of FPMRS programs accredited by the Accreditation Council for Graduate Medical Education. The survey assessed the structure of the fellowship, as well as the degree to which gynecology and urology are integrated into the fellowship training. In addition to descriptive statistics, Fisher exact test and Mann-Whitney U test were used for statistical analysis. RESULTS: Forty-one program directors (PDs) completed the survey for a 76% response rate. Of the respondents, 78% were gynecologists, and 22% were urologists. Sixty-five percent of the respondents considered their program gynecology based, 7.5% considered their program urology based, 22.5% considered their program fully integrated (urology and gynecology equal sharing), and 5% have separate tracks for urology fellows and gynecology fellows. Sixty-one percent of the programs accept both urology and gynecology fellows in their fellowship programs. Approximately two thirds of the PDs are happy with the fellowship model at their institution, whereas the remaining one third would like greater integration of gynecology and urology in fellowship training. Almost 90% of the respondents felt that there were benefits to an integrated program. The top benefits were reported as more exchange of information, better relationships, more comprehensive training, exposure to different treatment approaches, and improved care for women. For those PDs who desire a more integrated program, the top barriers listed were departmental competition/politics, lack of formally trained urology faculty, and expense. CONCLUSIONS: There are several FPMRS fellowship models. A significant proportion of PDs would like a more integrated fellowship program, and an overwhelming majority note benefits for themselves and their fellows that result from increased contact with a diverse FPMRS faculty.

Preoperative Urodynamic Parameters (Valsalva Leak Point Pressure and Maximum Urethral Closure Pressure), Urinary Collagen and Plasma Vitamin D Levels as Predictors of Mid Urethral Sling Surgery Outcome.

PURPOSE: To determine the best predictor of the mid urethral sling outcome we calculated the AUC of ROC curves of preoperative parameters, including Valsalva leak point pressure, maximum urethral closure pressure, urinary NTx (N-telopeptide of crosslinked type I collagen) and plasma vitamin D values (D2, D3 and D2 plus D3). MATERIALS AND METHODS: This was an ancillary study of TOMUS (Trial of Mid-urethral Slings) and the ValUE (Value of Urodynamics Evaluation) trial in which subjects underwent mid urethral sling surgery for stress urinary incontinence. Valsalva leak point pressure and maximum urethral closure pressure were measured in 427 subjects, whereas NTx, vitamin D2, vitamin D3 and vitamin D2 plus D3 levels were obtained from 150, 116, 115 and 116 subjects respectively. Outcome success was defined using identical outcome (subjective and objective) variables for all subjects. ROC curves with corresponding AUC values were compared. RESULTS: TOMUS and ValUE subjects were significantly different in age, body mass index, UDI (Urogenital Distress Inventory) scores. TOMUS subjects had a lower surgical success rate compared to ValUE subjects (66.3% vs 76.0%, p = 0.03). The AUC values of Valsalva leak point pressure, maximum urethral closure pressure, NTx, and vitamins D2, D3 and D2 plus D3 were 0.542, 0.561, 0.702, 0.627, 0.645 and 0.640, respectively. The AUC of NTx was significantly higher than the AUCs of Valsalva leak point pressure and maximum urethral closure pressure (p = 0.02 and 0.03, respectively). CONCLUSIONS: Urinary NTx was the best predictor of the mid urethral sling outcome. This test is not only noninvasive, it is also modifiable. Finding ideal modifiable risk factors prior to mid urethral sling surgery should be subject to future investigations.

Racial Disparities in Knowledge of Pelvic Floor Disorders Among Community-Dwelling Women.

OBJECTIVE: To evaluate racial and ethnic differences in knowledge about preventative and curative treatments for pelvic floor disorders (PFD). METHODS: The is a secondary analysis of responses from 416 community-dwelling women, aged 19 to 98 years, living in New Haven County, CT, who completed the Prolapse and Incontinence Knowledge Questionnaire. Associations between race/ethnicity (categorized as white, African American, and other women of color [combined group of Hispanic, Asian or "other" women] and knowledge proficiency about modifiable risk factors and treatments for PFD were evaluated. Associations were adjusted for age, marital status, socioeconomic status, education, working in a medical field, and PFD history. RESULTS: Compared to white women, African American women were significantly less likely to recognize childbirth as a risk factor for urinary incontinence (UI) and pelvic organ prolapse (POP), to know that exercises can help control leakage, and to recognize pessaries as a treatment option for POP. Other women of color were also significantly less likely to know about risk factors, preventative strategies, and curative treatment options for POP and UI; however, these findings may not be generalizable given the heterogeneity and small size of this group. CONCLUSIONS: Significant racial disparities exist in women's baseline knowledge regarding risk factors and treatment options for POP and UI. Targeted, culturally sensitive educational interventions are essential to enhancing success in reducing the personal and economic burden of PFD, which have proven negative effects on women's quality of life.

Use of vanilloids in urologic disorders.

The bladder is an organ rich in vanilloid targets: dense unmyelinated c-fibers partially responsible for bladder sensation and response to noxious stimuli. Drugs such as capsaicin and resiniferatoxin (RTX) interact with the VR1 vanilloid receptor subtype to initially excite then subsequently desensitize the c-fibers. This chapter examines the literature describing the use of vanilloid receptor agonists in the treatment of the following urological disorders: neurogenic bladder (NGB), overactive bladder (OAB), and interstitial cystitis/painful bladder syndrome (IC/PBS). Review of the literature was performed using Pubmed and the following key words "capsaicin," "resiniferatoxin (RTX)," and "neurogenic bladder," "overactive bladder (OAB)," and "interstitial cystitis," "painful bladder syndrome." Articles focusing on randomized trials comparing intravesical administration of a vanilloid receptor agonist to placebo and those in English were reviewed. We conclude that capsaicin and RTX do appear to provide some acceptable treatment results in patients with neurogenic bladder, though larger studies are needed to confirm this. Although efficacy has been shown in some studies, currently the use of vanilloids cannot be recommended for routine use in patients with OAB as the need for catheterization may cause the risk to outweigh the benefit of treatment. Similarly, for the treatment of BPS, vanilloid receptor agonists lack strong evidence for efficacy or tolerability; larger studies are needed to define their role. Understanding how vanilloids are able to impact these disorders, however, may help further elucidate their underlying pathophysiological processes.

Knowledge of pelvic floor disorders in a population of community-dwelling women.

OBJECTIVE: The objective of the study was to investigate baseline knowledge and demographic factors associated with a lack of knowledge about urinary incontinence (UI) and pelvic organ prolapse (POP). STUDY DESIGN: This study was a community-based, cross-sectional survey of 431 racially and socioeconomically diverse women aged 19-98 years. The Prolapse and Incontinence Knowledge Questionnaire was used to assess participants' knowledge. Primary endpoints were the total number of correct responses on the UI and POP scales, respectively. Percentages of individuals answering each item or group of items correctly were explored as secondary outcomes. RESULTS: All women lacked knowledge proficiency about UI and POP, although knowledge about UI was slightly greater than knowledge about POP. Overall, 71.2% of subjects lacked UI proficiency (<80% correct), whereas 48.1% lacked proficiency in POP knowledge (<50% correct). Black women demonstrated significantly less knowledge about UI and POP than white women, both before and after adjustment for age, education, and household income. When combined into 1 group, Asian, Hispanic, and other women also showed significantly less UI and POP knowledge than white women. Most women who reported symptoms of UI had not received treatment for their problems. CONCLUSION: There is a global lack of knowledge about UI and POP among community-dwelling women, with more pronounced knowledge gaps among nonwhite women. UI and POP are chronic medical conditions that should be included in routine screening questions for well-woman care. Further studies are needed to explore how best to educate and improve women's awareness of these prevalent pelvic floor disorders.

Surgical site infection after hysterectomy.

OBJECTIVE: Our objective was to estimate the occurrence of surgical site infections (SSI) after hysterectomy and the associated risk factors. STUDY DESIGN: We conducted a cross-sectional analysis of the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze hysterectomies. Different routes of hysterectomy were compared. The primary outcome was to identify the occurrence of 30-day superficial SSI (cellulitis) after hysterectomy. Secondary outcomes were the occurrence of deep and organ-space SSI after hysterectomy. Logistic regression models were conducted to further explore the associations of risks factors with SSI after hysterectomy. RESULTS: A total of 13,822 women were included in our final analysis. The occurrence of postoperative cellulitis after hysterectomy was 1.6% (n = 221 women). Risk factors that were associated with cellulitis were route of hysterectomy with an adjusted odds ratio (AOR) of 3.74 (95% confidence interval [CI], 2.26-6.22) for laparotomy compared with the vaginal approach, operative time >75th percentile (AOR, 1.84; 95% CI, 1.40-2.44), American Society of Anesthesia class ≥ 3 (AOR, 1.79; 95% CI, 1.31-2.43), body mass index ≥40 kg/m(2) (AOR, 2.65; 95% CI, 1.85-3.80), and diabetes mellitus (AOR, 1.54; 95% CI, 1.06-2.24) The occurrence of deep and organ-space SSI was 1.1% (n = 154 women) after hysterectomy. CONCLUSION: Our finding of the decreased occurrence of superficial SSI after the vaginal approach for hysterectomy reaffirms the role for vaginal hysterectomy as the route of choice for hysterectomy.