Urogynecology (Hagerstown, Md.)最新文献

Importance: There is a gap in objective methods to review applications for advanced medical training.

Objective: The objective of this study was to evaluate the accuracy of a new machine learning-based residency and fellowship applicant review program, Halsted (Medicratic) in urogynecology fellowship applicant selection compared with program director (PD) review.

Study design: This Institutional Review Board-approved study compared PD's standard assessment of fellowship applicants to the Halsted-based assessment at 3 programs in the 2023-2024 application cycle. Each program provided a score for each candidate on a 100-point scale in several domains. After the conclusion of the match, each PD completed a profile within Halsted that identified their preferred qualities in applicants. Halsted scores were obtained, which were compared with PD scores.

Results: A total of 126 applications were reviewed, with 59 applicants reviewed by more than 1 program. Program 1 (r=0.60; P=0.0019) and Program 2 (r=0.58; P<0.001) exhibited a significantly strong positive correlation between PD-assigned overall application scores and Halsted scores, while Program 3 exhibited a weak positive correlation between scores (r=0.33; P=0.0225). There were significant differences in the scoring of the same applicant between programs for PD-assigned mean overall scores (P<0.001) and Halsted scores (P<0.001).

Conclusions: A significant positive correlation was found between Halsted rankings of applicants and rankings assigned by PDs. In addition, significant differences in interprogram rankings of applicants suggest that there is a range of qualities that each program values and that application review is individualized. Machine learning assistance in application review is a developing tool with the potential to reduce bias and decrease program administrative burden.

Importance: Urogynecology patients increasingly investigate their problems using technology-based resources, but there is a lack of evidence surrounding the way they use these resources or how patients may describe their problems.

Objective: The aim of this study was to examine how patients describe their pelvic floor symptoms to an artificial intelligence chatbot and the specific information they seek during their initial consultation.

Study design: This was a mixed-methods secondary analysis of an Institutional Review Board-approved, single-center, randomized, nonblinded trial examining patient use of a large language model, Chat Generative Pre-trained Transformer (ChatGPT 4.0; OpenAI), at their initial urogynecologic visit. Patients who were randomized to an arm using ChatGPT were provided with a tablet and instructed to ask the program anything about their primary pelvic floor symptoms. A post hoc qualitative analysis of deidentified transcripts was performed by 2 independent reviewers with line-by-line coding and organized into themes using a predefined strategy.

Results: Seventy-nine conversation transcripts (41 previsit and 38 postvisit) were collected from 72 English-speaking and 9 Spanish-speaking patients. Five thematic domains were identified based on participant transcripts: (1) Language, (2) Disease-Specific, (3) Patient Experience, (4) Treatment, and (5) Chatbot Interactions.

Conclusions: Medical consultations are often structured, and patients may not acknowledge when they do not fully understand the information provided. This study provides a window into understanding the patient experience that was not previously available. Pelvic floor specialists may consider the identified themes as relevant when providing patient-centered education and during expectation setting.

Importance: Postoperative urinary retention (POUR) is common following midurethral sling (MUS) placement, and can be distressing for patients.

Objective: The objective of this study was to compare the effect of retropubic lidocaine versus saline placebo on POUR following MUS placement.

Study design: This double-blind, placebo-controlled trial randomized women undergoing MUS placement with or without anterior repair to 20 mL of retropubic 0.5% lidocaine+epinephrine (lidocaine) versus normal saline+epinephrine (saline). Primary outcome was a failed postoperative retrograde voiding trial. Visual Analog Scales (VAS) were administered 2 and 6 hours postoperatively, and 7-day diaries assessed pain and analgesic use. We required 150 participants to detect a 20% reduction in POUR with 80% power, two-sided alpha of 0.05, and 5% loss to follow-up.

Results: Between 2020 and 2024, 150 participants were randomized, 75 in each arm. Demographic and surgical characteristics were similar with mean age 51.5 years (44-63) and body mass index 29.0 (25.7-33.6). Participants were predominantly White (94.0%), postmenopausal (54.0%), and multiparous (95.3%). POUR was similar between groups (lidocaine 20.0% vs saline 18.7%, P = 0.84). Saline participants had significantly higher VAS scores at 2 and 6 hours postoperatively (2 h 21 [10-42] vs 11 [0-28], P = 0.008; 6 h 25 [13-50] vs 18 [9-33], P = 0.03), used more nonsteroidal anti-inflammatory drugs (NSAIDS) on POD 1 (76.2% vs 52.3%, P = 0.005) and reported higher levels of "worst pain in the first 24 hours" (6 [3.5-7.5] vs 4 [3-6], P = 0.013). At 6 weeks postoperatively, more lidocaine participants were satisfied or very satisfied with the outcome of their surgery (90.7% vs 77.3%, P = 0.03).

Conclusions: Compared with saline, retropubic lidocaine at the time of midurethral sling placement does not result in significantly higher rates of POUR, but significantly improves acute postoperative pain, NSAID use, and satisfaction with surgical outcomes.

Importance: Retropubic midurethral slings (RP-MUS) are placed utilizing external anatomic landmarks and tactile sensation as the trocar creates a pathway from vaginal entry-dissection to suprapubic exit-site. Training a novice in virtual reality (VR) to achieve expert-level surgical skills can avoid the need for models, cadavers, or practicing on patients, but it relies on the existence of clear and replicable expert-level pathways.

Objective: The objective of this study was to determine whether surgical motion and haptic feedback from experts can clearly distinguish performances from novice learners.

Study design: We tracked the motion and haptic feedback for novice medical students and board-certified urogynecologists as they performed RP-MUS surgery in VR. We measured differences using change of acceleration (jerk), similarity scores, and the number of clusters per participant group. Using a t-test, we examined differences between skill levels (expert vs. novice) in mean, magnitude, and jerk frequency scores.

Results: Eight experts and 16 novices participated in the study. Surgical pathways were less variable in experts versus novices, as indicated by fewer clusters for experts than novices (hand motion: 4 vs 18 clusters, head motion: 3 vs 17, haptic force: 6 vs 25). Overall, maximum motion-distance was also higher for novices than experts. Experts had more deliberate, efficient, smoother paths. T-tests found significant differences between experts and novices on time to complete the surgical simulation and jerk scores (hand motion and haptic pressure applied).

Conclusions: Across all measures, experts produced fewer sudden movements, demonstrated more consistent and purposeful motion, and completed tasks more efficiently. Although some metrics-such as cluster mean jerk and axis coordination-did not always reach statistical significance, they showed very large effect sizes favoring expert performance. Taken together, these results underscore that experts consistently outperform novices across both quantitative and qualitative assessments of procedural motion. Motion metrics can thus provide feedback for surgical training.

Importance: Functional concerns following urogynecologic procedures are common. Active recovery may help improve pain and pelvic floor symptoms in the postoperative period.

Objectives: Prescribed active recovery is safe and leads to improved healing in other surgical fields. Active recovery is relatively untested in urogynecology procedures. We created a postoperative active recovery program to mitigate bowel, bladder, and pain symptoms in the postoperative period. The objective of this study was to compare this active recovery protocol to the standard of care on pelvic floor symptoms in the immediate 12-week postoperative period.

Study design: This was a randomized control trial of patients undergoing minimally invasive apical prolapse reconstructive procedures at a single academic institution. Participants were randomized to either routine postoperative restrictions or the novel active recovery protocol for the first 12 weeks postoperatively. The primary outcome was the change in pelvic floor symptoms at 12 weeks postoperatively between the control group and the intervention group as measured by the Pelvic Floor Distress Inventory questionnaire (PFDI-20).

Results: Seventy-two participants were enrolled, 69 were randomized, and had baseline data. The active recovery group had a larger decrease in total PFDI-20 score (-87.7±54.0 vs -72.7±52.4, P=0.294), including the urinary (-33.3±30.2 vs -26.8±29.4, P=0.413) and colorectal subscales (-18.5±18.4 vs -9.9±16.9, P=0.072). Mean postoperative PFDI-20 and urinary subscale scores for the active recovery group were all significantly lower (P<0.05) than the routine group.

Conclusions: Prescribed active recovery improves pelvic floor outcomes in the immediate postoperative period, particularly bladder function.

Objective: The objective of this study was to explore Black women's perspectives on the management of recurrent UTIs to inform the development of digital interventions.

Study design: This qualitative study included 12 Black-identifying women with recurrent UTIs. Participants completed a demographic survey and a semistructured interview conducted by a Black physician. Socioeconomic disadvantage was assessed using the Area Deprivation Index (ADI). Interviews, guided by the Digital Healthcare Equity and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks, addressed the use of digital health technology, knowledge, cultural factors, social support, and barriers/facilitators to care. Three coders analyzed transcripts using grounded theory with excellent interrater reliability.

Results: Participants had a median age of 60 years; 75% were postmenopausal, and more than 90% had at least a high school education. Half were sexually active in the past year. The median ADI was in the 70th percentile, indicating high socioeconomic disadvantage. Common UTI prevention strategies included increased fluid intake (83%), over-the-counter products (58%), and prescription treatments (41%). Four key themes emerged: (1) despite socioeconomic disadvantage, most participants used a digital health portal to access care and online sources of information, (2) UTIs were viewed as sexually transmitted infections, fueling shame and isolation, (3) participants focused on treatment rather than prevention, and (4) participants recommended early education about UTIs for younger women.

Conclusions: Despite high levels of disadvantage, Black women use digital health technology around UTIs. By centering patient voices, these findings highlight the need to develop culturally responsive care models that integrate digital technology and reframe UTI as a chronic condition, emphasizing prevention over episodic treatment.

Importance: Midurethral slings are frequently placed during prolapse surgery.

Objectives: The objectives of this study were to compare retropubic midurethral sling (MUS) bladder trocar perforation rates among women undergoing MUS-only (soloMUS) surgery versus MUS with concomitant apical prolapse repair (popMUS).

Study design: A retrospective cohort study of women aged 18-89 years who underwent MUS surgery between January 2018 and October 2024 was performed. Transobturator sling surgery and nonapical concomitant prolapse repairs were excluded. The primary outcome was bladder trocar perforation rates. Secondary outcomes included emergency department visits, reoperation rates, and admissions within 30 days of the procedure.

Results: A total of 816 MUS procedures met eligibility criteria, with 236 patients in the popMUS group and 580 in the soloMUS group. Age was lower (52 vs 65, P<0.001) and body mass index (BMI) was higher in the soloMUS group (30 vs 28, P=0.001). The primary outcome, the bladder trocar perforation rate, was higher in the popMUS group (11.0% vs 4.3%, P<0.001). Readmissions and emergency department visits were higher for the popMUS group, but reoperations were similar. When controlling for age, BMI, concomitant hysterectomy, concomitant sacrocolpopexy, surgeon, and menopause status, sacrocolpopexy and surgeon remained significant. Women undergoing sacrocolpopexy were significantly more likely to have bladder perforation compared with those undergoing nonsacrocolpopexy prolapse repairs (OR,2.47; 95% CI, 1.04-5.89, P=0.04).

Conclusions: Overall, trocar perforations were higher in women undergoing concomitant apical prolapse repair, especially at the time of sacrocolpopexy. This may be due to differential tissue tension in the immediate postprolapse repair anatomy that differs from naturally supported anatomy. Further work is needed to identify perforation risks for concomitant surgical procedures and clinical sequelae.

Importance: Platelet-rich plasma (PRP) is an autologous biological with the potential to enhance tissue healing. Its use during native tissue pelvic organ prolapse (POP) repair has not been evaluated.

Objective: The objective of this study was to assess the acceptability and feasibility of PRP injection into the uterosacral ligament during uterosacral ligament suspension (USLS) for POP repair.

Study design: This prospective feasibility study was conducted from April to October 2024 at a large academic institution. Patients scheduled for USLS prolapse surgery for stage ≥2 POP were screened for eligibility to receive PRP injection at the time of surgery. The primary outcomes were the acceptance rate of PRP and the reasons for nonparticipation. Secondary outcomes included injection feasibility, 30-day complications, and comparison with a historical cohort of patients who underwent the same procedure from 2022 to 2023.

Results: Of 84 eligible patients, 63 met criteria. Thirty (47.6%) consented, 26 (41.3%) declined, and 7 (11.1%) did not respond. All participants successfully received PRP injections without technical issues. One intraoperative bladder cystotomy occurred. Postoperative complications included urinary tract infection (n=6, 20.7%), urinary retention (n=1, 3.4%), vaginal cuff cellulitis (n=1, 3.4%), and 1 readmission for sepsis (n=1, 3.4%). No complications were attributed to PRP. Compared with 206 historical controls, there were no statistically significant differences in intraoperative or 30-day postoperative complications.

Conclusions: PRP injection during USLS was acceptable to nearly half of the eligible patients, technically feasible, and not associated with adverse events. These findings support further investigation into PRP as a regenerative adjunct to improve surgical outcomes.

Importance: Patient-related factors contribute to unnecessary antibiotics for urinary tract infections (UTI).

Objective: The objective of this study was to determine the effectiveness of an algorithm-based texting platform for reducing the rate of unnecessary antibiotics in women with recurrent UTI.

Study design: Adult women with recurrent UTI were randomized in a 1:1 ratio to a texting platform or usual care at an urban academic center (March 2024 to March 2025). Participants in the texting group received access to an automated bidirectional evidence-based platform for symptom triage, shared decision making, and educational videos. Participants in the usual care group received treatment of UTI from their usual clinicians. The primary outcome was the rate of unnecessary antibiotics at 3 months from randomization.

Results: Women with recurrent UTI were randomized to the texting platform (n=51) or usual care (n=51). The mean number of UTI episodes was significantly lower in the texting group than in the usual care group (0.47±0.92 vs. 0.82±1.10, P=0.041). The overall rate of unnecessary antibiotics (11.8%, 95% CI, 4.4-23.9 vs. 29.4%, 95% CI, 17.5-43.8, P=0.028) and rate of unnecessary antibiotics for asymptomatic bacteriuria (2.0%, 95% CI, 0-10.4 vs. 19.6%, 95% CI, 9.8-33.1, P=0.004) were lower in the texting group than in the usual care group. In-person visits and nonbillable messages for UTI were lower in the texting group. Quality-of-life scores did not differ between groups.

Conclusion: An automated algorithmic texting platform reduced the number of UTI episodes, unnecessary antibiotic prescriptions, and health care utilization in women with recurrent UTI.

Importance: Sacrospinous hysteropexy (SSH) is increasingly being performed, yet limited evidence exists on whether an anterior versus posterior compartment surgical approach may affect postoperative prolapse symptoms or differences in adverse events.

Objectives: The objectives of this study were to evaluate whether an anterior versus posterior approach to SSH affects short-term postoperative bulge symptoms; secondarily, assess differences in intraoperative and 30-day postoperative complication rates.

Study design: A retrospective cohort analysis of women who underwent anterior or posterior compartment approach native tissue transvaginal SSH between 2016 and 2024 at 2 academic institutions was performed. The primary outcome was the presence of bulge symptoms. Secondary outcomes were retreatment with pessary or surgery, operative data, and 30-day postoperative adverse events categorized by the Clavien-Dindo system.

Results: Study inclusion criteria were met by 316 women. Women in the anterior approach group were older (mean ± SD shown), (70 ± 7 vs 64 ± 15) years, P < 0.0001, had a higher Charlson Comorbidity Index (CCI), median (IQR) (3 [2-4] vs 0 [0-0], P<0.0001), proportion of stage 3 and 4 prolapse (95/162 [58.6%] vs 65/154 [42.2%], P = 0.004), and greater point Ba on Pelvic Organ Prolapse Quantification (POP-Q) examination (2 [1, 3] vs 0 [-1, 2], P < 0.0001), respectively. Controlling for age, preoperative POP-Q stage, preoperative dominant prolapse compartment, and concomitant midvaginal repairs, proportional hazards modeling showed bulge symptoms earlier in the posterior approach group (P = 0.002). There was a higher proportion of Clavien-Dindo I and II 30-day complications in the anterior approach group (21.6% vs 7.1%, P = 0.0002).

Conclusions: Undergoing an anterior approach to native tissue SSH may be protective to both bulge symptom recurrence and retreatment but was associated with higher short-term complications. Prospective longer-term outcomes are needed.