Home practice for robotic surgery: a randomized controlled trial of a low-cost simulation model

Pre-operative simulated practice allows trainees to learn robotic surgery outside the operating room without risking patient safety. While simulation practice has shown efficacy, simulators are expensive and frequently inaccessible. Cruff (J Surg Educ 78(2): 379-381, 2021) described a low-cost simulation model to learn hand movements for robotic surgery. Our study evaluates whether practice with low-cost home simulation models can improve trainee performance on robotic surgery simulators. Home simulation kits were adapted from those described by Cruff (J Surg Educ 78(2): 379-381, 2021). Hand controllers were modified to mimic the master tool manipulators (MTMs) on the da Vinci Skills Simulator (dVSS). Medical students completed two da Vinci exercises: Sea Spikes 1 (SS1) and Big Dipper Needle Driving (BDND). They were subsequently assigned to either receive a home simulation kit or not. Students returned two weeks later and repeated SS1 and BDND. Overall score, economy of motion, time to completion, and penalty subtotal were collected, and analyses of covariance were performed. Semi-structured interviews assessed student perceptions of the robotic simulation experience. Thirty-three medical students entered the study. Twenty-nine completed both sessions. The difference in score improvement between the experimental and control groups was not significant. In interviews, students provided suggestions to increase fidelity and usefulness of low-cost robotic home simulation. Low-cost home simulation models did not improve student performance on dVSS after two weeks of at-home practice. Interview data highlighted areas to focus future simulation efforts. Ongoing work is necessary to develop low-cost solutions to facilitate practice for robotic surgery and foster more inclusive and accessible surgical education.

A Double-Blind Randomized Sham-Controlled Trial to Evaluate the Efficacy of Fractional Carbon Dioxide Laser Therapy on Genitourinary Syndrome of Menopause

BACKGROUND

Despite some prospective case series showing effectiveness of vaginal laser to treat genitourinary syndrome of menopause (GSM), there is a paucity of placebo-controlled level one evidence.

AIM

To assess the effect of fractional carbon dioxide (CO₂) laser therapy to treat GSM against a sham comparator.

METHODS

We conducted a parallel, randomized, double-blind, sham-controlled trial to compare menopausal women treated with fractional CO₂ laser against sham treatment for improvement in GSM-related dyspareunia. Three treatments were given 6 weeks apart, and participants attended a 6-month visit from study start for primary (proportion improved) and secondary (vaginal health index, VHI; visual analogue scale, VAS; modified global assessment, PGI-I; Female Sexual Function Index, FSFI; Day-to-Day Impact of Vaginal Aging, DIVA; Urinary Distress Inventory short-form, UDI-6) assessments.

OUTCOMES

The primary endpoint was a 2-stage improvement in GSM-related dyspareunia from baseline to 6 months determined by a severity scale, and the proportion of subjects who achieved this were compared between groups.

RESULTS

Thirty participants were randomized to laser (n = 14) or sham (n = 16). In the treatment arm, 13 attended all treatments, and 1 attended at least 2 while in the sham arm, 14 attended all treatments, and 2 attended at least 2 treatments. Twelve (86%) in the treatment arm and 16 (100%) in the sham arm attended the 6-month visit. There were no differences in the proportion improved between treatments and controls (64% vs. 67%, respectively, P = 1.000). Both arms showed significant within-group improvements based on VHI and VAS, but not between groups. Similar findings were observed on sexual impact questionnaires with improvements within both groups from baseline to 6 months but not by median differences between the groups at 6 months. There were no adverse events in either of the arms.

CLINICAL IMPLICATIONS

Further well-powered research is needed to determine efficacy of fractional CO₂ laser for the treatment of GSM, especially in light of a potential placebo effect.

STRENGTHS & LIMITATIONS

We present a sham-controlled double-blinded randomized trial using validated tools; the main limitation included an underpowered proportion of sexually active participants for the primary outcome.

CONCLUSION

This study was underpowered to draw conclusions regarding the efficacy of fractional CO₂ laser therapy in the treatment of GSM. We did observe improvements in the sham-arm to suggest a possible placebo contribution. Further well-powered level one research is needed to demonstrate the therapeutic effect of this novel modality. Cruff J, Khandwala S, A Double-Blind Randomized Sham-Controlled Trial to Evaluate the Efficacy of Fractional Carbon Dioxide Laser Therapy on Genitourinary Syndrome of Menopause. J Sex Med 2021;18:761-769.

Robotic Surgical Training at Home: A Low-Fidelity Simulation Method

OBJECTIVE

Laparoscopic box simulators provide surgical residents a cost-effective and accessible learning tool to practice basic laparoscopic skills. Despite effective, high-fidelity simulators used in robotic surgery training, a similar low-fidelity alternative simulation method is not available. The objective of this report and accompanying video is to introduce a low-fidelity method to help those new to robotic-assisted surgery learn fundamental skills even before sitting at the console.

METHOD

Using 2 fine-point metal tweezers with Velco loops for finger slots, I developed a user-friendly way to practice basic needle handling and intracorporeal knot tying activities similar to those encountered on a high-fidelity robotic simulator. These simple tools mimic the controllers at the actual robot console.

EXPERIENCE

This teaching tool is meant to help surgical trainees and those new to robotic surgery develop the initial dexterity and economy of motion for performing basic tasks. I have greatly improved my own surgical confidence and experience anecdotally using these tools before I sat for actual cases. I hope a motivated trainee may discover the same benefit.

CONCLUSIONS

A low-fidelity simulation method may enhance a learner's initial proficiency in robotic-assisted surgery, but future performance studies using this method will be needed.

Retrospective Analysis of Sexual Function After Transvaginal Mesh Surgery

INTRODUCTION

Despite ample research regarding the impact of reconstructive surgery on anatomic/functional outcomes of pelvic organ prolapse (POP), including incidence of dyspareunia, evidence regarding sexual outcomes is equivocal.

AIM

To assess changes in sexual function in women followed up for at least 12 months after transvaginal mesh surgery for POP.

METHODS

We conducted a retrospective review of women who underwent surgery for POP using different mesh products between 2008 and 2019. Baseline demographics were compiled along with intraoperative and postoperative information. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) was used to assess sexual function.

MAIN OUTCOME MEASURES

Women sexually active before and after surgery were assessed to determine changes in overall and question-specific PISQ-12 responses and potential factors to explain sexual function after surgery.

RESULTS

622 women underwent surgery using mesh at our center. 360 (58%) attended at least one visit at a median of 12 months (IQR 11-23 months), with 113 (31%) sexually active at baseline and 247 (69%) sexually inactive. 97 had complete PISQ-12 responses before and after surgery. There was an overall improvement in the median PISQ-12 scores of 2 points (P < .001); improvements persisted when scores were stratified by various factors. Specific improvements were noted in climax (P = .046) and orgasm intensity (P = .002), fear (P < .001) or actual incontinence during intercourse (P = .004), avoidance of intercourse due to prolapse (P < .001), and negative emotions (P < .001). There was a slight positive effect of the baseline PISQ-12 score on the postoperative PISQ-12 score (regression coefficient 0.24, 95% CI: 0.09-0.39), and a stronger negative effect of having a concomitant anal sphincteroplasty (-4.84, 95% CI: -8.42 to -1.25). Preoperative prolapse stage was not associated with postoperative sexual outcomes. There was a weak negative association between the postoperative PISQ-12 and Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) scores [rs(95) = -0.27, P = .008] and a moderate negative association between postoperative PISQ-12 and total Pelvic Floor Distress Inventory short form [rs(94) = -0.42, P < .001].

CONCLUSION

Transvaginal mesh surgery appears to positively impact sexual function, and improvements were independent of mesh or baseline prolapse severity. Khandwala S, Cruff J, Williams C. Retrospective Analysis of Sexual Function After Transvaginal Mesh Surgery. Sex Med 2021;9:100281.

The Role of Yoga in the Management of Bladder Pain Syndrome: A Single-Arm Pilot Study

BACKGROUND

Bladder pain syndrome (BPS) is a devastating urologic condition characterized by irritative bladder symptoms, pelvic pain, and dyspareunia. First-line treatment includes dietary, self-care and behavioral modifications. The ancient practice of yoga is well suited to treat BPS, but evidence is lacking on its use.

AIMS

To investigate the feasibility and efficacy of an integrated yoga module on BPS outcomes as measured by self-reported questionnaires from baseline to 3 months after therapy.

METHODS AND MATERIALS

This was a prospective single-arm study of 8 patients who underwent 3 months of integrated yoga therapy. The treatment module was performed 3 to 4 times weekly at home with 1 session performed weekly in-office during the first month to ensure proper performance of postures. Patients completed questionnaires (Pelvic Pain and Urgency/Frequency Patient Symptom Scale [PUF], Pelvic Floor Impact Questionnaire - short form 7 [PFIQ-7], Short Form 36 questionnaire [SF-36], Pittsburgh Sleep Quality Index [PSQI]) at baseline and 3 months, including Patient Global Impression of Improvement (PGI-I) at the 3-month follow-up visit. Voiding diaries were also requested at baseline and at the 3-month assessment.

RESULTS

There was a trend toward improvement regarding patients' responses to all questionnaires 3 months after yoga therapy, with the only statistically significant improvements noted in social function and pain components of the SF-36. There were no significant changes noted on the voiding diaries except a non-statistically significant trend toward increased voided volumes. Patients rated their experiences with yoga therapy positively.

CONCLUSIONS

Yoga therapy for BPS showed evidence of benefit for improving bothersome bladder symptoms, pain and voiding. A randomized controlled trial will follow to investigate the efficacy of this yoga module against a control group.

Single-incision Midurethral Sling by the Dynamic Intraoperative Standing Sling Technique as an Office-based Procedure: A Pilot Study

OBJECTIVES

To assess the safety, feasibility, and short-term success of placing Solyx (Boston Scientific, Marlborough, MA) single-incision midurethral sling (SIMUS) using the Dynamic Intraoperative Standing Sling Technique (DISST) in an office setting under local anesthesia.

METHODS

The safety and efficacy of the in-office Solyx DISST procedure for treatment of stress urinary incontinence was assessed 6 months from the procedure. Improvement in stress urinary incontinence was measured using validated questionnaires (Medical, Epidemiologic, and Social Aspects of Aging, MESA; Incontinence Impact Questionnaire-7, IIQ-7; Pelvic Organ Prolapse/Urinary Incontinence Sexual Function, PISQ-12) and by a negative standing provocative stress test. Postoperative complications were documented along with subjective pain diaries, return to work/activities, and overall satisfaction.

RESULTS

From July 2019 through February 2020, 20 subjects underwent in-office Solyx procedure by the DISST technique. Six of the 20 (30%) subjects required intraoperative sling adjustments. There were no complications as related to the office-based procedure. Participants reported a favorable intraoperative experience. Subjects had excellent postoperative pain control and early return to work and normal activities. At 6 months, all 20 subjects had negative standing provocative stress tests, showed statistically significant improvements on MESA, IIQ-7, and PISQ-12, and reported high satisfaction and acceptance for the procedure and outcomes. There were no late (>6 weeks) complications associated with the Solyx procedure.

CONCLUSIONS

It appears safe and feasible to perform Solyx SIMUS by the DISST method in the office. Subjects remained dry and reported excellent improvement in symptoms and quality of life 6 months from surgery.

Prospective analysis of transvaginal mesh hysteropexy in the treatment of uterine prolapse

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess the efficacy of using transvaginal mesh to correct uterine prolapse by hysteropexy.

METHODS

This was a single-center, prospective study of 40 subjects with bothersome uterine prolapse. Inclusion criteria were bothersome perception of a vaginal bulge on Pelvic Floor Distress Inventory short form (PFDI-20) and having a Pelvic Organ Prolapse Quantification System (POP-Q) point C of -2 or worse. Exclusionary criteria included inability to consent, history of pelvic malignancies, or any prior prolapse repair. Eligible subjects were treated with transvaginal mesh hysteropexy between March 2016 and July 2018 for a primary outcome of composite success, which was defined by a POP-Q point C value of -2 or higher, PFDI-20 question 3 indicating no bothersome perception of prolapse, and no retreatment. Secondary outcomes included responses to condition-specific and quality-of-life questionnaires, satisfaction/regret, and complications.

RESULTS

Transvaginal mesh hysteropexy was performed in 40 subjects. The majority (68%) had advanced stage (III/IV) uterine prolapse. At a median follow-up of 12 months, there was an 84% composite success, and considering only anatomic criteria (POP-Q point C < -1), there was a 92% success. No subject required reintervention for recurrent or persistent uterine prolapse. There were no cases of mesh exposures. In terms of safety, one subject required a blood transfusion for symptomatic anemia (Clavien-Dindo grade II), and one subject reported de novo dyspareunia from a perineal band that was released in office at 6 months (grade IIIa), but otherwise there were no serious immediate or late complications. There were significant improvements in both condition-specific and quality-of-life assessments from baseline. Subject satisfaction and acceptance for the procedure were high.

CONCLUSIONS

In this single-center case series of 40 women with bothersome uterovaginal prolapse, transvaginal mesh hysteropexy appears safe and effective for correcting advanced stage uterine prolapse at the short term. A future multicenter controlled trial would be needed to determine efficacy against native tissue repair.