Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES: PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION: In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION: Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022326255.

Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review.

OBJECTIVE: To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans. METHODS OF STUDY SELECTION: Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible. TABULATION, INTEGRATION, AND RESULTS: Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature. CONCLUSION: Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021272678.

Medium-Term Outcomes of Conservative and Surgical Treatments for Stress Urinary Incontinence: A Medicare Claims Analysis: Developed by the AUGS Payment Reform Committee.

OBJECTIVE: This study aimed to evaluate the 3- to 5-year retreatment outcomes for conservatively and surgically treated urinary incontinence (UI) in a population of women 66 years and older. METHODS: This retrospective cohort study used 5% Medicare data to evaluate UI retreatment outcomes of women undergoing physical therapy (PT), pessary treatment, or sling surgery. The data set used inpatient, outpatient, and carrier claims from 2008 to 2016 in women 66 years and older with fee-for-service coverage. Treatment failure was defined as receiving another UI treatment (pessary, PT, sling, Burch urethropexy, or urethral bulking) or repeat sling. A secondary analysis was performed where additional treatment courses of PT or pessary were also considered a treatment failure. Survival analysis was used to evaluate the time from treatment initiation to retreatment. RESULTS: Between 2008 and 2013, 13,417 women were included with an index UI treatment, and follow-up continued through 2016. In this cohort, 41.4% received pessary treatment, 31.8% received PT, and 26.8% underwent sling surgery. In the primary analysis, pessaries had the lowest treatment failure rate compared with PT (P<0.001) and sling surgery (P<0.001; survival probability, 0.94 [pessary], 0.90 [PT], 0.88 [sling]). In the analysis where retreatment with PT or a pessary was considered a failure, sling surgery had the lowest retreatment rate (survival probability, 0.58 [pessary], 0.81 [PT], 0.88 [sling]; P<0.001 for all comparisons). CONCLUSIONS: In this administrative database analysis, there was a small but statistically significant difference in treatment failure among women undergoing sling surgery, PT, or pessary treatment, but pessary use was commonly associated with the need for repeat pessary fittings.

Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence.

ABSTRACT: Historically, our health care system has been based on a fee-for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a paradigm in which health care providers are incentivized to provide cost-effective, coordinated, value-based care in an effort to control costs and ensure high-quality care for all patients. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was created and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development.

Establishing Validity for a Vaginal Hysterectomy Simulation Model for Surgical Skills Assessment.

OBJECTIVE: To use the Messick validity framework for a simulation-based assessment of vaginal hysterectomy skills. METHODS: Video recordings of physicians at different levels of training and experience performing vaginal hysterectomy on a high-fidelity vaginal surgery model were objectively assessed using a modified 10-item Vaginal Surgical Skills Index, a one-item global scale of overall performance, and a pass-fail criterion. Participants included obstetrics and gynecology trainees and faculty from five institutions. Video recordings were independently assessed by expert surgeons blinded to the identities of the study participants. RESULTS: Fifty surgeons (11 faculty, 39 trainees) were assessed. Experience level correlated strongly with both the modified Vaginal Surgical Skills Index and global scale score, with more experienced participants receiving higher scores (Pearson r=0.81, P<.001; Pearson r=0.74, P<.001). Likewise, surgical experience was also moderately correlated with the modified Vaginal Surgical Skills Index and global scale score (Pearson r=0.55, P<.001; Pearson r=0.58, P<.001). The internal consistency of the modified Vaginal Surgical Skills Index was excellent (Cronbach's alpha=0.97). Interrater reliability of the modified Vaginal Surgical Skills Index and global scale score, as measured by the intraclass correlation coefficient, was moderate to good (0.49-0.95; 0.50-0.87). Using the receiver operating characteristic curve and the pass-fail criterion, a modified Vaginal Surgical Skills Index cutoff score of 27 was found to most accurately (area under the curve 0.951, 95% CI 0.917-0.983) differentiate competent from noncompetent surgeons. CONCLUSION: We demonstrated validity evidence for using a high-fidelity vaginal surgery model with the modified Vaginal Surgical Skills Index or global scale score to assess vaginal hysterectomy skills.

Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations.

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

Comparing Ketorolac With Ibuprofen for Postoperative Pain: A Randomized Clinical Trial.

OBJECTIVES: The objective of this study was to identify differences in pain perception and satisfaction with pain control in women receiving nonsteroidal anti-inflammatory drugs postoperatively. METHODS: This was a prospective, randomized controlled trial including urogynecology surgical patients. After surgery, all patients were randomized to receive either intravenous (IV) ketorolac or ibuprofen. The patients completed 3 visual analog scales (VAS) assessing pain at rest, pain with ambulation, and satisfaction with pain control. Postoperative opioid use was also measured. RESULTS: A total of 224 patients (112 in each arm) were included. Pain scores (SD) at rest in all patients who received ketorolac versus those who received ibuprofen was 2.30 (2.1) versus 2.68 (2.34) (P = 0.20). Pain scores (SD) with ambulation was 3.94 (2.57) versus 4.16 (2.73) (P = 0.57) in patients who received ketorolac and ibuprofen, respectively. Patients who received ketorolac rated their satisfaction with their pain regimen similarly to those who received ibuprofen (P = 0.50). The average amount (SD) of hydromorphone used in the ketorolac and ibuprofen arm was 3.68 (4.58) mg and 4.04 (4.97) mg, respectively (P = 0.58). A subgroup analysis based on type of surgery showed decreased pain at rest (VAS, 2.77 vs 4.88; P = 0.04) and increased satisfaction (VAS, 1.69 vs 4.67; P = 0.003) in patients who had laparotomy and received ketorolac. CONCLUSIONS: There was no difference in pain and satisfaction with IV ketorolac compared with IV ibuprofen in patients who underwent all modalities of urogynecologic surgery. A subgroup of patients who underwent laparotomy had less pain with ketorolac.

Developing expertise in gynecologic surgery: reflective perspectives of international experts on learning environments and processes.

Research in medical education does not provide a clear understanding of how professional expertise develops among surgeons and what experiential factors contribute to that development. To address this gap, the researchers interviewed 16 international experts in female pelvic medicine and reconstructive surgery to assess their reflective perceptions of what specific opportunities and experiences initiated and supported their development toward expertise in their field. Characteristics and influences explaining the speed and quality of expertise development were sorted into the following themes: the dynamic process of expertise development, internal and personal characteristics, general aptitudes and preparatory skills, role modeling and interpersonal influences, opportunities to learn and practice, and roles and reference points. Across the narratives and perspectives of these expert surgeons, both individual characteristics and choices, and contextual activities and opportunities were necessary and important. Experiences with greatest impact on quality of expertise development included those provided by the environment and mentors, as well as those sought out by learners themselves, to elaborate and supplement existing opportunities. The ideal combination across experts was interaction and integration of individual characteristics with experiential opportunities. Grounded in theory and research in expertise development, these findings can support improvement of medical education, both for individual mentors and strategic program development. As surgery evolves at a continuously increasing pace, effective mentoring of promising surgical trainees will be critical to ensure that future generations of gynecologic surgeons will remain excellent. Effective, efficient surgical expertise development requires identifying trainees with the appropriate characteristics and providing them with the best development opportunities.

Defining Expertise in Gynecologic Surgery: Perspectives of Expert Gynecologic Surgeons.

OBJECTIVE: The aim of this study was to describe how professional expertise is defined and understood among gynecologic surgeons and what experiential factors contribute to that understanding. METHODS: Semistructured interviews with 16 experts in Female Pelvic Medicine and Reconstructive Surgery were conducted to identify how expertise in their field is defined, recognized, and assessed. Independent thematic analysis of the interview transcripts was performed by each member of the research team and then distilled and synthesized into convergent themes. RESULTS: Experts described surgical expertise as difficult to define but with several dominant themes including knowledge, technical skills, clinical experience, adaptability, continuous learning, communication, and professional recognition. Expertise requires judgment in applying technical skills to meet each patient's specific needs. Experts described unique ways of seeing and thinking during surgery, characterized by spatial awareness of relevant anatomy, temporal awareness of future changes, and rapidly adaptive application of their skills enabling them to do difficult tasks with fluidity, making the tasks seem easy to observers. These expert surgeons acknowledged that achieving expertise requires hard work and maintaining expertise requires continuous learning, highlighted by challenge seeking to do the most difficult tasks in their field. They also noted the importance of effective communication of their knowledge to others, which contributes to their perception as experts by colleagues in the field. CONCLUSIONS: Surgical expertise is a complex phenomenon with several meaningful themes. Understanding the authentic nature of surgical expertise can be used to support the development of competencies and the effective mentoring of promising surgical trainees to achieve surgical expertise.

Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach.

BACKGROUND: Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy. METHODS: Literature searches were conducted for studies reporting the neuroanatomical sources of pain after abdominal surgery. Also, studies identified by preceding search were reviewed for relevant publications and manually retrieved. RESULTS: Based on neuroanatomy, an optimal surgical site infiltration technique would consist of systematic, extensive, meticulous administration of local anesthetic into the peritoneum (or preperitoneum), subfascial, and subdermal tissue planes. The volume of local anesthetic would depend on the size of the incision such that 1 to 1.5 mL is injected every 1 to 2 cm of surgical incision per layer. It is best to infiltrate with a 22-gauge, 1.5-inch needle. The needle is inserted approximately 0.5 to 1 cm into the tissue plane, and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection. CONCLUSIONS: Meticulous, systematic, and extensive surgical site local anesthetic infiltration in the various tissue planes including the peritoneal, musculofascial, and subdermal tissues, where pain foci originate, provides excellent postoperative pain relief. This approach should be combined with use of other nonopioid analgesics with opioids reserved for rescue. Further well-designed studies are necessary to assess the analgesic efficacy of the proposed infiltration technique.

The Location and Distribution of Transurethral Bulking Agent: 3-Dimensional Ultrasound Study.

OBJECTIVES: To use 3-dimensional endovaginal ultrasound to describe the location and distribution of bulking agent after an uncomplicated transurethral injection. METHODS: Endovaginal ultrasound was performed in 24 treatment-naive patients immediately after bulking agent was injected. The distance between the center of the hyperechoic density of bulking agent and the urethrovesical junction (UVJ) was measured in the sagittal and axial views. This was calculated in percentile length of urethra. Also, the pattern of tracking of bulking agent was assessed if it is presented. RESULTS: After the 2 subjects were excluded because of the poor quality of images, 22 patients were included in this study. Eighteen (82%) subjects showed 2 sites of bulking agents, and mostly, they were located around 3- and 9-o'clock positions. The average distance of bulking agent from left UVJ was at 16.9% of the length of the urethra (6.2 mm; range, 0.5-17 mm) and at 25.5% of the length of the urethra (8.9 mm; range, 0-24.8 mm) in the right side. The average length of urethra was 36.7 mm. Eleven of the 22 subjects (50%) had both sides within upper one third of urethra. The difference in distance between the 2 sides was less than 10 mm in 12 of 22 patients (54%). Nine of the 22 patients (41%) had a significant spread of bulking agent mostly either into the bladder neck or toward the distal urethra. CONCLUSIONS: Although the bulking agent is most often found at 3- and 9-o'clock positions as intended, the distance from the UVJ is highly variable after an uncomplicated office-based transurethral injection. The bulking material does not form the characteristic spheres in 41% of cases and tracks toward the bladder neck or the distal urethra.

Informed consent training improves surgery resident performance in simulated encounters with standardized patients.

BACKGROUND: Although informed consent is vital to patient-physician communication, little training is provided to surgical trainees. We hypothesized that highlighting critical aspects of informed consent would improve resident performance. METHODS: Eighty (out of 88) surgical postgraduate year 1 surgical residents were randomly assigned to one of the 2 cases (laparoscopic cholecystectomy or ventral herniorrhaphy) and instructed to obtain and document informed consent with a standardized patient (SP) followed by a didactic training session. The residents then obtained and documented informed consent with the other case with the other SP. SPs graded encounters ("Checklist"); trained raters graded notes. Repeated measures multivariate analysis of variance (MANOVA) was used to determine differences between pre- and post-training and Checklist versus "Note" scores. RESULTS: Statistically significant pre- to post differences for Note (P < .01) and Checklist (P < .01) along with significant differences between Note and Checklist (P < .01) were noted. CONCLUSIONS: Training improved surgery residents' ability to discuss and document informed consent. Despite this improvement, significant differences between discussion and documentation persisted. Documentation training is a future area for improvement.

Validity: applying current concepts and standards to gynecologic surgery performance assessments.

Validity is critical for meaningful assessment of surgical competency. According to the Standards for Educational and Psychological Testing, validation involves the integration of data from well-defined classifications of evidence. In the authoritative framework, data from all classifications support construct validity claims. The two aims of this study were to develop a categorization method for validity evidence published in support of surgery performance assessments and to summarize the results of applying this methodology to the gynecologic surgery literature. This was a critical analysis of published observations reported as validity evidence in studies with a construct validity claim. Medline and Embase databases were searched using keywords: "surgery" and "construct validity". Parameters included English-language articles published from 2000 to 2012. Gynecologic studies were analyzed for definitions of construct validity and nonstandard terminology. Categorization criteria were developed and applied by the researchers to all observations. Two independent evaluators examined reported observations for compliance with guidelines provided by the Standards. Inter-rater agreement was calculated using weighted kappa. The initial search returned 167 articles. Twenty-five articles were left for inclusion in our analysis. Eighteen (72 %) articles defined construct validity as the ability to discriminate between expert and novice levels of proficiency. Within the sample, 80 discrete observations of reported validity evidence were identified and categorized according to standard classifications. Nearly 30 % of all published observations intended to demonstrate differences in performance by level of proficiency, 25 % described a scoring model, and 14 % demonstrated support of assessment content. Not one article contained a statistical correlation between assessment scores and objective outcomes from the authentic surgical environment. Medians for level of rigor ranged from 0 to 1 across all forms of evidence. Weighted kappa values ranged 0.60-0.91. Validity claims in gynecologic surgical assessment over-rely on generalizability evidence. No test-criterion evidence was observed. Increased awareness of current standards and systematic argument development is needed for gynecologic performance assessments.

Pain management strategies for urogynecologic surgery: a review.

OBJECTIVES: The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. METHODS: A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. RESULTS: Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. CONCLUSIONS: Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

Compounded estradiol cream: a cost conscious alternative.

BACKGROUND: Vaginal estrogen is a common therapy for many gynecologic conditions. Medication cost poses a barrier to medication compliance. The purpose of our study is to report patient cost savings by utilizing compounding pharmacies in the preparation of topical vaginal estrogen. METHODS: A survey of 10 topical vaginal estrogen compounding pharmacies was performed and prescription cost data was obtained. The University of Oklahoma Outpatient Pharmacy and the 2008 Wolters Kluwer Health Pharmaceutical Audit Suite were cost comparisons for compounded estrogen. All data was processed using statistical software yielding descriptive statistics. RESULTS: The average cost of compounded estrogen was $42.22. At the University of Oklahoma Outpatient Pharmacy, average cost for branded vaginal estrogen preparation was $137.70. The national cost average for branded vaginal estrogen preparations was $82.42. Cost savings of $94.98 (69%) locally and $40.20 (51%) nationally was identified. CONCLUSIONS: Compounded estrogen is a cost conscious alternative than branded preparations.