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OBJECTIVES Enhanced recovery programs (ERPs) are evidence-based perioperative interventions designed to reduce narcotic use, decrease hospital length of stay, decrease medical costs, and improve patient satisfaction. Given the increase in outpatient procedures in female pelvic medicine and reconstructive surgery, we sought to compare patient outcomes before and after implementation of an ERP for women undergoing outpatient pelvic reconstructive surgery. METHODS This was a prospective nonrandomized cohort quality improvement practice initiative. The ERP intervention group included consecutive patients (n = 66) undergoing elective outpatient pelvic reconstructive surgery from March 2016 to October 2016. Historical controls were consecutive patients (n = 124) who had undergone outpatient pelvic reconstructive surgery in the same period a year before ERP implementation. Our primary outcome was opioid use and postoperative pain scores. Secondary outcomes included procedure time, use of intravenous fluids, time to discharge, and total hospital cost. RESULTS There was an observed reduction in opioid use between the ERP patients and historic controls as measured by intraoperative morphine milligram equivalents (MMEs) and total MMEs, with no difference in postoperative pain scores or postoperative MME. In addition, reduction in length of procedure (P = 0.03), intraoperative intravenous fluids (P < 0.0001), and total hospital cost (P ≤ 0.01) was noted between the ERP patients and historic controls. CONCLUSIONS Implementation of an outpatient ERP for female pelvic reconstructive surgery was associated with decreased intraoperative and total MMEs, decreased length of procedure, decreased administration of intravenous fluids, and decreased total hospital cost without changing postoperative pain scores.

Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients. An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study. One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p

Objective Patient surveys highlight a prevalence of moderate to severe pain in the postanesthesia care unit. Multimodal analgesia has been promoted to improve this with fewer opioid-induced adverse effects. The aim of this study was to evaluate the opioid sparing and analgesic effect of postoperative intravenous (IV) ketorolac after outpatient transvaginal surgery. Methods Forty patients were enrolled in this institutional review board-approved, randomized, double-blind, placebo-controlled study, to receive either 30 mg of IV ketorolac or IV saline placebo postoperatively. Pain was assessed by visual analog scale at timed intervals. Narcotic pain medication was provided upon request. Narcotic use was reassessed by telephone 5 to 7 days postoperatively. Categorical characteristics were compared by χ. Continuous variables were evaluated by Mann-Whitney U test. Results Twenty patients were randomized to each group. Groups were similar in age, health, and operative factors. There was no significant difference in mean pain scores at any interval. The ketorolac group had a total morphine equivalent consumption median of 7.5 mg versus 4.0 mg for placebo, which was not significant (P = 0.17). Total use of narcotic pills postoperatively was equivalent (median, 5). There was no difference in postoperative nausea. One Dindo grade II complication was reported in the ketorolac group of a postoperative pelvic hematoma requiring transfusion. Discussion Intravenous ketorolac administered after outpatient transvaginal surgery did not result in a reduction of pain scores or total morphine consumption. There was one Dindo grade II complication in the ketorolac group. Larger randomized control trials are needed to validate these findings.

Enhanced recovery programs (ERPs) are evidence-based protocols designed to improve functional rehabilitation after surgery. ERPs have gained widespread acceptance in many surgical disciplines, and their use leads to significant improvements in patient outcomes while reducing hospital length of stay (LOS). There remains a paucity of data on the use of ERPs in benign gynecologic surgery. The purpose of this review was to evaluate current literature on the use of ERP concepts in benign gynecologic surgery. A systematic search of PubMed, CINAHL, Web of Science, and the Cochrane databases was conducted, cross-referencing search terms related to gynecologic surgery and ERP concepts. The search was limited to publications available in English. Studies published prior to 2000, and those involving gynecologic oncology, nonadult patients, and outpatient surgery were excluded. Nine studies were included in the analysis. Due to heterogeneity of the included studies, no statistical pooling was possible and comparison between studies was limited to their respective themes. Primary study outcomes included LOS, postoperative nausea and vomiting (PONV), pain management, patient satisfaction, and hospital costs. Five studies investigated ERPs, two evaluated measures to improve PONV, and four focused on unique aspects of pain management. Across the studies, ERPs that focused on the patients’ basic symptoms and recovery were found to have equal, if not better, outcomes than standard practice. This integrative review supports the implementation of ERPs in benign gynecologic surgery. The results showed that the use of ERPs decreased LOS, improved pain scores, and reduced hospital costs, without increasing perioperative complications. We suggest additional randomized controlled trials of ERP concepts in benign gynecologic surgery to support their more widespread use and application.

UNLABELLED Although complications of prosthesis products used for pelvic organ prolapse and stress urinary incontinence have been extensively characterized, little is known about their referral patterns and the time lapse from symptom onset to evaluation and treatment. The aim of our study was to retrospectively describe the patterns and timing of referral of prosthesis-related complications and initial prereferral treatments. METHODS We retrospectively identified patients referred to the University of Virginia from January 2002 to October 2012 with prosthesis complications related to previously placed devices for pelvic floor disorders. RESULTS We identified 55 prosthesis-related complications in 51 patients. The types of prostheses used included mesh or permanent suture for pelvic organ prolapse (vaginal prolapse, n = 24), tapes for stress urinary incontinence (midurethral, n = 21), and materials for abdominal sacrocolpopexies and vaginal vault suspensions (intraperitoneal, n = 10). Original surgeons, who most frequently were general obstetric/gynecology providers, were the referring physicians for only 3.6% of the time. Vaginal and midurethral prosthesis complications occurred most commonly in the early postoperative period, whereas intraperitoneal were more commonly delayed. Patients reported to have experienced adverse symptoms on average from several months up to years while receiving conservative therapies by secondary providers and/or surgical treatments with their original surgeon before referral to our institution. CONCLUSIONS Referral of prosthesis-related complications is often delayed, and most cases required evaluation by a secondary provider other than the original surgeon before a referral was initiated. Timing of symptom onset was dependent on the prosthesis type with up to 1 in 3 having a late presentation that may in part be delayed by prereferral treatments. Further education of original surgeons, primary care providers, and patients on the presentation, timing, and outcomes of potential prosthesis-related complications is needed to facilitate earlier management at tertiary care centers.

Surgical treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can include the use of synthetic materials. Placement of synthetic materials into the vaginal wall, through either the vagina or the abdomen, includes the risk of complications such as vaginal wall extrusion or pain. There is little data regarding outcomes following treatment of mesh complications. A retrospective chart review of patients who underwent excision of mesh placed for POP or SUI between 1 January 2001 and 31 October 2012 was performed at the University of Virginia. Chart abstraction queried patient demographics, clinical history, physical examination, pre- and post-excision symptoms, and operative findings. The International Continence Society (ICS) and International Urogynecological Association (IUGA) classification system was used to define the nature and location of mesh complications. A total of 57 patients (26 mid-urethral slings, 23 transvaginal prolapse, 9 intraperitoneal prolapse) with the diagnosis of mesh extrusion into the vaginal wall were analyzed. Twenty-five (average 2.8 cases/year) original mesh surgeries occurred between January 2001 and January 2010 and 41 (average 20.5 cases/year) occurred after January 2010. The most common presenting patient complaints were chronic pelvic pain (55.9 %), dyspareunia (54.4 %), and vaginal discharge (30.9 %). At a 6-week post-operative visit, 57.3 % of patient’s symptoms were completely resolved and 14.6 % were improved. Clinicians should be cognizant of the variable presentations of post-operative vaginal mesh complications. Mesh excision by experienced pelvic surgeons is an effective and safe treatment for these complications; however, a significant number of patients may have persistent symptoms following surgery.

Objective The purpose of this study was to determine the severity of anal incontinence and its impact on quality of life and sexual function in women after anal sphincteroplasty. Study design Eighty-six women who underwent anal sphincteroplasty during the years 1993 to 2004 were mailed validated survey instruments to evaluate continence status, health-related quality of life, and sexual functioning. Demographic and perioperative data were obtained from patient charts. Results At a mean follow-up time of 5.6 ± 3.0 years, 6 women (11%) were totally continent; 8 women (15%) were incontinent of flatus only, and 41 women (75%) were incontinent of liquid and/or solid stool. Sexual function scores were not correlated with continence scores; 24% vs 4% of subjects who had undergone an overlapping sphincteroplasty versus an end-to-end sphincteroplasty reported pain during intercourse ( P = .04). Conclusion Anal continence rates 5 years after anal sphincteroplasty are disappointing, adversely impact quality of life, yet do not appear to relate to sexual function.

The objective of the study was to examine the effect of center characteristics on educational experiences and female pelvic medicine knowledge changes in third-year students at 6 medical schools.: In this secondary analysis of data acquired during a prospective, multicenter study conducted from May 2008 through June 2009, preclerkship and postclerkship third-year medical students scored their knowledge of 12 female pelvic medicine topics and 4 office procedures (knowledge scores [KSs]). Postclerkship, students also reported the number and type of learning experiences they had encountered. Participating investigators provided data on length of clerkship, number of residents, number of fellowship-trained urogynecologists, presence of a fellowship program, clerkship grading system type, presence of a urogynecology clerkship rotation, and presence of a urogynecology lecture. Analyses used Wilcoxon tests/Spearman correlation, with an α = 0.05.: Paired preclerkship and postclerkship survey data were available for 323 students. Increased numbers of learning experiences were positively associated with number of clerkship weeks (rs = 0.22, P0.001), presence of a urogynecology rotation (P = 0.03), and urogynecology lecture (P0.001). Knowledge scores were positively associated with the number of fellowship-trained urogynecology faculty (rs = 0.17, P = 0.002) and grading system (letter gradespass/fail) (P0.001). Knowledge scores were negatively associated with increasing numbers of residents (rs = -0.29, P0.001) and presence of a urogynecology fellowship program (P0.001). The center characteristics of fellowship program and number of residents were highly correlated (rs = 0.74, P0.001); thus, multivariate modeling was not performed.: The presence of fellowship-trained faculty, urogynecology rotation, longer duration of clerkship, and urogynecology lecture were positively correlated with higher subjective KSs. The inverse association of KS with increased resident number and presence of fellowship was an unexpected finding.

OBJECTIVE : The objective of this study was to describe self-assessed student knowledge of female pelvic medicine (FPM) during the OBGYN clerkship. METHODS : Students at 6 sites scored their knowledge of 12 FPM topics and 4 procedures both before and after their clerkship. Analysis included Wilcoxon tests, Spearman correlation, and univariate and multivariate models. RESULTS : A total of 323 students completed paired surveys. Mean knowledge scores (KSs) across FPM topics (1.40 ± 0.12; 95% confidence interval) and procedures (0.77 ± 0.08) increased significantly, with larger increases for topics (P < 0.001). Topic and procedure KSs were correlated (rs = 0.32, P < 0.0001). Mean KSs were significantly related to number and number of types of learning experiences (r = 0.13 and 0.08, both P < 0.001). Learning through text and inpatient encounters had independent effects on KS change in multivariate analysis (P = 0.01 and 0.007). CONCLUSIONS : Students reported increased knowledge although less for procedures than for topics. Text and inpatient learning independently increased students' self-assessed change in knowledge.

Treatment strategies for stress incontinence are based on the concept that urethral mobility is the predominant causal factor with sphincter function a secondary contributor. To our knowledge the relative importance of these 2 factors has not been assessed in properly controlled studies.The Research on Stress Incontinence Etiology project is a case-control study that compared 103 women with stress incontinence and 108 asymptomatic controls in groups matched for age, race, parity and hysterectomy. Urethral closure pressure, urethral and pelvic organ support, levator ani muscle function and intravesical pressure were measured and analyzed using logistic regression and multivariable modeling.Mean +/- SD maximal urethral closure pressure was 42% lower in cases (40.8 +/- 17.1 vs 70.2 +/- 22.4 cm H(2)O, d = 1.47). Lesser effect sizes were seen for support parameters, including resting urethral axis and urethrovaginal support (d = 0.41 and 0.50, respectively). Other pelvic floor parameters, including genital hiatus size and urethral axis during muscle contraction (d = 0.60 and 0.58, respectively), differed but levator strength and levator defect status did not. Maximum cough pressure, which is an assessment of stress on the continence mechanism, was also different (d = 0.43). After adjusting for body mass index the maximal urethral closure pressure alone correctly classified 50% of cases. Adding the best predictors for urethrovaginal support and cough strength to the model added 11% of predictive ability.The finding that maximal urethral closure pressure and not urethral support is the factor most strongly associated with stress incontinence implies that improving urethral function may have therapeutic promise.