Discharge Instruction Reminders Via Text Messages After Benign Gynecologic Surgery: Quasi-Experimental Feasibility Study.

BACKGROUND: With the implementation of enhanced recovery after surgery protocols and same-day hospital discharge, patients are required to take on increasing responsibility for their postoperative care. Various approaches to patient information delivery have been investigated and have demonstrated improvement in patient retention of instructions and patient satisfaction. OBJECTIVE:  This study aimed to evaluate the feasibility of implementing a postoperative text messaging service in the benign gynecologic population. METHODS:  We used a quasi-experimental study design to evaluate patients undergoing outpatient laparoscopic surgery for benign disease with a minimally invasive gynecologist at an academic medical center between October 2017 and March 2018. In addition to routine postoperative instructions, 19 text messages were designed to provide education and support to postoperative gynecologic patients. Patients were contacted by telephone 3 weeks postoperatively and surveyed about their satisfaction and feelings of connectedness during their recovery experience. Demographic and operative information was gathered through chart review. The cost to implement text messages was US $2.85 per patient. RESULTS:  A total of 185 patients were eligible to be included in this study. Of the 100 intended intervention participants, 20 failed to receive text messages, leaving an 80% success in text delivery. No patients opted out of messaging. A total of 28 patients did not participate in the postrecovery survey, leaving 137 patients with outcome data (control, n=75; texting, n=62). Satisfaction, determined by a score ≥9 on a 10-point scale, was 74% (46/62) in the texting group and 63% (47/75) in the control group (P=.15). Connectedness (score ≥9) was reported by 64% (40/62) in the texting group compared with 44% (33/75) in the control group (P=.02). Overall, 65% (40/62) of those in the texting group found the texts valuable (score ≥9). CONCLUSIONS:  Postoperative text messages increased patients' perceptions of connection with their health care team and may also increase their satisfaction with their recovery process. Errors in message delivery were identified. Given the increasing emphasis on patient experience and cost effectiveness in health care, an adequately powered future study to determine statistically significant differences in patient experience and resource use would be appropriate.

Translating Sexual Dysfunction: Does Language Impact Clinical Discussion of Painful Sex?

OBJECTIVES: Dyspareunia and sexual dysfunction are estimated to affect up to 22% and 43% of women, respectively. There is concern that these statistics do not depict the true prevalence and that these conditions are frequently undiagnosed and untreated. By 2060, Latinos will make up 30% of the total population in the United States. Because our patient population becomes more diverse, we need to ensure that our healthcare practices accommodate the changes. METHODS: We surveyed a convenience sample of 107 English and 71 Spanish-speaking women, aged 18 to 45 years, at university-affiliated clinics to identify the prevalence of dyspareunia and sexual dysfunction within our community. In addition, we wanted to identify the rate that clinicians discuss painful sex with patients to identify whether language impacted communication. The surveys collected data on subjective reporting of pain with sex and objective identification of sexual dysfunction with the Female Sexual Function Index. Additional questions identified if subjects discussed pain with their clinician. These questions were analyzed between languages across all domains. RESULTS: A greater prevalence of both dyspareunia and sexual dysfunction was measured in our study population compared with previous reports (37.79% and 54.71%, respectively). Spanish-speaking women had significantly lower self-reported dyspareunia (28.99%) but scored significantly lower on the Female Sexual Function Index, qualifying for sexual dysfunction (63.24%). Spanish speakers discussed painful sex significantly less compared with the English cohort, but the overall discussion rate was only 17.26%. CONCLUSIONS: These pilot data demonstrate a need for further research on language as a barrier to communication about sexual function in clinic.

60S acidic ribosomal protein P1 (RPLP1) is elevated in human endometriotic tissue and in a murine model of endometriosis and is essential for endometriotic epithelial cell survival in vitro.

Endometriosis is a female disease which is defined as the presence of ectopic endometrial tissue and is dependent on estrogen for its survival in these ectopic locations. Expression of the ribosomal protein large P1 (RPLP1) is associated with cell proliferation and invasion in several pathologies, but a role in the pathophysiology of endometriosis has not been explored. In this study, we aimed to evaluate the expression and function of RPLP1 with respect to endometriosis pathophysiology. RPLP1 protein was localised by immunohistochemistry (IHC) in eutopic and ectopic tissue from 28 subjects with confirmed endometriosis and from 20 women without signs or symptoms of the disease, while transcript levels were evaluated by qRT-PCR in 77 endometriotic lesions and 55 matched eutopic endometrial biopsies, and protein expression was evaluated using western blotting in 20 of these matched samples. To evaluate the mechanism for enhanced lesion expression of RPLP1, an experimental murine model of endometriosis was used and RPLP1 expression was localized using IHC. In vitro studies using an endometriosis cell line coupled with shRNA knockdown was used to demonstrate its role in cell survival. Expression of RPLP1 mRNA and protein were significantly higher in ectopic lesion tissue compared to paired eutopic endometrium and immunohistochemical localisation revealed predominant localisation to epithelial cells. This pattern of lesion RPLP1 was recapitulated in mice with experimentally induced endometriosis. Stable knockdown of RPLP1 protein resulted in a significant decrease in cell survival in vitro. These studies reveal that RPLP1 is associated with cell proliferation and/or survival and may play a role in the pathophysiology of endometriosis.

Imaging Findings in Transgender Patients after Gender-affirming Surgery.

Gender-affirming surgeries expand the options for physical transition among transgender patients, those whose gender identity is incongruent with the sex assigned to them at birth. Growing medical insight, increasing public acceptance, and expanding insurance coverage have improved the access to and increased the demand for gender-affirming surgeries in the United States. Procedures for transgender women, those patients with feminine gender identity, include breast augmentation using implants and genital reconstruction with vaginoplasty. Some transgender women receive medically unapproved silicone injections for breast augmentation or other soft-tissue contouring procedures that can lead to disfigurement, silicone pulmonary embolism, systemic reactions, and even death. MRI is preferred over CT for postvaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men, patients with a masculine gender identity, include chest masculinization (mastectomy) and genital reconstruction (phalloplasty or metoidioplasty, scrotoplasty, and erectile device implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as leaks and fistulas. Despite a sizeable growth in the surgical literature about gender-affirming surgeries and their outcomes, detailed descriptions of the imaging features following these surgeries remain sparse. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation. Online supplemental material is available for this article. ©RSNA, 2019.

Human endometriotic lesion expression of the miR-144-3p/miR-451a cluster, its correlation with markers of cell survival and origin of lesion content.

Endometriosis is an inflammatory condition in which endometrial tissue grows in ectopic locations. Survival and growth of these ectopic lesions is associated with pain and infertility. MicroRNAs (miRNAs) have been postulated to play a role in the pathophysiology of the disease and we have previously demonstrated expression of miR-451 in human endometriotic lesion tissue. Here we report elevated expression of the miR-144-3p/miR-451a cluster in human endometriotic lesion tissue. Use of an endometriotic epithelial cell line (12Z) in which the miRNA processing enzyme, DROSHA, was knocked down resulted in an enrichment in the primary (pri) form of miR-144-3p but not that of pri-miR-451a. Using an experimental mouse model of endometriosis in which ectopic endometriotic lesions were deficient for both of these miRNAs revealed that miR-451a, but not miR-144-3p may be derived from exogenous sources such as the circulation/erythrocytes. Together, these data suggest that the miR-144-3p/miR-451a cluster is expressed in human endometriotic lesion tissue, the level of expression correlates with survival status of the lesion tissue and that miR-451a, but not miR-144-3p may be derived from exogenous sources such as erythrocytes.

Laparoscopic Major Vascular Injury Simulation Using a Synthetic Compared With Porcine Model.

BACKGROUND: Major vascular injury training may improve clinical skills and reduce patient morbidity during gynecologic laparoscopy; thus, reliable models for simulation should be identified. METHOD: Two laparoscopic major vascular injury simulations using synthetic or live porcine models were constructed. The primary surgeon was given the opportunity to complete both simulations. After obtaining peritoneal access, the surgeon quickly encountered a major vascular injury. Degrading vital signs and estimated blood loss coupled with the replay of a human heartbeat that increased in volume and intensity were provided to heighten tension during the synthetic simulation. EXPERIENCE: Twenty-two gynecologic surgery educators evaluated the simulations. Educators considered the porcine model superior to the synthetic model with regard to tissue handling. The synthetic model simulation was found to be equivalent to the porcine model on how likely the simulation would be able to improve performance in a clinical setting. Educators were more likely to implement the synthetic simulation over the porcine simulation. CONCLUSION: The synthetic model was found to be more feasible and as effective as the porcine model to simulate and teach the initial management steps of major vascular injury at laparoscopy by gynecologic educators.

Barriers to Pelvic Floor Physical Therapy Regarding Treatment of High-Tone Pelvic Floor Dysfunction.

OBJECTIVE: Chronic pelvic pain is a prevalent and debilitating condition with a wide range of etiologies. An estimated 30% to 70% of chronic pelvic cases involve musculoskeletal component pain including high-tone pelvic floor dysfunction (HTPFD). Pelvic floor physical therapy has been shown to be a beneficial treatment for HTPFD, yet many patients do not have access to this treatment. The objective of this study was to identify the barriers preventing patients from following through with the first-line management, physical therapy. METHODS: Participants with a diagnosis of HTPFD (n = 154) were identified from the list of referrals sent from the obstetrics and gynecology department to an affiliated PFPT center. Participants were contacted and asked to complete a phone survey addressing demographics and perceived barriers to care. Responses were collected in REDCap. Univariate and bivariate analyses were performed using a statistical analysis software. RESULTS: Seventy surveys were completed. The top barriers identified by participants were financial constraints (51.4%), perceived lack of utility (37.1%), time constraints (30.0%), and travel issues (18.6%); 84.4% of participants had 1 or more comorbid pain condition. Whereas 51.4% expressed some level of anxiety regarding the PFPT option, only 9.6% of participants did not start treatment because of fear of treatment. CONCLUSIONS: The majority of treatment barriers identified were concrete restraints, with insurance noncoverage and time constraints being the top issues. A fair number of participants expressed anxiety about the treatment or felt they received unclear explanations of the treatment. These are areas in which providers can potentially alleviate some barriers to care.

Advances in urogynaecological robotic surgery.

• Urogynaecology is a subspecialty practiced by both urologists and gynaecologists specialised in treating women with pelvic floor disorders and urinary incontinence. • While urogynaecology covers a vast range of disorders, two disorders frequently managed by urogynaecologists are pelvic organ prolapse (POP) and pelvic fistulae. • Surgical intervention is often the treatment option for both POP and pelvic fistulae after all conservative options have been attempted. The daVinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) has applications for the minimally invasive surgical management of POP and pelvic fistulas. • The following review will address the development and current state of robotic assistance in treating these disorders.

Understanding the financial impact of robotics in gynecologic surgery.

As surgical innovation and technological advancements evolve, the associated costs cannot be overlooked. Currently, the United States health care system is undergoing an attempted overhaul with technology such as robotics sitting front and center of the financial debate. As patient demand for less invasive surgical options increases and standards of practice change, patient outcomes must be carefully evaluated to justify the costs increase from traditional, often more invasive treatments. The collection of financial data is quite varied among hospital systems and so is the models used to determine the costs of robotics. Although limited thus far, various cost data have been ascertained in the areas of reproductive surgery, hysterectomy (both benign and oncologic), and pelvic reconstructive surgery.

Role of robotic surgery in urogynecologic surgery and radical hysterectomy: how far can we go?

PURPOSE OF REVIEW: The purpose is to review the current literature regarding robotic assistance in urogynecologic surgery and radical pelvic surgery and to discuss the future of robotics in these two areas of gynecology. RECENT FINDINGS: When the first and only Food and Drug Administration-approved robot-assisted device, the daVinci surgical system, was approved for use in gynecology in April 2005, many procedures were translated to a robotic approach. In the field of urogynecology, much attention was given to the use of robotic assistance for sacrocolpopexy. In oncology, there was an attraction to the use of robotics for radical hysterectomies. There are a number of published observational studies comparing the outcomes of both robot-assisted laparoscopic sacrocolpopexy (RALS) and robot-assisted radical hysterectomy (RRH) to their conventional laparoscopic and open versions. Overall, the literature suggests that the use of robotics for these procedures increases operative time and cost, but decreases estimated blood loss and length of stay. The complication rates appear to be similar. Recurrence of apical prolapse after RALS appears to be similar to that in conventional laparoscopic or open sacrocolpopexy. The number of lymph nodes harvested is the same or increases with RRH, whereas the disease-free progression and overall survival are similar for all the methods of radical hysterectomy. SUMMARY: Literature suggests that RALS and RRH have equivalent outcomes when compared to conventional laparoscopic and open techniques. The question is whether the use of robotics that combines the outcomes of an open procedure, the benefits of minimally invasive surgery, and easy adoptability will outweigh the increased cost and time associated with robotic surgery.

Advanced uterine manipulation technologies.

As the number of conventional laparoscopic and robot-assisted gynecologic surgeries continues to rise, efficient and safe uterine manipulation has become increasingly important. Currently described uterine manipulation techniques require constant manual manipulation by the surgeon or surgical assistant. This often necessitates extra operating room personnel, increases fatigue levels, and decreases efficiency. There are two new uterine manipulation devices that can improve these measures: the Uterine Positioning System® (UPS) (Cooper Surgical, Trumbull, CT) and the ViKY UP® "Vision Control for endoscopY" Uterine Positioner (EndoControl Medical, La Tronche, France). Both provide accurate and secure uterine positioning. The UPS can manipulate the uterus with minimal bedside involvement from the surgical team while the ViKY UP provides uterine manipulation through a robotic arm controlled by the surgeon remotely. These two devices can facilitate a multitude of conventional laparoscopic and robot-assisted gynecologic surgeries.

Systemic inflammatory response during cardiopulmonary bypass and strategies.

Organ dysfunction after cardiopulmonary bypass (CPB) still is a major problem in patients undergoing cardiovascular surgery. Studies have demonstrated that systemic inflammatory response (SIR) remains one of the major causes of CPB-associated organ injury. The mechanism of SIR during CPB includes the interaction of blood and artificial surface and endotoxemia. The interaction of blood and artificial surface is initiated by protein adsorption. As a result of series of chain reactions, the numerous powerful inflammatory mediators, including hormones and autacoids, are formed and released. Subsequently, the contact system, coagulation system, complement system, fibrinolysis system, and leukocytes, platelets, and endothelial cells, are all activated to participate in the interaction of blood and artificial materials. These activations of different systems and blood cells can interact and magnify each other. CPB-associated endotoxemia has been demonstrated to intensify and deteriorate SIR during CPB. SIR leads to organ injury. In clinical setting, the most common SIR-related organ damage is pulmonary dysfunction, which often is manifested by decreasing of lung compliance, rise in shunt fraction, work of breathing, and likelihood of atelectasis and pneumonia. Strategies to control CPB-related SIR have been developed, such as improvement of biocompatibility of artificial surface (new biomaterials), temporary inhibition of blood cells activation ("blood anesthesia") during CPB, and blockage of the bioactivities and effects of inflammatory mediators.