Uptake and outcomes of robotic gynaecological surgery in England (2006-2018): an account of Hospital Episodes Statistics (HES).

This was a retrospective study to review the uptake and outcomes of robotic gynaecological surgery in England between 1st April 2006 and 31st March 2018, analysing Hospital Episode Statistics form National Health Service hospitals in England. Women aged 18 years and above who had elective gynaecological surgery were included and those who had undergone robotic gynaecology surgery were included. Robotic gynaecological procedures were defined as procedures that used a robotic minimal access approach for hysterectomy, adnexal surgery and urogynaecological surgery (sacrocolpopexy, sacrohysteropexy and colposuspension). Numbers of procedures were reviewed by year and mapped to the 44 NHS healthcare regions. Length of stay (nights in hospital), laparotomy (conversion during primary procedure or after return to theatre for management of complication), and 30-day emergency readmission rates were calculated by year and procedure type. Overall 527,217 elective gynaecological procedures were performed in the English NHS (1st April 2006 and 31st March 2018), of which 4384 (0.83%) were performed with robotic assistance (3864 (88%) hysterectomy, 706 (16%) adnexal surgery, 192 (4%) urogynaecological surgery). There was gradual rise in the uptake of robotic surgery but there was a marked geographical variation. Median (IQR) length of stay (LOS) was 1(1-2) night, laparotomy rate was 0.3% and 30-day emergency readmission rate was 4.7%. LOS was statistically, but not clinically, different across time. Other outcomes did not differ by year. Robotic gynaecological procedures are increasingly being used in the English NHS, predominantly for hysterectomy, although in small proportions (2.6% in the most recent study year). There was wide geographical variation in robotic uptake across England and overall, outcomes were comparable to those reported in other countries.

Knowledge of the risk factors and symptoms associated with endometrial cancer in British South Asian and British White women.

OBJECTIVE: To explore differences in the background knowledge of Endometrial Cancer (EC), its risk factors, symptoms and prognosis of Endometrial Cancer (EC) between British White (BW) and British South Asian (BSA) women who had undergone treatment for stage I endometrial cancer within the past 3-years. STUDY DESIGN: Face-to-face, semi-structured interviews exploring knowledge; diagnosis; treatment; follow-up; and survivorship were undertaken and analysed using Thematic Analysis. RESULTS: Twenty-one women were interviewed (13 BW and 8 BSA). BW and BSA women reported similar views, experiences and concerns with regards to EC. Knowledge appeared to differ amongst the two groups with BSA women reporting being more aware that unscheduled vaginal bleeding could be associated with a malignancy but having lower levels of knowledge of the risk factors that can lead to EC, compared to BW women. There was a lack of understanding of the difference between cervical cancer and EC and as a result, many women reported taking reassurance from negative cervical cytology as excluding EC. There was also the misconception amongst some of the women that there was a link between sexual behaviour and EC. Women from both groups used the lay healthcare system to discuss their situation/symptoms, however BSA women reported to have specifically sought out women within their social network who had previously undergone treatment for EC. CONCLUSIONS: Greater effort is needed to raise awareness in both the BW/BSA communities of the symptoms associated with EC that should prompt medical review. Educational efforts are required to overcome the reported perception that EC is synonymous with cervical cancer and cannot be detected by cervical screening.

Knowledge, attitudes and awareness of the human papillomavirus amongst primary care practice nurses: an evaluation of current training in England.

Background: The incorporation of Human papillomavirus (HPV) testing into the English cervical screening programme has been met with fear and anxiety. Healthcare professionals need to be adequately informed about HPV to help alleviate patient concerns. The aim of this study was to evaluate the HPV training provided to practice nurses (PNs) and determine their level of HPV knowledge. Method: A web-based survey was distributed to 147 General Practice surgeries in the Leicester, Leicestershire and Rutland regions, between May and July 2015. The survey explored four broad areas; demographics/level of experience, HPV knowledge, attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge. Results: A total of 128 surveys were completed, with 94 complete responses. Overall awareness of basic HPV facts was adequate; however, detailed, and in some cases basic, knowledge was lacking. 9.6% failed to identify that HPV can cause cervical cancer and 62.8% believed that HPV requires treatment. Not all PNs felt adequately informed about HPV and a need to improve the provision of training was identified. Conclusion: PNs play a key role in increasing public awareness of HPV and implementing cervical cancer screening. The provision of education to PNs needs to be a priority and current methods of training need to be re-evaluated.

Maximum bladder volume as surrogate screening test for detrusor overactivity.

Maximum bladder volume could be a simple surrogate measure to screen for detrusor overactivity (DO) which manifests with a frequency and small volume voids. Urodynamic traces from 577 women were reviewed. Maximum bladder volume was obtained from bladder diary. The urodynamic traces were reviewed for data and were categorised as normal, urodynamic stress incontinence, mixed incontinence and DO. The urodynamic data and maximum voided volume were compared between different categories and Receiver operating characteristic (ROC) curves were constructed. The median value for maximum-voided volume for women with DO was not significantly different from the other categories, whereas significant differences were found for the median values for urodynamic variables. ROC curves demonstrated extremely poor sensitivity and specificity for recorded maximum bladder volume and for urodynamic variables. The maximum-voided volume recorded on a three-day bladder diary is not discriminatory as a screening test for DO.

Enhanced purinergic contractile responses and P2X1 receptor expression in detrusor muscle during cycles of hypoxia-glucopenia and reoxygenation.

Bladders from patients with detrusor overactivity have an increased atropine-resistant contractile response to nerve stimulation. The bladder has also been shown to be very susceptible to hypoxia-glucopenia and reperfusion injury, leading to the hypothesis that episodes of hypoxia-glucopenia and reoxygenation result in increased atropine-resistant responses to nerve stimulation in the detrusor muscle. Detrusor muscle strips were suspended in a Perspex organ bath chamber of volume 0.2 ml perfused with Krebs solution at 37°C aerated with 21% O2, 5% CO2 and the balance nitrogen. Hypoxia-glucopenia was induced by switching perfusion to Krebs solution without glucose, gassed with 95% nitrogen and 5% CO2. Atropine-resistant contractile responses increased by 40.5 ± 7.3% after four cycles of hypoxia-glucopenia (10 min) and reoxygenation (1 h), whereas α,ß-methylene ATP-resistant responses did not increase. Expression of P2X1 receptors in the bladder was increased after hypoxia-glucopenia and reoxygenation cycling, and ATP release from stimulated bladder strips during cycling was also increased. Other P2X receptor-mediated mechanisms may also be involved in the augmentation of bladder contraction during hypoxia-glucopenia and reoxygenation cycling, because a non-specific P2X antagonist blocked most of the augmented response, whereas a P2X1-specific antagonist prevented only part of the augmentation of contractile response induced by hypoxia-glucopenia and reoxygenation. In conclusion, four cycles of hypoxia-glucopenia and reoxygenation increased the purinergic, but not the cholinergic, contractile responses to nerve stimulation. Increased P2X1 receptor expression and ATP release may have contributed to the augmentation of contractile response induced by hypoxia-glucopenia and reoxygenation. Purinergic antagonists may, therefore, be a useful therapeutic option for the treatment of overactive bladder with increased purinergic-mediated contractions.

Validation of the Patient Global Impression scales for use in detrusor overactivity: secondary analysis of the RELAX study.

OBJECTIVE: To assess construct validity of the Patient Global Impression scales (Severity [PGI-S], Bother [PGI-B] and Improvement [PGI-I]) for symptoms of detrusor overactivity (DO). DESIGN: Secondary analysis of a randomised trial of onabotulinum toxin A. SETTING: Eight UK urogynaecology departments. POPULATION: A total of 240 women with DO refractory to medical treatment randomised to receive 200 iu onabotulinum toxin A or placebo in the RELAX trial and followed up for 6 months. MAIN OUTCOME MEASURES: Urinary diaries and disease-specific quality of life (QoL) questionnaires were completed at baseline and during follow up. Discriminatory ability of the PGI-S, PGI-B and PGI-I scales to identify symptom severity and change in severity was assessed by comparing mean diary and QoL outcomes across the response categories, analysed by one-way analysis of variance. RESULTS: Data were available from 237 women (98.8%) for validation of PGI-S and PGI-B at baseline, and 192 women (80%) at 6 weeks follow up for validation of PGI-I. Leakage episodes (P = 0.01), urgency episodes (P = 0.019), urgency severity (P = 0.012), and QoL scores (all P < 0.001) were greater in women with more severe problems on PGI-S. Similar results were seen for PGI-B: leakage (P = 0.051), urgency episodes (P < 0.001), urgency severity (P < 0.001), and QoL scores (all P < 0.001). PGI-I responses demonstrated significant relationships with size of change of all variables (P < 0.001). The generic instrument EQ-5D had weaker relationships (PGI-S, P = 0.09; PGI-B, P = 0.004; PGI-I, P = 0.06), suggesting that it was less sensitive. CONCLUSIONS: The PGI scales are robust and valid instruments to assess disease severity, bother and improvement after treatment in women with detrusor overactivity.

Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008.

OBJECTIVE: To report the numbers of patients having childbirth after pelvic floor surgery in England. DESIGN: Retrospective analysis of Hospital Episode Statistics data. SETTING: Hospital Episode Statistics database. POPULATION: Women, aged 20-44 years, undergoing childbirth after pelvic floor surgery between the years 2002 and 2008. METHODS: Analysis of the Hospital Episode Statistics database using Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code at the four-character level for pelvic floor surgery and delivery, in women aged 20-44 years, between the years 2002 and 2008. MAIN OUTCOME MEASURES: Numbers of women having delivery episodes after previous pelvic floor surgery, and numbers having further pelvic floor surgery after delivery. RESULTS: Six hundred and three women had a delivery episode after previous pelvic floor surgery in the time period 2002-2008. In this group of 603 women, 42 had a further pelvic floor surgery episode following delivery in the same time period. The incidence of repeat surgery episode following delivery was higher in the group delivered vaginally than in those delivered by caesarean (13.6 versus 4.4%; odds ratio, 3.38; 95% confidence interval, 1.87-6.10). CONCLUSIONS: There were 603 women having childbirth after pelvic floor surgery in the time period 2002-2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery.

Classification of episiotomy: towards a standardisation of terminology.

Seven episiotomy incisions are described in the literature, although only midline, mediolateral or lateral episiotomies are commonly used. Recent research has demonstrated variations in both site and direction of the incision, and differences between the angle of incision at the time of crowning of the fetal head and the angle of the scar once the wound has been repaired. We review this evidence and suggest that this variation may undermine the reliability of much published work. We suggest a standardised definition of each type of episiotomy to establish uniformity going forward, so that future studies are amenable to comparison and meta-analysis.

Colposuspension or TVT with anterior repair for urinary incontinence and prolapse: results of and lessons from a pilot randomised patient-preference study (CARPET 1).

In a multicentre randomised, unblinded patient preference pilot trial to assess the feasibility of a definitive randomised trial comparing colposuspension with tension-free vaginal tape (TVT) plus anterior repair in women with incontinence and prolapse, we found that 31 of 56 eligible women agreed to participate (55%). Recruitment was more successful face to face (87%) than by letter (16%). Only four of our women agreed to be randomised, 21 (68%) chose anterior repair+TVT and six (19%) chose colposuspension. This study demonstrates the importance of pilot work for complex trials to identify issues likely to adversely affect recruitment.

Continence nurse treatment of women's urinary symptoms.

The aim of this study was to establish how accurately a trained continence nurse could allocate appropriate second-line conservative treatment to women without urodynamic investigations. Depending on the number of patients coming taking up the service, there were between five and 12 nurses operating at any one time. Women aged 40 years and over, of which there were 2421 reporting lover urinary tract symptoms, were randomly allocated to a new nurse-led continence service. Of these women, 450 subsequently underwent urodynamic investigation, before which the nurses documented which second-line conservative treatment would be appropriate. The results showed that of all women with detrusor overactivity, 79.1% were correctly allocated anticholinergic treatment, and 64.8% were allocated pelvic floor exercises (PFE). Of all women with urodynamic stress incontinence, 88.8% were allocated only one treatment. This study showed that a trained continence nurse is able to allocate conservative treatment appropriately to the majority of women without the need for urodynamic investigation. This indicated that the management of urinary dysfunction by a team of trained, dedicated nurses has the potential to reduce waiting lists for urodynamic investigation, avoid unnecessary investigations and achieve greater patient satisfaction.

How doctors record breaking bad news in ovarian cancer.

Revealing the diagnosis of cancer to patients is a key event in their cancer journey. At present, there are no minimal legal recommendations for documenting such consultations. We reviewed the Hospital records of 359 patients with epithelial ovarian cancer in the Mersey Area between 1992 and 1994. We identified the following factors: age, hospital, postcode, surgeon, stage of disease and survival. These were compared to information recorded at the time of the interview such as person present, descriptive words used, prognosis, further treatment and emotional response. In 11.6%, there was no information recorded in the notes. The diagnosis was recorded in 304 (94.7%), prognosis in 66 (20.6%) and collusion with relatives in 33 (10.3%). A total of 42 separate words/phrases were identified relating to diagnosis; cancer was recorded in 60 (19.6%). Collusion was three times as common in the patients over 65 years (17.9 vs 5.7%, P=0.001). There was a reduction in the number of diagnostic words recorded in the patients over 65 years (90.3 vs 98.3%, P=0.002) and by type of surgeon (P=0.001). Information was often poorly recorded in the notes. We have shown that the quality of information varies according to patient age, surgeon and specialty.

Knowledge of female bladder care among medical staff, nurses and midwives: results of a questionnaire survey.

OBJECTIVE: To determine knowledge about bladder care among junior medical staff and allied health professionals, and to examine any difference in knowledge among the subgroups. SUBJECTS AND METHODS: Using a single-questionnaire survey in a large obstetrics and gynaecology Hospital Trust in an inner city setting, midwives, nurses and medical staff (not consultants) were asked eight questions about different aspects of female bladder physiology and care. The differences in responses among the professional groups were assessed. RESULTS: In all, 120 completed questionnaires were returned (32 doctors, 40 nurses, and 48 midwives). Knowledge was similar on urethral length, bladder capacity, daily fluid intake, ideal size of catheter, catheter balloon size, and the maximum time of use of a short-term catheter. Correct responses for normal daily fluid intake, duration of both short and long-term catheterization were given by fewer than half the respondents. There were significant differences among the professional groups in the correct response rate for long-term catheter duration (P = 0.031) and the normal time interval between voids (P = 0.038). CONCLUSION: There were significant differences in the knowledge of all subgroups about bladder care, and poor levels of knowledge in several areas. This is a potentially serious problem for women at risk of bladder complications after gynaecological surgery and childbirth. All staff involved in managing women after childbirth and gynaecological surgery should have formal training in bladder care, to optimize patient care.

Important clinical outcomes in urogynecology: views of patients, nurses and medical staff.

We attempted to grade treatment outcomes in female urinary incontinence by the perceived importance of these outcomes for patients, nursing staff and medical staff. One hundred millimeter visual analog scales (VAS) quantifying the relative importance of five clinical outcomes were sent to 100 patients, 50 nursing staff and 135 medical staff involved in continence care and median VAS scores for each outcome were compared between groups. Subjective improvement and improvement in quality of life were rated most highly. Median scores for subjective cure were 93 (76-99) for nurses, 93 (11-100) for patients and 91 (50-100) for ICS (UK) members. Median quality of life improvement scores were 92 (67-100), 93 (3-100) and 93 (74-100), respectively (not significant). There was a striking concordance of opinion regarding the importance of subjective improvement and improvement in quality of life. We suggest that these should become primary outcome measures in all future clinical trials and audits of incontinence treatments.