A Novel, Structured Fellow Training Pathway for Robotic-Assisted Sacrocolpopexy.

INTRODUCTION: We developed a novel fellow education pathway for robotic-assisted sacrocolpopexy (RASC) and aimed to compare step-specific and total operative times for RASC performed by Female Pelvic Medicine and Reconstructive Surgery (FPMRS) attendings with those in which FPMRS fellows performed part or all of the RASC. We further aimed to compare complication and readmission rates by fellow involvement. METHODS: We tracked RASC at 1 institution between 2012 and 2018. We recorded times for total procedure, sacrocolpopexy, and 6 individual steps. Fellows were designated F1-F3 by training year. We used independent samples t-tests and analysis of variance for continuous variables and χ2 and Fisher's exact tests for categorical variables. RESULTS: Of 178 RASC procedures, 76 (42.7%) involved fellows. Concomitant procedures included hysterectomy (62.4%), midurethral sling (50%), and colporrhaphy/perineorrhaphy (51.7%). RASC without and with fellows had similar demographic, clinical, and procedural characteristics, except for midurethral sling rate (attending, 42.2% vs fellow, 60.5%; p = 0.02). RASC without and with fellows had similar times for total procedure (208.9 ± 61.0 vs 209.1 ± 48.6 minutes, p = 0.98), sacrocolpopexy (116.9 ± 39.9 vs 122.7 ± 29.2 minutes, p = 0.27), and all RASC steps except docking (attendings, 9.9 ± 8.6 vs fellows, 7.2 ± 7.0 minutes; p = 0.03). Complication rates and severity were similar without and with fellows. There were no readmissions. DISCUSSION/CONCLUSION: Our novel structured training program provides safe limitations for total and step-specific procedural times during fellowship education in RASC. Such training programs warrant further study to determine potential contribution to quality and safety in the teaching environment.

Opportunistic Salpingectomy at the Time of Urogynecologic Surgery: Why, in Whom, and How?

OBJECTIVES: This review aims to (1) describe evidence supporting the fallopian tube as a site of high-grade serous carcinoma, (2) review literature regarding salpingectomy in high- and average-risk women, and (3) discuss feasibility and safety of salpingectomy in urogynecologic surgery. METHODS: PubMed and university library resources were used to retrieve relevant English-language publications via keyword search, including "ovarian cancer," "salpingectomy," "risk," "safety," "hysterectomy," "trends," "technique," and "urogynecology." Each publication was reviewed in detail and references incorporated, where relevant. RESULTS: Evidence supports the fimbriated portion of the fallopian tube as a site of high-grade serous carcinoma in both hereditary and sporadic cases. Routine opportunistic salpingectomy in average-risk women may reduce ovarian cancer risk by 42% to 65% and prevent future surgery for benign tubal disease. Opportunistic salpingectomy is cost-effective for sterilization and cost-saving during hysterectomy. For genetically predisposed women, salpingo-oophorectomy remains the recommended strategy for ovarian cancer risk reduction. Despite being feasible, safe, and cost-effective, concomitant salpingectomy is least commonly performed during vaginal hysterectomy compared with other hysterectomy routes. Salpingectomy rates during vaginal hysterectomy are influenced by geographic factors, surgeon experience, and adhesive disease. CONCLUSIONS: Opportunistic salpingectomy holds promise as a risk-reducing intervention for ovarian cancer. The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommend that physicians counsel average-risk women regarding opportunistic salpingectomy when planning pelvic surgery. Randomized controlled trials are needed to evaluate long-term implications of salpingectomy. Urogynecologic surgeons should discuss salpingectomy as part of surgical informed consent. Vaginal salpingectomy should be incorporated into residency and fellowship training programs.

Ergonomics in gynecologic surgery.

PURPOSE OF REVIEW: Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and result in significant disability. We aimed to review the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations of gynecologic surgery. RECENT FINDINGS: Surgeon WMSDs are prevalent, with rates ranging from 66 to 94% for open surgery, 73-100% for conventional laparoscopy, 54-87% for vaginal surgery, and 23-80% for robotic-assisted surgery. Risk factors for injury in open surgery include use of loupes, headlamps, and microscopes. Unique risks in laparoscopic surgery include table and monitor position, long-shafted instruments, and poor instrument handle design. In vaginal surgery, improper table height and twisted trunk position create injury risk. Although robotic surgery offers some advantages in neck and shoulder strain, it remains associated with trunk, wrist, and finger strain. SUMMARY: WMSDs are prevalent among surgeons but have received little attention because of under-reporting of injury and logistical constraints of studying surgical ergonomics. Future research must aim to develop objective surgical ergonomics instruments and guidelines and to correlate ergonomics assessments with pain and tissue-level damage in surgeons with WMSDs. Ergonomics training should be developed and implemented in order to protect surgeons from preventable, potentially career-altering injuries.

Recurrence of Rectal Prolapse After Surgical Repair in Women With Pelvic Organ Prolapse.

BACKGROUND: Pelvic organ prolapse is prevalent among women with rectal prolapse. OBJECTIVE: This study aimed to determine whether clinically significant pelvic organ prolapse impacts rectal prolapse recurrence after surgical repair. DESIGN: A retrospective cohort. SETTING: This study was performed at a single managed-care institution. PATIENTS: Consecutive women undergoing rectal prolapse repair between 2008 and 2016 were included. INTERVENTIONS: There were no interventions. MAIN OUTCOME MEASURES: Full-thickness rectal prolapse recurrence was compared between 4 groups: abdominal repair without pelvic organ prolapse (AR-POP); abdominal repair with pelvic organ prolapse (AR+POP); perineal repair without pelvic organ prolapse PR-POP; and perineal repair with pelvic organ prolapse (PR+POP). Recurrence-free period and hazard of recurrence were compared using Kaplan-Meier and Cox proportional hazards methods. To identify potential confounding risk factors for rectal prolapse recurrence, the characteristics of subjects with/without recurrence were compared with univariable and multivariable analyses. RESULTS: Overall, pelvic organ prolapse was present in 33% of 112 women and was more prevalent among subjects with rectal prolapse recurrence (52.4% vs 28.6%, p = 0.04). Median follow-up was 42.5 months; rectal prolapse recurrence occurred in 18.8% at a median of 9 months. The rate of recurrence and the recurrence-free period differed significantly between groups: AR-POP 3.8%, 95.7 months; AR+POP 13.0%, 86.9 months; PR-POP 34.8%, 42.1 months; PR+POP 57.1%, 23.7 months (p < 0.001). Compared with AR-POP the HR (95% CI) of rectal prolapse recurrence was 3.1 (0.5-18.5) for AR+POP; 14.7 (3.0-72.9) for PR-POP and 31.1 (6.2-154.5) for PR+POP. Compared with AR+POP, PR+POP had a shorter recurrence-free period (p < 0.001) and a higher hazard of recurrence (HR, 10.2; 95% CI, 2.1-49.3). LIMITATIONS: The retrospective design was a limitation of this study. CONCLUSIONS: Pelvic organ prolapse was associated with a higher rectal prolapse recurrence rate and earlier recurrence in women undergoing perineal, but not abdominal, repairs. Multidisciplinary evaluation can facilitate individualized management of women with rectal prolapse. Abdominal repair should be considered in women with concomitant rectal and pelvic organ prolapse. See Video Abstract at http://links.lww.com/DCR/A513.

Pelvic muscles' mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model.

BACKGROUND: Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles' mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect. OBJECTIVE: We sought to determine the mechanical impact of parturition-related strains on pelvic floor muscles' microstructure, and test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery. STUDY DESIGN: Three-month-old Sprague-Dawley late-pregnant (N = 20) and nonpregnant (N = 22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and nonpregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in intrapartum rats (N = 4) sacrificed during fetal delivery. Data were compared with repeated measures and 2-way analysis of variance, followed by pairwise comparisons, with significance set at P < .05. RESULTS: Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to intrapartum sarcomere lengths in all muscles (P > .4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in nonpregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P < .0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles. CONCLUSION: Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition.

Ergonomics in Surgery: A Review.

OBJECTIVE: Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and may result in practice modification. We aimed to perform a comprehensive review of the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations by route of surgery. METHODS: Multiple searches were performed of PubMed and University library resources to access English-language publications related to surgeon ergonomics. Combinations of keywords were used for each mode of surgery, including the following: "ergonomics," "guidelines," "injury," "operating room," "safety," "surgeon," and "work-related musculoskeletal disorders." Each citation was read in detail, and references were reviewed. RESULTS: Surgeon WMSDs are prevalent, with rates ranging from 66% to 94% for open surgery, 73% to 100% for conventional laparoscopy, 54% to 87% for vaginal surgery, and 23% to 80% for robotic-assisted surgery. Risk factors for injury in open surgery include use of loupes, headlamps, and microscopes. Unique risks in laparoscopic surgery include table and monitor position, long-shafted instruments, and poor instrument handle design. In vaginal surgery, improper table height and twisted trunk position create injury risk. Although robotic surgery offers some advantages, it remains associated with trunk, wrist, and finger strain. Surgeon WMSDs often result in disability but are under-reported to institutions. Additionally, existing research tools face limitations in the operating room environment. CONCLUSIONS: Work-related musculoskeletal disorders are prevalent among surgeons but have received little attention owing to under-reporting of injury and logistical constraints of studying surgical ergonomics. Future research must aim to develop objective surgical ergonomics instruments and guidelines and to correlate ergonomics assessments with pain and tissue-level damage in surgeons with WMSDs. Ergonomics training should be developed to protect surgeons from preventable, potentially career-altering injuries.

Risk Factors for Unscheduled 30-day Readmission after Benign Hysterectomy.

OBJECTIVES: Readmission rates after hysterectomy have been reported, but specific risk factors for readmission have not been fully delineated. We aimed to determine risk factors for and implications of 30-day unscheduled readmission after benign hysterectomy using data from the American College of Surgeons National Surgical Quality Improvement Program. METHODS: We identified benign hysterectomy procedures recorded at all participating National Surgical Quality Improvement Program institutions between 2011 and 2012. Outcomes of interest were 30-day unscheduled readmission rates, variables associated with readmission, and complication and mortality rates associated with readmission. Bivariate analyses were performed using Pearson χ(2) and independent t tests for categorical and continuous variables, respectively. Multivariable regression analysis was performed to identify factors independently associated with readmission. RESULTS: In total, 21,228 hysterectomies were identified during the study period. Thirty-day readmission rates were 3.8% for abdominal hysterectomy, 2.7% for laparoscopic hysterectomy, 2.9% for laparoscopic-assisted vaginal hysterectomy, and 3.0% for vaginal hysterectomy. Readmission was associated with increased perioperative complications (49.2% vs 6.1%, P < 0.001), return to the operating room (26.3% vs 0.6%, P < 0.001), and mortality (0.3% vs 0.01%, P < 0.001). The most common complications in patients requiring readmission were surgical site infections (28.4%), sepsis (12.8%), urinary tract infection (9.7%), and blood transfusion (6.7%). Variables that were independently associated with 30-day readmission after multivariable regression analysis included younger age (odds ratio [OR] 0.98/year, P < 0.001), smoking (OR 1.28, P = 0.01), diabetes mellitus (OR 1.47, P = 0.008), dyspnea (OR 1.48, P = 0.04), bleeding disorders (OR 1.82, P = 0.04), American Society of Anesthesiologists class ≥ 3 (OR 1.32, P = 0.009), prior surgery within 30 days (OR 3.60, P = 0.04), longer operative time (OR 1.20 per hour of operative time, P < 0.001), inpatient status (OR 1.36, P = 0.001), and longer length of hospital stay (OR 1.04/day, P < 0.001). CONCLUSIONS: Using a large national database, we identified several patient-related and procedural risk factors for unscheduled 30-day readmission after hysterectomy. Readmission was associated with significantly higher rates of complications, a return to the operating room, and a 30-fold increase in mortality. Our findings reinforce the importance of patient selection and optimization of comorbidities before hysterectomy. Future research should aim to further delineate differential risks of readmission by surgical route as well as modifiable risk factors for readmission.

Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications.

STUDY OBJECTIVE: The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications after laparoscopic and robotic hysterectomy. DESIGN: Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by Current Procedural Terminology code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses using χ(2), Fisher's exact, and one-way analysis of variance tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications. DESIGN CLASSIFICATION: Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than 1 center or research group). SETTING: American College of Surgeons NSQIP. PATIENTS: Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP. INTERVENTIONS: None, retrospective database study. MEASUREMENTS AND MAIN RESULTS: Of the 7630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (1.0%), and blood transfusion (1.0%). Return to the operating room was required in 97 patients (1.3%), and there were 4 deaths, for a mortality rate of .05%. Complications increased steadily with longer operative time. Operative time ≥ 240 minutes was associated with increased overall complications (13.8% vs 4.6%, p < .001), surgical complications (5.4% vs 1.5%, p < .001), medical complications (10.4% vs 3.2%, p < .001), return to the operating room (2.7% vs 1.2%, p = .002), deep venous thrombosis (.5% vs .06%, p = .011), pulmonary embolism (.7% vs .1%, p = .012), and blood transfusion (3.4% vs .8%, p < .001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.28-1.54; p < .001), medical complications (OR, 1.42; 95% CI, 1.28-1.57; p < .001), surgical complications (OR, 1.32; 95% CI, 1.17-1.49; p < .001), venous thromboembolism (OR, 1.47; 95% CI, 1.12-1.92; p = .005), UTI (OR, 1.20; 95% CI, 1.05-1.36; p = .006), blood transfusion (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and return to the operating room (OR, 1.25; 95% CI, 1.08-1.45; p = .003). CONCLUSION: We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.

Ureteral Trauma During Transvaginal Ultrasound-Guided Oocyte Retrieval: A Case Report.

BACKGROUND: Transvaginal ultrasound-guided oocyte retrieval is a safe and well-tolerated procedure. Complications are uncommon and usually limited to vaginal bleeding and pelvic infection. Ureteral injury following oocyte retrieval is exceedingly rare, with only 8 previously reported cases. CASE: A 34-year-old woman developed gross hematuria 4 hours after transvaginal ultrasound-guided oocyte aspiration. Cystoscopy, laparoscopy, and retrograde pyelography revealed bleeding from the left ureter, no intra-abdominal bleeding, and a patent left urinary collecting system. The ureteral bleeding was successfully managed with placement of a ureteral stent. CONCLUSION: Ureteral trauma during transvaginal-guided oocyte retrieval is a rare complication with a variable clinical presentation. If ureteral injuries are not promptly recognized, significant morbidity may occur. This case demonstrates that early identification of injury and timely intervention result in favorable outcomes.

Venous thromboembolism in reconstructive pelvic surgery.

OBJECTIVE: We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS). STUDY DESIGN: Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables. RESULTS: In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037). CONCLUSION: The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

Risk factors for 30-day perioperative complications after Le Fort colpocleisis.

PURPOSE: We identified rates of and risk factors for complications after colpocleisis using the American College of Surgeons NSQIP® database. MATERIALS AND METHODS: Women treated with Le Fort colpocleisis from 2005 to 2011 were identified in the database. Primary outcomes were 30-day complication rates. Secondary outcomes were risk factors for complications and the impact of age and a concomitant sling on morbidity. Clinical and procedural characteristics were compared using the chi-square test and 1-way ANOVA. RESULTS: We identified 283 women, of whom 23 (8.1%) experienced complications. The most common complication was urinary tract infection in 18 women (6.4%). There was 1 death for a 0.4% mortality rate. Increased complications were associated with age less than 75 years (p = 0.03), chronic obstructive pulmonary disease (p = 0.03), hemiplegia (p = 0.03), disseminated cancer (p = 0.03) and open wound infection (p = 0.02). Six patients (2.1%) required return to the operating room within 30 days. Complication rates did not differ based on operative time (p = 0.78), inpatient status (p = 0.24), resident involvement (p = 0.35), concomitant sling placement (p = 0.81) or anesthesia type (p = 0.27). Women undergoing colpocleisis without (191) and with (92) a sling had similar baseline characteristics. Colpocleisis without and with a sling had similar rates of complications (7.9% vs 8.7%, p = 0.81), urinary tract infection (5.8% vs 7.6%, p = 0.55), return to the operating room (2.1% vs 2.2%, p = 0.97) and mortality (0% vs 1.1%, p = 0.15). CONCLUSIONS: Mortality and complication rates after colpocleisis are low with urinary tract infection being the most common postoperative complication. Concomitant sling placement does not increase 30-day complication rates.

Posttranslational regulation of I-Ed by affinity for CLIP.

Several MHC class II alleles linked with autoimmune diseases form unusually low stability complexes with CLIP, leading us to hypothesize that this is an important feature contributing to autoimmune pathogenesis. To investigate cellular consequences of altering class II/CLIP affinity, we evaluated invariant chain (Ii) mutants with varying CLIP affinity for a mouse class II allele, I-E(d), which has low affinity for wild-type CLIP and is associated with a mouse model of spontaneous, autoimmune joint inflammation. Increasing CLIP affinity for I-E(d) resulted in increased cell surface and total cellular abundance and half-life of I-E(d). This reveals a post-endoplasmic reticulum chaperoning capacity of Ii via its CLIP peptides. Quantitative effects on I-E(d) were less pronounced in DM-expressing cells, suggesting complementary chaperoning effects mediated by Ii and DM, and implying that the impact of allelic variation in CLIP affinity on immune responses will be highest in cells with limited DM activity. Differences in the ability of cell lines expressing wild-type or high-CLIP-affinity mutant Ii to present Ag to T cells suggest a model in which increased CLIP affinity for class II serves to restrict peptide loading to DM-containing compartments, ensuring proper editing of antigenic peptides.