Endometrial Cancer Surgery With or Without Concomitant Stress Urinary Incontinence Surgery.

OBJECTIVE: To compare quality of life (QOL) among patients with endometrial intraepithelial neoplasia or early-stage endometrial cancer and stress urinary incontinence (SUI) who chose to have concomitant surgery with cancer surgery alone. METHODS: A multicenter, prospective cohort study was conducted across eight U.S. sites. Potentially eligible patients were screened for SUI symptoms. Those who screened positive were offered referral to urogynecology and incontinence treatment, including concomitant surgery. Participants were categorized into two groups: 1) concomitant cancer and SUI surgery or 2) cancer surgery alone. The primary outcome was cancer-related QOL as measured by the FACT-En (Functional Assessment of Cancer Therapy-Endometrial) (range 0-100; higher score indicates better QOL). The FACT-En and questionnaires assessing urinary symptom-specific severity and effects were assessed before surgery and 6 weeks, 6 months, and 12 months after surgery. Adjusted median regression accounting for clustering was used to examine the relationship between SUI treatment group and FACT-En scores. RESULTS: Of 1,322 (53.1%) patients, 702 screened positive for SUI with 532 analyzed; 110 (21%) chose concomitant cancer and SUI surgery, and 422 (79%) chose cancer surgery alone. FACT-En scores increased for both the concomitant SUI surgery and cancer surgery-only groups from the preoperative to the postoperative period. After adjustment for timepoint and preoperative covariates, the median change in FACT-En score (postoperative-preoperative) was 1.2 points higher (95% CI -1.3 to 3.6) for the concomitant SUI surgery group compared with the cancer surgery-only group across the postoperative period. Median time until surgery (22 days vs 16 days; P <.001), estimated blood loss (150 mL vs 72.5 mL; P <.001), and operative time (185.5 minutes vs 152 minutes; P <.001) were all greater for the concomitant cancer and SUI surgery group compared with the cancer-only group, respectively. CONCLUSION: Concomitant surgery did not result in improved QOL compared with cancer surgery alone for endometrial intraepithelial neoplasia and patients with early-stage endometrial cancer with SUI. However, FACT-En scores were improved in both groups.

Do Women Who Self-report More Exercise Have Increased Rates of Symptomatic Stress Urinary Incontinence After Midurethral Slings?

OBJECTIVES: There is a paucity of data on postoperative exercise and how it relates to surgical failure, specifically after midurethral sling (MUS) surgery. We aimed to assess if women with higher self-reported activity levels as measured by strenuous exercise are more likely to experience stress urinary incontinence (SUI) symptoms after MUS than women with lower self-reported activity. METHODS: This is a secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss: the OPTIMAL Trial, a randomized trial comparing sacrospinous ligament suspension versus uterosacral ligament suspension, both with concomitant retropubic MUS. Participants completed a validated assessment of activity preoperatively and postoperatively. Women in the upper quartile for strenuous exercise (≥90 minutes per week) were compared with the remaining participants. Symptomatic SUI was defined as retreatment or reoperation for SUI and/or any positive response to Pelvic Floor Disorders Inventory stress incontinence questions 20 to 22. RESULTS: A total of 351 participants in the OPTIMAL study received MUS along with their prolapse repair and had postoperative exercise and Pelvic Floor Disorders Inventory data. At 2 years, 87 (29%) of 305 exercised strenuously for at least 90 minutes per week, and 63 (23%) of 277 experienced SUI. Women who were less active at 2 years were significantly more likely to experience SUI than women who were more active (26.6% vs 12.8%, P = 0.0138). CONCLUSIONS: In this study, symptomatic SUI occurred more frequently in women with lower self-reported exercise levels 2 years after MUS surgery.

Ready for the robot? A cross-sectional survey of OB/GYN fellowship directors' experience and expectations of their incoming fellow's robotic surgical skills.

To describe OB/GYN fellowship directors' (FDs) observations, expectations, and preferences of incoming fellow's robotic surgery preparedness. Cross-sectional study. OB/GYN FDs in gynecologic oncology, minimally invasive gynecologic surgery, female pelvic medicine and reconstructive surgery, and reproductive endocrinology and infertility in the United States. 60 FDs answered the questionnaire. Participants completed an online questionnaire about their preferences and expectations of robotic surgery experience for incoming fellows. FDs observed that many incoming first-year fellows had a baseline understanding of robotic technology (60%) and robotic bedside assist experience (53%). However, few could perform more advanced robotic tasks; with FDs indicating fellows could infrequently robotically suture (18%), or perform the entire hysterectomy (15%). FDs reported higher composite observation than expectation scores (34.3 versus 22.2, p < 0.0001), and higher preference than expectation scores (34.0 versus 22.2, p < 0.0001). The composite expectation score of high-volume divisions was greater than of low-volume divisions (23.7 versus 14.0, p = 0.04). Among the domains identified, FDs most strongly preferred their fellows be able to bedside assist, have a basic understanding of robotic technology, and have basic robotic operative skills. While incoming fellows have more robotic skill than their FDs expect, few are deemed competent to independently operate the robot. Higher volume robotic surgery divisions have higher expectations of the robotic skills of their incoming fellows compared to low-volume divisions; however, FDs neither expected nor preferred their incoming fellows to be fully competent in all aspects of robotic surgery.

Can I Get a Suggestion? Medical Improv as a Tool for Empathy Training in Obstetrics and Gynecology Residents.

BACKGROUND: Physician empathy is associated with improved patient outcomes. No studies have examined the outcomes of medical improvisational (improv) training on empathy. OBJECTIVE: Our aims were to determine whether an improv workshop is an effective tool to deliver empathy training for obstetrics and gynecology (OB-GYN) residents, and whether that effect is sustained over time. METHODS: We conducted a prospective cohort study of OB-GYN residents undergoing empathy training through 4 improv games in a 1-hour session. Empathy surveys (score range 20-140) with validity evidence were administered 2 weeks prior to empathy training, immediately after, and 1, 3, and 6 months later. Fisher's exact test, Student's t test, and Wilcoxon rank sum test were used to compare statistical differences at each post-intervention assessment. RESULTS: All 22 invited residents participated in empathy training. Empathy scores improved immediately after (120.0 ± 9.8 versus 113.1 ± 10.6, P = .026), though they regressed toward baseline through 6 months (116.3 ± 11.0 versus 113.1 ± 10.6, P = .43). When asked on a scale of 1-5 how much the workshop would impact their work, there was an increase in scores both immediately after (mean 3.5 versus 4.6, P < .001) and 1 month later (mean 3.5 versus 4.1, P = .039), but this difference disappeared at 6 months. CONCLUSIONS: Using improv comedy to deliver empathy training is associated with a minor improvement in empathy scores in OB-GYN residents, which decreased at 6 months. Residents found the activity to be acceptable and reported the training would impact their clinical practice.

Audiovisual stimulus during urodynamics to provoke detrusor overactivity: A randomized trial.

OBJECTIVE: This study estimated the effect of adding an audiovisual (AV) intervention during urodynamic evaluation (UDE) on increasing detrusor contractions (DO) versus routine UDE testing without AV cues. METHODS: A randomized trial was conducted of women with overactive bladder (OAB) undergoing UDE with and without AV intervention. The AV intervention was a 1-minute video on continuous loop showing common OAB triggers. A continuous running waterfall provided auditory stimulation. The primary outcome was the proportion of patients who had DO on UDE, interpreted by masked clinicians. Secondary outcomes included the number, amplitude, and duration of DO and urinary leakage associated with DO. A sample size of 109 per group was calculated to have 80% power to detect a 20% difference with a significance level of 0.05. RESULTS: In all, 109 women each were randomized to standard UDE and to the AV intervention. There was no difference in the proportion of patients with DO on UDE between the intervention and control groups (35% vs 32%, respectively; P = 0.8). Furthermore, there were no differences between the intervention and control groups in leakage with DO on UDE (24% vs 21%, respectively), mean duration of detrusor contractions (23.9 vs 25.3 s, respectively), or mean maximum detrusor pressure during involuntary contractions (18.1 vs 20.6 cm H2 O, respectively). Clinical severity of OAB symptoms was not associated with the detection of DO or other UDE parameters. CONCLUSIONS: Addition of AV intervention during UDE did not increase the finding of detrusor contractions. The relationship between OAB triggers, urge incontinence, and urodynamic findings remains unclear.

Pelvic floor disorders in women with gynecologic malignancy.

PURPOSE OF REVIEW: This article serves as an update on issues relating to the intersection of pelvic floor disorders and gynecology oncology. RECENT FINDINGS: Gynecologic cancer survivors experience pelvic floor disorders (PFDs) at a higher rate than their age-matched peers, often because of shared risk factors and as sequelae of cancer treatment. Concomitant pelvic floor and oncologic surgery can serve as a method to promote quality of life. Studies have demonstrated concomitant surgery to be well tolerated in appropriately selected patients, but only about 2% of oncologic surgeries are coordinated to include the treatment of PFDs. Conversely, women undergoing surgery for PFD have a low, but real risk of occult malignancy. Therefore, preoperative counseling is warranted in select populations. This article will discuss the management of concurrent PFDs and gynecologic malignancies. SUMMARY: Healthcare providers should be familiar with screening, management and referral of women with pelvic floor disorders in the gynecologic oncology population.

Incorporating simulation into gynecologic surgical training.

Today's educational environment has made it more difficult to rely on the Halstedian model of "see one, do one, teach one" in gynecologic surgical training. There is decreased surgical volume, but an increased number of surgical modalities. Fortunately, surgical simulation has evolved to fill the educational void. Whether it is through skill generalization or skill transfer, surgical simulation has shifted learning from the operating room back to the classroom. This article explores the principles of surgical education and ways to introduce simulation as an adjunct to residency training. We review high- and low-fidelity surgical simulators, discuss the progression of surgical skills, and provide options for skills competency assessment. Time and money are major hurdles when designing a simulation curriculum, but low-fidelity models, intradepartmental cost sharing, and utilizing local experts for simulation proctoring can aid in developing a simulation program.

Vesicovaginal fistula: an unexpected consequence of changing sexual practices?

Vesicovaginal fistula (VVF) is commonly associated with obstetric trauma, but in developed nations it is typically iatrogenic. To date, there have been no published reports of VVF resulting from consensual sexual activity with sex toys. A 19-year-old gravida 0 presented with leakage of clear urine from the vagina following repetitive use of a sex toy with her female partner. The fistula was repaired in the operating room using a vaginal approach and a layered closure. This is the first case report of a VVF caused by consensual sex toy use between same-sex partners. As sex toy use increases, counselling providers will need to be aware of possible adverse sequelae.

Recurrence of Stress Urinary Incontinence After Midurethral Sling Revision: A Retrospective Cohort Study.

OBJECTIVES: The primary objective is to determine the relative risk (RR) of reoperation for stress urinary incontinence (SUI) recurrence after midurethral sling (MUS) division or excision. Our secondary objective is to determine the RR of SUI symptom recurrence according to differing techniques of revision. METHODS: This is a retrospective cohort study of all women who underwent surgical revision of an MUS by the Division of Urogynecology at the Women & Infants' Hospital during a 10-year period between October 1, 2004, and October 1, 2014. Sling division technique separates the sling from the urethra enough to permit transection either in the midline or lateral to the urethra. Revision was categorized as excision if a portion or the entirety of the sling was removed. Patients who underwent any operative procedure for SUI after revision were considered to have received reoperation. Subjectively, patients were considered to have postrevision recurrence of SUI if it was reported during routine evaluation/interviews or in the incontinence severity index questionnaire. RESULTS: There were 102 patients who underwent revision of a type 1 mesh MUS; 45 underwent sling division, and 57 underwent mesh excision. After sling division, 4.4% of the patients underwent reoperation for recurrent SUI compared with 28.1% after sling excision (RR, 0.16; 95% confidence interval, 0.04-0.65). Stress urinary incontinence symptoms recurred in 13% after sling division versus 56% after excision (RR, 0.24; 95% confidence interval, 0.11-0.52). CONCLUSIONS: The choice of technique may be dictated by the clinical scenario, but in situations in which sling division is an option, repeat operations and symptoms of SUI occur less frequently.

Patient-reported goal attainment and comprehensive functioning outcomes after surgery compared with pessary for pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse can have a negative impact on a woman's overall functioning. When choosing between surgery or pessary, many women have information needs about long-term expectations. Whereas it has been shown that both surgery and pessary can improve prolapse symptoms, there is less information comparing comprehensive functioning outcomes and goal attainment between the 2 treatments. OBJECTIVE: Our primary objective was to compare patient-reported goal attainment and comprehensive physical, social, and emotional functioning outcomes after surgery vs pessary for symptomatic prolapse. STUDY DESIGN: We conducted a prospective, observational, cohort study including women choosing surgery or pessary for symptomatic stage 2 or greater prolapse. Women undergoing any modality of prolapse surgery or those anticipating using a pessary long-term to avoid surgery were eligible. Women completed questionnaires at baseline (before treatment) and up to 12 months after treatment including the following: (1) pretreatment goals and actual posttreatment goals achieved; (2) 5 functioning outcomes encompassing physical, social, and emotional function using the Patient-Reported Outcomes Measurement Information System surveys; and (3) validated symptom and quality-of-life questionnaires. Treatment goals were categorized into symptom goals (prolapse, urinary, bowel, pain) and function goals (physical, social, emotional, sexual). Goals achieved were compared using a χ2 test. Multiple logistic regression was used to identify variables associated with not achieving all pretreatment goals. Mean improvements in functioning scores were compared within groups and between groups using paired and independent Student t tests. Assuming 80% of women would achieve complete goal attainment in the surgery group, 64 women per group would be needed to detect a 20% difference at an alpha of 0.05. We recruited 80 women per group to account for dropout. RESULTS: A total of 160 women were enrolled and 72 surgical (90%) (mean follow-up 12 months) and 64 pessary patients (80%) (mean follow up 8 months) had posttreatment data. Fourteen discontinued pessary use and 8 ultimately crossed over to surgery. At follow-up, a higher proportion of women in the surgery arm reported successfully achieving symptom goals and function goals compared with women who chose pessary (P < .05). Women who continued pessary use had comparable goal attainment with women in the surgery group for almost all goal categories, whereas women who discontinued the pessary or crossed over to surgery had significantly lower goal attainment compared with both the surgery and pessary continuation groups. On multiple logistic regression, only college education or higher was associated with an increased odds of not achieving all pretreatment goals (odds ratio, 2.70, 95% confidence interval, 1.1-6.6, P = .03). Regarding functioning outcomes, within groups, there were statistically significant improvements between pre- and posttreatment Patient-Reported Outcomes Measurement Information System functioning scores in all 5 domains for the surgery group and 4 of 5 domains in the pessary group (P < .05). When comparing between groups, women who had surgery reported significantly greater improvements in the physical function, social roles, and depression domains compared with the pessary group (P < .05). CONCLUSION: Women undergoing either surgery or pessary for symptomatic prolapse experience goal attainment and improvements in physical, social, and emotional functioning, although surgery is associated with greater improvements.

Effects of Repetition and Inactivity on Laparoscopic Skills Training.

STUDY OBJECTIVE: To describe the impact of task repetition and time between practice sessions on time to complete a surgical task using a high-fidelity laparoscopic simulator. DESIGN: An Institutional Review Board-approved retrospective cohort study of 33 obstetrics/gynecology residents with unlimited access to a high-fidelity laparoscopic simulator over a period of 12 months. Canadian Task Force design classification II-2. SETTING: Academic medical center and obstetrics/gynecology residency training program. PARTICIPANTS: Obstetrics/gynecology residents. INTERVENTIONS: Participation in a high-fidelity laparoscopic training exercise. MEASUREMENTS: Residents completed a standardized peg transfer exercise with data collected on the time to completion of the exercise, number of the attempt, and interval since the last day of practice. Data were analyzed using Spearman correlation coefficients and mixed-effects linear regression. MAIN RESULTS: A total of 33 residents participated during the 12-month period, completing 484 peg transfer exercises (mean, 16.2 per resident). Each repetition was correlated with a mean decrease in time to completion of 2.28 seconds (p < .0001). This correlation was most dramatic in the first 9 completed exercises, in which each repetition correlated with a decrease in time to complete of 7.98 seconds (p ≤ .0001). The lapse in practice preceding the exercise correlated with a negligible change in time to completion of 0.003 second (SD, 0.06; p = .90). CONCLUSION: The number of previous completed exercises was significantly correlated with decreased time to completion of this standardized exercise. Lapses in practice did not correlate with slower times to completion, suggesting that repetitive exposure to a simple surgical task has a greater impact on efficiency than lapse in practice.

The association between regional anesthesia and acute postoperative urinary retention in women undergoing outpatient midurethral sling procedures.

OBJECTIVE: The objective of the study was to estimate the association between regional anesthesia and acute postoperative urinary retention in women undergoing outpatient midurethral sling procedures. STUDY DESIGN: We performed a retrospective cohort study of women undergoing outpatient midurethral sling procedures. Exposure was defined as the type of anesthesia, categorized as regional (spinal or combined spinal/epidural) or nonregional (general endotracheal, monitored anesthesia care with sedation, or local). The outcome, acute postoperative urinary retention, was defined as a failed voiding trial prior to discharge. RESULTS: A total of 131 women met our inclusion criteria. Forty-two women (32%) had regional anesthesia and 89 (68%) women had non-regional anesthesia. Overall, 48 women (36.6%) had acute postoperative urinary retention. Women who had regional anesthesia had an increased odds (adjusted odds ratio, 4.4; 95% confidence interval, 1.9-10.2) of acute postoperative urinary retention compared with women receiving nonregional anesthesia. CONCLUSION: Regional anesthesia is a risk factor for acute postoperative urinary retention following outpatient midurethral slings.

Postoperative erosions of the Mersilene suburethral sling mesh for antiincontinence surgery.

The objective of the study was to describe the presentation of vaginal mesh erosions following Mersilene suburethral slings for urinary incontinence. We performed a retrospective review of all Mersilene suburethral slings placed at a tertiary referral center from 1996 to 2007. A total of 772 women underwent placement of a Mersilene suburethral sling. We identified 62 women that underwent surgical revision due to mesh erosion for an overall erosion rate of 8%. The most common presenting symptom was vaginal discharge reported in 37% of women. Other symptoms included vaginal bleeding in 31%, pain or dyspareunia in 13%, and voiding dysfunction in 21% of women. Seven women were found to have the mesh in the bladder on cystoscopy. Cellulitis complicated 8.3% of erosions. Patients with erosions of Mersilene mesh slings commonly complain of vaginal bleeding and discharge and may present up to 20 years after the surgery.

Impact of route of delivery on continence and sexual function.

Urinary and fecal incontinence have been linked to pregnancy and childbirth. This article reviews the rates of pelvic floor dysfunction following vaginal delivery and cesarean section as cited in short-term and long-term follow-up studies.

Impact of age on preoperative and postoperative urinary incontinence quality of life.

OBJECTIVE: The objective of the study was to estimate the effect of age on quality of life in women with urinary incontinence before and following antiincontinence surgery. STUDY DESIGN: We performed a retrospective cohort study of women who underwent surgery for stress urinary incontinence from December 2003 to August 2005. Younger women were defined as age younger than 60 years and older women were defined as age 60 years or older. Quality of life was measured using Incontinence Impact Questionnaire (IIQ)-7 and Urogenital Distress Inventory (UDI)-6 questionnaires pre- and postoperatively. Multiple linear regression was performed to estimate the effect of age on improvement in quality-of-life scores. RESULTS: One hundred sixty-eight younger women and 81 older women were included. Older women had lower mean baseline IIQ-7 scores (P < .01) and had less improvement in IIQ-7 scores postoperatively (P = .02) when compared with younger women. After adjusting for baseline IIQ-7 score using multiple linear regression, age was no longer associated with decreasing improvements in quality-of-life scores following surgical treatment. CONCLUSIONS: Antiincontinence surgery is associated with improved quality of life in both older and younger women.