Surgical education in urogynecology from low fidelity to virtual reality: Systematic review.

IMPORTANCE: Increase dissemination of educational tools in urogynecology. OBJECTIVE: Describe the effectiveness and public availability of published educational tools for urogynecologic surgery. STUDY DESIGN: A systematic review was conducted by searching MEDLINE, EMBASE, Cochrane Library, and Web of Science from 1946 to 2023 for articles describing educational tools in urogynecology. There were no restrictions on study design or language. Data were extracted in duplicate using a standardized piloted extraction form, and outcomes were combined descriptively. RESULTS: 2997 titles, 457 abstracts, and 97 full-text articles were analyzed. Of the 97 interventions included, 43 were manuscripts and 54 were conference abstracts. The median study quality was low, with a moderate risk of bias. Six intervention categories were identified: didactics, animal models, cadavers, static models, extended reality (XR), and multimodal workshops. Didactics were subjectively useful for teaching pelvic anatomy and diseases and improving surgical techniques. If good quality, animal models and cadavers provided visual and tactile learning and assessed performance in real-time. Animal models were also anatomically realistic and useful at half the cost of cadavers. Static models and XR improved confidence, knowledge, skills, and error rates despite lack of realism and accurate tissue texture in some models and steep learning curve with XR. Only four models were commercially accessible. Most studies did not assess long-term (>6 months) retention. CONCLUSION: All educational modalities for urogynecologic surgery are largely realistic and increase participant satisfaction, preparedness, knowledge, skills, and likelihood of use. But only 40% advanced to manuscripts, and even fewer (<5%) were widely available.

Immediate Postoperative Pelvic Organ Prolapse Quantification Measures and 2-Year Risk of Prolapse Recurrence.

OBJECTIVE: To assess whether resting genital hiatus, perineal body, and total vaginal length measured intraoperatively at the conclusion of surgery are associated with prolapse recurrence 2 years after native tissue pelvic organ prolapse reconstruction. METHODS: This ancillary analysis of the OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) trial included women who had an immediate postoperative pelvic organ prolapse quantification (POP-Q) examination and 2-year follow-up. Primary outcome was bothersome bulge symptoms. Secondary outcomes were anatomic failure, surgical failure (either anatomic failure or bothersome bulge symptoms), and sexual function. Descriptive statistics assessed relationships between postprocedure POP-Q measures and these four outcomes. Multivariable models were fit to the data to control for baseline differences in bivariate comparisons. Receiver operating characteristic curves were generated to identify an optimal genital hiatus cut point associated with bothersome bulge, and this threshold was explored. RESULTS: This analysis included 368 participants. Bivariate analyses identified age, body mass index, vaginal deliveries, baseline genital hiatus, perineal body, and advanced POP-Q stage (3 or higher vs 2) as clinically relevant variables to include in multivariable models. After adjusting for these variables, the association between immediate postoperative genital hiatus and bothersome bulge (adjusted odds ratio [aOR] 1.4; 95% CI 0.9-2.1) was not significant at the P<.05 level; however, immediate postoperative genital hiatus was associated with anatomic (aOR 1.6; 95% CI 1.1-2.3) and surgical failure (aOR 1.5; 95% CI 1.0-2.1). Immediate postoperative genital hiatus of 3.5 cm was the selected cutoff (area under the curve 0.58, 95% CI 0.50-0.66 from the bothersome bulge model). Women with genital hiatus 3.5 cm or greater were more likely to have anatomic and surgical failures at 2 years. No POP-Q measures were correlated with 2-year sexual function. CONCLUSION: A larger immediate postoperative genital hiatus measurement of 3.5 cm or greater is not associated with bothersome bulge symptoms or sexual dysfunction but is associated with anatomic and surgical failures 2 years after native tissue vaginal reconstructive surgery.

Effect of Surgery for Stress Incontinence on Female Sexual Function.

OBJECTIVE: To evaluate the effects of four different surgical interventions for stress urinary incontinence (SUI) on 2-year postoperative sexual function. METHODS: This is a combined secondary analysis of SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) and TOMUS (Trial of Mid-Urethral Slings). Women in the original trials were randomized to receive surgical treatment for SUI with an autologous fascial sling or Burch colposuspension (SISTEr), or a retropubic or transobturator midurethral sling (TOMUS). Sexual function (assessed by the short version of the PISQ-12 [Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire]) was compared between groups at baseline, 12 and 24 months. Secondarily, the effects of subjective and objective surgical cure rates and the effect of concomitant surgical procedures on 24-month sexual function was explored. RESULTS: Nine hundred twenty-four women were included in this study: 249 (26.9%) had an autologous fascial sling, 239 (25.9%) underwent Burch colposuspension, 216 (23.3%) had a retropubic midurethral sling placed, and 220 (23.8%) had transobturator midurethral sling placed. Baseline characteristics (including PISQ-12 scores) were similar between the four treatment arms, with notable exceptions including race-ethnicity, prolapse stage, concomitant surgery, and number of vaginal deliveries. After adjustment for differences between the groups, there was a clinically important improvement in PISQ-12 scores over the 24-month postoperative period for all treatment groups, with no significant differences attributed to the type of anti-incontinence procedure (baseline PISQ-12: 32.6, 33.1, 31.9, 31.4; 24-month PISQ-12: 37.7, 37.8, 36.9, 37.1, P<.01). There was no significant difference in mean PISQ-12 scores between 12 months and 24 months (12-month PISQ-12: 37.7, 37.8, 36.9, 37.1; 24 months as above, P=.97). Multivariable analysis showed independent associations between objective and subjective cure rates as well as concomitant procedures with a 24-month PISQ-12 score. CONCLUSION: Women undergoing anti-incontinence surgery show overall improvement in sexual function from baseline to 24 months postoperatively, without significant differences based on surgical procedure performed. The majority of this improvement occurs in the first 12 months and is maintained over 24 months.

Intraoperative Evaluation of Urinary Tract Injuries at the Time of Pelvic Surgery: A Systematic Review.

OBJECTIVE: The aim of this study was to determine the safety and efficacy of methods for intraoperative evaluation of urinary tract injury during pelvic surgery. METHODS: PubMed, EMBASE, CINAHL, Web of Science, Scopus, ProQuest, the Cochrane Library, and Clinicaltrials.gov were searched from 1947 to February 2018. Articles or abstracts describing the routine evaluation of urinary tract injuries during pelvic surgery in adults were included, surgical indications of urinary tract anomaly, stones, or malignancy were excluded. There were no restrictions on study design or language. Outcomes included injuries diagnosed intraoperatively, delayed diagnoses, adverse effects, subjective assessments, time to use, and cost. Data were extracted in duplicate at an individual-participant level. Prevalence of injuries, sensitivity, specificity, and predictive values of each diagnostic method were calculated. A combination of generalized linear models and a Bayesian approach were used to separately pool diagnostic accuracy measures. RESULTS: There were 5303 titles, 527 abstracts, and 164 full-text articles assessed for eligibility; 69 articles were analyzed. Diagnostic methods retrieved were cystoscopy using saline, dextrose or unspecified distention media, oral phenazopyridine and vitamin B, intravenous (IV) methylene blue, IV sodium fluorescein, IV indigo carmine, prophylactic retrograde ureteral stents, and transabdominal Doppler ultrasound. Prevalence of urinary tract injury ranged from 0.3% to 2.8%. Sensitivity ranged 63% to 91%, and specificity, 99.7% to 100%, with no significant differences suggested between methods. CONCLUSIONS: All evaluable methods of intraoperative urinary tract assessment during pelvic surgery are safe and effective with specificity of greater than 99% and low rates of complications. Larger, more rigorous studies are required to evaluate the diagnostic accuracy of some newer methods.

The Effect of Commonly Performed Exercises on the Levator Hiatus Area and the Length and Strength of Pelvic Floor Muscles in Postpartum Women.

OBJECTIVE: The aim oft his study was to compare the effects of 10 common exercises to traditional pelvic floor muscle (PFM) contractions (Kegel) on levator hiatus (LH) area and PFM length and strength. METHODS: This is a cross-sectional study of 15 healthy postpartum women. Ten exercises were studied. These were common variations of leg, core, and back exercises used in yoga, Pilates, strength training, and physical therapy. Each participant performed all 10 exercises at a single visit in 2 examination settings: transperineal ultrasound and perineometry. Ultrasound measured the LH area and PFM length, and perineometry measured the muscle strength (peak squeeze pressure). RESULTS: Kegel generates an increase in squeeze pressure (24.3 cm H2O), shortens the muscles (-0.46 cm) and narrows the LH (-0.13 cm). The bird-dog and plank exercises were not different from Kegel in any measurement. While the leg-lift ultrasound dimensions are similar to Kegel, leg lifts generated peak squeeze pressures stronger than any other exercise (including Kegel). Whereas ultrasound dimensions were similar to Kegel, tucked and untucked squats and thigh adductions generated weaker contractions than Kegel. While crunch generated a squeeze pressure similar to Kegel, the ultrasound dimensions showed a significantly wider LH and longer muscle than Kegel. Bridge, clam, and plié exercises affected the PFMs differently than Kegel in all measures. CONCLUSIONS: Bird-dog, plank, and leg-lift exercises should be evaluated as alternative exercises to Kegel as they affect PFM strength and length and LH area similarly to Kegel, and leg lifts generate a stronger contraction than Kegel.

An Interactive Holographic Curriculum for Urogynecologic Surgery.

BACKGROUND: Urogynecologic surgery, transvaginal pelvic floor surgery in particular, requires learning by feel and high-volume pattern recognition. In the era of limited duty hours and case numbers, we sought to develop a curriculum, one that can be self-guided, to help trainees develop a spatial understanding of the relationships of pelvic floor musculature, ligamentous supports, and surrounding neurovasculature outside of the operating room. INSTRUMENT: We created and piloted an innovative interactive holographic using an augmented reality headset to teach surgical anatomy, procedural steps, recognition, and management of the uterosacral ligament suspension and sacrospinous ligament fixation, the two most common native tissue vaginal prolapse repairs. EXPERIENCE: Our curriculum was independently trialed by obstetrics and gynecology residents and subspecialty fellows and was widely accepted by trainees, postgraduate levels 1-6. As compared with usual self-study, 88% ranked the modules as "much" or "very much better" and 81% would be "likely" or "very likely" to use mixed reality smartglasses to prepare for surgery. CONCLUSION: This interactive holographic curriculum is a novel technique to teach complex pelvic floor anatomy, key steps, and management of complications of the uterosacral ligament suspension and sacrospinous ligament fixation. It is widely accepted by obstetrics and gynecology residents and gynecologic subspecialty fellows.

Surgical Anatomy of the Uterosacral Ligament Colpopexy.

OBJECTIVE: The aim of this study was to describe the relationship of the uterosacral ligament (USL) to the ureter and rectum along a surgeon's target location for suture placement under conditions simulating live surgery. METHODS: Dissections were performed in 11 unembalmed female cadavers. Steps were taken to identify the USL simulating USL colpopexy. Pins were placed in the midportion of the USL at the level of the IS, and at 1-cm, 2-cm, and 3-cm increments traveling proximally toward the sacrum (Fig. 1). We measured minimum distances from the USL to the ureter and rectum at each target location. RESULTS: In general, the ureters range from 1.3 to 2.0 cm lateral to the USLs along the target length. The rectum ranges from 1.9 to 2.6 cm from the right USL and remains 1.5 cm from the left USL. The mean change in distance between the ureter and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% confidence interval [CI], 0.19-0.24) on the right and 0.2 cm (95% CI, 0.18-0.27) on the left. The mean change in distance between the rectum and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% CI, 0.19-0.24) on the right and 0.0 cm (95% CI, 0-0) on the left. CONCLUSIONS: For every centimeter traveled along the bilateral USLs from the IS toward the sacrum, the ureter moves 0.2 cm laterally away from the ligament, the rectum moves 0.2 cm medially away from the right USL, but maintains its position from the left USL.

Vaginal hysterectomy, vaginal salpingoophorectomy and uterosacral ligament colpopexy: a view from above (in English and Spanish).

AIM OF THE VIDEO: The aim of this video is to make vaginal hysterectomy (TVH), vaginal salpingoophorectomy and uterosacral ligament (USL) colpopexy approachable by showing the key procedural steps from both the vaginal and abdominal perspectives. METHODS: This production shows TVH with salpingoophorectomy and USL colpopexy that was performed on a cadaver and filmed simultaneously from the vaginal and abdominal views. The video begins with an anatomy overview from the open abdomen and proceeds with the TVH. The anterior and posterior peritoneal entries, a technique to safely and easily access the adnexa, as well as the placement of USL suspension sutures are highlighted. The proximity of the ureter and its distance from the three locations most vulnerable to injury during this procedure (the uterine artery pedicle, the infundibulopelvic ligament and the USL) are illustrated. The location of the USL suspension sutures in relation to the ischial spine, the rectum and the sacrum are demonstrated. For all of these crucial steps, a series of picture-in-picture views simultaneously showing the abdominal and vaginal perspectives are presented so that the viewer may better understand the spatial anatomy. CONCLUSION: This video provides the viewer with a unique anatomic perspective and helps more confidently perform TVH, vaginal salpingooophorectomy and USL colpopexy.

The effect of major depression on quality of life after surgery for stress urinary incontinence: a secondary analysis of the Trial of Midurethral Slings.

BACKGROUND: Depression has been associated with symptom amplification, functional impairment, and lower incontinence-specific quality of life in women with urinary incontinence. Although depression has been shown to impact both subjective and objective outcomes after many different surgeries, there are limited data on the effects of major depression on postoperative outcomes after antiincontinence surgery. OBJECTIVE: The purpose of this study was to determine whether major depression affects urinary incontinence severity and quality of life after midurethral sling surgery. STUDY DESIGN: This was a secondary analysis of the Trial of Midurethral Slings. Participants were assigned randomly either to a retropubic or transobturator sling for stress urinary incontinence. Each was classified as having major depression or not by the validated depression screening Patient Health Questionnaire-9. Pre- and postoperative urinary incontinence severity (which was assessed by the International Consultation on Incontinence Questionnaire), urinary incontinence-specific quality of life (which was assessed by the Incontinence Impact Questionnaire and the Urinary Distress Inventory), and sexual function (which was assessed by the Prolapse/Urinary Incontinence Sexual Questionnaire) was compared between groups at baseline and at 12 months. RESULTS: Five hundred twenty-six patients were included: 79 patients (15%) had major depression before surgery; 447 patients (85%) did not. Baseline incontinence severity was higher in women with major depression than in those without (International Consultation on Incontinence Questionnaire, 14.7 ± 4.1 vs 12.9 ± 4.0; P < .001). Similarly, baseline quality of life and sexual function were worse in depressed women than in nondepressed women (Incontinence Impact Questionnaire, 235.6 ± 95.8 vs 134.8 ± 89.8; P < .001; Urinary Distress Inventory, 162.7 ± 46 vs 128.6 ± 41.3; P < .001; and Prolapse/Urinary Incontinence Sexual Questionnaire-12, 27.2 ± 7.3 vs 33.9 ± 6.4; P < .001). After adjustment for differences between groups, baseline major depression did not negatively affect 12-month incontinence severity or quality of life. However, at 12 months after surgery, despite significant improvement in sexual function scores in depressed women, the 12-month scores were still significantly worse in the major depression group (Prolapse/Urinary Incontinence Sexual Questionnaire-12, 34.1 ± 7.1 vs 37.7 ± 6.1; P < .001); multivariable analysis showed independent association of baseline major depression with 12-month sexual function. At 12 months, 83% of those women (66/79) with baseline major depression were no longer depressed. CONCLUSION: Women with major depression who are planning surgery for stress urinary incontinence have worse quality of life than nondepressed women. However, women with major depression improve significantly more than those without major depression such that, at 12 months postoperatively, incontinence severity and quality of life are not different between groups. Sexual function is worse before and after the operation for depressed women.

Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates.

BACKGROUND: Intravenous indigo carmine has routinely been used to confirm ureteral patency after urogynecologic surgery. Recent discontinuation of the dye has altered clinical practice. In the absence of indigo carmine, we have used 10% dextrose in sterile water (D10) as cystoscopic fluid to evaluate ureteral patency. Glucosuria has been associated with urinary tract infection (UTI) in vivo and significantly enhanced bacterial growth in vitro. The concern is that the use of D10 would mimic a state of glucosuria albeit transient and increase the risk of postoperative UTI. OBJECTIVES: The objectives of this study were to compare the rates of postoperative UTI and lower urinary tract (LUT) injuries between patients who underwent instillation of D10 vs normal saline at the time of intraoperative cystoscopy after urogynecological surgery. STUDY DESIGN: This was a retrospective cohort study of all women who underwent cystoscopic evaluation of ureteral patency at the time of urogynecological surgery from May through December 2014 at a tertiary care referral center. We compared patients who received D10 cystoscopy fluid vs those who used normal saline. Outcomes included UTI and diagnosis of ureteral or LUT injuries. UTI was diagnosed according to Centers for Disease Control and Prevention guidelines by symptoms alone, urine dipstick, urinalysis, or urine culture. Descriptive statistics compared the rates of UTI between the 2 groups, and a multivariable model was fit to the data to control for potential confounders and significant baseline differences between the groups. RESULTS: A total of 303 women were included. D10 was used in 113 cases and normal saline (NS) was used in 190. The rate of UTI was higher in the D10 group than the NS group: 47.8% (95% confidence interval [CI], 38.3-57.4) vs 25.9% (95% CI, 19.8-32.8, P < .001). After adjusting for age, pelvic organ prolapse stage, use of perioperative estrogen, days of postoperative catheterization, menopausal status, diabetes mellitus, and history of recurrent UTI, the UTI rate remained significantly higher with the use of D10 (adjusted odds ratio, 3.4 [95% CI, 1.6-7.5], P = .002) compared with NS. Overall, 3 cases of transient ureteral kinking (1.0%) and one cystotomy (0.3%) were identified intraoperatively. However, ureteral and LUT injuries were not different between groups. No unidentified injuries presented postoperatively. CONCLUSION: Although the use of D10 cystoscopy fluid has been successful in identifying ureteral patency in the absence of indigo carmine, it is associated with an increased rate of postoperative UTI compared with NS.