Urogynecologic Procedures Research Articles

Suprapubic Catheters: The Mayo Approach

ObjectiveSuprapubic catheters are placed for a variety of indications and can be used for postoperative bladder drainage following urogynecologic procedures. Our group has found them to be very useful for postoperative management when patients live a long distance from the hospital. We created this instructional video to share our technique for safe suprapubic catheter placement.DescriptionThe goals of this video are to discuss the indications as well as the risks and benefits of suprapubic catheters to guide proper patient selection. We will then demonstrate how to place a suprapubic catheter followed by a brief discussion of complications that patients may experience.ConclusionWith proper patient selection and skillful technique, suprapubic catheters can be a safe and effective method of postoperative bladder management following urogynecologic procedures.DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:Annetta M. Madsen: Nothing to discloseShunaha Kim-Fine: Nothing to discloseSherif A. El-Nashar: Nothing to discloseJohn Gebhart: Nothing to disclose ObjectiveSuprapubic catheters are placed for a variety of indications and can be used for postoperative bladder drainage following urogynecologic procedures. Our group has found them to be very useful for postoperative management when patients live a long distance from the hospital. We created this instructional video to share our technique for safe suprapubic catheter placement. Suprapubic catheters are placed for a variety of indications and can be used for postoperative bladder drainage following urogynecologic procedures. Our group has found them to be very useful for postoperative management when patients live a long distance from the hospital. We created this instructional video to share our technique for safe suprapubic catheter placement. DescriptionThe goals of this video are to discuss the indications as well as the risks and benefits of suprapubic catheters to guide proper patient selection. We will then demonstrate how to place a suprapubic catheter followed by a brief discussion of complications that patients may experience. The goals of this video are to discuss the indications as well as the risks and benefits of suprapubic catheters to guide proper patient selection. We will then demonstrate how to place a suprapubic catheter followed by a brief discussion of complications that patients may experience. ConclusionWith proper patient selection and skillful technique, suprapubic catheters can be a safe and effective method of postoperative bladder management following urogynecologic procedures.DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:Annetta M. Madsen: Nothing to discloseShunaha Kim-Fine: Nothing to discloseSherif A. El-Nashar: Nothing to discloseJohn Gebhart: Nothing to disclose With proper patient selection and skillful technique, suprapubic catheters can be a safe and effective method of postoperative bladder management following urogynecologic procedures.

A classification of complications in urogynecology.

The frequency of female pelvic floor reconstruction surgery with synthetic materials has been systematically rising for the last 30 years. Nowadays, they are widely used in urogynecology with a high cure rate, and a statistically significant better outcome compared to classical vaginal repair procedures. This type of operation progressed in some areas from an indication for recurrent prolapse to that of using them in primary procedures. Nevertheless, implantation of synthetic material is associated with the occurrence of specific complications and side-effects. The number and type of complications varies, depending on the study, reaching as much as 10% in some centers. The International Continence Society (ICS) and International Urogynecological Association (IUGA) have introduced an interesting tool for the evaluation of complications related directly to the insertion of prostheses and grafts in the female pelvic floor. The purpose of this classification is to describe possible complications with numbers and letters which together form a code containing comprehensive information about the complication. This article presents the clinical and practical aspects of this classification and first comments about its usability. The presented classification may serve as a tool for the development of national and international registries of urogynecological procedures that would be a great source of information on the number and type of operations performed, their effectiveness and potential complications.

Vulvar Ulcer Causing Osteomyelitis of the Pubic Bone

Osteomyelitis of the pubic bone is a rare entity. Risk factors for infection of the symphysis pubis and osteomyelitis of the pubic bone include direct trauma, previous urogynecologic procedures, extreme physical exercise, and immunocompromised state. The treatment modalities range from conservative antibiotic treatment to extensive surgery. A 49-year-old woman with multiple sclerosis and borderline diabetes mellitus presented with bloody vulvovaginal discharge. The source was found out to be an ulcer located above the urethra with exposure of the underlying symphysis pubis. Intraoperative debridement of the ulcer followed by bone biopsies demonstrated osteomyelitis of the pubic bone. Prolonged intravenous antibiotics and 4 operative debridements were needed before the osteomyelitis was adequately addressed and the defect could be closed with a bulbocavernosus flap. This is the first report of a severe case of osteomyelitis of the pubic bone arising from a vulvar ulcer.

Patient reported outcome measures in women undergoing surgery for urinary incontinence and pelvic organ prolapse in Denmark, 2006–2011

The aim of this study was to evaluate the impact of urogynecological surgery on quality of life based on patient reported outcome measures (PROMs). Data were retrieved from the Danish Urogynaecological Database. Inclusion criteria were Danish women undergoing surgery for urinary incontinence (UI) or pelvic organ prolapse (POP) from 2006 to 2011. Using frequency of symptoms and a visual analogue scale (VAS) both pre- and postoperatively, their severity of symptoms and quality of life were measured by questionnaires. During the study period, 20,629 urogynecological procedures were performed. The questionnaires on severity of symptoms and the VAS had been completed both pre- and postoperatively for approximately one third of women undergoing surgery. For UI surgery, 83% had improved symptoms, 13% were unchanged, and 4% had worse symptoms postoperatively. For POP surgery, 80, 17, and 3% were improved, unchanged, and worsened, respectively. The postoperative bother of symptoms and interference in everyday life evaluated by VAS were significantly reduced for both UI [preoperative median VAS score 9, postoperative median score 1 (p < 0.001)] and POP [8 preoperatively and 0 postoperatively (p < 0.001)]. Based on PROMs, surgery for UI and POP is effective in alleviating symptoms associated with UI or POP, and it can improve quality of life in symptomatic women. Pre- and postoperative questionnaires are useful tools in assessing symptomatic outcome measures after surgery.

Controversies in utilization of transvaginal mesh

Due to technological advancements, transvaginal mesh use for prolapse and incontinence has exploded over the last decade with mixed results. Recent governmental guidelines have further increased the controversy regarding the risks and benefits of mesh use forcing clinicians to critically review the available data regarding transvaginal mesh use. With the success of the transvaginal tape procedure introduced in 1995 and re-popularization of the abdominal sacrocolpopexy using synthetic mesh, pelvic surgeons began to feel more comfortable using mesh in urogynecologic procedures and increasingly adopted the use of transvaginal mesh for repair of pelvic prolapse with the hopes of creating better long-term results with minimal complications. With introduction of commercially available kits and widespread adoption of these procedures amongst pelvic surgeons and general gynecologists, there is increasing concern regarding related complications including mesh exposure, dyspareunia/pelvic pain, infection, and organ injury. This has resulted in recent reappraisal of vaginal mesh use, increased medicolegal risk, and withdrawal of selected products. The data regarding transvaginal mesh use are controversial and incomplete. Its use is still in its infancy in terms of material development and clinical/scientific study, and clinicians should be careful and judicious in its use.

Cystoscopic removal of intravesical synthetic mesh extrusion with the aid of Endoloop sutures and endoscopic scissors

Synthetic mesh is commonly used in urogynecologic surgical procedures for correction of stress urinary incontinence and pelvic organ prolapse. Bladder mesh extrusion is a recognized complication and frequently requires extensive mesh resection. We present a case of intravesical polypropylene mesh extrusion following a combined mesh kit and midurethral sling placement. A novel transurethral approach, employing Endoloop sutures with endoscopic scissors, was used to resect the protruding mesh located in close proximity to a ureteral orifice. Medline was searched for other minimally invasive treatment strategies for bladder mesh extrusion. Various techniques for minimally invasive resection of extruded intravesical mesh have been described in the literature. Our strictly transurethral approach avoids the use of an energy source and eliminates the need for open or extensive surgery. Advantages of this new transurethral operative technique include decreased risk of injury associated with the use of an energy source within the bladder and avoidance of open surgical complications.

Vaginal Cuff Closure during Robotic-Assisted Total Laparoscopic Hysterectomy: Comparing Vicryl to Barbed Sutures

Empirical evidence is needed to assess clinical appropriateness of any new surgical device or material. Differences in surgical outcomes between Vicryl figure-of-8 and V-Loc barbed sutures for vaginal cuff closure during robotic hysterectomy were assessed. We examined the electronic medical records of 202 patients who underwent scheduled robotic-assisted total laparoscopic hysterectomy for benign indications, without concomitant urogynecologic procedures, between January 2008 and November 2010 at the Henry Ford Health System academic medical center. Cuff closure approach was selected by the surgeon. Data on demographics, vaginal cuff suture type, body mass index (BMI), estimated blood loss (EBL), perioperative hemoglobin change, procedure duration, hospital length of stay (LOS), specimen weight, and postoperative complications were obtained. The average age was 46 y (SD = 8.0 y). Women with Vicryl figure-of-8 closures (n = 133) were more likely than women with V-Loc barbed suture closures (n = 69) to have had a LOS > 1 d (48/133, 36.1% vs. 12/69, 17.4%; chi square P < .006), greater EBL (median 75 vs. 50 mL, Wilcoxon Rank Sum WRS P < .001), and longer procedure durations (175 vs. 135 min, WRS P < .001). These differences persisted even after considering uterine weight, BMI, smoking status, and concomitant oophorectomy. No differences with respect to the frequency of major (2 in each closure type) or minor complications were observed (P < .36). There were no differences in complications between the Vicryl figure-of-8 and V-Loc barbed sutures in our sample. However, the latter had lower EBL and shorter procedure duration and LOS.

Perioperative Pain Management for Patients on Chronic Buprenorphine: A Case Report

Here we present a patient with a Type I Chiari malformation who was receiving buprenorphine for chronic pain who underwent two separate urogynecologic procedures for removal of vaginal mesh with two different pain management regimens. For the first procedure at an outside hospital, the patient's usual dose of buprenorphine (8 mg sublingual every 8 hours) was continued up through her surgery and then a full opioid receptor agonist was used for postoperative pain management. The patient complained that this resulted in very poor pain control for her in the postoperative period. Prior to her second procedure, which was performed at our institution, buprenorphine was switched to a full opioid agonist (oral hydromorphone 4 mg every 4 to 6 hours, maximum 20 mg per day) for 5 days prior to surgery; postoperative pain was managed with full opioid receptor agonists. The patient again reported suboptimal pain control in spite of substantially increased doses of opioids. This case report highlights the difficulty of perioperative pain management for patients on chronic buprenorphine and emphasizes the need for additional investigation.

Does size matter? The effect of uterine weight on robot-assisted total laparoscopic hysterectomy outcomes.

The objective of this study was to determine whether uterine weight affects the surgical outcomes of robot-assisted total laparoscopic hysterectomy (RH) procedures. The design of this study is retrospective cohort study. The classification of the study design is level II-2 evidence. The study setting is the Henry Ford Health System's Community Teaching Hospitals. One-hundred and thirty-five patients underwent RH for benign indications at one of two hospitals between January1, 2008, and June 1, 2010. Interventions were scheduled RH without concomitant uro-gynecologic procedures as the intention to treat. Patient demographics, age, height, weight, estimated blood loss (EBL), procedure duration, uterine weight, pathology, length of hospital stay (LOS), and any complications were obtained from a detailed review of electronic medical records. Uterine weight ranged from 47 to 1,290g (<250g, n=87; 250-500g, n=28; >500g, n=18). Overall, uterine weight was highly correlated with procedure duration (r=.53, P<.001.). Median procedure duration increased from 150min for the <250g group, to 205min for the 250-500g group, and to 295min for the >500g group. Uterine weight was also moderately correlated with EBL (r=.30, P=.0005). Median EBL increased from 50ml for uteri <250g to 87.5ml for the 250-500g group, and 100ml for the >500g group. This correlation did not persist in the assessment of decrease in peri-operative hemoglobin (r=.09, P=.30). Ninety-one women had a LOS of 1day (67.4%), 31 women had a LOS of 2days (23%), and 13 women had a LOS of greater than 2days (9.6%). Uterine weight was not correlated with LOS (r=.14, P=.10) and was not associated with increased major or minor complications (WRS P=.79) re-admission (WRS P=.35), or blood transfusion (n=3). RH can be performed on patients with large uteri exceeding 500g without associated adverse outcomes. Although procedure duration is increased, there is no significant effect on EBL and no increase in the occurrence of complications or length of stay.

Effect of Body Mass Index on Robotic-Assisted Total Laparoscopic Hysterectomy

Study Objective To estimate the impact of body mass index (BMI) on the surgical outcomes of patients undergoing robotic-assisted total laparoscopic hysterectomy. Design Retrospective cohort study. Setting Henry Ford Health System academic medical center (Henry Ford and Henry Ford West Bloomfield Hospitals) Patients A total of 135 patients who underwent scheduled robotic-assisted total laparoscopic hysterectomy for benign indications, without concomitant urogynecologic procedures between January 2008 and June 2010. Interventions Patients underwent robotic-assisted total laparoscopic hysterectomy as the intention to treat. Two cases were converted to laparotomy. Measurements & Main Results Electronic medical records of all patients that underwent robotic-assisted total laparoscopic hysterectomy at Henry Ford Health System were reviewed. Data on demographics, BMI (kg/m 2), estimated blood loss, perioperative hemoglobin change, procedure duration, hospital length of stay, specimen weight, pathology, and postoperative complications were obtained. The women’s median age was 45 years (range 30–68), 61.5% were black, and BMI ranged from 14.8-56.2 kg/m2; 23.4% of women were normal weight or less (BMI <25, n = 31), 52.7% of women were obese (BMI >30, n = 70) and 36 of these patients (27.1%) were morbidly obese (BMI ≥35). BMI did not correlate with procedure duration (Spearman r = .12, p = .16), length of stay (Spearman r = .10, p = .24), or estimated blood loss (Spearman r = .12, p =.18). Our analysis did not identify any meaningful associations between BMI and absolute change in hemoglobin. In addition BMI was not associated with an increase in major or minor complications. Conclusion BMI is not associated with blood loss, duration of surgery, length of stay, or complication rates in patients undergoing robotic-assisted total laparoscopic hysterectomy. Robotic assistance may help surgeons overcome adverse outcomes sometimes found in obese patients.

Use of Bovine Pericardium in Pelvic Reconstructive Surgery

Hypothesis / aims of study With an estimated 30% of women needing additional surgery for pelvic organ prolapse recurrence, there has been a significant increase in the use of synthetic and biologic grafts. Our aim was to evaluate our experience with bovine pericardium (Veritas®, Synovis Surgical Innovations, Minneapolis, MN) in pelvic reconstructive surgery. Veritas® is a non-cross linked bovine pericardium implant that acts as a temporary scaffolding to allow ingrowth of deficient fascia by surrounding host tissues. Study design, materials and methods All patients at our institution who had urogynecologic surgery utilizing bovine pericardium graft were reviewed. The decision to use bovine pericardium was based on the surgeon’s intraoperative assessment of endopelvic fascial quality. For anterior repairs the graft was secured from apex to bladder neck and from arcus to arcus as an overlay to reinforce traditional midline plication. In vaginal enterocele repairs, a 4x7 piece of graft was utilized when the rectovaginal septum could not be successfully reattached to the vaginal apex. Data analyzed included demographics, prior urogynecologic surgery, postoperative POP-Q values, prolapse recurrence rates, complications, and healing abnormalities. The primary outcome was prolapse recurrence in the same compartment defined as POP-Q values ≥-1. Results From 2003 – 2009, 135 urogynecology procedures incorporated a bovine pericardium graft. Mean patient age was 62.2 ± 11.7. There were 53 anterior repairs reinforced with a bovine pericardium graft. Preoperative POP-Q values Aa and Ba were 1.21 and 1.77 cm respectively. At a median follow-up of 54 weeks (24-142.5), anatomical results were satisfactory with measurements of Aa and Ba at -2.33 and -2.28 cm respectively (p<0.0001). For patients with previous anterior repairs (6/53) there was also a statistically significant improvement in postoperative POP-Q values Aa and Ba. 10 patients had cystocele recurrence. None of these patients were symptomatic or required repeat surgery. There were 77 posterior enterocele repairs utilizing a bovine pericardium graft. Preoperative POP-Q values Ap and Bp were -0.18 and 0.31 cm respectively. At a median follow-up of 56 weeks (41-105), anatomical results were satisfactory with measurements of Ap and Bp at -2.66 and -2.68 cm respectively (p<0.0001). For patients with previous posterior repairs (13/77) there was also a statistically significant improvement in postoperative POP-Q values Ap and Bp. 5 patients had posterior wall recurrence. There were no significant differences between preoperative and postoperative rates of dyspareunia or bowel complaints. 5 patients underwent urethral diverticulum excision with reinforcement with bovine pericardium. All patients had concomitant suburethral sling and Veritas® was used for tissue reinforcement prior to placement of the sling. Postoperatively, all patients reported themselves as “cured/greatly improved” with no diverticula recurrence or graft erosion. Overall, patients were satisfied with surgical outcomes with 76% reporting themselves as either “cured” or “greatly improved”. Alterations in healing were evaluated by presence of granulation tissue at 6 weeks postoperatively and beyond. At 6 weeks, granulation tissue was present in 18.5% of anterior repairs and 16.9% of posterior repairs. The majority of these healing abnormalities were related to suture sites and resolved by 12 weeks postoperatively. There were no graft exposures/erosions and no patients required repeat surgery for graft related complications. Interpretation of results At one year follow up, bovine pericardium used in vaginal prolapse repair results in acceptable anatomical and functional outcomes without significant graft related complications. Concluding message Bovine pericardium is useful for tissue augmentation in pelvic organ prolapse surgery.

Effect of Body Mass Index on Robotic-Assisted Total Laparoscopic Hysterectomy

Study Objective: To analyze the impact of body mass index (BMI) on the surgical outcomes of patients undergoing Robotic-assisted total laparoscopic hysterectomy (RH). Design: Retrospective cohort study. Setting: Henry Ford Health System's (HFHS) community-based teaching hospitals. Patients: 120 patients who underwent scheduled RH for benign indications, without concomitant urogynecologic procedures, between January 2008 and March 2010. Intervention: Patients underwent RH as the intention to treat. 2 cases were converted to laparotomy. Measurements and Main Results: Electronic medical records of all patients that underwent RH at HFHS were reviewed. Data on demographics, BMI (kg/m2), estimated blood loss (EBL), peri-operative hemoglobin change, procedure duration, hospital length of stay (LOS), specimen weight, pathology and post operative complications were obtained. The women's average age was 45.2 years (SD=6.9 years), the majority were Black (60%), and BMI ranged from 14.8-56.2. Only 23% were of normal weight or less (BMI <25, n=27) with 53.4% of women being at least obese (BMI>30, n=64); 32, of these patients (26.7%) were morbidly obese (BMI>=35). Overall, BMI was not correlated with procedure duration or LOS (Spearman correlations r=.12 (p=.19), and r=.10 (p=.28) respectively). BMI was not associated with EBL (Spearman correlations r=.11 (p=.23)), and the assessment of peri-operative drop in Hemoglobin showed an inverse relationship, if any, to BMI (r=.29, p=.002), but the extent of difference showing a very small difference in median decrease in hemoglobin between normal weight (median -2.2 g/dL) and morbidly obese patients (median -1.1 g/dL). BMI was not associated with an increase in major or minor complications. Conclusion: BMI is not associated with adverse outcomes in patients undergoing Robotic-assisted total laparoscopic hysterectomy. There was no association with increased blood loss, duration of surgery, length of stay, or increase in complications. Robotic assistance may overcome adverse surgical outcomes associated with obesity.

Does Size Matter? The Effect of Uterine Weight on Robotic Assisted Total Laparoscopic Hysterectomy Outcomes

Study Objective: To determine whether benefits of robotic assisted total laparoscopic hysterectomy (RH) extend across the spectrum of uterine sizes. Design: Retrospective Cohort Study. Setting: Henry Ford Health System's Community Teaching Hospitals. Patients: 110 patients who underwent RH for benign indications, at one of two hospitals, between January 2008 and February 2010. Intervention: Scheduled RH without concomitant urogynecologic procedures as the intention to treat. Measurements and Main Results: Patient demographics, height, weight, age, estimated blood loss (EBL), procedure duration, uterine weight, pathology, length of hospital stay (LOS) and Immediate and delayed complications were obtained from a detailed review of the Electronic Medical Record. Uterine weight ranged from 47-1020 grams (<250 grams, n=71; 250-500 grams, n=24; >500 grams, n=13). Most women had a LOS of 1 day (n=73, 66.4%), 25 women had a LOS of 2 days (22.7%), and 12 women had a LOS of greater than 2 days (10.9%). Overall, the uterine weight was highly correlated with procedure duration (Spearman correlation, r=0.51, p<0.001.). Median procedure duration increased from 154 minutes in the < 250 gram group, to 201 minutes in the 250-500 gram group, to 294 minutes in the >500 gram group. Uterine weight was also moderately correlated with EBL (Spearman correlation r=0.29, p=0.003). Median EBL increased from 50 ml (<250 g group) to 100 ml in both the 250-500 gram and >500 gram groups. This was also reflected in the assessment of decrease in peri-operative hemoglobin. Uterine weight was not correlated with LOS (r=0.17, p=0.08) and had no impact on the risk of major or minor complications or blood transfusion. Conclusion: Results indicate that RH can be performed routinely and safely on patients of various uterine weights, including uteri > 500 grams, and even uteri >1000 grams without affecting outcomes. Although procedure duration is increased, complication rates and LOS are not increased, and there is no significant impact on EBL.

The use of infection prevention practices in female pelvic medicine and reconstructive surgery

This review discusses recently published and relevant data on the preventive techniques used to reduce perioperative infections in urogynecologic procedures. The consequences of postprocedural and postsurgical infections in Female Pelvic Medicine and Reconstructive Surgery can be challenging. Infections can range from a simple urinary tract infection to a devastating infection of vaginally implanted mesh that requires multiple subsequent reoperations. Measures taken to reduce the chances of postprocedural or postsurgical infections may provide better outcomes, with lower costs and less litigation. Recent studies on the outcomes of specific practices used in urology and urogynecology to prevent infectious complications can help guide clinicians through the decision-making process on which new practices to adopt. Good evidence-based practices to reduce or prevent infectious complications after procedures in female urology and urogynecology will save time, lower morbidity, reduce costs, and improve patient outcomes and satisfaction. However, there is still a great need for more level I evidence on infection prevention practices utilized in female urology and urogynecology.

Role of robotic surgery in urogynecologic surgery

Robotic surgery with its numerous advantages over conventional laparoscopy has assumed an ever-expanding role in pelvic and pelvic floor reconstructive surgery. Our goal is to review the literature regarding robotic use in urogynecologic surgery. The current literature demonstrates the feasibility and safety of performing robotic urogynecologic procedures in a wide variety of cases. Robotic sacrocolpopexy and hysterectomy are most commonly described, but the use of robotics in the repair of complex pelvic fistulae has also been examined. The available studies mainly consist of case series with short-term follow-up, but early outcomes appear to be comparable to open surgery with decreased patient morbidity. The role of robotics in urogynecologic surgery will continue to grow, as there is an increasing access to the robotic platform, and its use is being incorporated into residency training. More robust studies will be needed to validate the continued use of the robot, as there are concerns regarding cost, training, and credentialing.

Preliminary findings with the Solyx™ single-incision sling system in female stress urinary incontinence

The aim of this study was to test the safety and efficacy of the Solyx single-incision sling (SIS) in women with stress urinary incontinence (SUI). A retrospective study of 63 women who had undergone implantation at three medical centers (December-March 2009) was conducted. Mean patient age was 51 years (range, 30-87 years); 37 (59%) patients had concomitant urogynecological procedures. At a mean follow-up of 6.5 months (range, 5-8 months), 95% of patients were dry on the basis of subjective and objective assessment. Two patients experienced transient urinary retention, which resolved spontaneously. No complications of the procedure were reported, including no bladder, bowel, vessel, or nerve perforations and no erosions or extrusions. No pain was reported that was attributed to the implant. The very early efficacy results indicate that the Solyx SIS system is an attractive treatment option for SUI. The minimal number of steps involved in the procedure will facilitate uptake of the technique.

Role of Robot-Assisted Pelvic Surgery

The purpose of this study was to assess the current role of robot-assisted urological surgery in the female pelvis. The recently published English literature was reviewed to evaluate this role, with special emphasis on reconstructive procedures. These included colposuspension for genuine female stress urinary incontinence, repair of female genitourinary fistulas, ureterosciatic hernias, sacrocolpopexy for vault prolapse, ureterolysis and omental wrap for retroperitoneal fibrosis, ureteric reimplantation, and bladder surgery. To date, a wide spectrum of urogynecological reconstructive procedures have been performed with the assistance of the surgical robot and have been reported worldwide. Currently, a number of female pelvic ablative and reconstructive procedures are technically feasible with the aid of the surgical robot. While the role of robot-assisted surgery for bladder cancer, ureterolysis, ureteric reimplantation, repair of genitourinary fistulas, colposuspension, and sacrocolpopexy is nearly established among urologists, other procedures, such as myomectomy, simple hysterectomy, trachelectomy, and Wertheim's hysterectomy, are still evolving with gynecologists. The advantages of robot assistance include better hand-eye coordination, three-dimensional magnified stereoscopic vision with depth perception, intuitive movements with increased precision, and filtering of hand tremors. For most of the currently performed procedures in selected patients, the robot-assisted surgical outcomes appear to be relatively superior as compared to an open and purely laparoscopic surgical procedure.

Mask Interface and CPAP Adherence

72-year-old retired nurse with family history of obstructive sleep apnea, loud snoring, witnessed apneas, excessive daytime sleepiness, and inability to concentrate underwent polysomnography. The patient has history of hypertension, multiple urogynecological procedures for genitourinary prolapse, and has history of atrial fibrillation and congestive heart failure. On examination, the patient had a body mass index of 31.8 kg/m, 2 well controlled blood pressure, normal nasal passageway, and no evidence for decompensated heart failure. Cardiovascular examination revealed normal heart sounds and no murmurs, while respiratory examination revealed bilateral normal breath sounds. Abdominal examination was normal, and skin examination was normal as well. Examination of fin gers revealed the following nail findings shown in image below (Fig. 1). Polysomnography revealed severe obstructive sleep apnea with an apnea-hypopnea index of 33.2 per hour, and lowest oxygen saturation of 82% by finger pulse oximetry. The patient underwent continuous positive airway pressure titration on a second night, which was marked by significant improvement in AHI to 3 per hour while on CPAP of 8 cm H 2 O with a silicone nasal mask. The patient complained of suffocation, and polysomnography revealed marked reduction in sleep efficiency despite improvement in sleep disordered breathing. The day following the CPAP titration, the patient called the lab coordinator to complain about a “skin rash” on her face, nasal burning, itching, and rhinorrhea. Examination during a followup clinic visit on the same day did not reveal any maculopapular rash, however skin impressions demarcating the areas of mask contact around the nose were identified. A “skin allergy patch” was constructed using a piece of the nasal mask material and affixed onto the ventral aspect of the patient’s forearm using adhesive tape to discern any evidence of skin contact allergies. On a follow-up visit 2 days later, there was no evidence of any skin change underneath the patch.

ACOG Committee Opinion No. 372: The Role of Cystourethroscopy in the Generalist Obstetrician_Gynecologist Practice

Cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician-gynecologists to help improve patient care. Perhaps the most important indications for cystourethroscopy are to rule out cystotomy and intravesical or intraurethral suture or mesh placement and to verify bilateral ureteral patency during or after certain gynecologic surgical procedures. The granting of privileges for cystourethroscopy and other urogynecologic procedures should be based on training, experience, and demonstrated competence. Postgraduate education, including residency training programs in obstetrics and gynecology and continuing medical education, should include education in the instrumentation, technique, and evaluation of findings of cystourethroscopy, and in the pathophysiology of diseases of the lower urinary tract.

The state of residency training in female pelvic medicine and reconstructive surgery

To evaluate the state of resident training in female pelvic medicine and reconstructive surgery, the American Urogynecology Society (AUGS) education committee surveyed obstetrics and gynecology program directors on resident training and competence in performing common urogynecologic surgical and office procedure skills. One hundred thirty-two programs (50%) responded. Programs averaged 9 weeks of pelvic floor rotations during residency training. Program directors reported that 77% of residents could independently do some type of anti-incontinence procedure, but only 58% could independently perform apical vaginal support procedures. In 85% of the programs, residents could perform without help only four out of ten urogynecological procedures identified as procedures that residents should be able to do independently by the Council for Resident Education in Obstetrics and Gynecology and AUGS' guidelines.