Design, implementation and assessment of a novel, introductory curriculum into female, neurological and urodynamic urology: a 7-year experience of urology simulation bootcamp course.

PURPOSE: To present the seven-year experience of a multi-component and interactive module on female, neurological and urodynamic urology (FNUU) training at the UK National Urology Simulation Bootcamp Course (USBC) and demonstrate trainee satisfaction and competency progression. METHODS: During the week-long USBC, a four-hour module on FNUU was designed which consisted of short interactive presentations with an emphasis on practical stations in urodynamics, intravesical botulinum toxin injection, urethral bulking injection, female pelvic examination and, initially, mid-urethral tapes (subsequently replaced with percutaneous sacral nerve evaluation). The trainee's level of knowledge, operative experience and confidence were assessed pre- and post-course. The practical assessment consisted of preparation and intravesical administration of botulinum toxin, female pelvic examination, urodynamic trace interpretation or mid-urethral tape simulation. Trainee feedback was also collected. RESULTS: Two-hundred sixty-one newly appointed urology trainees participated in the USBC during this period. A high level of satisfaction was constantly reported. The highest rated session was urethral bulking with 72% being very satisfied, followed by Botox and urodynamics. The final assessment showed 70% had achieved level 4 competency in cystoscopy and Botox. Qualitative feedback was also obtained. CONCLUSION: To our knowledge, this is the first module of its kind, and it shows that it is feasible to develop, implement and evaluate an introductory curriculum into FNUU that is reproducible over a 7-year period with very positive feedback.

Management of levator ani avulsion: a systematic review and narrative synthesis.

PURPOSE: Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women. METHODS: MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427). RESULTS: Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients. CONCLUSIONS: Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

A review of levator ani avulsion after childbirth: Incidence, imaging and management.

Key Content • Levator ani muscle (LAM) avulsion injury occurs occultly during childbirth, most commonly during operative vaginal deliveries. • Injuries of levator ani have long term sequelae for pelvic floor health. As life expectancy increases the burden of disease upon urogynaecology services will need to be considered. • Diagnosis of this condition can be difficult as there is no agreed 'gold standard' imaging modality. • There is no consensus regarding surgical management of LAM avulsion. Learning objectives • Review anatomy and function of levator ani muscle • Identify the risk factors for levator ani avulsion injury • Role of imaging to appropriately identify LAM injury and current management options including appropriate follow up • Management of subsequent pregnancy following LAM avulsion Ethical issues • Is there value to the patient in diagnosing levator ani avulsion when there is no recommended treatment for these injuries?

The place of Kielland's forceps in reducing caesarean section rates.

The rise in births by caesarean section (CS) is a global issue. A skilled obstetrician with a midwife knowledgeable in Kielland's forceps (KF) is often able to achieve a successful rotational vaginal birth when safe. The KF, however, has risks--and outcomes must be audited. In this article we present the results of a literature review and retrospective audit, evaluate maternal and neonatal morbidity associated with KF in our unit and compliance with national standards. Our conclusion is that our unit complies with national standards and offers the woman an alternative to CS when it is safe to do so. Adverse outcomes with KF are not different from other modes of operative birth.

Perioperative outcomes and prospective patient reported outcome measures for transvaginal mesh surgery.

PURPOSE: To determine perioperative morbidity associated with the transvaginal mesh and analyse patient reported outcome measures following transvaginal mesh surgery via a prospective cohort study. METHODS: A retrospective review and a prospective cohort study of vaginal symptoms via a validated questionnaire (Ethically approved). 159 consecutive women who underwent transvaginal polypropylene mesh repair for pelvic organ prolapse from January 2009 to January 2012 by a single experienced urogynaecologist were identified using theatre records and formed the study population. The type and frequency of intraoperative and postoperative complications, mesh exposure rates and need for further surgery were recorded. 59/159 patients consented to complete both preoperative and postoperative assessment of vaginal symptoms using the validated International Consultation on Incontinence Modular Questionnaire-Vaginal symptoms (ICIQ-VS). 51/59 patients completed both questionnaires. RESULTS: The average age of the study population was 63 years (range 39-87 years). The mean BMI was 28.5 (range 20-40). 86 % (n = 138/159) had a previous hysterectomy. 98 % (n = 156/159) of patients did not have any intraoperative complications. 0.62 % (n = 1/159) had a bladder injury. Mesh exposure was noted in 4 % of the entire group (n = 6/135) at follow-up with overall reoperation rate of 9 % (n = 13/135). Statistically significant improvement in most arms of the ICIQ-VS questionnaire was noted in the cohort of 51 patients at follow-up. CONCLUSION: Our data revealed a very low intraoperative complication rate with a mesh exposure rate of 4 %. The prospective study showed a statistically significant improvement in vaginal symptoms.

Nerve hyperplasia: a unique feature of ketamine cystitis.

BACKGROUND: There is an emerging association between ketamine abuse and the development of urological symptoms including dysuria, frequency and urgency, which have a neurological component. In addition, extreme cases are associated with severe unresolving bladder pain in conjunction with a thickened, contracted bladder and an ulcerated/absent urothelium. Here we report on unusual neuropathological features seen by immunohistology in ketamine cystitis. RESULTS: In all cases, the lamina propria was replete with fine neurofilament protein (NFP+) nerve fibres and in most patients (20/21), there was prominent peripheral nerve fascicle hyperplasia that showed particular resemblance to Morton's neuroma. The nerve fascicles, which were positive for NFP, S100 and the p75 low-affinity nerve growth factor receptor (NGFR), were generally associated with a well-developed and in places, prominent, epithelial membrane antigen+/NGFR+ perineurium. This peripheral nerve fascicle hyperplasia is likely to account for the extreme pain experienced by ketamine cystitis patients. Urothelial damage was a notable feature of all ketamine cystitis specimens and where urothelium remained, increased NGFR expression was observed, with expansion from a basal-restricted normal pattern of expression into the suprabasal urothelium. CONCLUSIONS: The histological findings were distinguishing features of ketamine cystitis and were not present in other painful bladder conditions. Ketamine cystitis afflicts predominantly young patients, with unknown long-term consequences, and requires a strategy to control severe bladder pain in order to remove a dependency on the causative agent. Our study indicates that the development of pain in ketamine cystitis is mediated through a specific neurogenic mechanism that may also implicate the urothelium.

Obstetric anal sphincter injury in the UK and its effect on bowel, bladder and sexual function.

OBJECTIVE: To determine the incidence and factors associated with the development of bowel, urinary and sexual symptoms following obstetric anal sphincter injury (OASIS). STUDY DESIGN: A prospective cohort study involving 435 women who sustained OASIS, over a five-year period, in a large UK teaching hospital. Details of bowel, urinary and sexual function were documented using a structured questionnaire. The outcome measures included the incidence of symptoms following OASIS and factors which modify the risk of developing symptoms. RESULTS: The majority (96%) of women were faecally continent three months after primary OASIS repair. Nevertheless, 34.2% reported faecal urgency, 25% suffered poor flatal control, and nearly 30% reported pain and bleeding on defaecation. Sixteen percent of women reported stress urinary incontinence, 15% experienced urgency and 20% reported urinary frequency. Fifty-seven percent of women had resumed intercourse but 32% of those women reported dyspareunia. Women who developed faecal symptoms were significantly more likely to develop urinary symptoms. Advancing maternal age and the use of forceps, in particular rotational forceps, significantly increase the risk of developing faecal and urinary symptoms. CONCLUSIONS: Obstetric anal sphincter injuries continue to be responsible for significant morbidity, with approximately 30% of women reporting faecal, urinary or sexual symptoms, three months postpartum. This large prospective UK study provides up-to-date information relating to factors which increase the likelihood of such symptoms occurring. These data are useful for counselling and targeting more intensive follow up to women at higher risk of developing symptoms.

Assessing UK specialists' knowledge of the diagnostic criteria for painful bladder syndrome/interstitial cystitis.

The aim of this study was to assess UK clinicians' knowledge of the National Institute of Diabetes, Digestive and Kidney diseases (NIDDK) criteria for painful bladder syndrome (PBS)/interstitial cystitis (IC). A questionnaire survey was distributed nationally to 100 gynaecologists and urologists. The main outcome measure was to determine whether respondents knew the NIDDK diagnostic criteria for PBS/IC. All respondents cared for women with lower urinary tract dysfunction in their daily practice; 40% had a special interest in urogynaecology. Most (83%) knew that urgency, frequency and pain are required to diagnose PBS/IC; however, few were aware of exclusion/inclusion criteria. The minority perform double fill at cystoscopy, and only 56% were aware that glomerulations and/or Hunner's ulcers are required to diagnose IC. Urologists with a special interest in female urology answered nearly 75% of the questionnaire correctly in contrast to less than 40% of general gynaecologists. The findings suggest misdiagnosis of PBS/IC may be widespread in the UK. The NIDDK criteria are complex and appear to be of little relevance in clinical practice highlighting the need for more clearly defined diagnostic criteria.

Differentiation potential of urothelium from patients with benign bladder dysfunction.

OBJECTIVE: To develop a novel in vitro approach to test the hypothesis that failure of urothelial differentiation underlies the aetiopathology of interstitial cystitis (IC), where there is evidence of compromised urinary barrier function, as benign dysfunctional bladder disease encompass several poorly understood clinically defined conditions, including IC, idiopathic detrusor overactivity (IDO) and stress urinary incontinence (SUI). MATERIALS AND METHODS: Biopsy-derived urothelial cells from dysfunctional bladder biopsies were propagated as finite cell lines and examined for their capacity to differentiate in vitro, as assessed by the acquisition of a transitional cell morphology, a switch from a cytokeratin (CK)13(lo)/CK14(hi) to a CK13(hi)/CK14(lo) phenotype, expression of claudin 3, 4 and 5 proteins, and induction of uroplakin gene transcription. RESULTS: Two of 12 SUI cell lines showed early senescent changes in culture and were not characterized further; one of seven IC, one of five IDO and a further three SUI cell lines had some evidence of senescence at passage 3. Of the seven IC-derived cell lines, four showed a near normal range of differentiation-associated responses, but the remainder showed little or no response. Most IDO cell lines (four of five) showed a normal differentiation response, but at least three of the 10 SUI cell lines showed some compromise of differentiation potential. CONCLUSION: This study supports the existence of a subset of patients with IC in whom a failure of urothelial cytodifferentiation might contribute to the disease, and provides a novel platform for investigating the cell biology of urothelium from SUI and other benign dysfunctional conditions.

Groin abscess secondary to trans obturator tape erosion: case report and literature review.

AIMS: To report a case of groin abscess secondary to trans obturator tape erosion and review the literature on the incidence, predisposing factors, symptoms and management of tape erosion. METHODS: The clinical history, operative details, postoperative symptoms, findings and management of this case are reported. A thorough literature review of midurethral tape erosions and, in particular, transobturator tape erosions was performed. RESULTS: A 46-year-old woman with urodynamic stress incontinence underwent trans obturator tape insertion. Eight weeks later she developed vaginal discharge and was subsequently diagnosed with a left lateral vaginal wall tape erosion. The eroded section was excised under general anaesthetic. Two weeks later she presented with a large right sided groin abscess which required incision, drainage and debridement of necrotic areas of gracillis and adductor muscles. Short term results following trans obturator tape insertion report excellent efficacy rates (90-96% after 1 year), however there is a lack of long term data on safety and efficacy. Current literature on transobturator tape erosion is scanty and reported rates range from 1.9-7% depending on the tape inserted. Tape erosion commonly presents with vaginal discharge, bleeding or dyspareunia and several methods of management have been reported including conservative management, excision of the eroded section or removal of the entire tape. CONCLUSIONS: Groin abscess following tape erosion is a serious complication resulting in further surgery and months of morbidity for the woman. Prompt management of tape erosion is essential to minimise such complications and more data is required on the long term efficacy and safety of transobturator tapes.

Randomized controlled trial comparing Thermachoice III* in the outpatient versus daycase setting.

OBJECTIVE: To evaluate outpatient versus daycase Thermachoice III endometrial ablation. DESIGN: Randomized, controlled trial. SETTING: Large United Kingdom teaching hospital. PATIENT(S): Seventy-three women with menorrhagia. INTERVENTION(S): In the outpatient cohort (n = 39), women took ibuprofen 800 mg the evening before, and 1 hour before, performing Thermachoice III. Intraoperatively, they were offered "rescue analgesia" in the form of inhaled nitrous oxide. Postoperatively, women were offered oral tramadol 50-100mg. Neither local anesthetic nor IV sedation was used. In the daycase cohort (n = 34), women underwent a general anesthetic, i.e., propofol and inhalation gases. Intraoperatively, intravenous fentanyl 100 microg and rectal diclofenac 100 mg were administered. MAIN OUTCOME MEASURE(S): Main outcome measures included overall discomfort following Thermachoice III; intraoperative pain scores and a need for rescue analgesia during outpatient Thermachoice III; nausea and vomiting rates; and total time in hospital and the need for an overnight stay. RESULT(S): Eighty-seven percent (n = 34) of women in the outpatient cohort completed the full 8-minute treatment. The remaining five women requested the procedure be stopped because of pain. The mean intraoperative pain scores for the outpatient cohort remained below 45 mm (range, 0-100 mm) for every stage of treatment. The majority (64%) of women from the outpatient cohort required no rescue analgesia whatsoever. There was no significant difference between the overall mean pain score following Thermachoice III for either the outpatient (59 mm; range, 0-100 mm) or daycase (53 mm; range, 0-100 mm) cohorts. However, women from both cohorts reported wide ranges of pain scores (0-100 mm). There was no significant difference between the Likert -style descriptions of overall discomfort between the two groups, with the majority of women rating the pain as none to moderate. The presence of severe dysmenorrhea was statistically significantly correlated with higher overall visual analogue-style pain scores and Likert-style descriptions of discomfort. Significantly fewer women in the outpatient group experienced nausea (13% versus 65% in the daycase group) or vomiting (0 versus 24% in the daycase group), or required postoperative antiemetics (0 versus 56% in the daycase group). The mean total time spent in hospital was significantly shorter for the outpatient cohort at 1 hour and 40 minutes, versus 8 hours 12 minutes for the daycase group. CONCLUSION(S): Outpatient Thermachoice III could be performed in the majority (87%) of women, and was associated with similar overall pain scores as daycase Thermachoice III, however, the range was wide. Outpatient Thermachoice III was associated with significantly less nausea, vomiting, need for antiemetics, and time spent in hospital than was the daycase procedure.

Female sterilisation: a cohort controlled comparative study of ESSURE versus laparoscopic sterilisation.

OBJECTIVE: To compare patient satisfaction, discomfort, procedure time, success rate and adverse events of hysteroscopic (ESSURE, Conceptus Inc, San Carlos, USA) versus laparoscopic sterilisation. DESIGN: Cohort controlled comparative study. SETTING: The day surgery and outpatient unit of three large UK hospitals. POPULATION: Eighty-nine women requesting sterilisation were enrolled into the study. METHODS: A 2:1 ratio of ESSURE placement to laparoscopic sterilisation was undertaken. Laparoscopic sterilisation was carried out under general anaesthesia in the day surgery unit whereas all ESSURE procedures were carried out in a dedicated outpatient facility. All patients completed a self-assessment diary on days 7 and 90 post-operatively. Patient satisfaction, tolerance and discomfort were measured using an ordinal Likert style scale. Data were analysed using the chi(2) test for statistical significance. MAIN OUTCOME MEASURES: The primary outcome measure is patient satisfaction with ESSURE versus laparoscopic sterilisation. This included satisfaction with the decision to proceed with the relevant sterilisation method, recovery from the procedure and overall satisfaction following either ESSURE or laparoscopic sterilisation. Secondary outcome measures include successful completion of procedure, procedure time, tolerance, patient discomfort and post-operative adverse events. RESULTS: All women who underwent laparoscopic sterilisation had the procedure successfully completed whereas the overall bilateral device placement rate for ESSURE was 81%. Patient satisfaction with their decision to undergo either ESSURE or laparoscopic sterilisation was high with 94% of the ESSURE group being 'very' or 'somewhat' satisfied at 90 days post-procedure versus 80% in the laparoscopic sterilisation group. At 90 days post-procedure 100% of women in the ESSURE group were 'very satisfied' with their speed of recovery versus 80% in the laparoscopic sterilisation group. The procedure time (defined from the time of insertion of the hysteroscope or laparoscope to its removal) took significantly longer for ESSURE than laparoscopic sterilisation (mean = 13.2 vs 9.7 minutes, P= 0.045). However, the time required for insertion of a Verres needle and insufflation of the abdominal cavity is a necessary part of the laparoscopic sterilisation and had it been included would bring the procedures times more in line with each other. The mean time spent in hospital was significantly shorter for the ESSURE group than the laparoscopic group (188.7 vs 396.1 minutes, P < 0.005). Eighty-two percent of women in the ESSURE group described their tolerance of the procedure between 'good and excellent' compared with only 41% of the laparoscopic sterilisation group (P= 0.0002). Only 31% of the ESSURE group reported moderate or severe pain following the procedure compared with 63% of the laparoscopic sterilisation group (P= 0.08). Only 11% of patients had problems immediately post-operatively in the ESSURE group compared with 27% in the laparoscopy group. Finally, in the more medium term (three months post-operatively), patients still had an advantage in terms of post-procedure adverse events in the ESSURE group (21%vs 50%). CONCLUSIONS: This study provides evidence that ESSURE can be performed in the majority of women and, when successful, is associated with a greater overall patient satisfaction rate than laparoscopic sterilisation. Women also spend less time in hospital, have better tolerance of the procedure and describe less severe post-operative pain. However, the devices cannot be bilaterally placed in all cases and some women do not tolerate the procedure awake.

Thermachoice endometrial ablation in the outpatient setting, without local anesthesia or intravenous sedation: a prospective cohort study.

OBJECTIVE: To determine whether Thermachoice endometrial ablation (EA) is a safe and acceptable procedure when performed in the outpatient (OP) setting without local anesthesia or IV sedation. DESIGN: Prospective cohort (double group) study. SETTING: Hysteroscopy clinic of large UK hospital. PATIENT(S): Twenty-seven women with menorrhagia. INTERVENTION(S): The first cohort of women underwent Thermachoice EA without elective analgesia. The second cohort underwent Thermachoice after taking ibuprofen. MAIN OUTCOME MEASURE(S): To map pain scores and the requirement of "rescue analgesia." To assess speed of recovery and time away from home. RESULT(S): Thermachoice EA was successfully performed in the OP setting on 89% (n = 24) of women. Four women in the first cohort required rescue analgesia compared to none in the second. During the procedure there was little difference between the groups visual analogue style pain scores-with the overall score being 3.6 (range = 0-10). Postoperatively there was a lower mean pain score in the second cohort, with fewer women experiencing nausea and vomiting. Mean time away from home was 2.6 hours and mean time to make a full recovery was 3.3 days. Women required analgesia for 2.6 days, on average, and returned to their normal activities at this time. CONCLUSION(S): Thermachoice EA without local analgesia or IV sedation can be safely and successfully performed in the OP setting and if ibuprofen is taken preoperatively few women require "rescue analgesia."

The technique and overview of flexible hysteroscopy.

Flexible hysteroscopy is a safe, successful, and reliable method of investigation for abnormal uterine bleeding. When compared with rigid hysteroscopy flexible hysteroscopy is associated with less pain both at introduction of the hysteroscope and during the procedure itself especially when the diameter of the scope is reduced. This article provides evidence of the benefits of flexible hysteroscopy to the health service provider, clinician, and patient. Flexible hysteroscopy is acceptable to most women when performed in the outpatient setting without analgesia and offers a suitable alternative to rigid hysteroscopy.

Delivering an effective outpatient service in gynaecology. A randomised controlled trial analysing the cost of outpatient versus daycase hysteroscopy.

OBJECTIVE: To examine the cost implications of outpatient versus daycase hysteroscopy to the National Health Service, the patient and their employer. DESIGN AND INTERVENTIONS: Randomised controlled trial. SETTING: The gynaecology clinic of a large teaching hospital. PARTICIPANTS: Ninety-seven women with abnormal uterine bleeding requiring investigation. METHODS: Women were randomly allocated to either outpatient or daycase hysteroscopy. They were asked to complete diaries recording expenses and time off work. The National Health Service costs were calculated for a standard outpatient and daycase hysteroscopy. MAIN OUTCOME MEASURES: Costs to the National Health Service, costs to the employer, loss of income, childcare costs and travel expenses. RESULTS: The outpatient group required significantly less time off work compared with the daycase group (0.8 days vs 3.3 days), P < 0.001. Of those women who lost income due to the hysteroscopy, the average loss of income was twice as much in the daycase group ( pound 20.40 in the outpatient group vs pound 50.60 in the daycase group). The average cost of childcare required to cover the time spent in hospital undergoing the hysteroscopy was similar in both groups, however, the number of women requiring childcare was small. Travel costs incurred by the women were 74% more in the daycase group compared with the outpatient group-with an average cost of pound 3.46 in the outpatient group and pound 6.02 in the daycase group. Daycase hysteroscopy costs the National Health Service approximately pound 53.88 more per patient, than performing an outpatient hysteroscopy. Purchasing the hysteroscopes necessary to perform an outpatient hysteroscopy is a more expensive outlay than those required for daycase hysteroscopy. However, there are so many other savings that only 38 patients need to undergo outpatient hysteroscopy (even with a 4% failure rate) rather than daycase hysteroscopy in order to recoup the extra money required to set up an outpatient hysteroscopy service. CONCLUSION: Outpatient hysteroscopy offers many benefits over its traditional counterpart including faster recovery, less time away from work and home and cost savings to the woman and her employer and the National Health Service. Resources need to be made available to rapidly develop this service across the UK in order to better serve both patient and taxpayer.

Surviving hepatic rupture in pregnancy--a literature review with an illustrative case report.

Spontaneous hepatic rupture in pregnancy is a rare condition associated with significant maternal and perinatal mortality. Patients developing pre-eclampsia and especially HELLP syndrome require close monitoring for prompt diagnosis of hepatic rupture. However, the presenting symptoms and signs, e.g. epigastric pain, shoulder pain, nausea and vomiting, are common. Thus a high index of suspicion and early evaluation with imaging is vitally important. The important lesson to be learnt is that a Pfannenstiel incision does not allow for adequate assessment of the liver. If hepatic rupture is suspected a second upper abdominal incision should be performed. Improved survival can be achieved through early recognition and a multidisciplinary approach.