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.

Validity Evidence for Procedure-specific Competence Assessment Tools in General Surgery: A Scoping Review.

OBJECTIVE: This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery. SUMMARY OF BACKGROUND DATA: Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences. METHODS: A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework. RESULTS: There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited. CONCLUSIONS: This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation.

Calling for Openness to the Study of Cannabis Use in Chronic Pelvic Pain.

Chronic pelvic pain affects women across all demographics. Its management is complex and requires a multimodal approach. Cannabis has been legal for medical purposes for many years; however, its pharmacokinetics are just beginning to be understood, as are its analgesic effects and other benefits, such as improved sleep quality and reduced nausea and vomiting. Given the recent Canada-wide legalization of cannabis for non-medical use, patients may be more willing to disclose cannabis use and use it for pain management. Given the complexity of chronic pain management, physicians must be open to cannabis as an analgesic option. Cannabis use may decrease the need for opioids, a phenomenon that could reduce opioid dependency. Now is the ideal time to study patients' use of and perspectives on cannabis for pain relief in order to establish its effectiveness and safety. Cannabis shows potential to be a key player in a multimodal approach to chronic pelvic pain.

Two Intraoperative Techniques for Midurethral Sling Tensioning: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether the use of a Mayo Scissor as a suburethral spacer compared with a Babcock clamp holding a loop of tape under the urethra results in different rates of abnormal bladder outcomes 12 months after retropubic midurethral sling surgery. METHODS: The MUST (Mid-Urethral Sling Tensioning) trial was a block-randomized, double-blind, multicenter clinical trial that allocated women to have their retropubic midurethral slings tensioned by Scissor or Babcock technique. The primary outcome (abnormal bladder) was a composite of persistent stress urinary incontinence (SUI), overactive bladder, and urinary retention. Secondary outcomes included outcomes of the composite, postoperative catheterization, incontinence-related questionnaires, repeat incontinence treatment, and uroflowmetry. Sample size of 159 in each arm (N=318) was planned for a superiority trial, hypothesizing a 10% difference in primary outcome. RESULTS: From September 2015 to December 2017, 506 women were screened and 318 were randomized. Baseline characteristics were similar in each arm. At 12 months, 253 (79.6%) women provided information on primary outcome: 40 of 128 (31.3%) patients with midurethral slings tensioned by Scissor experienced abnormal bladder, compared with 23 of 125 (18.4%) of those with midurethral slings tensioned by Babcock (P=.018, relative difference 12.9%). Secondary analyses favored Babcock for median duration of catheterization and the proportions of women experiencing urinary retention requiring sling lysis. Uroflowmetry parameters suggest the Scissor technique is more restrictive. Rates of mesh erosion were lower for the Scissor arm. No differences occurred in proportions of women experiencing patient reported persistent SUI after surgery. CONCLUSION: Abnormal bladder outcomes were 12.9% less frequent for women with midurethral slings tensioned by Babcock. Both techniques provided a comparable patient reported cure for SUI at 12 months. Women with midurethral slings tensioned by Scissors experienced more intervention for obstruction, whereas those with midurethral slings tensioned by Babcock experienced higher rates of mesh erosion. This information about how the postoperative courses differ allows surgeons to better counsel patients preoperatively or tailor their choice of technique. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02480231. FUNDING SOURCE: Boston Scientific.

What Are the Clinical Factors That Are Predictive of Persistent Pessary Use at 12 Months?

OBJECTIVE: Urinary incontinence and pelvic organ prolapse are highly prevalent in women and have a significant impact on quality of life. Pessaries are devices that are used as a conservative management option. Many women use pessaries, which avoid surgical intervention with its associated morbidity and cost. However, not all women are good candidates for pessary use. The objective of this study was to determine clinical factors leading to persistent pessary use for incontinence or pelvic organ prolapse in a tertiary care centre at 12 months. Studying patient characteristics for long-term pessary use will contribute to better patient counselling, management, and health resource distribution. METHODS: This study was a retrospective outpatient chart review of new pessary fittings in patients in a tertiary care urogynaecology clinic between January and June 2014. Any woman over 18 years of age fitted with a pessary at that time was included in the study. All statistical analyses were performed using IBM SPSS Statistics version. 24 (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-3). RESULTS: A total of 152 women were fitted with pessaries. A multivariable logistic regression analysis found that a patient's diagnosis of prolapse or incontinence (P = 0.01) and a lack of complications (P < 0.0001) were statistically significant for persistent pessary use at 12 months. Patients with prolapse had 7.7 times higher odds (95% CI 1.51-39.35) of using a pessary at 12 months than did patients with incontinence. Patients without complications had 250 times higher odds (95% CI 18.52-2500) of pessary use. Patients who tried two to three pessaries had 16 times higher odds (95% CI 1.80-137.00) of persistent use than patients who trialed just one. CONCLUSION: This study has found that a lack of complications, the number of pessaries tried, and a primary diagnosis of prolapse are significant factors for continued pessary use at 12 months.

Pregnancy-Associated Pelvic Floor Health Knowledge and Reduction of Symptoms: The PREPARED Randomized Controlled Trial.

OBJECTIVES: Pregnancy and childbirth can lead to pelvic floor disorders, yet this topic is not routine in antenatal education. We aimed to determine the impact of a pregnancy workshop on women's postpartum pelvic floor health knowledge, performance of pelvic floor muscle exercises (PFME), symptoms, condition-specific quality of life, mode of delivery, and satisfaction. METHODS: This was a RCT. Pregnant primiparous women in a tertiary care centre received a pelvic floor health workshop intervention versus routine prenatal care. Thirty-six participants/group were needed to detect a significant knowledge difference (power = 0.80, α = 0.05). Participants completed questionnaires at recruitment and six weeks postpartum. Main outcome measures were: difference between groups in knowledge scores; PFME-specific knowledge and practice; pelvic symptoms and condition-specific quality of life; and mode of and satisfaction with delivery. RESULTS: Fifty women were recruited per group; 40 attended the workshop. Women were Caucasian (72%), college educated (96%), mean age 33.2. Mean demographics did not differ. Postpartum data were available for 37 women per group. The intervention group scored higher on a pelvic floor knowledge questionnaire (mean score 31.2/39 vs. 29.3/39, P = 0.02, 95% CI 0.3, 3.6). 58.3% of intervention participants reported daily performance of PFME compared with 22.9% of controls (P = 0.002) and rated higher confidence in correct performance (P = 0.004). The intervention group reported fewer bowel symptoms (P = 0.046). There were no differences in urinary or prolapse symptoms, mode of delivery, complications, or satisfaction. CONCLUSION: A pelvic floor health workshop improves postpartum knowledge, performance of PFME, and bowel-specific quality of life.

Rare Enterorectal Pelvic Floor Hernia-A Cadaveric Study.

We present a cadaveric case study of an 88-year-old woman with an unusual posterior perineal hernia containing small bowel, rectum, and mesentery. Dissection revealed several loops of the small bowel occupying the presacral space and displacement of the rectum into a large perineal evagination. The intestinal mucosa appeared to have been healthy at the time of death, and we did not find any indication of rectal prolapse. There was also no evidence of past surgery, suggestive of a primary hernia. We conclude this patient had a posterior enterorectal perineal hernia. Suggestions for surgical repair are described.

Is Pelvic Floor Dysfunction an Independent Threat to Sexual Function? A Cross-Sectional Study in Women With Pelvic Floor Dysfunction.

INTRODUCTION: Prior studies have reported an association of sexual dysfunction with pelvic floor dysfunction (PFD), but without defining causation. AIM: To investigate predictors of sexual function in women with PFD, including pelvic organ prolapse, stress urinary incontinence, overactive bladder, obstructed defecation, and fecal incontinence. METHODS: This retrospective cross-sectional study included 755 women (mean age = 56 years, 68% postmenopausal) referred for PFD (2008-2013). Subjects underwent standardized history and examination, including demographics and assessment of pelvic floor function and sexual function using validated quality-of-life instruments. The physical examination included body mass index, Pelvic Organ Prolapse Quantification measurements, and pelvic muscle strength (Oxford scale). Proportional odds regression analysis tested patient characteristics, PFD, and other determinants of sexual dysfunction as predictors of sexual function. MAIN OUTCOME MEASURES: The Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) to assess PFD and the Short Personal Experiences Questionnaire to assess sexual function. RESULTS: The prevalence of PFD included pelvic organ prolapse (72%), stress urinary incontinence (66%), overactive bladder (78%), fecal incontinence (41%), and obstructed defecation (70%). Most subjects (74%) had a sexual partner and most (56%) reported recent sexual intercourse. Participants reported a low level of sexual desire and sexual enjoyment and moderate levels of sexual arousal and orgasm. When stratified by sexual enjoyment, 46% enjoyed sex and this group had lower PFDI and PFIQ scores, reflecting less quality-of-life burden. Pelvic organ prolapse, obstructed defecation, and fecal incontinence were associated with not enjoying sex. However, when adjusted for other determinants of sexual dysfunction (eg, aging, dyspareunia, atrophy, and partner issues), these associations disappeared. CONCLUSION: Women with PFD also have a large burden of sexual dysfunction, although this appears to be mediated by factors not unique to PFD.

Pelvic Floor Health Education: Can a Workshop Enhance Patient Counseling During Pregnancy?

OBJECTIVES: Pelvic floor disorders commonly affect women's quality of life. Their etiology is multifactorial, yet pregnancy and vaginal delivery (VD) are major inciting risk factors. Our objectives were to assess pelvic floor health information given by maternity providers to their pregnant patients, to create a pelvic floor health information workshop, and to determine its impact on women's preferences for mode of delivery. METHODS: This descriptive study recruited primiparous women with a singleton gestation at St Paul's Hospital in Vancouver, Canada. Participants received a 2-hour workshop describing pelvic floor disorders and pregnancy, modes of delivery, as well as strategies for maintaining pelvic floor health and preventing disease. Women completed questionnaires assessing baseline knowledge and level of comfort with different modes of delivery before and after the workshop. RESULTS: Forty participants completed the workshop. Seventy percent had an obstetrician, 20% had a midwife, and 10% had a family physician. Five percent of the participants reported receiving information regarding pelvic organ prolapse as well as urinary and fecal incontinence. The workshop did not influence women's preferred mode of delivery, including VD (P = 1.00), forceps-assisted VD (P = 0.48), vacuum-assisted VD (P = 0.68), postlabor cesarean delivery (P = 0.32), and elective cesarean delivery (P = 0.86). CONCLUSIONS: Current antenatal care is lacking in the area of pelvic floor health education. Patient counseling can be enhanced via a standard workshop. Concerns about negatively influencing women's preferences for mode of delivery are unwarranted, as the pelvic floor health workshop, given during pregnancy, did not significantly change participants' preferences.

Study of Prolapse-Induced Cervical Elongation.

OBJECTIVE: The cervix often appears to be elongated in women with pelvic organ prolapse (POP). This can pose surgical challenges. MRI evidence has suggested that prolapsed cervices are significantly longer than those in normal controls. Our objective was to compare cervical length in surgical hysterectomy specimens from women with symptomatic POP with the length in specimens from women with other benign gynaecological conditions. METHODS: In this pilot, prospective, case-control study, hysterectomy specimens were collected at St. Paul's Hospital, Vancouver, BC, between 2013 and 2015. Recorded patient demographics were age at the time of hysterectomy, any prior history of cervical dysplasia, and reason for hysterectomy. Specimens from women in whom the indication for hysterectomy was POP were compared with the specimens from women with other benign gynaecological conditions. Specimens were excluded if there was a history of cervical dysplasia because we could not verify whether women had undergone previous procedures resulting in cervical shortening. After bivalving each uterus, cervical and total uterine lengths were measured by staff pathologists, and the ratios of cervical length to total uterine length were calculated. Measurements in the two hysterectomy groups were compared using linear regression. RESULTS: Seventy-seven specimens were collected, 52 from women with POP and 25 from women without POP. The most common indication for hysterectomy in women without POP was uterine fibroids. Women with POP were on average older than women without POP (mean 58.5 years vs. 47.8 years, P < 0.001). The ratio of cervical length to total uterine length in women with POP was 0.10 higher (95% CI 0.03, 0.16; P = 0.005) than in women without POP. CONCLUSION: Women with symptomatic POP have significantly higher ratios of cervical length to total uterine length than women without POP.

Bilateral sacrospinous vault fixation with tailored synthetic mesh arms: clinical outcomes at one year.

OBJECTIVES: Bilateral sacrospinous fixation with tailored mesh arms (bSSVF) uses polypropylene mesh to suspend the vault to the sacrospinous ligaments bilaterally with minimal tension, recreating nulliparous midline anatomy. It can be used with uterine conservation. Our primary objective was to determine objective cure rate at one year following bSSVF compared with a control group undergoing abdominal sacrocolpopexy (ASC). Secondary objectives were to compare symptoms, quality of life, sexual function, pain, and global satisfaction before and after surgery and between bSSVF and ASC groups at one year. METHODS: This prospective cohort study enrolled patients with symptomatic prolapse who chose to undergo bSSVF or ASC. Baseline demographics were obtained. Prolapse quantification, validated symptom questionnaire scores, and McGill pain scores were obtained at baseline, six weeks, and one-year postoperatively. Global satisfaction was recorded. The primary outcome measure was the difference in cure rate (vault stage ≤ 1) between groups. RESULTS: Fifty patients were recruited: 30 underwent bSSVF and 17 ASC. Forty-three patients were available for one-year follow-up. Baseline data were similar. There was no difference in vault stage between bSSVF and ASC groups at one year. Five women who underwent bSSVF had cervical elongation, and four of these were classified as POP recurrence. Women who underwent bSSVF had more anterior recurrences but fewer postoperative complications, shorter hospital stay, and less use of narcotics than controls. Questionnaire scores were similar at one year. All respondents felt subjective improvement after either surgical procedure. CONCLUSIONS: Objective and subjective cure rates are comparable after bSSVF and ASC. Hysteropexy may cause cervical elongation that merits further research.

Objectifs : La fixation sacro-vertébrale bilatérale du dôme vaginal au moyen de languettes de treillis adaptées (bSSVF) fait appel à du treillis de polypropylène pour suspendre bilatéralement le dôme vaginal aux ligaments sacro-vertébraux en n'ayant recours qu'à une tension minimale, ce qui permet de recréer une anatomie alignée sur le plan médian semblable à celle de sujets témoins nullipares. Son utilisation peut s'accompagner d'une préservation de l'utérus. Nous avions pour objectif principal de déterminer le taux de guérison objectif à un an à la suite de la bSSVF, par comparaison avec un groupe témoin faisant appel à la sacrocolpopexie abdominale (SCA). Nos objectifs secondaires étaient de comparer les symptômes, la qualité de vie, la fonction sexuelle, la douleur et la satisfaction globale avant et après la chirurgie, et entre les groupes « bSSVF ¼ et « SCA ¼ à un an. Méthodes : Cette étude de cohorte prospective a sollicité la participation de patientes présentant un prolapsus symptomatique qui avaient choisi de subir une bSSVF ou une SCA. Leurs caractéristiques démographiques de base ont été documentées. Nous avons également documenté la quantification du prolapsus, les scores obtenus à un questionnaire validé portant sur les symptômes et les scores de douleur McGill au départ, ainsi qu'à six semaines et à un an à la suite de l'opération. La satisfaction globale a été consignée. La différence constatée en matière de taux de guérison (stade du dôme ≤ 1) entre les deux groupes constituait le critère d'évaluation principal. Résultats : La participation de 50 patientes a été sollicitée : 30 ont subi une bSSVF et 17, une SCA. Nous avons pu joindre 43 de ces patientes aux fins du suivi à un an. Les données de base étaient semblables. Aucune différence en ce qui concerne le stade du dôme n'a été constatée entre les groupes « bSSVF ¼ et « SCA ¼ à un an. Cinq des femmes ayant subi une bSSVF ont connu une élongation du col utérin; quatre de ces cas ont été classés comme constituant une récurrence du prolapsus des organes pelviens. Bien que les femmes ayant subi une bSSVF aient connu un plus grand nombre récurrences antérieures, elles ont également connu moins de complications postopératoires, leur hospitalisation a été de plus courte durée et on leur a administré moins de narcotiques, par comparaison avec les témoins. Les scores obtenus aux questionnaires étaient semblables à un an. Toutes les répondantes ressentaient une amélioration subjective après avoir subi l'une ou l'autre de ces interventions chirurgicales. Conclusions : Les taux de guérison objective et subjective sont comparables à la suite d'une bSSVF et d'une SCA. L'hystéropexie pourrait causer une élongation du col utérin qui justifie la poursuite de la recherche.

Timing cervicovesical fistula repair with repeat cesarean section.

We present a case in which there was optimal management of recurrent cervicovesical fistula. The patient sustained a fistula shortly after a cesarean for cephalopelvic disproportion in the second stage. She underwent an unsuccessful attempt at vaginal repair 3 months postpartum and continued experiencing intermittent urinary leakage through the vagina. She expressed a wish for further childbearing and was counseled to undergo fistula repair at the time of repeat cesarean section. Twenty-seven months after her first delivery, she had a second healthy pregnancy and the repair of her cervicovesical fistula was performed with collagen graft interposition at the time of her elective cesarean section. This case report highlights the importance of surgical timing and comments on various factors that possibly enhance the success of the fistula repair.

Cervical elongation following sacrospinous hysteropexy: a case series.

In recent years, pelvic floor surgeons have increasingly repaired pelvic organ prolapse around an intact uterus. Uterine conservation and hysteropexy have been driven by patient preference, less risk of mesh erosion, shorter operative time, and decreased blood loss and postoperative pain. We present a case series of patients with cervical elongation after vaginal sacrospinous hysteropexy using polypropylene mesh arms, a novel technique developed by the senior author. We defined cervical elongation as greater than or equal to a two-fold increase in cervical length compared with preoperative measurements. Of the 8 patients who underwent this procedure, 5 (62.5 %) had cervical elongation during the first year postoperatively. In the most severe case, the cervix extended to 4 cm beyond the hymenal ring. Most of the patients were mildly symptomatic and chose expectant management. The cases are reviewed in detail. A brief literature review on cervical elongation is presented.