Surgical journal clubs: Navigating the post-pandemic landscape.

Pandemic-related distancing regulations gave medical educators at our college an opportunity to reimagine and expand our evidenced-based medicine curriculum to an asynchronous, virtual format. We share the experience of course directors, faculty, and students with our new surgical journal club format. Our goal was to support learners' critical appraisal skills of the surgical literature through active learning modalities such as visual abstract generation and audio-synopsis creation. We included surgeons whose practice locations and schedules may preclude participation. The curriculum was applied to our pre-existing community-based journal clubs. The asynchronous, virtual format allowed us to expand these journal clubs to include rural surgeons.

Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review.

BACKGROUND: The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals. OBJECTIVE: We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books. STUDY DESIGN: We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms. RESULTS: In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms. CONCLUSION: We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

Demographic and delivery characteristics associated with obstetric fistula in Kigali, Rwanda.

OBJECTIVE: To assess the characteristics of Rwandan women undergoing surgical correction of obstetric fistula. METHODS: A retrospective, cross-sectional study was conducted of women undergoing surgery to repair obstetric fistula as part of a program run by the International Organization for Women and Development in Kigali, Rwanda, between April 1, 2010, and February 28, 2011. Data were collected from medical records, including demographics, obstetric history, and results of the physical examination. RESULTS: A total of 65 women underwent fistula surgery in the study period. Among 59 women for whom relevant data were available, 43 (73%) reported that the fetus did not survive the pregnancy during which the fistula developed. Delivery had occurred in a healthcare facility for 49 (82%) of 60 women. Delivery was by cesarean in 31 (48%) women included in the analyses. Cervicovesical or uterovesical fistula occurred more frequently among women who underwent cesarean delivery (9 [29%]) than among those who underwent vaginal delivery (3 [9%] of 34; P=0.04). There was no difference in the number of fetal or neonatal deaths between the two groups (P=0.2). CONCLUSION: Approximately half of the women in the sample delivered by cesarean, and these women were more likely to have a fistula involving the uterus or cervix.

Effect of intrinsic sphincter deficiency on midurethral sling outcomes in women with mixed urinary incontinence.

OBJECTIVE: The objective of this study was to estimate the effect of intrinsic sphincter deficiency (ISD) on frequency and urge incontinence after midurethral sling (MUS) in women with mixed urinary incontinence (MUI). METHODS: We performed a retrospective study of 137 women with MUI who underwent MUS placement. We defined MUI as an affirmative response to the urge incontinence item (no. 16) on the Pelvic Floor Distress Inventory in a cohort of women with urodynamic stress incontinence. Intrinsic sphincter deficiency was defined as preoperative positive leak point pressure of less than 60 cm H2O and/or urethral closure pressure less than 20 cm H2O. Outcomes included resolution of frequency and urge incontinence as well as resolution of stress incontinence. Multivariable logistic regression was performed to estimate the association between ISD and urinary outcomes. RESULTS: One hundred thirty-seven women met our study inclusion criteria. Fifteen (11%) had preoperative ISD, and 122 (89%) did not. At 6 to 12 months after MUS placement, 67% of women with ISD-MUI versus 39% with non-ISD-MUI had complete resolution of both urinary frequency and urge incontinence (P = 0.04). The 2 groups did not differ postoperatively in regard to complete resolution of stress incontinence symptoms (85% vs 90%, P = 0.63). On regression analysis, women with ISD-MUI had increased odds of complete resolution of frequency and urge incontinence compared with women with non-ISD-MUI (adjusted odds ratio, 5.38 [95% confidence interval, 1.50-19.3]). CONCLUSIONS: In women with MUI, preoperative ISD is associated with increased odds of urinary frequency and urge incontinence resolution after MUS.

Variables impacting care-seeking for pelvic floor disorders among African American women.

OBJECTIVES: This study aimed to identify variables impacting care-seeking for pelvic floor disorders (PFDs) among (1) a general population of professional African American (AA) women and (2) professional AA women with prevalent PFD symptoms. METHODS: A cross-sectional survey of women registered for the 37th National Assembly of the Links, Inc, a volunteer service organization of professional AA women, was conducted. Our de-identified questionnaire addressed several domains including PFD symptoms, history of PFD diagnoses, attitudes regarding PFDs, and help-seeking. We asked what respondents would do if they experienced PFD symptoms and defined our outcome as the response "I would not seek care." Barriers were covariates associated with not seeking care. RESULTS: Of 568 questionnaires distributed, 362 (64%) with complete data were returned; 6.4% (23/362) of respondents reported they "would not seek care" if experiencing a PFD symptom. On logistic regression, attitude that PFDs are a normal part of aging [adjusted odds ratio (AOR), 5.56; 95% confidence interval (CI), 1.46-21.23] and concerns about insurance (AOR, 3.80; 95% CI, 1.39-10.33) were barriers to care-seeking, adjusting for health status and embarrassment about discussing PFDs.Thirty percent (110/362) of women reported having current PFD symptoms. In this subset, only 26% had accessed care. On logistic regression, prolapse symptoms in the previous 3 months and age 65 years or older were negatively associated with not seeking care (ie, were predictors of care-seeking) (AOR, 0.11; 95% CI, 0.02-0.67) and (AOR, 0.17; 95% CI, 0.03-0.85), respectively, adjusting for pelvic floor distress inventory scores. CONCLUSIONS: Among educated and insured AA women, attitudes about aging and insurance complexity are barriers to care-seeking for PFDs. In women with current PFD symptoms, recent prolapse symptoms and age 65 years or older were predictors of care-seeking.

Unrecognized bladder perforation leading to severe progressive cellulitis and candidal infection.

BACKGROUND: Retropubic midurethral slings are a minimally invasive surgical procedure used in the treatment of stress urinary incontinence and are typically associated with high cure rates and low complication rates. Bladder perforation is a known intraoperative complication that, if left unrecognized, can have significant morbidity. CASE: A 47-year-old underwent a retropubic midurethral sling, anterior colporrhaphy, and cystoscopy. She developed a suprapubic wound cellulitis that progressed to involve the right trunk and flank as well as persistent fever for more than 48 hours despite broad-spectrum antibiotics. Upon return to the operating room, the patient was found to have an unrecognized bladder perforation with mesh in the bladder. Wound culture was remarkable for Candida parapsilosis and Escherichia coli. CONCLUSION: Unrecognized bladder perforation and nonbacterial causes of infection should be considered in patients with severe progressing cellulitis despite broad-spectrum antibiotic coverage after retropubic midurethral sling placement.

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.

Barriers to pelvic floor physical therapy utilization for treatment of female urinary incontinence.

OBJECTIVE: The purpose of this study was to estimate the effect of insurance status on pelvic floor physical therapy (PFPT) nonparticipation for the treatment of urinary incontinence. STUDY DESIGN: A cross-sectional study of women referred to PFPT for urinary incontinence between January 2009 and June 2010 was conducted. A telephone questionnaire was administered. Multiple logistic regression was used to identify risk factors for nonparticipation. RESULTS: Thirty-three percent of women with private insurance and 17% with other insurance were PFPT nonparticipants. On multiple logistic regression, women with Medicare were more likely to participate in PFPT (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01-0.72). Risk factors for nonparticipation included insurance noncoverage (OR, 103.85; 95% CI, 6.21-infinity) and a negative perception regarding the benefit of PFPT (OR, 5.07; 95% CI, 2.16-12.49). CONCLUSION: Among women who were referred to PFPT for urinary incontinence, insurance noncoverage and negative patient perception of efficacy were risk factors for nonparticipation, although having Medicare was protective. Improving patient education and insurance coverage for PFPT may increase usage.

The association between obesity and stage II or greater prolapse.

OBJECTIVE: We sought to evaluate the association between obesity and vaginal prolapse as well as pelvic organ prolapse symptoms. STUDY DESIGN: This was a cross-sectional study of women referred for urogynecologic care. The exposure was obesity and outcome, stage>or=II prolapse. Secondary outcomes were symptom bother and disease-specific quality of life. RESULTS: Our study included 721 women. No difference in stage>or=II prolapse was observed between obese (n/N 58/721 [35.8%]) and nonobese (n/N=463/721 [64.2%]) women (50.8% vs 52.7%; P=.62). Obesity was associated with increased distress on the Pelvic Floor Distress Inventory-20 (100 [+/-57.3] vs 87.4 [+/-53.1]; P=.003) due to higher scores on the Colorectal-Anal Distress Inventory-8 (22.9 [+/-21.5] vs 18.3 [+/-19.7]; P=.003) and the Urinary Distress Inventory-6 (48.8 [+/-27] vs 42.4 [+/-26.1]; P=.002). CONCLUSION: Obesity was not associated with stage>or=II prolapse but was associated with increased pelvic floor symptoms secondary to urinary and anal incontinence subscales.

The Association Between Stage II or Greater Posterior Prolapse and Bothersome Obstructive Bowel Symptoms.

OBJECTIVE: : The primary objective of this study was to estimate the association between stage II or greater posterior prolapse and individual obstructive bowel symptoms. METHODS: : We conducted a cross-sectional study of all women presenting for initial visit at a tertiary center for pelvic floor disorders. Exposure was defined as stage II or greater posterior vaginal prolapse as measured by pelvic organ prolapse quantification measurements. Outcomes included the separate bothersome obstructive bowel symptoms of splinting, straining, or incomplete bowel emptying. RESULTS: : Our study included 721 women. Univariate analysis did not show an association between stage II or greater posterior prolapse and the bothersome symptoms of straining or incomplete emptying. Stage II or greater posterior prolapse was associated with bothersome splinting (adjusted OR, 1.63; 95% CI, 1.06-2.53). CONCLUSIONS: : Stage II or greater posterior prolapse was associated with the bothersome symptom of splinting, but not bothersome straining or the sensation of incomplete evacuation.

New considerations in the use of vaginal mesh for prolapse repair.

The proliferation of mesh-based transvaginal prolapse surgical repair methods and products has generated increased scrutiny of the evidence-based foundation in support of these techniques. Recent developments in this arena include the publication of the Society of Gynecologic Surgeons Systematic Review Group, which concluded that supportive evidence for transvaginal mesh is limited, and a Public Health Notification from the Food and Drug Administration (FDA), regarding "serious complications associated with transvaginal placement of surgical mesh in repair of pelvic organ prolapse and stress urinary incontinence." This article reviews available literature regarding transvaginal mesh use, specifically regarding material, technique, and patient characteristics that may influence the rates of iatrogenic complications of transvaginal mesh prolapse repairs. Compliance with the FDA Public Health Notification is encouraged, and additional clinical practice guidelines are provided.

Implant infection after two-stage sacral nerve stimulator placement.

To report our experience with implant infection after two-stage sacral nerve stimulator placement. We reviewed the records of all patients who underwent implantation with a sacral nerve stimulator for the management of refractory cases of urge urinary incontinence, urinary frequency, and non-obstructive urinary retention. Baseline demographic data, interval to the development of infection, and the organism cultured are reported. After stage II neurostimulator placement, 5 out of 37 (13.5%) women required device removal for culture positive wound infections. Patients returned an average of 147.4 days after device implantation with evidence of infection. Infection occurred a minimum of 33 days, a median of 76 days, and a maximum of 461 days after sacral nerve stimulator implantation. The most common pathogen cultured was Staphylococcus aureus. After device removal, all patients resolved their infections. Two patients underwent uncomplicated reimplantation in the contralateral buttock 14 and 16 days after stimulator removal. The risk of infection after tined lead pretest and neurostimulator placement may be higher than previously observed in older techniques.