Peter S. Finamore

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

Introduction and hypothesisThe objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery.MethodsThe charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial.ResultsForty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3–9.8).ConclusionsA higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Establishing the Learning Curve of Robotic Sacral Colpopexy in a Start-up Robotics Program

STUDY OBJECTIVE To determine the learning curve of the following segments of a robotic sacral colpopexy: preoperative setup, operative time, postoperative transition, and room turnover. DESIGN A retrospective cohort study to determine the number of cases needed to reach points of efficiency in the various segments of a robotic sacral colpopexy (Canadian Task Force II-2). SETTING A university-affiliated community hospital. PATIENTS Women who underwent robotic sacral colpopexy at our institution from 2009 to 2013 comprise the study population. INTERVENTIONS Patient characteristics and operative reports were extracted from a patient database that has been maintained since the inception of the robotics program at Winthrop University Hospital and electronic medical records. Based on additional procedures performed, 4 groups of patients were created (A-D). MEASUREMENTS AND MAIN RESULTS Learning curves for each of the segment times of interest were created using penalized basis spline (B-spline) regression. Operative time was further analyzed using an inverse curve and sequential grouping. A total of 176 patients were eligible. Nonparametric tests detected no difference in procedure times between the 4 groups (A-D) of patients. The preoperative and postoperative points of efficiency were 108 and 118 cases, respectively. The operative points of proficiency and efficiency were 25 and 36 cases, respectively. Operative time was further analyzed using an inverse curve that revealed that after 11 cases the surgeon had reached 90% of the learning plateau. Sequential grouping revealed no significant improvement in operative time after 60 cases. Turnover time could not be assessed because of incomplete data. CONCLUSIONS There is a difference in the operative time learning curve for robotic sacral colpopexy depending on the statistical analysis used. The learning curve of the operative segment showed an improvement in operative time between 25 and 36 cases when using B-spline regression. When the data for operative time was fit to an inverse curve, a learning rate of 11 cases was appreciated. Using sequential grouping to describe the data, no improvement in operative time was seen after 60 cases. Ultimately, we believe that efficiency in operative time is attained after 30 to 60 cases when performing robotic sacral colpopexy. The learning curve for preoperative setup and postoperative transition, which is reflective of anesthesia and nursing staff, was approximately 110 cases.

Delayed small bowel obstruction after robotic-assisted sacrocolpopexy.

We report 2 unusual cases of partial bowel obstruction resulting from adherence to a barbed suture presenting 3 to 4 weeks after robotic-assisted sacrocolpopexy for uterovaginal prolapse. Both patients underwent an uncomplicated robotic-assisted supracervical hysterectomy and sacrocolpopexy. Immediate postoperative recovery was uncomplicated. Three to four weeks after surgery, both patients presented with symptoms of nausea, vomiting, and abdominal pain and were found to have small bowel obstructions requiring a return to the operating room. Upon surgical exploration, a loop of small bowel was found to be adhered to a segment of the barbed suture at the sacral promontory, which had been used to close the peritoneum over the mesh. Subsequent to release, both patients had an uneventful recovery.

Reoperation After Robotic and Vaginal Mesh Reconstructive Surgery: A Retrospective Cohort Study.

Objectives Our primary objective was to compare reoperations after robotic-assisted sacrocolpopexy and transvaginal mesh for apical prolapse repair. Our secondary aim was to record perioperative complications after robotic and vaginal surgeries. Methods We reviewed medical records of women who underwent vaginal apical mesh support procedures or robotic sacrocolpopexy at Winthrop University Hospital between August 2009 and August 2013. We compared reoperations and perioperative complications between the 2 groups. Results There were 245 eligible cases during the 4-year study period. One hundred eighty-one women underwent robotic-assisted sacrocolpopexy and 64 women underwent transvaginal mesh. Women who underwent robotic surgery were younger and had decreased blood loss. Patients were followed up for a median of 3 months after robotic surgery and 11.5 months after transvaginal mesh. We found no difference in overall rate of reoperation between robotic and transvaginal mesh repair for apical prolapse. Specifically, there was no difference in the rate of reoperation for mesh exposure. Conclusions Despite recent controversies, transvaginal mesh offers the benefit of an effective minimally invasive procedure with shorter operative times, and may not pose additional risk for reoperation when compared to robotic-assisted sacrocolpopexy.

Inclusion of body mass index in the history of present illness.

OBJECTIVE: To estimate the degree of association between body mass index (BMI) and some of the most common adverse outcomes and conditions in obstetrics and gynecology, and to compare it with the traditional descriptors such as age, gravidity, parity, history of preterm births, history of abortions or miscarriages, and race and ethnic status. METHODS: Using a PubMed search, abstracts were identified that dealt with the associations between each of the descriptors (age, gravidity, parity, history of preterm births, history of abortions, racial and ethnic identification, and BMI) and a variety of adverse outcomes and conditions in both obstetrics and in gynecology. RESULTS: Body mass index had the highest association with the most common adverse outcomes and conditions in obstetrics and in gynecology (53 of 57 [93%]) as compared with the traditional descriptors (age, 39 of 57 [88%]; gravidity, 19 of 57 [33%]; parity, 24 of 57 [42%]; previous preterm births, 22 of 57 [39%]; abortions, 14 of 57 [25%]; and race and ethnic status, 26 of 57 [46%]). CONCLUSION: This study underscores the prominence BMI plays regarding its frequently cited associations with an array of obstetric and gynecologic conditions. Body mass index should be included in the opening statement of the history of present illness and in all communications of health care providers regarding obstetric and gynecologic patients.

Patient safety in clinical research articles.

Patient safety has remained one of the most important priorities over the past decade, particularly in hospital settings. Implementation of patient safety measures has focused not only on reducing medication and surgical errors but also on the development of a culture of safety, including enhanced communication among all healthcare stakeholders. Academic medicine may further contribute to the culture of safety if all relevant clinical article submissions address patient safety. In order to improve communication between the authors of clinical research articles and practicing physicians, we propose that each clinical research article may be accompanied by a clear statement from the authors regarding practice implications and patient safety.