Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries. DATA SOURCES: PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included. METHODS: Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals. RESULTS: Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures. CONCLUSION: Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Comparative Thermal Effects of J-Plasma®, Monopolar, Argon, and Laser Electrosurgery in a Porcine Tissue Model.

INTRODUCTION: The objective of this study was to understand how J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) surgical energy compares to monopolar, argon beam, and CO2 laser devices in terms of depth of penetration and lateral thermal spread in a porcine tissue model. MATERIALS AND METHODS: Using a porcine animal model, we applied the thermal energy of the J-Plasma® laser, Bovie Monopolar Pencil™ (Bovie Medical Corporation, Clearwater, Florida), argon beam coagulator, and CO2 laser to porcine small bowel, bladder, and peritoneal tissues at equivalent settings. Tissue was excised and sent to pathology for histologic evaluation. Primary outcome was depth of penetration and lateral thermal spread. RESULTS: When applied to peritoneum tissue, CO2 laser had the greatest lateral thermal spread at 2.99mm, while the argon beam had the lowest at just under 1.5mm. With regard to depth of penetration, the monopolar pencil had the highest while J-Plasma® had the lowest. When applied to bladder tissue, the argon beam was associated with the greatest lateral thermal spread (3.1mm) as compared to the other three devices (all less than 1mm). In terms of depth of penetration of bladder tissue, J-Plasma® again had the lowest value, while the monopolar pencil had the highest. When applied to small intestine tissue, the argon beam had the greatest lateral spread (3.51mm), while J-Plasma® had the lowest (less than 1mm). Regarding depth of penetration of small intestine tissue, argon beam had the highest value at 1.8mm compared to the other three devices (all below 0.6mm). CONCLUSION: Consistent with our previous study, J-Plasma® had minimal lateral and depth spread when applied to various tissue types. J-Plasma® performed better or similar when compared to monopolar, argon beam, and laser electrosurgical devices. Further studies in-vivo are needed to evaluate safety and surgical application of the J-Plasma® device.

Military Surgeon Volume and Stress Incontinence Surgery Complications: A Retrospective Cohort Study.

STUDY OBJECTIVE: To compare 12-month postoperative complication rates in women who underwent sling procedures by high-volume versus low-volume surgeons at US military treatment facilities (MTFs). DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: US MTFs. PATIENTS: Female military beneficiaries enrolled in TRICARE. INTERVENTIONS: Sling surgery for stress urinary incontinence between January 1, 2011 and December 31, 2012. MEASUREMENTS AND MAIN RESULTS: The primary exposure was surgeon volume (high vs low). Surgeon volume was categorized as high or low based on the number of slings performed in the previous 2 years at US MTFs (January 1, 2009 to December 31, 2010). The primary outcome was a composite variable indicating at least 1 postoperative complication within 12 months. We used International Classification of Diseases, 9th revision and Current Procedural Terminology codes to identify postoperative complications that occurred in the 12 months after the index sling procedure. During the study period 348 gynecologic and urologic surgeons performed 1632 slings. The average patient age was 47.2 years. Based on our data distribution we classified surgeons as high volume (>12 slings/2 years) or low volume (<4 slings/2 years). High-volume surgeons operated on patients who were older, more likely to have comorbidities, and more likely to receive concomitant prolapse surgery. Using a cluster analysis the overall likelihood of at least 1 postoperative complication in 12 months for high-volume versus low-volume surgeons was 48.4% versus 42.2% (adjusted odds ratio, 1.24; 95% confidence interval, .99-1.54; p = .06). There were no differences between high- and low-volume surgeons in the rate of almost all other postoperative complications. CONCLUSION: No significant differences in 12-month complication rates after sling surgery, stratified by surgeon volume, were seen in a setting of overall low-volume military surgeons.

Trends in the Management of Nonviable Pregnancies of Unknown Location in the United States.

BACKGROUND: When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL. METHODS: A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States. RESULTS: A total of 214 physicians responded. When presented with a PUL by ultrasound and a ßhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional ßhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial ßhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians. CONCLUSIONS: Based on our findings, there does not appear to be a consensus regarding the management of a PUL.

Intrauterine Pressure During Hysteroscopic Morcellation: A Comparison of Three Commercially-Available Devices.

STUDY OBJECTIVE: Our objective was to compare intrauterine pressures during resection and aspiration modes among three types of commercially-available hysteroscopic morcellators. DESIGN: This was a benchtop study (Canadian Task Force level II-1). This study cannot feasibly and ethically be done in-vivo, so an ex-vivo study design was chosen. SETTING: A silicone uterine model was attached to a manometer via tubing, with the tip inside the cavity to allow for intracavity pressure measurements. Each hysteroscopic morcellator was then introduced, and intracavity pressures were recorded every one to two seconds in three modes (static, resection, and aspiration) and at three set point pressures (45, 85, and 125 mmHg). PATIENTS: No human subjects were involved in this study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were a total of 4,872 pressure measurements during this study across the three devices, over the three modes, and at the three set point pressures combined. Using mixed-effects linear regression, the mean observed intracavity pressure was not greater than the set pressure for each of the three devices. This result held true in both aspiration and resection modes. In our statistical models, the coefficient on the terms representing the interaction between device and time were not statistically significant in either resection or aspiration modes. This indicates that, statistically, the change in intracavity pressure over time was not significantly different across the three devices. CONCLUSION: In this first of its kind head-to-head benchtop study, we found that all three commercially-available hysteroscopic morcellators appear to be similar to each other in terms of their abilities to maintain intracavity pressure below the set pressure, which is important in avoiding intravasation in-vivo. These findings are important because many gynecologists do not have the ability to choose between the three available devices on the market at their institution.

Thermal Effect of J-Plasma® Energy in a Porcine Tissue Model: Implications for Minimally Invasive Surgery.

OBJECTIVE: To evaluate tissue effect of J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) in porcine liver, kidney, muscle, ovarian, and uterine tissue blocks. DESIGN: Prospective study utilizing porcine tissue blocks to evaluate the thermal spread of J-Plasma® device on liver, kidney, muscle, ovarian, and uterine tissue at various power settings, gas flow, and exposure times. MATERIALS AND METHODS: J-Plasma® helium was used in porcine liver, kidney, and muscle tissue at 20%, 50%, and 100% power, and 1 L/min, 3 L/min, and 5 L/min gas flow at one, five, and 10-second intervals. J-Plasma® was then used in ovarian and uterine tissue at maximum power and gas flow settings in intervals of one, five, 10, and 30 seconds. Histologic evaluation of each tissue was then performed to measure thermal spread. RESULTS: Regardless of tissue type, increased power setting, gas flow rate, and exposure time correlated with greater depth of thermal spread in liver, kidney, and muscle tissue. J-Plasma® did not exceed 2 mm thermal spread on liver, kidney, muscle, ovarian, and uterine tissue, even at a maximum setting of 100% power and 5 L/min gas flow after five seconds. Prolonged exposure to J-Plasma® of up to 30 seconds resulted in increased length and width of thermal spread of up to 12 mm, but did not result in significantly increased depth at 2.84 mm. CONCLUSIONS: The J-Plasma® helium device has minimal lateral and depth of thermal spread in a variety of tissue types and can likely be used for a multitude of gynecologic surgical procedures. However, further studies are needed to demonstrate device safety in a clinical setting.

The McCarus-Volker ForniSee®: A Novel Trans-illuminating Colpotomy Device and Uterine Manipulator for Use in Conventional and Robotic-Assisted Laparoscopic Hysterectomy.

PURPOSE: The purpose of this paper is to introduce a novel trans-illuminating culdotomy and uterine manipulator device. MATERIALS AND METHODS: The study was a prospective, non-randomized, non-blinded observational clinical study involving 50 female patients undergoing total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for benign indications. The surgeries were performed from March through May 2012 at two institutions. The primary study objectives were to demonstrate the safety and adequate clinical performance of the uterine manipulator device and to illustrate its potential widespread future use in minimally invasive gynecologic procedures. RESULTS: Average patient age was 45.1 years and, of the 50 patients, 33 had undergone previous intra-abdominal surgery. There were no reports of adverse events, difficulty with placement of the instrument, multiple attempts at placement, or difficulty with uterine manipulation. There was only one device-related uterine perforation, and pneumoperitoneum was maintained in all cases during culdotomy. Vaginal tissue left on subjects was less than 5mm. Overall, there were no ureteral injuries, there were two reported incidental cystotomies, and average blood loss was 99.0cc. Postoperative courses were normal for all patients, with only two reported postoperative complications: a possible vaginal cuff abscess and a 2cm vaginal mucosal cuff separation. CONCLUSIONS: The McCarus-Volker ForniSee® (LSI Solutions, Inc., Victor, New York) is a novel trans-illuminating culdotomy device and uterine manipulator that is safe, efficient, functional, and easy to use. Trans-illumination additionally delineates and enhances identification of critical anatomic planes, such as the vesicovaginal junction and cervicovaginal junction.

Women's Understanding of the Term 'Pap smear': A Comparison of Spanish-Speaking Versus English-Speaking Women.

Objective To compare the understanding of the term 'Pap smear' among Spanish-speaking women, as compared to their English-speaking counterparts. Methods Surveys were distributed to English and Spanish speaking female patients in an urban Obstetrics and Gynecology clinic. Patients were at least 18 years old or they were less than 18 years old and pregnant. Results A majority of participants (77.3 % English-speaking vs. 74.1 % Spanish-speaking, respectively) were able to identify at least one correct descriptor for the term Pap smear. However, Spanish-speaking women were significantly less likely to choose incorrect descriptors. Spanish-speaking women were much less likely to say that a Pap smear was the same as a Pelvic exam (45.7 vs. 78.8 %; p = 0.001), or a test for a sexually transmitted disease (25 vs. 60.6 %; p = 0.001). Conclusions for Practice Compared to English-speaking women, Spanish-speaking women are much less likely to conflate a pelvic exam with a Pap smear. Overall understanding was suboptimal, regardless of primary language, indicating that major efforts are still needed to improve functional health literacy with respect to cervical cancer screening.

Women's understanding of the term 'Pap smear'.

To assess the understanding of the term 'Pap smear' among women across the entire adult lifespan after recent changes to the guidelines on cervical cancer screening. Women attending the Obstetrics and Gynecology clinic at a large safety net teaching hospital in a Midwestern city were provided one of two versions of a confidential and anonymous survey to complete. The difference between the two versions was the way the primary research question was worded. There were 174 participants ranging in age from 15 to 69 (mean = 33.9) years. Of the 73 women who completed version A of the survey, 74 % were able to identify at least one correct descriptor for the term 'Pap smear.' Women who could identify at least one correct descriptor for the term 'Pap smear' were on average older than those who could not (mean = 36.9 vs. 28.7 years; p = 0.012). Of the 94 patients completing survey version B, 67 % could not differentiate a pelvic exam from a Pap smear. There was no association between age and ability to differentiate a pelvic exam from a Pap smear. The majority of women cannot distinguish a Pap smear from a pelvic exam. The unexpected finding of less understanding among younger women prompts a need for further research and invites discussion of whether more cervical cancer prevention education, with more emphasis on HPV vaccines in recent years, has neglected the importance of Pap smears-which is beginning to show up in knowledge of younger women. Both these findings suggest a need for increased patient education during female preventive health clinic visits.

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review.

OBJECTIVE: To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. DATA SOURCES: We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. METHODS OF STUDY SELECTION: Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. TABULATION, INTEGRATION, AND RESULTS: The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. CONCLUSION: Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022327490.

Physician attitudes toward over the counter availability for oral contraceptives.

To assess physician attitude towards making oral contraceptives available over the counter in the United States (US). We assessed physician attitudes towards a transition from prescription only to over-the-counter availability (rx-OTC) for oral contraceptive pills by disseminating an electronic survey directed primarily to residents training in Obstetrics and Gynecology (OBGYN) and Family Practice in the US. An overwhelming majority of 638 respondents (71 %) were against an rx-OTC switch for combined oral contraceptives and among this subset of respondents the primary concern was safety (92.3 %). Overall, respondents were evenly divided on the issue of an rx-OTC switch for progestin-only-pills but of those who opposed, 73.2 % cited safety as their primary concern. For progestin-only-pills female respondents were more likely to support OTC availability. Most OBGYN and Family Practice residents opposed to OTC availability for oral contraceptives cite safety as their primary concern. Considering the abundant evidence as to the overall safety of oral contraceptives, especially progestin-only-pills, there appears to be a knowledge deficit among OBGYN and Family Practice residents regarding the safety of oral contraceptives.

What are the factors predictive of hysterosalpingogram compliance after female sterilization by the Essure procedure in a publicly insured population?

To determine what factors are predictive of post-Essure hysterosalpingogram (HSG) compliance. We conducted a retrospective chart review of all patients who underwent the Essure procedure at the two campuses of the Truman Medical Center, Kansas City, Missouri, from January 1, 2005 through December 31, 2010. Our study population consisted primarily of women who were publicly insured (89.0 %) and unmarried (76.7 %). Of 132 patients referred for HSG, 70 (53.0 %) complied. In adjusted analyses women 35 years and older had an almost fourfold higher odds of HSG compliance (OR = 3.72, 95 % CI 1.35-10.23) and women with 3 or more living children had a 64 % lower odds of HSG compliance (OR = 0.36, 95 % CI 0.16-0.82). Women younger than 35 who had 3 or more children had the lowest compliance rate (36.4 %) suggesting an interaction between age and parity. Women undergoing the Essure procedure at the campus with a dedicated protocol to ensure compliance had an almost fourfold higher odds of HSG compliance (OR = 3.67, 95 % CI 1.01-13.40). In a population consisting largely of publicly insured, unmarried women, several factors are predictive of post-Essure HSG compliance. These include age, parity and the presence or absence of an institutional protocol to keep track of patients after their Essure procedure.

Use of intraoperative fluoroscopy during laparotomy to identify fragments of retained Essure microinserts: case report.

In previous case-reports of Essure microinsert perforation, the microinsert was successfully removed at laparoscopy. Herein is discussed the scenario of persistent pelvic pain over several years after an apparently successful laparoscopic retrieval of a perforating right-sided microinsert. In the interim, the patient underwent 2 unsuccessful exploratory laparotomy procedures in an attempt to retrieve additional microinsert fragments that had perforated the uterus. Successful management of Essure microinsert perforation in this patient ultimately required use of intraoperative fluoroscopy. Surgeons performing laparoscopy or laparotomy to retrieve Essure microinserts that have perforated should be aware that these are not always visible to the naked eye, and there should be a low threshold to use intraoperative fluoroscopy to ensure that all perforating fragments have been removed.

A comparison of surgical outcomes among robotic cases performed with an employed surgical assist versus a second surgeon as the assist.

To examine whether utilizing an employed surgical first assistant or a physician as an assistant during gynecologic robotic cases affects surgical variables. A high volume gynecologic oncologist's robotic case data spanning fourteen years (2005-2018) was analyzed. We separated the cases based on the type of assistant used: either an employed surgical first assist or another physician. The assisting physicians were either members of the same practice or general gynecologists in the community. The two groups were compared for console time and estimated blood loss. We controlled for patient Body Mass Index (BMI), uterine weight, use of the fourth robotic arm, benign versus malignant pathology, and the surgeon's subjective estimate of the difficulty of the case using a conventional laparoscopic versus robotic approach. Cases with an employed surgical assist had a mean adjusted robotic console time that was 0.32 h (19.2 min) faster than cases with a physician as the assist (95% CI 0.26 h-0.37 h faster, p < 0.001). Cases with an employed surgical assist also had an estimated blood loss (EBL) that was 47.5 cc lower than cases with a physician assisting (95% CI 38.8 cc-56.3 cc lower EBL, p < 0.001). The use of an employed surgical assist was associated with a faster console time and lower blood loss compared to using an available physician even adjusting for confounding factors. This deserves further exploration, particularly in regards to complication rates, operating room efficiency, utilization of health care personnel, and cost.

Maternal incarceration during pregnancy and infant birthweight.

The primary aim of this study was to examine whether incarceration during pregnancy is associated with infant birthweight. Our second objective was to illustrate the sensitivity of the relationship between infant birthweight and exposure to prison during pregnancy to the method used to measure and model this exposure. The data consisted of delivery records of 360 infants born between January 1, 2002 and December 31, 2004 to pregnant women incarcerated in Texas state prisons. Weighted linear regression, adjusting for potential confounders, was used to model infant birth weight as a function of: (1) the number of weeks of pregnancy spent incarcerated (Method A) and (2) the gestational age at admission to prison (Method B), respectively. These two exposure measures were modeled as continuous variables with and without linear spline transformation. The association between incarceration during pregnancy and infant birthweight appears strongest among infants born to women incarcerated during the first trimester and very weak to non-existent among infants born to women incarcerated after the first trimester. With Method A, but not Method B, linear spline transformation had a distinct effect on the shape of the relationship between exposure and outcome. The association between exposure to prison during pregnancy and infant birth weight appears to be positive only among women incarcerated during the first trimester of pregnancy and the relation is sensitive to the method used to measure and model exposure to prison during pregnancy.

Does serum hemoglobin A1C during early pregnancy predict performance on the 1-hour glucose challenge test?

PURPOSE: To determine the negative and positive predictive values of hemoglobin A1c (HgbA1c) levels in predicting abnormal 1-hour glucose challenge test (GCT) results in pregnancy. METHODS: This retrospective cohort study consisted of pregnant patients from a private practice obstetrics clinic. The primary exposure was early HgbA1c measurement, and the primary outcome was third trimester 1-hour GCT results above or below 140 mg/dL. We calculated the predictive value of early HgbA1c to identify a 1-hour GCT of ≤140 mg/dL or >140 mg/dL. RESULTS: Of the 1404 one-hour GCT results, 635 were associated with HgbA1c being measured in a patient on the same day or before the 1-hour GCT. The median interval between the HgbA1c test and the 1-hour GCT was 95 days (IQR 56-122 days). Among women with a hgbA1c less than or equal to 4.9, 5.0 and 5.1, respectively, the probability of their 1 hour GCT being 140 mg/dl or less was 91.3%, 91.0% and 90.1%, respectively (Table 1). Among our study population, 14.5%, 22.8% and 35.0% had an Hgb A1c less than or equal to 4.9, 5.0 and 5.1 respectively. Among women with HgbA1c greater than 6.1, the probability of their 1-hour GCT being greater than 140 mg/dL was 100%. Only 0.3% of our population had HgbA1c greater than 6.1. There was no other cut point for HgbA1c, where the positive predictive value for predicting an abnormal 1-hour GCT was equal to or greater than 90%. CONCLUSIONS: The greatest value of an early HgbA1C test appears to be that very low values (5.1 or less) can predict a normal 1 h GCT with high probability (at least 90%). However, it has limited ability to predict abnormal 1 h GCT. Overall, an early HgbA1C cannot replace the 1 h GCT based on the current body of evidence.

Occult Uterine Malignancy at the Time of Surgery for Pelvic Organ Prolapse: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis to estimate the prevalence of occult uterine malignancy of any subtype specifically at the time of hysterectomy for pelvic organ prolapse (POP). METHODS: We primarily used MEDLINE to access existing literature. The search terms used were "occult malignancy" or "occult uterine pathology" paired with "morcellation" or "hysterectomy." Our cutoff date for articles was March 25, 2019. We further narrowed articles down based on whether they included data on occult malignancy at time of hysterectomy specifically for POP. RESULTS: Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review. Eight studies provided specific data on occult uterine malignancy among women undergoing surgery for POP and formed the basis for this meta-analysis. Among the 8 studies examined, the total number of patients combined was 35,880, and there were 144 total occult uterine malignancies. There were 7 case series and 1 population-based study included. The pooled prevalence of occult uterine malignancy at the time of hysterectomy for POP was 0.22% (95% confidence interval, 0.11%-0.35%]. There was very little heterogeneity observed across the 8 studies (I2 = 12.06%, Q χ2[7] = 7.96, P = 0.336). CONCLUSIONS: The pooled prevalence of occult uterine malignancy, of any subtype, at the time of surgery for POP specifically is 0.22% based on meta-analysis of existing studies. Surgeons can use this statistic as part of the preoperative counseling of patients with POP before hysterectomy.

Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years.

OBJECTIVE: Our objective was to characterize the most frequently cited articles published in obstetrics and gynecology journals during the last 50 years. STUDY DESIGN: We utilized the 2008 edition of Journal Citation Reports and Social Sciences Citation Index database to determine the most frequently cited articles published after 1956. Articles were evaluated for several characteristics, and an unadjusted categorical analysis was performed to compare pre- and post-1980 articles. RESULTS: The 100 most frequently cited articles were published in 11 journals between 1957 and 2004. Most articles were published by US-based authors. Forty-four articles were related to obstetrics and 56 were related to gynecology. The most common study design was observational. There were only 7 randomized controlled trials, and randomized controlled trials were not more common after 1980 (6.3% vs 8.1%; P = .71). CONCLUSION: Most "citation classics" in obstetrics and gynecology are observational studies published in high-impact journals by US-based authors after 1980.