Gender Equity in Academic Female Pelvic Medicine and Reconstructive Surgery Departments: A Cross-Sectional Observational Study.

IMPORTANCE: Gender equity in obstetrics and gynecology remains a barrier to career mobility and workplace satisfaction. OBJECTIVE: This study aimed to evaluate gender equity for academic positions in female pelvic medicine and reconstructive surgery (FPMRS) divisions with an Accreditation Council for Graduate Medical Education-accredited fellowship in the United States. STUDY DESIGN: This was a cross-sectional observational study of all FPMRS divisions with an Accreditation Council for Graduate Medical Education-accredited fellowship program in the United States in July 2020 using publicly available demographic and academic data collected from online search engines. Gender equity in academic FPMRS was assessed by gender representation, academic appointment, and research productivity of each attending physician within the division. Research productivity was assessed using both the H-index with career length controlled for with the M-quotient. RESULTS: There were 348 attending physicians from 72 FPMRS divisions (198 female [56.9%], 150 male [43.1%]). A large percentage of female attending physicians were at the assistant professor level (75.8% [94 of 124]) when compared with their male counterparts (24.4% [30 of 124]; P < 0.001). Conversely, there were a larger percentage of male attending physicians (62.2% [56 of 90]) at the professor level when compared with their female counterparts (37.8% [34 of 90]; P < 0.001). There was no difference in research productivity between male and female attending physicians after controlling for career length with the M-quotient (P = 0.65). Only age (odds ratio, 1.14; 95% confidence interval, 1.05-1.24) and the M-quotient (odds ratio, 36.17, 95% confidence interval, 8.57-152.73) were significantly associated with professorship. CONCLUSIONS: Our study found that there are more female attending physicians in FPMRS and that most are assistant professors. Male and female FPMRS attending physicians had similar research productivity with respect to their career lengths. Gender was not a determinant for achieving a "professor" appointment.

Long-term quality of life and pelvic floor dysfunction after bariatric surgery.

OBJECTIVE: To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. STUDY DESIGN: Prospective cohort study of 44 women undergoing bariatric surgery. RESULTS: Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (-34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). CONCLUSION: Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh.

INTRODUCTION AND HYPOTHESIS: We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery. METHODS: In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test. RESULTS: Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months. CONCLUSIONS: Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

Virtual Interviews During COVID-19: Perspectives of Female Pelvic Medicine and Reconstructive Surgery Program Directors.

OBJECTIVE: The aim of the study was to evaluate female pelvic medicine and reconstructive surgery (FPMRS) fellowship program directors' opinions regarding the effectiveness of virtual interviews for selecting fellows and their future interview mode preferences. METHODS: This was a cross-sectional online survey of all FPMRS program directors in the United States conducted from April 29, 2020, to May 30, 2020. At the time of this study, there were 73 program directors and 69 obstetrics and gynecology and urology-accredited FPMRS programs nationwide. The primary outcome was to subjectively assess the effectiveness of virtual interviews as compared with in-person interviews for evaluating applicants. RESULTS: Fifty seven (82.6%) of the program directors completed the survey. A total of 80.7% (46/57) of the respondents had participated in interviews for the active match cycle. Of the programs that participated in the interview process, almost all conducted interviews using virtual platforms (97.8%, 45/46). Program directors who conducted interviews virtually found them effective in evaluating applicants (88.9%, 40/45) and were satisfied with the virtual interview process (86.7%, 39/45). A total of 31.1% of respondents (14/45) preferred a virtual platform to an in-person setting for future interviews, and 60% (27/45) reported that they will likely perform future interviews virtually. CONCLUSIONS: Although the pandemic resulted in a sudden reformatting of FPMRS fellowship interviews, most program directors nationally were satisfied with the process and found virtual interviews effective for assessing applicants. More than 50% of FPMRS program directors are likely to consider the virtual format for future interviews.

Effect of hormone replacement and selective estrogen receptor modulators (SERMs) on the biomechanics and biochemistry of pelvic support ligaments in the cynomolgus monkey (Macaca fascicularis).

OBJECTIVE: To evaluate the effect of selective estrogen receptor modulators and ethinyl estradiol on the biomechanical and biochemical properties of the uterosacral and round ligaments in the monkey model of menopause. STUDY DESIGN: A randomized, double-blind, placebo-controlled study on 11 female macaque monkeys. Ovariectomized monkeys received 12 weeks of placebo, raloxifene, tamoxifen, or ethinyl estradiol. Biomechanical step-strain testing and real-time polymerase chain reaction was performed on the uterosacral and round ligaments. RESULTS: Tamoxifen and raloxifene uterosacrals expressed differing collagen I/III receptor density ratios, but both selective estrogen receptor modulators showed decreased tensile stiffness compared to ethinyl estradiol and controls. CONCLUSION: These findings support a possible effect of selective estrogen receptor modulators on biomechanical and biochemical properties of uterosacrals. This may play a role in pelvic organ prolapse.

Sling procedures after repair of obstetric vesicovaginal fistula in Niamey, Niger.

INTRODUCTION AND HYPOTHESIS: The purpose of this paper is to evaluate the results of sling procedures for stress incontinence after repair of vesicovaginal fistulae at the National Hospital in Niamey, Niger. METHODS: This study is a retrospective chart review of 701 women surgically treated for vesicovaginal fistulae. One hundred forty women subsequently underwent a sling procedure for stress incontinence after fistula repair. RESULTS: The demographics among the groups were similar. No significant difference was seen in results between the sling types except the risk of erosion was significantly greater in the synthetic sling group. There was a trend towards greater sling success in the fascia lata group. CONCLUSIONS: Correction of incontinence is a common and difficult challenge following repair of obstetric vesicovaginal fistula. Compared to published studies on sling procedures, these patients have higher rates of continued incontinence. This is likely due to the frequent loss of a urethral sphincter as well as high prevalence of detrusor overactivity and decreased bladder capacity.

Neurologic injury and patient displacement in gynecologic laparoscopic surgery using a beanbag and shoulder supports.

OBJECTIVE: To quantify the incidence of peripheral neuropathy in gynecologic laparoscopic surgery using a combination of beanbag, eggcrate foam, and shoulder supports; and to assess patient displacement during surgery in a steep Trendelenburg position and determine variables correlated with displacement. METHODS: A retrospective study included all gynecologic laparoscopic surgeries performed by one high-volume surgeon at a US center between September 15, 2007, and September 15, 2012. Data included neurologic deficits or extremity pain, any other complications, and-for the final study year-surgical time as well as patient and beanbag displacement. RESULTS: Among 967 patients, no long-term neuropathy was reported, 6 (0.6%) patients had transient shoulder pain beyond the first 24 hours (resolved by initial postoperative visit), and 7 (0.7%) were lost to follow-up. No neurologic complications were reported. Median beanbag and total patient displacement were 0 cm (interquartile range 0-0) and 0 cm (interquartile range 0-2), respectively. Patient displacement relative to the table was correlated with the total surgical time (P=0.025) and patient weight (P=0.023). The median displacement was greater in hysterectomy than non-hysterectomy procedures (P=0.003). CONCLUSION: Use of beanbags with shoulder supports and convoluted foam armboard pads was associated with minimal patient displacement and risk of arm and leg neurologic injury.

Commonalities among women who experienced vesicovaginal fistulae as a result of obstetric trauma in Niger: results from a survey given at the National Hospital Fistula Center, Niamey, Niger.

OBJECTIVE: The purpose of this study was to evaluate the histories of women with urinary incontinence caused by vesicovaginal fistulae in Niger. This is an exploratory analysis to investigate possible contributing factors to the development of vesicovaginal fistulae. STUDY DESIGN: From September 2005 to January 2006, 58 women who were treated for vesicovaginal fistulae at the National Hospital Fistula Center, Niamey, Niger, were interviewed. RESULTS: The average age of marriage was 15.6 years and of first pregnancy was 17.3 years; 44.9% of the women were primigravid; and 94.8% of the women began labor at home. By delivery, 91.4% of the women sought additional care. The average labor lasted 2.61 days. An average of 1.61 days passed before further assistance was sought; 91.4% of infants were stillborn. CONCLUSION: Early marriage, young age at first pregnancy, and labor length are common findings in our population of women with vesicovaginal fistulae. Most women who experienced fistulae also had poor obstetric outcomes. Increasing access to emergency obstetric care is of paramount importance to prevent fistula formation.

Suprapubic abscess and vaginal fistula 22 years after bladder neck suspension with Dacron buttresses.

BACKGROUND: Erosion and fistula formation are known complications of nonabsorbable materials in gynecologic surgery. The majority are diagnosed within months after surgery. CASE: A 45-year-old woman who had recurrent vaginal discharge for 4 years presented with a suprapubic abscess with a fistulous retropubic tract into the right side of the vagina 22 years after a bladder neck suspension with Dacron buttresses. The abscess was incised and drained, and the buttresses were removed (suprapubically and vaginally). The patient recovered well with antibiotics. The vagina and suprapubic skin were closed by second intention. CONCLUSION: Erosion and fistula formation can present more than two decades after using permanent material in pelvic reconstructive surgery. These complications should be included in the differential diagnosis of unexplained pelvic symptoms.

Teaching of pelvic organ prolapse quantification system among obstetrics/gynecology and urology residents in the United States.

OBJECTIVES: The objective of this study was to compare the Pelvic Organ Prolapse Quantification (POPQ) system teaching practices among obstetrics/gynecology (ob/gyn) and urology residents in the United States. METHODS: Anonymous Web-based survey was e-mailed to the residency program directors/coordinators of all urology and ob/gyn programs in the United States with a request to forward it to all their residents. Fisher exact and z tests for proportions and multivariate regression analysis examining factors associated with POPQ system use were used in the statistical analysis. RESULTS: Sixty percent (45/75) of urology and 78.9% (105/133) of responding ob/gyn residents (P = 0.006) reported having used the POPQ system, whereas 42.7% and 59.4% of them, respectively, reported current use (P = 0.03). The latter also reported more protected educational time (P < 0.001), more urogynecologists in their programs (P = 0.032), and learning more frequently from drawings (P = 0.025). Opinions about the routine clinical and scientific usefulness of POPQ system and the perceived difficulty in learning it did not vary between groups. After performing multivariate logistic regression analysis, the presence of a fellowship, the number of subspecialists in the program, and the number of POPQ system teaching sessions were the studied variables found to contribute independently to the residents' use of that system. CONCLUSIONS: Obstetrics/gynecology residents use POPQ system more frequently than do urology residents. This could be related to differences in teaching practices between urology and ob/gyn programs.

Robot-assisted laparoscopic myomectomy is an improvement over laparotomy in women with a limited number of myomas.

STUDY OBJECTIVE: To compare surgical and immediate postoperative results of robot-assisted laparoscopic myomectomy vs myomectomy via laparotomy in patients with 3 myomas or fewer. DESIGN: Case-control (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Seventy-five women who had undergone robotic-assisted laparoscopic myomectomy were compared with patients who had undergone myomectomy via laparotomy. INTERVENTIONS: Medical records were reviewed for surgical and postoperative variables. Both groups had 3 myomas or fewer confirmed at preoperative magnetic resonance imaging or final pathology report. MEASUREMENTS AND MAIN RESULTS: No significant differences were observed between patients insofar as preoperative demographic data. There was a significant increase in mean duration of surgery for robotic-assisted myomectomy. There was a significant decrease in blood loss, change in hematocrit concentration on postoperative day 1, length of stay, number of days to regular diet, and febrile morbidity in robotic-assisted myomectomies. There were no significant differences in operative or postoperative complications. CONCLUSION: Although robotic-assisted myomectomy took substantially longer, most of the other variables improved in comparison with similar procedures performed via laparotomy.

An evaluation of the resident learning curve in performing laparoscopic supracervical hysterectomies as compared with patient outcome: five-year experience.

STUDY OBJECTIVE: To compare surgical and postoperative results after laparoscopic supracervical hysterectomy between the first 2 cases and last 2 cases performed by each senior resident. DESIGN: Retrospective, case-control study (Canadian Task Force classification II-B). SETTING: University hospital. PATIENTS: Two hundred six women underwent laparoscopic supracervical hysterectomy. INTERVENTIONS: Charts were reviewed to determine length of surgery, operative and postoperative complications, and other surgical values. A comparison was made between the first 2 and last 2 cases of 25 chief residents. MEASUREMENTS AND MAIN RESULTS: There was no statistically significant difference between the first 2 and last 2 patients of each resident in terms of age, indication for surgery, uterine mass, ethnicity, body mass index, or parity. There was a significant decrease in the mean time of the first 2 cases versus the last 2 cases: 201.4 minutes versus 137.2 minutes (p <.001). There was no significant difference in blood loss, change in hematocrit, length of hospital stay, and surgical or postoperative complications. CONCLUSIONS: Laparoscopic supracervical hysterectomy is a technically challenging procedure that nevertheless can be learned quickly with rapid improvement in operative time and without undue risk to the patient. Since initially presenting these data in 2003, the senior residents are now getting twice the amount of exposure to this surgery. In addition, these data now include residents who were exposed to this type of surgery as junior residents. Although residents are beginning to have increased experience in performing laparoscopic supracervical hysterectomy before their chief year, there is still a significant difference in operative time from the initial 2 procedures to the last 2 procedures completed by a chief resident.

Location of adenomyosis in total hysterectomy specimens.

STUDY OBJECTIVE: To determine the location of adenomyosis in hysterectomy specimens and estimate a risk of leaving the disease in patients undergoing supracervical hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University teaching hospital. SUBJECTS: Total hysterectomy specimens from 32 women. MEASUREMENTS AND MAIN RESULTS: Each patient had six slides representing anterior and posterior cuts of the uterus at the cervix, lower uterine segment, and fundus. Analyzing the six groups separately, no significant difference was seen in the number of nests between anterior and posterior slides at the same uterine level. A substantial difference was noted between each site and all other sites on other uterine levels. Grouping the anterior and posterior together, a significant difference was found in the number of nests between all levels (p <0.001). Evaluating only for presence of disease, no significant difference was found between the anterior and posterior of each level, a significant difference was seen between each site and sites at all other levels, and a difference was noted among all levels when the anterior and posterior were grouped (all p <0.001). CONCLUSION: Adenomyosis has a significant propensity to be present in the uterine fundus but it is extremely rare in the cervix. Supracervical hysterectomy for adenomyosis is unlikely to leave disease in the patient as long as the entire lower uterine segment is excised.