Ellen R. Solomon

Risk of deep venous thrombosis and pulmonary embolism in urogynecologic surgical patients

OBJECTIVE We sought to determine the incidence of symptomatic deep venous thrombosis and pulmonary embolism, collectively referred to as venous thromboembolic events (VTE), in patients undergoing urogynecologic surgery to guide development of a VTE prophylaxis policy for this patient population. STUDY DESIGN We conducted a retrospective analysis of VTE incidence among women undergoing urogynecologic surgery over a 3-year period. All patients wore sequential compression devices intraoperatively through hospital discharge. RESULTS Forty of 1104 patients (3.6%) undergoing urogynecologic surgery were evaluated with chest computed tomography, lower extremity ultrasound, or both for suspicion of VTE postoperatively. The overall rate of venous thromboembolism in this population was 0.3% (95% confidence interval, 0.1-0.8). CONCLUSION Most women undergoing incontinence and reconstructive pelvic surgery are at a low risk for VTE. Sequential compression devices appear to provide adequate VTE prophylaxis in this patient population.

Residency Training in Pediatric and Adolescent Gynecology Across Obstetrics and Gynecology Residency Programs: A Cross-Sectional Study

STUDY OBJECTIVE To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. DESIGN Prospective, anonymous, cross-sectional study. PARTICIPANTS United States program directors of Obstetrics and Gynecology residency programs, N = 242; respondents 104 (43%). RESULTS 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n = 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n = 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P = .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P = .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P = .03). CONCLUSIONS Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training.

Common postoperative pulmonary complications after hysterectomy for benign indications

OBJECTIVE The purpose of this study was to estimate the incidence of postoperative pulmonary complications after hysterectomy for benign indications. STUDY DESIGN This was a retrospective cohort study of all women who underwent hysterectomy for benign indications at the Cleveland Clinic from Jan. 1, 2001, to Dec. 31, 2009. Exclusion criteria incorporated patients who underwent hysterectomy for premalignant or malignant conditions. Pulmonary complications were defined as postoperative pneumonia, respiratory failure, atelectasis, and pneumothorax based on International classification of diseases, ninth revision, codes. RESULTS In the 9-year study period, 3226 women underwent hysterectomy for benign indications (abdominal, 38.4%; vaginal, 39.3%; laparoscopic, 22.3%). Ten of the 3226 women (0.3%; 95% confidence interval, 0.17-0.57%) who underwent hysterectomy were identified with postoperative pulmonary complications. Among the different types of hysterectomy, the incidence of pulmonary complications was not different (total abdominal hysterectomy, 0.9%; vaginal hysterectomy, 0.12%; laparoscopic hysterectomy, 0.9%; P = .8). CONCLUSION The incidence of postoperative pulmonary complications after hysterectomy for benign indications is low.

The quality of health information available on the internet for patients with pelvic organ prolapse

Objective This study aimed to assess the quality of Web sites that provide information on pelvic organ prolapse using validated quality measurement tools. Methods The Google search engine was used to perform a search of the following 4 terms: “pelvic organ prolapse,” “dropped bladder,” “cystocele,” and “vaginal mesh.” The DISCERN appraisal tool and JAMA benchmark criteria were used to determine the quality of health information of each Web site. Cohen &kgr; was performed to determine interrater reliability between reviewers. Kruskal-Wallis and Wilcoxon rank sum tests were used to compare DISCERN scores and JAMA criteria among search terms. Results Interrater reliability between the two reviewers using DISCERN was &kgr; = 0.71 [95% confidence interval (CI), 0.68–0.74] and using JAMA criteria was &kgr; = 0.98 (95% CI, 0.74–1.0). On the basis of the DISCERN appraisal tool, the search term “vaginal mesh” had significantly lower Web site quality than “pelvic organ prolapse” and “cystocele,” respectively [mean difference of DISCERN score, −14.65 (95% CI, −25.50 to 8.50, P < 0.0001) and −12.55 (95% CI, −24.00 to 7.00, P = 0.0007)]. “Dropped bladder” had significantly lower Web site quality compared to “pelvic organ prolapse” and “cystocele,” respectively (mean difference of DISCERN score, −9.55 (95% CI, −20.00 to 3.00, P = 0.0098) and −7.80 (95% CI, −18.00 to 1.00, P = 0.0348). Using JAMA criteria, there were no statistically significant differences between Web sites. Conclusions Web sites queried under search terms “vaginal mesh” and “dropped bladder” are lower in quality compared with the Web sites found using the search terms “pelvic organ prolapse” and “cystocele.”

Interventions to decrease pain and anxiety in patients undergoing urodynamic testing: A randomized controlled trial

To determine if music (at 60 beats/min) or watching a pre‐procedure educational video decreases pain and anxiety in women undergoing multichannel urodynamic testing compared to usual care.

Removing a misplaced retropubic midurethral sling from the urethra and bladder neck using ear, nose, and throat instruments.

BACKGROUND: The retropubic tension-free vaginal tape (TVT) procedure is a common procedure with complications attributed to voiding dysfunction, bladder perforation, and bleeding. We present a case of successful removal of a retropubic midurethral sling from the urethra using a head lamp and a combination of ear, nose, and throat instruments. CASE: A 63-year-old woman presented to our clinic with the symptom of gross hematuria after having undergone a TVT procedure. On office cystoscopy, the sling was noted to be placed within the urethral mucosa. Removal of the mesh was performed using a nasal speculum, left and right ethmoid scissors, left and right Blakesley graspers, and a head lamp to dissect the mesh directly out of the urethra. CONCLUSION: The utilization of ear, nose, and throat tools allowed us to resect the intraurethral mesh without necessitating incision of the urethral sphincter.

Laparoscopic repair of recurrent lateral enterocele and rectocele

It is difficult to determine what types of procedures should be attempted in patients who have recurrent prolapse. We present a case of recurrent lateral enterocele and rectocele after the patient had undergone multiple surgeries for pelvic organ prolapse (POP), including a vaginal hysterectomy, bladder-neck suspension, anterior colporrhaphy, site-specific rectocele repair, apical mesh implant, iliococcygeus vault suspension, and transobturator suburethral sling procedure. With recurrence, the patient underwent robot-assisted laparoscopic sacral colpopexy, tension-free vaginal tape transobturator sling insertion, rectocele repair, and perineorrhaphy with cystoscopy. She then presented with defecatory outlet obstruction and constipation and subsequently was treated with a stapled transanal rectal resection. The patient returned with continued defecatory dysfunction and a recurrent lateral enterocele and rectocele. The recurrence was treated laparoscopically using a lightweight polypropylene mesh. The postoperative period was uneventful. Two years later, the patient reported decreased defecatory symptoms and no further symptomatic prolapse.

Qualitative analysis addressing physician-perceived barriers to usage of electronic patient questionnaires in a colorectal clinic

Abstract Background The Knowledge Program (KP) was created to electronically collect information about patients quality of life on tablet computers. The questionnaires included in the KP are validated and provide further information for the physician to use during the new patient exam. Despite replacing paper questionnaires, usage rates for KP have not been sustained in the colorectal clinic, and are lower than desired. Objective The goal of this study was to qualitatively assess Cleveland Clinic colorectal surgeons’ perspectives regarding what factors influence usage rates of the electronic KP questionnaires. A further aim of this study was to determine if physicians could identify ways to improve use of the KP. Methods Eleven semi-structured cognitive interviews with colorectal surgeons were audio recorded and transcribed verbatim. The text was then interpreted by three investigators using thematic analysis with qualitative software. Results Three major barriers to KP usage were identified by the investigators, the majority encompassing physician-perceived patient interest in KP and inadequately educated department employees. Physician perceived improvement of usage involved suggestions to improve distribution and physician and staff education. Conclusions It was reported by participating surgeons that education about the KP for all department employees and patients is essential to increasing the usage rates for KP questionnaires.

General Complications of Pelvic Reconstructive Surgery

Before a patient undergoes pelvic reconstructive surgery, the risk of potential complications should be carefully assessed and addressed with the patient. Complications may occur during or after the procedure and it is imperative to recognize high-risk patients and minimize risk from surgery before a patient is brought to the operating room. The lifetime risk of a woman undergoing prolapse or incontinence surgery by the age of 80 is 11.1% [1]. The prevalence of perioperative complications among women undergoing reconstructive pelvic surgery has been reported to be as high as 33% [2]. There are a multitude of factors which are found to increase perioperative risk. A large retrospective cohort study including 1,931 women who had undergone prolapse surgery found an overall complication rate of 14.9% [3]. The complications identified included infection, bleeding, surgical injuries, pulmonary, and cardiovascular morbidity. These complications were associated with medical comorbidities (odds ratio 11.2) and concomitant hysterectomy (odds ratio 1.5). Risk factors for complications after pelvic reconstructive surgery are listed in Table 2.1.