[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to describe posterior prolapse (pPOP) and obstructed defecation (OD) symptoms 5 years after open abdominal sacrocolpopexy (ASC).
Female pelvic medicine & reconstructive surgery. 09/2014; 20(5):261-266.
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to estimate the minimum important difference (MID) for the Fecal Incontinence Severity Index (FISI), the Colorectal-Anal Distress Inventory (CRADI) scale of the Pelvic Floor Distress Inventory, the Colorectal-Anal Impact Questionnaire (CRAIQ) scale of the Pelvic Floor Impact Questionnaire, and the Modified Manchester Health Questionnaire (MMHQ).
Female pelvic medicine & reconstructive surgery. 09/2014;
[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: To measure surgical judgment across the Obstetrics and Gynecology (OBGYN) continuum of practice and identify factors that correlate with improved surgical judgment. Methods: A 45-item written examination was developed using script concordance theory, which compares an examinee's responses to a series of "ill-defined" surgical scenarios to a reference panel of experts. The examination was administered to OBGYN residents, Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows, practicing OBGYN physicians and FPMRS experts. Surgical judgment was evaluated by comparing scores against the experts. Factors related to surgical experience were measured for association with scores. Results: In total, 147 participants including 11 residents, 37 fellows, 88 practicing physicians and 11 experts completed the 45-item examination. Mean scores for practicing physicians (65.2 ± 7.4) were similar to residents (67.2 ± 7.1), and worse than fellows (72.6 ± 4.2, p < 0.001) and experts (80 ± 5, p < 0.001). Positive correlations between scores and surgical experience included: annual number of vaginal hysterectomies (r = 0.32, p = <0.001), robotic hysterectomies (r = 0.17, p = 0.048), stress incontinence (r = 0.29, p < 0.001) and prolapse procedures (r = 0.37, p < 0.001). Inverse correlation was seen between test scores and years in practice. (r = -0.19, p = 0.02). Conclusion: Intraoperative judgment in practicing OBGYN physicians appears similar to resident physicians. Practicing physicians who perform FPMRS procedures perform poorly on this examination of surgical judgment; lower performance correlates with less surgical experience and the greater amount of time in practice.
[Show abstract][Hide abstract] ABSTRACT: Fecal incontinence is the involuntary loss of solid or liquid stool. While the true prevalence of fecal incontinence is difficult to discern, it is estimated that almost 9 % of non-institutionalized women in the US experience this condition. Disorders leading to fecal urgency alone are usually related to rectal storage abnormalities while incontinence is often a result of anatomic or neurologic disruption of the anal sphincter complex. Many risk factors exist for fecal incontinence and include female sex, increasing age, higher body mass index (BMI), limited physical activity, smoking, presence of neuropsychiatric conditions, higher vaginal parity and history of obstetrical trauma, presence of chronic diarrhea and irritable bowel syndrome, or history of rectal surgery, prostatectomy and radiation. Evaluation of fecal incontinence involves a careful patient history and focused physical exam. Diagnostic tests include endorectal ultrasonography, anal manometry, anal sphincter electromyography, and defecography. Treatment strategies include behavioral, medical and surgical therapies as well as neuromodulation. Treatment is based on the presumed etiology of the condition and a multi-modal approach is often necessary to achieve the maximum benefit for patients.
[Show abstract][Hide abstract] ABSTRACT: To construct and validate a prediction model for estimating the risk of de novo stress urinary incontinence (SUI) after vaginal pelvic organ prolapse (POP) surgery and compare it with predictions using preoperative urinary stress testing and expert surgeons' predictions.
Using the data set (n=457) from the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial, a model using 12 clinical preoperative predictors of de novo SUI was constructed. De novo SUI was determined by Pelvic Floor Distress Inventory responses through 12 months postoperatively. After fitting the multivariable logistic regression model using the best predictors, the model was internally validated with 1,000 bootstrap samples to obtain bias-corrected accuracy using a concordance index. The model's predictions were also externally validated by comparing findings against actual outcomes using Colpopexy and Urinary Reduction Efforts trial patients (n=316). The final model's performance was compared with experts using a test data set of 32 randomly chosen Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial patients through comparison of the model's area under the curve against: 1) 22 experts' predictions; and 2) preoperative prolapse reduction stress testing.
A model containing seven predictors discriminated between de novo SUI status (concordance index 0.73, 95% confidence interval [CI] 0.65-0.80) in Outcomes Following Vaginal Prolapse Repair and Midurethral Sling participants and outperformed expert clinicians (area under the curve 0.72 compared with 0.62, P<.001) and preoperative urinary stress testing (area under the curve 0.72 compared with 0.54, P<.001). The concordance index for Colpopexy and Urinary Reduction Efforts trial participants was 0.62 (95% CI 0.56-0.69).
This individualized prediction model for de novo SUI after vaginal POP surgery is valid and outperforms preoperative stress testing, prediction by experts, and preoperative reduction cough stress testing. An online calculator is provided for clinical use.
[Show abstract][Hide abstract] ABSTRACT: To develop a valid laparoscopic sacrocolpopexy simulation model for use as an assessment and learning tool for performing this procedure.
A training model was developed to simulate performing a laparoscopic sacrocolpopexy. Construct validity was measured by comparing observed masked performances on the model between experienced Female Pelvic Medicine and Reconstructive Surgeons, 'Experts,' and upper level trainees, 'Trainees,' at two tertiary academic centers. All video-taped performances were scored by two surgeons who were masked to subject's identity utilizing the valid and reliable Global Operative Assessment of Laparoscopic Skills (GOALS) scale.
The 'Expert' group included Female Pelvic Medicine and Reconstructive Surgeons (N=5) experienced with laparoscopic sacrocolpopexy and the 'Trainee' group (N=15) included fourth year gynecology residents (N=5) and fellows in Female Pelvic Medicine and Reconstructive Surgery and Minimally Invasive Gynecologic Surgery (N=10). 'Experts' performed significantly better than 'Trainees' in the total score and in every domain of the GOALS scale ('Expert' group median = 33 [30.5-39] vs. 20.5 [range 13.5-30.5], p=0.002). Previous surgical experience had a strong association with performance on the model (Rho > 0.75). The majority of subjects 'agreed' or 'strongly agreed' that the model was authentic to the live procedure and a useful training tool. There was strong agreement between masked raters (Interclass Correlation Coefficient 0.84).
This simulation model is valid and reliable for assessing performance of laparoscopic sacrocolpopexy and may be used for practicing key steps of this procedure.
Journal of Minimally Invasive Gynecology 01/2014; · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We describe the presentation, diagnosis, and management of ureterovaginal fistula over a 7-year period at a tertiary care center.
A retrospective review of ureterovaginal fistula cases between 2003 and 2011 was performed. Demographic information, antecedent event, symptoms, diagnostic modalities, and management strategies were reviewed.
Nineteen ureterovaginal fistulas were identified during the 7-year study period. One fistula followed a repeat cesarean section and 18 fistulas followed a hysterectomy (9 total abdominal, 6 total laparoscopic, 3 vaginal hysterectomies). Ureteral injuries were not recognized in any of the patients at the time of index surgery. Computed tomography (CT) urography was the most commonly utilized diagnostic modality (58 %). Primary non-surgical management with ureteral stents was attempted and successful in 5 out of 7 cases (71 %). There were 14 total surgical repairs, including 2 cases in which stents were successfully placed, but the fistula persisted, and 6 additional cases where attempted stent placement failed. Surgical repair consisted of 10 ureteroneocystostomies performed via laparotomy and 4 performed laparoscopically, 3 of which were robotically assisted.
Despite being uncommon, ureterovaginal fistula should remain in the differential diagnosis of new post-operative urinary incontinence after gynecological surgery. Conservative management with ureteral stent appears to be the best initial approach in selected patients, with a success rate of 71 %. Minimally invasive approaches to performing ureteroneocystostomy have high success rates, comparable to those of open surgical repair.
International Urogynecology Journal 12/2013; · 2.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties.
An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system.
A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence.
Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited.
Medical Education 07/2013; 47(7):650-73. · 3.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To compare operative time and intra- and post-operative complications between laparoscopic (TLH) and robotic-assisted total laparoscopic hysterectomy (RA-TLH). STUDY DESIGN: This study was a blinded, prospective randomized controlled trial conducted at two institutions. Subjects consisted of women who planned laparoscopic hysterectomy for benign indications. Pre-operative randomization to TLH or RA-TLH was stratified by surgeon and uterine size (> or ≤12 weeks). Validated questionnaires (SF-36), activity assessment scales, and visual analogue scales were administered at baseline and during follow-up. RESULTS: 62 women consented, enrolled, and were randomized while 53 women underwent surgery (laparoscopic n=27, robotic n=26). There were no demographic differences between groups. Compared to laparoscopic hysterectomy, total case time (skin incision to skin closure) was significantly longer in the robotic group (mean difference +77 minutes [95% CI 33-121, p<0.001] as was total operating room time (entry into OR to exit) (mean difference +72 [95% CI 14-130, p=0.016] minutes). Mean docking time was 6 (±4) minutes. There were no significant differences between groups in estimated blood loss, pre- and post-operative hematocrit change, and length of stay. There were very few complications, with no difference in individual complication types or total complications between groups. Postoperative pain and return to daily activities were no different between groups. CONCLUSION: Although laparoscopic and robotic-assisted hysterectomies are safe approaches to hysterectomy, robotic-assisted hysterectomy requires a significantly longer operative time.
American journal of obstetrics and gynecology 02/2013; · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of the study was to develop a model that predicts an individual applicant's probability of successful placement into a surgical subspecialty fellowship program.
Candidates who applied to surgical fellowships during a 3-year period were identified in a set of databases that included the electronic application materials.
Of the 1281 applicants who were available for analysis, 951 applicants (74%) successfully placed into a colon and rectal surgery, thoracic surgery, vascular surgery, or pediatric surgery fellowship. The optimal final prediction model, which was based on a logistic regression, included 14 variables. This model, with a c statistic of 0.74, allowed for the determination of a useful estimate of the probability of placement for an individual candidate.
Of the factors that are available at the time of fellowship application, 14 were used to predict accurately the proportion of applicants who will successfully gain a fellowship position.
Journal of Surgical Education 05/2012; 69(3):364-70. · 1.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare the efficacy of a single-incision mini-sling, placed in the "U" position, with tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence.
Women with urodynamic stress incontinence with or without genital prolapse were randomized to receive a mini-sling or TVT (N=263). Those randomized to the mini-sling received two "sham" suprapubic incisions to facilitate blinding. The primary outcome was subjective cure (absence of any urinary incontinence or retreatment) as assessed at 1 year. This trial was a noninferiority study design.
Participants receiving the mini-sling were less likely to have a bladder injury (0.8% compared with 4.8%; P=.0.46), more likely to be discharged without a catheter (78.5% compared with 63%; P=.008), and had less pain for postoperative days 1-3. One year after surgery, the rate of cure was similar between treatment groups (mini-sling 55.8% compared with TVT 60.6%; mean difference, 4.8%; 95% confidence interval, -16.7 to +7.2); however, this did not meet our predefined noninferiority criteria of -12%. Incontinence severity at 1 year was greater with the mini-sling than with TVT (mean severity score ± SD: 2.2±2.7 compared with 1.5±1.9; P=.015), resulting predominantly from a higher proportion of participants with "severe" incontinence postoperatively (16% compared with 5%; P=.025).
The mini-sling placed in the "U" position results in similar subjective cure rates to TVT 1 year after surgery but postoperative incontinence severity is greater with the mini-sling than with TVT.
[Show abstract][Hide abstract] ABSTRACT: We determined the genetic contribution of and associated factors for bladder pain syndrome using an identical twin model.
Multiple questionnaires were administered to adult identical twin sister pairs. The O'Leary-Sant Interstitial Cystitis Symptom and Problem Index was administered to identify individuals at risk for bladder pain syndrome. Potential associated factors were modeled against the bladder pain syndrome score with the twin pair as a random effect of the factor on the bladder pain syndrome score. Variables that showed a significant relationship with the bladder pain syndrome score were entered into a multivariable model.
In this study 246 identical twin sister pairs (total 492) participated with a mean age (± SD) of 40.3 ± 17 years. Of these women 45 (9%) were identified as having a moderate or high risk of bladder pain syndrome (index score greater than 13). There were 5 twin sets (2%) in which both twins met the criteria. Correlation of bladder pain syndrome scores within twin pairs was estimated at 0.35, suggesting a genetic contribution to bladder pain syndrome. Multivariable analysis revealed that increasing age (estimate 0.46 [95% CI 0.2, 0.7]), irritable bowel syndrome (1.8 [0.6, 3.7]), physical abuse (2.5 [0.5, 4.1]), frequent headaches (1.6 [0.6, 2.8]), multiple drug allergies (1.5 [0.5, 2.7]) and number of self-reported urinary tract infections in the last year (8.2 [4.7, 10.9]) were significantly associated with bladder pain syndrome.
Bladder pain syndrome scores within twin pairs were moderately correlated, implying some genetic component. Increasing age, irritable bowel syndrome, frequent headaches, drug allergies, self-reported urinary tract infections and physical abuse were factors associated with higher bladder pain syndrome scores.
The Journal of urology 11/2011; 187(1):148-52. · 4.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI).
Seventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects.
Anal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95-1.16) and -likelihood ratio of 0.6 (95% CI, 0.2-1.24) for detecting a complete EAS defect on endoanal US.
DRE has poor specificity for detecting anal sphincter defects seen on endoanal US.
International Urogynecology Journal 11/2011; 23(6):765-8. · 2.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare conventional laparoscopic and robotic-assisted laparoscopic sacrocolpopexy for vaginal apex prolapse.
This single-center, blinded randomized trial included participants with stage 2-4 posthysterectomy vaginal prolapse. Participants were randomized to laparoscopic or robotic sacrocolpopexy. The primary outcome was total operative time from incision to closure. Secondary outcomes were postoperative pain, functional activity, bowel and bladder symptoms, quality of life, anatomic vaginal support, and cost from a health care system perspective.
A total of 78 patients enrolled and were randomized (laparoscopic n=38; robotic n=40). Total operative time was significantly longer in the robotic group compared with the laparoscopic group (+67-minute difference; 95% confidence interval [CI] 43-89; P<.001). Anesthesia time, total time in the operating room, total sacrocolpopexy time, and total suturing time were all significantly longer in the robotic group. Participants in the robotic group also had significantly higher pain at rest and with activity during weeks 3 through 5 after surgery and required longer use of nonsteroidal anti-inflammatory drugs (median, 20 compared with 11 days, P<.005). The robotic group incurred greater cost than the laparoscopic group (mean difference +$1,936; 95% CI $417-$3,454; P=.008). Both groups demonstrated significant improvement in vaginal support and functional outcomes 1 year after surgery with no differences between groups.
Robotic-assisted sacrocolpopexy results in longer operating time and increased pain and cost compared with the conventional laparoscopic approach.
Obstetrics and Gynecology 11/2011; 118(5):1005-13. · 4.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP).
This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support.
Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7-20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6-3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3-4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8-4.1).
Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.
American journal of obstetrics and gynecology 02/2011; 204(6):537.e1-5. · 3.28 Impact Factor