Procedure-specific simulation for vaginal surgery training: A randomized controlled trial.

INTRODUCTION: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS: gov: Registration no. NCT05887570. RESULTS: We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS: Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Do Patients Understand the Role of Resident Physicians in the Operating Room? A Survey of Gynaecology Patients.

OBJECTIVE: Studies from disciplines outside gynaecology have found that most patients do not understand the clinical responsibilities allocated to physicians-in-training. No research on this topic has been published in gynaecology, despite litigation against gynaecological surgeons regarding the role of residents in surgery. The goal of this research was to explore what gynaecological surgery patients understand about the role of resident doctors. METHODS: A questionnaire was distributed to female patients in gynaecological surgery pre-admission clinics in Edmonton, Alberta. Surveys included knowledge and opinion statements about residents' duties. Anonymous responses were entered into a secure database. Descriptive statistics were used to characterize the results. RESULTS: Of 108 participants, 83% understood that residents had a higher level of training than medical students, yet 40% were unsure whether residents were doctors. Almost one half (43%) of participants were uncertain whether residents required supervision, including while operating (20%). Most (92%) believed it was important to know their physician's level of training, yet only 63% reported knowing this information. Only 50% of participants would be comfortable with residents operating on them under supervision. A considerable number (56%) wanted to learn more about residents' roles. CONCLUSION: Patients do not fully understand the role of residents, and many are uncomfortable with trainees operating on them under supervision. Considering the significant role of residents in patient care, educating patients is essential to improve their comfort and the overall consent process.

Retrospective Cohort Study of Cervical Pessary Use in Women with Short Cervix at Risk of Preterm Delivery.

OBJECTIVE: A paucity of effective interventions exists for the prevention of preterm birth (PTB). Renewed interest has focused on cervical pessaries, which have the benefits of being inexpensive, nonsurgical, and easily inserted and removed. In this study, we aim to describe our experience with this device in a Canadian tertiary care centre. Primary outcomes were rates of spontaneous or iatrogenic PTB before 37, 34, and 28 weeks gestation in pregnancies complicated by short cervix treated with cervical pessary. METHODS: This was a retrospective cohort study of women with singleton, twin, and triplet pregnancies with pessary placement from August 2013 to March 2015 in the Urogynecology Clinic at the Lois Hole Hospital for Women in Edmonton, AB. Included women were deemed to be at high risk of PTB due to short cervix (≤25 mm) found on ultrasound. RESULTS: Among 115 women included, pessaries were placed at a mean gestation of 25.3 weeks. Forty-nine singleton women (52.7%) delivered at term. Of these deliveries, 75% were spontaneous. Rates of PTB before 34 and 28 weeks gestation for all deliveries, respectively, were 37.4% and 10.4%. Removal data were available for 87.8% of patients, and the pessary remained in situ for a mean of 48 days. CONCLUSION: In this study's high-risk obstetrical population, the rates of preterm birth remained high. The effectiveness of pessary use, particularly when compared to other preventative strategies, remains a topic in need of further investigation. To our knowledge, this is the first study to contribute pessary data from a Canadian population.

Prosthetic joint infections of the shoulder: A review of the recent literature.

Introduction: Shoulder arthroplasty is a common treatment for shoulder arthritis. Prosthetic joint infection of the shoulder (PJIS) is a debilitating complication to the patient and the healthcare system. Incidence of infection is 0.98-5% for primary arthroplasty. The mean hospital cost for two-stage revision was approximately $35,824. The aim of this paper is to review the recent literature and collate the latest evidence to aid diagnosis and treatment of this serious complication. Methods: A literature review was performed using PubMed and Google Scholar databases. A search strategy was adopted using the keywords: 'infection' AND 'shoulder arthroplasty' OR 'total shoulder arthroplasty'OR 'TSA' OR 'reverse shoulder arthroplasty' OR 'RSA' OR 'rTSA'. This initial search resulted in 349 articles. A PRISMA flowchart process was followed. Duplicates were removed, screening was performed and the resulting full texts were analysed and further excluded, leaving 46 articles suitable for inclusion. A PICO search strategy was also used. Results and interpretation: Risk factors for PJIS include procedure type, trauma indications and patient factors.The organism commonly isolated is Cutebacterium acnes, which makes diagnosis challenging due to its indolent nature. Investigations include biochemical tests, synovial aspirate, tissue cultures and radiological examinations.Treatment depends on the depth of the infection and the patient requirements. Medical treatment with antibiotics to local debridement, cement spacer and revision arthroplasty have all been described in the literature. A multidisciplinary decision is made on the microbiological evidence and patient factors. Conclusion: PJIS is a rare but potentially devastating complication of shoulder arthroplasty and diagnosis is often challenging. There has been much research performed recently, providing more evidence on how to optimise management.

Prevalence and risk factors for urinary and fecal incontinence four months after vaginal delivery.

OBJECTIVE: To determine the prevalence of and risk factors for urinary and fecal incontinence four months after vaginal delivery. METHODS: All patients who had vaginal deliveries at a tertiary care hospital over a three-month period were approached during their postpartum hospital stay regarding participation in the study. Participants underwent a telephone interview at four months after their delivery to determine the presence and type of any incontinence. RESULTS: Of 632 patients, 145 (23%) had stress incontinence, 77 (12%) had urge incontinence, 181 (29%) had any urinary incontinence and 23 (4%) had fecal incontinence. In univariate analysis, stress incontinence was found to be increased in patients>or=30 years of age (26.2%) compared with patients<30 years of age (19.3%) (RR 1.4; 95% CI 1.0-1.8, P=0.05). Urge incontinence was increased in patients who had a forceps delivery (21%) compared with no forceps delivery (9%) (RR 2.2; 95% CI 1.4-3.6, P=0.005), an episiotomy (32.4%) compared with no episiotomy (18.7%) (RR 1.9; 95% CI 1.2-2.9, P<0.01) and a longer second stage of labour (108 min vs. 77 min, P=0.01). The prevalence of any urinary incontinence was increased with forceps delivery (15.5%) compared with no forceps delivery (8.7%) (RR 1.5; 95% CI 1.1-2.1, P=0.01) and maternal age of >or=30 years (34.1%) compared to <30 years (23.5%) (RR 1.5; 95% CI 1.1-1.9, P=0.003). In multivariate analysis, the two variables that remained significant for any urinary incontinence were maternal age>or=30 years (P<0.01) and forceps delivery (P<0.01). There were no identified risk factors for fecal incontinence. CONCLUSION: Urinary incontinence is common in women at four months post partum. Fecal incontinence is less common. Maternal age and forceps assisted delivery were risk factors for urinary incontinence.

Is an interdisciplinary session on ethics and law in obstetrics and gynaecology effective?

OBJECTIVE: To evaluate the effects of an interdisciplinary session on medical ethics and legal issues related to obstetrics and gynaecology on medical students' knowledge, attitudes, and behaviours. METHODS: Second-year medical students at the University of Alberta were asked to complete surveys before and after an interdisciplinary panel session on ethics and legal issues in reproductive health. Survey questions were related to knowledge of ethics and law, attitudes toward controversial topics in reproductive health, and predicted behaviours in specific clinical scenarios. In the postsession survey, students were asked to evaluate the session's usefulness and impact. RESULTS: Fifty-seven students completed both the pre- and postsession surveys. Most students listed family, religion, culture, peer groups, scientific thought and theory, and school and education as influences on their own personal ethics and morality. Fifty-five students (97%) stated that the panel session was useful. Most students (79%) reported that the session increased their knowledge of ethical and legal issues in reproductive health. Many students felt that the panel session would change the way they practise in similar clinical situations (63%). The panel session appeared to affect knowledge and predicted behaviour. CONCLUSION: A large-group interdisciplinary panel session can influence medical students' knowledge and future behaviours related to ethics and law in obstetrics and gynaecology. Medical students gave this session a high rating.

RETIRED: Choice of surgery for stress incontinence.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

RETIRED: Tension-free vaginal tape (TVT) procedure.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Pelvic floor disorders: Case study.

Interactive case study discussions were an integral part of the program at the 3(rd) Annual Canadian Urology Forum (2013). The following is a summary of discussions pertaining to a case illustrating the difficulties in the management of pelvic floor disorders.

Improving resident competence and knowledge regarding tension-free vaginal tape procedure: an educational module.

OBJECTIVE: The purpose of this study was to determine the effectiveness of a teaching module using simulation for the tension-free vaginal tape (TVT) procedure on procedural knowledge and skill. METHODS: Twenty-five gynecology residents participated in a teaching module about the TVT procedure and urinary incontinence, which included a simulated insertion on a training model. Questionnaires using 10-point scales for self-rated competence and knowledge and a written examination were administered before and after the module. A simulated TVT insertion was evaluated at an examination at 7 weeks and at 7 months. RESULTS: A significant median improvement of 44% on the written examination and at least one point on each of the self-rated competence and knowledge scales were observed after the teaching module. Residents performed the insertion well at both examinations (89% and 90%), regardless of surgical experience. More than 94% agreed the module was useful and improved their understanding of the procedure. CONCLUSION: A short teaching module and simulation session can effectively teach residents and improve their perceived competence with the TVT procedure.

Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success.

OBJECTIVE: An aging population has resulted in higher prevalence of urinary incontinence (UI) and pelvic organ prolapse (POP). This study examines a nurse-run clinic and analyzes the factors contributing to successful pessary use. STUDY DESIGN: A retrospective chart review of 1,216 patients was completed. History, pelvic examination and pessary fitting was done. Data was analyzed utilizing a categorical model of maximum-likelihood estimation to investigate relationships. RESULTS: Median patient age was 63 years. Median number of pessaries tried was two. Eighty-five percent of post-menopausal women were on hormone replacement therapy (HRT) prior to fitting. Highest success rate of 78% was in the group on both systemic and local HRT. Success rates ranged from 58% for urge incontinence to 83% for uterine prolapse. Prior vaginal surgery was a factor impacting success. In our series highest success rates for fitting were obtained with ring pessaries, ring with support, and gellhorns. CONCLUSIONS: This model is a viable, option for the conservative management of UI and POP. Local HRT plays an important role in successful pessary fitting. Complications are rare.

A randomized controlled trial of early versus "traditional" postoperative oral intake after major abdominal gynecologic surgery.

OBJECTIVE: The purpose of this study was to compare early oral intake and the traditional timing of feeding after major gynecologic surgery and the effects on the length of hospital stay. STUDY DESIGN: Gynecologic oncology and urogynecology patients who underwent major abdominal gynecologic surgery were prospectively randomized to 1 of 2 groups. The traditional feeding group (group A, 49 patients) received nothing by mouth until documentation of bowel function. They were then advanced slowly to solid diet. The patients allocated to the early feeding regimen (group B, 47 patients) began clear fluids on the first postoperative day. Once 500 mL of clear fluid was tolerated, they received a regular diet. The groups were compared with regard to length of hospital stay, postoperative day that solids were tolerated, and the incidence of adverse effects. Statistical analyses were performed with the chi(2) test, the Fisher exact test, the Student t test, and analysis of variance. RESULTS: The demographic characteristics of the 2 groups were similar. There was a statistically significant reduction in the length of hospital stay for those patients on the early feeding regimen. The median length of stay for group A was 6.0 days and for group B was 4.0 days (P =.0001). There was no difference in the incidence of emesis, ileus, or other postoperative complications between the 2 groups. CONCLUSION: Early postoperative dietary advancement after major abdominal gynecologic surgery results in a decreased length of hospital stay and appears to be safe, with no increased adverse effects.