Procedure-specific simulation for vaginal surgery training: A randomized controlled trial.

INTRODUCTION: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS: gov: Registration no. NCT05887570. RESULTS: We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS: Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

A systematic review of motor control tests in low back pain based on reliability and validity.

BACKGROUND: Low back pain (LBP) is common. Motor-control-dysfunctions (MCD) might play an important role in the development of LBP. OBJECTIVES: Find reliable and valid clinical tests to identify MCD in patients with LBP. DATA SOURCES: PubMed and Medline Library databases were searched over a period of ten years till November 2019. DATA EXTRACTION: Studies examining clinical tests for MCD published in English or German were included. Studies examining clinical outcome, apparatus-based tests or acute pain were excluded. The inclusion/exclusion was determined by stated criteria and consensus between two reviewers. The risk of bias was examined by the critical appraisal tool (Brink and Louw, 2012). METHODS: The studies were assessed according to aim, population and methods and by implementing criteria from literature (Landies and Koch, 1977; Portney and Watkins, 2015). RESULTS: Nine studies (376 patients, 23 tests) met the inclusion criteria. 22 tests examined interrater reliability, five measured intra-rater-reliability, and five assessed the construct/discriminative validity. Fifteen tests showed good/very good interrater-reliability. The intra-rater-reliability ranged from moderate to good. Two studies evaluated construct validity with good results, and one discriminative validity with poor results. CONCLUSIONS: Tests with good reliability should be considered for validity testing DISCUSSION: Of all the tests reviewed, two can be recommended for clinical use. All the other tests should undergo further evaluation or be reconsidered. LIMITATIONS: Relevant studies might be missed, since they were older than ten years, not included in the searched databases, be published in other languages, or were not picked up by the set criteria.

Temporal trends in obstetric anal sphincter injury from the first vaginal delivery in Austria, Canada, Norway, and Sweden.

INTRODUCTION: Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC). MATERIAL AND METHODS: Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2-O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004-2016. RESULTS: The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (ß 0.49) and 6.2% (ß -1.15) (trend, all p < 0.001) in 2016. CONCLUSIONS: This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy.

Knowledge of pelvic floor disorders amongst immigrant women in Canada.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders (PFD) have a detrimental effect on quality of life. Despite the available treatments, women often do not seek medical care. Patient knowledge has been identified as a major barrier to accessing care. The objective of this study was to assess knowledge on PFD amongst women in Edmonton, hypothesizing that immigrant women are less knowledgeable about PFD than Canadian-born women. METHODS: A cross-sectional study of immigrant women and Canadian-born women was conducted. Immigrant women were recruited at the Multi-Cultural Health Brokers Co-op (MCHB) and Canadian-born women at a colposcopy clinic. The Prolapse and Incontinence Knowledge Questionnaire (PIKQ) was administered. Scores for UI and POP were calculated and compared using a Mann-Whitney U test and a t test. A subgroup analysis of immigrants was carried out according to length of stay in Canada and ethnicity. Ethics approval was obtained from the University of Alberta Human Research Ethics Office. RESULTS: A total of 106 immigrants and 102 Canadian-born women completed the PIKQ. The overall PIKQ scores were 12.7 for immigrant women and 14.4 for Canadian-born women (p = 0.04). Immigrant women who had lived in Canada for >10 years had higher scores (mean = 13.2) compared with women with less than 10 years in Canada (mean = 11.8). Women from South Asia had higher overall PIKQ scores (mean = 14.6) whereas women from sub-Saharan Africa had the lowest scores (mean = 12.1). CONCLUSIONS: Immigrant women in Edmonton were found to have less knowledge on PFD than Canadian-born women.

Directive clinique n° 411 : Utilisation des pessaires.

OBJECTIF: Passer en revue l'utilisation, l'entretien et l'ajustement des pessaires. POPULATION CIBLE: Les femmes qui ont besoin d'utiliser un pessaire en raison d'un prolapsus génital et/ou d'une incontinence urinaire d'effort. L'utilisation peut être indiquée chez les femmes enceintes dans certains scénarios cliniques liés à la grossesse, dont l'incarcération utérine et le risque de travail préterme liée à l'incompétence du col. OPTIONS: Les pessaires constituent une option pour les femmes atteintes d'un prolapsus et/ou d'une incontinence urinaire d'effort. De plus, certains types de pessaires peuvent être utilisés chez des patientes atteintes d'incompétence du col ou d'une incarcération utérine. ISSUES: Il est possible de trouver un pessaire efficace chez la plupart des femmes atteintes d'un prolapsus génital ou d'une incontinence urinaire d'effort de façon à obtenir un excellent soulagement des symptômes, un taux de satisfaction élevé et des complications minimes. BéNéFICES, RISQUES ET COûTS: Les femmes atteintes d'un prolapsus génital et/ou d'une incontinence urinaire d'effort peuvent choisir d'utiliser un pessaire pour traiter leurs symptômes au lieu de subir une intervention chirurgicale ou dans l'attente d'une telle intervention. Des complications majeures ont été observées seulement en cas de soins de pessaire négligés. Les complications mineures (telles que les pertes vaginales, les odeurs et les érosions) sont généralement traitables avec succès. DONNéES PROBANTES: Des recherches ont été effectuées dans la base de données Medline afin de récupérer les articles pertinents publiés jusqu'en décembre 2018. Le présent document constitue une mise à jour de la mise à jour technique de la SOGC publiée en 2013, laquelle a été la première directive clinique publiée à l'international relativement à l'utilisation des pessaires. Une ligne directrice australienne sur l'utilisation des pessaires pour le traitement du prolapsus a été publiée plus tard en 2013. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la solidité des recommandations au moyen des critères du cadre méthodologique du Groupe d'étude canadien sur les soins de santé préventifs (annexe A). PROFESSIONNELS CONCERNéS: Gynécologues, obstétriciens, médecins de famille, physiothérapeutes, résidents et moniteurs cliniques (fellows). DÉCLARATIONS SOMMAIRES: RECOMMANDATION.

Guideline No. 411: Vaginal Pessary Use.

OBJECTIVE: To review the use, care, and fitting of pessaries. TARGET POPULATION: Women requiring the use of vaginal pessaries for pelvic organ prolapse and/or stress urinary incontinence. Use may also be indicated for women with certain pregnancy-related clinical scenarios, including incarcerated uterus. OPTIONS: Pessaries are an option for women presenting with prolapse and/or stress urinary incontinence. In addition, certain types of pessaries can be considered for patients with cervical insufficiency or incarcerated uterus. OUTCOMES: Most women with prolapse or stress urinary incontinence can be successfully fitted with a pessary and experience excellent symptom relief, high satisfaction rates, and minimal complications. BENEFITS, HARMS, AND COSTS: Women with pelvic organ prolapse and/or stress urinary incontinence may choose to use a pessary to manage their symptoms rather than surgery or while waiting for surgery. Major complications have been seen only when pessaries are neglected. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. EVIDENCE: Medline was searched for relevant articles up to December 2018. This is an update of the SOGC technical update published in 2013, which was the first internationally published guidance on pessary use. Subsequently, an Australian guideline on the use of pessaries for the treatment of prolapse was published later in 2013. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the approach of the Canadian Task Force on Preventive Health Care (Appendix A). INTENDED AUDIENCE: Gynaecologists, obstetricians, family physicians, physiotherapists, residents, and fellows. SUMMARY STATEMENTS: RECOMMENDATION.

The Edmonton Obesity Staging System Predicts Mode of Delivery After Labour Induction.

OBJECTIVE: This study sought to evaluate the use of the Edmonton Obesity Staging System (EOSS) in predicting cesarean delivery among term, nulliparous, singleton pregnancies in women with overweight or obesity who are undergoing an induction of labour. METHODS: A prospective cohort study was performed in Edmonton, Alberta. Women undergoing an induction of labour at term were recruited to either a sample cohort, including women with a body mass index of ≥25 kg/m2 at first antenatal visit, or a control cohort with a body mass index of 18.5 to 24.9 kg/m2. Participating women provided a self-reported health history and consented to review of their medical records allowing allocation into EOSS categories. The primary outcome was the rate of cesarean delivery based on EOSS category. Secondary outcomes consisted of a summary score of adverse maternal, delivery, and neonatal events (Canadian Task Force Classification II-2). RESULTS: Overall, 345 women were recruited, with a participation rate of 93.7%. The sample cohort consisted of 276 women with overweight or obesity, whereas the control cohort included 69 normal-weight women. The overall rate of cesarean delivery was 30.4% for the control cohort and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS category 0, 1, 2, and 3, respectively (P < 0.001). A summary score was not indicative of overall rate of adverse maternal, delivery, and neonatal events (P = 0.22). CONCLUSION: The EOSS may help predict the chance of cesarean delivery in a high-risk group of nulliparous women with overweight or obesity who are undergoing an induction of labour at term.

Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries.

OBJECTIVE: The purpose of this study was to describe associations between episiotomy at the time of forceps or vacuum-assisted delivery and obstetrical anal sphincter injuries (OASIS). METHODS: This population-based retrospective cohort study used delivery information from a provincial perinatal clinical database. Full-term, singleton, in-hospital, operative vaginal deliveries of vertex-presenting infants from April 1, 2006 to March 31, 2016 were identified. Odds ratios (ORs) and 95% confidence intervals (CIs) for associations between episiotomy and third- or fourth-degree lacerations were calculated in multiple logistic regression models (Canadian Task Force Classification II-2). RESULTS: Episiotomy was performed in 34% of 52 241 operative vaginal deliveries. OASIS occurred in 21% of forceps deliveries and 7.6% of vacuum deliveries. Episiotomy was associated with increased odds of severe perineal lacerations for vacuum deliveries among women with (OR 2.48; 95% CI 1.96-3.13) and without (OR 1.12; 95% CI 1.02-1.22) a prior vaginal delivery. Among forceps deliveries, episiotomy was associated with increased odds of OASIS for those with a previous vaginal delivery (OR 1.52; 95% CI 1.12-2.06), but it was protective for women with no previous vaginal delivery (OR 0.73; 95% CI 0.67-0.79). Midline compared with mediolateral episiotomy increased the odds of OASIS in forceps deliveries (OR 2.73; 95% CI 2.37-3.13) and vacuum deliveries (OR 1.94; 95% CI 1.65-2.28). CONCLUSION: In conclusion, results suggest that episiotomy should be used with caution, particularly among women with a previous vaginal delivery and in the setting of vacuum-assisted delivery. Episiotomy may protect against OASIS in forceps-assisted deliveries for women without a prior vaginal delivery.

What Are the Clinical Factors That Are Predictive of Persistent Pessary Use at 12 Months?

OBJECTIVE: Urinary incontinence and pelvic organ prolapse are highly prevalent in women and have a significant impact on quality of life. Pessaries are devices that are used as a conservative management option. Many women use pessaries, which avoid surgical intervention with its associated morbidity and cost. However, not all women are good candidates for pessary use. The objective of this study was to determine clinical factors leading to persistent pessary use for incontinence or pelvic organ prolapse in a tertiary care centre at 12 months. Studying patient characteristics for long-term pessary use will contribute to better patient counselling, management, and health resource distribution. METHODS: This study was a retrospective outpatient chart review of new pessary fittings in patients in a tertiary care urogynaecology clinic between January and June 2014. Any woman over 18 years of age fitted with a pessary at that time was included in the study. All statistical analyses were performed using IBM SPSS Statistics version. 24 (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-3). RESULTS: A total of 152 women were fitted with pessaries. A multivariable logistic regression analysis found that a patient's diagnosis of prolapse or incontinence (P = 0.01) and a lack of complications (P < 0.0001) were statistically significant for persistent pessary use at 12 months. Patients with prolapse had 7.7 times higher odds (95% CI 1.51-39.35) of using a pessary at 12 months than did patients with incontinence. Patients without complications had 250 times higher odds (95% CI 18.52-2500) of pessary use. Patients who tried two to three pessaries had 16 times higher odds (95% CI 1.80-137.00) of persistent use than patients who trialed just one. CONCLUSION: This study has found that a lack of complications, the number of pessaries tried, and a primary diagnosis of prolapse are significant factors for continued pessary use at 12 months.

Obstetrical Anal Sphincter Injuries and the Need for Adequate Care.

BACKGROUND: An estimated 4% to 6.6% of women delivering vaginally sustain obstetrical anal sphincter injuries (OASI). Despite this, a gap exists in the provision of postpartum care to women globally. Given the negative impact of OASI, action is needed, and multidisciplinary perineal clinics can help. Consequently, such a clinic was established in 2011 at the Royal Alexandra Hospital (RAH), a tertiary care center in Edmonton, Alberta. OBJECTIVE: This study assesses the state of perineal clinics specializing in OASI internationally and locally by investigating the literature for descriptions of specialized perineal clinics for women with OASI, describing the RAH perineal clinic, and assessing the prevalence of OASI at the RAH in the context of the clinic. METHODS: A search of peer-reviewed literature was conducted on Medline and observations and interviews of RAH perineal clinic staff were conducted, as was a medical chart review. RESULTS: Articles describing only 10 perineal clinics specializing in OASI were found, with varying structures. The multidisciplinary RAH clinic, like one other clinic, has a strong physiotherapy focus, with education and Pilates classes and one-on-one appointments offered by pelvic floor physiotherapists. In 2016, of the 326 (6.9%) vaginal deliveries that resulted in OASI at the RAH, only 66.0% (215) were referred to the clinic. CONCLUSIONS: Multidisciplinary perineal clinics are needed globally. Despite the creation of the perineal clinic at the RAH, women continue to lack specialized care after OASI. It is crucial that healthcare professionals specializing in OASI share their experiences to establish best practices and create new, and improve existing, perineal clinics.

Retrospective Cohort Study of Cervical Pessary Use in Women with Short Cervix at Risk of Preterm Delivery.

OBJECTIVE: A paucity of effective interventions exists for the prevention of preterm birth (PTB). Renewed interest has focused on cervical pessaries, which have the benefits of being inexpensive, nonsurgical, and easily inserted and removed. In this study, we aim to describe our experience with this device in a Canadian tertiary care centre. Primary outcomes were rates of spontaneous or iatrogenic PTB before 37, 34, and 28 weeks gestation in pregnancies complicated by short cervix treated with cervical pessary. METHODS: This was a retrospective cohort study of women with singleton, twin, and triplet pregnancies with pessary placement from August 2013 to March 2015 in the Urogynecology Clinic at the Lois Hole Hospital for Women in Edmonton, AB. Included women were deemed to be at high risk of PTB due to short cervix (≤25 mm) found on ultrasound. RESULTS: Among 115 women included, pessaries were placed at a mean gestation of 25.3 weeks. Forty-nine singleton women (52.7%) delivered at term. Of these deliveries, 75% were spontaneous. Rates of PTB before 34 and 28 weeks gestation for all deliveries, respectively, were 37.4% and 10.4%. Removal data were available for 87.8% of patients, and the pessary remained in situ for a mean of 48 days. CONCLUSION: In this study's high-risk obstetrical population, the rates of preterm birth remained high. The effectiveness of pessary use, particularly when compared to other preventative strategies, remains a topic in need of further investigation. To our knowledge, this is the first study to contribute pessary data from a Canadian population.

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair.

OBJECTIVE: To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. OPTIONS: Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. OUTCOMES: The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Objectif : Analyser les données probantes traitant des lésions obstétricales du sphincter anal (LOSA) en ce qui concerne leur diagnostic, les techniques visant leur réparation et les résultats de l'intervention. Formuler des recommandations permettant d'éclairer les conseils offerts aux patientes ayant connu des LOSA en ce qui a trait à la voie d'accouchement à privilégier dans le cadre des grossesses subséquentes. Options : Les fournisseurs de soins obstétricaux qui comptent des patientes ayant connu des LOSA disposent de l'option de réparer le sphincter anal en faisant appel à la méthode de suture « bout à bout ¼ (end-to-end) ou à la méthode « en paletot ¼ (overlapping). Ils pourraient également être appelés à conseiller des femmes ayant déjà connu des LOSA en ce qui a trait à la voie d'accouchement à privilégier pour les grossesses subséquentes. Issues : Le critère d'évaluation était la continence anale à la suite d'une réparation primaire de LOSA et à la suite d'un accouchement subséquent. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, EMBASE et The Cochrane Library en mai 2011 au moyen d'un vocabulaire contrôlé (p. ex. anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) et de mots clés (p. ex. obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Aucune restriction n'a été imposée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en septembre 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : Parmi les avantages de la mise en œuvre de la présente directive clinique, on trouve : l'amélioration du diagnostic des LOSA, l'obtention d'issues fonctionnelles optimales à la suite de la réparation et l'offre de conseils reposant sur des données probantes aux femmes en ce qui concerne leurs futures grossesses. Déclarations sommaires 1. Les lésions obstétricales du sphincter anal mènent à des comorbidités considérables, dont l'incontinence anale, les fistules rectovaginales et la douleur. (II-2) 2. Les lésions obstétricales du sphincter anal sont plus souvent associées aux accouchements par forceps qu'aux accouchements par ventouse obstétricale. (II-2) 3. Réparation des lésions obstétricales du sphincter anal : a. L'utilisation de polyglactin 2-0 ou de polydioxanone 3-0 donne lieu, après six semaines, à des taux semblables de morbidité liée aux sutures. (I) b. La réparation du sphincter anal interne est recommandée puisque les femmes chez lesquelles la présence d'une anomalie affectant ce sphincter est révélée au cours de l'échographie postpartum sont plus susceptibles de connaître une incontinence anale. (III) c. La réparation du sphincter anal externe devrait englober la gaine fasciale. Le recours à la technique de suture « en paletot ¼ (chevauchement) nécessite souvent une mobilisation et une dissection de plus grande envergure des extrémités du sphincter; l'utilisation de cette technique n'est possible qu'en présence de déchirures sphinctériennes de degré 3b ou plus. (III) d. La présence persistante d'une anomalie du sphincter anal externe longtemps après l'accouchement pourrait accroître le risque de voir apparaître une aggravation des symptômes à la suite des accouchements vaginaux subséquents. (II-2) 4. Les lésions obstétricales du sphincter anal sont associées à une hausse du risque de rétention urinaire postpartum. (II-2) 5. À la suite de la réparation réussie d'une lésion obstétricale du sphincter anal, la plupart des femmes peuvent connaître un accouchement vaginal en toute sûreté dans le cadre d'une grossesse subséquente. (III) 6. Services de counseling offerts aux femmes au sujet de leurs accouchements subséquents : a. Le risque de récurrence d'une lésion obstétricale du sphincter anal dans le cadre d'un accouchement subséquent est de 4-8 %. (II-2) b. On a calculé que, pour prévenir un cas d'incontinence anale chez des femmes ayant déjà subi une lésion obstétricale du sphincter anal, la tenue de 2,3 césariennes planifiées s'avérerait nécessaire, le tout s'accompagnant alors d'une hausse des risques maternels. (II-2) Recommandations 1. Toutes les femmes devraient faire l'objet d'un examen rigoureux visant la détection de déchirures périnéales ou vaginales; celles qui présentent une déchirure dont la profondeur est plus que superficielle devraient, avant la mise en œuvre d'une réparation, faire l'objet d'un examen rectal systématique cherchant à établir la présence de lésions obstétricales du sphincter anal. (II-2B) 2. Le système de classification de l'Organisation mondiale de la santé devrait être utilisé pour classer les lésions obstétricales du sphincter anal. Ce système permet l'établissement d'une distinction entre le degré de déchirure du sphincter externe (3a < 50 % ou 3b ≥ 50 %) et la présence d'anomalies du sphincter interne (3c). La présence d'une lésion en boutonnière (button-hole injury) constitue un incident distinct et devrait être classée en conséquence. (III-B) 3. Chez les femmes qui connaissent un accouchement vaginal spontané, le taux de lésions obstétricales du sphincter anal est amoindri lorsque le fournisseur de soins obstétricaux ralentit la tête fœtale au moment du dégagement. (II-2A) 4. Épisiotomie : a. Dans le cadre d'un accouchement vaginal spontané ou instrumental, le fournisseur de soins obstétricaux devrait, pour assurer la prévention des lésions obstétricales du sphincter anal, respecter une politique prévoyant une utilisation « restreinte ¼ de l'épisiotomie (c.-à-d. seulement lorsque cela s'avère indiqué), plutôt qu'une utilisation « libre ¼ de cette intervention (c.-à-d. de façon systématique). (I-A) b. Lorsque la tenue d'une épisiotomie est jugée indiquée, l'octroi d'une préférence envers la tenue d'une incision médiolatérale (plutôt qu'envers la tenue d'une incision médiane) devrait être envisagé. (II-2B) L'angle d'incision optimal semble être d'au moins 45 degrés (idéalement, aux alentours de 60 degrés). (II-2B) 5. La réparation peut être différée (pendant 8-12h) sans effets nuisibles. La mise en œuvre d'un délai pourrait s'avérer nécessaire jusqu'à ce que les services d'un fournisseur de soins disposant de l'expérience nécessaire pour procéder à la réparation puissent être retenus. (I-A) 6. L'administration prophylactique d'une dose intraveineuse unique d'antibiotiques (céphalosporine de 2e génération, p. ex. céfotétan ou céfoxitine) devrait être mise en œuvre pour assurer la baisse des taux de complications de lésion périnéale à la suite de la réparation des lésions obstétricales du sphincter anal. (I-A) 7. Des laxatifs (p. ex. lactulose) devraient être prescrits à la suite de la réparation primaire d'une lésion obstétricale du sphincter anal puisqu'ils sont associés à des premières selles moins douloureuses et survenant plus rapidement, et à l'obtention plus rapide du congé de l'hôpital. L'utilisation d'agents constipants et d'agents de gonflement n'est pas recommandée. (I-A) 8. Les anti-inflammatoires non stéroïdiens et l'acétaminophène sont les analgésiques de première intention. Les opioïdes ne devraient être utilisés qu'avec précaution. La constipation devrait être évitée au moyen d'un laxatif ou d'un émollient fécal. (1-A) 9. À la suite de la constatation d'une lésion obstétricale du sphincter anal, les fournisseurs de soins devraient divulguer à leurs patientes le degré de la lésion subie et prendre les dispositions nécessaires à la mise en œuvre d'un suivi. Il est nécessaire de procéder à la documentation détaillée de la lésion et de sa réparation. (III-L) 10. Les femmes qui connaissent une incontinence anale après avoir subi une lésion obstétricale du sphincter anal devraient être orientées vers des services de physiothérapie du plancher pelvien. (I-A).

Single incision device (TVT Secur) versus retropubic tension-free vaginal tape device (TVT) for the management of stress urinary incontinence in women: a randomized clinical trial.

BACKGROUND: In 2006, Ethicon Inc. introduced a new minimally invasive single incision sling device for the surgical treatment of stress urinary incontinence, the Gynecare TVT Secur®. For device licensing, no new evidence of TVT Secur efficacy and safety was needed: rather evidence was provided of the long-term follow-up of patients who had a procedure using a predecate retropubic tension-free vaginal tape device. Before adopting TVT Secur into our routine clinical practice, we decided to evaluate it. The objective of our Canadian multi-centre pragmatic randomized controlled trial was to compare the effectiveness of the new single-incision device, TVT Secur, to the established TVT device, in terms of objective cure of stress urinary incontinence (SUI) at 12 months postoperatively. Other outcomes included: complications, symptoms, and incontinence-related quality of life. RESULTS: The sample size estimate for our trial was 300, but the trial stopped early because of poor recruitment. 74 women participated (40 allocated to TVT Secur, 34 to TVT). At 12 months postoperatively, 27/33(82%) of TVT Secur group were cured, compared with 25/28(89%) of the TVT group (relative risk 0.92, 95% confidence interval 0.75 to 1.13, p=0.49). Most women reported little or no SUI symptoms (35/37(95%) vs 29/30(97%), >0.999). Quality of life improved significantly from baseline for both groups (IIQ-7 mean change -25 for both groups) but did not differ between groups (p=0.880). CONCLUSION: Our small randomized trial did not find statistically significant differences in outcomes between women allocated to the TVT Secur device versus those allocated to the TVT device for stress urinary incontinence. Despite the discontinuation of TVT Secur in March 2013 for commercial reasons, the importance of our study lies in making evidence available for the many women who had a TVT Secur device implanted and their physicians who may be considering alternative treatments. Our experience illustrates the difficulty of undertaking research on new licensed devices in a rapidly changing surgical specialty, and further highlights the need for research before licensing if surgeons and their patients are to be confident in the effectiveness and safety of new surgical devices. TRIAL REGISTRATION: ClinicalTrials.gov NCT00685217, 22 May 2008.

RETIRED: Technical update on pessary use.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Ce document a été archivé, car il contient des informations périmées. Il ne devrait pas être consulté pour un usage clinique, mais uniquement pour des recherches historiques. Veuillez consulter le site web du journal pour les directives les plus récentes.

A retrospective review of tension-free vaginal tape/transobturator tape procedures done concomitantly with prolapse repair.

OBJECTIVE: Midurethral slings have become the standard of care for women with stress urinary incontinence; prolapse repair is often also required. The primary objective of our study was to compare voiding dysfunction rates and the need for reoperation between patients having midurethral sling procedures alone versus those having midurethral sling procedures with concomitant prolapse repair. METHODS: We performed a retrospective chart review over a two-year period in a tertiary urogynaecology clinic. Of 108 charts, 93 had complete data for analysis. RESULTS: Patients having concomitant prolapse repair had a longer operating time, a longer hospital stay, and a longer time to resume normal voiding in the immediate postoperative period. CONCLUSION: Although tension-free vaginal tape or transobturator tape procedures with concomitant prolapse repair have a higher incidence of voiding dysfunction in the immediate postoperative period, we found that this did not persist to the six-week follow-up visit. There appeared to be no greater risk of lasting voiding dysfunction or need for reoperation after concomitant procedures.

Objectif : Les interventions de fronde mi-urétrale sont devenues la norme pour les femmes qui présentent une incontinence urinaire à l'effort; une réparation du prolapsus est également souvent nécessaire. Notre étude avait pour objectif principal de comparer, chez les patientes ne subissant qu'une intervention de fronde mi-urétrale et chez celles qui subissaient une intervention de fronde mi-urétrale et une réparation concomitante du prolapsus, les taux de dysfonction mictionnelle et la nécessité de procéder à une deuxième opération. Méthodes : Nous avons mené une analyse rétrospective des dossiers sur une période de deux ans au sein d'une clinique tertiaire d'urogynécologie. Sur 108 dossiers, 93 comptaient des données complètes aux fins de l'analyse. Résultats : Les patientes subissant une réparation concomitante du prolapsus connaissaient une durée d'opération prolongée, une hospitalisation prolongée et un délai prolongé avant le retour de la miction normale au cours de la période postopératoire immédiate. Conclusion : Bien que les interventions par bandelette vaginale sans tension ou par bandelette transobturatrice s'accompagnant d'une réparation concomitante du prolapsus comptent une incidence accrue de dysfonction mictionnelle au cours de la période postopératoire immédiate, nous avons constaté que cette situation s'était résorbée au moment de la consultation de suivi à six semaines. À la suite de la tenue d'interventions concomitantes, il ne semblait pas y avoir de hausse du risque de dysfonction mictionnelle prolongée et nous n'avons également pas constaté une nécessité accrue de procéder à une deuxième opération.