Highlights of the 32nd Annual Scientific Meeting of the Society of Gynecologic Surgeons

April 3-5, 2006; Tucson, Arizona

Steven D. Kleeman, MD, FACOG; Mickey Karram, MD, FACOG


July 06, 2006

In This Article


The "Society of Gynecologic Surgeons" held its 32nd Annual Scientific Meeting from April 3-5, 2006 in Tucson, Arizona. The primary themes of the meeting, as stated by the President of the Society, Karl Podratz, MD, PhD, were education and research in gynecologic surgery. Dr. Rebecca Rogers and the Research Committee also scheduled a special education retreat on April 2, 2006. They invited national experts, Dr. Ajit K. Sachdeva (Division of Education, American College of Surgeons) and Dr. Rebecca Henry (Michigan State University, East Lansing), to further educate investigators interested in establishing multisite educational protocols.

This year's SGS meeting was the largest freestanding conference, to date, in the history of the Society, with more abstract submissions than ever before. The meeting kicked off on Sunday, April 2nd with a postgraduate course on "Minimally Invasive Approaches to Advanced Gynecologic Surgery." The course had an internationally renowned faculty and featured discussions on vaginal and laparoscopic approaches to prolapse, minimally invasive synthetic midurethral slings, as well as laparoscopic- and robotic-assisted pelvic surgeries.

The scientific session included 23 oral presentations, 8 video presentations, 12 oral poster presentations, and 54 traditional poster presentations. The Telinde Lecturer was Thomas R. Russell, MD, who is the Executive Director of the American College of Surgeons. He addressed the important topic of "Quality Assessment -- Our Professional Obligation." For the third consecutive year, breakfast roundtables and debates were held on Tuesday morning from 6:30 AM to 7:30 AM and included a variety of interesting topics that were very well received by the attendees. Highlights from the scientific session included the following:

  • Sensory nerve injury after uterosacral ligament suspension;

  • Long-term outcome of sexual function and quality of life and severity of anal incontinence after anal sphincteroplasty;

  • Surgical training in obstetrics and gynecologic residency programs;

  • A Web-based virtual pelvic trainer, used for teaching residents pelvic anatomy and fundamentals of urogynecologic diseases;

  • Defecatory dysfunction after surgery for pelvic organ prolapse;

  • Correlation between posterior vaginal wall prolapse and fecal symptoms and objective measures of anorectal function;

  • Randomized trial of 3 surgical techniques for rectocele repair, which included graft augmentation;

  • Impact of pessaries on lower urinary tract symptoms; and

  • A randomized crossover trial of Ring vs Gelhorn pessaries with satisfaction outcomes.

The vaginal correction of a vaginal vault prolapse using the uterosacral ligament bilaterally has become a relatively popular procedure. A study entitled "Sensory Nerve Injury after Uterosacral Ligament Suspension" was presented by Dr. M. Flynn (University of Rochester, New York) and colleagues. This was a retrospective case series of patients from Duke University and the University of Rochester. The authors reported that 7 of 182 patients between January 2002 and August 2005 developed pain in the postoperative period radiating from the buttock down to the posterior part of the thigh. All of the patients had undergone a high uterosacral vaginal vault suspension using Allen stirrups. None of the patients had preoperative lower-extremity pain. All of the patients complained of pain in the middle of the posterior thigh. On neurologic examination, there were no associated motor findings. Three of the 7 patients also had pain on vaginal examination, and these were the 3 patients that ultimately had the offending suture removed from the uterosacral ligament and noted immediate relief of their pain. Five of the subjects had pain in the right thigh; 1 subject had pain in the left thigh, and 1 subject in both. Six of the 7 subjects experienced excruciating pain with walking, standing, or sitting. The remaining 4 patients, who continued to experience pain, were treated with gabapentin and narcotics. Three of these 4 had resolution within 12 weeks, and the last subject's pain resolved by 6 months. The authors proposed that underlying etiology was that the posterior femoral cutaneous nerve, which comes from the sacrospinous routes S1, S2, and S3, was entrapped or pulled on. This nerve has only sensory innervation and no motor components. The authors speculated that sutures were placed too deep or too lateral in these patients who developed pain.

Functional Aspects Related to Surgeries of the Posterior Vaginal Wall and the Anal Sphincter

Numerous papers were presented on functional aspects related to the posterior vaginal wall and the anal sphincter.

Dr. E.R. Trowbridge and associates (University of Michigan, Ann Arbor) presented a paper entitled "Sexual Function/Quality of Life and Severity of Anal Incontinence following Anal Sphincteroplasty." The aim of this study was to determine the severity of anal incontinence and its impact on quality of life and sexual function in women who had undergone anal sphincteroplasty. The authors identified 84 women who underwent sphincteroplasty between the years of 1993 and 2004. They were then mailed validated health-related, quality-of-life questionnaires, including "Fecal Incontinence Severity Index" (FISI), Colorectal Anal Impact Questionnaire" (CRAIQ), "Patient Health Questionnaire" (PHQ), and Pelvic Organ Prolapse and Urinary Incontinence/Sexual Questionnaire" (PISSQU). Of the 103 patients initially identified, 19 had no address that could be found; of the 86 patients who were left, 59 responded to the survey for a 70% response rate. The long-term results were unexpectedly very poor, with only 10% being completely continent; 15% admitted to flatal incontinence, and 75% admitted to incontinence to solid or liquid stool. Sexual function did not correlate with fecal severity, and dyspareunia was 6-fold higher with an overlapping sphincteroplasty vs an end-to-end sphincteroplasty. Limitations of the study were that no data prior to the surgery were obtained, and there was no indication of why certain women underwent overlapping sphincteroplasty vs end-to-end type repairs.

Another presentation related to defecatory dysfunction, by Dr. C.S. Bradley for the Pelvic Floor Disorders Network, was entitled "Bowel Symptoms in Women Planning Surgery for Pelvic Organ Prolapse." Data were obtained from the Pelvic Floor Disorders Network, and the study was part of the Colpopexy and Urinary Reduction Efforts (CARE) study. The objective was to compare bowel symptoms of pelvic organ prolapse as they correlate with the vaginal descent and prolapse in women. CARE is a randomized trial of sacrocolpopexy with and without Burch colposuspension in stress-incontinent women with stages 2 to 4 pelvic organ prolapse. On the basis of responses to focused questionnaires, the authors concluded that the bowel symptoms do not have a linear association with the stage of prolapse; or, in other words, as the stage of prolapse gets worse, defecatory dysfunction or bowel symptoms, in general, do not necessarily worsen.

Another study that noted similar results was entitled "Posterior Vaginal Wall Prolapse Does Not Correlate with Fecal Symptoms or Objective Measures of Anorectal Function." The objective of this study, presented by Dr. G. Da Silva (Maimonides Medical Center, Brooklyn, New York) and colleagues, was to evaluate the association between the degree of posterior vaginal wall prolapse and anorectal symptomatology and physiology. The authors again noted no correlation between degree or extent of prolapse and bowel symptoms. They found that patients with a more significant degree of prolapse had a higher sphincter pressure on testing. Limitations of the study included the fact that not everyone had all the physiologic tests done and that only 10% of women had advanced prolapse.

One of the highlights of the meeting was a prospective randomized trial of 3 surgical techniques to correct a symptomatic rectocele. This was presented by Dr. M.R. Paraiso and her colleagues from The Cleveland Clinic Foundation, Cleveland, Ohio. A total of 106 women with symptomatic rectocele were randomized to traditional posterior colporrhaphy, a defect-specific rectocele repair, or a site-specific rectocele repair that was augmented with a biologic material (specifically, in this study, porcine small intestinal submucosa). One year after the surgery, individuals who received a site-specific repair with graft augmentation had a greater failure rate (9/27) than those who received a defect-specific repair (5/37) or a traditional posterior colporrhaphy (3/33). There was no change in the rate of dyspareunia between the groups despite the fact that they showed increased sexual function or improvement in sexual function on the PUIS 12 questionnaire.

Education in Gynecologic Surgery

Another big area of interest at the meeting was education in the area of gynecologic surgery. A very impressive Web-based virtual pelvic trainer was presented by Dr. B.S. Hampton and her associates in the Urogynecology Division at New York University, New York. This is an interactive tool for teaching residents and fellows the basics of pelvic floor anatomy and the fundamentals of urogynecology, such as how to take a history and perform a physical exam. The pelvic trainer was interactive and very well received. The pelvic trainer is available online at https://education.med.nyu.edu/vpt/dspLogin.cfm.

There was a very well-received session entitled "Surgical Training Exigency for Reassessment -- Factors Necessitating Change." This panel discussion was chaired by Dr D. Fenner (University of Michigan Health System, Ann Arbor). Dr. Fenner cited the number of hysterectomies that have been performed by residents over the past 20 to 30 years. In the 1980s, the number of abdominal hysterectomies performed per resident was approximately 120, with approximately 50 vaginal hysterectomies. In the 1990s, this number decreased to approximately 81 abdominal hysterectomies and 25 vaginal hysterectomies, and in 2005 to approximately 80 abdominal hysterectomies with 22 vaginal hysterectomies. She also stated that only 30% of all hysterectomies currently performed in the United States are done via the vaginal route. She quoted a 2004 paper by K. Anders Ericcson in which he remarked that to become an expert at anything -- be it dancing ballet, playing a violin, or obtaining surgical skills -- it generally takes approximately 10,000 hours of experience. Typical Ob/Gyn residency dedicates approximately 8 months to gynecology and urogynecology, and according to Dr. Fenner, this adds up to only about 5700 hours over the 4-year residency period.

The committee discussed that the majority of training currently ongoing in obstetrics and gynecologic training programs is aimed toward obstetrics. Dr. W.A. Cliby (Mayo Clinic College of Medicine, Rochester, Minnesota) talked about the move from individual encounters to more modular training. He gave the example of being on call many nights in order to encounter 1 postpartum hemorrhage or 1 shoulder dystocia. He likened this to airline pilots learning on simulators. They would have to fly many hours in order to practice for 1 near miss. He suggested that we have modular training where these types of experiences are actually practiced by the residents. He also questioned the reasoning behind requiring a board certified gynecologic oncologist to know how to deliver obstetrics in an ever increasing and complex field of medicine.

Another oral presentation at the meeting was entitled "Clinical Anatomy and Surgical Skills Training" (CASST), presented by Dr. K. Kenton (Loyola University Medical Center, Maywood, Illinois) and coworkers. The aim of the study is to develop a needs assessment/learning objective curriculum, assess the learning process, and evaluate the program. The authors initially administered a needs assessment on basic surgical skills and clinical anatomy to junior residents from 4 residency training program in Chicago. They then developed five 3-hour workshops that included didactics, a surgical skills laboratory, and cadaveric dissections to teach basic surgical skills and anatomy. The authors used a program budget that was developed for a single residency program with 6 juniors and compared this with a budget for 4 residencies. The faculty is made up of gynecologists and urologists from 3 of the academic medical centers. A pretest was given prior to the first session to assess baseline knowledge and will be repeated at the end of the fifth session to determine long-term and short-term retention.

Dr. Kenton presented the assessment and pretest results. Thirty-two residents participated in the program. The cost of the program with 4 participating sites was $800 per resident. When only 1 site with 6 residents was used, the per-resident cost would be approximately $1700. Ninety-three percent of the participants preferred a hands-on model or cadavers to didactic lectures. All participants agree that they could benefit from formal training of basic surgical skills before entering the operating room. Eighty-six percent thought that the cadavers would increase their knowledge of anatomy. Over half the residents thought that knowledge and/or skills in the areas surveyed, except knot tying, were much poorer. Urology residents were more likely to report that their knowledge of pelvic anatomy and hysterectomy was poor compared with that of gynecology residents. On the needs assessment, 27% of residents could correctly identify the 3 branches of the pudendal nerve and 40% accurately described differences between 1st, 2nd, 3rd, and 4th degree perineal lacerations. Only 10% knew the 3 most common sites of ureteral injury during hysterectomy, and another 30% could name 2 sites.

Finally, there were 2 presentations of interest that involved pessary use. The first presentation was "Do Pessaries Improve Lower Urinary Tract Symptoms," by Dr. J. Schaeffer (University of Texas, Southwestern Medical Center, Dallas) and colleagues. The objective was to determine the effects of pessary use on lower urinary tract symptoms in patients with symptomatic pelvic organ prolapse and to compare symptoms in women using Gelhorn- and Ring-type pessaries. The study was a subanalysis of data collected through a multicenter, randomized, crossover trial comparing Gelhorn and Ring with support pessaries in the relief of prolapse symptoms. Urinary symptoms were assessed using the urinary scale of the Pelvic Floor Distress Inventory (PFDI), which is divided into 3 subscales -- obstructive, irritative, and stress. The study concluded that there is a modest but significant reduction in all subscales of PFDI. There were no significant differences in urinary symptoms between the 2 types of pessary use.

As mentioned, these data were derived from a larger randomized crossover trial of Ring and Gelhorn pessaries looking at overall satisfaction outcomes, which was presented by Dr. G.W. Cundiff (Johns Hopkins University School of Medicine, Baltimore, Maryland) and colleagues. Patients were randomized to 1 of the 2 pessaries for 3 months. After data were collected, the patients were then switched to the other pessary for 3 months. Patients could quit at any time. Outcome data included visual analogue satisfaction scale, quality-of-life data from the PFDI, and responses to the Pelvic Floor Impact questionnaire and the PISSQU questionnaire. Subjects were predominantly white, parous, and postmenopausal; 48% of the patients had stage 2 prolapse, 42% had stage 3, and 10% had stage 4. For the study presented, 134 subjects were enrolled with 63 initially randomized to a Ring and 71 to a Gelhorn. Eighteen patients could not be fitted (7 with Ring pessaries, 5 with Gelhorn and neither pessary for 6 patients), and 56 patients did not complete 1 of the 3-month trials. Twenty-six patients discontinued the Ring pessary and 30 discontinued the Gelhorn pessary; 6 patients were lost to follow-up. Subjects who could not wear a pessary tended to be younger. There were no differences between satisfactory scores for Ring and Gelhorn, but only 35% of patients or 22 patients had high satisfaction scores with both pessaries. Thirty six or 58% reported high satisfaction with Ring pessaries and these patients tended to be older, more parous, and nonwhite. Thirty-nine patients, or 63%, reported a high satisfaction with a Gelhorn pessary and they were less apt to have had a hysterectomy or prior prolapse surgery.


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