Preoperative Simulation of Retropubic Midurethral Sling to Decrease Bladder Perforation Rate Among Obstetrics and Gynecology Residents.

IMPORTANCE: Bladder perforation is an often avoidable complication of retropubic midurethral sling procedures. Bladder injury rates decrease with surgeon experience, but literature on techniques to train novice surgeons is limited. OBJECTIVE: Our objective was to decrease the bladder perforation rate among obstetrics and gynecology residents during retropubic midurethral sling procedures through implementation of an instructional video and low-fidelity simulation. STUDY DESIGN: A baseline bladder perforation rate was determined by retrospective chart review. A prospective educational intervention, consisting of a 10-minute instructional video with preoperative simulation using a simple bony pelvis model, was then implemented among residents on the urogynecology service from December 2017 through March 2020. The primary outcome was the change in the bladder perforation rate. Compliance with the intervention protocol was a secondary outcome. Categorical data were evaluated using the χ 2 or Fisher exact test. Continuous variables were assessed using the Student t test or Mann-Whitney U test as appropriate. RESULTS: Two hundred fifteen retropubic midurethral sling cases were included in analysis. There were no significant demographic differences between the patients undergoing surgery preintervention and postintervention. Resident surgeons were in their second (47.4%) and third (52.6%) years of training. The postintervention bladder perforation rate was 6.5%, which is a 35% reduction from the preintervention perforation rate of 10% ( P = 0.19). The instructional video and preoperative simulation were successfully implemented in 193 of 215 (89.8%) eligible cases. CONCLUSION: Despite high compliance, the combination of the instructional video and preoperative low-fidelity bony pelvis simulation was not effective in reducing tension-free vaginal tape-associated bladder perforations among residents.

Specimen Fragmentation and Loop Electrosurgical Excision Procedure and Cold Knife Cone Biopsy Outcomes.

OBJECTIVE: Surgical technique for loop electrosurgical excision procedure (LEEP) and cold knife cone (CKC) emphasizes a uniform specimen, but sequelae of specimen fragmentation are not established. We evaluated outcomes between fragmented and unfragmented excisional biopsy specimens. MATERIALS AND METHODS: Loop electrosurgical excision procedure and CKCs from January 2010 to October 2013 were reviewed. Intraepithelial lesion grade, fragmentation, margin, and Endocervical curettage status were analyzed. Adenocarcinoma in situ and cancer were excluded. Repeat procedures during the study period were included in follow-up. Loop electrosurgical excision procedures with top hat with no separate fragments were analyzed independently versus those with fragmented LEEP and/or top hat. Indeterminate margin was defined as inconclusive or unevaluable margin, or intraepithelial lesion in unidentifiable margin or fragment. Outcomes involved residual or recurrent disease and repeat procedures for intraepithelial lesion. χ was used for statistical analysis. RESULTS: Fragmented specimens were more likely to have any positive margin (p = .01), multiple positive margins (p < .001), and indeterminate margin (p < .001) than unfragmented specimens. There was no significant difference in rates of positive, insufficient, or high-grade Endocervical curettage (p = .74, 0.54, 0.92). Patients with fragmented specimens were more likely to have high-grade lesion recurrence in the following 3 years (p = .04) versus patients with index unfragmented specimens, though not compared with those with unfragmented LEEP + top-hat cases. Overall rates of repeat LEEP/CKC or hysterectomy for dysplasia were not different (p = .56). CONCLUSIONS: Fragmentation of LEEP and CKC specimens is associated with higher rates of positive margins, recurrent high-grade intraepithelial lesions, and indeterminate margins. These may cause diagnostic uncertainty, require closer follow-up, and increase cost with more visits and studies.