Pelvic Pain and Apical Prolapse Surgery: A Population-Based Retrospective Cohort Study.

OBJECTIVES: The aims of this study were to evaluate the association of preoperative pelvic pain with operative characteristics and the association of patient and operative characteristics with postoperative pain. METHODS: This is a retrospective cohort study utilizing Clinformatics DataMart, a large national commercial insurance database. We collected data for patients older than 18 years who underwent apical prolapse surgery between January 2005 and December 2014. We stratified data by preoperative (prior) pain and analyzed for associations of prior and postoperative pain. Logistic regression analysis was performed using SAS software. RESULTS: A total of 14,440 patients met inclusion criteria and were analyzed. Patients with prior pain were more likely to have an abdominal (open or laparoscopic) approach, a concomitant hysterectomy, but less likely to have additional repairs or a mesh insertion (P < 0.001). Postoperative pain was less with a concomitant hysterectomy, whether they had prior pain (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.41-0.77) or not (OR, 0.68; 95% CI, 0.56-0.82). Additional vaginal repairs were associated with more postoperative pain for those without prior pain (OR, 1.63; 95% CI, 1.3-2.04). Age older than 45 years was associated with less pain. Length of hospital stay of more than 2 days was associated with more pain. CONCLUSIONS: Patients with prior pain were more likely to undergo an abdominal approach and have a concomitant hysterectomy. Postoperative pain was less with a concomitant hysterectomy, but more with additional vaginal repairs. There is a need to include pain as an outcome in future studies, particularly clinical trials.

Four Surgical Strategies for the Treatment of Cesarean Scar Defect: A Systematic Review and Network Meta-analysis.

OBJECTIVE: This network meta-analysis compared treatment via laparoscopy, hysteroscopy (HP), combined laparoscopy with HP (LH), and vaginal repair (VR) for reducing intermittent abnormal uterine bleeding and cesarean scar defect (CSD) diverticulum depth in patients with CSD. DATA SOURCES: Electronic databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trials, MEDLINE, ClinicalTrials.gov, Chinese Biomedical Literature Database, and China National Knowledge Integrated) were searched for articles published through June 13, 2018. METHODS OF STUDY SELECTION: The search included randomized controlled trials (RCTs) and observational studies of surgical treatment for CSD. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were reported. RCTs were evaluated by the Cochrane risk-of-bias tool, observational studies by Risk of Bias in Nonrandomized Studies of Intervention, and overall evidence quality by grade. Data were analyzed by STATA (version 15.0; StataCorp, College Station, TX) and R software for windows (version 3.5.0; R Core Team, 2018). TABULATION, INTEGRATION, AND RESULTS: Ten studies (n = 858; 4 RCTs and 6 observational studies) were included. Patients who underwent uterine diverticulum resection by LH had a shorter duration of abnormal uterine bleeding than those by HP (SMD = 1.36, 95% CI, 0.37-2.36; p = .007) and VR (SMD = 1.58, 95% CI, 0.97-2.19; p <.0001). LH reduced the CSD diverticulum depth more than VR (SMD = 1.57, 95% CI, 0.54-2.61; p = .003). There was no significant difference in efficacy among the surgical procedures. CONCLUSION: LH reduced intermittent abnormal uterine bleeding and scar depth more than the other surgical interventions. Larger clinical trials are warranted to verify this analysis.

Classification of Ovarian Cancer Surgery Facilitates Treatment Decisions in a Gynecological Multidisciplinary Team.

OBJECTIVE: Proper planning of intervention and care of ovarian cancer surgery is of outmost importance and involves a wide range of personnel at the departments involved. The aim of this study is to evaluate the introduction of an ovarian surgery classification (COVA) system for facilitating multidisciplinary team (MDT) decisions. MATERIALS AND METHODS: Four hundred eighteen women diagnosed with ovarian cancers (n = 351) or borderline tumors (n = 66) were selected for primary debulking surgery from January 2008 to July 2013. At an MDT meeting, women were allocated into 3 groups named "pre-COVA" 1 to 3 classifying the expected extent of the primary surgery and need for postoperative care. On the basis of the operative procedures performed, women were allocated into 1 of the 3 corresponding COVA 1 to 3 groups. The outcome measure was the predictive value of the pre-COVA score compared with the actual COVA performed. RESULTS: The MDT meeting allocated 213 women (51%) to pre-COVA 1, 136 (33%) to pre-COVA 2, and 52 (12%) to pre-COVA 3. At the end of surgery, 168 (40%) were classified as COVA 1, 158 (38%) were classified as COVA 2, and 28 (7%) were classified as COVA 3. Traced individually, 212 (51%) patients were correctly preclassified at the MDT meeting and distributed into 110 (52%) COVA 1, 71 (52%) COVA 2, and 17 (32%) COVA 3. Analyzing the subgroup of patients with cancer, 164 (47%) were correctly preclassified. Regarding the International Federation of Gynecology and Obstetrics (FIGO) stages, the pre-COVA classification predicted the actual COVA group in 79 (49%) FIGO stages I to IIIB and in 85 (45%) FIGO stages IIIC to IV. CONCLUSIONS: The COVA classification system is a simple and useful tool in the MDT setting where specialists make treatment decisions based on advanced technology. The use of pre-COVA classification facilitates well-organized patient care-relevant procedures to be undertaken. Pre-COVA accurately predicts the final COVA in 51% classified women.

Obstetrical and Gynecological Devices; Reclassification of Surgical Instrumentation for Use With Urogynecologic Surgical Mesh. Final order.

The Food and Drug Administration (FDA or the Agency) is reclassifying surgical instrumentation for use with urogynecologic surgical mesh from class I (general controls) exempt from premarket notification to class II (special controls) and subject to premarket notification, and identifying them as "specialized surgical instrumentation for use with urogynecologic surgical mesh." FDA is designating special controls that are necessary to provide a reasonable assurance of safety and effectiveness of the device. FDA is reclassifying this device on its own initiative based on new information.

Managing expectations of surgical training: a national perspective on gynaecologic endoscopy practice.

OBJECTIVE: To determine if the opinion of obstetrics and gynaecology postgraduate trainees differs from practising gynaecologists with respect to the expected endoscopic surgical skill set of a general gynaecologist upon graduation from residency. METHODS: An electronic survey was designed, validated, and pre-tested. It was sent to 775 Canadian obstetrics and gynaecology residents, fellows, and practising physicians through the Society of Obstetricians and Gynaecologists of Canada's electronic mailing list. Survey respondents were asked their opinion on the level of training (no extra post-residency training vs. fellowship) required to perform various endoscopic procedures. RESULTS: We received 301 responses (39% response rate). Obstetrics and gynaecology trainees and practising physicians agreed on the training and skill level necessary to perform many endoscopic procedures. However, there were significant differences of opinion among trainees and practising physicians regarding advanced endoscopic procedures such as laparoscopic hysterectomy, cystotomy and enterotomy repair, and appendectomy. More trainees felt that a general gynaecologist without additional post-residency surgical training should be competent to perform such procedures, while practising physicians felt fellowship training was necessary. CONCLUSION: Our survey highlights the different expectations of learners versus those in practice with regard to skills required to perform certain endoscopic procedures, particularly laparoscopic hysterectomy. Trainees who responded believed that after graduation from residency any obstetrician-gynaecologist should be able to perform more advanced endoscopic procedures, but practising physicians did not agree. This discordance between learners and practising colleagues highlights an important educational challenge in obstetrics and gynaecology surgical training. Greater clarification of what is expected of our training programs would be beneficial for both residents and training programs.

Objectif : Déterminer si l'opinion des stagiaires postdoctoraux en obstétrique-gynécologie diffère de celle des gynécologues praticiens en ce qui a trait à l'ensemble de compétences en chirurgie endoscopique dont devrait disposer un gynécologue généraliste à la fin de sa résidence. Méthodes : Un sondage électronique a été conçu, validé et prétesté. Nous l'avons fait parvenir, par l'intermédiaire de la liste de diffusion électronique de la Société des obstétriciens et gynécologues du Canada, à 775 résidents, boursiers et praticiens canadiens du domaine de l'obstétrique-gynécologie. Nous avons demandé aux répondants de nous fournir leur opinion quant au niveau de formation requis (aucune formation post-résidence supplémentaire vs fellowship) pour l'exécution de diverses interventions endoscopiques. Résultats : Nous avons reçu 301 réponses (taux de réponse de 39 %). Les stagiaires en obstétrique-gynécologie et les gynécologues prati­ciens étaient du même avis quant au niveau de formation et aux compétences nécessaires pour l'exécution de nombreuses interventions endoscopiques. Toutefois, nous avons constaté des différences d'opinion considérables entre les stagiaires et les praticiens en ce qui concerne les interventions endoscopiques avancées (comme l'hystérectomie laparoscopique, la réparation de cystostomie et d'entérostomie, et l'appendicectomie). Un plus grand nombre de stagiaires étaient d'avis qu'un gynécologue généraliste devrait, sans formation chirurgicale post-résidence supplémentaire, disposer de la compétence requise pour mener de telles interventions, tandis que les praticiens estimaient qu'une formation de type fellowship s'avérait nécessaire. Conclusion : Notre sondage souligne les différences en matière d'attentes, entre les stagiaires et les praticiens, en ce qui concerne les compétences requises pour mener certaines interventions endoscopiques (particulièrement l'hystérectomie laparoscopique). Les stagiaires ayant répondu au sondage estimaient que, à la fin du programme de résidence, tout obstétricien-gynécologue devrait être en mesure de mener des interventions endoscopiques plus avancées, mais les praticiens ne partageaient pas cet avis. Cet écart entre les stagiaires et les praticiens souligne l'existence d'un important défi pédagogique en ce qui concerne la formation chirurgicale en obstétrique-gynécologie. Une meilleure clarification des attentes envers nos programmes de formation s'avérerait bénéfique tant pour les résidents que pour les programmes de formation.

[Pelvic organ prolapse-surgical technique (POP-ST): a classification of techniques of mesh augmented repairs for pelvic organ prolapse by vaginal route]. / Proposition d'une classification des techniques chirurgicales de cure de prolapsus (pelvic organ prolapse-surgical technique [POP-ST]) avec mise en place d'une prothèse par voie transvaginale.

OBJECTIVE: The aim of this study was to propose a classification of surgical techniques for treatment of prolapse by vaginal route using prosthetic reinforcements and to relate the evaluation of surgeons involved in the care of surgical patients. METHODS: A literature review was conducted searching for all articles relating novel technique of surgical management of patients with use of prosthetic reinforcements vaginally. The classification was made from descriptions found and then assessed by questionnaires filled out by surgeons. RESULTS: The classification takes account of all the techniques available today and can integrate new. Among the surgeons, 56.5% (13/23) found that the POP-ST is adapted to reflect the reality and variety of techniques and 60.8% (14/23) will be ready for daily use. CONCLUSION: A classification covering all the techniques put them at risk of a final tool too complex for routine use. The simplification would make it more usable but limited the comprehensiveness and evolutionary. Only 23 surgeons returned the questionnaire. A larger sample would be desirable. The POP-ST is the first classification of this type. We believe that it would assess the new techniques to better understand the complications.

[Validity of the registration and reporting of vaginal prolapse surgery]. / Validitet af kodning og indberetning ved vaginal prolapskirurgi.

INTRODUCTION: To validate the coding and local registration of vaginal prolapse surgery in 1996-1998, and reporting of such data to the Danish National Patient registry (LPR). MATERIAL AND METHODS: Comparison of different sets of data from the local data base (GS) and LPR, and retrospective study of 296 patient files. RESULTS: The concordance between two GS-data sets was 96.4%, and 0-100% between different LPR-data sets. The validity of reporting of data from GS to LPR was 96.2% on the level of patient ID (cpr), and 99.3% concerning length of hospital stay. If a procedure was registered as a vaginal prolapse procedure the validity of this being true was 93.6%. 18 non-prolapse procedures were registered as vaginal procedures. The registration was incomplete in 12.5% due to typing or hearing errors or missing codes. The coding was misleading in 11.8%, due to lack of consensus on coding. 86.6% of errors were passed through from the patient file to GS and LPR. Through simple guidelines misleading use of combination of codes was reduced from 7% to 0.5%. CONCLUSION: The validity of the two sets of GS data, and the reporting from GS to LPR of vaginal surgical procedures is satisfactory on the cpr-level. However, the validity of such register data is affected by the risk of errors when drawing such data, and by coding errors. The main problems are lack of consensus on which codes to use, and that codes for very different procedures are very much alike. To improve the quality and usefulness of register data in monitoring vaginal prolapse procedures consensus on coding is desirable. Different methods to increase the quality of coding are discussed.

Associations between surgical site infection risk and hospital operation volume and surgeon operation volume among hospitals in the Dutch nosocomial infection surveillance network.

OBJECTIVE: To examine the association between hospital operation volume and surgeon operation volume and the risk of surgical site infection (SSI). DESIGN: Prospective, multicenter cohort study based on surveillance data. METHODS: Data were obtained from the Dutch surveillance network for nosocomial infections (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]) on 9 different types of orthopedic surgery, general surgery, and gynecology procedures performed during 1996-2003. Multilevel logistic regression analysis was performed to assess the independent effect of hospital volume and surgeon volume on SSI risk. RESULTS: Hospital volume was not significantly associated with SSI risk for any of the selected procedures. Low surgeon volume was associated with an increased risk for an infection for 7 of 9 types of procedures, although this effect was statistically significant only for knee arthroplasty. For 4 procedures, the odds of exceeding the 75th percentile for duration of surgery were greater when the surgeon volume was low than when the surgeon volume was moderate or high. CONCLUSIONS: Patients operated on by surgeons with a low operation volume seem to have a higher risk of developing an SSI with some procedures, particularly knee arthroplasty. The higher SSI risk for surgeons with a low operation volume is possibly partly mediated by the longer duration of surgery, a well-known risk factor for development of SSI.

Factors that influence length of stay for in-patient gynaecology surgery: is the Case Mix Group (CMG) or type of procedure more important?

OBJECTIVES: To compare the association between the Case Mix Group (CMG) code and length of stay (LOS) with the association between the type of procedure and LOS in patients admitted for gynaecology surgery. METHODS: We examined the records of women admitted for surgery in CMG 579 (major uterine/adnexal procedure, no malignancy) or 577 (major surgery ovary/adnexa with malignancy) between April 1997 and March 1999. Factors thought to influence LOS included age, weight, American Society of Anesthesiologists (ASA) score, physician, day of the week on which surgery was performed, and procedure type. Procedures were divided into six categories, four for CMG 579 and two for CMG 577. Data were abstracted from the hospital information costing system (T2 system) and by retrospective chart review. Multivariable analysis was performed using linear regression with backwards elimination. RESULTS: There were 606 patients in CMG 579 and 101 patients in CMG 577, and the corresponding median LOS was four days (range 1-19) for CMG 579 and nine days (range 3-30) for CMG 577. Combined analysis of both CMGs 577 and 579 revealed the following factors as highly significant determinants of LOS: procedure, age, physician, and ASA score. Although confounded by procedure type, the CMG did not significantly account for differences in LOS in the model if procedure was considered. Pairwise comparisons of procedure categories were all found to be statistically significant, even when controlled for other important variables. CONCLUSION: The type of procedure better accounts for differences in LOS by describing six statistically distinct procedure groups rather than the traditional two CMGs. It is reasonable therefore to consider changing the current CMG codes for gynaecology to a classification based on the type of procedure.