Development and Validation of a Laparoscopic Sacrocolpopexy Simulation Model for Surgical Training

To promote the recognition and care of patients with female genital mutilation/cutting (FGM/C), we aimed to evaluate the awareness, clinical experience and knowledge of FGM/C among female pelvic medicine and reconstructive surgery (FPMRS) specialists. FGM/C is a cultural practice whereby there is removal of external female genitalia for non-therapeutic reasons. Despite the high prevalence of urogynecologic complications, there is a paucity of literature discussing FGM/C from the lens of urologists and urogynecologists. By cross-sectional design, we distributed a 27-item survey via email to members of the Society of Urodynamics, Female Pelvic Medicine and Reconstructive Surgery. We collected variables pertaining to previous FGM/C education, clinical confidence, cultural and medical knowledge, and desire for future education. A total of 54 US-based, mostly urologists and FPMRS specialists, completed the survey. All providers had heard of FGM/C; however only 13% received formal education during medical training. Over 50% had encountered a patient with FGM/C in clinical practice. Only 19% and 13% felt completely confident recognizing and discussing FGM/C, respectively. Seventy percent believed religious doctrine informed FGM/C practice and 24% correctly identified FGM/C type on clinical representation. Finally, only 17% of respondents were aware of FGM/C guidelines, and providers expressed a desire for increased availability of multimodal resources. Education regarding FGM/C remains sparse and variable for US FPMRS specialists. Cultural and clinical knowledge is also lacking, which is a detriment to patient care. In order to strengthen awareness and knowledge, we must develop high-quality FGM/C educational resources for urologists and gynecologists.

Impact of surgical training on the performance of proposed quality measures for hysterectomy for pelvic organ prolapse

It is unclear whether the current distribution of surgeons practicing female pelvic medicine and reconstructive surgery in the United States is adequate to meet the needs of a growing and aging population. We assessed the geographic distribution of female pelvic surgeons as represented by members of the American Urogynecologic Society (AUGS) throughout the United States at the county, state, and American Congress of Obstetricians and Gynecologists district levels. County-level data from the AUGS, American Congress of Obstetricians and Gynecologists, and the United States Census were analyzed in this observational study. State and national patterns of female pelvic surgeon density were mapped graphically using ArcGIS software and 2010 US Census demographic data. In 2013, the 1058 AUGS practicing physicians represented 0.13% of the total physician workforce. There were 6.7 AUGS members available for every 1 million women and 20 AUGS members for every 1 million postreproductive-aged women in the United States. The density of female pelvic surgeons was highest in metropolitan areas. Overall, 88% of the counties in the United States lacked female pelvic surgeons. Nationwide, there was a mean of 1 AUGS member for every 31 practicing general obstetrician-gynecologists. These findings have implications for training, recruiting, and retaining female pelvic surgeons. The uneven distribution of female pelvic surgeons throughout the United States is likely to worsen as graduating female pelvic medicine and reconstructive surgery fellows continue to cluster in urban areas.

The Leadership Landscape: The Role of Gender in Current Leadership Positions in Obstetrics and Gynecology Departments

Introduction: Female urethral strictures are rare, and there is no consensus on proper surgical treatment. The literature is primarily limited to case reports and small case series. Surgical treatment has frequently been extrapolated from male urethroplasty techniques. However, female urethroplasty differs significantly from male urethroplasty because it is performed directly across the urinary sphincter. 1 We describe our rationale and technique for female ventral urethroplasty utilizing a modified Martius flap. Materials and Methods: Two female patients, aged 46 and 58 years, with chronic urethral strictures underwent a ventral modified Martius flap urethroplasty. After guidewire and open-ended ureteral stent placement across the stricture, an inverted U-flap incision was made from the distal urethra to the bladder neck. A full thickness incision into the urethral lumen was made, extending past the bladder neck, and sounded with a 30F urethral sound. An ∼5 × 2 cm portion of nonhair bearing inner labia tissue was harvested and mobilized on the anterior pedicle of a Martius flap. This was then tunneled under the vaginal wall and rotated over the area of the urethral defect. The flap was sutured in place with two 4-0 polyglactin running suture lines, covering the entire gap in the urethra with good mucosal apposition. The remaining fatty tissue of the Martius flap was rotated over the suture lines, adding an extra layer to the repair. The inverted U flap incision was closed over the repair and the skin edges of the Martius flap harvest site were closed in two layers with a deep 2-0 polyglactin layer and a superficial 4-0 poliglecaprone subcuticular suture, resulting in a cosmetic closure. Results: Postoperative voiding cystourethrogram revealed an open bladder neck and no recurrent stricture for both patients. Average Uroflow peak flow was 18 mL/s. The patients had no complaints of stress incontinence (SUI) and a negative cough leak test at 1 month follow-up. At 6 months follow-up, both patients continued to deny any SUI and had no obstructive voiding complaints with minimal post-void residuals. Conclusions: Our technique using a ventral approach to urethroplasty in women with a Martius flap is effective in the management of female urethral stricture disease. This approach offers lower risk of damage to the sphincter, avoids possible clitoral nerve injury, allows for better maintenance of urethral support, and is an approach familiar to most female pelvic medicine and reconstructive surgeons. Music utilized in video obtained royalty-free from (www.bensound.com). No competing financial interests exist. The authors have received and archived patient consent for video recording and publication in advance of video recording procedure. Runtime of video: 6 mins 33 mins This project was presented at the following academic conferences: Arizona Urological Society, August 1, 2021; Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU), February 25, 2022; American Urological Association (AUA) General Meeting, May 14, 2022 ( https://doi.org/10.1097/JU.0000000000002586.08 ).

Understanding differences in female pelvic medicine and reconstructive surgery (FPMRS) urology and gynecology-based fellowships is important because both are accredited by the American Board of Medical Subspecialties. The aim of the study was to characterize urology-based and gynecology-based FPMRS fellowships. An institutional review board-approved 21-item survey was emailed to Accreditation Council for Graduate Medical Education-accredited FPMRS fellowship program directors from January 8 through March 9, 2021. The survey aimed to characterize fellowships through a series of common and specialty-specific questions. Responses were collected with Qualtrics and analyzed using STATA/MP Version 16.1. The response rate was 75% (52/69). Many programs accept both gynecology- and urology-trained applicants (urology-based fellowships, 45.4%; gynecology-based fellowships, 68.3%) since the Accreditation Council for Graduate Medical Education accreditation in 2012. Within the gynecology-based cohort, there have been 10 urology-trained graduates among 7 programs (n = 1-2). Barriers to accepting urology applicants were limited gynecologic knowledge/experience (n = 14) and length of training (n = 11). Thirty-seven (94.8%) reported their graduates log more than 30 hysterectomies and 8.3% (n = 3) log 3 or more urinary diversions.Within the urology-based cohort, there have been 16 gynecology-trained graduates among 4 programs (n = 2-7). Lack of urologic clinical knowledge (n = 4) and training length (n = 2) were cited as barriers to accepting gynecology-trained applicants. Three (27%) reported that their graduates log more than 30 hysterectomies, while 8 (72.7%) reported that graduates log 3 or more urinary diversions. Despite many FPMRS programs stating that they accept gynecology or urology-trained applicants, few fellows graduate from outside specialty FPMRS training programs. Several barriers were identified that may prevent trainees acceptance outside of their residency specialty. Procedural training experience differs between urology- and gynecology-based fellowships.

There are advantages and disadvantages of subspecialty certification for physicians, trainees, patients, and society at large. As female pelvic medicine and reconstructive surgery (FPMRS) became the second subspecialty of urology to offer subspecialty certification, understanding the effects of FPMRS subspecialty certification on the healthcare system is important. While subspecialty certification may improve training, identify experts, and ultimately lead to improved patient outcomes, certification might also be unnecessary for some physicians, weaken residency training, and limit the number of physicians who are deemed qualified to offer certain treatments. As pelvic floor disorders can considerably affect quality of life, and their prevalence is expected to increase with the aging population, high-quality FPMRS care is needed. In this article, we describe the history of FPMRS subspecialty certification as well as its potential advantages and disadvantages as suggested by literature. There are advantages and disadvantages of FPMRS subspecialty certification. Further research is needed to assess the effect of FPMRS subspecialty certification on patient outcomes.

The aim of this study was to evaluate reasons and factors associated with patient calls in the postoperative period after female pelvic medicine and reconstructive surgery. A retrospective review using electronic medical records was performed on consecutive patients who underwent surgery within our academic female pelvic medicine and reconstructive surgery practice during a 6-month period. Calls after postoperative discharge until first scheduled postoperative visit were included. Reasons and number of calls were tabulated. Clinical and surgical factors were extracted. Continuous data were evaluated with a Student t test or analysis of variance; categorical data were evaluated with a χ test. P < 0.05 was considered significant. During the designated period, 302 patients underwent surgery, and 173 (57.3%) patients made 345 calls (mean ± SD, 2.0 ± 1.5 calls). Reasons were categorized under 6 distinct domains: bowel, pain, activity, medication regimen, urinary, and bleeding. The most frequent concern within each domain was constipation (11.6%), abdominal pain (6.4%), physical activity (8.7%), pain regimen (14.5%), urinary catheter related (13.3%), and vaginal bleeding (12.1%), respectively. A greater number of phone calls were recorded among patients discharged home with catheters (P = 0.015), and patients who underwent posterior colporrhaphy (P = 0.005) and retropubic urethropexy (P = 0.014). Patients discharged with home nursing (11, 6.4%) demonstrated a significantly higher number of phone calls (3.8 ± 2.5, P < 0.001). Evaluations were required for 37% of callers. Twelve patients were seen in the emergency department, of whom 3 (1.7%) were readmitted to the hospital. Postoperative patient-initiated telephone calls after pelvic reconstructive surgery are common. Bowel-, urinary-, and medication-based phone calls account for the highest frequency and volume.

Contemporary US resident exposure to Female Pelvic Medicine and Reconstructive Surgery (FPMRS) faculty during urology residency is unknown. Accredited US urology residencies were identified through the American Urological Association (AUA). Accredited, urology-based FPMRS fellowships were identified through the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. The number of faculty and residency positions were obtained from program AUA profiles if they were last modified within the current application cycle; this information was obtained from program websites if AUA profiles were outdated. Data on faculty fellowship training was manually extracted from program websites. A quality control cross-check of program and faculty training characteristics was performed through direct communication with 5% of programs. Of 139 accredited residency programs assessed, 10.8% were affiliated with an accredited, urology-based FPMRS fellowship. In total, 29.5% of residency programs, representing 25% of US urology residents, had neither a FPMRS fellowship nor any FPMRS certified faculty. The national FPMRS faculty-to-resident ratio was 1:10.8, and 7.4% of faculty at all residency programs were FPMRS certified. In comparison, faculty-to-resident ratios for other subspecialties were: 1:4.7 for pediatrics, 1:3.6 for oncology, 1:5.9 for minimally invasive surgery/endourology, 1:14.2 for trauma/reconstruction, and 1:11.8 for andrology or male sexual/reproductive health. The FPMRS faculty-to-resident ratio was 1:5.1 in programs with a urology-based FPMRS fellowship compared with 1:13.4 in programs without a FPMRS fellowship. 30% of US urology residency programs lack FPMRS trained faculty. Even when FPMRS faculty are on staff, the field is often underrepresented relative to other urologic subspecialties. Further studies are required to ascertain if inadequate exposure to FPMRS cases and mentors during training contribute to the shortage of urology residents who choose to specialize in FPMRS. This link has important implications for the current shortage of FPMRS providers.

Comparison of Trendelenburg Angles in Vaginal, Laparoscopic, and Robotic Uterovaginal Apical Prolapse Repairs

Development of Female Pelvic Medicine and Reconstructive Surgery Fellowship Programs following the Deadline for Senior Accreditation

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway

The aim of this study was to assess the current status of female pelvic medicine and reconstructive surgery (FPMRS) in Canada, including level of training, practice patterns, barriers to practice and opinions among obstetrician-gynecologists (OB/GYNs) and urologists. Electronic surveys were distributed to 737 OB/GYNs through the Society of Obstetricians and Gynaecologists of Canada and to 489 urologists through the Canadian Urological Association. Complete responses were collected from 301 (41%) OB/GYNs and 39 (8%) urologists. Of the OB/GYN respondents, 57% were generalists (GEN), and 22% completed FPMRS fellowship training (FPMRS-GYN). OB/GYN GENs were less likely than FPMRS-GYNs to report comfort with pelvic organ prolapse quantification assessment, urodynamic testing, cystoscopy, treatment of mesh complications, and management of overactive bladder. Urologists were less likely than FPMRS-GYNs to report comfort completing a pelvic organ prolapse quantification assessment, fitting pessaries, and treating mesh complications but more likely to report comfort managing overactive bladder. FPMRS-GYNs were more likely than other providers to report high volumes (>20 cases in the past year) of vaginal hysterectomy, as well as incontinence and prolapse procedures. OB/GYN GENs and urologists frequently cited lack of formal training in residency as a barrier to performing FPMRS procedures, whereas FPMRS-GYNs reported a lack of operating room facilities and support personnel. Overall, 76% of the respondents were of the opinion that FPMRS should be a credentialed Canadian subspecialty (92% FPMRS-GYN, 69% OB/GYN GEN, 59% urologists). OB/GYN GENs reported low case volumes and cited inadequate training in residency as a barrier to surgically managing pelvic floor disorders. Most respondents felt that FPMRS should be a credentialed subspecialty.

Linguistic differences suggestive of gender bias have been detected in letters of recommendation (LOR) for female and male residency and fellowship program applicants within multiple medical specialties. The aim of the study was to determine whether linguistic differences exist in LOR for female and male physicians applying to female pelvic medicine and reconstructive surgery (FPMRS) fellowship. A retrospective analysis of FPMRS fellowship applications submitted to a university-affiliated academic center from 2010 to 2020 was performed. Linguistic Inquiry and Word Count, a text analysis software, was used to characterize the linguistic content of letters. Multivariable analysis was used to compare letter characteristics with applicant and letter writer demographics. Of 306 applications reviewed, 221 (72.2%) applicants were female and 85 (27.8%) were male. Of the 1,062 letters analyzed, 457 (43.0%) were written by female letter writers, 586 (55.2%) by males, and 19 (1.8%) were a combination. Multivariable analysis controlling for race, Step 1 score, and letter writer gender demonstrated more frequent use of affiliation words for female applicants compared with males (3.1% ± 0.3 vs. 2.9% ± 0.3, P = 0.02). No additional differences were noted in average letter length or all other linguistic categories analyzed. Multiple differences were detected between writing styles of female and male letter writers, including average letter length, use of multiple word categories, and use of communal (relationship-oriented) language. Data were stratified into 2-year periods and no longitudinal trends in linguistic differences were detected. No linguistic differences, suggestive of gender bias, were found between female and male applicants to FPMRS fellowship.

The aim of this study was to assess the perception of female pelvic medicine and reconstructive surgery (FPMRS) program directors (PDs) and obstetrics and gynecology (OG) FMPRS fellows regarding the adequacy of OG residency as preparation for FPMRS fellowship. Electronic invitations to complete a modified version of a validated survey were extended to FPMRS PDs and their second- and third-year OG FPMRS fellows who had just completed their first or second year of FPMRS fellowship, respectively. The survey consisted of 5 domains; qualitative questions and recommendations for improvement were elicited. Program directors (33%, 16/48) and second-year (64%, 29/45) and third-year (53%, 26/49) fellows completed the surveys. While incoming fellows were deemed professional, serious surgical skill competency issues were identified: (1) PDs felt they could not leave their incoming fellow to operate independently on a major case for 30 minutes while in the next room compared with fellow responses (PDs: 33.3% vs second-year fellows: 67.9%; P = 0.03); (2) no PDs felt their fellows could suture laparoscopically; and (3) there was group consensus that incoming fellows were not proficient at cystoscopy (PDs: 40.0%, second-year fellows: 39.3%, third-year fellows: 32.0%; P = 0.82). Mostly, fellows could clinically evaluate and manage patients. Program directors thought their fellows had better understanding of statistics than fellows believed of themselves (P = 0.05). Increasing FPMRS exposure during residency was favored as the method to better prepare OG residents for fellowship. Quantitative and emerging qualitative outcomes highlight that fellows are professional and are largely able to evaluate and care for patients but that achieving independence, surgical skills, and scholarship requires further training.