A New Force-Activated Separation Device for the Prevention of Peripheral Intravenous Restarts.

The high failure rate (46%) of peripheral intravenous catheters (PIVCs) is well-documented. There is limited research examining the effect of forces/pulls on PIVC complications. New breakaway connectors called force-activated separation devices (FASD) separate when a damaging force is placed on a PIVC. In a randomized, controlled trial, patients were assigned 1:1 to a control group receiving PIVC standard of care (SOC) or SOC with FASD added to the catheter. The primary outcome was total mechanical complications requiring a PIVC restart. Secondary outcomes were delay in therapy, PIVC restarts, and adverse events. Outcomes were compared in an intention-to-treat analysis (N = 302) and per-protocol analysis (N = 287). There were less total mechanical complications in FASD compared with SOC (22 vs 41, respectively; P < .01). The treatment group was a predictor of total delay in therapy (minutes), indicating a greater estimated total delay in therapy in SOC than FASD (B = 69.53; 95% CI, 28.32-110.73; P = .001). There were more adverse events in SOC (127) than FASD (76; P = .001). Results were consistent in the per-protocol analysis. Use of a FASD showed a reduction in total mechanical complications. These results support use of the FASD as a safer and time-saving alternative to current SOC.

The Value of a Support Person During the Surgical Consent Process: A Prospective Cohort Study.

OBJECTIVE: The objective of this study is to investigate the impact of support person participation during the preoperative appointment. METHODS: This is a prospective cohort study involving patients scheduled to undergo pelvic reconstructive surgery. Eligible patients were enrolled at the preoperative appointment and compared by presence or absence of a support person. Questionnaires were completed before and after the preoperative appointment, 1-3 days before surgery, and at the postoperative appointment. Previsit questionnaires included the Generalized Anxiety Disorder-7, 6-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-6), and Brief Health Literacy screen. Postvisit questionnaires included the STAI-6, satisfaction with decision scale for pelvic floor disorders, preoperative preparedness questionnaire, and knowledge questionnaire. At the postoperative appointment, participants completed the patient global impression of improvement and postoperative symptom and satisfaction questionnaire. Primary outcome was patient anxiety measured by the STAI-6. RESULTS: Seventy-six patients participated in the study: 37 were categorized in the support person cohort and 39 were categorized in the no support person cohort. The mean scores of the STAI-6 did not differ between the support person and no support person cohorts at all time points (previsit: 42.97 ± 13.23 vs 41.53 ± 17.11, P = 0.68; postvisit: 38.11 ± 12.76 vs 36.33 ± 11.72, P = 0.53, and 1-3 days before surgery: 42.61 ± 13.0 vs 41.05 ± 16.39, P = 0.65). Overall preparedness, satisfaction with decision scale for pelvic floor disorders, and knowledge questionnaire did not differ between cohorts at both time points. Perioperative phone calls were similar between cohorts. CONCLUSION: Our study suggests that the presence of a support person at preoperative counseling for pelvic floor surgery should be a personal preference and not a recommendation.

Getting back to work: A framework and pivot plan to resume elective surgery and procedures after COVID-19.

INTRODUCTION: The COVID-19 pandemic has compelled a majority of hospital systems to reduce surgical and procedural volumes in an attempt to preserve resources. Elective surgery and procedures resumption has proven to be a calculated risk between COVID-19 exposure and resource depletion and patient morbidity and mortality from surgical deferral. METHODS: Within a few days of halting elective surgery and procedures, our 7-hospital (2427 in-patient beds, 26,647 inpatient surgeries) healthcare system developed a multidisciplinary Pivot Plan with the primary outcome of a phased resumption of elective surgery and procedures. The plan entailed the integration of our electronic medical record, order entry automatization, perioperative staff utilization, partnering with primary care providers, and a stepwise COVID-19 testing algorithm based on a predetermined hierarchy of case acuity and timeliness of patient care. RESULTS: The Pivot Plan was instituted on May 10, 2020. Since then, 22,624 patients have been tested for COVID-19 in anticipation of an elective surgery and procedures; 140 (0.62%) tested positive for COVID-19 and had their procedure deferred. As our testing capability has increased, we have been able to increase our added elective surgery and procedures capacity from 13 cases per day to 531 cases per day. In turn, we have seen the case volume increase by 52%. CONCLUSION: Our academic healthcare system located in one of the initial COVID-19 hotspots in the United States has successfully resumed elective surgery and procedures in part due to a receptive and supportive culture based upon nimbleness, agility, and rapid integration of multiple resources from a cohort of diverse disciplines applied to the perioperative services workflow.

A comprehensive model for pain management in patients undergoing pelvic reconstructive surgery: a prospective clinical practice study.

BACKGROUND: Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption. OBJECTIVE: This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents. STUDY DESIGN: This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4-6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4-6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman's rho (ρ) with α=0.05. RESULTS: A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5-112.5). The median postdischarge narcotic use was 24.0 (0-82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45-112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4-6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4-6 time points. At postoperative weeks 4-6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P=.495). Patients reported median brief pain inventory scores for "average pain" of 0 (no pain) at postoperative week 1 and postoperative weeks 4-6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use. CONCLUSION: Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction.

Patient-Initiated Telephone Calls in the Postoperative Period After Female Pelvic Reconstructive Surgery.

OBJECTIVE: The aim of this study was to evaluate reasons and factors associated with patient calls in the postoperative period after female pelvic medicine and reconstructive surgery. METHODS: A retrospective review using electronic medical records was performed on consecutive patients who underwent surgery within our academic female pelvic medicine and reconstructive surgery practice during a 6-month period. Calls after postoperative discharge until first scheduled postoperative visit were included. Reasons and number of calls were tabulated. Clinical and surgical factors were extracted. Continuous data were evaluated with a Student t test or analysis of variance; categorical data were evaluated with a χ test. P < 0.05 was considered significant. RESULTS: During the designated period, 302 patients underwent surgery, and 173 (57.3%) patients made 345 calls (mean ± SD, 2.0 ± 1.5 calls). Reasons were categorized under 6 distinct domains: bowel, pain, activity, medication regimen, urinary, and bleeding. The most frequent concern within each domain was constipation (11.6%), abdominal pain (6.4%), physical activity (8.7%), pain regimen (14.5%), urinary catheter related (13.3%), and vaginal bleeding (12.1%), respectively. A greater number of phone calls were recorded among patients discharged home with catheters (P = 0.015), and patients who underwent posterior colporrhaphy (P = 0.005) and retropubic urethropexy (P = 0.014). Patients discharged with home nursing (11, 6.4%) demonstrated a significantly higher number of phone calls (3.8 ± 2.5, P < 0.001). Evaluations were required for 37% of callers. Twelve patients were seen in the emergency department, of whom 3 (1.7%) were readmitted to the hospital. CONCLUSIONS: Postoperative patient-initiated telephone calls after pelvic reconstructive surgery are common. Bowel-, urinary-, and medication-based phone calls account for the highest frequency and volume.

Predictive Factors of Postdischarge Narcotic Use After Female Pelvic Reconstructive Surgery.

OBJECTIVE: The aim of the study was to evaluate the association of patient factors, amount of in-hospital postoperative narcotics, and pain scores on postdischarge narcotic use (PDNU). METHODS: This is a secondary analysis of a randomized controlled trial comparing a postoperative usual-care regimen with multimodal pain regimen after pelvic reconstructive surgery. This analysis evaluated patients in the multimodal arm. Postdischarge narcotic use (as mg oral morphine equivalents, MME, calculated from narcotic tablets remaining) was assessed postoperative days 7 to 10. Brief Pain Inventory (BPI) surveys were collected preoperatively and at postoperative day 1. Patient factors were evaluated using univariate and multivariate analysis. Correlations examined the relationships between PDNU and postoperative in-hospital narcotic use and BPI scores. RESULTS: Sixty-eight patients randomized to the multimodal pain regimen arm had median (interquartile range) PDNU of 22.5 (0-159.4) MME. After excluding postdischarge narcotic nonusers (34.8%), the median PDNU was 127.5 (22.5-180.0) MME. The median PDNU was 172.5 (150.0-180.0) MME after abdominal reconstructive surgery (n = 7), 82.5 (28.1-180.0) MME after laparoscopic reconstructive surgery (n = 22), and 37.5 (13.1-181.2) MME after vaginal reconstructive surgery (n = 14). A linear correlation was noted between the amount of postoperative narcotics used in-hospital and the amount needed postdischarge after abdominal (r = 0.588, P = 0.057), laparoscopic (r = 0.439, P = 0.019), and vaginal (r = 0.455, P = 0.017) reconstructive surgeries. The BPI scores on postoperative day 1 for "average" pain (r = 0.388, P = 0.002) and "now" pain (r = 0.490, P < 0.001), and on postoperative week 1 for "average" pain (r = 0.383, P = 0.002) and "now" pain (r = 0.389, P = 0.002) correlated with PDNU. CONCLUSIONS: Amount of postoperative in-hospital use of narcotic medications and BPI scores can be valuable predictors of PDNU in patients undergoing pelvic reconstructive surgery.

Randomized double-blind trial of short- versus long-acting analgesia at the sacrospinous ligament.

INTRODUCTION AND HYPOTHESIS: Pain control is a key component of postoperative care; our objective was to evaluate if use of long-acting local anesthesia at the sacrospinous ligament leads to decreased postoperative pain versus short-acting local anesthesia in patients undergoing sacrospinous ligament fixation. METHODS: Women ≥ 18 years old undergoing sacrospinous ligament fixation to treat pelvic organ prolapse were eligible to participate in this randomized trial. Enrolled patients were randomized 1:1 to one of two study arms: (1) lidocaine arm (LA) or (2) liposomal bupivacaine arm (LBA). Patients in the LA received 30 ml 0.5% lidocaine with 1:200,000 epinephrine local injection at the sacrospinous ligament. Patients in the LBA received 20 ml 1.3% bupivacaine liposomal mixed with 10 ml 0.5% bupivacaine at the sacrospinous ligament. All patients received 50 ml 0.5% lidocaine with 1:200,000 epinephrine for anterior and/or posterior colporrhaphy. The primary outcome of this study was postoperative buttock pain. RESULTS: Of the 37 patients enrolled, 33 completed study procedures. Mean age (± SD) was 62.3 years (± 11.6) in the LA and 66.8 years (± 14.4) in the LBA (p = 0.32). All participants underwent sacrospinous ligament fixation; the rate of concomitant procedures did not differ between study arms. Visual analog scale scores for buttock-specific pain were compared between arms at 1, 3, 6, 12, 24, 36, 48, 72, 96, and 120 h postoperatively, and no differences were found. CONCLUSIONS: Use of long-acting local analgesia at the sacrospinous ligament at the time of sacrospinous ligament fixation does not provide any benefit over short-acting local analgesia.

Postoperative Catheter Management After Pelvic Reconstructive Surgery: A Survey of Practice Strategies.

OBJECTIVE: The aim of this study was to evaluate practice preferences in catheter management after a failed inpatient voiding trial after pelvic reconstructive surgery. METHODS: This is a cross-sectional study of postoperative catheter management after pelvic reconstructive surgery after failed voiding trial. Physicians practicing at ACGME-accredited residencies and fellowships in Obstetrics and Gynecology (Ob/Gyn), Urology, and Female Pelvic Medicine and Reconstructive Surgery (FPMRS) within the United States completed a Web-based questionnaire in March 2017. Respondents were asked about voiding trial protocols, definitions of abnormal postvoid residual (PVR), type of catheterization used after failed voiding trials, and antibiotic use. Primary outcome was type of catheterization after failure of an inpatient voiding trial. Data were analyzed using χ statistical tests. RESULTS: One hundred five respondents had a mean age of 36.5 years (range, 36 years). A total of 45.9% of participants practiced in FPMRS, 36.5% in Ob/Gyn, and 17.6% in Urology. Catheters were discontinued most frequently by postoperative day 1 after all procedures. Distribution of catheterization by specialty differed. Clean-intermittent straight catheterization had the greatest prevalence in all specialties and was the highest, by percentage, in Urology (33% Ob/Gyn, 40.6% FPMRS, and 69% Urology); P = 0.026. Type of catheterization differed significantly between Ob/Gyn and FPMRS respondents (P = 0.045). A total of 77.7% measured PVR by ultrasound and 22.3% performed catheterization. This distribution was similar across the specialties (70% Ob/Gyn, 79% FPMRS, and 100% Urology; P = 0.092). Abnormal PVR was defined most frequently as 150 mL or greater (30.5%). A minority of respondents routinely administer antibiotics during catheterization (17.1%). Duration and time until repeat voiding trial varied from 1 day to 2 weeks. CONCLUSIONS: Practice variability in catheterization after pelvic reconstructive and incontinence surgery is high. Distribution of catheterization type by specialty varies significantly, with clean-intermittent straight catheterization most prevalent. Future studies are necessary to establish a consensus on optimal catheterization management technique for patients with acute postoperative voiding dysfunction.

Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial.

BACKGROUND: Postoperative pain control is crucial to any successful recovery plan. Many currently used medication regimens are narcotic-focused. OBJECTIVE: The objective of our study was to evaluate the efficacy of a multimodal pain regimen after pelvic reconstructive surgery. STUDY DESIGN: The primary outcome measure was narcotic use. Secondary outcomes included pain, nausea, and constipation. Patients were randomized to either usual care postoperative treatment or multimodal pain regimen. Usual care included no specific preoperative or intraoperative medications, and postoperative narcotics with ibuprofen. Multimodal pain regimen included preoperative and postoperative celecoxib, gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and ibuprofen, and narcotics as needed. All narcotics were converted to milligram equivalents of oral morphine for standardization according to Centers for Disease Control and Prevention guidelines where conversion factors for oral hydrocodone = 1, oral oxycodone = 1.5, and oral hydromorphone = 4. Patients were given the validated Brief Pain Inventory survey preoperatively (baseline), at postoperative day 1, and 1 week postoperatively. At 1 week, bowel function and narcotics usage was assessed. RESULTS: Seventy patients were randomized to the usual care arm and 68 to the multimodal pain regimen arm. Patients in the multimodal pain regimen arm used significantly fewer intravenous narcotics in the operating room (90.7 ± 39.1 mg vs 104.6 ± 33.5 mg; P = .026) and while in the hospital (10.8 ± 15.1 mg vs 31.2 ± 29.6 mg; P < .001) and were more likely to use 0 oral narcotics after discharge to home (34.8% of patients vs 10.6%; P = .001). Of the patients who did use oral narcotics after discharge to home, there was no difference in amount used between groups (121.3 ± 103.7 mg in the multimodal pain regimen arm vs 153.0 ± 113.8 mg in the usual care arm; P = .139). Total narcotic usage (operating room + hospital + home) was significantly less in the multimodal pain regimen arm of the study (195.5 ± 147.2 mg vs 304.0 ± 162.1 mg; P < .001). There were no significant differences in pain scores between the 2 arms of the study on either postoperative time point. There were no significant differences in antiemetic use while in hospital, consistency of first bowel movement, length of stay, or number of telephone calls to nurses in first 3 weeks postoperatively. CONCLUSION: A multimodal pain regimen in pelvic reconstructive surgery was found to decrease postoperative opioid requirements, while providing equivalent pain control.

Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines.

OBJECTIVE: The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. DATA SOURCES: Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY ELIGIBILITY: We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. STUDY APPRAISAL AND SYNTHESIS METHODS: Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. RESULTS: Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. CONCLUSION: Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

Resident Education in Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVE: The aim of this study was to evaluate whether obstetrics and gynecology trainees feel satisfied with the female pelvic medicine and reconstructive surgery (FPMRS) education received in residency. METHODS: This is a survey study of obstetrics and gynecology residents in the United States and Puerto Rico during the 2015-2016 academic year. The anonymous 29-question survey was approved by the Hartford HealthCare institutional review board. Responses were included only if the trainee had ever rotated on the FPMRS service. Descriptive analyses were performed using mean and SD for continuous data; categorical data were described using frequencies, expressed as percentages. The results were analyzed for statistical significance using χ for categorical variables and Student t test for continuous variables. All results yielding P < 0.05 were deemed statistically significant. RESULTS: Of the 333 responses received, 172 met criteria for inclusion. Regarding amount of training in FPMRS, 126 trainees (73.3%) reported satisfaction, 40 (23.3%) reported too little training, and 6 trainees (3.5%) reported too much. Residents in programs with a board-certified FPMRS surgeon more commonly reported satisfaction with training (75.0 vs 28.6%, P = 0.02). When fourth-year residents were asked if they would feel comfortable performing specific surgical procedures independently after graduation, the percentage answering affirmatively ranged from 23.6% to 98.8%. CONCLUSIONS: Satisfaction with training in FPMRS has improved, but poor confidence performing surgical procedures compared with previous reports demonstrates that improvements in resident training are still needed.

Phenazopyridine for Evaluation of Ureteral Patency: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the usefulness of phenazopyridine for confirmation of ureteral patency during intraoperative cystoscopy. METHODS: We conducted a randomized controlled trial comparing use of phenazopyridine with no medications for evaluation of ureteral patency during intraoperative cystoscopy in women undergoing pelvic surgery. The primary study outcome was time to visualize ureteral urine efflux. To detect a 3-minute difference with α of 0.05 using a two-sided, two-sample t test and ß 0.80 required 98 patients equally divided into two groups. RESULTS: A total of 104 women were randomized from April to December 2015. Patients in the treatment group tended to be older (P=.02); otherwise, study groups were similar. Time to visualize ureteral urine efflux did not differ between study groups with a mean time of 2 minutes 40 seconds (±2 minutes 38 seconds) in the control group and 2 minutes 53 seconds (±4 minutes 35 seconds) in the treatment group (P=.77). Regarding the surgeon survey, surgeons felt less frustrated and impatient in visualization of ureteral urine efflux in the treatment group compared with the control group (mean response 1.5±0.8 in treatment compared with 2.0±1.0 in control, P=.007), and surgeons felt that the cystoscopy took too long more often in the control than in the treatment group (1.7±0.9 in treatment compared with 2.1±1.0 in control, P=.02). Trial of void result differed significantly between groups with fewer patients in the treatment group failing a void trial (P=.04). There were no adverse events related to phenazopyridine use. CONCLUSION: Preoperative phenazopyridine is a useful and cost-saving medication for use in planned cystoscopy for evaluation of ureteral patency. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02424149.

Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis.

OBJECTIVE: To systematically review outcomes after mesh sacrocolpopexy compared with native tissue vaginal repairs in women with apical prolapse. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through June 4, 2012. METHODS OF STUDY SELECTION: For anatomic and functional analyses, we included studies comparing mesh sacrocolpopexy to native tissue vaginal repairs with at least 6 months follow-up. The primary outcome was anatomic "success" after surgery. Secondary outcomes were reoperation and symptom outcomes. We included large case series and comparative studies with shorter follow-up to increase power for adverse event analyses. TABULATION, INTEGRATION, AND RESULTS: Evidence quality was assessed with the Grades for Recommendation, Assessment, Development and Evaluation system. Meta-analyses were performed when at least three studies reported the same outcome. We included 13 comparative studies for anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supports improved anatomic outcomes after mesh sacrocolpopexy; very low-quality evidence shows no differences in reoperation between sacrocolpopexy and native tissue vaginal repairs. Evidence was insufficient regarding which procedures result in improved bladder or bowel symptoms. Low-quality evidence showed no differences in postoperative sexual function. Adverse event data were compiled and meta-analyzed from 79 studies. When including larger noncomparative studies, ileus or small bowel obstruction (2.7% compared with 0.2%, P<.01), mesh or suture complications (4.2% compared with 0.4%, P<.01), and thromboembolic phenomena (0.6% compared with 0.1%, P=.03) were more common after mesh sacrocolpopexy compared with native tissue vaginal repairs. CONCLUSION: When anatomic durability is a priority, we suggest that mesh sacrocolpopexy may be the preferred surgical option. When minimizing adverse events or reoperation is the priority, there is no strong evidence supporting one approach over the other.

Discrepancies in the female pelvic medicine and reconstructive surgeon workforce.

INTRODUCTION: It is unclear whether the current distribution of surgeons practicing female pelvic medicine and reconstructive surgery in the United States is adequate to meet the needs of a growing and aging population. We assessed the geographic distribution of female pelvic surgeons as represented by members of the American Urogynecologic Society (AUGS) throughout the United States at the county, state, and American Congress of Obstetricians and Gynecologists district levels. MATERIALS AND METHODS: County-level data from the AUGS, American Congress of Obstetricians and Gynecologists, and the United States Census were analyzed in this observational study. State and national patterns of female pelvic surgeon density were mapped graphically using ArcGIS software and 2010 US Census demographic data. RESULTS: In 2013, the 1058 AUGS practicing physicians represented 0.13% of the total physician workforce. There were 6.7 AUGS members available for every 1 million women and 20 AUGS members for every 1 million postreproductive-aged women in the United States. The density of female pelvic surgeons was highest in metropolitan areas. Overall, 88% of the counties in the United States lacked female pelvic surgeons. Nationwide, there was a mean of 1 AUGS member for every 31 practicing general obstetrician-gynecologists. CONCLUSIONS: These findings have implications for training, recruiting, and retaining female pelvic surgeons. The uneven distribution of female pelvic surgeons throughout the United States is likely to worsen as graduating female pelvic medicine and reconstructive surgery fellows continue to cluster in urban areas.

Pain management strategies for urogynecologic surgery: a review.

OBJECTIVES: The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. METHODS: A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. RESULTS: Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. CONCLUSIONS: Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

Do patients with pelvic organ prolapse have an increased frequency of asymptomatic microscopic hematuria?

OBJECTIVE: To determine the prevalence of asymptomatic microscopic hematuria (AMH) in patients with pelvic organ prolapse. METHODS: The Urogynecology patient database was reviewed for patients presenting between July 2010 and April 2011 inclusive. We compared the prevalence of AMH in patients with no prolapse with those with prolapse. A post-hoc analysis was performed to evaluate if overall stage of prolapse was related to the presence of AMH. Pearson chi-square analysis was used for categorical variables, and P values<.05 were deemed statistically significant. RESULTS: Of the 230 women with evaluable AMH data, 29 (12.6%) had AMH. Baseline patient demographic data did not significantly differ between groups. Women with prolapse had a higher prevalence of AMH compared with women with no prolapse (18.3% vs 5.1%, P=.003). There was a significant difference in the distribution of AMH by stage of prolapse, with AMH more prevalent among women with higher stages of prolapse (P=.007). CONCLUSION: Women with prolapse beyond the hymen have a significantly higher prevalence of AMH when compared with women with prolapse at or above the hymen. We suggest an overall rate of AMH in the Urogynecologic population of 12.6%.

Can visuospatial ability predict performance and learning curves on a robotic surgery simulator?

OBJECTIVE: This study aimed to examine the correlation between visuospatial ability, measured with the Perceptual Ability Test (PAT), and da Vinci robot simulator performance on the da Vinci Skills Simulator. METHODS: Twenty-five consenting medical students naive to both the PAT and the da Vinci robot completed the PAT and then performed a single simulation (Ring-walk 2) 10 consecutive times. Raw PAT scores were compared with composite simulator scores for all subjects. Participants were divided into those with high and low visuospatial ability based on whether they scored above or below (or equal) to the median on the PAT. We compared the mean composite simulator scores and the time to complete each exercise between the high and the low PAT performers. RESULTS: The mean (SD) raw PAT score (out of 90) was 45.5 (18.3) (median, 43.0). The mean composite simulator score was 65.5 (24.1) (median, 72.2). The high (n = 12) and low (n = 13) PAT performers had a mean (SD) (median) simulator score of 79.1 (9.8) (80.3) and 53.0 (26.7) (65.9), respectively. On average, the high PAT performers scored 26.1 points (95% confidence interval, 9.2-43.0, P = 0.005), or 49.2%, higher on the simulation than the low PAT performers. The high PAT performers completed the exercise in 96.5 seconds (95% confidence interval, 26.0-167.0; P = 0.009), or 36.2%, faster than the low PAT performers. CONCLUSIONS: Better visuospatial ability relates to improved performance on a robotic surgery simulator.

Pelvic organ prolapse quantification use in the literature.

OBJECTIVE: This study aimed to determine whether the Pelvic Organ Prolapse Quantification (POPQ) system should be simplified based on its use in the peer-reviewed literature. METHODS: The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and International Urogynecology Journal were used for this study. All articles relating to pelvic organ prolapse published in these journals from January 2005 to December 2010 were reviewed for their use of the POPQ system. The POPQ points described in the Materials and/or Results sections of these articles were recorded. RESULTS: Two hundred eighty-three articles using the POPQ system were identified. One hundred thirty-two (47%) articles used the POPQ system but only to determine the stage of prolapse. Specific points were not mentioned. One hundred two (36%) articles evaluated specific POPQ points (Aa, Ba, Ap, Bp, C, D). Forty-nine (17%) articles evaluated points Gh, Pb, and Tvl. CONCLUSIONS: The POPQ system, based on its use in the peer-reviewed literature, may need revisions. An abbreviated version of the system may be considered, allowing for more widespread use.

Venous thromboembolism prophylaxis in gynecologic surgery: a systematic review.

OBJECTIVE: To comprehensively review and critically assess the available gynecologic surgery venous thromboembolism prophylaxis literature and provide clinical practice guidelines. DATA SOURCES: MEDLINE and Cochrane databases from inception to July 2010. We included randomized controlled trials in gynecologic surgery populations. Interventions and comparators included graduated compression stockings, intermittent pneumatic compression, unfractionated heparin, and low molecular weight heparin; placebo and routine postoperative care were allowed as comparators. METHODS OF STUDY SELECTION: One thousand two hundred sixty-six articles were screened, and 14 randomized controlled trials (five benign gynecologic, nine gynecologic oncology) met eligibility criteria. In addition, nine prospective or retrospective studies with at least 150 women were identified and provided data on venous thromboembolism risk stratification, gynecologic laparoscopy, and urogynecologic populations. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently screened articles with discrepancies adjudicated by a third. Eligible randomized controlled trials were extracted for these characteristics: study, participant, surgery, intervention, comparator, and outcomes data, including venous thromboembolism incidence and bleeding complications. Studies were individually and collectively assessed for methodologic quality and strength of evidence. Overall incidence of clinical venous thromboembolism was 0-2% in the benign gynecologic population. With use of intermittent pneumatic compression for benign major procedures, venous thromboembolism incidence was less than 1%. No venous thromboembolisms were identified in prospective studies of benign laparoscopic procedures. Overall quality of evidence in the benign gynecologic literature was poor. Gynecologic-oncology randomized controlled trials reported venous thromboembolism incidence (including "silent" venous thromboembolisms) of 0-14.8% with prophylaxis and up to 34.6% without prophylaxis. Fair quality of evidence supports that unfractionated heparin and intermittent pneumatic compression are both superior to placebo or no intervention but insufficient to determine whether heparins are superior to intermittent pneumatic compression for venous thromboembolism prevention. Combining two of three risks (aged 60 years or older, cancer, or personal venous thromboembolism history) substantially elevated the risk of venous thromboembolism. CONCLUSION: Intermittent pneumatic compression provides sufficient prophylaxis for the majority of gynecology patients undergoing benign surgery. Additional risk factors warrant the use of combined mechanical and pharmacologic prophylaxis.