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.

Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score.

INTRODUCTION AND HYPOTHESIS: We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model. METHODS: We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic. RESULTS: For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all). CONCLUSIONS: A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Pelvic Floor Health Index: Initial validation of a practical postpartum tool for busy clinicians.

OBJECTIVE: To design a primary care clinical tool (Pelvic Floor Health Index [PFHI]) to screen for postpartum pelvic floor disorders, as well as complete its psychometric validation. DESIGN: Prospective cohort study. SETTING: Two tertiary care obstetric centres in Vancouver, BC. PARTICIPANTS: Primiparous women older than 19 years of age who were in the immediate postpartum period. MAIN OUTCOME MEASURES: The PFHI was administered to 74 primiparous women immediately postpartum and at 2, 4, and 6 months postpartum. For evaluation of convergent and divergent construct validity, participants also completed several validated questionnaires, including the Female Sexual Functioning Index, the Pelvic Floor Distress Inventory, the 36-Item Short Form Health Survey, and the Edinburgh Postnatal Depression Scale. Fifteen women repeated their 6-month questionnaires 2 weeks later in order to determine test-retest reliability. Responsiveness was assessed by measuring the PFHI score change from baseline to 6 months postpartum. RESULTS: Pelvic Floor Health Index score was inversely correlated with subscale scores on the Pelvic Floor Distress Inventory at all time points. There were moderate correlations between PFHI score and the Female Sexual Functioning Index and 36-Item Short Form Health Survey scores at several time points. There were weak correlations with postpartum depression scores. The intraclass correlation coefficient for test-retest reliability was 0.78 (95% CI 0.47 to 0.92). The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum. CONCLUSION: The PFHI is a 10-item, newly validated, and psychometrically robust questionnaire that can be administered to patients in the postpartum period to screen for pelvic floor dysfunction.

Reducing urinary tract infection in female pelvic surgery: A retrospective cohort study.

OBJECTIVE: To compare prebundle versus postbundle implementation urinary tract infection (UTI) rates among inpatients within 6 weeks of clean-contaminated pelvic reconstructive surgery. METHODS: The authors conducted a retrospective cohort study from September 2019 to December 2021 at a tertiary hospital. The bundle strategy included the following: universal preoperative UTI check with treatment if positive, replacing prolonged postoperative voiding trials on the ward with earlier discharge and indwelling catheter removal by a nurse continence advisor the next day, and daily cranberry extract for 6 weeks postoperatively. UTI was defined as positive urine culture (≥100 000 colony-forming unit per mL) in a symptomatic patient. Data analysis involved hypothesis testing and logistic regression. RESULTS: The authors reviewed 132 postbundle inpatient charts and retained 93 for analyses. The results were compared with 204 prebundle inpatient charts. The rate of postoperative UTI decreased from 17.6% in the prebundle group to 6.5% after bundle implementation (P = 0.01). The adjusted odds ratio for postbundle versus prebundle likelihood of UTI was 0.35 (95% confidence interval, 0.13-0.98; P = 0.045). Significantly more postbundle patients compared with prebundle patients were discharged home on the first day postoperatively (76.3% vs. 37.7%, P < 0.001). CONCLUSIONS: A clinical bundle can significantly decrease both UTI rates and hospital stay after pelvic reconstructive surgery.

Cannabis use preferences in women with myofascial pelvic pain: A cross-sectional study.

Objective: Myofascial tenderness is present in most chronic pelvic pain conditions and causes significant distress to patients. Treatment is challenging and often not curative. Cannabis is often used for self-management of chronic pelvic pain. However, we do not know which concentrations and routes of administration are most acceptable to users. We aimed to investigate patterns and willingness of cannabis product use among both habitual users and non-users with myofascial pelvic pain (MPP), to inform therapeutic development. Study design: We conducted a cross-sectional study of questionnaire responses from female patients with MPP from two tertiary pelvic pain centers. We aimed for a convenience sample of 100 responses with representation from both centers. Inclusion criteria were age over 18 with pelvic floor muscle tenderness on standard gynecologic examination. We collected information on demographics, pelvic pain history, cannabis use status, cannabis use preferences, validated opioid misuse risk assessment, and interest in using gynecologic cannabis products and used descriptive analyses. Results: 77/135 (57 %) questionnaire respondents were cannabis users and 58 (43 %) were non-users. Most users consume cannabis daily, (48.1 %) orally (66.2 %) or by smoking (60.7 %), and rated cannabis as effective at relieving pelvic pain. 37/58 (63.8 %) non-cannabis users responded that they would be willing to use cannabis for pelvic pain. Lack of information and potential adverse effects were the most common reasons for unwillingness to use. Approximately 3 of 4 respondents were willing to try vaginal or vulvar application of cannabis products for pelvic pain. Conclusions: This cross-sectional study describes cannabis use patterns in MPP patients. Topical vulvar and vaginal cannabis products are of strong interest to both cannabis users and non-users and warrant further research.

Symptom and Anatomical Phenotypes Provide Insights Into Interactions of Prolapse Symptoms and Anatomy.

IMPORTANCE: Women pursue treatment to relieve symptoms, while surgeons repair anatomy, underlining the importance of the relationship between symptoms and anatomy. OBJECTIVE: We hypothesized different anatomical and symptom phenotypes associated with pelvic organ prolapse (POP). Our objective was to investigate prevalence of phenotypes to explore associations of symptoms with anatomical defects. METHODS: We defined 420 anatomical phenotypes from combinations of POP Quantification parameters and 128 symptom phenotypes from symptoms described by condition-specific questionnaires (Pelvic Floor Disorders Inventory, Short Form of the Personal Experience Questionnaire). We applied these to an anonymized database of 719 subjects with symptomatic pelvic floor disorders. Bar graphs were used to illustrate the distribution of anatomical and symptom phenotypes, as well as anatomical phenotypes of patients with specific symptoms. We then used biclustering analysis with the multiple latent block model, to identify patterns of clustered groups of subjects and features. RESULTS: The most common symptom phenotypes have multiple (3-5) symptoms. A third of the theoretical anatomical phenotypes existed in our cohort. Bar graphs for specific symptom composites demonstrated unique distributions of anatomical phenotypes suggesting associations between anatomy and symptoms. Biclustering converged on 2 subject clusters (C1, C2) and 8 feature clusters. Cluster 1 (68%) represented a younger subpopulation with lower stage POP, more stress urinary incontinence and sexual dysfunction (P < 0.001 all). Cluster 2 had more protrusion (P < 0.001) and obstructed voiding (P = 0.001). Features that clustered together, such as stress urinary incontinence and sexual dysfunction, may represent underlying relationships. CONCLUSIONS: We demonstrated a relationship between locations of anatomical POP and certain symptoms, which may generate new hypotheses and guide clinical decision making.

Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study.

INTRODUCTION AND HYPOTHESIS: Severe perineal tears can predict bothersome pelvic floor disorders later in life. We have a poor understanding of pelvic floor changes during the third trimester and the first few postpartum months. We aimed to compare women with severe perineal trauma during childbirth with women who experienced minimal trauma, for condition-specific quality of life, sexual function, mental health and overall quality of life in the first 6 months postpartum. METHODS: We recruited primiparous women with third- or fourth-degree tears (obstetric anal sphincter injuries, OASIS) and age-matched controls with no tears or first-degree tears in the immediate postpartum period. Participants completed validated questionnaires at baseline, 2, 4 and 6 months postpartum. Mixed effects linear regression or quantile regression adjusted for baseline score were used to compare the groups as appropriate. RESULTS: A total of 74 women completed at least one questionnaire (35 OASIS, 39 controls). Both groups had similar demographics. Women with OASIS tended to have worse Pelvic Floor Distress Index-40 scores at month 2; median scores were similar in the two groups by month 6. They also had significantly lower Female Sexual Function Index scores (mean difference: -6.1; 95% CI: -11.9, -0.2, p=0.043) at month 2. There were no mental health group differences and quality of life improved over time, mainly in the OASIS group. Six-month participant attrition rate was 52%. CONCLUSIONS: Women with OASIS encounter specific pelvic floor challenges during the first 6 months postpartum. Although our recruitment rate was high, the attrition rate was also high, demonstrating challenges with retention of postpartum women into longitudinal research.

Labor and delivery outcomes by delivery method in term deliveries in occiput posterior position: a population-based retrospective cohort study.

BACKGROUND: Occiput posterior is the most common malposition in labor. Deliveries in occiput posterior position have been shown to have higher rates of adverse short-term maternal and neonatal outcomes compared with deliveries in occiput anterior position. There are no guidelines providing recommendations nor summarizing risks of adverse outcomes by delivery method to inform the decision-making process in occiput posterior delivery management. Population-based studies examining the outcomes associated with various management processes of occiput posterior position at the time of labor or delivery are lacking. OBJECTIVE: This study aimed to describe the current management of term singleton occiput posterior deliveries in British Columbia, Canada and to examine the association between different management strategies and adverse outcomes by describing the rates of: occiput posterior malposition; and spontaneous vaginal delivery, operative vaginal delivery, and cesarean delivery from occiput posterior malposition. We also analyzed the rates of adverse labor and delivery outcomes stratified by fetal position and delivery mode, and the interaction effect of occiput posterior position and delivery mode on the rates of adverse outcomes. STUDY DESIGN: This was a retrospective cohort study of cephalic term singleton deliveries in British Columbia from 2004 to 2020, using the British Columbia Perinatal Data Registry. The obstetrical adverse outcome index (a composite of 10 adverse maternal or neonatal events), adverse outcome index subcomponent rates, and adverse outcome index-derived weighted scores were compared between deliveries stratified by fetal position at delivery (occiput posterior or occiput anterior) and occiput posterior deliveries stratified by delivery method. Multivariable log-binomial logistic regression was used to model the adverse outcome index score. RESULTS: Of 306,237 term births, 19% had occiput posterior position during labor, 37% of which persisted in occiput posterior position at delivery. Among occiput posterior deliveries, 27% were spontaneous vaginal deliveries, 8% vacuum, 5% forceps, 1% mixed vacuum-forceps, and 59% were cesarean delivery; this distribution differed from that of occiput anterior deliveries (P<.0001). Overall, adverse outcome index scores were significantly higher in persistent occiput posterior deliveries (8.8% had ≥1 adverse outcomes; adjusted rate ratio, 1.07 [1.01-1.14]) than in occiput posterior labors that rotated to occiput anterior deliveries; the most frequent adverse outcome was third- or fourth-degree lacerations. Neonatal adverse outcomes were also more frequent in occiput posterior delivery (4.3% vs 3.3%; adjusted rate ratio, 1.21 [1.10-1.35]), whereas maternal outcomes were similar between groups (4.8% vs 6.0%; adjusted rate ratio, 1.04 [0.96-1.13]). Among persistent occiput posterior deliveries, spontaneous vaginal delivery and cesarean delivery had the lowest proportion of deliveries with ≥1 adverse outcomes (6.1% and 6.2%), whereas forceps deliveries had the highest (38.1%); the largest contributor to the adverse outcomes were third- or fourth-degree lacerations. Among occiput posterior deliveries with any adverse outcome, cesarean delivery had the highest Severity Index score, due in part to the inclusion of third- or fourth-degree tears (which are assigned a comparatively low score) as the most common adverse event in the other vaginal delivery modes, and because of outcomes with a higher severity score being associated with cesarean delivery, such as uterine rupture (a reason for cesarean delivery) and intensive care unit admission (an outcome following cesarean delivery). Overall, in a multivariable regression model, delivery mode and the interaction between delivery mode and occiput posterior position were significant predictors of a delivery with ≥1 adverse outcomes, whereas occiput posterior position itself was not. CONCLUSION: One in five singleton deliveries at term gestation had occiput posterior position in labor; most of these rotated to occiput anterior by delivery, which had better outcomes than persistent occiput posterior deliveries. Among the latter, spontaneous vaginal delivery and cesarean delivery had the lowest frequency of adverse outcomes, whereas forceps deliveries had the highest. This study provides a robust updated analysis of birth outcomes following different occiput posterior management strategies, which can inform provider decision-making and counseling. Its observational design may limit its use for direct recommendations for management of occiput posterior malposition, yet the study helps to define the risks associated with different modes of delivery in the setting of occiput posterior malposition. With additional studies examining success rates of intermediate occiput posterior-occiput anterior rotation, other delivery management steps, and long-term outcomes, this study helps to define safe management of occiput posterior delivery.

Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model.

AIMS: Postoperative urinary retention (POUR) is a common complication of urogynecological surgery. Our study aimed to identify demographic and perioperative risk factors to construct a prediction model for POUR in urogynecology. METHODS: Our retrospective cohort study reviewed all patients undergoing pelvic reconstructive surgeries at our tertiary care center (Jan 1, 2013-May 1, 2019). Demographic, pre-, intra- and postoperative variables were collected from medical records. The primary outcome, POUR, was defined as (1) early POUR (E-POUR), failing initial trial of void or; (2) late POUR (L-POUR), requiring an indwelling catheter or intermittent catheterization on discharge. Risk factors were identified through univariate and multivariate logistic regression analyses. A clinical prediction model was constructed with the most significant and clinically relevant risk factors. RESULTS: In 501 women, 182 (36.3%) had E-POUR and 61 of these women (12.2% of the entire cohort) had L-POUR. Multivariate logistic regression revealed preoperative postvoid residual (PVR) over 200 ml (odds ratio [OR]: 3.17; p = 0.026), voiding dysfunction symptoms extracted from validated questionnaires (OR: 3.00; p = 0.030), and number of concomitant procedures (OR: 1.30 per procedure; p = 0.021) as significant predictors of E-POUR; preoperative PVR more than 200 ml (OR: 4.07; p = 0.011) and antiincontinence procedure with (OR: 3.34; p = 0.023) and without (OR: 2.64; p = 0.019) concomitant prolapse repair as significant predictors of L-POUR. A prediction model (area under the curve: 0.70) was developed for E-POUR. CONCLUSIONS: Elevated preoperative PVR is the most significant risk factor for POUR. Alongside other risk factors, our prediction model for POUR can be used for patient counseling and surgical planning in urogynecologic surgery.

Documenting Perineal and Obstetrical Anal Sphincter Injury Care at Childbirth: A Cross-Sectional Study.

OBJECTIVE: This study evaluates whether maternity care providers document guideline-based recommendations for the prevention and care of obstetrical anal sphincter injuries (OASIS) for their labour and delivery patients. METHODS: We performed a cross-sectional study, aiming for a convenience sample of 60 primiparous women, over 19 years of age, equally representative of patients who experienced severe (third- and fourth-degree) and minimal (intact or first-degree) tears during vaginal birth. Information on patient demographics, delivery details, and guideline-endorsed preventative and management measures were collected. Descriptive statistics were used when appropriate. RESULTS: We enrolled a total of 73 women, 34 of whom had severe tears and 39 of whom had minimal tears. Preventative measures, including fetal head control and perineal support during delivery, were documented for 1 out of 73 patients. The use of perineal massage and warm compress to the perineum was not documented. A rectal exam after delivery was documented for 30% (22/73) of all patients and 62% (21/34) of patients with OASIS. Sixty-five percent (22/34) of patients with OASIS received intravenous antibiotics, 88% (30/34) received laxatives, and 100% received nonsteroidal anti-inflammatory drugs. Post-void residual was not documented for any patients. Patients recalled being informed about their OASIS in 68% (23/34) of cases and being referred to pelvic physiotherapy in 47% (16/34) of cases. CONCLUSION: In our study, perineal care practices during and after childbirth, as detailed in the national OASIS guideline, were incompletely documented. This may indicate partial guideline adherence or suboptimal medical record-keeping.

Preoperative Depression and Anxiety Impact on Inpatient Surgery Outcomes: A Prospective Cohort Study.

Objectives: To determine the association of preoperative mood symptoms and postoperative adverse outcomes; to explore sex-specific differences. Background: Depression and anxiety can increase postoperative mortality. Psychological stress is associated with a chronic inflammatory response unfavorable to postsurgical healing. Methods: Prospective cohort study. Patients were recruited from surgical preadmission clinics at a university hospital. Preoperative depression and anxiety were measured via the Beck Depression and Beck Anxiety Inventories (BDI-II and BAI). Our primary outcome was a composite of postoperative complications, extended length of stay (ELOS) and early readmission. Associated variables included demographics, preoperative pain, pain tolerance/catastrophizing, coping mechanisms, postoperative pain, and opioid use. We adjusted for age, comorbidities, and surgical specialty. Results: Of 1061 recruited patients (ten surgical specialties, 2015-2020), 455 males and 486 females had preoperative and postoperative data available. Mean age was 62.9 (range 20.2-96.2). At baseline, 9.3% of patients had moderate or severe depression; 7.4% had moderate or severe anxiety. Females were more likely to be moderately or severely depressed (11% vs 7%, P = 0.036) and moderately or severely anxious (9% vs 6%, P = 0.034). Females had significantly fewer reported comorbidities and lower American Society of Anesthesiologists category (P < 0.001). Increasing BDI-II and BAI scores significantly increased likelihood of postoperative complications, ELOS, and/or hospital readmission in females (adjusted odds ratio [aOR] = 2.57 for BDI-II 1-19 vs 0, P = 0.041; aOR = 4.48 for BDI-II > 19 vs 0, P = 0.008; aOR = 1.54 for BAI ≤ 6 vs >6, P = 0.038) but not in males. Mood symptoms did not influence postoperative pain or opioid use. Conclusion: Preoperative depression and anxiety negatively impact surgical outcomes in female patients undergoing major surgery.

Recreational Cannabis Use Before and After Legalization in Women With Pelvic Pain.

OBJECTIVE: To evaluate the prevalence and characteristics of recreational cannabis use in women with pelvic pain, and to examine the influence of cannabis legalization on these parameters. METHODS: We conducted a retrospective analysis of a prospective registry of women with self-reported moderate-to-severe pelvic pain referred to a tertiary care clinic in Vancouver, Canada, 2013-2019. We excluded patients aged 18 years or younger and those with unknown data on cannabis use. Demographic, clinical, and validated questionnaire data were extracted for two main analyses: 1) comparison of current cannabis users with current nonusers, and 2) comparison of current cannabis users who entered the registry before cannabis legalization (October 17, 2018) with those who entered the registry on or after legalization. RESULTS: Overall, 14.9% (509/3,426) of patients were classified as current cannabis users. Compared with nonusers, cannabis users were younger (P<.001), had lower levels of education (P<.001) and lower household income (P<.001), were taking opioids (P<.001), antiinflammatories (P=.003), neuromodulators (P=.020), and herbal medications (P<.001) more frequently. They had worse questionnaire scores for depression, anxiety, pain catastrophizing, quality of life, and pelvic pain severity (P<.001 for all). After cannabis legalization, prevalence of current cannabis use increased from 13.3% (366/2,760) to 21.5% (143/666) (P<.001). Compared with prelegalization, postlegalization users were associated with higher levels of education (P<.001), worse anxiety (P=.036), and worse pain catastrophizing (P<.001) scores. They were taking fewer antiinflammatories (P<.001), neuroleptics (P=.027) and daily opioids or narcotics (P=.026), but more herbal medications (P=.010). CONCLUSION: Recreational cannabis use increased among patients with pelvic pain after legalization in Canada. Cannabis users had worse pain-related morbidities. Postlegalization, cannabis users were less likely to require daily opioids compared with cannabis users before legalization. The role, perceived benefits, and possible risks of cannabis for pelvic pain require further investigation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02911090.

Fibroid Surgery and Long-Term Improvement in Bladder Symptoms.

OBJECTIVE: Short-term studies have demonstrated improvement in urinary symptoms after fibroid debulking surgery, yet long-term data are lacking. This study assessed the long-term impact of fibroid debulking on urinary symptoms several years postoperatively. METHODS: This case series prospectively investigated changes in urinary symptoms of women who underwent fibroid debulking surgery by several gynaecological surgeons at one centre (2011-2016). A follow-up demographics questionnaire and the Urinary Distress Inventory (UDI) were administered. Changes in total UDI scores and UDI subscale scores from preoperative baseline to long-term follow-up were calculated. RESULTS: Thirty participants were recruited from the original cohort of 61 women (49% long-term follow-up). There were significant improvements in total UDI scores (P < 0.001), obstructive subscale score (P < 0.001), and irritative subscale score (P < 0.001) 2-7 years postoperatively. Stress subscale scores were not significantly improved even in a subgroup of patients with significant baseline bother (P = 0.101). Six of eight women (75%) were cured of bothersome urge urinary incontinence, and three of eight women (37.5%) were cured of bothersome stress urinary incontinence. Baseline fibroid characteristics or type of surgery did not significantly influence outcomes. There were no significant demographic differences between women with sustained improvements and women with no improvement or worsening symptoms. The results are considered Level III evidence as per the Canadian Task Force on Preventive Health Care Levels of Evidence. CONCLUSION: Surgical fibroid removal produces long-term improvement in most bladder symptoms except for stress-related symptoms that persist over time. Women with bothersome urinary symptoms should be investigated for fibroids and counselled on potential long-term benefits of debulking surgery.

Depression, Anxiety, and Pelvic Floor Symptoms Before and After Surgery for Pelvic Floor Dysfunction.

OBJECTIVES: We aimed to explore the correlation between perioperative symptoms of depression and anxiety with pelvic floor symptoms after urogynecologic surgery. Postoperative pain, goal attainment, quality of life, and satisfaction were assessed. METHODS: A prospective cohort study of women undergoing inpatient urogynecologic surgery was conducted. Preoperative questionnaires included Beck Depression and Beck Anxiety Inventories, Pain Catastrophizing Scale, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and a detailed goals and perioperative supports questionnaire. Postoperative pain was assessed via the Short-Form McGill Pain Questionnaire. Questionnaires were readministered 6 weeks postoperatively. Descriptive statistics were obtained. Spearman correlation determined the relationship between preoperative and postoperative questionnaire scores. Quantile regression assessed the potential moderating effect of patient characteristics on these relationships. RESULTS: Sixty women (mean age, 58.5 years) were recruited. Fifty-seven (95%) completed follow-up. Most common surgical indication was pelvic organ prolapse (59/60; 98%). Depression and anxiety symptoms were minimal in most women. There was significant median change in preoperative to postoperative scores for Beck Anxiety Inventory (-2.0, P = 0.011), Pelvic Floor Distress Inventory-20 (-69.4, P < 0.001), and Pelvic Floor Impact Questionnaire-7 (-23.8, P = 0.001). Baseline depression and anxiety symptoms were correlated with higher immediate postoperative pain, but not other outcomes. The most common goal, achieved by 47 (92%) of 51, was to reduce condition-specific symptoms. Postoperative depression and anxiety symptoms, and pelvic floor distress and impact were significantly correlated. CONCLUSIONS: Baseline depression and anxiety symptoms were not significantly associated with postoperative pelvic floor symptom burden or surgical satisfaction. Bothersome postoperative pelvic floor symptoms were associated with postoperative depressive symptoms.

Urinary tract infection after clean-contaminated pelvic surgery: a retrospective cohort study and prediction model.

INTRODUCTION AND HYPOTHESIS: Postoperative urinary tract infection (UTI) leads to increased patient morbidity and health care costs. A prediction model may identify patients at highest risk for UTI development. Our primary objective was to determine the rate of UTI in the first 6 weeks after benign gynecologic surgery. Our secondary objective was to identify risk factors and build a predictive model for postoperative UTI. METHODS: We reviewed 310 patient records, which represent all patients who underwent clean-contaminated surgery at a tertiary center (2016-2017). UTI was defined as positive urine culture (> 100,000,000 CFU/l) in a symptomatic patient. Pre-, intra- and postoperative variables were collected. The relation between these variables and UTI was assessed through logistic regression. A clinical prediction model was built. RESULTS: Patients' mean age was 58.5 years and mean body mass index was 27.5 kg/m2. Most were inpatients (65.8%) and 269 had urogynecologic procedures, with the remainder undergoing pelvic surgery for other indications. The most common operation was vaginal reconstruction for prolapse (59.7%), associated with concomitant synthetic midurethral sling in 1/3 cases. Forty patients (12.9%) developed UTI. Multivariate prediction modeling showed increasing age (OR 1.33, CI 1.01-1.75), increasing number of procedures (OR 1.42, CI 1.14-1.78) and prolonged voiding dysfunction (OR 3.78, CI 1.66-8.60) to be significant UTI predictors. CONCLUSIONS: Urinary tract infection in the first 6 weeks after complex pelvic surgery is common. Our prediction model identifies that patients who are older women, have prolonged voiding dysfunction and have a greater number of concomitant pelvic floor surgeries have higher risk of postoperative UTI.

Optimizing resident operative self-confidence through competency-based surgical education modules: are we there yet?

INTRODUCTION AND HYPOTHESIS: Self-confidence is the belief in one's ability to perform and can be enhanced by training. Surgical education should aim to optimize trainee confidence. We designed three procedure-specific competency-based modules to teach vaginal hysterectomy (VH), anterior (AR) and posterior repair (PR) to novice gynecology residents. We hypothesized each module would improve self-confidence and satisfaction during index procedure performance in the operating room. METHODS: This was an ancillary analysis of a larger randomized-controlled trial of gynecologic educational interventions. Residents at three Canadian universities were included if they had previously performed fewer than five index procedures independently. Intervention residents received educational modules; controls engaged in self-directed learning. All residents performed one or more of the three surgeries and filled out a validated Self-Confidence Scale and a Satisfaction Scale. Scores were compared between groups. Correlations were sought between self-confidence and various variables. RESULTS: Forty-six residents at three Canadian universities were randomized (21 intervention, 25 control). Most residents had never performed the index procedure. Overall, self-confidence was significantly higher (p = 0.021) in the intervention group for VH, but not for AR and PR (p = 0.94 and p = 0.12, respectively). Compared with controls, self-confidence was also significantly higher in intervention residents who had never performed VH (p = 0.026) or PR (p = 0.027) and in first and second year intervention residents. There was a positive correlation between self-confidence and satisfaction. CONCLUSIONS: Surgical modules improved self-confidence preferentially in the most junior residents and for more complicated procedures. The wide self-confidence ranges observed suggest that optimization should be an important goal for surgical educators.

Pelvic floor hypertonicity in women with pelvic floor disorders: A case control and risk prediction study.

AIM: Myofascial pelvic pain is a chronic and debilitating condition, sometimes associated with pelvic floor disorders (PFD) such as urinary incontinence, defecatory dysfunction or pelvic organ prolapse. Our aim was to identify risk factors in women with PFD and hypertonic pelvic floor, compared to controls without hypertonicity. METHODS: Case control study (2009-2017) of patients with PFD and a diagnosis of hypertonic pelvic floor. Cases were matched with patients who presented with the same PFD but without pelvic floor hypertonicity. Postoperative patients with hypertonic pelvic floor were matched with patients who underwent surgery for the same PFD but did not develop pain. Risk factors were compared between groups. RESULTS: Ninety-five cases were matched; 71% had urogynecologic surgery as a possible trigger for myofascial pain. Most were post-menopausal. Overall, case patients were younger than controls (mean 54 vs 59, P = 0.002). Multivariate logistic regression identified risk factors of younger age (OR 1.45, 95%CI 1.04-2.07), history of depression (OR 3, 95%CI 1.03-9.09), musculoskeletal spine injury (OR 4.32, 95%CI 1.01-21.26) and transobturator midurethral sling (OR 8.36, 95%CI 2.68-31.32). Retropubic midurethral sling was protective against pelvic floor hypertonicity (OR 0.37, 95%CI 0.15-0.86). A clinical prediction model including depression, endometriosis, irritable bowel, spine injury and type of midurethral sling was developed to estimate the probability for myofascial pain after urogynecologic surgery. CONCLUSIONS: Specific risk factors predispose women with PFD to chronic pelvic floor hypertonicity. Knowledge of these can help with patient counselling and choice of midurethral sling prior to PFD surgery.

Fibroid surgery and improvement in bladder symptoms: The FAB study.

AIMS: Uterine fibroids are the most common tumor of the female reproductive tract [Baird et al Am J Obstet Gynecol. 188:100-107, 2003] and bladder symptoms are more prevalent in these women [Pron et al Fertil Steril. 79:112-119, 2003; Volkers et al Am J Obstet Gynecol. 196:519.e1-e11, 2007] However, the effect of various fibroid debulking surgeries on different types of urinary incontinence symptoms is poorly understood. Our primary objective was to determine whether surgical debulking of uterine fibroids affects urinary symptoms. Secondary objectives were: to define the baseline prevalence of bladder symptoms in women undergoing fibroid surgery; to explore links between fibroid characteristics, size of debulked fibroids, type of surgery, and postoperative changes in bladder function. MATERIALS AND METHODS: Prospective cohort study (2011-2016) of women undergoing vaginal or abdominal myomectomy or hysterectomy. Baseline demographics were obtained. All women underwent a detailed pelvic ultrasound preoperatively. The Urinary Distress Inventory (UDI) questionnaire of the validated Pelvic Floor Distress Inventory (PFDI) was administered before and 6 weeks after surgery. Score changes were assessed using Wilcoxon signed rank test. RESULTS: Sixty-one women completed the study. At baseline, regardless of fibroid characteristics, 96.6% of women had various bothersome urinary symptoms including storage, voiding, and incontinence. Following surgical fibroid debulking, median improvement in the UDI total score was clinically and statistically significant at 39.9 (P < 0.001). All urinary subscale scores were also significantly improved. 11/17 women (64.7%) and 11/18 women (61.1%) were cured of moderately to severely bothersome symptoms of urge and stress urinary incontinence respectively. CONCLUSIONS: Urinary symptoms are common in women undergoing surgery for uterine fibroids. Fibroid debulking may be offered as treatment for bladder symptoms in symptomatic women.

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.