Objectives:Urinary tract injuries are a known complication of gynecologic surgery, occurring
in 0.18% -0.80% of procedures and most commonly involving the bladder. Appropriate
identification, evaluation, treatment, and follow-up by gynecologic surgeons are
important to reduce the associated long-term morbidities.The
purpose of this study was to implement a comprehensive cadaver curriculum in
cystotomy repair for OBGYN residents. Methods: This was a prospective observational
cohort study including 10 OBGYN residents (PGY1-3) at a single institution in
2020 (56% of the 18 eligible residents). The curriculum consisted of a one-hour
didactic lecture and one-hour hands-on surgical skills training with fresh
frozen cadavers. Residents were evaluated in three domains: 1) knowledge, 2)
surgical skills, and 3) confidence. Knowledge, confidence, and resident
satisfaction were evaluated with pre- and post-surveys. The bladder model,
derived from the ACOG Simulation Working Group, was used to evaluate surgical
skills at baseline and at completion of the curriculum. Results: Across
all three PGY levels, statistically significant improvements were observed in
knowledge, surgical skills, and confidence after didactic and cadaver education
(p = 0.001, p < 0.02, and p = 0.009 respectively). The largest increases in
confidence occurred in residents’ ability to describe and perform cystotomy
repairs. Conclusions: Educating and training OBGYN residents to manage
and repair cystotomies can be challenging given the low incidence of injury
References
[1]
Satitniramai, S. and Manonai, J. (2017) Urologic Injuries during Gynecologic Surgery: A 10-Year Review. Journal of Obstetrics and Gynaecology Research, 43, 557-563. https://doi.org/10.1111/jog.13238
[2]
Wong, J.M.K., Bortoletto, P., Tolentino, J., Jung, M.J. and Milad, M.P. (2018) Urinary Tract Injury in Gynecologic Laparoscopy for Benign Indication: A Systematic Review. Obstetrics & Gynecology, 131, 100-108.
https://doi.org/10.1097/AOG.0000000000002414
[3]
Glaser, L.M. and Milad, M.P. (2019) Bowel and Bladder Injury Repair and Follow-Up after Gynecologic Surgery. Obstetrics & Gynecology, 133, 313-322.
https://doi.org/10.1097/AOG.0000000000003067
[4]
Frankman, E.A., Wang, L., Bunker, C.H. and Lowder, J.L. (2010) Lower Urinary Tract Injury in Women in the United States, 1979-2006. American Journal of Obstetrics & Gynecology, 202, 495.e1-495.e5.
https://doi.org/10.1016/j.ajog.2010.01.013
[5]
Sharp, H.T. and Adelman, M.R. (2016) Prevention Recognition and Management of Urologic Injuries during Gynecologic Surgery. Obstetrics & Gynecology, 127, 1085-1096. https://doi.org/10.1097/AOG.0000000000001425
[6]
Findley, A.D. and Solnik, M.J. (2016) Prevention and Management of Urologic Injury during Gynecologic Laparoscopy. Current Opinion in Obstetrics and Gynecology, 28, 323-328. https://doi.org/10.1097/GCO.0000000000000296
[7]
Kaestner, L. (2019) Management of Urological Injury at the Time of Urogynaecology Surgery. Best Practice & Research Clinical Obstetrics & Gynaecology, 54, 2-11.
https://doi.org/10.1016/j.bpobgyn.2018.06.007
[8]
Kim-Fine, S. and Brennard, E.A. (2016) Surgical Simulation and Competency. Obstetrics and Gynecology Clinics of North America, 43, 575-590.
https://doi.org/10.1016/j.ogc.2016.04.007
[9]
Kolozsvari, N.O., Feldmand, L.S., Vassiliou, M.C., Demyttenaere, S. and Hoover, M.L. (2011) Sim One, Do One, Teach One: Consideration in Designing Training Curricula for Surgical Simulation. Journal of Surgical Education, 68, 421-427.
https://doi.org/10.1016/j.jsurg.2011.03.010
[10]
Windsor, J.A. (2009) Role of Simulation in Surgical Education and Training. ANZ Journal of Surgery, 79, 127-132. https://doi.org/10.1111/j.1445-2197.2008.04829.x
[11]
McClusky, D.A. and Smith, C.D. (2008) Design and Development of a Surgical Skill Simulation Curriculum. World Journal of Surgery, 32, 171-181.
https://doi.org/10.1007/s00268-007-9331-9
[12]
Aggarwal, R., Grantcharov, T.P. and Darzi, A. (2007) Framework for Systematic Training and Assessment of Technical Skill. Journal of the American College of Surgeons, 204, 697-705. https://doi.org/10.1016/j.jamcollsurg.2007.01.016
[13]
Sturm, L.P., Windsor, J.A., Cosman, P.H., Cregan, P., Hewett, P.J. and Maddern, G.J. (2008) A Systematic Review of Skills Transfer after Surgical Simulation Training. Annals of Surgery, 248, 166-179.
https://doi.org/10.1097/SLA.0b013e318176bf24
[14]
Sharma, M., Macafee, D. and Horgan, A.F. (2013) Basic Laparoscopic Skills Training Using Fresh Frozen Cadaver: A Randomized Controlled Trial. American Journal of Surgery, 206, 23-31. https://doi.org/10.1016/j.amjsurg.2012.10.037
[15]
Giger, U., Fresard, I., Haflinger, A., Bergmann, M. and Krähenbühl, L. (2008) Laparoscopic Training on Thiel Human Cadavers: A Model to Teach Advanced Laparoscopic Procedures. Surgical Endoscopy, 22, 901-906.
https://doi.org/10.1007/s00464-007-9502-7
[16]
Supe, A., Dalvi, A., Prabhu, R., Kantharia, C. and Bhuiyan, P. (2005) Cadaver Model for Laparoscopic Training. Indian Journal of Gastroenterology, 24, 111-113.
[17]
Reed, A.B., Crafton, C., Giglia, J.S. and Hutto, J.D. (2009) Back to Basics: Use of Fresh Cadavers in Vascular Surgery Training. Surgery, 146, 757-763.
https://doi.org/10.1016/j.surg.2009.06.048
[18]
Barton, D.P.J., Davies, D.C., Mahadevan, C., Dennis, L., Adib, T., Mudan, S., et al. (2009) Dissection of Soft-Preserved Cadavers in the Training of Gynaecological Oncologists: Report of the First UK Workshop. Gynecologic Oncology, 113, 352-356.
https://doi.org/10.1016/j.ygyno.2009.02.012
[19]
Lim, C.P., Roberts, M., Chalhoub, T., Waugh, J. and Delgaty, L. (2018) Cadaveric Surgery in Core Gynaecology Training: A Feasibility Study. Gynecological Surgery, 15, Article No. 4. https://doi.org/10.1186/s10397-017-1034-0
[20]
Chong, W., Downing, K., Leegant, A., Banks, E., Fridman, D. and Downie, S. (2017) Resident Knowledge, Surgical Skill, and Confidence in Transobturator Vaginal Tape Placement: The Value of a Cadaver Laboratory. Female Pelvic Medicine & Reconstructive Surgery g, 23, 392-400. https://doi.org/10.1097/SPV.0000000000000458
[21]
Braun, K., Ray, C., Stager, R. and Rungruang, B. (2018) Teaching Cystotomy Repair: Low Fidelity Model Provides Effective Simulation at Minimal Cost. Obstetrics & Gynecology, 122, 43S. https://doi.org/10.1097/01.AOG.0000546625.12433.e2
[22]
Martin, J.A., Regehr, G., Reznick, R., Macrae, H., Murnaghan, J., Hutchison, C., et al. (1997) Objective Structured Assessment of Technical Skill (OSATS) for Surgical Residents. BJS (British Journal of Surgery), 84, 273-278.
https://doi.org/10.1046/j.1365-2168.1997.02502.x
[23]
Gilmour, D.T. and Baskett, T.F. (2005) Disability and Litigation from Urinary Tract Injuries at Benign Gynecologic Surgery in Canada. Obstetrics & Gynecology, 105, 109-114. https://doi.org/10.1097/01.AOG.0000144127.78481.8c
[24]
Akar, B., Aslancan, R., Dogan, O., Sivaslιoglu, A. and Çalιskan, E. (2020) The Effect of Hands-On Cadaver and Live Surgery Practice on Surgeons’ Performance in Urogynecologic Operations: One-Year Follow-Up. Journal of Gynecologic Surgery, 36, 41-46. https://doi.org/10.1089/gyn.2019.0041
[25]
Zahn, C.M., Siddique, S., Hernandez, S. and Lockrow, E.G. (2007) Anatomic Comparison of Two Transobturator Tape Procedures. Obstetrics & Gynecology, 109, 701-706. https://doi.org/10.1097/01.AOG.0000255662.79008.18
[26]
Neuman, M., Masata, J., Hubka, P., Bornstein, J. and Martan, A. (2012) Sacrospinous Ligaments Anterior Apical Anchoring for Needle-Guided Mesh Is a Safe Option: A Cadaveric Study. Urology, 79, 1020-1022.
https://doi.org/10.1016/j.urology.2012.01.045
[27]
Bonnet, P., Waltregny, D., Reul, O. and de Leval, J.E. (2005) Transobturator Vaginal Tape Inside Out for the Surgical Treatment of Female Stress Urinary Incontinence: Anatomical Considerations. Journal of Urology, 173, 1223-1228.
https://doi.org/10.1097/01.ju.0000148364.13525.7b
[28]
Masata, J., Hubka, P. and Martan, A. (2012) Pudendal Neuralgia Following Transobturator Inside-Out Tape Procedure (TVT-O)—Case Report and Anatomical Study. International Urogynecology Journal, 23, 505-507.
https://doi.org/10.1007/s00192-011-1555-4
[29]
Corton, M.M., Wai, C.Y., Vakili, B., Boreham, M.K., Schaffer, J.I. and Coleman, R.L. (2003) A Comprehensive Pelvic Dissection Course Improves Obstetrics and Gynecology Resident Proficiency in Surgical Anatomy. American Journal of Obstetrics & Gynecology, 189, 647-651. https://doi.org/10.1067/S0002-9378(03)00881-0
[30]
Nakamura, M., Fujii, T., Imanishi, N., Jinzaki, M., Yamada, M., Kuribayashi, S., et al. (2014) Surgical Anatomy Imaging Associated with Cervical Cancer Treatment: A Cadaveric Study. Clinical Anatomy, 27, 503-510. https://doi.org/10.1002/ca.22319
[31]
Barksdale, P.A., Brody, S.P., Garely, A.D., Elkins, T.E., Nolan, T.E. and Gasser, R.F. (1997) Surgical Landmarks of the Ureter in the Cadaveric Female Pelvis. Clinical Anatomy, 10, 324-327.
https://doi.org/10.1002/(SICI)1098-2353(1997)10:5%3C324::AID-CA6%3E3.0.CO;2-Q
[32]
Hammond, I., Taylor, J., Obermair, A. and McMenamin, P. (2004) The Anatomy of Complications Workshop: An Educational Strategy to Improve the Training and Performance of Fellows in Gynecologic Oncology. Gynecologic Oncology, 94, 769-773. https://doi.org/10.1016/j.ygyno.2004.06.022
[33]
Kraima, A.C., Derks, M., Smit, N.N., van de Velde, C.J.H., Kenter, G.G. and DeRuiter, M.C. (2016) Careful Dissection of the Distal Ureter Is Highly Important in Nerve-Sparing Radical Pelvic Surgery: A 3D Reconstruction and Immunohistochemical Characterization of the Vesical Plexus. International Journal of Gynecologic Cancer, 26, 959-966. https://doi.org/10.1097/IGC.0000000000000709
[34]
Morgan, H., Marzano, D., Lanham, M., Stein, T., Curran, D. and Hammoud, M. (2014) Preparing Medical Students for Obstetrics and Gynecology Milestone Level One: A Description of a Pilot Curriculum. Medical Education Online, 19, Article ID: 25746. https://doi.org/10.3402/meo.v19.25746
[35]
Goldman, E.M., Wydo, S., Green, R., Huff, S. and Germaine, P. (2018) A Pre-Surgical Residency Refresher Course That Advances Students from the Cadaver Lab to the Surgical Suite. Medical Science Educator, 28, 227-234.
https://doi.org/10.1007/s40670-017-0503-4
[36]
Levine, R.L., Kives, S., Cathey, G., Blinchevsky, A., Acland, R., Thompson, C., et al. (2006) The Use of Lightly Embalmed (Fresh Tissue) Cadavers for Resident Laparoscopic Training. Journal of Minimally Invasive Gynecology, 13, 451-456.
https://doi.org/10.1016/j.jmig.2006.06.011
[37]
Kerbage, Y., Debarge, V., Lucot, J.P., Clouqueur, E. and Rubod, C. (2016) Simulation Training to Teach Postpartum Hemorrhage Surgery to Residents. European Journal of Obstetrics & Gynecology, 201, 27-30.
https://doi.org/10.1016/j.ejogrb.2016.03.013
[38]
Selçuk, I., Yassa, M., Tatar, I. And Huri, E. (2018) Anatomic Structure of the Internal Iliac Artery and Its Educative Dissection for Peripartum and Pelvic Hemorrhage. Turkish Journal of Obstetrics and Gynecology, 15, 126-129.
https://doi.org/10.4274/tjod.23245
[39]
Emmanuelli, V., Lucot, J.P., Closset, E., Cosson, M. and Deruelle, P. (2013) Development and Assessment of a Workshop on Repair of Third and Fourth Degree Obstetric Tears. Journal de Gynécologie Obstétrique et Biologie de la Reproduction, 42, 184-190. https://doi.org/10.1016/j.jgyn.2012.12.011
