Trainee Perspectives Regarding the Effect of the Dobbs v. Jackson Women's Health Organization Supreme Court Decision on Obstetrics and Gynecology Training.

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review.

OBJECTIVE: To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION: The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS: Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION: Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021234511.

Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review.

OBJECTIVE: To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM). DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators. METHODS OF STUDY SELECTION: We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group. TABULATION, INTEGRATION, AND RESULTS: Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function. CONCLUSION: Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVE: To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated. DATA SOURCES: PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines. METHODS OF STUDY SELECTION: Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded. TABULATION, INTEGRATION, AND RESULTS: Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes. CONCLUSION: Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021278796.

An evaluation of pelvic floor disorders in a public and private healthcare setting.

INTRODUCTION AND HYPOTHESIS: The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans. METHODS: A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type. RESULTS: A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size. CONCLUSIONS: Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.

Rate of Mesh Erosion After Sacrocolpopexy With Concurrent Supracervical Compared With Total Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of concomitant supracervical hysterectomy compared with total hysterectomy during abdominal sacrocolpopexy on the rate of mesh erosion by performing a systematic review and meta-analysis of the existing literature. DATA SOURCES: From database inception through January 2022, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov , and Cochrane Central Register of Controlled Trials. Studies comparing the rate of mesh erosion in women undergoing abdominal sacrocolpopexy who had concomitant supracervical hysterectomy compared with total hysterectomy were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of mesh erosion was compared, and odds ratios (ORs) with 95% CIs were estimated. TABULATION, INTEGRATION, AND RESULTS: Nineteen studies with 10,572 women who underwent abdominal sacrocolpopexy were identified, including 4,285 women in the supracervical group and 6,287 women in the total hysterectomy group. The overall mean postprocedure follow-up time was 30.7±15.1 months (median 12.4, range 1.5-44.2). The median (95% CI) point prevalence of mesh erosion was 0.36% (0-1.9%) in women who had supracervical hysterectomy compared with 3.8% (1.8-8.7%) in women who had total hysterectomy. The overall rate of mesh erosion in women who had supracervical hysterectomy was lower compared with women who had total hysterectomy (pooled OR 0.26, 95% CI 0.18-0.38, I 2 0%). CONCLUSION: In women with symptomatic apical pelvic organ prolapse who undergo abdominal sacrocolpopexy with concomitant hysterectomy, supracervical hysterectomy is associated with a lower risk of mesh erosion compared with total hysterectomy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022301862.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries. DATA SOURCES: PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included. METHODS: Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals. RESULTS: Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures. CONCLUSION: Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Postoperative Pain and Urinary Retention After Vaginal Reconstructive Surgery.

OBJECTIVE: The objective of this study was to evaluate the effect of patients' immediate prevoiding pain level after vaginal pelvic reconstructive surgery on their ability to void. METHODS: We conducted a retrospective cohort study of women with and without urinary retention after urogynecologic procedures. Postoperative pain, measured by a visual analog scale, was recorded for each patient before a voiding trial. Demographic, surgical characteristics, prevoiding trial pain, and rate of postoperative urinary retention were compared. Multiple-logistic regression analysis was used with all analyses controlled for univariate variables with a P value of ≤0.1 to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Two-tailed tests were used, with P < 0.05. RESULTS: A total of 458 patients were identified, of which 21% (97/458) failed their voiding trial. In our study, 62% (284/458) of women had a voiding trial on postoperative day 1, and 38% (174/458) underwent a same-day voiding trial. No differences were noted between groups comparing race, ethnicity, hysterectomy, urinary sling, estimated surgical blood loss, utilization of intraoperative or postoperative narcotics, or the proportion of same-day voiding trials. Women with postoperative urinary retention had higher mean prevoiding pain when compared with women without urinary retention (pain visual analog scale, 25 mm vs 12 mm [P < 0.001], respectively). After multiple-logistic regression analysis, a significant association between postoperative urinary retention persisted for prevoiding trial pain score (aOR, 1.02; 95% CI, 1.01-1.03), age (aOR, 1.05; 95% CI, 1.02-1.02), and anterior colporrhaphy (aOR, 2.13; 95% CI, 1.18-3.8). CONCLUSIONS: Prevoiding pain after pelvic surgery is significantly associated with increased rates of postoperative urinary retention.

Barriers to Care Affecting Presentation to Urogynecologists in a Community Setting.

OBJECTIVE: To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings. METHODS: Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care. RESULTS: One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01). CONCLUSION: This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care.

Empleabilidad de los egresados de Estomatología / Employability of graduates of Stomatology

RESUMEN Objetivo: Evaluar la empleabilidad de los egresados de estomatología en base a la Encuesta Nacional a Egresados Universitarios 2014 del Instituto Nacional de Estadística e Informática. Material y métodos: La investigación fue descriptiva, retrospectiva y transversal. La población del estudio fueron 245 egresados de 33 universidades del país, entre los años 2006 y 2010. Resultados: El 79,6% de los egresados se encontraban empleados y principalmente como odontólogos (77,3%), siendo el promedio de horas laboradas de 33,8 horas por semana y la retribución económica de 505,3 soles. El 33,5% de los egresados se encontraba en Lima, 68,25% titulados, 21,2% con grado de bachiller y el 33,5% con estudios de posgrado. El 22,2% tenían otro trabajo, principalmente de odontólogo (66,5%). El 35,1% cambió de empleo y el primer empleo tenía relación con la profesión en el 96,5%. El tiempo que toma conseguir el primer empleo es menor a un mes (40,7%) y por medio de familiares y amigos (37,2%). Conclusiones: Los egresados de estomatología adquirieron competencias para la empleabilidad.

SUMMARY Objective: To evaluate the employability of the stomatology graduates based on the National Survey of University Graduates 2014 of the National Institute of Statistics and Informatics. Material and methods: The research was descriptive, retrospective and transversal. The study population included 245 graduates from 33 universities in the country, from 2006 to 2010. Results: 79.6% of the graduates were employed and mainly as dentists (77.3%), with an average of 33.8 hours per week worked hours and an economic compensation of 505.3 soles. 33,5% of the graduates were in Lima, 68.25% graduates, 21.2% with a bachelor's degree and 33.5% with postgraduate studies. 22.2% had another job, mainly dentistry (66.5%). 35.1% changed employment and the first job was related to the profession in 96.5%. The time it takes to get the first job is less than one month (40.7%) and through family and friends (37,2%). Conclusions: Stomatology graduates acquired skills for employability.

Valoración del Podcasting en la enseñanza clínica en el área de odontología restauradora / Valuation of the use of Podcasting for clinical education in the area of restorative dentistry

RESUMEN Objetivo : Describir la valoración del podcasting en el proceso de aprendizaje en estudiantes de odontología en una universi- dad privada. Material y métodos : La investigación fue de naturaleza cuantitativa, descriptiva, no experimental. La muestra estuvo constituida por 47 estudiantes de una facultad de odontología de la ciudad de Lima, Perú. Para la experiencia se to- maron artículos en PDF de las clases teóricas cuyo contenido fueron grabados usando unos audífonos convencionales y el aplicativo de Spreaker REC® , aplicativo gratuito que se instaló en un teléfono inteligente Iphone 8, se procedió a grabar producir y editar en un tiempo menor a 15 minutos el artículo en PDF usando dicho aplicativo. Ulteriormente se envió al grupo de WhatsApp® el link para que pudieran acceder al audio. Este podía ser repetido tantas veces como el estudiante lo desee escuchar. Se realizaron tres Podcast. Se recolectó la información mediante encuestas a través de un cuestionario utilizado la escala tipo Licker. Resultados : El 70,22% de los encuestados consideraron que el podcast compartido en el grupo de WhatsApp® tuvo un a alta y muy alta contribución en su desempeño clínico. Se encontró que el podcast fue considerado como una herramienta de fácil consulta (95,74%), facilitan el aprendizaje (75,74%) y contribuye a aprender en menos tiempo (93,62%). El 62,07% lo consideró un buen recurso para contenidos teóricos. Conclusiones : Los estudiantes consideran que el podcast es una herramienta que contribuye a su aprendizaje, sobretodo es muy útil para el aprendizaje de contenidos teóricos.

SUMMARY Objective : To describe the valuation of podcasting as a tool in the learning process by dental students at a private university. Material and methods : The research was quantitative, descriptive, and non-experimental. The sample consisted of 47 students from a dental school. For the experience, articles in PDF format from the theoretical classes were recorded using conventional headphones and the application Spreaker REC®, a free application that was installed in a smartphone Iphone 8. The article in PDF format was processed, recorded and edited in less than 15 minutes using said application. Subsequently, the link was sent to the WhatsApp® group so the students could access the audio. The podcast could be repeated as many times as the student desired. Three podcasts were made. The information was collected through surveys using a Licker-type survey. Results : The 70.22% of the respondents considered that the shared podcasts in the WhatsApp® group had a high and very high contribution to their clinical performance. It was found that the podcasts were of easy consultation (95,74%), facilitated learning (75,74%) and contributed to a shorter learning time (93,62%). Overall, 62,07% considered podcasting a good resource for the theoretical content. Conclusions : Students consider that podcasting is a tool that contributes to their learning, particularly as a very useful vehicle for learning theoretical content.

Neural control properties of the external anal sphincter in young and elderly women.

AIMS: The prevalence of fecal incontinence (FI) increases with age and affects more than 15% of the elderly population. Sarcopenia, skeletal muscle structural, and functional decline with aging, is known to be caused by neuromuscular dysfunction. However, age-related alterations of the neuromuscular function of the external anal sphincter (EAS) have not been studied. This study aims to quantitatively characterize the effect of aging on the EAS by assessing the firing patterns and size of motor unit action potential (MUAP) using high-density surface electromyography (HD-sEMG) recording and analysis techniques. METHODS: Thirteen young (31.0 ± 3.6 years) and 14 elderly (64.3 ± 6.2 years) healthy women were recruited for this study. EMG activity of the EAS during maximal voluntary contraction was recorded by a 64-Channel, HD-sEMG intra-rectal probe. HD-sEMG signals were decomposed into MUAP spike trains to extract the firing rate and amplitudes thereof. RESULTS: HD-sEMG decomposition was successfully performed. For the young and elderly groups, mean motor unit (MU) firing rates of 11.4 ± 2.1 pulses per second (PPS) and 9.6 ± 2.3 PPS, and mean MUAP amplitudes of 45.2 ± 14.3 µV and 61.9 ± 21.2 µV were respectively obtained. Both the MU firing rate and MUAP amplitude were significantly different between two groups (P < .05). Moreover, the MUAP firing rate and amplitude correlated with age with a linear regression model (P < .05). CONCLUSIONS: This study represents the first effort to examine the effect of aging on the neuromuscular function of EAS. Results suggest an age-related impairment of lower motor neuron descending excitation to the EAS with a compensatory increase in mean MU size.

Improving Documentation of Obstetric Anal Sphincter Injuries (OASIS) Using a Standardized Electronic Template at Two University-Affiliated Institutions.

OBJECTIVES: Adequate repair is vital to reduce the long-term sequelae of obstetric anal sphincter injuries (OASIS). Sufficient documentation is necessary to reflect the quality of care provided, to guide future management, and to reduce medicolegal liability. With the advent of electronic health records, proper methods of documentation can be more easily disseminated and applied for general use. The objectives of our study were to assess whether documentation of OASIS management is improved by introducing a standardized electronic operative report, determining rates of readmission due to complications, and measuring adherence to practice guidelines. METHODS: A pre- and postintervention study was conducted by auditing electronic charts of patients affected by OASIS at two university-affiliated delivery units throughout the 2016 calendar year. Unit A is a safety-net hospital and unit B is private. A standardized electronic template was created in the electronic health records of both units. The primary outcome was the quality of repair documentation, which was quantified using a scale that included all relevant aspects of the repair. RESULTS: Analyzing both units separately, baseline characteristics including operator training level, episiotomy rate, and operative delivery were similar pre- and postintervention. The quality of documentation measured by the scale score improved significantly postintervention. Proper use of antibiotics and bowel regimen significantly increased after the intervention at both units. CONCLUSIONS: The use of a standardized electronic template for reporting the diagnosis and repair of OASIS improves the thoroughness of documentation and appears to promote the implementation of best practice guidelines.

Robotic Single-Site Sacrocolpopexy with Retroperitoneal Tunneling.

INTRODUCTION: This series of cases was an investigation of the safety and feasibility of robotic laparoendoscopic single-site surgery (R-LESS) as a method of performing sacrocolpopexy. CASE PRESENTATION: This is a retrospective series of 15 cases of R-LESS sacrocolpopexy with the V-Loc (Medtronic, Minneapolis, Minnesota, USA) suture and a retroperitoneal tunneling technique performed by a single surgeon, combined with a literature review. Patient demographic information and perioperative data were analyzed. The standard robotic sacrocolpopexy steps were followed, but the surgeon used a combined technique of V-Loc suture and retroperitoneal tunneling to simplify the procedure. No additional ports were necessary in any of the patients. MANAGEMENT AND OUTCOME: Using the pelvic organ prolapse quantification (POP-Q) scoring method, the mean preoperative C-point of the 15 patients was +1.16 compared to the mean immediate postoperative C-point, which was -5.5. The mean total sacrocolpopexy time was 74.7 (range, 50-99) minutes and mean mesh anchoring time was 22.60 ± 3.85 minutes. The mean sacral promontory fixation and tunneling and mesh position times were 11.87 ± 3.02 and 5.80 ± 2.14 minutes, respectively. All 15 cases were performed without perioperative or long-term complications. DISCUSSION: R-LESS in combination with the V-Loc suture and the retroperitoneal tunneling technique can be safely and feasibly performed, especially in sacrocolpopexy and, potentially, in other POP surgeries. With adequate and systematic training, surgeons can acquire the necessary skills to perform this complex surgical procedure.

On the variation in maternal birth canal in vivo viscoelastic properties and their effect on the predicted length of active second stage and levator ani tears.

The pubovisceral muscles (PVM) help form the distal maternal birth canal. It is not known why 13% of vaginal deliveries end in PVM tears, so insights are needed to better prevent them because their sequelae can lead to pelvic organ prolapse later in life. In this paper we provide the first quantification of the variation in in vivo viscoelastic properties of the intact distal birth canal in healthy nulliparous women using Fung's Quasilinear Viscoelastic Theory and a secondary analysis of data from a clinical trial of constant force birth canal dilation to 8 cm diameter in the first stage of labor in 26 nullipara. We hypothesized that no significant inter-individual variation would be found in the long time constant, τ2, which characterizes how long it takes the birth canal to be dilated by the fetal head. That hypothesis was rejected because τ2 values ranged 20-fold above and below the median value. These data were input to a biomechanical model to calculate how such variations affect the predicted length of the active second stage of labor as well as PVM tear risk. The results show there was a 100-fold change in the predicted length of active second stage for the shortest and longest τ2 values, with a noticeable increase for τ2 values over 1000 s. The correlation coefficent between predicted and observed second stage durations was 0.51. We conclude that τ2 is a strong theoretical contributor to the time a mother has to push in order to deliver a fetal head larger than her birth canal, and a weak predictor of PVM tear risk.

Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum. METHODS: In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate. RESULTS: From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2). CONCLUSION: The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.

A constitutive model description of the in vivo material properties of lower birth canal tissue during the first stage of labor.

Remarkable changes must occur in the pelvic floor muscles and tissues comprising the birth canal to allow vaginal delivery. Despite these preparatory adaptations, approximately 13% of women who deliver vaginally for the first time (nulliparas) sustain tears near the origin of the pubovisceral muscle (PVM) which can result in pelvic organ prolapse later in life. To investigate why these tears occur, it is necessary to quantify the viscoelastic behavior of the term pregnant human birth canal. The goal of this study was to quantify the in vivo material properties of the human birth canal, in situ, during the first stage of labor and compare them to published animal data. The results show that pregnant human, ovine and squirrel monkey birth canal tissue can be characterized by the same set of constitutive relations; the interspecies differences were primarily explained by the long time constant, τ2, with its values of 555s, 1110s, and 2777s, respectively. Quantification of these viscoelastic properties should allow for improved accuracy of computer models aimed at understanding birth-related injuries.

Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review.

OBJECTIVE: To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy. DATA SOURCES: MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries. METHODS OF STUDY SELECTION: Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14-0.7% compared with 0.02-0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04-1.92). Coronary heart disease (HR 1.26, 95% CI 1.04-1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27-2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results. CONCLUSION: Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.