Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial.

BACKGROUND: Opioids are routinely prescribed for postoperative pain control after gynecologic surgery with growing evidence showing that most prescribed opioids go unused. Restrictive opioid prescribing has been implemented in other surgical specialties to combat the risk for opioid misuse and diversion. The impact of this practice in the urogynecologic patient population is unknown. OBJECTIVE: This study aimed to determine if a restrictive opioid prescription protocol is noninferior to routine opioid prescribing in terms of patient satisfaction with pain control after minor and major surgeries for prolapse and incontinence. STUDY DESIGN: This was a single-center, randomized, noninferiority trial of opioid-naïve patients who underwent minor (eg, colporrhaphy or mid-urethral sling) or major (eg, vaginal or minimally invasive abdominal prolapse repair) urogynecologic surgery. Patients were excluded if they had contraindications to all multimodal analgesia and if they scored ≥30 on the Pain Catastrophizing Scale. Subjects were randomized on the day of surgery to the standard opioid prescription protocol (wherein patients routinely received an opioid prescription upon discharge [ie, 3-10 tablets of 5 mg oxycodone]) or to the restrictive protocol (no opioid prescription unless the patient requested one). All patients received multimodal pain medications. Participants and caregivers were not blinded. Subjects were asked to record their pain medication use and pain levels for 7 days. The primary outcome was satisfaction with pain control reported at the 6-week postoperative visit. We hypothesized that patient satisfaction with the restrictive protocol would be noninferior to those randomized to the standard protocol. The noninferiority margin was 15 percentage points. Pain level scores, opioid usage, opioid prescription refills, and healthcare use were secondary outcomes assessed for superiority. RESULTS: A total of 133 patients were randomized, and 127 (64 in the standard arm and 63 in the restrictive arm) completed the primary outcome evaluation and were included in the analysis. There were no statistically significant differences between the study groups, and this remained after adjusting for the surgery type. Major urogynecologic surgery was performed in 73.6% of the study population, and minor surgery was performed in 26.4% of the population. Same-day discharge occurred for 87.6% of all subjects. Patient satisfaction was 92.2% in the standard protocol arm and 92.1% in the restrictive protocol arm (difference, -0.1%; P=.004), which met the criterion for noninferiority. No opioid usage in the first 7 days after hospital discharge was reported by 48.4% of the patients in the standard protocol arm and by 70.8% in the restrictive protocol arm (P=.009). Opioid prescription refills occurred in 8.5% of patients with no difference between the study groups (9.4% in the standard arm vs 6.7% in the restrictive arm; P=.661). No difference was seen in the rate of telephone calls and urgent visits for pain control between the study arms. CONCLUSION: Among women who underwent minor and major surgery for prolapse and incontinence, patient satisfaction rates were noninferior after restrictive opioid prescribing when compared with routine opioid prescribing.

Perineal lacerations and social media: can patients find reliable information on Instagram and TikTok?

INTRODUCTION AND HYPOTHESIS: Social media content related to patient experiences and education continues to grow. Information on how obstetric perineal lacerations are represented on social media is limited. Our goal is to characterize available social media content on obstetric perineal lacerations. METHODS: This is an IRB-exempt study using publicly available data on commonly searched topics about perineal lacerations to create a list of queries for Instagram and TikTok. The ten queries and "keyword" searches with the highest number of posts were identified from this list. The 50 most recent posts were reviewed for relevance, quality of content, and authorship. Topic-relevant posts were analyzed. RESULTS: The search yielded 427 posts on Instagram and 500 on TikTok. Instagram yielded more topic-relevant posts than TikTok (94.1% vs 44.8%). Almost 50% of posts were categorized as educational. Instagram identified more patient experience-related posts (29.6%) whereas TikTok provided more humorous content (26.3%). Patients produced 27.6% of content on Instagram and 43.3% on TikTok. Physical therapists produced 18.9% of posts on Instagram and 21.9% on TikTok. They constituted the largest group of health professionals to post overall. Physician-created educational content accounted for 10.3% of posts on Instagram and 6.0% on TikTok. CONCLUSIONS: Compared with TikTok, Instagram may be a more informative social media platform for educational or patient experience-related content. Given the paucity of physician-created content and given that only half of all posts are educational, providers should encourage social media engagement for community and networking purposes, while encouraging caution with regard to cosmetic products and advertisements.

Postpartum urinary retention: an expert review.

Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.

Is there an association between 6-month genital hiatus size and 24-month composite prolapse recurrence following minimally invasive sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS: Although an enlarged postoperative genital hiatus (GH) size has been identified as a predictor of recurrence following pelvic organ prolapse (POP) surgery, the protective role of concurrent level III support procedures to reduce the GH size at the time of minimally invasive sacrocolpopexy (MI-SCP) remains unclear. The objective of this study was to compare 24-month composite prolapse recurrence following MI-SCP between patients with a 6-month postoperative GH measurement of <3 cm versus ≥3 cm; and to explore the impact of concurrent level III support procedures on prolapse recurrence, bowel, and sexual function. METHODS: This was a secondary analysis of two randomized controlled trials of women who underwent MI-SCP from 2014 to 2020. Our primary outcome was composite prolapse recurrence defined as retreatment with either pessary or surgery, and/or subjective bothersome vaginal bulge. A receiver operating characteristic (ROC) curve was generated to identify a 6-month GH cutoff point associated with 24-month composite recurrence. RESULTS: Of the 108 women who met the inclusion criteria, 13 (12%) had composite prolapse recurrence at 24 months: 12 patients (11.1%) reported a bothersome vaginal bulge, and 3 patients (2.8%) underwent retreatment with surgery. A ROC curve demonstrated that a 6-month postoperative GH size of 3 cm had 84.6% sensitivity to predict vaginal bulge and/or retreatment at 24 months (area under curve = 0.52). There was no difference in the composite prolapse recurrence between the groups; however, only patients with a 6-month GH >3 cm underwent retreatment. CONCLUSIONS: Twenty-four-month composite prolapse recurrence does not differ based on 6-month GH size; however, surgical failure may be more common in those with a GH size greater than 3 cm.

Starting a peripartum pelvic floor disorder clinic: what to expect in the first thirty-six months.

INTRODUCTION AND HYPOTHESIS: Subspecialty peripartum pelvic floor disorder (PFD) clinics provide care to a unique patient population. We aim to describe the experiences of such a clinic in the first 36 months after its establishment. METHODS: This is a descriptive case series of all women who presented to a subspecialty PFD clinic at an academic medical center over 36 months (January 2018-December 2020). Patient characteristics, referral patterns, and care plans will be described. RESULTS: Four hundred eighty-three women presented for care. Women were a mean age of 31.0 ± 4.2 years, most were primiparous (404, 83.6%), and over half (279, 57.8%) had a spontaneous vaginal delivery. Three hundred eighteen women (66.9%) had obstetric anal sphincter injury (OASI), which was also the primary referral indication in 313 (64.8%). Most consultations were from an obstetrician (246, 51.3%), and the median time from delivery to evaluation was 17 days (IQR 11.0-34.0). The majority of women had one additional follow-up visit (330, 68.3%). One hundred forty-one (29.9%) women underwent minor office procedures, and 26 (5.4%) underwent surgery. The number of referrals sequentially increased from year 1 (59, 12.2%) to year 3 (215, 44.5%). CONCLUSIONS: The 36-month experiences in our growing subspecialty peripartum PFD clinic demonstrate both sustainability and feasibility of this new service line, with consistent clinical growth over time and 483 new consultations, 2/3 of which were for OASI and the other 1/3 for a variety of peripartum pelvic floor indications. Our data outline a model for care, including timeline for follow-up, treatments administered, and number of interventions, both office and surgical.

Postoperative pain and the need for intervention after sacrospinous ligament hysteropexy compared to colpopexy: a retrospective cohort study.

OBJECTIVES: To compare postoperative pain between patients undergoing sacrospinous ligament colpopexy (SSLF) and hysteropexy (SSLH). METHODS: This was a retrospective cohort study of all patients undergoing native tissue SSLF and SSLH between January 2013 and March 2020. The electronic medical record was queried for demographic and perioperative data until the postoperative visit. The primary outcome was a composite incidence of any of the following: telephone calls, urgent office visits, additional analgesic prescriptions and need for intervention for pain in the buttocks, posterior thigh or perirectal area. Secondary outcomes were the incidence of persistent pain at the postoperative visit and perioperative risk factors associated with reported pain. RESULTS: A total of 406 patients met inclusion criteria (308 SSLF, 98 SSLH). The composite pain outcome was seen in 99 patients (24.4%; 95% CI 20.5%-28.8%), and there was no statistical difference between cohorts. Persistent pain was seen in 15.6% and 13.3% of SSLF and SSLH patients at 6 weeks (p = 0.58). Twelve patients (3.0%) underwent interventions for pain, including physical therapy (2), trigger point injections (5) and suture release (5). Compared to SSLF patients, SSLH patients were more likely to need interventions (7 [7.1%] vs. 5 [1.6%], p = 0.005) and office visits (14 [14.3%] vs. 13 [4.2%], p = 0.0005) for pain. CONCLUSIONS: There was no difference in the overall incidence of postoperative pain between patients who underwent SSLF or SSLH. However, patients who underwent hysteropexy were more likely to need intervention and office evaluation for postoperative pain.

Outcomes of labiaplasty in women with labial hypertrophy.

INTRODUCTION AND HYPOTHESIS: High-quality data are lacking to understand outcomes in women who undergo labiaplasty for labial hypertrophy and whether there is an association with body dismorphic disorder (BDD). METHODS: This was a cross-sectional study of a retrospective cohort of women who underwent labiaplasty for labial hypertrophy at a tertiary care referral center. Women were identified by CPT codes and were included if the procedure was performed by a urogynecologist. The health record was queried for demographic, pre-, intra-, and postoperative data. For the cross-sectional component of the study, participants were contacted to complete a survey. RESULTS: Thirty-six women met study inclusion criteria; 21 participated in the survey, and retrospective data were available for 20. At the time of labiaplasty, the women had a mean age of 30 ± 12 years and mean BMI of 23.9 ± 4.4 kg/m2. The most common preoperative motivation for undergoing labiaplasty, based on the medical record, was pain (85.0% 17/20). Complications were uncommon and minor. No women met criteria for BDD. Participant survey-reported primary motivation for undergoing partial simple vulvectomy was "pinching" in 10 (47.6%), "pain" in 4 (19.0%), and "appearance" in 7 (33.3%). The majority of women reported that labiaplasty achieved their preoperative goal (20/21, 95.2%). CONCLUSIONS: Women who underwent labiaplasty were primarily motivated by functional concerns, and outcomes indicate a high satisfaction with genital appearance postoperatively as well as a positive effect on body image and quality of life. We recommend that surgeons work to understand what motivates women to pursue surgical intervention by asking about cosmetic concerns.

Peripartum pelvic floor disorder clinics inform obstetric provider practices.

INTRODUCTION AND HYPOTHESIS: The objective of this study is to evaluate obstetric providers' knowledge and practice patterns since the establishment of a peripartum pelvic floor disorder clinic. METHODS: This is a prospective, cross-sectional survey study of obstetric providers at an academic tertiary care health system. A 22-question survey was designed to collect provider demographic data, indications for and barriers to referrals, provider satisfaction, and impact of the clinic's existence on peripartum pelvic floor dysfunction diagnosis and management. Eligibility criteria included obstetrics and gynecology trainees, attending physicians, certified nurse midwives, and advanced practice providers. RESULTS: There were 86 survey responses yielding a response rate of 72.1%. The majority of respondents were staff obstetricians (57.0%) or trainees (26.7%). Most commonly reported referral indications were third- and fourth-degree lacerations (94.9%), complex lacerations (70.5%), wound breakdown (57.7%), and urinary retention (53.8%). Regarding satisfaction with the peripartum pelvic floor disorder clinic, of referring providers, 77 (98.7%) agreed or strongly agreed that evaluations were useful for patients and 78 (100%) agreed or strongly agreed that evaluations were useful for themselves. Seventy-six (97.4%) respondents reported that they were very satisfied with the peripartum pelvic floor disorder clinic overall. The majority of respondents agreed or strongly agreed that the clinic increased their awareness of both obstetric anal sphincter injuries and their impact on maternal health (84.6%). CONCLUSION: The introduction of a peripartum pelvic floor disorder clinic results in high obstetric provider satisfaction and positively impacts patient care through increased provider knowledge and awareness on the management of obstetric anal sphincter injuries.

Complications following vaginal colpopexy for the repair of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The primary aim of this study was to compare differences in complication rates across different types of vaginal colpopexy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. METHODS: Patients who underwent intra- or extraperitoneal vaginal colpopexy with or without concurrent hysterectomy were identified in the 2014-2016 NSQIP database using Current Procedural Terminology codes. Patient demographics, preoperative comorbidities, American Society of Anesthesiologists (ASA) classification system scores, and total operating time were obtained. NSQIP-tracked 30-day codes were used to determine the complication, reoperation, and readmission rates. RESULTS: A total of 9546 colpopexies were performed during the study period. The mean age was 62 ± 12 years, and the mean body mass index (BMI) was 28 ± 6 kg/m2. The majority of patients were white (73%) with an ASA class of 2 (65%). The overall rate of postoperative complications was 10.5%. The most common complications were urinary tract infections (UTI) (5.1%), transfusion (1.0%), and superficial surgical site infection (0.7%). Excluding UTI, the rate of postoperative complications was 5.4%. After performing multivariable logistic regression, higher ASA class (class 3: aOR 1.69, 95% CI 1.16-2.51; class 4: aOR 3.98, 95% CI 1.51, 9.30) and extraperitoneal colpopexy with hysterectomy were independently associated with a higher odds of experiencing a non-UTI postoperative complication (aOR1.43, 95% CI 1.10, 1.84). Minority race was also independently associated with higher odds of experiencing a non-UTI postoperative complication (aOR 1.33, 95% CI 1.15, 1.52). CONCLUSION: One in ten women undergoing vaginal colpopexy experienced a postoperative complication. Minority race and extraperitoneal colpopexy with concurrent hysterectomy were independently associated with an increased risk of a non-UTI postoperative complication.

Evaluation of Strategies to Prevent Urinary Tract Injury in Minimally Invasive Gynecologic Surgery: A Systematic Review.

OBJECTIVE: To systematically review tools for the prevention of urinary tract injury in adult women undergoing minimally invasive gynecologic surgery. DATA SOURCES: A medical librarian (M.P.H.) searched Ovid Medline 1946 to, Ovid Embase 1929 to, CINAHL 1965 to, Cochrane Library 1974 to, Web of Science 1926 to, and SCOPUS 1974 to present on April 2 and April 3, 2020. METHODS OF STUDY SELECTION: Articles evaluating strategies for the prevention of urinary tract injury at the time of minimally invasive gynecologic surgery were included. Articles that were nongynecologic, nonhuman, and nonadult were excluded. If a study did not describe the surgical approach or type of surgical procedures performed, it was excluded. If the study population was <50% gynecologic or <50% minimally invasive, it was excluded. Articles evaluating techniques for the diagnosis or management of injury, rather than prevention, were excluded. TABULATION, INTEGRATION, AND RESULTS: The search yielded 2344 citations; duplicates were removed, inclusion criteria were applied, and 9 studies remained for analysis. Three studies evaluated bladder catheters, and 6 evaluated ureteral catheters. In the 3 studies evaluating bladder catheters, there were no urinary tract injuries. Urinary tract infection was greater in women who received a bladder catheter. In the studies evaluating the use of ureteral catheters, we found inconsistent reporting and heterogeneity that precluded meta-analysis. The results of the available studies do not indicate that ureteral catheters decrease the risk of injury, and indicate that they increase morbidity. CONCLUSION: The evidence is insufficient to support the routine use of bladder catheters or ureteral catheters for the prevention of urinary tract injury at the time of minimally invasive gynecologic surgery.

Accurate diagnosis and repair of obstetric anal sphincter injuries: why and how.

Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.

Subspecialty care for peripartum pelvic floor disorders.

Obstetrical perineal and anal sphincter lacerations can be associated with considerable sequelae. The diagnosis of short-term bowel, bladder, and healing problems can be delayed if patients are not seen until the traditional postpartum visit at 4 to 6 weeks. Specialized peripartum clinics create a unique opportunity to collaborate with obstetrical specialists to provide early, individualized care for patients experiencing a variety of pelvic floor issues during pregnancy and in the postpartum period. Although implementation of these clinics requires thoughtful planning and partnering with care providers at all levels in the obstetrics care system, many of the necessary resources are available in routine gynecologic practice. Using a multidisciplinary approach with pelvic floor physical therapists, nurses, advanced practice providers, and other specialists is important for the success of this service line and enhances the level of care provided. Overall, these clinics provide a structured means by which pregnant and postpartum women with pelvic floor symptoms can receive specialized counseling and treatment.

A randomized controlled noninferiority trial of reduced vs routine opioid prescription after prolapse repair.

BACKGROUND: Given the accelerating opioid crisis in the United States and evidence that patients use fewer opioid tablets than prescribed, surgeons may choose to decrease prescribed quantities. The effect this may have on patient satisfaction with pain control after hospital discharge is unknown. OBJECTIVE: The primary objective of this study was to compare patient satisfaction with postoperative pain control between patients receiving a routine or reduced quantity opioid prescription after prolapse repair. Secondary objectives included a comparison of opioid-related side-effects, the number of opioid tablets used, and the number of excess tablets prescribed between these groups. STUDY DESIGN: This was a single-center, unmasked, 2-arm, randomized controlled noninferiority trial of women who underwent a prolapse repair with a planned overnight hospitalization. Patients were assigned randomly to 1 of 2 study arms: routine (28 tablets of oxycodone 5 mg) or reduced (5 tablets) prescription of opioid tablets. Patients were eligible if they were at least 18 years of age and undergoing a prolapse repair with an anticipated overnight hospital stay. Exclusion criteria included a history of chronic pain, preoperative opioid use, intolerance to study medication, or a score of ≥30 on the Pain Catastrophizing Scale. In addition to their opioid prescription, all patients received multimodal pain medications at discharge. Patients were asked to complete 6 weeks of diaries to record pain and medication use. The primary outcome (patient satisfaction) was collected as part of a postoperative survey completed at patients' routine postoperative visit 6 weeks after surgery. The sample size for noninferiority was calculated at 59 patients per group for a total of 118 patients. RESULTS: One hundred eighteen patients were assigned randomly; the primary outcome was available for 116. The majority of patients were white, postmenopausal, and nonsmokers; the mean age was 62±10.4 years. The most common surgery was a hysterectomy with native tissue repair (n=71; 60%). One hundred ten patients (93%) were satisfied with postoperative pain control. Statistical analysis constructed for noninferiority showed that the difference between the groups was <15% (93% vs 93%; P=.005). Subjects in the reduced arm reported requiring an additional opioid prescription more frequently than in the routine arm (15% vs 2%; P=.01). Patients in the routine arm used more opioid tablets than the reduced arm (median, 3 [interquartile range, 0-14] vs 1 [interquartile range, 0-3]), but overall opioid utilization was low. As such, patients in the routine arm had significantly more unused opioid tablets (median, 26 [interquartile range, 15-28] vs 4 [interquartile range, 2-5]). CONCLUSION: Patient satisfaction with pain control was noninferior in patients who received a reduced quantity of opioid tablets after prolapse repair compared with those who received a routine prescription. A large quantity of excess opioid tablets was seen in both groups. Surgeons should consider prescribing 5-10 opioid tablets after prolapse repair surgery and consider applying these findings to postoperative prescribing after other gynecologic procedures.

Resident Education in Complex Obstetric Procedures: Are We Adequately Preparing Tomorrow's Obstetricians?

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) milestones for obstetrics and gynecology (OB/GYN) residents include obstetrical technical skills. We sought to describe resident experience with surgical obstetrics and comfort performing procedures independently postgraduation. STUDY DESIGN: An anonymous 27-question e-survey was sent to OB/GYN residents in United States in March 2018, using the Council of Resident Education in Obstetrics and Gynecology coordinator listserv. Complex obstetric procedures included: forceps-assisted vaginal delivery (FAVD) and vacuum-assisted vaginal delivery (VAVD), cerclage, breech second twin, breech delivery, perineal repairs, and cesarean hysterectomy. Technical skill questions included experience as primary surgeon, comfort performing procedures independently, and for 4th year residents-comfort performing procedures postresidency. Demographic information was queried. Descriptive statistics was used to analyze responses. RESULTS: A total of 417 residents completed the survey. Respondents were 88% female, 75% from academic programs, and 48% postgraduate year 3 and 4. Among all residents, many had been primary surgeon in operative vaginal deliveries (51% FAVD, 72% VAVD), fewer for breech vaginal delivery (21%), breech second twin (34%), cesarean hysterectomy (21%), and 4th degree repairs (37%). All 4th-year respondents stated that they would feel comfortable performing either VAVD or FAVD postresidency. Note that 17, 33, 28, and 74% would not feel comfortable performing a 4th degree repair, cesarean hysterectomy, breech second twin, and breech vaginal delivery, respectively, postresidency. CONCLUSION: Despite ACGME recommendations, data suggest that many graduating residents may not be comfortable with these complex procedures.

Randomized double-blind trial of short- versus long-acting analgesia at the sacrospinous ligament.

INTRODUCTION AND HYPOTHESIS: Pain control is a key component of postoperative care; our objective was to evaluate if use of long-acting local anesthesia at the sacrospinous ligament leads to decreased postoperative pain versus short-acting local anesthesia in patients undergoing sacrospinous ligament fixation. METHODS: Women ≥ 18 years old undergoing sacrospinous ligament fixation to treat pelvic organ prolapse were eligible to participate in this randomized trial. Enrolled patients were randomized 1:1 to one of two study arms: (1) lidocaine arm (LA) or (2) liposomal bupivacaine arm (LBA). Patients in the LA received 30 ml 0.5% lidocaine with 1:200,000 epinephrine local injection at the sacrospinous ligament. Patients in the LBA received 20 ml 1.3% bupivacaine liposomal mixed with 10 ml 0.5% bupivacaine at the sacrospinous ligament. All patients received 50 ml 0.5% lidocaine with 1:200,000 epinephrine for anterior and/or posterior colporrhaphy. The primary outcome of this study was postoperative buttock pain. RESULTS: Of the 37 patients enrolled, 33 completed study procedures. Mean age (± SD) was 62.3 years (± 11.6) in the LA and 66.8 years (± 14.4) in the LBA (p = 0.32). All participants underwent sacrospinous ligament fixation; the rate of concomitant procedures did not differ between study arms. Visual analog scale scores for buttock-specific pain were compared between arms at 1, 3, 6, 12, 24, 36, 48, 72, 96, and 120 h postoperatively, and no differences were found. CONCLUSIONS: Use of long-acting local analgesia at the sacrospinous ligament at the time of sacrospinous ligament fixation does not provide any benefit over short-acting local analgesia.

Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery.

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n = 103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0-2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.

Suburethral sling procedures in the United States: complications, readmission, and reoperation.

INTRODUCTION AND HYPOTHESIS: Hospital readmission is increasingly used as a measure of quality care. Our objective was to evaluate the rate of readmission and associated factors in women undergoing suburethral sling placement in the USA. METHODS: This is a cohort study of suburethral sling procedures performed in the USA from 2012 to 2014 using the American College of Surgeons' National Surgical Quality Improvement Program database. The database was queried for suburethral sling procedures. Records were excluded if concomitant surgery had been performed. Patient and surgical characteristics were evaluated for association with readmission using Chi-squared test for categorical variables and Student's t test for continuous variables. All results yielding p < 0.05 were deemed statistically significant. RESULTS: A total of 7,117 suburethral sling procedures were identified. There were 83 (1.16%) hospital readmissions. Those who were readmitted tended to be older (p = 0.011), non-Hispanic (p = 0.04), smokers (p < 0.001), and have an American Society of Anesthesiologists Physical Status Classification System score of 3 or 4 (p = 0.001). A history of bleeding disorder (p < 0.001), congestive heart failure (p < 0.001), or chronic obstructive pulmonary disease (p < 0.001) was associated with readmission. Fifty-four (0.75%) patients underwent reoperation within 30 days of suburethral sling placement. The most common reoperation procedure was sling excision (20 patients). The most common complication was urinary tract infection, which occurred in 189 patients (2.7%). CONCLUSIONS: Suburethral sling placement is a safe procedure with a low rate of readmissions, reoperations, and complications. Consistent with other types of surgery, infection is the most common post-operative complication.

Peripheral Tibial Nerve Stimulation for Overactive Bladder Syndrome: Treatment Success and Patient Satisfaction.

OBJECTIVE: To evaluate the success rate and patient satisfaction ofperipheral tibial nerve stimulation (PTNS) therapy. METHOD: Retrospective cohort study assessing PTNS treatment success and patient satisfaction. RESULTS: Data from 34 women were included. On average, patients were 70.2 (± 12) years of age, had a BMI of 29.9 (± 8.9) kg/M², and traveled 11.2 (± 12.3) miles to receive weekly PTNS treatments. Overall, 22 patients (64.7%) were satisfied, four (11.8%) unsatisfied, and eight (23.5%) undecided. Those who were satisfied completed an average of 10.9 treatments (± 2.4), those who were unsatisfied completed an average of 9.5 treatments (± 2.6), and those left undecided completed an average of 7.2 treatments (± 4.3). The fourth treatment visit was the most likely to predict whether a patient would be satisfied or unsatisfied by the 12th treatment. CONCLUSION: Overall the success of the PTNS therapy was 64.7%, consistent with previous studies. Most patients note improvement after the fourth treatment.

Development and validation of a laparoscopic hysterectomy cuff closure simulation model for surgical training.

BACKGROUND: The number of robotically assisted hysterectomies is increasing, and therefore, the opportunities for trainees to become competent in performing traditional laparoscopic hysterectomy are decreasing. Simulation-based training is ideal for filling this gap in training. OBJECTIVE: The objective of the study was to design a surgical model for training in laparoscopic vaginal cuff closure and to present evidence of its validity and reliability as an assessment and training tool. STUDY DESIGN: Participants included gynecology staff and trainees at 2 tertiary care centers. Experienced surgeons were also recruited at the combined International Urogynecologic Association and American Urogynecologic Society scientific meeting. Participants included 19 experts and 21 trainees. All participants were recorded using the laparoscopic hysterectomy cuff closure simulation model. The model was constructed using the an advanced uterine manipulation system with a sacrocolopexy tip/vaginal stent, a vaginal cuff constructed from neoprene material and lined with a swimsuit material (nylon and spandex) secured to the vaginal stent with a plastic cable tie. The uterine manipulation system was attached to the fundamentals of laparoscopic surgery laparoscopic training box trainer using a metal bracket. Performance was evaluated using the Global Operative Assessment of Laparoscopic Skills scale. In addition, needle handling, knot tying, and incorporation of epithelial edge were also evaluated. The Student t test was used to compare the scores and the operating times between the groups. Intrarater reliability between the scores by the 2 masked experts was measured using the interclass correlation coefficient. RESULTS: Total and annual experience with laparoscopic suturing and specifically vaginal cuff closure varied greatly among the participants. For the construct validity, the participants in the expert group received significantly higher scores in each of the domains of the Global Operative Assessment of Laparoscopic Skills Scale and for each of the 3 added items than did the trainees. The median total Global Operative Assessment of Laparoscopic Skills Scale score (maximum 20) for the experts was 18.8 (range, 11-20), whereas the median total Global Operative Assessment of Laparoscopic Skills Scale score for the trainees was 10 (range, 8-18) (P = .001). The overall score that included the 3 new domains (maximum 35) was 33 (range, 18-35) for the experts and 17.5 (range, 14-31.5) for trainees (P = .001). For the face validity testing, the majority of the study participants (32 [85%]) agreed or strongly agreed that the model is realistic and all participants agreed or strongly agreed that the model appears to be useful for improving technique required for this task. For the interrater reliability, the scores assigned by each observer had an interclass correlation coefficient of 0.8 (95% confidence interval, 0.7-0.93). CONCLUSION: This model is easily constructed and has an acceptable cost. We have demonstrated evidence of construct validity. This is a valuable education tool that can serve to improve skills, which are essential to the gynecological surgeon but are often lacking in residency training because of national changes in practice patterns.

Quality Evaluation of Abstracts Presented at the Society of Gynecologic Surgeons Annual Scientific Meeting.

STUDY OBJECTIVE: To examine the rate of abstract publication from the Society of Gynecologic Surgeons Annual Scientific Meeting (SGSASM), 2004 to 2012. STUDY DESIGN: This is a retrospective study in which all abstracts presented at the SGSASM from 2004 to 2012 were reviewed. Information was collected on oral (O), oral poster (OP), and poster (P) presentations. To evaluate for publication, all abstracts were searched for in the US National Library of Medicine's PubMed database. Chi-square tests were used to evaluate whether there were differences in distribution of published studies by first author location and affiliation and number of abstract authors. DESIGN CLASSIFICATION: Canadian Task Force III. MEASUREMENTS AND MAIN RESULTS: In total, 867 abstracts were reviewed, including all O, OP, and P presentations. Video and tips and tricks presentations were excluded. Overall rate of publication for all abstracts from 2004 to 2012 was 55.7%, comprising 82.4% for O presentations, 60.9% for OP presentations, and 41.4% for P presentations. There was no significant difference in location for published abstracts (p = .878), although published abstracts had a significantly greater number of authors (p < .001). Abstracts presented by authors from university programs were more likely to be published (p < .001). For all presentation types, the mean number of citations for published abstracts was different for the 9-year period (O, OP, and P: p < .001), with an overall decline toward the end of the assessment period. CONCLUSION: Over a 9-year period (2004-2012), the rate of abstract publication at the SGSASM was 55.7%, which is similar to other academic meetings. The comparability of this publication rate shows that the abstract selection committee is able to select high-quality research with limited information provided in abstract submissions.