Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score.

INTRODUCTION AND HYPOTHESIS: We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model. METHODS: We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic. RESULTS: For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all). CONCLUSIONS: A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Procedure-specific simulation for vaginal surgery training: A randomized controlled trial.

INTRODUCTION: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS: gov: Registration no. NCT05887570. RESULTS: We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS: Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study.

INTRODUCTION AND HYPOTHESIS: Severe perineal tears can predict bothersome pelvic floor disorders later in life. We have a poor understanding of pelvic floor changes during the third trimester and the first few postpartum months. We aimed to compare women with severe perineal trauma during childbirth with women who experienced minimal trauma, for condition-specific quality of life, sexual function, mental health and overall quality of life in the first 6 months postpartum. METHODS: We recruited primiparous women with third- or fourth-degree tears (obstetric anal sphincter injuries, OASIS) and age-matched controls with no tears or first-degree tears in the immediate postpartum period. Participants completed validated questionnaires at baseline, 2, 4 and 6 months postpartum. Mixed effects linear regression or quantile regression adjusted for baseline score were used to compare the groups as appropriate. RESULTS: A total of 74 women completed at least one questionnaire (35 OASIS, 39 controls). Both groups had similar demographics. Women with OASIS tended to have worse Pelvic Floor Distress Index-40 scores at month 2; median scores were similar in the two groups by month 6. They also had significantly lower Female Sexual Function Index scores (mean difference: -6.1; 95% CI: -11.9, -0.2, p=0.043) at month 2. There were no mental health group differences and quality of life improved over time, mainly in the OASIS group. Six-month participant attrition rate was 52%. CONCLUSIONS: Women with OASIS encounter specific pelvic floor challenges during the first 6 months postpartum. Although our recruitment rate was high, the attrition rate was also high, demonstrating challenges with retention of postpartum women into longitudinal research.

Pelvic Floor Health Index: Initial validation of a practical postpartum tool for busy clinicians.

OBJECTIVE: To design a primary care clinical tool (Pelvic Floor Health Index [PFHI]) to screen for postpartum pelvic floor disorders, as well as complete its psychometric validation. DESIGN: Prospective cohort study. SETTING: Two tertiary care obstetric centres in Vancouver, BC. PARTICIPANTS: Primiparous women older than 19 years of age who were in the immediate postpartum period. MAIN OUTCOME MEASURES: The PFHI was administered to 74 primiparous women immediately postpartum and at 2, 4, and 6 months postpartum. For evaluation of convergent and divergent construct validity, participants also completed several validated questionnaires, including the Female Sexual Functioning Index, the Pelvic Floor Distress Inventory, the 36-Item Short Form Health Survey, and the Edinburgh Postnatal Depression Scale. Fifteen women repeated their 6-month questionnaires 2 weeks later in order to determine test-retest reliability. Responsiveness was assessed by measuring the PFHI score change from baseline to 6 months postpartum. RESULTS: Pelvic Floor Health Index score was inversely correlated with subscale scores on the Pelvic Floor Distress Inventory at all time points. There were moderate correlations between PFHI score and the Female Sexual Functioning Index and 36-Item Short Form Health Survey scores at several time points. There were weak correlations with postpartum depression scores. The intraclass correlation coefficient for test-retest reliability was 0.78 (95% CI 0.47 to 0.92). The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum. CONCLUSION: The PFHI is a 10-item, newly validated, and psychometrically robust questionnaire that can be administered to patients in the postpartum period to screen for pelvic floor dysfunction.

Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model.

AIMS: Postoperative urinary retention (POUR) is a common complication of urogynecological surgery. Our study aimed to identify demographic and perioperative risk factors to construct a prediction model for POUR in urogynecology. METHODS: Our retrospective cohort study reviewed all patients undergoing pelvic reconstructive surgeries at our tertiary care center (Jan 1, 2013-May 1, 2019). Demographic, pre-, intra- and postoperative variables were collected from medical records. The primary outcome, POUR, was defined as (1) early POUR (E-POUR), failing initial trial of void or; (2) late POUR (L-POUR), requiring an indwelling catheter or intermittent catheterization on discharge. Risk factors were identified through univariate and multivariate logistic regression analyses. A clinical prediction model was constructed with the most significant and clinically relevant risk factors. RESULTS: In 501 women, 182 (36.3%) had E-POUR and 61 of these women (12.2% of the entire cohort) had L-POUR. Multivariate logistic regression revealed preoperative postvoid residual (PVR) over 200 ml (odds ratio [OR]: 3.17; p = 0.026), voiding dysfunction symptoms extracted from validated questionnaires (OR: 3.00; p = 0.030), and number of concomitant procedures (OR: 1.30 per procedure; p = 0.021) as significant predictors of E-POUR; preoperative PVR more than 200 ml (OR: 4.07; p = 0.011) and antiincontinence procedure with (OR: 3.34; p = 0.023) and without (OR: 2.64; p = 0.019) concomitant prolapse repair as significant predictors of L-POUR. A prediction model (area under the curve: 0.70) was developed for E-POUR. CONCLUSIONS: Elevated preoperative PVR is the most significant risk factor for POUR. Alongside other risk factors, our prediction model for POUR can be used for patient counseling and surgical planning in urogynecologic surgery.

Documenting Perineal and Obstetrical Anal Sphincter Injury Care at Childbirth: A Cross-Sectional Study.

OBJECTIVE: This study evaluates whether maternity care providers document guideline-based recommendations for the prevention and care of obstetrical anal sphincter injuries (OASIS) for their labour and delivery patients. METHODS: We performed a cross-sectional study, aiming for a convenience sample of 60 primiparous women, over 19 years of age, equally representative of patients who experienced severe (third- and fourth-degree) and minimal (intact or first-degree) tears during vaginal birth. Information on patient demographics, delivery details, and guideline-endorsed preventative and management measures were collected. Descriptive statistics were used when appropriate. RESULTS: We enrolled a total of 73 women, 34 of whom had severe tears and 39 of whom had minimal tears. Preventative measures, including fetal head control and perineal support during delivery, were documented for 1 out of 73 patients. The use of perineal massage and warm compress to the perineum was not documented. A rectal exam after delivery was documented for 30% (22/73) of all patients and 62% (21/34) of patients with OASIS. Sixty-five percent (22/34) of patients with OASIS received intravenous antibiotics, 88% (30/34) received laxatives, and 100% received nonsteroidal anti-inflammatory drugs. Post-void residual was not documented for any patients. Patients recalled being informed about their OASIS in 68% (23/34) of cases and being referred to pelvic physiotherapy in 47% (16/34) of cases. CONCLUSION: In our study, perineal care practices during and after childbirth, as detailed in the national OASIS guideline, were incompletely documented. This may indicate partial guideline adherence or suboptimal medical record-keeping.

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.

Fibroid Surgery and Long-Term Improvement in Bladder Symptoms.

OBJECTIVE: Short-term studies have demonstrated improvement in urinary symptoms after fibroid debulking surgery, yet long-term data are lacking. This study assessed the long-term impact of fibroid debulking on urinary symptoms several years postoperatively. METHODS: This case series prospectively investigated changes in urinary symptoms of women who underwent fibroid debulking surgery by several gynaecological surgeons at one centre (2011-2016). A follow-up demographics questionnaire and the Urinary Distress Inventory (UDI) were administered. Changes in total UDI scores and UDI subscale scores from preoperative baseline to long-term follow-up were calculated. RESULTS: Thirty participants were recruited from the original cohort of 61 women (49% long-term follow-up). There were significant improvements in total UDI scores (P < 0.001), obstructive subscale score (P < 0.001), and irritative subscale score (P < 0.001) 2-7 years postoperatively. Stress subscale scores were not significantly improved even in a subgroup of patients with significant baseline bother (P = 0.101). Six of eight women (75%) were cured of bothersome urge urinary incontinence, and three of eight women (37.5%) were cured of bothersome stress urinary incontinence. Baseline fibroid characteristics or type of surgery did not significantly influence outcomes. There were no significant demographic differences between women with sustained improvements and women with no improvement or worsening symptoms. The results are considered Level III evidence as per the Canadian Task Force on Preventive Health Care Levels of Evidence. CONCLUSION: Surgical fibroid removal produces long-term improvement in most bladder symptoms except for stress-related symptoms that persist over time. Women with bothersome urinary symptoms should be investigated for fibroids and counselled on potential long-term benefits of debulking surgery.

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.

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.

Fibroid surgery and improvement in bladder symptoms: The FAB study.

AIMS: Uterine fibroids are the most common tumor of the female reproductive tract [Baird et al Am J Obstet Gynecol. 188:100-107, 2003] and bladder symptoms are more prevalent in these women [Pron et al Fertil Steril. 79:112-119, 2003; Volkers et al Am J Obstet Gynecol. 196:519.e1-e11, 2007] However, the effect of various fibroid debulking surgeries on different types of urinary incontinence symptoms is poorly understood. Our primary objective was to determine whether surgical debulking of uterine fibroids affects urinary symptoms. Secondary objectives were: to define the baseline prevalence of bladder symptoms in women undergoing fibroid surgery; to explore links between fibroid characteristics, size of debulked fibroids, type of surgery, and postoperative changes in bladder function. MATERIALS AND METHODS: Prospective cohort study (2011-2016) of women undergoing vaginal or abdominal myomectomy or hysterectomy. Baseline demographics were obtained. All women underwent a detailed pelvic ultrasound preoperatively. The Urinary Distress Inventory (UDI) questionnaire of the validated Pelvic Floor Distress Inventory (PFDI) was administered before and 6 weeks after surgery. Score changes were assessed using Wilcoxon signed rank test. RESULTS: Sixty-one women completed the study. At baseline, regardless of fibroid characteristics, 96.6% of women had various bothersome urinary symptoms including storage, voiding, and incontinence. Following surgical fibroid debulking, median improvement in the UDI total score was clinically and statistically significant at 39.9 (P < 0.001). All urinary subscale scores were also significantly improved. 11/17 women (64.7%) and 11/18 women (61.1%) were cured of moderately to severely bothersome symptoms of urge and stress urinary incontinence respectively. CONCLUSIONS: Urinary symptoms are common in women undergoing surgery for uterine fibroids. Fibroid debulking may be offered as treatment for bladder symptoms in symptomatic women.

Pregnancy-Associated Pelvic Floor Health Knowledge and Reduction of Symptoms: The PREPARED Randomized Controlled Trial.

OBJECTIVES: Pregnancy and childbirth can lead to pelvic floor disorders, yet this topic is not routine in antenatal education. We aimed to determine the impact of a pregnancy workshop on women's postpartum pelvic floor health knowledge, performance of pelvic floor muscle exercises (PFME), symptoms, condition-specific quality of life, mode of delivery, and satisfaction. METHODS: This was a RCT. Pregnant primiparous women in a tertiary care centre received a pelvic floor health workshop intervention versus routine prenatal care. Thirty-six participants/group were needed to detect a significant knowledge difference (power = 0.80, α = 0.05). Participants completed questionnaires at recruitment and six weeks postpartum. Main outcome measures were: difference between groups in knowledge scores; PFME-specific knowledge and practice; pelvic symptoms and condition-specific quality of life; and mode of and satisfaction with delivery. RESULTS: Fifty women were recruited per group; 40 attended the workshop. Women were Caucasian (72%), college educated (96%), mean age 33.2. Mean demographics did not differ. Postpartum data were available for 37 women per group. The intervention group scored higher on a pelvic floor knowledge questionnaire (mean score 31.2/39 vs. 29.3/39, P = 0.02, 95% CI 0.3, 3.6). 58.3% of intervention participants reported daily performance of PFME compared with 22.9% of controls (P = 0.002) and rated higher confidence in correct performance (P = 0.004). The intervention group reported fewer bowel symptoms (P = 0.046). There were no differences in urinary or prolapse symptoms, mode of delivery, complications, or satisfaction. CONCLUSION: A pelvic floor health workshop improves postpartum knowledge, performance of PFME, and bowel-specific quality of life.

Is Pelvic Floor Dysfunction an Independent Threat to Sexual Function? A Cross-Sectional Study in Women With Pelvic Floor Dysfunction.

INTRODUCTION: Prior studies have reported an association of sexual dysfunction with pelvic floor dysfunction (PFD), but without defining causation. AIM: To investigate predictors of sexual function in women with PFD, including pelvic organ prolapse, stress urinary incontinence, overactive bladder, obstructed defecation, and fecal incontinence. METHODS: This retrospective cross-sectional study included 755 women (mean age = 56 years, 68% postmenopausal) referred for PFD (2008-2013). Subjects underwent standardized history and examination, including demographics and assessment of pelvic floor function and sexual function using validated quality-of-life instruments. The physical examination included body mass index, Pelvic Organ Prolapse Quantification measurements, and pelvic muscle strength (Oxford scale). Proportional odds regression analysis tested patient characteristics, PFD, and other determinants of sexual dysfunction as predictors of sexual function. MAIN OUTCOME MEASURES: The Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) to assess PFD and the Short Personal Experiences Questionnaire to assess sexual function. RESULTS: The prevalence of PFD included pelvic organ prolapse (72%), stress urinary incontinence (66%), overactive bladder (78%), fecal incontinence (41%), and obstructed defecation (70%). Most subjects (74%) had a sexual partner and most (56%) reported recent sexual intercourse. Participants reported a low level of sexual desire and sexual enjoyment and moderate levels of sexual arousal and orgasm. When stratified by sexual enjoyment, 46% enjoyed sex and this group had lower PFDI and PFIQ scores, reflecting less quality-of-life burden. Pelvic organ prolapse, obstructed defecation, and fecal incontinence were associated with not enjoying sex. However, when adjusted for other determinants of sexual dysfunction (eg, aging, dyspareunia, atrophy, and partner issues), these associations disappeared. CONCLUSION: Women with PFD also have a large burden of sexual dysfunction, although this appears to be mediated by factors not unique to PFD.

Observational Study of Neonatal Safety for Outpatient Labour Induction Priming with Dinoprostone Vaginal Insert.

OBJECTIVES: To evaluate the safety of outpatient induction with dinoprostone insert in low-risk labour inductions for premature rupture of membranes or postdates gestation. METHODS: This retrospective cohort study compared outpatient labour induction priming with inpatient induction in terms of neonatal safety, mode of delivery, and obstetrical parameters. The sample included all inductions for premature rupture of membranes or postdate gestation. The analysis used logistic regression. The statistical power of the sample was 80% to detect a difference of 5.6% for the composite neonatal safety outcome (5-minute Apgar score <7 and NICU admission for >12 hours or transfer to a level III nursery). RESULTS: Compared with the inpatient cohort (n = 568), the outpatient cohort (n = 611) included more postdate gestations (93% vs. 67%) with less cervical dilatation (0.5 cm vs. 1.0 cm) and larger infants (3705 g vs. 3551 g). There were no differences in measures of neonatal safety or mode of delivery. The outpatient cohort required more dinoprostone inserts (1.59 vs. 1.23) and were less likely to deliver within 24 hours (OR 0.24, 95% CI 0.17 to 0.34) but were also less likely to deliver by CS (OR 0.71, 95% CI 0.54 to 0.95), after adjusting for obstetrical parameters. CONCLUSION: An outpatient model of labour induction using dinoprostone inserts is feasible and safe.

Mid-urethral slings on YouTube: quality information on the internet?

INTRODUCTION AND HYPOTHESIS: Scant literature exists about the quality of urogynecological content on social media. Our objective was to measure the accuracy and comprehensiveness of YouTube videos related to mid-urethral sling (MUS) procedures. METHODS: YouTube was searched using the terms "mid-urethral sling," "vaginal tape," "TVT," "TOT," "TVT surgery," and "TOT surgery." Duplicates and videos with less than 1,000 views were excluded. We developed a standardized questionnaire for this project, assessing each video's target audience, main purpose, relevance, informed consent elements, surgical steps, and bias. The primary outcome was the presence of all elements of informed consent. Inter-rater reliability (IRR) was calculated using the Fleiss' kappa statistic. Descriptive statistics were also obtained. RESULTS: Five reviewers each rated 56 videos. Mean IRR was moderate (Fleiss' kappa 0.58 ± 0.24). Video content was classified as physician educational material (67.9 %), patient information (16.1 %), advertisement (10.7 %), lawsuit recruitment (1.8 %), and unclear (3.6 %). MUS was the primary topic for 82.1 % of the videos. The remainder discussed other types of anti-incontinence procedures or prolapse surgery. None of the videos mentioned all four elements of informed consent. Of 32 videos demonstrating surgical technique, none showed the complete list of pre-determined surgical steps. The mean number of listed steps was 7.6/16. Only four videos mentioned at least one post-operative patient instruction. A marketing element was shown in 26.8 % of videos. CONCLUSIONS: Patient information about MUS on YouTube is lacking and often biased. Physicians and students viewing YouTube videos for educational purposes should be cognizant of the variability in the surgical steps demonstrated.

Study of Prolapse-Induced Cervical Elongation.

OBJECTIVE: The cervix often appears to be elongated in women with pelvic organ prolapse (POP). This can pose surgical challenges. MRI evidence has suggested that prolapsed cervices are significantly longer than those in normal controls. Our objective was to compare cervical length in surgical hysterectomy specimens from women with symptomatic POP with the length in specimens from women with other benign gynaecological conditions. METHODS: In this pilot, prospective, case-control study, hysterectomy specimens were collected at St. Paul's Hospital, Vancouver, BC, between 2013 and 2015. Recorded patient demographics were age at the time of hysterectomy, any prior history of cervical dysplasia, and reason for hysterectomy. Specimens from women in whom the indication for hysterectomy was POP were compared with the specimens from women with other benign gynaecological conditions. Specimens were excluded if there was a history of cervical dysplasia because we could not verify whether women had undergone previous procedures resulting in cervical shortening. After bivalving each uterus, cervical and total uterine lengths were measured by staff pathologists, and the ratios of cervical length to total uterine length were calculated. Measurements in the two hysterectomy groups were compared using linear regression. RESULTS: Seventy-seven specimens were collected, 52 from women with POP and 25 from women without POP. The most common indication for hysterectomy in women without POP was uterine fibroids. Women with POP were on average older than women without POP (mean 58.5 years vs. 47.8 years, P < 0.001). The ratio of cervical length to total uterine length in women with POP was 0.10 higher (95% CI 0.03, 0.16; P = 0.005) than in women without POP. CONCLUSION: Women with symptomatic POP have significantly higher ratios of cervical length to total uterine length than women without POP.

Validation of a New Heart Rate Measurement Algorithm for Fingertip Recording of Video Signals with Smartphones.

INTRODUCTION: This study investigates the accuracy of a heart rate (HR) measurement algorithm applied to a pulse wave. This was based on video signals recorded with a smartphone. The results of electrocardiographic HR and standard linear heart rate variability (HRV) analysis were used for reference. MATERIALS AND METHODS: On a total of 68 subjects, an electrocardiogram (ECG) and the pulse curve were simultaneously recorded on an Apple iPhone 4S. The HR was measured using an algorithm developed by the authors that works according to a method combining the detection of the steepest slope of every pulse wave with the correlation to an optimized pulse wave pattern. RESULTS: The results of the HR measured by pulse curves were extremely consistent (R > 0.99) with the HR measured on ECGs. For most standard linear HRV parameters as well, high correlations of R ≥ 0.90 in the analysis were achieved in the time and frequency domain. CONCLUSION: In conclusion, the overall accuracy of HR and HRV indices of pulse wave analysis, based on video signals of a smartphone, with the developed algorithm was sufficient for preclinical screening applications.

Bilateral sacrospinous vault fixation with tailored synthetic mesh arms: clinical outcomes at one year.

OBJECTIVES: Bilateral sacrospinous fixation with tailored mesh arms (bSSVF) uses polypropylene mesh to suspend the vault to the sacrospinous ligaments bilaterally with minimal tension, recreating nulliparous midline anatomy. It can be used with uterine conservation. Our primary objective was to determine objective cure rate at one year following bSSVF compared with a control group undergoing abdominal sacrocolpopexy (ASC). Secondary objectives were to compare symptoms, quality of life, sexual function, pain, and global satisfaction before and after surgery and between bSSVF and ASC groups at one year. METHODS: This prospective cohort study enrolled patients with symptomatic prolapse who chose to undergo bSSVF or ASC. Baseline demographics were obtained. Prolapse quantification, validated symptom questionnaire scores, and McGill pain scores were obtained at baseline, six weeks, and one-year postoperatively. Global satisfaction was recorded. The primary outcome measure was the difference in cure rate (vault stage ≤ 1) between groups. RESULTS: Fifty patients were recruited: 30 underwent bSSVF and 17 ASC. Forty-three patients were available for one-year follow-up. Baseline data were similar. There was no difference in vault stage between bSSVF and ASC groups at one year. Five women who underwent bSSVF had cervical elongation, and four of these were classified as POP recurrence. Women who underwent bSSVF had more anterior recurrences but fewer postoperative complications, shorter hospital stay, and less use of narcotics than controls. Questionnaire scores were similar at one year. All respondents felt subjective improvement after either surgical procedure. CONCLUSIONS: Objective and subjective cure rates are comparable after bSSVF and ASC. Hysteropexy may cause cervical elongation that merits further research.

Objectifs : La fixation sacro-vertébrale bilatérale du dôme vaginal au moyen de languettes de treillis adaptées (bSSVF) fait appel à du treillis de polypropylène pour suspendre bilatéralement le dôme vaginal aux ligaments sacro-vertébraux en n'ayant recours qu'à une tension minimale, ce qui permet de recréer une anatomie alignée sur le plan médian semblable à celle de sujets témoins nullipares. Son utilisation peut s'accompagner d'une préservation de l'utérus. Nous avions pour objectif principal de déterminer le taux de guérison objectif à un an à la suite de la bSSVF, par comparaison avec un groupe témoin faisant appel à la sacrocolpopexie abdominale (SCA). Nos objectifs secondaires étaient de comparer les symptômes, la qualité de vie, la fonction sexuelle, la douleur et la satisfaction globale avant et après la chirurgie, et entre les groupes « bSSVF ¼ et « SCA ¼ à un an. Méthodes : Cette étude de cohorte prospective a sollicité la participation de patientes présentant un prolapsus symptomatique qui avaient choisi de subir une bSSVF ou une SCA. Leurs caractéristiques démographiques de base ont été documentées. Nous avons également documenté la quantification du prolapsus, les scores obtenus à un questionnaire validé portant sur les symptômes et les scores de douleur McGill au départ, ainsi qu'à six semaines et à un an à la suite de l'opération. La satisfaction globale a été consignée. La différence constatée en matière de taux de guérison (stade du dôme ≤ 1) entre les deux groupes constituait le critère d'évaluation principal. Résultats : La participation de 50 patientes a été sollicitée : 30 ont subi une bSSVF et 17, une SCA. Nous avons pu joindre 43 de ces patientes aux fins du suivi à un an. Les données de base étaient semblables. Aucune différence en ce qui concerne le stade du dôme n'a été constatée entre les groupes « bSSVF ¼ et « SCA ¼ à un an. Cinq des femmes ayant subi une bSSVF ont connu une élongation du col utérin; quatre de ces cas ont été classés comme constituant une récurrence du prolapsus des organes pelviens. Bien que les femmes ayant subi une bSSVF aient connu un plus grand nombre récurrences antérieures, elles ont également connu moins de complications postopératoires, leur hospitalisation a été de plus courte durée et on leur a administré moins de narcotiques, par comparaison avec les témoins. Les scores obtenus aux questionnaires étaient semblables à un an. Toutes les répondantes ressentaient une amélioration subjective après avoir subi l'une ou l'autre de ces interventions chirurgicales. Conclusions : Les taux de guérison objective et subjective sont comparables à la suite d'une bSSVF et d'une SCA. L'hystéropexie pourrait causer une élongation du col utérin qui justifie la poursuite de la recherche.

Symptom and Anatomical Phenotypes Provide Insights Into Interactions of Prolapse Symptoms and Anatomy.

IMPORTANCE: Women pursue treatment to relieve symptoms, while surgeons repair anatomy, underlining the importance of the relationship between symptoms and anatomy. OBJECTIVE: We hypothesized different anatomical and symptom phenotypes associated with pelvic organ prolapse (POP). Our objective was to investigate prevalence of phenotypes to explore associations of symptoms with anatomical defects. METHODS: We defined 420 anatomical phenotypes from combinations of POP Quantification parameters and 128 symptom phenotypes from symptoms described by condition-specific questionnaires (Pelvic Floor Disorders Inventory, Short Form of the Personal Experience Questionnaire). We applied these to an anonymized database of 719 subjects with symptomatic pelvic floor disorders. Bar graphs were used to illustrate the distribution of anatomical and symptom phenotypes, as well as anatomical phenotypes of patients with specific symptoms. We then used biclustering analysis with the multiple latent block model, to identify patterns of clustered groups of subjects and features. RESULTS: The most common symptom phenotypes have multiple (3-5) symptoms. A third of the theoretical anatomical phenotypes existed in our cohort. Bar graphs for specific symptom composites demonstrated unique distributions of anatomical phenotypes suggesting associations between anatomy and symptoms. Biclustering converged on 2 subject clusters (C1, C2) and 8 feature clusters. Cluster 1 (68%) represented a younger subpopulation with lower stage POP, more stress urinary incontinence and sexual dysfunction (P < 0.001 all). Cluster 2 had more protrusion (P < 0.001) and obstructed voiding (P = 0.001). Features that clustered together, such as stress urinary incontinence and sexual dysfunction, may represent underlying relationships. CONCLUSIONS: We demonstrated a relationship between locations of anatomical POP and certain symptoms, which may generate new hypotheses and guide clinical decision making.