Michael S. Guy

Preparedness of Obstetrics and Gynecology Residents for Fellowship Training.

OBJECTIVE: To evaluate the perceptions of fellowship program directors of incoming clinical fellows for subspecialty training. METHODS: A validated survey by the American College of Surgeons was modified and distributed to all fellowship program directors in four subspecialties within obstetrics and gynecology: female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal–fetal medicine, and reproductive endocrinology–infertility. The 59-item survey explored five domains concerning preparedness for fellowship: professionalism, independent practice, psychomotor ability, clinical evaluation, and academic scholarship. A Likert scale with five responses was used and tailored to each subspecialty. Standard statistical methods were used to compare responses between subspecialties and to analyze data within each subspecialty individually. RESULTS: One hundred thirty directors completed the survey, for a response rate of 60%. In the domain of professionalism, more than 88% of participants stated that incoming fellows had appropriate interactions with faculty and staff. Scores in this domain were lower for gynecologic oncology respondents (P=.046). Responses concerning independent practice of surgical procedures (hysterectomy, pelvic reconstruction, and minimally invasive) were overwhelmingly negative. Only 20% of first-year fellows were able to independently perform a vaginal hysterectomy, 46% an abdominal hysterectomy, and 34% basic hysteroscopic procedures. Appropriate postoperative care (63%) and management of the critically ill patient (71%) were rated adequate for all subspecialties. CONCLUSION: Graduating residents may be underprepared for advanced subspecialty training, necessitating an evaluation of the current structure of resident and fellow curriculum. LEVEL OF EVIDENCE: III

Robotic surgical skills: acquisition, maintenance, and degradation.

In newly trained surgeons, this study found that robotic surgical skills degraded significantly within 4 weeks of inactivity. Animate training may provide different skills than those acquired in dry lab.

Outcomes of women with atypical glandular cells on preoperative cytology and endometrial cancer.

Objective This study aims to examine the prognostic importance of preoperative cervical cytologic diagnosis with atypical glandular cells (AGC) or malignant cells (MC) as a predictor of poor outcomes in endometrial cancer. Materials and Methods A total of 563 patients were surgically staged for endometrial adenocarcinoma from 2002 to 2012 at our institution. Of these patients, 106 were included to perform a case-control study (39 patients with AGC or MC and 67 controls). Included patients were not significantly different from excluded patients and were matched for age, race, and body mass index. Outcome variables included presence of extrauterine disease (International Federation of Gynecology and Obstetrics stage ≥II) and high intermediate risk (HIR) disease. Further analysis sought to improve the prediction combining AGC or MC with other factors, such as grade and CA-125 levels. Standard statistical analyses were used. Results Among the patients with AGC or MC, 53.8% had HIR disease compared with 30.3% with normal cervical cytologic diagnosis (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.18–6.09; P = 0.02). Extrauterine disease was found in 43.6% of patients with AGC or MC compared with that of 15.2% in patients with normal cervical cytologic diagnosis (OR, 4.33; 95% CI, 1.72–10.90; P < 0.01). Multivariate analysis confirmed that AGC or MC was an independent predictor of HIR disease (OR, 8.41; 95% CI, 1.34–52.78; P = 0.02) and extrauterine disease (OR, 4.78; 95% CI, 1.26–18.1; P = 0.02). The combination of elevated CA-125 levels with AGC or MC cervical cytologic diagnosis increased the statistical prediction of extrauterine disease (OR, 13.3; 95% CI, 3.1–56.8; P < 0.01) and HIR disease (OR, 5.83; 95% CI, 1.44–23.71; P = 0.02). Conclusions Patients with AGC or MC on preoperative cervical cytology are at risk for extrauterine and HIR disease. These preoperative findings should warn surgeons of the potential of extrauterine or occult metastatic disease.

Influence of Gelatin-Thrombin Matrix Tissue Sealant on Bacterial Colony Formation and Risk of Pelvic Infection

Objective. Gelatin-thrombin matrix (GTM) tissue sealant use was previously identified as an independent predictor of pelvic infection following hysterectomies. We aim to elucidate contributing factors by assessing influence of GTM on bacterial colony formation and characterizing bacteria present at the vaginal cuff. Methods. Escherichia coli was incubated in phosphate-buffered saline (PBS) and pelvic washings with and without GTM to assess influence on colony formation. Pelvic washings of the vaginal cuff were collected from hysterectomies occurring from June through October 2015. In vitro techniques, 16S rRNA gene qPCR, and 16S amplicon sequencing were performed with washings to characterize bacteria at the vaginal cuff. Results. Mean bacterial colony formation in PBS was greater for E. coli incubated in the presence of GTM (1.48 × 107 CFU/mL) versus without (9.95 × 105 CFU/mL) following 20-hour incubation (p = 0.001). Out of 61 pelvic washings samples, 3 were culture positive (≥5000 CFU/mL) with Enterococcus faecalis. Conclusion. In vitro experiments support a facilitating role of GTM on colony formation of E. coli in PBS. However, given the negative results of surgical site washings following adequate disinfection, the role of GTM in promoting posthysterectomy pelvic infections may be limited. Analysis of pelvic washings revealed presence of E. faecalis, but results were inconclusive. Further studies are recommended.

The use of the Cervilenz device to aid in the diagnosis of premature labor

Abstract Objective: A short cervix measured by transvaginal ultrasound has been correlated with increased risk for preterm delivery (PTD). Many patients presenting with a complaint of possible premature labor (PL); may not have access to cervical length (CL) screening by ultrasound. Cervilenz is an FDA cleared disposable device for obtaining vaginal CL measurements. This study was conducted to correlate Cervilenz measurements of CL with the occurrence of PTD. Methods: Women presenting with regular uterine contractions at gestational age (GA) ≥22 and <34 weeks with intact membranes and cervical dilation <3 cm were recruited. A speculum examination was performed and Cervilenz measurement of CL was obtained. Patients were treated with tocolytics and/or corticosteroids based upon the attending physician’s judgment. The occurrences of PTD as a result of PL or premature rupture of membranes within 7 days, <32 weeks, <34 weeks and <37 weeks, were determined. Patients who were delivered preterm for other maternal or fetal indications were excluded. Negative predictive value (NPV) was calculated. Results: Of the 220 women recruited, 20 were subsequently excluded from analysis because they required PTD for unrelated indications. The mean GA at enrollment was 29.8 ± 2.8 (SD) weeks. One (0.5%), 2 (1.0%), 4 (2.0%) and 29 (14.5%) women delivered at ≤7 days from enrollment, ≤32 weeks, ≤34 weeks, and ≤37 weeks, inclusively. Seventy-seven (38.5%), 39 (19.5%) and 19 (9.5%) women had Cervilenz measurement of ≤30, ≤25 and ≤20 mm, respectively. The NPV for a Cervilenz measurement of >20 mm for delivery at, ≤32, ≤34 and ≤37 weeks were 99.2%, 98.3% and 86.7%, respectively. Conclusion: Cervilenz measurement >20 mm appears to have high NPV for PTD prior to 34 weeks.