Obstetric laceration repair in the United States: is there a common practice?

OBJECTIVE: To assess practice preferences in the repair of severe obstetric lacerations among obstetrician/gynecologists in the United States. STUDY DESIGN: A survey detailing third and fourth degree laceration repair techniques was distributed to 634 obstetrician/gynecologists from demographically diverse areas of the United States. Categorical outcomes were compared among respondents using chi2 or Fisher's exact test where appropriate. RESULTS: Of the 266 respondents, there were 124 self-reported "experts" (47%) and 106 physicians-in-training (40%). Repair techniques were compared between experts versus nonexperts and trainees versus practicing physicians. There were no significant differences found between either comparison group on the type and size of suture utilized or preferred method of closure for repair. CONCLUSION: There is little variation in the practice pattern of complex laceration repairs among obstetrician-gynecologists in the United States. This commonality should encourage the design of standard teaching models and techniques for physicians in training.

Periurethral aggressive angiomyxoma: a case report.

Aggressive angiomyxoma is a rare soft tissue tumor of the pelvis. Notorious for its locally infiltrative behavior, this tumor is identified by pathological appearance. Grossly gelatinous, spindle cells widely separated by collagen fibrils with vascular components can be microscopically visualized. Wide local excision is the treatment of choice. A 19-year-old woman presented with a periurethral mass that extended beyond the hymen with Valsalva. With imaging, the differential was narrowed to a soft tissue mass. Surgical excision was performed and histopathological findings were consistent with the diagnosis of aggressive angiomyxoma. Twenty-four months later the patient remains recurrence free. The typical findings of aggressive angiomyxoma are highlighted as well as the novel presentation as a periurethral mass. Histological and radiological findings are reviewed as well as current treatment options.

Neuropilin-VEGF signaling pathway acts as a key modulator of vascular, lymphatic, and inflammatory cell responses of the bladder to intravesical BCG treatment.

Recent findings indicate that VEGF receptors and coreceptors (neuropilins; NRP) are expressed on nonendothelial cells in human bladder urothelium, in one human bladder cancer cell line (J82), and in the mouse bladder urothelium. In addition, VEGFR1, VEGFR2, NRP1, and NRP2 expressions were upregulated in animal models of chronic bladder inflammation induced by four weekly instillations of protease-activated receptors (PAR)-activating peptides or bacillus Calmette-Guérin (BCG) into the mouse bladder. Here, we used four weekly instillations of BCG as a model for chronic bladder inflammation to further investigate whether VEGF receptors and NRPs play a role in the migration of inflammatory cells and inflammation-induced lymphangiogenesis and angiogenesis. For this purpose, we used neutralizing antibodies that were engineered to specifically block the binding of VEGF to NRP (anti-NRP1(B)) and the binding of semaphorins to NRP (anti-NRP1(A)). C57BL/6 mice received intraperitoneal injections of PBS, anti-NRP1(A)- or anti-NRP1(B)-neutralizing antibodies and then were challenged chronically with intravesical PBS or BCG. At the end of chronic challenge period, a fluorescent internalizable tracer, scVEGF/Cy5.5, was administered to all mice and near-infrared fluorescence images were obtained in vivo and in real time. BCG increased the overall accumulation of scVEGF/Cy5.5 in the urinary bladder urothelium and inflammatory cells. In addition, BCG increased the density of blood and lymphatic vessels concomitantly with an upregulation of NRP2 expression in lymphatic vessels. Treatment of the mice with NRP1-neutralizing antibodies dramatically reduced scVEGF/Cy5.5 uptake, polymorphonuclear (myeloperoxidase-positive cells) and dendritic cell (CD11c-positive cells) infiltration, and decreased the overall density of BCG-induced blood and lymphatic vessels. These results implicate NRPs as critical in vivo regulators of the vascular and inflammatory responses to the intravesical administration of BCG.

Training community gynecologists to perform intraoperative cystoscopy: a competency-based training experience.

OBJECTIVE: This study aimed to pilot a cystoscopy training program for community gynecologists that is validated by posttraining examination. METHODS: Twenty-eight gynecologists were trained to perform cystoscopy using a competency-based training approach. Baseline information included years in practice and number of incontinence procedures and/or cystoscopies performed per month. Three 5-hour workshops were administered that included applied practice. After learners individually trained until they felt comfortable with their skills on a model, they were individually tested on a cadaver. Performance was evaluated with 2 instruments, namely, a task-specific checklist and a global rating scale based on the objective structured assessment of technical skill model. Failure was defined as inability to independently complete elements of the task-specific checklist for cystoscopic examination. Likert-type self-report scales were used during pretesting and posttesting, assessing confidence to perform component tasks for diagnostic cystoscopy. RESULTS: Twenty-four of 28 trainees successfully performed a systematic cadaveric bladder examination during the primary posttest. After debriefing, the 4 trainees who initially failed successfully performed cystoscopy during a second trial. Median age was 51 years and median time in practice was 19.5 years. All participants reported high confidence in identifying ureteral injury at the course's conclusion. CONCLUSIONS: A task-specific training program can successfully improve the confidence and skill of community gynecologists to perform intraoperative diagnostic cystoscopy. Professionals may not be able to define when they have received enough instruction in terms of hands-on training with models, before acquisition of technical skills. Formal evaluation of technical skills is recommended after training to ensure competence.

Management of ileus and small-bowel obstruction following benign gynecologic surgery.

OBJECTIVE: To describe practice preferences for the diagnosis and management of ileus and small-bowel obstruction (SBO) following benign gynecologic surgery. METHODS: A secondary descriptive analysis was performed on data from a multicenter case-control study of patients who underwent gynecologic surgery and subsequently developed ileus or SBO. Information was collected regarding interventions such as type of imaging ordered for diagnosis, diet alterations, antiemetic administration, and need for reoperation. RESULTS: In total, 144 cases were identified. Abdominal X-ray was the most common imaging modality, occurring in 54 (37.5%) cases. Sixty-nine (65.1%) of the 106 women who underwent imaging were given definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]); 57.9% (n=11) of the SBO diagnoses and 90.0% (n=45) of the ileus diagnoses were managed conservatively. Eighteen (12.5%) patients underwent reoperation for bowel obstruction. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P=0.18), or between diet statuses on postoperative day 1 (P=0.08). CONCLUSION: Most study centers initially performed an abdominal X-ray for diagnostic purposes. The majority used a multimodal treatment approach. None of the management options decreased the likelihood of reoperation.

A case-control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery.

OBJECTIVE: To identify risk factors leading to the development of postoperative ileus and small-bowel obstruction (SBO) after benign gynecologic surgery. METHODS: In a multicenter case-control study across the United States, data were examined from women with International Classification of Diseases 9 (ICD-9) and Current Procedural Terminology (CPT) codes who underwent benign gynecologic surgery between January 2005 and June 2010 and subsequently developed an ileus or SBO. Each patient with ileus or SBO was matched to 2 control women who underwent the same benign gynecologic procedure but did not develop ileus or SBO. RESULTS: During the study period, 144 cases and 288 controls were identified. By conditional multivariate logistic regression, risk factors for ileus or SBO included cystotomy (odds ratio [OR], 8.7; 95% confidence interval [CI], 1.48-51.47), concomitant bowel surgery (OR, 4.3; 95% CI, 1.18-15.78), perioperative transfusion (OR, 2.9; 95% CI, 1.44-5.95), and lysis of adhesions (OR, 1.7; 95% CI, 1.03-2.83). CONCLUSION: Lysis of adhesions, concomitant bowel surgery, and perioperative complications such as blood transfusion and cystotomy were found to be risk factors for the development of ileus and/or SBO after benign gynecologic surgery.

Transmural vaginal-to-bladder injury from an obstructed labor pattern.

BACKGROUND: A vesicovaginal fistula, among other devastating sequelae, is a complication that can arise from obstetric trauma such as prolonged obstructed labor patterns. These are rarely seen as obstetric-related complications in well-developed countries. They are thought to arise from direct ischemic injury that can occur between the fetal head and the adjacent tissues. CASE: A patient presented to the emergency room in obstructed labor. Examination revealed a crowning fetal head, no fetal heart tones, and purulent vaginal discharge. Postpartum, the patient experienced irritative voiding symptoms, vaginal stenosis, and cystoscopic evidence of injury to the bladder base. CONCLUSION: These findings may provide evidence of the transmural vaginal-to-bladder damage that can occur from obstructed labor.