Evaluation of Real and Perceived Risk to Health Care Workers Caring for Patients With the Omicron Variant of the SARS-CoV-2 Virus in Surgery and Obstetrics.

OBJECTIVES: The Omicron variant of the SARS-CoV-2 virus is described as more contagious than previous variants. We sought to assess risk to health care workers (HCWs) caring for patients with COVID-19 in surgical/obstetrical settings, and the perception of risk among this group. METHODS: From January to April 2022, reverse transcription polymerase chain reaction was used to detect the presence of SARS-CoV-2 viral ribonucleic acid in patient, environmental (floor, equipment, passive air) samples, and HCWs' masks (inside surface) during urgent surgery or obstetrical delivery for patients with SARS-CoV-2 infection. The primary outcome was the proportion of HCWs' masks testing positive. Results were compared with our previous cross-sectional study involving obstetrical/surgical patients with earlier variants (2020-2021). HCWs completed a risk perception electronic questionnaire. RESULTS: Eleven patients were included: 3 vaginal births and 8 surgeries. In total, 5/108 samples (5%) tested positive (SARS-CoV-2 Omicron) viral ribonucleic acid: 2/5 endotracheal tubes, 1/22 floor samples, 1/4 patient masks, and 1 nasal probe. No samples from the HCWs' masks (0/35), surgical equipment (0/10), and air (0/11) tested positive. No significant differences were found between the Omicron and 2020/21 patient groups' positivity rates (Mann-Whitney U test, P = 0.838) or the level of viral load from the nasopharyngeal swabs (P = 0.405). Nurses had a higher risk perception than physicians (P = 0.038). CONCLUSION: No significant difference in contamination rates was found between SARS-CoV-2 Omicron BA.1 and previous variants in surgical/obstetrical settings. This is reassuring as no HCW mask was positive and no HCW tested positive for COVID-19 post-exposure.

Detection of SARS-CoV-2 contamination in the operating room and birthing room setting: a cross-sectional study.

BACKGROUND: The exposure risks to front-line health care workers caring for patients with SARS-CoV-2 infection undergoing surgery or obstetric delivery are unclear, and an understanding of sample types that may harbour virus is important for evaluating risk. We sought to determine whether SARS-CoV-2 viral RNA from patients with SARS-CoV-2 infection undergoing surgery or obstetric delivery was present in the peritoneal cavity of male and female patients, in the female reproductive tract, in the environment of the surgery or delivery suite (surgical instruments or equipment used, air or floors), and inside the masks of the attending health care workers. METHODS: We conducted a cross-sectional study from November 2020 to May 2021 at 2 tertiary academic Toronto hospitals, during urgent surgeries or obstetric deliveries for patients with SARS-CoV-2 infection. The presence of SARS-CoV-2 viral RNA in patient, environmental and air samples was identified by real-time reverse transcription polymerase chain reaction (RT-PCR). Air samples were collected using both active and passive sampling techniques. The primary outcome was the proportion of health care workers' masks positive for SARS-CoV-2 RNA. We included adult patients with positive RT-PCR nasal swab undergoing obstetric delivery or urgent surgery (from across all surgical specialties). RESULTS: A total of 32 patients (age 20-88 yr) were included. Nine patients had obstetric deliveries (6 cesarean deliveries), and 23 patients (14 male) required urgent surgery from the orthopedic or trauma, general surgery, burn, plastic surgery, cardiac surgery, neurosurgery, vascular surgery, gastroenterology and gynecologic oncology divisions. SARS-CoV-2 RNA was detected in 20 of 332 (6%) patient and environmental samples collected: 4 of 24 (17%) patient samples, 5 of 60 (8%) floor samples, 1 of 54 (2%) air samples, 10 of 23 (43%) surgical instrument or equipment samples, 0 of 24 cautery filter samples and 0 of 143 (95% confidence interval 0-0.026) inner surface of mask samples. INTERPRETATION: During the study period of November 2020 to May 2021, we found evidence of SARS-CoV-2 RNA in a small but important number of samples obtained in the surgical and obstetric operative environment. The finding of no detectable virus inside the masks worn by the health care teams would suggest a low risk of infection for health care workers using appropriate personal protective equipment.

Nomogram to Predict Risk of Postoperative Urinary Retention in Women Undergoing Pelvic Reconstructive Surgery.

OBJECTIVE: To develop a nomogram that determines an individual's risk of postoperative urinary retention (POUR) following pelvic floor reconstructive surgery. METHODS: We performed a retrospective chart review of women who underwent reconstructive surgery for pelvic organ prolapse and/or stress urinary incontinence. Short-term POUR was defined as failure of the trial of void (post-void residual >150 mL with a void of >200 mL) on postoperative day one or the need for re-catheterization in the first 2 postoperative days. Potential pre- and intraoperative risk factors for POUR were compared between patients with and without POUR. Multivariate binary logistic regression analysis with best-subsets variable selection was used to create a predictive nomogram. RESULTS: Most patients (275 of 332) had concomitant or combined procedures. The overall incidence of POUR was 31% (103 of 332 patients). The risk of POUR was higher for patients with high-grade anterior prolapse and those who had undergone anterior vaginal repair, vaginal hysterectomy, or a laparoscopic sling procedure. Patients who did not experience POUR tended to have fewer co-morbidities and were more likely to have undergone laparoscopic colposacropexy. Risk factors for POUR in the nomogram were diabetes, multiple medical co-morbidities, laparoscopic sling procedure, anterior vaginal repair, laparoscopic colposacropexy, and vaginal hysterectomy. The nomogram allows clinicians to calculate a patient's risk of POUR (range <10% to >80%). CONCLUSION: While the predictive nomogram in this study was developed using a single surgeon's case series and may not be generalizable to all surgeons, it demonstrates that the risk of POUR may be predicted based on clinical characteristics and the type of surgery performed. This kind of prediction model could help guide clinicians in preoperative patient counseling.

The Effect of Medical Consultation on Patients' Concerns Regarding Vaginal Mesh Use in Pelvic Reconstructive Surgery.

OBJECTIVE: This study sought to determine patients' background knowledge and attitudes towards the use of mesh in pelvic floor reconstructive surgery (PFRS) and the effect of medical consultation on their knowledge and attitudes about mesh use. METHODS: New urogynecology patients seen for pelvic organ prolapse and/or stress urinary incontinence were asked to complete pre-consultation questionnaires involving 12 questions on demographics and knowledge, attitudes, and concerns about the use of vaginal mesh. If PFRS was discussed, a post-consultation questionnaire was administered. RESULTS: A total of 202 new patients were surveyed. Of these patients, 73.8% had heard of vaginal mesh, and most of this information came from a media source followed by their health care provider. A total of 102 of 202 patients completed both the pre- and post-consultation questionnaire. Before medical consultation, patients' "level of concern" on a Likert scale (1 = not at all concerned, 10 = very concerned) was 5.98 ± 3.04. After consultation, the level of concern decreased significantly to 4.25 ± 2.68 (P = 0.00005). Before consultation, 33.3% of patients stated that they would be willing to proceed with surgery using mesh; however, after receiving standardized information on vaginal mesh risks and complications on the basis of the most current information available, 62.8% stated that they would be willing to proceed with mesh if required (P = 0.00001). CONCLUSION: Almost 75% of patients presenting for urogynecologic consultation had heard of vaginal mesh use, and 55.7% cited the media as their source of information. Medical consultation significantly reduced the patients' level of concern regarding the use of mesh in PFRS and significantly increased the proportion of patients willing to have mesh placed if appropriate.

Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict.

OBJECTIVE: In the health care sector, intercollegial conflict is inevitable. Such conflict may have an adverse effect on employee turnover, workplace morale, and patient safety and care. Conversely, skillful management of conflict may result in beneficial change and improvement. Improved conflict management (CM)/dispute resolution (DR) knowledge for health care professionals (HCPs) has been shown to reduce the negative impacts of conflict. This study aimed to determine whether HCPs feel equipped to manage collegial workplace conflict and whether they feel there is a need for CM training. METHODS: An electronic survey was developed to determine the attitudes, experience, and background training HCPs have had with CM, as well as whether respondents felt they needed CM/DR training. The survey was emailed to 660 HCPs in 2013 at Sunnybrook Health Sciences Centre, Toronto, Ontario. RESULTS: The response rate was 46% (303 of 660). Of 303 respondents, 128 (42%) reported previous formal training in CM/DR, but only 80 of 303 (26%) felt adequately trained to manage conflict and resolve disputes in the workplace, with 59% believing they need more conflict training. Among respondents, 76% wanted to see these skills incorporated into their own career training opportunities, but only 34% were aware of courses available to improve their CM/DR skills, and 50% stated they would be interested in taking such courses; 79% wanted to see these skills incorporated into medical school curricula. CONCLUSION: This needs assessment survey found that most HCPs did not believe that they have adequate training to manage workplace conflict comfortably, and they felt more training is needed in CM/DR.

Unusual Perils of Pelvic Organ Prolapse.

BACKGROUND: Prolapse can be treated with expectant management, pessary, or surgery. Although we consider the first two options benign, rare but serious complications can arise. CASE 1: A 64-year-old presented with recurrent grade 4 prolapse. After 6 months of expectant management, she developed a fistula from an ulcerated area of the prolapse into the peritoneal cavity. CASE 2: An 81-year-old who diligently cared for her ring pessary for 18 years presented with a vesicovaginal fistula. CASE 3: An 80-year-old with a longstanding pessary who stopped using vaginal estrogen for 2 years before developing a vesicovaginal fistula. CONCLUSION: Management of prolapse expectantly and with pessaries are effective treatments, especially to avoid surgery, but can present with their own unusual and infrequent complications, such as fistula formation.

The Unintended Consequences of an FDA Warning: The Case of Power Morcellation in Myoma Surgery.

OBJECTIVE: To study patients' perspectives regarding the risks and benefits of the use of power morcellation. DESIGN: Cross-sectional survey (Canadian Task Force classification II-3). SETTING: Academic tertiary referral hospital. PATIENTS: Women waiting in gynecology waiting rooms. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Of the 321 women invited, 310 (97%) responded to the survey; 19% of the participants had myomas requiring treatment, and the other 81% did not. Women with myomas were more likely to be aware of the risks of morcellation (32% vs 14%; p < .001); 29% obtained their information directly from their physicians, while 71% obtained it from other resources. After reading about the risks and benefits of open and MIS approaches to myoma removal, 65% would choose an MIS approach if the risk of cancer spread was up to 0.3% (1 in 350). The majority of women (75%) felt that the government should not have a role in surgical decision making, but should provide information to help patients make decisions. CONCLUSION: Women have different risk tolerances. Most women would be willing to take the 1 in 350 (0.3%) risk of undiagnosed sarcoma spread to benefit from MIS approaches. FDA warnings may have unintended consequences by limiting the acceptable medical choices available for patients.

Laparoscopic two-team slings for women with stress urinary incontinence.

STUDY OBJECTIVE: To review long-term success and complication rates of laparoscopic two-team sling procedures in women with stress urinary incontinence or mixed incontinence confirmed by urodynamic testing and cystoscopy. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Tertiary urogynecology unit at a university-affiliated teaching hospital. PATIENTS: One hundred seventy-five women. INTERVENTIONS: Laparoscopic two-team sling procedure. MEASUREMENTS AND MAIN RESULTS: The extraperitoneal approach to the space of Retzius was accomplished using a balloon device, and the intraperitoneal approach involved a transverse incision through the anterior parietal peritoneum 6 cm above the symphysis. A 1.5- to 2.0-cm wide strip of polypropylene mesh was inserted through a vertical incision along the anterior vaginal wall, perforating the urogenital diaphragm under laparoscopic guidance. The mesh was sutured to Cooper's ligaments bilaterally with 0 polypropylene sutures. Mean operating time was 80.1 +/- 30.0 minutes, mean estimated blood loss was 160 +/- 146 ml, and mean hospital stay was 2.4 +/- 1.2 days. Patients were followed at 6 weeks, 6 months, 1 year, and yearly (mean 17.8 mo, range 1-5 yrs). CONCLUSION: Laparoscopic two-team sling procedures can be performed safely in women with recurrent stress incontinence and those with risk factors for failure of retropubic urethropexy. Long-term success rates are excellent (91.1%) with few complications.