A Novel, Structured Fellow Training Pathway for Robotic-Assisted Sacrocolpopexy
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We developed a novel fellow education pathway for robotic-assisted sacrocolpopexy (RASC) and aimed to compare step-specific and total operative times for RASC performed by Female Pelvic Medicine and Reconstructive Surgery (FPMRS) attendings with those in which FPMRS fellows performed part or all of the RASC. We further aimed to compare complication and readmission rates by fellow involvement.We tracked RASC at 1 institution between 2012 and 2018. We recorded times for total procedure, sacrocolpopexy, and 6 individual steps. Fellows were designated F1-F3 by training year. We used independent samples t-tests and analysis of variance for continuous variables and χ2 and Fisher's exact tests for categorical variables.Of 178 RASC procedures, 76 (42.7%) involved fellows. Concomitant procedures included hysterectomy (62.4%), midurethral sling (50%), and colporrhaphy/perineorrhaphy (51.7%). RASC without and with fellows had similar demographic, clinical, and procedural characteristics, except for midurethral sling rate (attending, 42.2% vs fellow, 60.5%; p = 0.02). RASC without and with fellows had similar times for total procedure (208.9 ± 61.0 vs 209.1 ± 48.6 minutes, p = 0.98), sacrocolpopexy (116.9 ± 39.9 vs 122.7 ± 29.2 minutes, p = 0.27), and all RASC steps except docking (attendings, 9.9 ± 8.6 vs fellows, 7.2 ± 7.0 minutes; p = 0.03). Complication rates and severity were similar without and with fellows. There were no readmissions.Our novel structured training program provides safe limitations for total and step-specific procedural times during fellowship education in RASC. Such training programs warrant further study to determine potential contribution to quality and safety in the teaching environment.Keywords:
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No AccessJournal of UrologyAdult Urology1 Aug 2016Outcomes of Autologous Fascia Pubovaginal Sling for Patients with Transvaginal Mesh Related Complications Requiring Mesh Removal Olugbemisola McCoy, Taylor Vaughan, S. Walker Nickles, Matt Ashley, Lara S. MacLachlan, David Ginsberg, and Eric Rovner Olugbemisola McCoyOlugbemisola McCoy Department of Urology, Medical University of South Carolina, Charleston, South Carolina , Taylor VaughanTaylor Vaughan Department of Urology, Medical University of South Carolina, Charleston, South Carolina , S. Walker NicklesS. Walker Nickles Department of Urology, Medical University of South Carolina, Charleston, South Carolina , Matt AshleyMatt Ashley Department of Urology, University of Southern California, Los Angeles, California , Lara S. MacLachlanLara S. MacLachlan Leahy Clinic, Burlington, Massachusetts , David GinsbergDavid Ginsberg Department of Urology, University of Southern California, Los Angeles, California , and Eric RovnerEric Rovner Department of Urology, Medical University of South Carolina, Charleston, South Carolina View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2976AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We reviewed the outcomes of the autologous fascial pubovaginal sling as a salvage procedure for recurrent stress incontinence after intervention for polypropylene mesh erosion/exposure and/or bladder outlet obstruction in patients treated with prior transvaginal synthetic mesh for stress urinary incontinence. Materials and Methods: In a review of surgical databases at 2 institutions between January 2007 and June 2013 we identified 46 patients who underwent autologous fascial pubovaginal sling following removal of transvaginal synthetic mesh in simultaneous or staged fashion. This cohort of patients was evaluated for outcomes, including subjective and objective success, change in quality of life and complications between those who underwent staged vs concomitant synthetic mesh removal with autologous fascial pubovaginal sling placement. Results: All 46 patients had received at least 1 prior mesh sling for incontinence and 8 (17%) had received prior transvaginal polypropylene mesh for pelvic organ prolapse repair. A total of 30 patients underwent concomitant mesh incision with or without partial excision and autologous sling placement while 16 underwent staged autologous sling placement. Mean followup was 16 months. Of the patients 22% required a mean of 1.8 subsequent interventions an average of 6.5 months after autologous sling placement with no difference in median quality of life at final followup. At last followup 42 of 46 patients (91%) and 35 of 46 (76%) had achieved objective and subjective success, respectively. There was no difference in subjective success between patients treated with a staged vs a concomitant approach (69% vs 80%, p = 0.48). Conclusions: Autologous fascial pubovaginal sling placement after synthetic mesh removal can be performed successfully in patients with stress urinary incontinence as a single or staged procedure. References 1 : Midurethral sling is the dominant procedure for female stress urinary incontinence: analysis of case logs from certifying American urologists. J Urol2013; 82: 1267. Google Scholar 2 : Urinary incontinence in women. Med Clin North Am2011; 95: 101. Google Scholar 3 : Salvage surgery after failed treatment of synthetic mesh sling complications. J Urol2013; 190: 1281. Link, Google Scholar 4 : Biologic bladder neck sling for stress urinary incontinence. In: Urogynecology and Reconstructive Pelvic Surgery. Edited by . Philadelphia: Elsevier Saunders2014. chapt 19, pp 262–271. Google Scholar 5 : Standardisation of terminology of lower urinary tract function. Neurourol Urodyn1988; 7: 403. Crossref, Google Scholar 6 : The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg2009; 250: 187. Google Scholar 7 : Outcome after anterior vaginal prolapse repair: a randomized controlled trial. Obstet Gynecol2008; 111: 891. Google Scholar 8 : Complication and reoperation rates after apical vaginal prolapse surgical repair. Obstet Gynecol2009; 113: 367. Google Scholar 9 : Surgical management of mesh-related complications after prior pelvic floor reconstructive surgery with mesh. Int Urogynecol J2011; 22: 1395. Google Scholar 10 : Perioperative complications and reoperations after incontinence and prolapse surgeries using prosthetic implants. Obstet Gynecol2012; 119: 539. Google Scholar 11 : Salvage autologous fascial sling after failed synthetic midurethral sling: greater than 3-year outcomes. Int J Urol2016; 23: 178. Google Scholar 12 : The autologous fascia pubovaginal sling for complicated female stress incontinence. Can Urol Assoc J2012; 6: 36. Google Scholar 13 : Success of autologous pubovaginal sling after failed synthetic mid urethral sling. J Urol2015; 193: 916. Link, Google Scholar 14 : Outcomes following sling surgery: importance of definition of success. J Urol2008; 180: 998. Link, Google Scholar 15 : Tension-free vaginal tape and autologous rectus fascia pubovaginal sling for the treatment of urinary stress incontinence: a medium-term follow-up. Med Princ Pract2008; 17: 209. Google Scholar 16 Aberger M, Gomelsky A and Padmanabhan P: Comparison of retropubic synthetic mid-urethral slings to fascia pubovaginal slings following failed sling surgery. Neurourol Urodyn 2015; Epub ahead of print. Google Scholar 17 Parker WP, Gomelsky A and Padmanabhan P: Autologous fascia pubovaginal slings after prior synthetic anti-incontinence procedures for recurrent incontinence: a multi-institutional prospective comparative analysis to de novo autologous slings assessing objective and subjective cure. Neurourol Urodyn 2015; Epub ahead of print. Google Scholar 18 : The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction. J Urol1999; 161: 196. Link, Google Scholar 19 : Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol1998; 160: 1312. Link, Google Scholar © 2016 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 196Issue 2August 2016Page: 484-489 Advertisement Copyright & Permissions© 2016 by American Urological Association Education and Research, Inc.Keywordssurgical meshautograftsurinary incontinencesuburethral slingssalvage therapyMetricsAuthor Information Olugbemisola McCoy Department of Urology, Medical University of South Carolina, Charleston, South Carolina More articles by this author Taylor Vaughan Department of Urology, Medical University of South Carolina, Charleston, South Carolina More articles by this author S. Walker Nickles Department of Urology, Medical University of South Carolina, Charleston, South Carolina More articles by this author Matt Ashley Department of Urology, University of Southern California, Los Angeles, California More articles by this author Lara S. MacLachlan Leahy Clinic, Burlington, Massachusetts More articles by this author David Ginsberg Department of Urology, University of Southern California, Los Angeles, California More articles by this author Eric Rovner Department of Urology, Medical University of South Carolina, Charleston, South Carolina More articles by this author Expand All Advertisement PDF downloadLoading ...
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We reviewed a consecutive series of 16 patients above 60 years of age (mean age 71 years) who underwent reconstruction with pedicled flaps in the lower extremity. The soft tissue defects ranged from 9 to 50 cm and were caused in 11 patients (70%) by surgical complications from previous surgeries. Of these, 5 patients underwent a total joint replacement of the knee (4 cases) and of the ankle (1 case). Surgery consisted of 19 muscular flaps, and 3 fasciocutaneous flaps. Six patients were treated with a combination of 2 flaps. The overall surgical complication rate after reconstruction was 44%. There was no perioperative mortality and there were no medical complications. One patient required an above-the-knee amputation because of uncontrollable postoperative bleeding. A thrombectomy was performed in another patient to treat a postoperative popliteal artery occlusion with critical ischemia of the leg. Other complications included recurrent total joint replacement infections (2 cases), marginal flap necrosis (4 cases), and skin necrosis at the donor site (1 case). The mean hospitalization stay was 46 days. All patients but 1 completely healed, although secondary surgery was performed in 7 patients. The occurrence of complications was not correlated with the preoperative morbidity or an age above 75 years. The local complication rate was higher than reported for free flap in the same age category, but the lack of perioperative mortality and medical complications make it a low-risk option for reconstruction of small- to middle-sized defects in the elderly.
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We analyzed the effect of concomitant prolapse surgery performed at the time of sling surgery on short-term postoperative outcomes in women with urinary incontinence.We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of female beneficiaries who underwent sling procedures. Subjects were tracked for 12 months after surgery to assess short-term complications. Concomitant prolapse repairs and prolapse repairs performed in the first 12 months after sling surgery were identified by CPT-4 procedure codes. Postoperative complications and treatments were identified by ICD-9 diagnosis codes and CPT-4 procedure codes, respectively. Bivariate and multivariate analyses were performed to measure the effect of concomitant prolapse surgery on sling outcomes.Concomitant prolapse repairs were performed in 34.4% of sling cases. Women who underwent prolapse repair at the time of the sling surgery were significantly more likely to be diagnosed with postoperative outlet obstruction (9.4% vs 5.5%, p <0.007) than those who did not. Women who underwent concomitant prolapse repair were less likely to undergo a repeat procedure for stress incontinence in postoperative year 1 (4.7% vs 10.2%, p = 0.0005). Multivariate analysis revealed that women who underwent prolapse repair at the time of the sling surgery were significantly less likely to undergo a reoperation for prolapse within 1 year after the sling surgery (OR 0.31, 95% CI 0.22-0.44).Our findings suggest that addressing prolapse at the time of stress incontinence surgery may avoid an early repeat operation for either prolapse or stress incontinence. However, rates of postoperative outlet obstruction are higher.
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No AccessJournal of UrologyCLINICAL UROLOGY: Original Articles1 Jun 2003Outcome of Urethral Reconstructive Surgery in a Series of 74 Women ADAM J. FLISSER and JERRY G. BLAIVAS ADAM J. FLISSERADAM J. FLISSER and JERRY G. BLAIVASJERRY G. BLAIVAS View All Author Informationhttps://doi.org/10.1097/01.ju.0000061763.88247.16AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluated the results of vaginal flap reconstructive surgery of the female urethra. Materials and Methods: A series of 74 consecutive women who presented with urethral pathology requiring surgical reconstruction were assessed for anatomical and functional outcome. Followup was 1 to 15 years (median 1.5). Outcome assessment included success or failure of the anatomical repair based on physical examination as well as voiding habits and continence assessed by voiding diary, questionnaire and patient self-assessment. Results: A total of 74 procedures were performed, including 72 vaginal flap repairs (56 with a concomitant pubovaginal sling). Five vaginal flap repairs were performed with a concomitant modified Pereyra procedure and 1 was done with Kelly plication. A patient in whom vaginal flap repair was planned underwent a Tanagho anterior bladder flap procedure, 1 underwent extensive lysis of urethral and periurethral scarring with primary urethral repair and 12 underwent vaginal flap repair without an incontinence procedure. A total of 72 women with an average age ± SD of 54 ± 13 years were followed a median of 1.5 years after vaginal flap reconstruction and 2 were lost to followup. Of the 62 patients with preoperative incontinence 54 (87%) considered themselves cured or improved. Successful anatomical repair by single procedure vaginal flap repair was achieved in all except 5 patients (93%). Conclusions: Single stage vaginal flap reconstruction with concurrent pubovaginal sling and Martius flap graft has a high degree of anatomical and functional success for treating a difficult surgical problem. References 1 : Surgical fistulae. In: Textbook of Female Urology and Urogynaecology. Edited by . London: Isis Medical Media Ltd.2001. Google Scholar 2 : Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization. Urology1994; 43: 499. Google Scholar 3 : The late occurrence of urinary tract damage in patients successfully treated by radiotherapy for cervical carcinoma. J Urol1989; 141: 1347. Link, Google Scholar 4 : Female urethral reconstruction. In: . Boston: Blackwell Scientific Publications, Inc.1993: 63. part 8. Google Scholar 5 : Noninvasive outcome measures for urinary incontinence and lower urinary tract symptoms: a multicenter study of micturition diary and pad tests. J Urol2000; 164: 698. Abstract, Google Scholar 6 : Transurethral penetration of a tension-free vaginal tape. BJOG2001; 108: 763. Google Scholar 7 : Urethral erosion of tension-free vaginal tape. Urology2002; 59: 601. Google Scholar 8 : Urethral substitution in women. Br J Urol1989; 63: 80. Google Scholar 9 : A report of thirty-four instances of urethrovaginal and bladder neck fistulas. Surg Gynecol Obstet1993; 177: 77. Google Scholar 10 : The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol1990; 75: 727. Google Scholar 11 : Reconstruction of urethra totally destroyed in labour. Br Med J1969; 1: 147. Google Scholar 12 : Vaginal wall bipedicled flap and other techniques in complicated urethral diverticulum and urethrovaginal fistula. J Am Coll Surg1995; 180: 150. Google Scholar 13 : Genitourinary reconstruction in obstetric fistulas. J Urol1994; 152: 403. Abstract, Google Scholar From the Departments of Obstetrics and Gynecology, and Urology, Joan and Sanford Weill College of Medicine, Cornell University and Department of Urogynecology, Lenox Hill Hospital, New York, New York© 2003 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byFaiena I, Koprowski C and Tunuguntla H (2015) Female Urethral ReconstructionJournal of Urology, VOL. 195, NO. 3, (557-567), Online publication date: 1-Mar-2016.Blaivas J, Purohit R, Weinberger J, Tsui J, Chouhan J, Sidhu R and Saleem K (2013) Salvage Surgery after Failed Treatment of Synthetic Mesh Sling ComplicationsJournal of Urology, VOL. 190, NO. 4, (1281-1286), Online publication date: 1-Oct-2013.Xu Y, Sa Y, Fu Q, Zhang J, Xie H and Feng C (2012) A Rationale for Procedure Selection to Repair Female Urethral Stricture Associated with Urethrovaginal FistulasJournal of Urology, VOL. 189, NO. 1, (176-181), Online publication date: 1-Jan-2013.Blaivas J, Santos J, Tsui J, Deibert C, Rutman M, Purohit R and Weiss J (2012) Management of Urethral Stricture in WomenJournal of Urology, VOL. 188, NO. 5, (1778-1782), Online publication date: 1-Nov-2012.Simonato A, Varca V, Esposito M and Carmignani G (2010) Vaginal Flap Urethroplasty for Wide Female Stricture DiseaseJournal of Urology, VOL. 184, NO. 4, (1381-1385), Online publication date: 1-Oct-2010.Wadie B, ElHifnawy A and Khair A (2018) Reconstruction of the Female Urethra: Versatility, Complexity and AptnessJournal of Urology, VOL. 177, NO. 6, (2205-2210), Online publication date: 1-Jun-2007.Tsivian A and Sidi A (2018) Dorsal Graft Urethroplasty for Female Urethral StrictureJournal of Urology, VOL. 176, NO. 2, (611-613), Online publication date: 1-Aug-2006. Volume 169Issue 6June 2003Page: 2246-2249 Advertisement Copyright & Permissions© 2003 by American Urological Association, Inc.Keywordsvaginasurgical flapsreconstructive surgical proceduresurethraMetricsAuthor Information ADAM J. FLISSER Current address: Urocenter of New York, 445 East 77th St., New York, New York 10021. More articles by this author JERRY G. BLAIVAS Financial interest and/or other relationship with Eli Lilly, Pharmacia and Yamanouchi. More articles by this author Expand All Advertisement PDF downloadLoading ...
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Incisional hernias develop in up to 11% of surgical abdominal wounds with a possible recurrence following repair of 44%. We describe our experience with a combined fascial and prosthetic mesh repair. Thirty-five patients (16M:19F) have been treated. The original operation was bowel related in 19 cases, gynaecological in 8, hepatopancreaticobiliary in 3 patients, aortic aneurysm repair in 2 and involved a thoraco-laparotomy in 3. The incisions were midline in 26 cases, transverse in 6, paramedian in 2 and rooftop in one patient. The hernias were considered subjectively to be large in 15, medium in 14 and small in 6 of the patients. A proforma was completed for each patient noting intra-operative and post-operative complications, post-operative hospital stay and analgesic requirements. Post-operative complications included seroma formation in 6 patients, deep vein thrombosis in one and a non-fatal pulmonary embolism in another. One patient developed a wound haematoma and one had a superficial wound infection. Post-operative in-hospital stay ranged from 1 to 27 days with a mean of 6.2 days. Of the 35 patients 33 were available for follow-up. Follow-up was for a median of 20.3 months (range 6.0 to 54.1 months). Two of these (6%) patients reported a persistent lump and one (3%) reported persistent pain but none of the remaining 33 was found to have a recurrence. We advocate this technique because it is applicable to all hernias, most of the mesh is behind the rectus sheath and has 2 points of fixation, it is relatively pain-free allowing early mobilisation, has a modest complication rate and a low recurrence rate.
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