Postoperative urinary retention after pelvic organ prolapse repair: Vaginal versus robotic transabdominal approach.

AIMS: Postoperative urinary retention has been reported in 13-32% of patients that undergo pelvic organ prolapse (POP) repair. The purpose of our study was to compare rates of urinary retention between transvaginal and robotic transabdominal approaches and identify risk factors for postoperative urinary retention following POP repair. METHODS: Medical records of patients that underwent POP repair were reviewed. Surgeries included transvaginal high uterosacral ligament suspension (HUSLS) and robotic-assisted sacral colpopexy (RASCP). All patients underwent a retrograde fill voiding trial (RGVT) postoperatively. Demographics, comorbidities, preoperative urodynamic findings, and surgical procedures were compared between women that passed their RGVT and those that did not. RESULTS: Out of 484 patients reviewed, 333 underwent POP repair with a transvaginal HUSLS and 151 underwent RASCP. Postoperative urinary retention was identified in 128 (26.4%) patients where 113 underwent transvaginal HUSLS and 15 underwent RASCP. The odds ratio (OR) of postoperative urinary retention following transvaginal HUSLS was 3.26 (CI 1.72-6.18; P < 0.001) compared to RASCP. Older age was also a risk factor for postoperative urinary retention (OR 1.03, CI 1.01-1.05; P = 0.012). While parity, preoperative post-void residual (PVR), and rates of concomitant transvaginal anterior/posterior repair were significantly higher in patients that developed postoperative urinary retention on univariate analysis, these factors did not demonstrate significance on multivariate analysis. CONCLUSIONS: Transvaginal HUSLS demonstrates a 3.26 OR for postoperative urinary retention compared to the robotic transabdominal approach. Older age is also a significant risk factor whereas parity, preoperative PVR, and rates of concomitant transvaginal anterior/posterior repair were not significant risk factors on multivariate analysis.

Indocyanine green for intraoperative localization of ureter.

Intraurethral injection of indocyanine green (ICG; Akorn, Lake Forest, IL) and visualization under near-infrared (NIR) light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Patients were scheduled to undergo robot-assisted laparoscopic sacrocolpopexy. Before the robotic surgery started, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10-mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The ICG reversibly stained the inside lining of the ureter by binding to proteins on urothelial layer. During the course of robotic surgery, the NIR laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used to excite ICG molecules, and infrared emission was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed its definitive identification throughout the entire case. In all cases of >10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness that depended on the depth of the ureter from the peritoneal surface. For example, in a morbidly obese patient, the ureters were not as bright green. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of ureter and allowed a safe approach to tissues that were adjacent to the urinary tract. The advantage of our technique is that it requires the insertion of just the tip of ureteral catheter. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous and intrabiliary ICG. Intraurethral injection of ICG and visualization under NIR light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery.

UVA-photoactivated riboflavin treatment of vaginal cells derived from pelvic organ prolapse cases.

BACKGROUND: The pathophysiology of pelvic organ prolapse (POP) involves vaginal collagen degradation. Strengthening collagen by UVA-photoactivated cross-linking has been demonstrated and suggested target applications include the vaginal wall. AIM: To identify UVA irradiation and riboflavin effects on vaginal cells. MATERIALS AND METHODS: Vaginal cells were incubated for 24 h (DMEM/F-12 Ham's media) and were exposed to riboflavin (0, 0.1 and 10%) for 30 min before UVA photoactivation. Percentages of live, apoptotic and necrotic cells were determined by propidium iodide/Hoechst 33342 stains. RESULTS: UVA decreased vaginal cell viability [mean ± standard error of the mean: 26.2 ± 0.5% vs. control (43.9 ± 3.8%)], but riboflavin blocked UVA-induced damage (57.9 ± 2.7 and 56.7 ± 2.1% at 0.1 and 10% riboflavin, respectively). Cells treated with low- and high-dose riboflavin had lower apoptosis (32.9 ± 1.0 and 35.5 ± 0.9%, respectively). Furthermore, riboflavin-treated cells had reduced necrosis (9.3 ± 1.7, 7.8 ± 3.0%) versus UVA-only (32.4 ± 5.5%) or control (17.1 ± 2.8%). Viability was similar for cells from the cervical and hymenal segments. CONCLUSION: The results demonstrated that riboflavin attenuated UVA damage in vaginal cells by inhibiting necrosis. Cervical and hymenal end vaginal cells were equally affected by UVA. UVA phototoxicity was reduced by the presence of riboflavin.

The relationship of intravenous dextrose administration during emergence from anesthesia to postoperative nausea and vomiting: a randomized controlled trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) may occur despite antiemetic prophylaxis and is associated with unanticipated hospital admission, financial impact, and patient dissatisfaction. Previous studies have shown variable impact of IV dextrose on PONV. We sought to determine the relationship of IV dextrose administered during emergence from anesthesia to PONV. METHODS: This was a prospective, double-blind randomized placebo-controlled trial. Adult female ASA physical status I and II nondiabetic patients scheduled for outpatient gynecologic, urologic, or breast surgery were randomly assigned to infusion of 250 mL lactated Ringer's solution (group P; n = 75) or dextrose 5% in lactated Ringer's solution (group D; n = 87) over 2 hours beginning with surgical closing. Blood glucose was determined using a point-of-care device before transfer to the operating room, in the operating room immediately before study fluid infusion, and in the recovery room after study fluid infusion. No antiemetics were given before arrival in the recovery room. PONV scores were recorded at 0, 30, 60, and 120 minutes and 24 hours after arrival in the recovery room. Medication administration was recorded. RESULTS: Data from 162 patients with normal baseline blood glucose were analyzed. There were no significant intergroup differences in demographics, history of PONV, or tobacco use. There was no significant intergroup difference in PONV during the first 2 hours after anesthesia (group D 52.9% vs group P 46.7%; difference, 6.2%; 95% confidence interval [CI], -9.2% to 21.6%; P = 0.43). Patients in groups D or P who developed PONV within 2 hours of anesthesia had similar number of severity scores ≥1 during recovery stay (1.5 vs 1.0; difference, 0; 95% CI, 0%-0%; P = 0.93); and similar proportions of: PONV onset within 30 minutes of recovery room arrival (65.2% vs 57.1%; difference, 8.1%; 95% CI, -13.1% to 28.8%; P = 0.46); more than 1 dose of antiemetic medication (56.5% vs 62.9%; difference, 6.3%; 95% CI, -26.9% to 15.1%; P= 0.65); or more than 1 class of antiemetic medication (50.0% vs 54.3%; difference, 4.3%; 95% CI, -25.5% to 17.4%; P = 0.82). CONCLUSIONS: The administration of dextrose during emergence from anesthesia was not associated with a difference in the incidence of PONV exceeding 20% or in the severity of PONV in the first 2 hours after anesthesia. The relationship between PONV and the optimal dose and timing of IV dextrose administration remains unclear and may warrant further study.

Lighted stents facilitate robotic-assisted laparoscopic ureterovaginal fistula repair.

Three cases of ureterovaginal fistula (UVF) repair were reviewed in order to improve the minimally invasive surgical technique. We successfully repaired UVF robotically using five ports by placing a lighted ureteral stent preoperatively to assist with ureter identification and dissection. Placement of a lacrimal duct probe allowed fistula tract identification and obliteration. Preoperative surgical team planning is useful to avoid errors and delays. A multispecialty and an experienced robotic surgical team were paramount for the success of our robotic repair.

What is hiding behind the pessary?

Vaginal pessaries are routinely used for initial management of pelvic organ prolapse and for women who are poor surgical candidates. Serious complications of long-term use without routine follow-up include erosion into surrounding organs and the development of fistulas. It is unclear however, if long-term use and chronic irritation could potentially contribute to development or delay the diagnosis of vaginal or cervical cancers. A 72-year-old Caucasian woman with a vaginal pessary retained for 3 years, who presented with leukocytosis and coagulopathy, was discovered to have stage II vaginal adenosquamous carcinoma upon surgical pessary removal. Chronic irritation and lack of follow-up with pessary use may contribute to masking the development and delaying the diagnosis of vaginal cancer in women with risk factors. Pessary use requires frequent follow-up to prevent complications.

Delayed presentation of complete ureteral obstruction deligated transvaginally.

Complete ureteral obstruction with delayed presentation is managed first by percutaneous nephrostomy and later with ureteral deligation, reimplantation, and stenting. Transvaginal deligation of complete obstruction after delayed presentation has not been described. We present two cases of ureteral ligation after pelvic reconstructive surgery. The first patient underwent high uterosacral ligament vaginal vault suspension then presented on postoperative day 22. The second patient underwent anterior colporrhaphy and presented on postoperative day 6. Both patients had flank pain, elevated creatinine, and signs of complete obstruction on CT scan. They both underwent transvaginal ureterolysis, retrograde stent placement, and later removal without any sequelae. Transvaginal ureterolysis of complete obstruction after delayed presentation is better tolerated and less morbid than traditional management.

Oxidative stress markers in patient-derived non-cancerous cervical tissues and cells.

High-risk human papillomaviruses (HPV) are the causative agents of cervical cancer. However, not all infected women develop cervical cancer. Cervical tumorigenesis is characterized by a multifactorial etiology, with oxidative stress (OS) likely playing a major role. In addition to exogenous sources, metabolic processes also contribute to OS. In principle, variability in levels of cervical OS has the potential to influence the likelihood of conversion to cervical cancer. To ask whether such variability indeed existed, we assessed the levels of ROS and the oxidative DNA damage biomarker 8-oxodG in normal non-cancerous cervical tissues and cells obtained from women with uterovaginal pelvic organ prolapse following vaginal hysterectomy. We demonstrated five and ten-fold variability between tissues isolated from the transformation zone (TZ) and ectocervix (EC) of different women, respectively. Despite the greater variability (likely due to differences in tissue composition), the overall pattern of ROS levels in EC tissues mirrored those obtained in their corresponding TZ tissues. Our results also show that the levels of ROS in TZ tissues were always higher than or equal to those found in the respective EC tissues, providing a possible explanation for TZ tissue being the primary target for HPV infection and cervical carcinogenesis. Interestingly, primary keratinocytes isolated and cultured from these cervical specimens also displayed high variability in ROS levels, with some strongly mirroring the levels of ROS observed in their corresponding tissues, while others were less closely associated. Finally, we demonstrated that the levels of DNA damage mirrored the levels of ROS in the cultured primary cells. Understanding the factors and mechanisms that dispose certain individuals to develop cervical cancer has the potential to enable the development of approaches that make the conversion of HPV infection to cancer development even more rare.

What Is the Best Lens Angle for Rigid Diagnostic Cystoscopy? A Comparison of 30-Degree and 70-Degree Lenses.

The optimal degree of cystoscope to perform diagnostic cystoscopy is dependent on the surgeon's discretion because there are no studies addressing the superiority of one degree of cystoscope over another. The objective was to determine which lens, 70-degree versus 30-degree lens, was better in identifying lesions scattered throughout the bladder. METHODS: A simulation was created using 3 different artificial bladder models complete with sutures representing lesions placed at different locations in each bladder. Gynecologists and urologists performed cystoscopy using both the 30- and 70-degree lenses on the bladder models in a randomized and single-blinded fashion. The physicians performed routine diagnostic cystoscopy and noted the number of lesions throughout the bladder. The number of lesions each physician identified and the time to complete cystoscopy were noted. A total of 16 physicians participated, and there were a total of 18 lesions among the 3 different bladder models. RESULTS: A total of 86 cystoscopy trials were obtained from all physicians and bladder models attempted. The odds of detecting a lesion with the 70-degree lens cystoscope was 1.77 times greater than the 30-degree lens cystoscope (95% confidence interval, 1.24-2.53; P = 0.002). There was also difference in the average number of lesions found between the 30- and 70-degree cystoscopes with 2.6 ± 2.7 more lesions identified using the 70-degree cystoscope compared with the 30-degree cystoscope. In terms of specific location, 2.6 ± 1.7 more lesions were found at the bladder neck using the 70-degree lens scope versus the 30-degree lens scope (95% confidence interval, 1.37-3.83; P = 0.013). CONCLUSIONS: The results suggested that the 70-degree lens was the better choice for the identification of bladder lesions when compared with the 30-degree lens in rigid diagnostic cystoscopy.

Intravesical electrical stimulation treatment for overactive bladder: An observational study.

Purpose: Intravesical electrical stimulation treatment (IVES) has been successfully used to treat neurogenic bladder. We report the results of an observational study regarding the use of IVES for women with overactive bladder syndrome (OAB) and/or urgency urinary incontinence (UUI). Materials and Methods: IVES was performed in women with OAB (defined by frequency ≥8/day, nocturia ≥2/night, or ≥3 episodes of UUI on 3-day voiding diary) who failed prior medical therapy. Subjects underwent 4 weeks of treatment with an 8-Fr Detruset™ IVES catheter. Primary outcome was Patient Global Impression of Improvement (PGI-I) at 3 months. Secondary outcomes included Visual Analog Scale (VAS), Short Form OAB Questionnaire (OAB-q SF), Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), reduction in frequency and UUI on voiding diary, and adverse effects. Analysis was done with paired t-tests and Wilcoxon signed rank tests. Results: Seventeen subjects completed the study. At 4 weeks post-treatment, 15 improved on PGI-I (11 subjects: 'a little better', 2: 'much better', 2: 'very much better'). There were significant improvements in symptom bother and health-related quality of life as measured by OAB-q SF and pelvic organ prolapse and urinary distress as measured by PFDI. Frequency decreased from 10.3±4.3 at baseline to 8.9±2.3 (p=0.04) at 3 months. No pain was reported during treatment. There was one urinary tract infection during the study period. No other adverse events were reported. Conclusions: IVES appears to be a safe and effective novel treatment for OAB. Larger comparative studies are needed to investigate its potential for long-term treatment.

Effects of an educational workshop on performance of fourth-degree perineal laceration repair.

OBJECTIVE: To develop a valid and reliable tool to objectively measure surgical skill necessary for repair of fourth-degree perineal lacerations and then to use this tool to measure improvement after a workshop. METHODS: We measured baseline surgical ability and clinical knowledge of 26 residents (postgraduate year [PGY]-1 to PGY-4) using the Objective Structured Assessment of Technical Skills (OSATS) and a written examination. The OSATS consists of a global surgical skills assessment (OSATS-G), a procedure checklist (OSAT-C), and pass/fail grade. Five weeks after our baseline evaluation, a 1.5-hour workshop was administered to approximately half of the 26 residents (n=14). One week after this intervention, the residents were re-examined using the same assessment tools. RESULTS: The OSATS demonstrated construct validity as scores on the examination increased on both the OSATS-G and the OSATS-C from PGY-1 through PGY-4 (P=.001 and P=.041, respectively). Reliability indices for the OSATS were high. Eighty-one percent of the residents failed the OSATS before intervention because of failure to identify and repair the internal anal sphincter. After educational intervention, senior residents improved on all assessments (OSATS-G, P=.041; OSATS-C, P=.004; written examination, P=.008), and all residents passed the OSATS. CONCLUSION: A valid and reliable OSATS and written examination were developed to assess surgical skills, knowledge, and judgment necessary to properly manage fourth-degree perineal lacerations. Residents improved on the OSATS and the written examination after undergoing a structured educational workshop. LEVEL OF EVIDENCE: II.

Sexual function following anal sphincteroplasty for fecal incontinence.

OBJECTIVE: The objective of the study was to assess sexual function following anal sphincteroplasty and determine associations between sexual function and fecal incontinence. STUDY DESIGN: Women 1 year or longer following anal sphincteroplasty with or without other reconstructive surgery were matched to controls. Subjects were mailed the Female Sexual Function Index (FSFI), Fecal Incontinence Quality of Life (FIQOL), Fecal Incontinence Severity Index (FISI), and a general questionnaire. RESULTS: Twenty-six cases and 26 controls responded; 73% were sexually active. Sexual function scores were similar between the groups. Seventeen sphincteroplasty patients and 8 controls complained of fecal incontinence at follow up. Significant correlations were found between FSFI domains and the FIQOL depression/self-perception scale, FISI fecal incontinence of solid stool, and total FISI. CONCLUSION: Sexual activity and function was similar following anal sphincteroplasty, compared with controls, despite worse symptoms of fecal incontinence. Fecal incontinence of solid stool and depression related to fecal incontinence were correlated with poorer sexual function.

Sexual function after vaginal surgery for pelvic organ prolapse and urinary incontinence.

OBJECTIVE: The objective of the study was to assess sexual function following vaginal surgery and to determine the impact on postoperative sexual function in women who undergo concurrent antiincontinence procedures, compared with those who do not. STUDY DESIGN: Sexually active women undergoing vaginal repairs for prolapse or urinary incontinence were prospectively enrolled. Subjects completed the Female Sexual Function Index (FSFI), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and a standardized questionnaire. Follow-up occurred at 6 months. RESULTS: Forty-nine subjects (96%) returned their postoperative surveys; 48 were sexually active. Improvements were noted in postoperative prolapse stage, UDI-6, and IIQ-7. However, sexual function and frequency were similar. The most bothersome barrier to sexual activity before repair was vaginal bulging; postoperatively it was vaginal pain. Twelve subjects (25%) commented on the negative impact of vaginal pain postoperatively. Finally, FSFI scores were not different based on performance of antiincontinence surgery. CONCLUSION: Sexual function was unchanged following vaginal reconstructive surgery despite anatomic and functional improvements; lack of benefit may be attributable to postoperative dyspareunia.

Male age and sperm necrosis in assisted reproductive technologies.

INTRODUCTION: Sperm apoptosis is well characterized but studies on the effect of male age and necrozoospermia are lacking. The objectives were: (a) to analyze percentages of apoptotic and necrotic sperm in ejaculates, and (b) to compare the results between younger and older age groups. MATERIALS AND METHODS: Routine semen analyses were carried out (n = 189 males) and sperm cells were analyzed by dual fluorescence assay Hoechst 33342 and propidium iodide, and the acridine orange test. RESULTS: The percentage of necrotic sperm in the ejaculate increased by 22% for males aged over 35. There was a positive correlation between age and necrosis (R = 0.30). Sperm apoptosis increased by 17% in males aged 45 and older. The population of DNA intact sperm declined in males aged 40 and over (R = -0.21). There were no age-related changes in strict normal morphology, sperm concentration and semen volume. A decrease in rapid progressive motility was correlated (R = -0.24) with male age and was significant after age 35. CONCLUSIONS: The study demonstrated increased necrosis, DNA damage and apoptosis while rapid progression and total motility declined with advancing age in the male beginning as early as age 35. The order of the observed changes was sequential, suggesting the involvement of different pathways in sperm necrosis after age 40.

Perioperative serum creatinine changes and ureteral injury.

PURPOSE: To illustrate a simple method that screens for ureteral injury in the acute postoperative period after urogynecologic surgeries. METHODS: Serum creatinine measurements in the preoperative (baseline) and postoperative periods of urogynecologic surgeries were determined and the correlation of the change to ureteral injury and/or obstruction analyzed. The sample size calculation showed 7 cases and 28 controls were sufficient to detect significant changes in creatinine. Each of the seven cases was matched for age and type of surgery with a control patient in a 1:4 ratio following standard protocol. RESULTS: Chart review of patients (273 cases) undergoing urogynecologic surgeries from October 2009 to June 2014 were undertaken. There were 7 cases of ureteral injury and 28 matching control cases. All cases had intraoperative cystoscopy confirming bilateral ureteral flow. In the ureteral injury group, blockage of ureter was confirmed by CT scan with IV contrast. There was a 59.8% increase in serum creatinine levels postoperative in the ureteral injury group versus a 3.8% decrease in controls. A difference of creatinine levels greater than or equal to 0.3 mg/dL over baseline was evident in ureteral injury cases. CONCLUSION: A small change in serum creatinine level over baseline after urogynecologic surgery alerted the possibility of ureteral injury or obstruction. A simple and inexpensive evaluation of perioperative creatinine levels can promptly diagnose ureteral damage in the acute postoperative period for gynecologic reconstructive surgeries.

The Location and Distribution of Transurethral Bulking Agent: 3-Dimensional Ultrasound Study.

OBJECTIVES: To use 3-dimensional endovaginal ultrasound to describe the location and distribution of bulking agent after an uncomplicated transurethral injection. METHODS: Endovaginal ultrasound was performed in 24 treatment-naive patients immediately after bulking agent was injected. The distance between the center of the hyperechoic density of bulking agent and the urethrovesical junction (UVJ) was measured in the sagittal and axial views. This was calculated in percentile length of urethra. Also, the pattern of tracking of bulking agent was assessed if it is presented. RESULTS: After the 2 subjects were excluded because of the poor quality of images, 22 patients were included in this study. Eighteen (82%) subjects showed 2 sites of bulking agents, and mostly, they were located around 3- and 9-o'clock positions. The average distance of bulking agent from left UVJ was at 16.9% of the length of the urethra (6.2 mm; range, 0.5-17 mm) and at 25.5% of the length of the urethra (8.9 mm; range, 0-24.8 mm) in the right side. The average length of urethra was 36.7 mm. Eleven of the 22 subjects (50%) had both sides within upper one third of urethra. The difference in distance between the 2 sides was less than 10 mm in 12 of 22 patients (54%). Nine of the 22 patients (41%) had a significant spread of bulking agent mostly either into the bladder neck or toward the distal urethra. CONCLUSIONS: Although the bulking agent is most often found at 3- and 9-o'clock positions as intended, the distance from the UVJ is highly variable after an uncomplicated office-based transurethral injection. The bulking material does not form the characteristic spheres in 41% of cases and tracks toward the bladder neck or the distal urethra.

Unsuccessful foley catheterization had an unexpected explanation.

BACKGROUND: Foley catheterization is a simple procedure routinely performed during many obstetric and gynecologic procedures. Failure to adequately drain the bladder with catheter insertion should prompt further investigation to minimize morbidity to the patient. CASE: After repeated attempts to place a Foley catheter during a cesarean section, the urinary bladder did not drain. Postoperatively, it was found that the catheter was positioned inside the left ureter, and cystoscopy confirmed an ectopic ureter inserting into the proximal urethra. CONCLUSIONS: This case presents an unusual cause of oliguria in an operative patient requiring Foley catheterization. An ectopic ureteral orifice should be considered in the differential diagnosis of a patient presenting with unexplained oliguria or anuria and failure to decompress the bladder with catheter placement.

UVA-photoactivated riboflavin effect on isolated vaginal tissues derived from pelvic organ prolapse cases.

PURPOSE: To determine the optimal riboflavin exposure time before UVA irradiation and to study the effects of exogenous collagen on the mechano-tensile stiffness of isolated vaginal tissue strips after riboflavin UVA photoactivation. METHODS: Vaginal tissue strips from pelvic organ prolapse (POP) cases were soaked in 0.1% riboflavin (0, 10, 20, 30 min), exposed to UVA photoactivation, and tensile stiffness was measured with a tensiometer. Collagen solution was injected (0.2 mL) into each strip, exposed to riboflavin with or without UVA photoactivation, and tensile stiffness was measured (n=6). RESULTS: Vaginal tissues treated with riboflavin for 10, 20 or 30 min followed by UVA irradiation displayed 21.2, 32.4 and 33.9% stronger tensile stiffness, respectively. Exogenous collagen administered before riboflavin UVA photoactivation resulted in 20% improvement in tensile stiffness. The tensile stiffness of vaginal tissues injected with collagen without the riboflavin UVA treatment was similar to control tissues. CONCLUSION: The results demonstrated increased tensile stiffness in isolated POP-derived vaginal tissues after riboflavin UVA photoactivation suggesting improved mechanical properties from collagen cross-linking. Administering exogenous collagen before riboflavin UVA treatment also improved tensile stiffness. More studies are needed to corroborate the present minimally invasive approach for strengthening vaginal tissues.

Perceptions and practice patterns of general gynecologists regarding urogynecology and pelvic reconstructive surgery.

OBJECTIVES: The purpose of this study was to describe the current practice patterns of general gynecologists regarding management of various urogynecologic conditions. METHODS: A 15-item Web-based survey was sent to obstetrician and gynecologists in 2011. Subjects who chose to participate answered questions about their comfort level with management of various urogynecologic conditions, their perceptions of the need for a pelvic reconstructive surgeon in their community, and when they feel it is appropriate to refer to a specialist. RESULTS: Two hundred ninety-four obstetrics/gynecology generalists responded to the survey with overall 33% response rate. There was a wide range of comfort level depending on the complexity of the condition. Most of the subjects felt comfortable in the management of stress and urge incontinence, cystocele, rectocele, and uterine prolapse. On the other hand, most of the subjects were uncomfortable with management of intrinsic sphincter deficiency, fecal incontinence, recurrent incontinence after failed surgery, and complications of vaginal mesh surgery. In addition, there was wide variation in types of surgical options offered by different practitioners. When we compared the results by age, younger gynecologists have a smaller repertoire of procedures they offer for treatment of urogynecologic conditions. Burch colposuspension, uterosacral ligament suspension, and colpocleisis were performed more often by older surgeons than younger surgeons. On the other hand, cystoscopy was performed more commonly by the younger group. CONCLUSIONS: Among general gynecologists, there is a wide range in both comfort level for management of different urogynecologic conditions and types of urogynecologic services performed.

Attitudes and perceptions regarding subspecialty training in female pelvic medicine and reconstructive surgery.

The objective of the study was to evaluate perceptions regarding subspecialty training in female pelvic medicine and reconstructive surgery (FPMRS) in the United States. A 57-item questionnaire was anonymously mailed to fellows and applicants to FPMRS fellowship. Seventy-four American fellowship interviewees and current fellows completed the entire questionnaire (56% response rate). Key factors associated with higher interest in FPMRS compared to general obstetrics and gynecology (OBG) included competitiveness to get into fellowship and new developments. Key factors associated with higher interest in FPMRS compared to other subspecialties in obstetrics and gynecology (SUB) were lower risk of malpractice and higher sense of career satisfaction. Commonly cited attributes of FPMRS that attract to the field relate to the complexity of cases and the quantity of time spent in the operating room. Majority of responders preferred academics over private practice or a mixture (55.4%, 17.6%, and 27%, respectively). The most important reason for interest in FPMRS compared to OBG and SUB is quality time in the operating room and lower risk of malpractice, respectively. Results of this study may help attract medical students to OBG and help mentors with career counseling.