Factors Influencing Post-Operative Short-Term Outcomes of Vesicovaginal Fistula Repairs in a Community Hospital in Liberia.

OBJECTIVES: To assess factors influencing short-term outcomes of vesicovaginal fistula (VVF) repairs in community-dwelling women of Liberia, Africa. METHODS: Forty patients who underwent VVF repairs were analyzed. Primary outcome was continence status at 14 days post repair. Factors influencing continence status were characterized. RESULTS: The mean duration of leakage was 9.6 ± 8.3 years, (3 months-28 years). Thirteen (33%) had previous repairs, and 6 (15%) had multiple fistula sites. Twenty-eight (70%) were continent at catheter removal. First time repairs had a higher continence rate compared to women with previous repairs, 78% and 54% respectively (p= 0.15). Seven (47%) juxtaurethral repairs were considered failures, while only one (9%) juxtacervical fistulas remained incontinent (p= 0.069). Controlling for duration of leakage, women with previous repairs were significantly less likely to be continent (p = 0.04; adjusted OR = 0.07; 95% CI: 0.005, 0.83). CONCLUSIONS: Patients with previous VVF repairs and juxtaurethral fistulae experience lower success rates; surgery remains an effective treatment for many VVF patients.

Testing and validation of a low-cost cystoscopy teaching model: a randomized controlled trial.

OBJECTIVE: To estimate whether the use of a low-cost cystoscopy model effectively trains residents in cystourethroscopy and to validate the model as a teaching tool. METHODS: A randomized, controlled, and evaluator-blinded study was performed. Twenty-nine obstetrician-gynecologist residents had access to fresh-frozen cadavers on which baseline cystoscopic skills were assessed using the validated Objective Structured Assessment of Technical Skills checklists for cystourethroscopy. Subsequently, residents were randomized to one of two arms, a didactic study arm using the cystoscopy model and a control arm. Repeated technical skills testing was performed. RESULTS: The study group demonstrated statistically significant decreases in cystoscope assembly time (128.8 seconds at baseline to 54.9 seconds postintervention; P=.005), and increases in task-specific checklist scores (from 59.3 at baseline to 92.9 postintervention; P<.001) and in global rating scale scores (from 61.0 at baseline to 87.8 postintervention; P<.001). Further, there was a significant improvement in task-specific checklist (P<.001), global rating scale (P=.002), and knowledge quiz scores (P=.011) in the study arm compared with the control arm. CONCLUSION: Use of the bladder model exhibited validity in enhancing performance and knowledge of cystourethroscopy among ob-gyn residents. LEVEL OF EVIDENCE: I.

Sphincter tears in primiparous women: is age a factor?

Anal sphincter tears during vaginal delivery may result in serious sequelae. We examined whether younger primiparous patients were at increased risk for sphincter tears during vaginal delivery. Data from an obstetric automated record were analyzed. Primiparous women delivering term infants (n = 5,937) were included to test for an association between age and sphincter tear rates. Three age groups were considered: young adolescents (≤ 16 years), older adolescents (17-20 years), and adults (≥ 21 years). No significant difference was found in tear rates among age cohorts (9.2%, 8.0%, and 9.6% respectively; p = 0.12). Logistic regression modeling revealed that young adolescents were not more likely to have sphincter tears compared to older cohorts. Younger adolescents may not be at increased risk of anal sphincter tears. Decisions regarding interventions to decrease sphincter tears during vaginal delivery should not be made on the basis of maternal age alone.

Predictors of success with postoperative voiding trials after a mid urethral sling procedure.

PURPOSE: We identified predictors of passing a voiding trial after incontinence surgery with a mid urethral sling and examined if successful performance on a voiding trial was maintained. MATERIALS AND METHODS: A total of 89 women scheduled for incontinence surgery were enrolled from July 2005 until April 2006. Voiding trials were performed the day of discharge from the hospital, with a two-thirds volume void after a 300 ml fill considered passing. Those who passed underwent a second voiding trial 3 hours later. RESULTS: Of the participants 60 (67.4%) underwent tension-free vaginal tape surgery, 29 underwent transobturator tape (32.6%) and 64 (71.9%) underwent concurrent vaginal repairs. A total of 59 (67.0%) participants passed the first voiding trial. Univariate analysis identified 12 potential predicting variables for passing the first voiding trial. From these 12, model building via backward stepwise logistic regression found maximum flow on preoperative uroflowmetry to be the only significant predictive variable (p = 0.0002). Of the 59 women who passed the initial voiding trial 9 (16.4%) failed the second voiding trial. None of the 11 participants who had maximal flow rates greater than 30 cc per second failed the first or second voiding trial, whereas 17 of 22 subjects (77.3%) who had maximal flow rates less than 15 cc per second failed either of these trials. CONCLUSIONS: Maximum flow rates on preoperative uroflowmetry were the best predictor of passing an initial voiding trial after undergoing a mid urethral sling procedure for incontinence. However, the ability to maintain performance on a second voiding trial, even only 3 hours after passing an initial trial, is not assured.

Torsion of the appendix mimicking ovarian torsion.

BACKGROUND: Appendiceal torsion is rare and generally seen more frequently in children than adults. Untreated it can lead to necrosis, ulceration, and subsequent peritonitis. CASE: A middle-aged female presented with a 5-day history of cramping abdominal pain and nausea and vomiting. Abdominal wall guarding and rebound tenderness was noted on examination. Computerized tomography showed an 8 x 4 cm mass anterior to the uterus, suggestive of degenerating fibroid versus ovarian dermoid cyst. Laparoscopy was performed for presumed ovarian torsion. Torsion of the appendix was discovered and treated by laparoscopic appendectomy. CONCLUSION: Patients with presumed ovarian torsion should undergo urgent laparoscopy for diagnosis and attempted ovarian salvage. The possibility of conditions that may require different surgical interventions, such as appendiceal torsion, should be considered.