Virtual Education in Urogynecology: Enhancing Understanding and Management of Pelvic Fistulas.

Introduction: Pelvic fistulas affect a significant number of patients globally, with a relatively low prevalence in the United States. Virtual education offers an effective, scalable solution to bridge this educational gap and lead to a deeper understanding of more common conditions, such as urinary and fecal incontinence. Methods: We developed two virtual cases on rectovaginal and vesicovaginal/ureterovaginal fistulas to enhance medical students' exposure, knowledge, and confidence regarding assessment of pelvic fistulas. The cases could be completed in approximately 30 minutes, asynchronously, and at students' own pace. The cases were integrated into an OB/GYN clerkship. We conducted a survey among students receiving the cases to gather feedback on usability, acceptability, and educational value, which guided subsequent improvements. Results: Forty medical students, ranging from first to third year, participated in the urogynecology elective; 21 (53%) completed the survey. Ninety-one percent agreed or strongly agreed they were satisfied with the cases. All respondents found the format easy to use and appropriate for their level of learning. Most reported the cases improved their confidence in nonsurgical and surgical management options for pelvic fistulas. Discussion: Offering virtual and interactive patient cases on e-learning platforms represents an innovative approach to increasing clinical exposure to urogynecologic disorders. By providing medical students with the opportunity to interact with pelvic fistulas virtually, these cases can help bridge a gap in clinical education. Future exploration is valuable for examining knowledge deficiencies and developing cost-effective, self-paced, easily accessible educational resources to advance medical training and optimize patient care.

Risk Factors of Pelvic Floor Disorders Among Women in Rural Nepal: A Case-Control Study.

INTRODUCTION AND HYPOTHESIS: Risk factors for pelvic floor disorders (PFDs) are not well understood in lower resource settings. The objective of this study is to determine the risk factors associated with stress urinary incontinence (SUI), urge urinary incontinence (UUI), and pelvic organ prolapse (POP) among women of reproductive age in rural Nepal. METHODS: This is a case-control study nested within a community-based cross-sectional survey of parous women of reproductive age with PFDs in the Sarlahi District of Nepal. The presence of PFDs was confirmed by clinical assessment. Detailed sociodemographic information and histories were captured. RESULTS: We examined 406 women; the mean (SD, range) age was 32.7 (8.5, 16-49) years, mean BMI (SD) was 19.7 (3.3) kg/m2, and median (range) number of pregnancies was 4 (1-11). Two hundred and three women (50.0%) had either SUI or UUI, 85 (17.8%) had both SUI and UUI, and 71 (17.5%) had POP at or beyond the hymen. After controlling for other variables significant on bivariate analysis, age (adjusted odds ratio [aOR] 1.06 [95% CI 1.03-1.09]), illiteracy (aOR 2.24 [95% CI 1.04-4.80]), and presence of upper gastrointestinal issues (aOR 3.30, [95% CI 1.77-6.16]) were independently associated with SUI/UUI. Age (aOR 1.05 [95% CI 1.02-1.09]), bispinous diameter (aOR 2.88 ([95% CI 1.11-7.47]), and subpubic angle (aOR 2.78 [95% CI 1.55-5.03]) were independently associated with POP. CONCLUSION: Risk factors for PFDs in a homogenous community of parous women of reproductive age in rural Nepal are similar to those found in parous women in higher income countries.

Nocturnal Urinary Symptoms as Screening Tools for Obstructive Sleep Apnea.

IMPORTANCE: Nocturnal lower urinary tract symptoms are part of obstructive sleep apnea (OSA), and urogynecology clinics may serve as OSA screening sites. OBJECTIVE: This study's aim was to determine the accuracy of nocturia and nocturnal enuresis (NE) as screening tools for OSA in new patients at a urogynecology clinic. STUDY DESIGN: Using a retrospective study design, we gathered information regarding diagnostic OSA testing, continuous positive airflow pressure use, and lower urinary tract symptoms improvement from women in a urogynecology clinic who were previously screened for OSA using validated questionnaires. Nocturia and NE were tested for sensitivity and specificity using positive OSA diagnosis by polysomnography as the gold standard. RESULTS: Nocturia with a cutoff of ≥2 episodes per night had the best test characteristics-86.4% sensitivity (95% confidence interval [CI], 65.1-97.1) and 58.5% specificity (95% CI, 44.1-71.9) for an overall accuracy of 78.4% (95% CI, 67.0-89.8). Nocturnal enuresis with a cutoff of ≥1 episode per week had the best NE characteristics with 31.8% sensitivity (95% CI, 13.9-54.9) and 79.3% specificity (95% CI, 65.9-89.2) for an overall accuracy of 56.1% (95% CI, 41.2-71). CONCLUSIONS: Lower urinary tract symptoms such as nocturia and NE are routinely assessed in urogynecology clinics, making them useful for OSA screening and referral. The present study found nocturia symptoms with ≥2 episodes per night to retain acceptable test characteristics in screening for OSA, whereas NE was found to have less acceptable test characteristics for OSA screening. Urogynecology clinics may utilize nocturia symptoms in clinical decision making for OSA referral.

Primary care providers practice patterns regarding female pelvic floor disorders.

INTRODUCTION: Pelvic floor disorders (PFDs) pose substantial physical and psychological burdens for a growing number of women. Given the ubiquity of these conditions and known patient reluctance to seek care, primary care providers (PCPs) have a unique opportunity to increase treatment and provide appropriate referrals for these patients. METHODS: An online survey was administered to PCPs to assess provider practices, knowledge, comfort managing and ease of referral for PFDs. Logistic regression was used to assess the association between demographic/practice characteristics of PCPs and two primary outcomes of interest: discomfort with management and difficulty with referral of PFDs. RESULTS: Of the 153 respondents to the survey, more felt comfortable managing stress urinary incontinence (SUI) and overactive bladder (OAB), compared with pelvic organ prolapse (POP) and faecal incontinence (FI) and were less likely to refer patients with urinary symptoms. Few providers elicited symptoms for POP and FI as compared with SUI and OAB. Provider variables that were significantly associated with discomfort with management varied by PFD, but tended to correlate with less exposure to PFDs (eg, those with fewer years of practice, and internal medicine and family physicians as compared with geriatricians); whereas the factors that were significantly associated with difficulty in referral, again varied by PFD, but were related to practice characteristics (eg, specialist network, type of practice, practice setting and quantity of patients). CONCLUSION: These findings highlight the need to increase PCPs awareness of PFDs and develop effective standardised screening protocols, as well as collaboration with pelvic floor specialists to improve screening, treatment and referral for patients with PFDs.

Effect of pre-operative warm-up on trainee intraoperative performance during robot-assisted hysterectomy: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The objective was to study the effect of immediate pre-operative warm-up using virtual reality simulation on intraoperative robot-assisted laparoscopic hysterectomy (RALH) performance by gynecology trainees (residents and fellows). METHODS: We randomized the first, non-emergent RALH of the day that involved trainees warming up or not warming up. For cases assigned to warm-up, trainees performed a set of exercises on the da Vinci Skills Simulator immediately before the procedure. The supervising attending surgeon, who was not informed whether or not the trainee was assigned to warm-up, assessed the trainee's performance using the Objective Structured Assessment for Technical Skill (OSATS) and the Global Evaluative Assessment of Robotic Skills (GEARS) immediately after each surgery. RESULTS: We randomized 66 cases and analyzed 58 cases (30 warm-up, 28 no warm-up), which involved 21 trainees. Attending surgeons rated trainees similarly irrespective of warm-up randomization with mean (SD) OSATS composite scores of 22.6 (4.3; warm-up) vs 21.8 (3.4; no warm-up) and mean GEARS composite scores of 19.2 (3.8; warm-up) vs 18.8 (3.1; no warm-up). The difference in composite scores between warm-up and no warm-up was 0.34 (95% CI: -1.44, 2.13), and 0.34 (95% CI: -1.22, 1.90) for OSATS and GEARS respectively. Also, we did not observe any significant differences in each of the component/subscale scores within OSATS and GEARS between cases assigned to warm-up and no warm-up. CONCLUSION: Performing a brief virtual reality-based warm-up before RALH did not significantly improve the intraoperative performance of the trainees.

Case studies in adaptation: centring equity in global health education during the COVID-19 pandemic and beyond.

The COVID-19 pandemic disrupted all aspects of life globally and laid bare the pervasive inequities in access to education, employment, healthcare and economic security in both high-resource and low-resource settings. The global health field's brittle attempts of addressing global health inequities, through efforts that in some cases have evoked the colonialist forces implicated in shaping these disparities, have been further challenged by the pandemic. COVID-19 has forced global health leaders to reimagine their field through innovation such as shifting the application of global health to a local focus, collaborating with community organisations and exploring virtual education technologies. We present four case studies illustrating this promising movement towards a more sustainable, ethical and equitable model of global health education practice.Case 1: trainees from the Massachusetts General Hospital Center for Global Health partnered with the Board of Health of Holyoke, a majority Latinx city with high poverty levels, to respond to the COVID-19 pandemic through research and intervention. Case 2: Prevencasa, a community health organisation in Tijuana, Mexico, providing healthcare to local underserved communities, shifted its focus from hosting international trainees to developing a multidisciplinary training programme for Mexican healthcare professionals. Case 3: the Johns Hopkins Global Health Leadership Program adapted its curriculum into a hybrid online and in-person migrant health and human rights elective, collaborating with local organisations. Case 4: a US-based and a Latin American-based organisation collaborated to create a longitudinal, virtual urogynaecology training programme with hybrid simulation practice to increase accessibility of procedural-based training.

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.

Women's sexual activity and experiences following female genital fistula surgery.

BACKGROUND: Surgical repair has a transformative impact on the lives of women affected by female genital fistula; however, various physical, social, and economic challenges may persist postrepair and prevent complete reengagement in relationships and communities. Nuanced investigation of these experiences is needed to inform programming that aligns with women's reintegration needs. AIM: We investigated the sexual activity resumption, experiences, and concerns of women in Uganda during the year following genital fistula repair surgery. METHODS: Women were recruited from Mulago Hospital between December 2014 and June 2015. We collected data at baseline and 4 times postsurgery about sociodemographic characteristics and physical/psychosocial status; we also assessed sexual interest and satisfaction twice. We performed in-depth interviews with a subset of participants. We analyzed quantitative findings via univariate analyses, and qualitative findings were coded and analyzed thematically. OUTCOMES: We assessed sexual readiness, fears, and challenges following surgical repair of female genital fistula using quantitative and qualitative measures of sexual activity, pain with sex, sexual interest/disinterest, and sexual satisfaction/dissatisfaction. RESULTS: Among the 60 participants, 18% were sexually active at baseline, which decreased to 7% postsurgery and increased to 55% at 1 year after repair. Dyspareunia was reported by 27% at baseline and 10% at 1 year; few described leakage during sex or vaginal dryness. Qualitative findings showed wide variance of sexual experiences. Some reported sexual readiness quickly after surgery, and some were not ready after 1 year. For all, fears included fistula recurrence and unwanted pregnancy. CONCLUSION: These findings suggest that postrepair sexual experiences vary widely and intersect meaningfully with marital and social roles following fistula and repair. In addition to physical repair, ongoing psychosocial support is needed for comprehensive reintegration and the restoration of desired sexuality.

Pelvic floor disorder assessment of knowledge and symptoms: an educational intervention for Spanish-speaking women (PAKS study).

INTRODUCTION AND HYPOTHESIS: Educational interventions have been effective in improving postpartum knowledge, performance of pelvic floor exercises, and bowel-specific quality-of-life. Our primary objective was to determine if a video-based educational intervention on pelvic floor disorders (PFDs) would increase Spanish-speaking women's knowledge of PFDs, and secondarily to assess if it would decrease pelvic floor symptoms. We hypothesized that Spanish-speaking women would improve their pelvic floor knowledge and symptoms post-intervention. METHODS: Inclusion criteria included women age 18 years and older and self-reported as a predominantly Spanish-speaker or equally bilingual English- and Spanish-speaker. Changes in knowledge were assessed with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). Changes in symptoms were assessed with the Pelvic Floor Distress Inventory-20 (PFDI-20). Linear regression assessed for independent effects. RESULTS: One hundred and fourteen women were enrolled and 112 completed the pre- and post-intervention PIKQ. Mean (standard deviation [SD]) age was 50 (14) years. Immediate post-intervention scores showed significant improvement in knowledge. Total PIKQ score improved by 5.1 (4.7) points (p < 0.001). POP subscore improved by 2.7 (2.7) points (p<0.001) and UI subscore improved by 2.3 (2.5) points (p < 0.001). Improvement in knowledge continued after four weeks (p < 0.001). PFDI-20 prolapse (p=0.02), colorectal-anal (p < 0.001) and urinary (p = 0.01) scores significantly improved only for the most symptomatic women at baseline. Using linear regression, total PIKQ (p = 0.03) and total PFDI-20 scores (p = 0.04) were associated with predominantly Spanish-speakers versus fully bilingual. CONCLUSION: Findings support the efficacy of a video-based educational intervention to improve knowledge of PFDs in Spanish-speaking women. The most symptomatic women benefitted from this intervention.

Prolapse and mesh reoperations following sacrocolpopexy: comparing supracervical hysterectomy, total hysterectomy, and no hysterectomy.

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is effective for apical prolapse repair and is often performed with hysterectomy. It is unknown whether supracervical or total hysterectomy at time of sacrocolpopexy influences prolapse recurrence and mesh complications. The primary objective of this study is to compare reoperations for recurrent prolapse after sacrocolpopexy with either supracervical hysterectomy or total hysterectomy, or without concomitant hysterectomy. We also sought to compare these three groups for the incidence of mesh complications and describe cervical interventions following supracervical hysterectomy. METHODS: A retrospective cohort study of sacrocolpopexy was performed using the MarketScan® Research Database. Women > 18 years who underwent sacrocolpopexy between 2010 to 2014 were identified. Utilizing diagnostic and procedural codes, reoperations for prolapse and mesh complications were identified. Women with < 2 years of follow-up were excluded. RESULTS: From 2010 to 2014, 3463 women underwent sacrocolpopexy with at least 2 years of follow-up, 910 (26.3%) with supracervical hysterectomy, 1243 (35.9%) with total hysterectomy, and 1310 (37.8%) without hysterectomy. Reoperations for prolapse were similar after supracervical hysterectomy (1.5%), after total hysterectomy (1.1%, p = 0.40), and without hysterectomy (1.5%, p = 0.98). Mesh complications after sacrocolpopexy were similar after supracervical hysterectomy (1.8%), after total hysterectomy (1.5%, p = 0.68), and without hysterectomy (2.8%, p = 0.11). Following supracervical hysterectomy, 0.9% underwent cervical procedures. CONCLUSIONS: When comparing supracervical and total hysterectomy at time of sacrocolpopexy, there were no significant differences in reoperations for recurrent prolapse, reoperations for mesh complications, or mesh complication diagnoses. This study shows that surgeons can be reassured on performing hysterectomy with sacrocolpopexy.

The impact of anxiety on postoperative pain following pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Despite the prevalence of anxiety, its impact on postoperative pain remains poorly characterized. The present study was aimed at assessing the impact of preoperative anxiety on postoperative pain in patients undergoing pelvic reconstructive surgery. We hypothesized that greater anxiety would be associated with increased postoperative pain for patients undergoing pelvic reconstructive surgery. METHODS: This was a prospective multi-center observational study in Baltimore between September 2018 and June 2019. The Beck Anxiety Inventory was used to assess preoperative anxiety and the validated Surgical Pain Scale instrument was used to assess pain in the postoperative period. The association between anxiety and postoperative pain was analyzed using multivariate logistic regression, adjusting for relevant confounders. RESULTS: A total of 149 patients undergoing pelvic reconstructive surgery completed preoperative surveys. The median age of the study population was 59. The prevalence of preoperative anxiety (anxiety score > 9) in our study population was 26.8% (95% CI 19.7-34.0%). Women with preoperative anxiety reported higher postoperative pain on days 1-2 (relative odds 1.05, 95% confidence interval 1.01-1.10) and day 14 (relative odds 1.53, 95% confidence interval 1.00-2.34). CONCLUSIONS: A large fraction of women undergoing pelvic reconstructive surgery have moderate to severe preoperative anxiety. Women with preoperative anxiety appear to have greater odds of increased postoperative pain. Understanding this association may help surgeons with preoperative counseling and expectations regarding postoperative pain.

Polypharmacy and Multimorbidity in the Urogynecology Population and Their Effect on Pelvic Floor Symptoms.

IMPORTANCE: Polypharmacy and multimorbidity are common in older adults but has not been well studied in the urogynecologic patient population. OBJECTIVES: The objective of this study was to determine the prevalence of polypharmacy and multimorbidity in a diverse outpatient urogynecologic population and to examine whether polypharmacy and/or multimorbidity were associated with lower urinary tract symptoms, pelvic organ prolapse, defecatory distress, and/or female sexual dysfunction. STUDY DESIGN: This is a secondary analysis of a dual-center cross-sectional study of new patients presenting for evaluation of pelvic floor disorders at 2 urban academic outpatient urogynecology clinics. Baseline demographics and clinical characteristics were obtained from the electronic medical record. Validated surveys were administered to determine severity of lower urinary tract symptoms (Overactive Bladder Validated 8-Question Screener, Urogenital Distress Inventory-6), pelvic floor dysfunction (Pelvic Organ Prolapse Distress Inventory-6, Colorectal-Anal Distress Inventory-8), and sexual dysfunction (6-item Female Sexual Function Index). Standard statistical techniques were used. RESULTS: One hundred ninety-seven women with mean age 58.8 years (SD, 13.4 years) were included, and most were of minority race/ethnicity (Black, 34.0%; Hispanic, 21.8%). The majority of participants met criteria for polypharmacy (58.4%) and multimorbidity (85.8%), with a mean prescription number of 6.5 (SD, ± 4.9) and mean number of medical comorbidities of 4.9 (SD, ± 3.3). Polypharmacy and multimorbidity were significantly associated with higher CRADI-8 scores. Specifically, polypharmacy was associated with straining with bowel movements and painful stools, whereas multimorbidity was associated with incomplete emptying and fecal urgency. There was no significant association between polypharmacy and multimorbidity with urinary symptoms, prolapse, or sexual dysfunction. CONCLUSIONS: Polypharmacy and multimorbidity are common in the urogynecologic population. There is a relationship between greater defecatory distress and polypharmacy and multimorbidity.

Creation and Implementation of Virtual Urogynecology Patient Cases for Medical Student Education.

Introduction: Urogynecologic disorders are highly prevalent, and many physicians across various specialties will encounter and care for patients with pelvic floor disorders. Yet most medical students have had limited to no experience in diagnosing and managing pelvic floor disorders, resulting in a gap in clinical education. Methods: Three virtual and interactive urogynecologic patient cases were developed on an e-learning platform with an overall goal of increasing clinical exposure to various pelvic floor disorders. The cases were integrated into the medical student obstetrics and gynecology clerkship during the 2020-2021 academic year (n = 40). Participants provided feedback regarding usability, acceptability, and educational value of the cases. Results: Twenty-one students (52%) completed the survey. Ninety percent (n = 19) agreed or strongly agreed that they were satisfied with the cases, and 71% (n = 15) agreed or strongly agreed that they would recommend the virtual patient cases to other students. All students (n = 21) felt that the format was easy to use and reported that the cases were appropriate for their level of learning. Most students felt that the cases increased or significantly increased their confidence regarding nonsurgical and surgical management options for pelvic floor disorders. Discussion: Our findings suggest that these interactive virtual patient cases are an acceptable, valuable, and effective tool for learners. Utilizing the cases can help mitigate existing disparities in exposure to pelvic floor disorders both highlighted by and preceding the COVID-19 pandemic.

Obstructed defecation syndrome in the first week after pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Research shows that patients are concerned about postoperative bowel function after pelvic reconstructive surgery. The objectives of this study were to estimate the proportion of patients with obstructed defecation syndrome (ODS), a subtype of constipation, in the week after surgery, to identify associated patient-level and perioperative characteristics and the associated bother. METHODS: Women completed a preoperative and postoperative ODS questionnaire and postoperative bowel diary. Characteristics of women with and without postoperative ODS were compared. Chi-squared or Fisher's exact tests compared categorical variables. Student's t test or Wilcoxon rank-sum tests compared continuous variables. Multivariate logistic regression was assessed for independent effects. Wilcoxon rank-sum tests compared the groups with regard to bother. Spearman correlation coefficients described the relationship among bother, postoperative ODS score, and bowel diary variables. RESULTS: Of the 186 participants enrolled, 165 completed the postoperative ODS questionnaire. Of these, 39 women (23.6%, 95% CI 17.2-30.1) had postoperative ODS. Postoperative ODS was significantly associated with preoperative ODS (p < 0.001), posterior colporrhaphy (p = 0.03), surgery type (p = 0.01), and longer duration of surgery (p = 0.03). Using multivariate logistic regression controlling for age, only preoperative ODS was significantly associated with postoperative ODS (OR 2.68, 95% CI 1.73-4.17). Women with postoperative ODS reported more bother with their defecatory symptoms (p < 0.001). The degree of bother was significantly associated with postoperative ODS score (p < 0.001). CONCLUSION: Using a validated disease-specific questionnaire to identify ODS, this complication was identified in 23.6% of patients in the week after pelvic reconstructive surgery. Preoperative ODS was a significant and important risk factor for this complication.

Validation of an obstetric fistula screening questionnaire: a case-control study with clinical examination.

BACKGROUND: Obstetric fistula (OF) is a significant cause of maternal morbidity in lower resource settings where women experience obstructed labor without timely access to skilled obstetric care. The true prevalence of OF is unknown; however, it is estimated to affect 2 to 3.5 million women globally. The Demographic and Health Surveys' (DHS) Fistula Module includes the OF symptom questions most frequently used for prevalence estimates, but these questions have not been validated. The aim of this study is to validate a symptom-based screening questionnaire for OF, including a question in the DHS' Fistula Module. METHODS: With an international panel of fistula surgeons, we developed and face-validated a screening questionnaire that assessed for symptoms of lower urinary tract fistula (LUTF) and lower gastrointestinal tract fistula (LGTF), as well as urinary and fecal incontinence (UI, FI). We evaluated the discriminative ability of the questionnaire using a case-control study design in a 1:2:2 ratio: cases were parous women with fistula confirmed on examination, controls included parous women without fistula on examination, with and without UI symptoms. All women underwent screening for fistula symptoms and a physical examination, with examiners blinded to screening results. RESULTS: Of the 367 Rwandan women who completed the questionnaires and underwent clinical examination, 59 women had LUTFs and 34 had LGTFs, 274 women were classified as controls with and without symptoms of UI. All LUTF screening questions performed well, including the DHS fistula question. The combination of two LUTF screening questions had the highest sensitivity (100%; 95% CI 94%, 100%), specificity (96%; 95% CI 93%, 98%), and area under the curve (AUC) (0.98). The combination of a LGTF screening question and FI question demonstrated the highest sensitivity (97%; 95% CI 85%, 100%), specificity (98%; 95% CI 95%, 99%) and AUC (0.98). CONCLUSIONS: Our OF screening questionnaire, including the DHS fistula question, demonstrated high sensitivities, specificities, and AUC.

Obstetric fistula (OF) is a birth injury which may occur in women living in lower resource settings who experience obstructed labor (not progressing normally) without access to skilled obstetric care. This injury causes a woman to constantly leak urine and/or feces from her birth canal. As OF affects poor women who live far from healthcare it is difficult to fully understand how many women worldwide have an OF. Furthermore, although some Demographic and Health Surveys (DHS) include OF symptom questions, the accuracy of these questions in identifying women with OF has not been studied.To more accurately determine which women may have an OF, we developed an OF screening questionnaire after consulting OF experts worldwide, which included a DHS OF question. We asked women from Rwanda this questionnaire and then examined these women to see if they have OF. Through this process we identified 59 women with a LUTF, 34 with a LGTF, and 274 without an OF. The best performing questions were able to identify women with LUTF 100% of the time and women with LGTF 97% of the time. We also showed that one DHS question detects women with LUTF and LGTF 100% and 85% of the time, respectively. Public health officials can now use the questions we studied to more accurately estimate how many women worldwide have OF, and best direct resources and skilled health care workers to the areas with the greatest need.

Function and disability status among women with fistula using WHODAS2.0: A descriptive study from Rwanda and Democratic Republic of Congo.

OBJECTIVE: To assess function and disability among women in Rwanda and Democratic Republic of Congo living with fistula and identify characteristics associated with higher disability scores. METHODS: Women presenting for fistula care were recruited. Eligible participants underwent a physical examination to classify fistula type and completed the WHO Disability Assessment Schedule 2.0 questionnaire to ascertain the impact of fistula on function across six domains: cognition, mobility, self-care, getting along, life activities, and participation. Disability scores were calculated (where 0 = no disability and 100 = complete disability). Participants were grouped according to no, low, or high disability status; results were examined to determine the domains most affected. RESULTS: Among 69 participants, fistula type included: vesicovaginal (59.4%), ureterovaginal (14.5%), total absence of proximal urethra (11.6%), and rectovaginal (14.5%). Median disability score was 43.0/100 (interquartile range 26.0-67.0); 83% exhibited high disability status. Life activities and participation in society domains were most affected. Women with rectovaginal fistula reported the lowest scores, and those with total absence of proximal urethra reported the highest scores. CONCLUSION: WHO Disability Assessment Schedule 2.0 represents a simple, robust measure of global disability status, aligns with research efforts to estimate maternal disability, and may inform health needs and resource allocation for this population. In this study, disability was common, varied by fistula type, and affected physical, mental, and social domains.

Virtual Reality Simulation Has Weak Correlation with Overall Trainee Robot-Assisted Laparoscopic Hysterectomy Performance.

STUDY OBJECTIVE: Both simulator practice and intraoperative performance serve to inform surgical trainee training, but the skill transfer from simulation to the intraoperative setting remains unclear. This study evaluates the correlation between trainee performance on virtual reality simulation and (1) overall intraoperative performance during robotic-assisted laparoscopic hysterectomy (RALH) procedures and (2) suturing performance during vaginal cuff closure portion of the case. DESIGN: Retrospective subgroup analysis of randomized controlled trial. SETTING: Academic hospital. PATIENTS: Patients with RALH (N = 29). INTERVENTIONS: Gynecological trainees (N = 21) performed simulation tasks using the da Vinci skills simulator on the day of surgery before performing RALH. Attending surgeons assessed participants' intraoperative performance using Global Evaluative Assessment of Robotic Skills (GEARS). Performance of the vaginal cuff closure step was subsequently assessed using GEARS scoring of anonymized videos. Spearman's correlation was used to quantify the relationship between simulation and intraoperative performances. MEASUREMENTS AND MAIN RESULTS: Trainees achieved a median intraoperative GEARS score of 18.5/30 (interquartile range: 17-22) and a median total simulator score of 84.4/100 (interquartile range: 78.1-87.5). More advanced residents exhibited worse overall simulator performance (median score 86.6/100 compared with 78.8/100, p = .03) and similar intraoperative GEARS scores during overall RALH and vaginal cuff closure compared with less experienced trainees. Total simulation performance score was negatively correlated with GEARS Bimanual Dexterity (ρ = -0.46, p = .02) and Force Sensitivity subscores (ρ = -0.39, p = .05). There was no correlation between total GEARS intraoperative vaginal cuff closure scores and overall simulation performances; however, total Tubes simulation score was correlated with higher GEARS Force Sensitivity subscore (ρ = 0.73, p = .05). CONCLUSIONS: In this study, there was limited correlation between simulation score metrics and trainees' overall intraoperative performance. Furthermore, we identified that GEARS scores could not distinguish between similar trainee skill levels. These findings underscore the need to develop intraoperative assessment tools that can better discriminate different but similar skill levels.

Impact of frailty in benign gynecologic surgery: a systematic review.

INTRODUCTION AND HYPOTHESIS: Frailty has been associated with increased risks of perioperative complications. This systematic review explores the associations between preoperative frailty and perioperative complications in benign gynecologic surgery. METHODS: A comprehensive, systematic literature search was conducted using the PubMed interface for Medline, Embase, and Scopus databases through August 12, 2020. Articles were included if they described the utilization of frailty assessment tools in benign gynecologic patients in the pre- or perioperative setting. Study quality and evidence were evaluated by the Cochrane Risk of Bias Tool in Non-Randomized Studies and Grading of Recommendations, Assessments, Development, and Evaluations criteria. RESULTS: One thousand one hundred twenty unique citations were identified, and five studies assessing frailty and perioperative outcomes were included. Three retrospective cohort studies utilized the American College of Surgeons National Surgical Quality Improvement Program database to assess the impact of frailty on perioperative outcomes in hysterectomies and pelvic organ prolapse repair procedures. One retrospective cohort study utilized a California database to assess frailty in prolapse repair surgeries. One cross-sectional study assessed frailty in new urogynecology patient visits. Four of these studies found that preoperative frailty is associated with an increased risk of perioperative complications. Overall, the evidence from the included studies is of low quality and at moderate to critical risk of bias. CONCLUSIONS: There are few studies assessing the impact of frailty on perioperative complications in benign gynecologic surgery. This review demonstrates that preoperative frailty is significantly associated with adverse perioperative outcomes, but additional studies are needed to further explore this association.

Rehabilitative care practices in the management of childbirth-related pelvic fistula: A systematic review.

INTRODUCTION AND HYPOTHESIS: Childbirth-related pelvic fistula (CRF) often requires surgery, yet even with successful repair, mental health conditions, musculoskeletal impairments, urinary and fecal incontinence and sexual dysfunction persist for many women. Postoperative rehabilitation, (i.e., physiotherapy, mental health counseling) may address these concerns and has been reported for this population. This review aims to summarize the literature and level of evidence of rehabilitative care practices in fistula care to inform clinical practice, research and policy recommendations. METHODS: A systematic literature review was conducted using Africa-Wide Information, CINAHL, Cochrane, Embase, Global Health, PAIS Index, PubMed and SCOPUS searching keywords and MeSH terms to identify women with CRF admitted for surgery. Two researchers progressively screened titles, abstracts and full-text articles. Eligible articles were classified primary if intervention details and outcomes were reported or secondary if rehabilitation was described, but no specific outcomes reported. Relevant study details, strengths and limitations, and key findings were extracted. RESULTS: Eighteen articles were included: eight primary, ten secondary. Primary articles reported on urethral plugs for postoperative urinary incontinence (UI) (2/8), menstrual cup to manage UI (1/8), physiotherapy and health education (3/8) and mental health counseling (2/8). Secondary articles describe rehabilitation components in the context of program descriptions, qualitative analyses or reviews. All evidence was low or very low quality. CONCLUSIONS: Research on rehabilitative care is very limited and highlights inconsistencies in practice. This review provides support for the feasibility of rehabilitation and establishes the need for future interventional studies that involve a comparator and reliable outcome measures.

Decisions and Consequences: Validation of High-Stakes Simulation-Based Assessments in Gynecologic Surgery.

STUDY OBJECTIVE: Simulation-based assessment is poised for application in educational promotion and credentialing in gynecologic surgery. With high-stakes assessment, validation necessitates evidence, not just about the trustworthiness of decisions but of beneficial consequences to education and healthcare as well. In this paper, we unpack the modern conceptualization of validity as it pertains to surgical simulation and high-stakes competency assessment. DESIGN: N/A SETTING: N/A PATIENTS: N/A INTERVENTIONS: N/A MEASUREMENTS AND MAIN RESULTS: N/A CONCLUSION: Validity in high-stakes simulation-based assessment necessitates evidence, not just about the trustworthiness of score-based decisions but of beneficial consequences to education and healthcare as well.