Incidence of successful voiding and predictors of early voiding dysfunction after retropubic sling.

INTRODUCTION AND HYPOTHESIS: There is a paucity of literature on resumption of normal voiding predictors after synthetic retropubic sling insertion and lack of a standardized method of determination. Our goals were to determine the incidence of a successful voiding trial; whether clinical, operative, or urodynamic variables predict discharge with a catheter; and incidence of later retention in those who were initially successful. METHODS: We performed an internal-review-board (IRB)-approved retrospective chart review of 229 consecutive patients who underwent retropubic sling (TVT, Boston Scientific, Natick, MA, USA)) from 2001 to 2010. Exclusions were concomitant surgery or cystotomy at the time of retropubic sling insertion. All participants underwent a voiding trial in recovery consisting of 300 cc sterile-water retrograde fill and were discharged home without a catheter after single void of at least 200 cc following catheter removal. RESULTS: Of 170 patients, 136 (80 %) passed the voiding trial the same day, with 165 (97 %) passing within 1 day. Factors associated with delayed voiding were age ≥65 years (p < 0.05), presence of Valsalva voiding (p < 0.01), lower body mass index (BMI) (p < 0.05), and higher gravidity (p < 0.05) and parity (p < 0.01). Age ≥65 years [adjusted odds ratio (aOR) 3.72, 95 % confidence interval (CI) 1.40-9.90, p < 0.01] and Valsalva voiding (aOR 3.89, 95 % CI 1.56-9.69, p < 0.01) remained significant independent predictors in multivariate analysis. CONCLUSIONS: The majority of patients with retropubic sling can be safely discharged home the same day without a catheter after retrograde fill. Women >65 years or Valsalva voiders had nearly four times the odds of being discharged with a catheter. Most patients resume normal voiding within 24 h after retropubic sling insertion, but >65 years and Valsalva voiding are risk factors for voiding inability at discharge.

Bladder perforation during tension-free vaginal tape procedures: abdominal versus vaginal approach.

OBJECTIVE: Bladder perforation rates for the tension-free vaginal tape (TVT) are higher with inexperienced surgeons. The purpose of this study was to examine if surgical approach affects this rate. METHODS: We performed a retrospective cohort study of consecutive patients undergoing a TVT as the sole procedure. All cases were performed by senior residents using 2 different surgical approaches-vaginal or abdominal trocar passage. Power analysis indicated that 103 patients in each group (vaginal and abdominal approach) were required to demonstrate a 50% reduction in perforation rates. RESULTS: The rate of perforation was 37.9% (95% confidence interval [CI], 28.5%-47.3%) for the vaginal compared with 6.8% (95% CI, 1.9%-11.7%) for the abdominal technique (P < 0.001). The relative risk that the abdominal technique results in bladder injury compared with the original transvaginal was 0.18 (95% CI, 0.08-0.38). CONCLUSIONS: Bladder perforation occurs significantly less frequently with abdominal needle placement for the TVT procedure. We recommend this technique to less experienced surgeons.

Outcomes of Retropubic Synthetic Midurethral Gynecare TVT Slings When Performed by Urogynecologists, Urologists, and General Gynecologists in a Private Community Hospital.

OBJECTIVES: : To compare perioperative outcomes of a retropubic synthetic midurethral Gynecare TVT slings (Gynecare Worldwide, division of Ethicon Inc, NJ) performed by urogynecologists, urologists, and general gynecologists. METHODS: : This is a retrospective, cohort study of retropubic synthetic midurethral Gynecare TVT sling outcomes performed between 2001 and 2007 at a single institution. Other synthetic and nonsynthetic slings, or slings performed with concurrent surgeries were excluded. The primary outcomes were mean sling operating room (OR) time in minutes (min) and estimated blood loss in milliliters (mL). All variables were stratified by the surgeon's specialty: urogynecology (URO-GYN), urology (URO), and general gynecology (GYN). RESULTS: : Of 279 Gynecare TVT sling procedures, 126 were performed by URO-GYN, 30 by URO, and 123 by GYN. Mean sling OR time was 38.8 ± 8.5 minutes for URO-GYN, 42.6 ± 11.2 minutes for URO, and 39.8 ± 14.3 minutes for GYN, P = 0.30. Estimated blood loss was 56.6 ± 68.3 mL for URO-GYN, 69.7 ± 82.6 mL for URO, and 68.8 ± 73.4 mL for GYN, P = 0.37. The intraoperative complications (bladder, urethral perforations, and hemorrhage) were similar among the specialties. In the postoperative period, there was no difference in subsequent need for urethrolysis (cutting or removal of the sling), return to OR, and readmission to the hospital after the procedure among all 3 specialties. CONCLUSIONS: : All 3 specialties (urogynecologist, urologists, and general gynecologists) had similar major perioperative outcomes in performing retropubic synthetic midurethral Gynecare TVT slings.

Reduction in the incidence of chronic lung disease in very low birth weight infants: results of a quality improvement process in a tertiary level neonatal intensive care unit.

OBJECTIVE: Our objective was to reduce the incidence of chronic lung disease by introducing potentially better practices in our delivery room and NICU. METHODS: We compared the incidences of chronic lung disease in infants with birth weights of 501 to 1500 g in 2002 and 2005, after implementation of the changes. Medical records for infants of 501 to 1500 g who were born in 2002 and 2005 were reviewed for maternal characteristics, care of the infant in the delivery room and the NICU (including surfactant usage, duration of ventilation, duration of continuous positive airway pressure therapy, and duration of oxygen treatment), length of stay, and short-term clinical outcomes (eg, pneumothorax, severe intracranial hemorrhage, retinopathy of prematurity, and weight gain). RESULTS: There was a significant reduction in our incidence of chronic lung disease, from 46.5% in 2002 to 20.5% in 2005. The number of infants discharged from the hospital with oxygen therapy also decreased significantly, from 16.4% in 2002 to 4.1% in 2005. The overall relative risk reduction for chronic lung disease in 2005, compared with 2002, was 55.8%. CONCLUSIONS: By using a quality improvement process that included avoidance of intubation, adoption of new pulse oximeter limits, and early use of nasal continuous positive airway pressure therapy, we demonstrated a significant reduction in the incidence of chronic lung disease in infants with birth weights of <1500 g in 2005, in comparison with 2002. These results have persisted to date. There were no significant short-term complications.

Outcomes of hysterectomies performed by supervised residents vs those performed by attendings alone.

OBJECTIVE: The objective of the study was to compare the outcomes of hysterectomies performed by residents under supervision of a teaching physician with those performed by attendings alone. STUDY DESIGN: This was a retrospective cohort analysis of hysterectomies performed at the Greater Baltimore Medical Center from 2004 to 2006. RESULTS: Of 159 nonteaching and 265 teaching cases, there was no significant difference in any of the surgical outcomes, except mean operating room time in minutes (94.8 [+/- 47.0] vs 107.4 [+/- 42.4]; P = .005), seromas (2.5% vs 0%; P = .02), and others (5% vs 0.8%; P = .007) in nonteaching vs teaching cases, respectively. The demographics and comorbidities were similar. The mean operating room time difference of 13 minutes was not clinically significant. CONCLUSION: Although teaching hysterectomies take a bit longer to perform, there were no greater adverse outcomes.

Patients' knowledge of potential pelvic floor changes associated with pregnancy and delivery.

Physicians cite pelvic floor injury as a major reason for Cesarean section as their personal preferred delivery mode. This study was undertaken to determine whether patients receive information about possible pelvic floor complications of pregnancy/delivery. Day 1 post-partum women completed a 52-item questionnaire assessing information given during routine antenatal care. Pelvic floor and general questions were intermixed. Of the 232 patients, the mean age was 26.9 years, with 59.5% white, 32.8% African-American and 7.7% other. Most (84.5%) had at least grade 12 education. The following percentage of patients reported receiving no information about: Kegel exercises 46.1%; episiotomy 51.3%; urinary incontinence 46.6%; fecal incontinence 80.6%; change in vaginal caliber 72.8%; neuropathy 84.9%. Counseling on all of these issues occurred significantly less frequently than education on general pregnancy topics. Our results suggest that knowledge and instruction of pelvic floor risks is very much lacking and provide us with an impetus to develop educational tools.

Bladder perforation during tension-free vaginal tape procedures: analysis of learning curve and risk factors.

OBJECTIVE: To estimate whether rates of bladder perforation decrease with increasing surgical experience. METHODS: We performed a review of all patients undergoing a tension-free vaginal tape procedure performed by senior resident physicians under the guidance of a single surgeon. Physician experience was assessed by sequentially assigning case numbers to each procedure for each resident. For analysis of learning curve, cases were grouped in fives (ie, first five representing cases 1 to 5, second five cases 6 to 10). RESULTS: Twenty-three residents performed 278 procedures. The median number of cases performed was 13 (range 3 - 22); mean number was 12.1 (sd = +/- 5.6). The rate of perforation was 34.2% (95/278, 95% confidence interval 28.8-39.9%). Age and weight were significantly associated with perforation. The cystotomy group was, on average 4.5 years younger (P = .007) and 7.86 kg (17.3 lb) lighter (P < .001). Rate of injury in the first five series was 40.9%, 30.7% in second series of five, and 25.9% in the third series of five and was statistically significant (linear-by-linear association chi(2) = 4.286, df = 1, P = .038). The relationship between the incidence of cystotomy and the cumulative number of cases performed was inversely correlated. As the number of cases a resident completed increased, there was a slight tendency for cystotomy to decrease (P.033). On cystoscopic examination, residents missed 35 of the 95 injuries (37%, 95% confidence interval 27.8-46.9%). CONCLUSION: A learning curve exists for tension-free vaginal tape procedures. Many injuries are missed on initial resident cystoscopic inspection, highlighting the need for comprehensive cystoscopic training during residency. LEVEL OF EVIDENCE: II-3.

Anatomic relationship between the vaginal apex and the bony architecture of the pelvis: a magnetic resonance imaging evaluation.

OBJECTIVE: This study was undertaken to define anatomic relationships between the vaginal apex and the ischial spines and sacrum for nulliparous women with normal support. STUDY DESIGN: We retrospectively evaluated the magnetic resonance images of 11 consecutive women who underwent pelvic imaging at Johns Hopkins. Coordinates were recorded for the posterior fornix, sacrum, ischial spines, and cervical vaginal junctions. We calculated vector distances with means, SDs, and 95% CIs. Intraclass correlation coefficients tested interobserver reliability and the Wilcoxon signed rank test compared right- and left-sided measurements. RESULTS: Mean age was 30.4 +/- 9.1 years. The cervical vaginal junction was 1.6 +/- 0.5 cm superior, 1.1 +/- 0.5 cm anterior, and 4.7 +/- 0.4 cm medial to the ipsilateral ischial spine. The posterior fornix was 1.0 +/- 1.0 cm anterior and 5.3 +/- 0.8 cm inferior to the second sacral vertebra. There was excellent interobserver reliability (interclass correlation coefficients = 0.997, P < .001) and no detectable difference between sides. CONCLUSION: Consistent relationships exist between the vaginal apex and ischial spines and sacrum, which may be useful in reconstructive pelvic surgery.

Comparison of long-term outcomes of autologous fascia lata slings with Suspend Tutoplast fascia lata allograft slings for stress incontinence.

OBJECTIVE: This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI). STUDY DESIGN: We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001. RESULTS: Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007). CONCLUSION: Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.

A comparison of anticipatory and postprocedure pain perception in patients who undergo urodynamic procedures.

OBJECTIVE: The purpose of this study was to compare anticipatory and postprocedure pain perception in female patients who undergo multichannel urodynamic evaluation in an office setting. STUDY DESIGN: One hundred consecutive patients completed a visual analogue pain scale before and after urodynamic testing. RESULTS: The mean postprocedure pain score of 2.32 cm was significantly lower than the anticipatory pain rating of 4.35 cm (P<.05). The lower postprocedure pain score was not influenced by previous hysterectomy, body mass index, menopausal status, estrogen replacement therapy, or analgesic or psychiatric medication usage. Patients who had undergone previous anti-incontinence surgery reported significantly higher levels of pain during the procedure (mean visual analogue pain scale score, 3.10 cm vs 2.06 cm; P=.027). CONCLUSION: Patients who undergo urodynamic testing anticipate higher degrees of discomfort than they perceive during the procedure. Previous anti-incontinence surgery appears to lower the pain threshold.

Voiding dysfunction after surgery for stress incontinence: literature review and survey results.

Postoperative voiding dysfunction is a potential complication of anti-incontinence procedures. Reported rates of urethral obstruction range from 5% to 20%. There is a lack of consensus in the literature regarding the appropriate evaluation and management of this distressing problem. A literature search was carried out using Medline (1966-2001) for postoperative voiding dysfunction. The key word urethrolysis was cross-referenced with surgical complications and stress urinary incontinence to identify all published English-language articles. The bibliographies of reviewed articles were searched manually. We also mailed a survey to the members of American Urogynecologic Society (AUGS) regarding their management of this problem. Overall, 262 members (31.4%) responded to the survey. Success rates reported in the literature between retropubic and vaginal techniques of urethrolysis are comparable, but morbidity is lower with the vaginal approach. The success rates are equivalent with (68%) or without (74%) resuspension following transvaginal urethrolysis. The incidence of postoperative SUI is acceptably low even without resuspension of the urethra (6% for both). Results of the AUGS survey reveal that most providers favor a transvaginal approach (74%) when performing urethrolysis, and they do not routinely resupport the bladder neck (82%).

The position of the urethrovesical junction after incontinence surgery: early postoperative changes.

This study prospectively evaluated the position of the urethrovesical junction using the Q-tip angle to assess early postoperative changes for different anti-incontinence surgeries. All procedures resulted in a statistically significant change in resting angle from the intraoperative value. The mean change for the transvaginal tape was 25.74 degrees (27.43 to 3.28); Burch 11.18 degrees (-20.44 to -10.0) and fascia sling 13.9 degrees (26.57 to 15.68). The mean change in Q-tip angle was greater after transvaginal tape placement than after Burch ( p=0.000) and fascial sling ( p=0.022) procedures. These findings show that the resting position of the urethrovesical junction after surgery is different for all procedures. The transvaginal tape results in the greatest change in angle. This may help to negate the so-called 'tension-free' nature of the procedure. Surgeons need to be aware of this, as it may be an etiological factor in cases of late urinary retention and urethral erosion.

The effects of knowledge management on surgeon behavior.

Knowledge management is an important process for health care researchers and administrators. The way we manage and transfer knowledge in an organization can have a substantial impact on behavior and performance. In this article, we examine the behavioral effects of transferring performance-efficiency knowledge to a group of hospital-based surgeons. We observe the way the knowledge transfer impacts their sense of professional accountability and practice patterns for a limited set of diagnoses. We defined performance efficiency for a surgeon as the deviation from expected average length of inpatient hospital stay, and from expected average hospital charges (adjusted for risk and outcomes) for three of the most frequently performed and most costly surgical procedures in our subject hospital. We communicated knowledge of their performance efficiency to the group of hospital-based surgeons, along with benchmarked professional best practices, and included an identification of dimensions where performance could be improved. We then measured and compared their performance efficiency one year later. We did observe differences in performance efficiency, but not in consistent directions, and not in statistically significant magnitudes. Also, surgeons who initially had low levels of efficiency continued to have low levels of efficiency one year later. Within a professional accountability system, transfer of performance-efficiency knowledge alone did not provide sufficient motivation to induce consistent, significant change in practice behaviors among the group of surgeons. We conclude that medical opinion leaders and individualized strategies for surgeon motivation may have greater promise for improving performance efficiency if linked to the knowledge transfer system.

A comparison of anticipated pain before and pain rating after the procedure in patients who undergo cystourethroscopy.

OBJECTIVE: The purpose of this study was to compare anticipated pain before the procedure and actual pain rating after the procedure in female patients who undergo cystourethroscopy. STUDY DESIGN: Eighty-seven consecutive female patients completed a 10-cm visual analog pain scale before and after cystourethroscopy. A 24F urethroscope was used initially to inspect the urethra and was followed by a systematic survey of the bladder with a 17F cystoscope that was lubricated with 2% lidocaine gel. The visual analog pain scale scores were evaluated for significance with the use of the Student t test and the Pearson correlation coefficient. RESULTS: Visual analog pain scale analysis demonstrated a mean anticipated pain score of 3.75 cm before the procedure versus a mean pain rating score of 2.83 cm after the procedure (P <.05). Neither a history of previous cystoscopy (visual analog pain scale score, 3.03 vs 2.30 cm; P =.18) nor talking with someone about the procedure beforehand (visual analog pain scale score, 2.74 vs 2.89 cm; P =.76) influenced the lower pain rating after the procedure. There was no significant correlation between age, parity, body mass index, or presence of pelvic organ prolapse and anticipated or realized pain perception. CONCLUSION: Patients who undergo cystourethroscopy consistently anticipate higher degrees of discomfort than they actually perceive during the procedure.

Optimal waiting period for foot salvage surgery following limb revascularization.

It is not clear how soon after bypass surgery tissue perfusion in the ischemic foot is adequate for healing. The purpose of this study was to determine the time interval for tissue to receive adequate oxygenation for healing following limb revascularization. Eleven patients with severe foot ischemia as defined by a transcutaneous oxygen tension (TcPO2) of 30 mm Hg or less were included in the study. TcPO2 measurements were performed prior to the lower extremity bypass and at postoperative day 1, 2, and 3. The mean preoperative value (9.27 mm Hg) was compared with the mean value at postoperative day 1 (17.73 mm Hg), postoperative day 2 (20.36 mm Hg), and postoperative day 3 (36.82 mm Hg) using paired samples t-tests. Statistically significant differences were observed between the mean preoperative TcPO2 measurement and the mean TcPO2 measurement taken on the 3rd postoperative day. The mean TcPO2 level increased from 9.27 mm Hg preoperatively to 36.82 mm Hg by the 3rd postoperative day (p = .001). There was also a statistically significant difference between the mean values on the 2nd (20.36 mm Hg) and 3rd postoperative day (36.82 mm Hg) (p = .002). Despite this finding, 5 of the 11 patients still had individual TcPO2 readings of less than 30 mm Hg on the 3rd postoperative day. Therefore, it can be concluded that in most instances tissue oxygenation reaches an adequate level after waiting at least 3 days following a bypass. Waiting 3 or more days could give adequate time for tissue reperfusion to promote healing of the surgical site.

Episiotomy and perineal repair. An evaluation of resident education and experience.

OBJECTIVE: To describe current training practices and experience with episiotomy and perineal repair in obstetrics and gynecology residency programs in the United States. STUDY DESIGN: A questionnaire mailed to all directors of accredited programs in the United States for distribution to fourth-year residents in their last four months of training included 30 questions regarding formal teaching, supervision, experience and repair techniques. RESULTS: A total of 297 of 1,177 (25.2%) residents, representing 47% of programs, responded. The response rates for the various program sizes were: 32.0% for < or = 12 residents, 29.5% for 13-19 residents, 24.6% for 20-24 residents and 18% for > or = 25 residents. Of the residents, 59.9% received no didactics on episiotomy repair techniques; 59.3% had no formal teaching on pelvic floor anatomy; and 27.7% of third-degree repairs were supervised by attending physicians. Of the respondents, 6.8% had repaired > 20 fourth-degree lacerations and 40.3%, > 20 third-degree lacerations. Ten percent of the graduates felt inadequately trained in perineal repair. CONCLUSION: This survey of fourth-year residents from 47% of obstetric programs indicated that the majority of residents received no formal training in pelvic floor anatomy, episiotomy or perineal repair and, when engaged in such activities, had limited supervision.