Browsing by Author "Walters, Mark D"

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Open Access
Assessing intraoperative judgment using script concordance testing through the gynecology continuum of practice.
(Med Teach, 2014-08) Kow, Nathan; Walters, Mark D; Karram, Mickey M; Sarsotti, Carlos J; Jelovsek, J Eric
OBJECTIVE: To measure surgical judgment across the Obstetrics and Gynecology (OBGYN) continuum of practice and identify factors that correlate with improved surgical judgment. METHODS: A 45-item written examination was developed using script concordance theory, which compares an examinee's responses to a series of "ill-defined" surgical scenarios to a reference panel of experts. The examination was administered to OBGYN residents, Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows, practicing OBGYN physicians and FPMRS experts. Surgical judgment was evaluated by comparing scores against the experts. Factors related to surgical experience were measured for association with scores. RESULTS: In total, 147 participants including 11 residents, 37 fellows, 88 practicing physicians and 11 experts completed the 45-item examination. Mean scores for practicing physicians (65.2 ± 7.4) were similar to residents (67.2 ± 7.1), and worse than fellows (72.6 ± 4.2, p < 0.001) and experts (80 ± 5, p < 0.001). Positive correlations between scores and surgical experience included: annual number of vaginal hysterectomies (r = 0.32, p = <0.001), robotic hysterectomies (r = 0.17, p = 0.048), stress incontinence (r = 0.29, p < 0.001) and prolapse procedures (r = 0.37, p < 0.001). Inverse correlation was seen between test scores and years in practice. (r = -0.19, p = 0.02). CONCLUSION: Intraoperative judgment in practicing OBGYN physicians appears similar to resident physicians. Practicing physicians who perform FPMRS procedures perform poorly on this examination of surgical judgment; lower performance correlates with less surgical experience and the greater amount of time in practice.
Open Access
Establishing cutoff scores on assessments of surgical skills to determine surgical competence.
(Am J Obstet Gynecol, 2010-07) Jelovsek, J Eric; Walters, Mark D; Korn, Abner; Klingele, Christopher; Zite, Nikki; Ridgeway, Beri; Barber, Matthew D
OBJECTIVE: The aim of this study was to establish minimum cutoff scores on intraoperative assessments of surgical skills to determine surgical competence for vaginal hysterectomy. STUDY DESIGN: Two surgical rating scales, the Global Rating Scale of Operative Performance and the Vaginal Surgical Skills Index, were used to evaluate trainees while performing vaginal hysterectomy. Cutoff scores were determined using the Modified Angoff method. RESULTS: Two hundred twelve evaluations were analyzed on 76 surgeries performed by 27 trainees. Trainees were considered minimally competent to perform vaginal hysterectomy if total absolute scores (95% confidence interval) on Global Rating Scale = 18 (16.5-20.3) and Vaginal Surgical Skills Index = 32 (27.7-35.5). On average, trainees met new cutoffs after performing 21 and 27 vaginal hysterectomies, respectively. With the new cutoffs applied to the same cohort of fourth-year obstetrics and gynecology trainees, all residents achieved competency in performing vaginal hysterectomy by the end of their gynecology rotations. CONCLUSION: Standard-setting methods using cutoff scores may be used to establish competence in vaginal surgery.
Open Access
Functional bowel disorders and pelvic organ prolapse: a case-control study.
(Female Pelvic Med Reconstr Surg, 2010-07) Jelovsek, John Eric; Walters, Mark D; Paraiso, Marie Fidela R; Barber, Matthew D
OBJECTIVES: : To compare the relative frequencies of constipation and other functional bowel disorders between patients with and without pelvic organ prolapse (POP). METHODS: : This was a case-control study design. Cases were patients with stage 3-4 POP presenting to a urogynecology clinic and controls were patients presenting to a general gynecology or women's health clinic for annual examinations with stage 0-1 vaginal support. Constipation disorders were defined using responses to the Rome II Modular Questionnaire for functional bowel disorders as well as predefined defecatory disorders. RESULTS: : 128 cases and 127 controls were enrolled. After controlling for race, education, and comorbidities, women with POP were more likely to report symptoms consistent with outlet constipation, including straining during a bowel movement (odds ratio [OR] 3.9, confidence interval [CI] 2.1-7.3), feeling of incomplete rectal emptying (OR 4.0, CI 2.1-7.7), a sensation that stool cannot be passed (OR 3.4, CI 1.7-6.7), and splinting (OR 2.7, CI 1.3-5.7). In spite of this, cases were just as likely to meet the criteria for functional constipation or irritable bowel syndrome (IBS) with constipation as controls but more likely to meet the criteria for IBS-any type (OR 3.8, CI 1.6-9.1) as women with POP reported more discomfort or pain in the abdomen (OR 3.4 CI 1.6-7.1) and >3 bowel movements per day (OR 2.9, CI 1.3-6.3). CONCLUSIONS: : Patients with POP are more likely to have symptoms of outlet constipation and other functional bowel disorders compared with patients without POP. The Rome II criteria may not be an appropriate classification system for functional bowel disorders in patients with advanced POP.
Open Access
Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse.
(Am J Obstet Gynecol, 2015-05) Unger, Cecile A; Walters, Mark D; Ridgeway, Beri; Jelovsek, J Eric; Barber, Matthew D; Paraiso, Marie Fidela R
OBJECTIVE: We sought to describe perioperative and postoperative adverse events associated with uterosacral colpopexy, to describe the rate of recurrent pelvic organ prolapse (POP) associated with uterosacral colpopexy, and to determine whether surgeon technique and suture choice are associated with these rates. STUDY DESIGN: This was a retrospective chart review of women who underwent uterosacral colpopexy for POP from January 2006 through December 2011 at a single tertiary care center. The electronic medical record was queried for demographic, intraoperative, and postoperative data. Strict definitions were used for all clinically relevant adverse events. Recurrent POP was defined as the following: symptomatic vaginal bulge, prolapse to or beyond the hymen, or any retreatment for POP. RESULTS: In all, 983 subjects met study inclusion criteria. The overall adverse event rate was 31.2% (95% confidence interval [CI], 29.2-38.6), which included 20.3% (95% CI, 17.9-23.6) of subjects with postoperative urinary tract infections. Of all adverse events, 3.4% were attributed to a preexisting medical condition, while all other events were ascribed to the surgical intervention. Vaginal hysterectomy, age, and operative time were not significantly associated with any adverse event. The intraoperative bladder injury rate was 1% (95% CI, 0.6-1.9) and there were no intraoperative ureteral injuries; 4.5% (95% CI, 3.4-6.0) of cases were complicated by ureteral kinking requiring suture removal. The rates of pulmonary and cardiac complications were 2.3% (95% CI, 1.6-3.5) and 0.8% (95% CI, 0.4-1.6); and the rates of postoperative ileus and small bowel obstruction were 0.1% (95% CI, 0.02-0.6) and 0.8% (95% CI, 0.4-1.6). The composite recurrent POP rate was 14.4% (95% CI, 12.4-16.8): 10.6% (95% CI, 8.8-12.7) of patients experienced vaginal bulge symptoms, 11% (95% CI, 9.2-13.1) presented with prolapse to or beyond the hymen, and 3.4% (95% CI, 2.4-4.7) required retreatment. Number and type of suture used were not associated with a higher rate of recurrence. Of the subjects who required unilateral removal of sutures to resolve ureteral kinking, 63.6% did not undergo suture replacement; this was not associated with a higher rate of POP recurrence. CONCLUSION: Perioperative and postoperative complication rates associated with severe morbidity after uterosacral colpopexy appear to be low. Uterosacral colpopexy remains a safe option for the treatment of vaginal vault prolapse.
Open Access
Long-Term Effectiveness of Uterosacral Colpopexy and Minimally Invasive Sacral Colpopexy for Treatment of Pelvic Organ Prolapse.
(Female Pelvic Med Reconstr Surg, 2017-08-01) Unger, Cecile A; Barber, Matthew D; Walters, Mark D; Paraiso, Marie Fidela R; Ridgeway, Beri; Jelovsek, J Eric
OBJECTIVES: The objective of this study was to estimate rates of recurrent pelvic organ prolapse (POP) 6 years after patients underwent transvaginal uterosacral colpopexy, or laparoscopic or robotic sacral colpopexy at a large tertiary care center. We hypothesized that recurrence rates would be higher than those previously reported. METHODS: This is a retrospective study of women who underwent uterosacral colpopexy, laparoscopic, and robotic sacral colpopexy for treatment of POP between 2006 and 2012. A composite outcome for recurrent POP was defined as subjective failure (vaginal bulge symptoms), objective failure (prolapse to or beyond the hymen), or any retreatment for POP (reoperation or use of a pessary). Kaplan-Meier survival curves were generated from each patient's date of follow-up, and parametric survival modeling was used to estimate recurrent POP over 6 years. Annual estimated recurrence rates by type of colpopexy are reported using the composite and individual definitions for recurrent POP. RESULTS: One thousand three hundred eighty-one subjects met inclusion criteria: 983 (71.1 %) uterosacral, 256 (18.5%) laparoscopic, and 142 (11.2%) robotic colpopexies. Median (range) months to failure using composite recurrence were as follows: uterosacral, 17.1 (7.6-41); laparoscopic, 10.1 (4.7-25.1); robotic, 9.7 (1.6-17.2). By year 6 in the model, the estimated composite recurrence rates for the uterosacral colpopexy, robotic, and laparoscopic sacral colpopexy groups were 43%, 49%, and 57%, respectively. CONCLUSIONS: Estimated recurrence rates for uterosacral ligament colpopexy, laparoscopic, and robotic sacral colpopexy may be as high as 40% to 60% 6 years after surgery.
Open Access
Objective assessment of vaginal surgical skills.
(Am J Obstet Gynecol, 2010-07) Chen, Chi Chiung Grace; Korn, Abner; Klingele, Christopher; Barber, Matthew D; Paraiso, Marie Fidela R; Walters, Mark D; Jelovsek, J Eric
OBJECTIVE: To develop and validate an instrument to assess surgical skills during vaginal surgery. STUDY DESIGN: Trainees from 2 institutions were directly assessed in the operating room by supervising surgeons while performing a vaginal hysterectomy using the new Vaginal Surgical Skills Index, global rating scale, and visual analogue scale. Trainees were assessed again by the same surgeons 4 weeks after the live surgery and by a blinded outside reviewer using a videotape of the case. Internal consistency, interrater and intrarater reliability, and construct validity were evaluated. RESULTS: Two hundred twelve evaluations were analyzed on 76 surgeries from 27 trainees. There was good internal consistency, interrater, and intrarater reliability. Vaginal Surgical Skills Index scores correlated with global rating score and visual analog scale scores. Increasing Vaginal Surgical Skills Index scores significantly correlated with year of training and surgical volume with an estimated increase in score of 0.3 per hysterectomy performed. CONCLUSION: The Vaginal Surgical Skills Index is a feasible, reliable, and valid instrument to assess vaginal surgical skills.