Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery.

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

Obliterated Posterior Cul-de-sac Laparoscopic Surgical Simulation.

BACKGROUND: Obliteration of the posterior cul-de-sac is a challenging, often unexpected surgical finding. Developing the dissection skills required to manage this finding during laparoscopy is essential for optimizing treatment of many pain disorders during hysterectomy or ovarian surgery; however, exposure of trainees to cul-de-sac dissection is variable. Currently, there are no widely available simulation models for teaching and practicing this technique. METHOD: Our aim is to design a low-cost and high-fidelity laparoscopic simulation model that represents key anatomical structures and emphasizes skills for laparoscopic dissection of an obliterated posterior cul-de-sac. EXPERIENCE: A three-dimensional model was created and is described. Nine experts (gynecologic surgery fellows and attendings) and 17 residents completed a single 30-minute simulation session and completed several assessments to begin establishing the face validity of this model. CONCLUSION: Experts and residents rated the obliterated cul-de-sac simulation as highly realistic and useful. Residents showed a statistically significant increase in comfort with the dissection, from a median Likert score of 1 out of 5 (interquartile range 1-1) to 3 out of 5 (interquartile range 2-3) (P<.001). Experts scored better than residents on blinded video grading of model performance (P<.001). This low-cost and easily reproducible model fills a critical gap in gynecologic surgery education.

Clinical profile of comorbid dysmenorrhea and bladder sensitivity: a cross-sectional analysis.

BACKGROUND: Antecedents of chronic pelvic pain are not well characterized, but pelvic organ visceral sensitivity is a hallmark of these disorders. Recent studies have identified that some dysmenorrhea sufferers are much more likely to exhibit comorbid bladder hypersensitivity. Presumably, these otherwise healthy women may be at higher risk of developing full-blown chronic bladder pain later in life. To encourage early identification of patients harboring potential future risk of chronic pain, we describe the clinical profile of women matching this putative pain-risk phenotype. OBJECTIVE(S): The objectives of the study were to characterize demographic, menstrual, pelvic examination, and psychosocial profiles of young women with comorbid dysmenorrhea and bladder hypersensitivity, defined using a standardized experimental visceral provocation test, contrasted with healthy controls, pure dysmenorrhea sufferers, and women with existing bladder pain syndrome. STUDY DESIGN: This prospective cohort study acquired data on participants with moderate to severe dysmenorrhea (n = 212), healthy controls (n = 44), and bladder pain syndrome (n = 27). A subgroup of dysmenorrhea patients was found on screening with noninvasive oral water challenge to report significantly higher bladder pain during experimentally monitored spontaneous bladder filling (>15 out of 100 on visual analogue scale, based on prior validation studies) and separately defined as a group with dysmenorrhea plus bladder pain. Medical/menstrual history and pain history were evaluated with questionnaires. Psychosocial profile and impact were measured with validated self-reported health status Patient Reported Outcomes Measurement Information System short forms and a Brief Symptom Inventory for somatic sensitivity. Pelvic anatomy and sensory sensitivity were examined via a standardized physical examination and a tampon provocation test. RESULTS: In our largely young, single, nulliparous cohort (24 ± 1 years old), approximately a quarter (46 out of 212) of dysmenorrhea sufferers tested positive for the dysmenorrhea plus bladder pain phenotype. Dysmenorrhea-only sufferers were more likely to be African American (24%) than healthy controls (5%, post hoc χ2, P = .007). Pelvic examination findings did not differ in the nonchronic pain groups, except for tampon test sensitivity, which was worse in dysmenorrhea plus bladder pain and dysmenorrhea sufferers vs healthy controls (2.6 ± 0.3 and 1.7 ± 0.2 vs 0.7 ± 0.2, P < .05). Consistent with heightened pelvic sensitivity, participants with dysmenorrhea plus bladder pain also had more nonmenstrual pain, dysuria, dyschezia, and dyspareunia (P's < .05). Participants with dysmenorrhea plus bladder pain had Patient Reported Outcomes Measurement Information System Global Physical T-scores of 47.7 ± 0.9, lower than in women with dysmenorrhea only (52.3 ± 0.5), and healthy controls 56.1 ± 0.7 (P < .001). Similarly, they had lower Patient Reported Outcomes Measurement Information System Global Mental T-score than healthy controls (47.8 ± 1.1 vs 52.8 ± 1.2, P = .017). Similar specific impairments were observed on Patient Reported Outcomes Measurement Information System scales for anxiety, depression, and sleep in participants with dysmenorrhea plus bladder pain vs healthy controls. CONCLUSION: Women with dysmenorrhea who are unaware they also have bladder sensitivity exhibit broad somatic sensitivity and elevated psychological distress, suggesting combined preclinical visceral sensitivity may be a precursor to chronic pelvic pain. Defining such precursor states is essential to conceptualize and test preventative interventions for chronic pelvic pain emergence. Dysmenorrhea plus bladder pain is also associated with higher self-reported pelvic pain unrelated to menses, suggesting central nervous system changes are present in this potential precursor state.

Surgical interventions for chronic pelvic pain.

PURPOSE OF REVIEW: The objective of this study is to review an evidence-based approach to surgical treatment of key chronic pelvic pain (CPP) contributors emphasizing the importance of preoperative evaluation and counseling. RECENT FINDINGS: CPP is a poorly understood but highly prevalent condition and there are limited, well constructed studies to guide effective, durable treatment. CPP arises from factors originating in multiple organ systems, including reproductive, urologic, gastrointestinal, and myofascial, all informing the central nervous system. For those with severe disabling conditions, who have a suboptimal response to medical management, surgical interventions can be offered for diagnostic evaluation and/or treatment. Leiomyoma, adenomyosis, adnexal disorder, pelvic adhesions, and pelvic varicosities are common considerations in the differential diagnosis of CPP amenable to surgical approach. SUMMARY: Surgical treatments of CPP range from conservative/fertility-sparing approaches to extirpative therapy. Consistently, successful outcomes often are predicated on correctly identifying the abnormal peripheral pain process (which often is only part of the complete picture for these patients). Further research is needed to better guide clinicians as to when to choose surgical therapy vs. targeting secondary contributors to pelvic pain.

Power morcellators: a review of current practice and assessment of risk.

Power morcellation has come under scrutiny because of a highly publicized case of disseminated leiomyosarcoma following a laparoscopic hysterectomy. A recent Federal and Drug Administration safety communication discouraging use of power morcellators on presumed uterine leiomyoma further highlights the need for reexamination of uterine tissue extraction. This clinical opinion aims to summarize current approaches to uterine/fibroid tissue extraction including the associated immediate and long-term potential risks of open power morcellation. The known data about risk of uterine sarcoma is reviewed followed by a discussion of acceptable risk and informed consent in the context of shared-decision making.

Deliberate practice improves obstetrics and gynecology residents' hysteroscopy skills.

INTRODUCTION: Development of surgical skills is an integral component of residency education in obstetrics and gynecology. OBJECTIVE: We report data from a supervised, deliberate, dry lab practice in hysteroscopy for junior obstetrics-gynecology residents, undertaken to evaluate whether simulation training improved hysteroscopy performance to a skill level similar to that of senior residents. METHODS: A prospective, comparative, multicenter trial compared Objective Structured Assessment Of Technical Skills (OSATS) performance of 2 groups: 19 postgraduate year (PGY)-1 and PGY-2 and 18 PGY-3 and PGY-4 Ob-Gyn residents. PGY-1 and PGY-2 participants underwent 4 sessions of brief, deliberate, focused training in hysteroscope assembly and operative hysteroscopic polypectomy using uterine models. Subsequently, all participants completed a simulated hysteroscopic polypectomy OSATS, and procedure times and structured assessment scores were compared among groups. RESULTS: PGY-1 and PGY-2 residents who had completed OSATS training performed at or above the level of untrained PGY-3 and PGY-4 residents. Junior residents had better assembly times and scores, resection scores, and global skills scores (P < .05). Resection times did not differ between groups but differed among institutions. DISCUSSION: Brief, hands-on training sessions, which were task-specific and repetitive facilitated short-term gains in learning operative hysteroscopy and increased the dry lab skill level of junior residents compared to that of senior residents. This curriculum was effectively implemented at 3 institutions and generated comparable results, suggesting generalizability.

Route of hysterectomy influence and teaching hospital status.

OBJECTIVE: The purpose of this study was to evaluate whether teaching hospitals are more likely to perform abdominal (laparotomy) compared with nonabdominal (vaginal, laparoscopic) hysterectomies for benign indications. METHODS: We conducted a retrospective, observational study comparing abdominal and nonabdominal inpatient hysterectomies performed in Illinois between 2000 and 2005 using the COMPdata database. Obvious cancer, prolapse, or indicated-abdominal surgeries (infection and pregnancy-related cases) were excluded. The final analysis included 94,599 cases. Diagnoses and patient demographics were analyzed from the database and hospitals' teaching status, as determined by telephone interviews. The relationship between route of hysterectomy and teaching hospital status was modeled using multivariable logistic regression with a P value cutoff of less than 0.05. RESULTS: Eight-two percent of hysterectomies performed at teaching hospitals were performed abdominally compared with 77% at nonteaching hospitals. After adjusting for age and diagnoses, teaching hospitals were less likely to perform hysterectomy by abdominal approach (odds ratio 0.69, 95% confidence interval 0.49-0.97, P<.035). Clinical variables associated positively with vaginal hysterectomies included primary diagnoses of menstrual disorders, other female genital disorders, and menopausal disorders. Complication rate did not differ by teaching status. Laparoscopic hysterectomy, even after adjustment for confounders, was associated with fewer complications compared with both abdominal and vaginal routes. CONCLUSION: The route of hysterectomy is only minimally influenced by teaching hospital status. These findings are important for clinician-educators responsible for teaching the nation's next generation of gynecologic surgeons. Strategies to overcome presumed physician-level factors are needed to optimize patient outcomes through appropriate use of nonlaparotomy surgery. LEVEL OF EVIDENCE: III.

Laparoscopic excision of endometriosis of the obturator nerve: a case report.

Endometriosis, a common cause of cyclic and chronic pelvic pain in women, can present with a multitude of symptoms. Numerous case reports exist describing the involvement of the sciatic nerve with endometriosis; however, there are few reported cases of infiltration of the other pelvic nerves such as the obturator nerve. To our knowledge, this is the first case of laparoscopic management of symptomatic endometriosis of the obturator nerve.

Surgical techniques: robot-assisted laparoscopic myomectomy with the da Vinci(®) surgical system.

Myomectomy remains the surgical option of choice for women with symptomatic leiomyomata who desire uterine conservation or in particular future fertility. The ability to enucleate leiomyomata and repair the uterus with a multilayer-sutured closure is both crucial and technically challenging. Advanced gynecologic pathology and the surgical limitations of conventional laparoscopy have often been cited as impediments to not only these critical steps but also to converting a myomectomy from a procedure predominantly performed by laparotomy to one accomplished by laparoscopy. Recently, the use of robotic technology as a means to facilitate the laparoscopic completion of a myomectomy was introduced. Advantages to this approach have been the improved dexterity and precision of the instruments coupled with three-dimensional imaging. Published preliminary data have shown the feasibility and safety to this approach. This paper will outline a safe and efficient surgical technique for completing a robot-assisted laparoscopic myomectomy with the da Vinci(®) surgical system.

Interstitial pregnancy.

A 20-year-old woman with an interstitial pregnancy who underwent ultrasonographic and laparoscopic imaging before surgical management is described.