Faculty Bibliography

PURPOSE: There is controversy regarding performing concomitant anti-incontinence procedures at the time of pelvic organ prolapse (POP) repair. Data supports improvement in stress urinary incontinence (SUI) with concomitant sling, but increased adverse events. We assessed trends in preoperative SUI evaluation, concomitant anti-incontinence procedure at POP surgery, and post-operative anti-incontinence procedures at our institution before and after the 2011 FDA Public Health Notification pertaining to vaginal mesh. MATERIALS AND METHODS: A retrospective review was performed on patients who underwent POP surgery from 2009-2015. Preoperative workup included assessment of subjective SUI and/or evaluation for leakage with reduction of POP on physical exam, urodynamics or pessary trial. Percentage of concomitant and post-operative anti-incontinence procedures were compared before and after the 2011 FDA notification. RESULTS: 775 women underwent POP repair. The percentage of anti-incontinence procedures at POP repair decreased from 54.8% to 38.0% after the FDA notification (p = 0.002) while the incidence of pre-operative objective SUI on exam, urodynamics and pessary trials remained constant. The incidence of post-operative anti-incontinence procedures within one year of the index surgery remained low. CONCLUSIONS: We found a decrease in incidence of concomitant anti-incontinence procedures at the time of POP repair following the 2011 FDA notification despite no significant decline in subjective SUI or demonstrable SUI on preoperative evaluation. Further analysis is warranted to assess the impact of the FDA notification on management patterns of women with POP and SUI.

Objectives: To evaluate the effect of a pelvic model simulation on performance of sacrospinous ligament fixation (SSLF) and to develop and validate a reliable Objective Structured Assessment of Technical Skills (OSATS) to measure the necessary surgical skills to perform SSLF. Methods: After developing a pelvic model for SSLF, we enrolled OB/GYN residents as well as experts who routinely perform the procedure. Baseline resident knowledge on SSLF was evaluated using a written test. All residents underwent a didactic session pertinent to SSLF and were then randomized to simulation training vs. no training. During the simulation, participants were taught to perform the procedure in a systematic fashion on a pelvic model that permitted the trainees to visualize spatial relationships and understand the procedure in a 3-dimensional space. All residents were then evaluated using a modified OSATS which consisted of a global rating scale (GRS) to examine performance during the entire testing process and a task-specific checklist (TSC). The GRS was comprised of 5 domains related to surgical performance graded on a 5-point scale from 1 to 5 (poor to excellent performance). The TSC consisted of an 8 item surgical check list and was graded on a 3-point scale from 0-2. Two blinded experienced independent raters used the OSATS scale for SSLF to evaluate each individual performance. After completion, knowledge was reassessed using a written post-test and participants were asked to evaluate the training session. Construct validity was measured by comparing OSATS scores between experts and trainees. Data collected included year of residency and self-reported number of prior procedures. Written test scores (paired t- test) and OSATS scores (Wilcoxon signed rank test) between the groups were compared. A p-value < 0.05 was considered significant. Results: The trainee group consisted of 20 residents, 11 of whom underwent simulation training and 9 who did not. 4 subjects were included in the expert group (3 urologists and 1 gynecologist). After simulation, OSATS mean total GRS scores (18.4+/-0.9 vs. 11.1+/-0.5, p=0.0005) and mean total TSC scores (12.6+/-1.4 vs. 6.1+/-0.6, p=0.0003) were significantly better for the simulation group vs. the traditional learning group. Mean time required to complete the procedure was also significantly different between the two resident groups (p=.0006). Results were still significant when adjusting for year of residency and number of prior procedures. There was improvement in mean written post-test scores in all the trainees (p=0.0005); however, there was no difference in scores between the two randomized groups. Experts had higher total GRS scores (25+/-0.7 vs. 15.1+/-0.8, p=0.006) and TSC scores (13.7+/-0.6 vs. 9.7+/-1.2, p=0.02) as well as higher scores in each subscale. Experts also required less time to complete the procedure than trainees (p=0.02). All participants agreed that the pelvic model was useful for learning SSLF and felt it would improve their ability to perform the procedure in vivo. Conclusions: Simulation for urogynecologic procedures like our SSLF model can be useful in improving skills and confidence in trainees. Additionally, the OSATS scale demonstrated validity in differentiating novices from experts

Objective: Vaginal deliveries have been associated with pelvic organ prolapse and incontinence. The objective was to show whether markers of ischemia/reperfusion injury are dependent upon the mode of delivery and length of labor. Method: Complete venipuncture sets were obtained on 62 subjects. All samples collected were analyzed for serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH). Lipid peroxidation was analyzed, using thiobarbituric acid reactive substances (TBARS), on a subset of 37 patients. Results: There was a significant increase in CPK from admission to 1 h postpartum and postpartum day 1 in vaginal delivery versus cesarean delivery. Longer second stages were associated with significant increases in CPK. There were no significant changes in either LDH or TBARS from admission to any other time point regardless of mode of delivery. Conclusion: Vaginal delivery and longer second stages were associated with a much greater increase in one of these injury markers

OBJECTIVE: Fecal incontinence affects 0.2% of women aged 15-64 years and about 1.3% of women over 64 years. Most cases are related to instrumental deliveries affecting the anal sphincter complex. We propose a simple technique using the generally available transvaginal transducer to evaluate the anal sphincter complex. METHODS: Ninety-two patients underwent ultrasound examination. Group I consisted of 53 nulliparous patients. In Group II there were six patients with normal spontaneous vaginal deliveries without episiotomies. In Group III there were 14 patients with vaginal deliveries and one to three episiotomies but no lacerations. In Group IV there were nine postpartum patients with recently repaired (48 h to 3 weeks) third- and fourth-degree lacerations. All women in Groups I-IV were asymptomatic. Group V consisted of 10 patients symptomatic for fecal incontinence. We used a vaginal probe (5-9-MHz) with the footprint placed in the fourchette pointing towards the anus in a transverse and then in a median (sagittal) plane. If seen, the combined internal and external anal sphincter thickness at the 12 o'clock location was measured. We visualized normal star-shaped mucosal folds on the transverse section and described the sonographic anatomy in both planes. RESULTS: The mean sphincter thickness measured at 12 o'clock in Group I was 2.3 (range, 1.0-4.7) mm, in Group II it was 2.9 (range, 2.4-3.4) mm, and in Group III it was 2.3 (range, 1.0-3.7) mm. The differences between these three groups were not significant. Patients from Group IV showed thinning or discontinuous sphincter anatomy at the 12 o'clock position. All symptomatic patients from Group V showed abnormal sphincter anatomy, and the normal star-like appearance of the anal mucosa on the transverse section was deformed, radiating from the point of the sphincter damage. Four of the 10 patients in this group underwent surgical repair. In these patients the sonographic findings were confirmed. CONCLUSIONS: The images obtained using this imaging modality show the sphincter muscle anatomy as well as the possible pathology. Due to its simplicity the technique can be applied in any place where a vaginal transducer is available

The aim of this study was to determine the prevalence of urinary incontinence in women with familial dysautonomia (FD). A telephone survey was conducted on 68 known surviving female FD patients over 13 years of age registered with the Dysautonomia Centers in the USA and Israel. The mean age of the surveyed group was 27.1+/-9.8 years and 99% of the patients were nulliparous. The overall reported prevalence of urinary incontinence was 82% (n=56). Of the patients with incontinence, 59% (n=33) reported stress incontinence, 11% (n=6) reported urge incontinence, and 30% (n=17) reported symptoms of both, or mixed incontinence. In most women urinary loss was both small and infrequent, but 36% of women (n=20) with incontinence experienced a loss sufficient to necessitate the use of protection (panty liners, pads or diapers); in 7% (n=4) such loss occurred daily. Twelve per cent of all women with FD surveyed experienced primary nocturnal enuresis and 26% experienced nocturia. The prevalence of urinary incontinence is high in young female patients with familial dysautonomia. Neurophysiologic testing in this population may provide a better understanding of the role of the autonomic nervous system in urinary incontinence

OBJECTIVE: The aim of this study was to determine the influence of advance knowledge of board scores on interviewers' assessments of residency applicants. STUDY DESIGN: During a 2-year period we prospectively evaluated our residency selection process. In year 1 interviewers were provided with each candidate's entire application, whereas in year 2 the United States Medical Licensing Examination scores were not included. In each year interviewers were asked to provide numerical assessments of the applicants solely on the basis of their own impressions of the interviews. Analysis was performed only for evaluations by interviewers who participated during both study periods under review. Interview scores were compared with United States Medical Licensing Examination part I scores within each year by means of a scatter plot and correlation coefficients. RESULTS: Applicant demographic characteristics were similar during years 1 and 2. Interview scores did not differ between year 1 (4.2 +/- 0.1) and year 2 (4.3 +/- 0.1; P > .05). During year 1 interview and board scores were significantly correlated (correlation coefficient, 0.64; slope of best-fit line, 13.9), whereas there was a negative correlation in year 2 (correlation coefficient, -0.06; slope, -1.3). CONCLUSION: When they are available to interviewers, markers of academic achievement such as United States Medical Licensing Examination scores may bias the interview evaluation. The interview process when conducted in this manner may simply be a validation process for candidates already judged on the basis of the application alone. Knowledge of United States Medical Licensing Examination scores by the interviewers may therefore negate the interview as an independent means of evaluating candidates

OBJECTIVE: To compare pregnancy outcomes between morbidly obese and nonobese women and to determine the effect of gestational weight gain on pregnancy outcome in morbidly obese women. METHODS: A retrospective cohort study was conducted comparing 613 morbidly obese and 11,313 nonobese women who were delivered of a singleton live birth. Morbid obesity was defined as a body mass index greater than 35. The incidence of selected perinatal and neonatal outcomes was assessed for the two groups. Multiple logistic regression analysis was used to evaluate the association between morbid obesity and various measures of outcome while controlling for potential confounders. A subanalysis of the morbidly obese patients was performed to assess the effect of gestational weight gain on pregnancy outcome. RESULTS: Morbidly obese patients were more likely to experience pregnancy complications including diabetes, hypertension, preeclampsia, and arrest-of-labor disorders; however, these were not affected by gestational weight gain. Morbidly obese patients were more likely to experience fetal distress and meconium and to undergo cesarean delivery than their nonobese counterparts (P < .05). Weight gains of more than 25 lb were associated strongly with birth of a large for gestational age (LGA) neonate (P < .01); however, poor weight gain did not appear to increase the risk of delivery of a low birth weight neonate. CONCLUSION: Gestational weight gain was not associated with adverse perinatal outcome, but it did influence neonatal outcome. To reduce the risk of delivery of an LGA newborn, the optimal gestational weight gain for morbidly obese women should not exceed 25 lb

OBJECTIVE: To evaluate steroid hormone receptor status in the uterosacral ligament, a structure that contributes to pelvic support. METHODS: A descriptive study was conducted by sampling the uterosacral ligaments from 25 consecutive women undergoing hysterectomy by the primary author for nonmalignant conditions. Using immunohistochemical staining techniques, uterosacral ligaments were assessed for the presence and location of estrogen and progesterone receptors. Positive and negative controls were used. Confirmation of the uterosacral ligament was performed histologically. RESULTS: Using commercially available monoclonal antibodies, estrogen and progesterone receptors were detected in the nuclei of smooth muscle cells of the uterosacral ligament in all patients, regardless of variations in age, race, menopausal status, parity, body mass index, and medications affecting serum steroid hormone levels. Hormone receptors were not found in the collagen, vascular, or neuronal components. CONCLUSION: The presence of estrogen and progesterone receptors in the uterosacral ligaments means that this structure may be a target for estrogen and progesterone. This finding might suggest a possible role for steroid hormones in pelvic support