Impact of clinical audits on cesarean section rate.

OBJECTIVE: Many countries have noted a substantial increase in the cesarean section rate (CSR). Several methods for lowering the CSR have been described. Understanding the impact of clinical audits on the CSR may aid in lowering CSR. Thus, our aim is to elucidate the effect of clinical audits on the CSR. MATERIALS AND METHODS: We retrospectively analyzed 3781 pregnant women who gave birth in a medical center between January 2008 and January 2011. Pregnant women who delivered between January 2008 and July 2009 were enrolled as the pre-audit group (n = 1592). After August 2009, all cesarean section cases that were audited were enrolled in the audit group (n = 2189). The CSR was compared between groups. RESULTS: The overall CSR (34.5% vs. 31.1%, adjusted odds ratio [OR] = 0.83, p = 0.008) and the cesarean section rate due to dystocia (9.6% vs. 6.2%, p < 0.001) were significantly lower in the audit group than the pre-audit group. However, there was no significant difference in the rate of operative vaginal delivery between groups. Consensus on the unnecessity for cesarean section was achieved in 16 (8.2%) of 195 audit cases in the monthly audit conference. In nulliparous pregnant women (n = 2148), multivariate analysis revealed that clinical audit (OR = 0.78), maternal age (OR = 1.10), gestational age at delivery (OR = 0.80), and fetal body weight at birth (OR = 1.0005) were independent predictors of cesarean section (all p < 0.05). Most variables of maternal and perinatal morbidity and mortality did not differ before and after audits were implemented. CONCLUSION: Clinical audits appear to be an effective strategy for reducing the CSR. Therefore, we recommend strict monitoring of the indications in dystocia for cesarean section to reduce the CSR.

Evaluation of bladder diary parameters based on correlation with the volume at strong desire to void in filling cystometry.

Accurate assessment of patient bladder capacity is important in determining the proper initial treatment for lower urinary tract dysfunctions and as well as for monitoring therapeutic outcomes. However, urodynamic study is an invasive procedure. Thus, it is important to find a surrogate for invasive urodynamic study, and the aim of this study is to identify the parameter from patient-recorded bladder diary that is best correlated to the volume at strong desire to void (VSD) derived from urodynamic studies. A total of 900 women who underwent urodynamic studies at a university hospital between January 2009 and December 2011. Correlation between bladder diary parameters and VSD was investigated by Spearman rank-correlation coefficient. Days 1 to 3 average maximum daytime voided volumes excluding the first morning void (DVVmaxavg) (mean 263 ml) had the highest correlation with VSD (mean 261 ml; ρ = 0.51, p<0.001). The predictive value of VSD was 146+0.44 × DVVmaxavg. The days 1, 2, and 3 daytime maximum voided volumes excluding the first morning void (DVVmax) were all significantly associated with VSD and had similar mean volumes (ρ = 0.43-0.46, all p<0.001). DVVmaxavg had the highest area under the receiver operating characteristic curve (0.75; 95% confidence interval = 0.72-0.78) for predicting bladder oversensitivity. The threshold of DVVmaxavg <250 ml had good predictive value for detecting bladder oversensitivity (sensitivity 70.9%; specificity 65.8%), and day 1 DVVmax <250 ml had similar sensitivity (70.6%) and specificity (59.1%). Besides, the correlation coefficients (ρ) between day 1, day 2 and day 3 DVVmax and DVVmaxavg were good with a range of 0.70-0.89. In conclusion, DVVmaxavg was the bladder diary parameter best correlated with VSD. DVVmaxavg and day 1 DVVmax may be useful in screening for bladder oversensitivity.

Comparison of robot-assisted laparoscopic myomectomy and traditional laparoscopic myomectomy.

AIM: The benefit of robot-assisted laparoscopic myomectomy (RALM) over traditional laparoscopic myomectomy (TLM) remains undetermined. The aim of this study was to reveal any potential advantage of RALM over TLM. MATERIAL AND METHODS: Between June 2010 and October 2011, all women presenting with symptomatic uterine myomas were enrolled in this study. Perioperative variables were compared between these two groups. The patients recruited in this study were allocated into the two groups based on their financial considerations. RESULTS: A total of 42 patients received RALM (n = 20) or TLM (n = 22) for symptomatic uterine myomas. The operation time was longer in the RALM group; but the total abdominal drainage amount on postoperative day 1 was significantly less in the RALM group than the TLM group. Multivariate analysis revealed that the RALM procedure (coefficient = 79.1, P < 0.001), number of myomas (coefficient = 15.4, P = 0.002), and the presence of a cervical myoma (coefficient = 54.9, P = 0.01) were independent factors affecting operation time; the maximum myoma diameter was the only factor affecting blood loss (coefficient = 113.4, P = 0.003). However, the RALM procedure was the only factor affecting the amount of abdominal drainage on postoperative day 1 (coefficient = -86.3, P = 0.006). CONCLUSIONS: Although RALM is a longer operation than TLM, it might result in less postoperative abdominal drainage than TLM and help alleviate short-term morbidity.

Factors associated with fecal incontinence in women with lower urinary tract symptoms.

AIM: The aim of this study was to identify the factors associated with fecal incontinence in female patients with lower urinary tract symptoms. MATERIAL AND METHODS: Data regarding clinical and urodynamic parameters and history of fecal incontinence of 1334 women with lower urinary tract symptoms who had previously undergone urodynamic evaluation were collected and subjected to univariate, multivariate, and receiver-operator characteristic curve analysis to identify significant associations between these parameters and fecal incontinence. RESULTS: Multivariate analysis identified age (odds ratio [OR]=1.03, 95% confidence interval [CI]=1.01-1.05, P=0.005), presence of diabetes (OR=2.10, 95%CI=1.22-3.61, P=0.007), presence of urodynamic stress incontinence (OR=1.90, 95%CI=1.24-2.91, P=0.003), pad weight (OR=1.01, 95%CI=1.00-1.01, P=0.04), and detrusor pressure at maximum flow (OR=1.02, 95%CI=1.01-1.03, P=0.003) as independent risk factors for fecal incontinence. Receiver-operator characteristic curve analysis identified age≥55years, detrusor pressure at maximum flow≥35 cmH(2) O, and pad weight≥15g as having positive predictive values of 11.4%, 11.5%, and 12.4%, respectively, thus indicating that they are the most predictive values in concomitant fecal incontinence. CONCLUSIONS: Detrusor pressure at maximum flow and pad weight may be associated with fecal incontinence in female patients with lower urinary tract symptoms, but require confirmation as indicators by further study before their use as screening tools.