Amy E. Young

Local analgesia in laparoscopy: A randomized trial

OBJECTIVE: To investigate whether local infiltration of bupivacaine reduces postoperative pain at trocar sites during gynecologic laparoscopy. METHODS: This was a randomized, placebo-controlled, double-blind clinical trial, using patients as their own controls. For each patient, 2 opposite trocar sites were infiltrated. One site was randomly chosen to receive 0.5% bupivacaine, and the other received 0.9% saline. In addition, patients were randomized into 2 cohorts to receive either preincision or postsurgical infiltration. Surgeons, patients, and interviewers were blinded toward the exposure. Postoperative pain was evaluated at 1 hour, 4 hours, and 24 hours after surgery using a 100-mm visual analog scale. Patients rated their pain at each of the infiltrated trocar sites. A 20-mm difference between pain scores was considered clinically significant. A paired t test was used for analysis. RESULTS: Infiltration of bupivacaine at completion of surgery resulted in significantly decreased pain at 1 hour postoperatively (mean pain score 25.8 versus 48.6, P = .02). Mean pain scores at 4 hours and 24 hours were decreased, but not statistically different. Patients receiving bupivacaine before surgery did not have a statistically significant decrease in pain scores. CONCLUSION: Infiltration of bupivacaine at completion of gynecologic laparoscopic surgery decreases pain at trocar sites in the immediate postoperative period. LEVEL OF EVIDENCE: I

Perceived proficiency in endoscopic techniques among senior obstetrics and gynecology residents

STUDY OBJECTIVES To assess current training methods in laparoscopic surgery employed in United States obstetrics and gynecology residency programs, level of proficiency in various minimally invasive surgery procedures amongst senior obstetrics and gynecology residents, and ways in which training in minimally invasive surgery can be improved. DESIGN Survey (Canadian Task Force classification III). SETTING Accredited obstetrics and gynecology programs in the United States. SUBJECTS All fourth-year residents in accredited obstetrics and gynecology programs in the United States. INTERVENTION Residents received a survey regarding their perceived proficiency performing various laparoscopic procedures and the type of training they received in these techniques. MEASUREMENTS AND MAIN RESULTS Responses were received from 133 programs (52.4%) and 295 residents (26.8%). Of these, 67% of residents thought emphasis on laparoscopic surgery training should be increased or greatly increased; 87% thought laparoscopic skills were important for building a successful practice. Formal teaching methods were clearly associated with improved perception of proficiency, and those with higher perception of proficiency expected to perform more laparoscopic procedures after graduation. Residents lacked perceived competency in most advanced laparoscopic procedures. CONCLUSION Residents seem to benefit significantly from a formal curriculum in minimally invasive surgery, but they do not feel competent performing some advanced procedures on graduation. In our opinion, more emphasis should be placed on training in laparoscopic surgery in United States obstetrics and gynecology programs.

Topical analgesia for endometrial biopsy: a randomized controlled trial

Objective: To estimate whether benzocaine spray applied to the cervix and the endocervical canal before performing office endometrial biopsy improves patient comfort during the procedure. Methods: Eighty-eight women were randomly assigned to receive either 20% benzocaine spray or placebo to the outside of the cervix and into the endocervical canal before an endometrial biopsy was performed. The main outcome measure was pain during the endometrial biopsy, assessed by a visual analog scale. Statistical analysis was performed using Wilcoxon rank-sum test and Student t test. Results: There were no statistically significant differences between the study group and the control group in mean age, race, parity, body mass index, menopausal status, tenaculum use, or history of chronic pelvic pain. No statistically significant differences were found in median pain scores between the 2 treatment groups. Conclusion: Topical benzocaine spray does not appear to offer effective pain control in patients undergoing an endometrial biopsy. Level of Evidence: I

Extra-relational sex among Hispanic women and their condom-related behaviours and attitudes

Limited data are available concerning sexual behaviour of Hispanic women. A total of 318 Hispanic women were surveyed concerning extra-relational sex and their condom-related attitudes. Fifteen per cent of the sample had a secondary sex partner (apart from the first partner) during the three months preceding the survey. Of these women, 77 and 53% used condoms with their secondary and primary partners, respectively. Among women in monogamous relationships, condom use was low (17%), and nearly two-thirds (61%) of those with a high-risk partner did not use condoms. The most common concerns about condom use among these Hispanic women were a reduction in pleasurable sensations and embarrassment associated with buying condoms. Women with concurrent partners as compared to those with a single partner felt more at risk for HIV and STDs, were less likely to believe condoms have side effects or are unacceptable to their male partners and were more able to use condoms in long-term relations. In conclusion, extra-relational sex among Hispanic women may be higher than previously reported, although more favourable attitudes to condom use are seen among women with concurrent than those with a single partner. HIV/STD programmes in the Hispanic community should tailor to the sexual behaviour of their participants.

Pediatric and Adolescent Gynecology Learned via a Web-Based Computerized Case Series

STUDY OBJECTIVE To increase resident knowledge in pediatric and adolescent gynecology via a Web-based self-tutorial. STUDY DESIGN Prospective cohort involving 11 third- and fourth-year residents in a large university program. Residents were asked to complete a Web-based teaching series of cases involving common topics of pediatric and adolescent gynecology (PAG). A pretest and a posttest were completed to assess knowledge gained. Residents were asked to give feedback regarding improvements to the Web-based series for future case development. SETTING University-affiliated residency program in a major metropolitan area. PARTICIPANTS Resident physicians in the Department of Obstetrics and Gynecology. INTERVENTIONS Introduction of a Web-based teaching series to enhance resident education. MAIN OUTCOME MEASURES Improvement of resident knowledge in PAG. RESULTS All residents improved their knowledge in PAG after reviewing the series of cases. The pretest group mean score was 50%. The posttest group score was 69% (P < .05). All (100%) of participants said that this tool was an effective way to improve resident knowledge in PAG. CONCLUSION A computer-based self-tutorial in pediatric and adolescent gynecology is a feasible and satisfactory teaching adjunct to PAG.

Spanish language translation of pelvic floor disorders instruments

The purpose of the study is to translate existing measures of pelvic symptoms and quality of life from English into Spanish, facilitating research participation of Hispanic/Latina women. The forward–backward translation protocol was applied then adjudicated by a concordance committee. The measures included the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), Medical, Epidemiological, and Social Aspects of Aging (MESA) Questionnaire, Hunskaar Severity Measure, Fecal Incontinence Severity Index and modified Manchester Questionnaire, Pelvic Organ Prolapse/Urinary Incontinence Sexual Functioning Questionnaire (PISQ), and the Life Orientation Test (LOT). English and Spanish versions were administered to 50 Hispanic/Latina women with pelvic symptoms. Kappa correlations of items and correlation coefficients for scales were computed. Psychometric testing for translations demonstrated good (0.80–0.89), very good (0.90–0.95), or excellent (>0.95) correlations for primary scales of the PFDI, PFIQ, MESA, Hunskaar, PISQ, and LOT. Strict translation techniques and testing yielded valid Spanish translations of instruments assessing pelvic symptoms/functional life impact in women with pelvic floor disorders.

Uterine artery embolization for the treatment of symptomatic leiomyomata

Abstract Objective: To evaluate uterine artery embolization as an emerging minimally invasive technique in the treatment of patients symptomatic from uterine leiomyomata. Methods: Twenty patients (ages 31–52 years) underwent uterine artery embolization with permanent polyvinyl alcohol particles. Patients were assessed by the same examiner for uterine size and symptomatology. A questionnaire was answered as well as interval ultrasonography to assess uterine volume, as well as total fibroid volume. Volume was calculated using the formula for the prolate epsiloid. Results: At 1 year, 100% of patients with menorrhagia related to fibroids demonstrated complete resolution. One hundred percent of patients with mass symptomatology (pressure on adjacent structures, dyspareunia, or pelvic pain) reported improvement. All women stated that they would undergo the procedure again. Bilateral embolization was successful in all cases except one in which unilateral embolization was achieved. Decrease in uterine and fibroid volume ranged between 39% and 69% over 1 year. Commonly occurring postprocedural effects were low-grade fever and pain. One patient experienced a urinary tract infection; and, in another, an episode of pseudomembranous colitis related to prophylactic antibiotic use was documented by stool culture requiring rehospitalization. Nineteen of 20 patients returned to work within 3 weeks. Conclusions: Uterine artery embolization is a safe and effective alternative for women who desire less invasive management of leiomyomata.

Does a Minimally Invasive Surgery Fellowship Impact Surgical Experience Among Gynecology Residents

STUDY OBJECTIVE To examine the impact of a minimally invasive surgery (MIS) fellowship on resident experience and to survey the general attitude toward effects of fellowship programs on resident education. DESIGN Survey (Canadian Task Force classification III). SETTING An accredited obstetrics and gynecology program in the United States. SUBJECTS Obstetrics and gynecology residents. INTERVENTION Residents received a survey regarding the potential impact of a MIS surgery fellowship on resident experience. MEASUREMENTS AND MAIN RESULTS One year after creation of a MIS fellowship at our institution, we conducted an anonymous survey among residents. We also compared total number of surgical procedures and laparoscopic procedures performed before and after the fellowship commenced. We had a response rate of 70%. The overall impact of the newly established fellowship was regarded as positive. The median approval rating of endoscopic training before and after institution of the fellowship was 3.0 and 4.0, respectively (p < .001). There were no statistically significant changes in caseload between the two periods. CONCLUSION A fellowship in MIS at an academic institution does not detract from resident experience in gynecologic surgery, with most residents viewing the fellowship positively.

A simple, inexpensive device for teaching the loop electrosurgical excision procedure

OBJECTIVE To develop an inexpensive and practical inanimate model to teach the loop electrosurgical excision procedure in a resident clinic. TECHNIQUE A vaginal speculum is inserted into one end of a cardboard tube. At the opposite end, a piece of knockwurst sausage is inserted into the cardboard tube. A grounding pad is attached to the distal end of the sausage. The teaching session proceeds using a colposcope or direct visualization. After the training session, the excised and uncut portions of sausage can be examined. EXPERIENCE Faculty found this inanimate model an excellent way to teach residents how to use the loop electrode, and the resident staff appreciated its merits as a useful prelude to treating cervical disease in women. The house staff adapted to the confines of the vagina and transferred skills acquired from working with the cardboard tube, where instruction and constructive criticism can be given without the presence of apprehensive patients. CONCLUSION A simple, inexpensive, inanimate model has been developed to teach the loop electrosurgical excision procedure. The materials required to construct it are available to any colposcopy clinic.

Transition to Office-based Obstetric and Gynecologic Procedures: Safety, Technical, and Financial Considerations

Office-based surgery is increasingly desired by patients and providers due to ease of access, overall efficiency, reimbursement, and satisfaction. The adoption of office-based surgery requires careful consideration of safety, efficacy, cost, and feasibility within a providers practice. This article reviews the currently available data regarding patient and provider satisfaction as well as practical considerations of staffing, equipment, and supplies. To aid the practitioner, issues of office-based anesthesia and safety with references to currently available national guidelines and protocols are provided. Included is a brief review of billing, coding, and reimbursement. Technical procedural aspects with information and recommendations are summarized.